Nathalie Kapel

Tube Feeding Improves Intestinal Absorption in Short Bowel Syndrome Patients

BACKGROUND & AIMS Tube feeding, recommended for patients with short bowel syndrome in only the postoperative period, has not been compared with oral feeding for absorption. We studied whether tube feeding increased absorption in patients with short bowel syndrome following the postoperative period. METHODS A randomized crossover study compared absorption between isocaloric tube feeding and oral feeding in 15 short bowel syndrome patients more than 3 months after short bowel constitution. An oral feeding period combined with enriched (1000 kcal * day(-1)) tube feeding was also tested. We measured the net intestinal absorption rates of proteins, lipids, and total calories using elemental nitrogen, Van de Kamer, and bomb calorimetry methods, respectively. RESULTS Tube feeding increased the mean (+/-SD) percent absorption (P < .001) of proteins (72% +/- 13% vs 57% +/- 18%), lipids (69% +/- 25% vs 41% +/- 27%), and energy (82% +/- 12% vs 65% +/- 16%) compared with oral feeding. In the group given the combined feedings (n = 9), the total enteral intake and net percent absorption increased (P < .001) for proteins (67% +/- 10%), lipids (59% +/- 19%), and total energy (75% +/- 8%) compared with oral feeding. Absorption (kcal * day(-1)) was greater (P < .001) with tube (2225 +/- 457) and combined feedings (2323 +/- 491) than with oral feeding (1638 +/- 458). CONCLUSIONS In patients with short bowel syndrome, continuous tube feeding (exclusively or in conjunction with oral feeding) following the postoperative period significantly increased net absorption of lipids, proteins, and energy compared with oral feeding.

A fermented formula in pre-term infants: clinical tolerance, gut microbiota, down-regulation of faecal calprotectin and up-regulation of faecal secretory IgA

Intestinal bacterial colonisation in pre-term infants is delayed compared with full-term infants, leading to an increased risk of gastrointestinal disease. Modulation of colonisation through dietary supplementation with probiotics or prebiotics could decrease such a risk. The present study evaluated clinical tolerance, the effects on gut microbiota, and inflammatory and immunological mucosal responses to an infant formula adapted for pre-term infants that included in its manufacturing process a fermentation step with two probiotic strains, Bifidobacterium breve C50 and Streptococcus thermophilus 065, inactivated by heat at the end of the process. A total of fifty-eight infants (gestational age: 30-35 weeks), fed either the fermented pre-term formula or a standard pre-term formula, were followed up during their hospital stay. Clinical tolerance, faecal microbiota using a culture and a culture-independent method (temporal temperature gel electrophoresis), faecal calprotectin and secretory IgA were analysed weekly. No difference was observed regarding anthropometric data and digestive tolerance, except for abdominal distension, the incidence of which was lower in infants fed the fermented formula for 2 weeks. Bacterial colonisation was not modified by the type of feeding, particularly for bifidobacteria. Faecal calprotectin was significantly lower in infants fed the fermented formula for 2 weeks, and secretory IgA increased with both mothers milk and the fermented formula. The fermented formula was well tolerated and did not significantly modulate the bacterial colonisation but had benefits on inflammatory and immune markers, which might be related to some features of gastrointestinal tolerance.

Fecal calprotectin: cutoff values for identifying intestinal distress in preterm infants.

This study aimed to determine cutoff levels for fecal calprotectin as a marker of intestinal distress in preterm neonates. A total of 126 infants born at a median gestational age of 33 weeks (range 25.7–35 weeks) were enrolled. Samples (n = 312) were collected weekly from the end of the first week of life until the end of the first month and if any gastrointestinal event occurred. Receiver operating characteristic curves analysis gave cutoff values of 363 μg/g (sensitivity 0.65, specificity 0.82) and 636 μg/g (sensitivity 0.72, specificity 0.95) for the development of mild or severe enteropathy.

Effect of recombinant human growth hormone on intestinal absorption and body composition in children with short bowel syndrome.

