Kenneth L. Cox

Experience with home parenteral nutrition

Twenty-nine patients underwent courses of home parenteral nutrition therapy ranging from 1.5 to 52 months (mean 14.5 months). The primary diagnoses responsible for the requirement of home parenteral nutrition were radiation enteritis in seven patients, short bowel syndrome secondary to resection in seven, Crohns disease in two, malabsorption states in six, and other reasons in seven. Seventeen patients (57 percent) had at least one complication. Nine patients had intravenous catheter complications and nine had metabolic complications. Nine patients have died, 11 have been successfully weaned from home parenteral nutrition, and 9 continue to receive home parenteral nutrition. Home parenteral nutrition is useful in a variety of catastrophic clinical situations, including preparation for subsequent operative therapy, temporary malabsorption, and permanent disability of the gastrointestinal tract. Complications are frequent and may be life-threatening.

Gastroesophageal scintigraphy with and without compression.

This study compares the results of radionuclide gastroesophagography performed by the compression and computer-assisted noncompression techniques. The overall accuracy of the compression and noncompression methods was 71% and 84%, respectively. The use of computer processing significantly enhances the ability to detect minor degrees of reflux and may explain the better results obtained with the noncompression method. Other advantages of the noncompression technique include its technical ease and uniformity and the acquisition of more physiologic data for comparison with results of the acid reflux test.

BARRETT'S EPITHELIUM RESULTING FROM CHRONIC GASTROESOPHAGEAL REFLUX |[lpar]|GER|[rpar]| IN CHILDREN

Histologic changes seen on esophageal biopsies in children with GER may include normal squamous epithelium, changes in rete peg height & inflammatory infiltrates of PMNs or eosinophils. While severe GER in adults may be accompanied by replacement of normal esophageal epithelium with columnar epithelium (Barretts epithelium), this complication is not appreciated in children.4 children (ages 2-10 yrs) with severe GER complicating mental deficiency syndromes or multiple congenital abnormalities (VATER syndrome) were found to have Barretts esophagus. Severe GER was documented in each : UGI (+4/4), Tc99m milk scan (+4/4), 24 hr. esophageal pH monitoring (+4/4). The endoscopic appearance of the mucosa was consistent with moderate esophagitis in 3/4, mild esophagitis in 1. Biopsies were obtained at least 3 cm proximal to the GE junction or at an area of demarcation between normal and abnormal mucosa. All patients had evidence of gastric columnar epithelium upon histological examination of the tissue; 3/4 showed fundal mucosa with chief cells, 1 showed junctional type mucosa. In addition, all patients had infiltrates of chronic inflammatory cells in the lamina propria. 3/4 patients underwent elective fundoplication.Conclusion: Barretts epithelium may be seen as a complication of GER in children. Because the natural history of Barretts following correction of GER is unknown in children, careful survalence is indicated due to the premalignant potential of these changes.

536 EFFECT OF CHRONIC CIMETIDINE (C) ADMINISTRATION ON GROWTH IN CYSTIC FIBROSIS (CF) PATIENTS

Twenty-five CF patients (7.5-17.9 years) participated in a one-year double-blind cross-over study to assess the influence of chronic cimetidine administration on growth parameters. Assessment of the group prior to entering the studies revealed coefficient of fat absorption while receiving pancreatic enzyme supplements from 35-95% (mean 64%), pulmonary function (FVC) from 32-100% predicted (mean 71%), and growth retardation with weight < 5% in 19, height < 5% in 14, and delayed bone age in 16 patients. Growth was assessed by height, weight, K40 lean body mass (LBM), muscle mass estimated by 24 hour urine creatinine, fat content by skin fold thickness, and bone age. RESULTS: 1) Average increases for any parameter were no greater on cimetidine than placebo. 2) Growth parameters did not show parallel changes. 3) No toxic effects were observed. 4) Two patients had no height increase and one patient had weight loss but 8 had decreases in LBM during the year. 5) Cimetidine reduced basal and pentagastrin stimulated gastric acid secretion at least by 50% in 19 cases. CONCLUSION: 1) Chronic cimetidine administration should not be a routine part of CF care. 2) Height and weight may be misleading parameters to follow in assessment of nutrition status.

526 DELAYED GASTRIC EMPTYING IN CHILDREN WITH GASTROESOPHAGEAL REFLUX (GER)

The contribution of abnormal gastric motility to GER has not been established to date. 14 children (ages: 2 mo to 3 yr) with GER diagnosed by standard criteria (2 or more (+) studies: UGI, esophageal manometry, acid reflux studies, radionuclide reflux study or endoscopy) were evaluated for delayed gastric emptying using an isotope-labeled formula technique. Emptying curves and T½ values were computed using Tc-99mSC in cows milk or soy formula (0.67 cal/cc) administered as a single bolus of 300 cc/1.73m2 in the supine position. Normal T½ values were established in patients without GER. 9/14 patients with GER demonstrated significantly delayed gastric emptying:The patients with delayed emptying had “flat” curves compared to biphasic curves in normals. Therapy with urecholine in selected patients had variable effects on emptying studies. 6/9 GER patiients with delayed emptying required surgery due to failure of medical management; 1/5 GER patients with normal emptying required surgery.Conclusion: Delayed gastric emptying appears to be a contributing factor to GER in children and may be associated with a poor response to medical therapy.

1622 BROVIAC CATHETERS FOR PROLONGED ANTIBIOTIC ADMINISTRATION IN CYSTIC FIBROSIS PATIENTS

An efficient and safe program for continuous home administration of parenteral antibiotics was developed for chronically ill cystic fibrosis children. Six patients, ages 9 to 20 yrs, who required frequent hospitalizations for pseudomonas bronchitis had Broviac or Hickman catheters placed under general anesthesia. Catheters were utilized over intervals of one month to two years. A combination of tobramycin (5-7.5 mg/kg/day) and carbenicillin or ticarcillin (300 mg/kg/day) was given every six to eight hours by patients or their parents. Peak tobramycin levels between 5 - 10 μg/ml were achieved. Compared to a control period prior to beginning the program, a decreased frequency of hospitalizations for pulmonary symptoms was noted in 4 of 6 patients. All patients benefited by their ability to maintain normal activities at home and at school. No objective improvement in pulmonary function tests utilizing peak flow measurements was observed in this patient group. No catheter-related complications were observed. Two catheters required repair because of leakage of the external segment. Prolonged administration of antibiotics utilizing the Broviac catheter may benefit some patients with cystic fibrosis. However, the long term effects of this therapy on the progression of their pulmonary disease are unknown.