Jon Shaffer

Hepatobiliary complications of total parenteral nutrition

The relationships between various hepatobiliary disorders and the administration of total parenteral nutrition (TPN) were reviewed and, in particular, the role of TPN in their pathogenesis was critically evaluated. Several clinical and pathological entities including steatosis, steatohepatitis, cholestasis, and cholelithiasis have been commonly linked to TPN, and instances of chronic decompensated liver disease have been reported. However, it is concluded that it is often difficult to extricate the effects of TPN on hepatobiliary function from many other hepatotoxic factors that may be operative in these patients. Thus, whereas considerable evidence exists to support a role fro carbohydrate or calorie excess in TPN solutions in the pathogenesis of steatosis, a loss of enteric stimulation and not TPN per se may be the primary factor in the development of cholestasis, biliary sludge, and gallstones. The apparent predilection of infants to TPN-related cholestasis may be based on the relative immaturity of the neonatal biliary excretory system.

Psychological disorder and severity of inflammatory bowel disease predict health-related quality of life in ulcerative colitis and Crohn's disease

OBJECTIVE:The determinants of health-related quality of life in inflammatory bowel disease are not completely understood. The present study aimed to assess two factors in patients with inflammatory bowel disease: a) whether health-related quality of life is independently associated with both bowel disease severity and psychological disorder, and b) whether Crohns disease is associated with more marked psychological disorder than ulcerative colitis.METHODS:116/170 (68%) consecutive patients with inflammatory bowel disease attending a GI clinic (37 patients with ulcerative colitis, 75 patients with Crohns disease, and four unspecified) completed the following self-report questionnaires: demographic details, a modified disease activity index, a total severity measure, the Hospital Anxiety and Depression Scale, and the Short Form-36.RESULTS:Thirty patients (25.9%) scored 11 or more on either the depression or anxiety subscales of the Hospital Anxiety and Depression Scale indicating probable psychological disorder; 55% (47.4%) scored over 8 indicating possible psychological disorder. Stepwise multiple regression analyses showed that both psychological symptoms and disease severity or activity contributed independently to impaired health-related quality of life. After severity of disease was taken into account, there were no significant differences between Crohns disease and ulcerative colitis in terms of depression scores and health-related quality of life.CONCLUSIONS:The presence of psychological disorder in inflammatory bowel disease contributes to poor health-related quality of life, regardless of the severity of the condition. Detection and treatment of psychological disorder in inflammatory bowel disease carries the potential to improve health-related quality of life for these patients.

Home parenteral nutrition in adults: a Europeanmulticentre survey in 1997

Abstract A retrospective survey on home parenteral nutrition (HPN) in Europe was performed fromJanuary to December 1997. Data were compared to a similar study performed in 1993. A questionnaire of HPN practice was designed by the members of the ESPEN-HAN group. This involvedadult patients (older than 16 years) newly registered in an HPN program between 1 January and 31 December 1997 and included: number of patients, underlying diseases and a 6–12 month outcome. Incidence and prevalence (at 1.1.1998) of adult HPN were calculated according to the estimated total population in 1997 for the countries in which more than 80% of HPN patients were reported. A total of 494 patients were registered in 73 centres from nine countries (Belgium (B), Denmark (D), France (F), Poland (P), Spain (S), Sweden (Sw), United Kingdom (UK), The Netherlands (N) and Germany (G). The underlying diseases for HPN in 494 patients were cancer (39%), Crohns (19%), vascular diseases (15%), radiation enteritis (7%), AIDS (2%), other diseases with intestinal failure (18%). Incidence (patients/million inhabitants/year) were in N (3), F. (2.9), D. (2.8), B. (2.6), UK (1.2), S (0.7) and P (0.36), respectively. Prevalence were in D. (12.7). U.K. (3.7), N. (33), F (3.6), B (3.0), P (1.1), S (0.65). After this 6–12 months follow-up (n=284), the mortality was respectively 4% in Crohns disease, 13% in vascular diseases, 16% in others, 21% in radiators enteritis, 34% in AIDS, 74% in cancer. Incidences and prevalences modestly increased in these seven European countries in 1997 in comparison to 1993. The percentages of underlying diseases in these countries remained similar except for ADS that significantly decreased (from 7% to 2%). Outcomes did not significantly differ in the 4-year period except for AIDS (34% instead of 88% mortality) and could have been related to newer, more efficacious therapy.