This prospective study aimed to establish the effect of recombinant human growth hormone (rhGH) on intestinal function in children with short bowel syndrome (SBS). Eight children with neonatal SBS were included. All were dependent on parenteral nutrition (PN) for >3 years (range, 3.8-11.6 years), with PN providing >50% of recommended dietary allowance for age (range, 50%-65%). The subjects received rhGH (Humatrope) 0.13 mg/kg/d subcutaneously over a 12-week period. The follow-up was continued over a 12-month period after rhGH discontinuation. Clinical and biological assessments were performed at baseline, at the end of the treatment period, and 12 months after the end of treatment. No side effects related to rhGH were observed. PN requirements were decreased in all children during the course of rhGH treatment. Between baseline and the end of treatment, significant increases were observed in concentrations (mean ± standard deviation) of serum insulin-like growth factor 1 (103.1 ± 49.9 µg/L vs 153.5 ± 82.2 µg/L; P < .01), serum insulin-like growth factor-binding protein 3 (1.7 ± 0.6 mg/L vs 2.5 ± 0.9 mg/L; P < .001), and plasma citrulline (16.5 ± 14.8 µmol/L vs 25.2 ± 18.3 µmol/L; P < .05). A median 54% increase in enteral intake (range, 10%-244%) was observed (P < .001) and net energy balance improved significantly (P < .002). It was necessary for 6 children to be maintained on PN or restarted after discontinuation of rhGH treatment, and they remained on PN until the end of the follow-up period. A 12-week high-dose rhGH treatment allowed patients to decrease PN, but only 2 patients could be definitively weaned from PN. Indications and cost-effectiveness of rhGH treatment for SBS pediatric patients need further evaluation.

Faecal D/L lactate ratio is a metabolic signature of microbiota imbalance in patients with short bowel syndrome.

Our objective was to understand the functional link between the composition of faecal microbiota and the clinical characteristics of adults with short bowel syndrome (SBS). Sixteen patients suffering from type II SBS were included in the study. They displayed a total oral intake of 2661±1005 Kcal/day with superior sugar absorption (83±12%) than protein (42±13%) or fat (39±26%). These patients displayed a marked dysbiosis in faecal microbiota, with a predominance of Lactobacillus/Leuconostoc group, while Clostridium and Bacteroides were under-represented. Each patient exhibited a diverse lactic acid bacteria composition (L. delbrueckii subsp. bulgaricus, L. crispatus, L. gasseri, L. johnsonii, L. reuteri, L. mucosae), displaying specific D and L-lactate production profiles in vitro. Of 16 patients, 9/16 (56%) accumulated lactates in their faecal samples, from 2 to 110 mM of D-lactate and from 2 to 80 mM of L-lactate. The presence of lactates in faeces (56% patients) was used to define the Lactate-accumulator group (LA), while absence of faecal lactates (44% patients) defines the Non lactate-accumulator group (NLA). The LA group had a lower plasma HCO3− concentration (17.1±2.8 mM) than the NLA group (22.8±4.6 mM), indicating that LA and NLA groups are clinically relevant sub–types. Two patients, belonging to the LA group and who particularly accumulated faecal D-lactate, were at risk of D-encephalopathic reactions. Furthermore, all patients of the NLA group and those accumulating preferentially L isoform in the LA group had never developed D-acidosis. The D/L faecal lactate ratio seems to be the most relevant index for a higher D- encephalopathy risk, rather than D- and L-lactate faecal concentrations per se. Testing criteria that take into account HCO3− value, total faecal lactate and the faecal D/L lactate ratio may become useful tools for identifying SBS patients at risk for D-encephalopathy.

Fecal Tumor Necrosis Factor alpha, Eosinophil Cationic Protein and IgE Levels in Infants with Cows Milk Allergy and Gastrointestinal Manifestations

Abstract Infants with atopic eczema exhibit a specific fecal protein pattern after oral challenge with cows milk, characterized by an increase in both eosinophil cationic protein (ECP) and tumor necrosis factor (TNF)α. The aim of our study was to determine the pattern of these proteins in allergic infants with intestinal manifestations. TNFα, ECP and immunoglobulin E (IgE) were measured in stools from 13 infants with intestinal symptoms and 10 healthy infants. The allergic infants underwent two stool collections, one before a cows milk challenge and the other after the challenge, either at the onset of clinical manifestations (n=6) or 15 days after the challenge if no clinical manifestations occurred (n=7). Baseline TNFα, ECP and IgE levels were low in all infants. The concentration of TNFα increased after the challenge in infants positive to challenge (p<0.05) but not in those negative to challenge. ECP and IgE levels remained low after the challenge in all the allergic infants. These data confirm that fecal TNFα and ECP levels indicate various reaction types of food allergy and that different immunologic disturbances lead to atopic eczema or intestinal symptoms during food allergy. Fecal protein pattern can thus be a useful tool in diagnosing food allergy in infants with intestinal manifestations.