Review article: intestinal failure

Intestinal failure is a specific disease entity resulting from intestinal resection or disease‐associated malabsorption and characterized by the inability to maintain protein‐energy, fluid, electrolyte or micronutrient balance. We performed a MEDLINE search (1966–2006) to identify relevant articles, using keywords intestinal failure, parenteral or enteral nutrition, intestinal fistula and short bowel syndrome.

Home enteral nutrition in adults: a European multicentre survey

AIMS This study was undertaken to report indications and practice of home enteral nutrition (HEN) in Europe. METHODS A questionnaire on HEN practice was sent to 23 centres from Belgium (B), Denmark (D), France (F), Germany (G), Italy (I), Poland (P), Spain (S) and the United Kingdom (UK). This involved adult patients newly registered in HEN programme from 1 January 1998 to 31 December 1998. RESULTS A total of 1397 patients (532 women, 865 men) were registered. The median incidence of HEN was 163 patients/million inhabitants/year (range: 62-457). Age distribution was 7.5%, 16-40 years; 37.1%, 41-65 years; 34.5%, 66-80 years and 20.9% >80 years. The chief underlying diseases were a neurological disorder (49.1%), or head and neck cancer (26.5%); the main reason for HEN was dysphagia (84.6%). A percutaneous endoscopic gastrostomy (58.2%) or a naso-gastric tube (29.3%) were used to infuse commercial standard or high energy diets (65.3%), or fibre diets (24.5%); infusion was cyclical (61.5%) or bolus (34.1%). Indications and feeds were quite similar throughout the different centres but some differences exist concerning the underlying disease. There was greater variation in the choice of tubes and mode of infusion. In F, G, I, S, and UK, costs of HEN are fully funded. In B, D, and P patients have to pay part or all of the charges. CONCLUSIONS In Europe, HEN was utilised mainly in dysphagic patients with neurological disorders or cancer, using a standard feed via a PEG. However, there were important differences among the countries in the underlying diseases treated, the routes used, the mode of administration and the funding.

Review article: the management of long‐term parenteral nutrition

Home parenteral nutrition (HPN) is currently the management of choice for patients with chronic intestinal failure.

Opiate and Sedative Dependence Predicts a Poor Outcome for Patients Receiving Home Parenteral Nutrition

BACKGROUND Home parenteral nutrition (HPN) is used to treat intestinal failure. A minority of HPN patients are dependent on opiates and benzodiazepines to control pain and anxiety. The aim of this study was to determine what effects such drug dependence had on patient outcomes. METHODS Ten dependent patients were prospectively compared with 10 well-matched, nondependent HPN patients for the same 12-month period. Episodes of line sepsis and other complications were documented and the cost of treatment estimated. Health status was measured using the SF36 and EuroQol instruments. RESULTS The dependent group had significantly more episodes of central line sepsis (p = .0007) as well as other complications (p = .0002). This led to significantly longer periods of inpatient care (p = .0004) and therefore higher costs of treatment. Health status was lower in the dependent group; they reported more pain (p = .04) and less energy (p = .04). CONCLUSIONS The complication rate and increased cost of treatment for opiate- and sedative-dependent patients receiving HPN significantly detract from the overall outcome of this therapy.

Quality of life on home parenteral nutrition: a single centre study of 37 patients

Quality of life was assessed in 37 patients receiving home parenteral nutrition (HPN) for intestinal failure. A questionnaire was developed specifically for this purpose and the results were compared with those obtained by subjective assessment using a simple linear scale. The majority of patients (n = 26, 70.3%) had a good objective quality of life and most (n = 16, 53.3%) of those eligible (n = 30, 81.1%) did not express an interest in intestinal transplantation. Despite the apparent good quality of life enjoyed by patients receiving HPN, there were numerous areas in which patients with intestinal failure felt that their quality of life left much to be desired: many patients reported significant psychological symptoms (n = 15, 40.5%) sexual (n = 10, 27.0%) and social dysfunction (n = 19, 51.3%) and most patients with intestinal failure were unable to return to work (n = 24, 88.9%). Detailed quality of life assessment reveals that there is much still to be done to ensure that provision of care for patients with intestinal failure involves not only prolongation of life but also an improvement in quality of life.

Central Venous Catheter Salvage in Home Parenteral Nutrition Catheter-Related Bloodstream Infections Long-Term Safety and Efficacy Data

BACKGROUND Catheter-related bloodstream infections (CRBSIs) are a serious complication in the provision of home parenteral nutrition (HPN). Antibiotic salvage of central venous catheters (CVCs) in CRBSI is recommended; however, this is based on limited reports. We assessed the efficacy of antibiotic salvage of CRBSIs in HPN patients. MATERIALS AND METHODS All confirmed CRBSIs occurring in patients receiving HPN in a national intestinal failure unit (IFU), between 1993 and 2011, were analyzed. A standardized protocol involving antibiotic and urokinase CVC locks and systemic antibiotics was used. RESULTS In total, 588 patients were identified with a total of 2134 HPN years, and 297 CRBSIs occurred in 137 patients (65 single and 72 multiple CRBSIs). The overall rate of CRBSI in all patients was 0.38 per 1000 catheter days. Most (87.9%) infections were attributable to a single microorganism. In total, 72.5% (180/248) of CRBSIs were salvaged when attempted (coagulase-negative staphylococcus, 79.8% [103/129], Staphylococcus aureus, 56.7% [17/30]; polymicrobial infections, 67.7% [21/30]; and miscellaneous, 66.1% [39/59]). CVC salvage was not attempted in 49 episodes because of life-threatening sepsis (n = 18), fungal infection (n = 7), catheter problems (n = 20), and CVC tunnel infection (n = 4). Overall, the CVC was removed in 33.7% (100/297) of cases. There were 5 deaths in patients admitted to the IFU for management of the CRBSI (2 severe sepsis at presentation, 3 metastatic infection). CONCLUSIONS This is the largest reported series of catheter salvage in CRBSIs and demonstrates successful catheter salvage in most cases when using a standardized protocol.

Nutritional status and assessment of patients on home parenteral nutrition: anthropometry, bioelectrical impedance, or clinical judgment?

The optimal method of assessing protein energy nutritional status in patients receiving home parenteral nutrition (HPN) is unknown. We evaluated protein energy nutritional status in 47 outpatients (23 male; 24 female) on HPN by measuring anthropometry, plasma proteins, and lymphocyte counts and compared these with the results of subjective clinical assessment and bioelectrical impedance measurements. Sixteen of the 47 patients (34%) were underweight (body mass index < 5th percentile of the reference) and 21 (45%) were below the 5th percentile of the reference for both triceps skinfold thickness and midarm muscle circumference. Plasma proteins were subnormal in 1-5 patients (2-11%). Lymphocyte counts were subnormal in 19 patients (40%). Clinical assessment classified 23 patients (49%) as well nourished and 24 (51%) as moderately malnourished. Moderately malnourished patients had a significantly lower body mass index than well-nourished patients (P = 0.02). Clinical assessment did not correlate with bioelectrical impedance analysis. Fat-free mass determined by bioelectrical impedance analysis resulted in values up to 9.4 kg lower and 8 kg higher than fat-free mass obtained by anthropometry. Weighing combined with a subjective clinical assessment is sufficient for evaluation of protein calorie nutritional status in patients on HPN.