Faecal Calprotectin in Term and Preterm Neonates

Objectives: The aim of this review was to examine the characteristics of the faecal calprotectin assay in neonates and the evidence for its use as a noninvasive marker of intestinal illnesses during the neonatal period. Methods: Bibliographic searches were performed in the MEDLINE electronic database up to February 2010 looking for the following words (all fields): “infants” or “neonates” and “calprotectin.” Twenty studies, in which 1180 neonates were enrolled, were selected. Results: During the neonatal period, calprotectin levels are characterized by significantly higher values in both healthy full-term and preterm infants during their first year of life compared with reference values established for children and adults. No difference was observed according to gestational age or birth weight, whereas a higher faecal calprotectin level was detected during intestinal distress in neonates with either inflammatory or patent digestive alterations. Despite high interindividual variations, cutoff levels are proposed to identify infants with a high risk of intestinal illnesses. Conclusions: Compared with adults and children, healthy full-term and preterm neonates have high calprotectin levels. The measurement of calprotectin levels in faeces can be a promising noninvasive clinical screening test for intestinal distress in neonates.

Evaluation of Four Commercial Rapid Immunochromatographic Assays for Detection of Cryptosporidium Antigens in Stool Samples: a Blind Multicenter Trial

ABSTRACT In a multicenter study, potassium dichromate-preserved stools from patients infected with Cryptosporidium parvum (n = 20), C. hominis (n = 20), and other Cryptosporidium species (n = 10) and 60 controls were examined using four immunochromatographic assays. Assay sensitivity ranged between 50.1% and 86.7% for C. parvum and C. hominis but was <35% for other species.

Inefficacy of intestinal secretory immune response to Cryptosporidium in acquired immunodeficiency syndrome

BACKGROUND/AIMS An alteration of the secretory immune response has been forwarded to explain frequent and chronic mucosal infections in patients with acquired immunodeficiency syndrome (AIDS). The aim of this study was to explore the intestinal immunoglobulin (Ig) secretions in patients with AIDS and their relationships to cryptosporidiosis. METHODS Patients with AIDS and enteric cryptosporidiosis (n = 12), other enteric infections (n = 10), and no identifiable enteric pathogen (n = 10) and human immunodeficiency virus-seronegative controls (n = 18) were studied. The number of intestinal IgA and IgM plasma cells of the duodenal lamina propria mucosa and total and anti-Cryptosporidium IgA, IgM, and IgG were measured in serum and feces. RESULTS Although not significantly increased, the number of IgA and IgM plasma cells was greater in patients with AIDS (n = 20) than in controls (n = 5). In feces, total IgA outputs and specific anti-Cryptosporidium IgA levels were significantly higher in patients with AIDS and cryptosporidiosis than in the two other groups of patients with AIDS (P < 0.05 and P < 0.01, respectively) and controls (P < 0.001 and P < 0.01, respectively). Total fecal IgM output and specific anti-Cryptosporidium IgM coproantibodies were increased only in the Cryptosporidium-infected patients relative to the controls (P < 0.05). CONCLUSIONS Despite the development of pathogen-specific mucosal antibody responses, patients with AIDS and cryptosporidiosis fail to clear the parasite.

Increased intestinal absorption by segmental reversal of the small bowel in adult patients with short-bowel syndrome: a case-control study

BACKGROUND Segmental reversal of the small bowel (SRSB) is proposed in patients with short-bowel syndrome (SBS) as a rehabilitative therapy, but its effects on absorption have not been studied. OBJECTIVE We aimed to determine intestinal macronutrient absorption and home parenteral nutrition (HPN) dependence in SBS patients with intestinal failure. DESIGN We included in a retrospective study all consecutive patients who had an SRSB between 1985 and 2010 and underwent a study of macronutrient absorption. Patients were matched to SBS controls with the same digestive characteristics. Energy and macronutrient absorption were measured. The dependence on HPN was expressed by the number of infusions per week and by the calories infused daily divided by the basal energy expenditure multiplied by 1.5. RESULTS Seventeen patients who had an SRSB were matched to 17 control patients. Intestinal absorption was higher in the SRSB group for total calories (69.5% compared with 58.0%), fat (48.4% compared with 33.2%), and protein (62.7% compared with 53.4%) (P < 0.05). Median oral autonomy was 100% ± 38.4% in the SRSB group, whereas it was 79% ± 39.6% in the control group (P < 0.05). The number of calories infused was lower in the SRSB group (500 ± 283 compared with 684 ± 541; P < 0.05), as was HPN dependence (33% ± 20% compared with 48% ± 38%; P < 0.05) at the time of the study. CONCLUSION SRSB allows a gain in macronutrient absorption, which is associated with a lower HPN dependence. To our view, SRSB should be integrated in intestinal rehabilitative adult programs.