Short bowel syndrome and intestinal failure: consensus definitions and overview

The effects of different parenteral nutrition lipid formulations on clinical and laboratory endpoints in patients receiving home parenteral nutrition: A systematic review

BACKGROUND

Home parenteral nutrition (HPN) is a life-sustaining therapy for individuals with intestinal failure in a community setting. It refers to the intravenous infusion of macronutrients, micronutrients, fluids and electrolytes. Routinely used HPN solutions contain different quantities of these components. Consequently, each HPN solution may have different impacts on metabolism, inflammation and oxidative stress. Long-term use of HPN can lead to a number of adverse health outcomes including the development of metabolic bone disease, intestinal failure associated liver disease and poor quality of life but whether, and how, the composition of HPN solutions contributes to these health sequelae is poorly understood. The aim of this study is to systematically review and evaluate the evidence for the differential effects of HPN solutions and to understand what features are associated with differences in clinical endpoints.

METHODS

A systematic literature search was conducted between September and December 2020, and updated in July 2021 using the MEDLINE (Ovid), EMBASE, Scopus, and Web of Science databases. Studies were selected according to the following criteria (a) adult participants (>18 years old) dependent on HPN; (b) randomised controlled trials, prospective cohort and cross-sectional study designs; (c) primary research comparing two or more HPN solutions and (d) published in English language. Data were extracted and study quality assessed using Cochrane Collaboration's tools: Risk of Bias for Randomised Controlled Trials (RCTs); Risk of Bias in Non-Randomised Studies of Interventions; and the Newcastle Ottawa Scale for cross-sectional studies.

RESULTS

Of the 5148 articles identified, seven RCTs, two prospective cohort and one cross-sectional study were included with a total of 295 participants. Studies varied in terms of duration (one to 60 months) and sample size (n = 5 to 88). Ten studies compared lipid emulsions (LE) and one study also compared LE with lipid-free HPN. No studies were found that compared the amino acid, vitamin, trace element or electrolyte components of HPN. In general, LE were well tolerated with no significant adverse effects. LE containing olive +/or fish oil were associated with a lower ω-6:ω-3 fatty acid ratio, positive reductions in markers of liver function, and changes in blood and cell fatty acid profiles.

CONCLUSIONS

Despite the increasing use of HPN, there is surprisingly little evidence available to guide the provision of macro and micronutrients in the adult population requiring this therapy. Although LE containing olive +/or fish oil show promise with regards to liver function and blood and cell fatty acid profiles, further studies are needed before drawing definitive conclusions on the clinical value of these emulsions. It is likely that one type of HPN solution alone cannot be uniformly applied to patient care, and each patient should be assessed on an individual basis.

Normal anthropometry does not equal normal body composition in pediatric intestinal failure

BACKGROUND

Published reports on abnormal body composition in pediatric patients with intestinal failure have been in patients with poor growth. The goal of the current study is to report the body composition of normally growing patients with intestinal failure.

METHODS

Children 8-18 years old with a dual-energy x-ray absorptiometry (DXA) between January 1, 2013, and July 15, 2018, were included in the study. Data were retrospectively collected from the medical charts and included demographics, residual bowel anatomy, nutrition support, height, and weight. DXA data, including total body less head bone mineral density (BMD), fat mass (FM), and fat-free mass (FFM), were collected and compared with published literature controls matched for age and sex.

RESULTS

Thirty-four children met inclusion criteria. Mean age at the time of DXA was 9.6 ± 1.8 years. Weight- and height-for-age z-scores were -0.4 ± 0.9 and -0.5 ± 1.0, respectively. Mean BMD z-score was -1.0 ± 1.3. Twenty-six percent of patients (n = 9) had reduced BMD. Patients with intestinal failure had higher FM (P = .02) and lower FFM (P = .02) compared with controls.

CONCLUSIONS

These data show that, despite reference range z-scores for height and weight, children with intestinal failure are at risk for abnormal body composition. Body composition should be routinely measured in children with intestinal failure to direct nutrition interventions.

Usefulness of blood flow evaluation with indocyanine green fluorescence imaging during laparoscopic surgery for strangulated bowel obstruction: A cohort study

INTRODUCTION

Intestinal blood flow evaluation during strangulated bowel obstruction is often based on the subjective assessment of the operator. Therefore, we aimed to comprehensively determine the presence or absence of intestinal blood flow based on normal light and indocyanine green (ICG) fluorescence imaging. Moreover, we ascertained whether the chosen surgical plan was appropriate, based on the patients' postoperative course and pathological findings.

METHODS

All 14 patients diagnosed with strangulated bowel obstruction at our hospital who underwent laparoscopic surgery between July 2019 and January 2021 were enrolled. Surgical plans were chosen based on normal light imaging combined with near-infrared imaging after intravenous ICG injection. Intestinal resection was performed via a small laparotomy if resection was considered necessary. In the intestinal resection group, the presence of intestinal necrosis was examined based on the pathological findings of the resected specimens. In the intestinal preservation group, postoperative complications, such as delayed intestinal perforation and intestinal stricture, were examined.

RESULTS

Intestinal resection was performed in 4 cases. The pathological findings of the resected specimens showed necrosis of the small intestine in all cases. No intra-abdominal complication occurred any of the cases, and the median postoperative hospital stay was 9.9 days.

CONCLUSIONS

The selection of a surgical plan in conjunction with ICG fluorescence findings was valid in all 14 cases. ICG fluorescence imaging is useful in laparoscopic surgery for strangulated bowel obstruction and may be a novel method for evaluating intestinal blood flow during surgery.

Characterization of American teduglutide consumers from 2015 to 2020: A large database study

INTRODUCTION

Teduglutide, a glucagon-like peptide-2 analog, is a novel therapy for intestinal failure that reduces need for parenteral support, especially in patients without a functional terminal ileum or colon. It can also predispose patients to accelerated progression of gastrointestinal (GI) malignancy and fluid overload. We demographically and clinically characterized American patients prescribed teduglutide.

METHODS

The Explorys database is an aggregate of deidentified patient data from dozens of US healthcare systems. We used SNOMED classification to identify patients prescribed teduglutide from 2015 to 2019. Through the browse cohort feature we determined the demographics, postsurgical anatomy, comorbidities, and indication for teduglutide use among these patients.

RESULTS

Of approximately 72 million patients, 170 were prescribed teduglutide. A large majority were female (70.6%). Most common etiologies of short-bowel syndrome were intestinal obstruction (52.9%) and Crohn's disease (41.2%). Common postsurgical anatomy included total colectomy (41.2%) and ileostomy. Common incident symptoms included abdominal pain (41.2%) and nausea (23.5%). Thirty (17.6%) patients were prescribed teduglutide despite comorbid heart failure, and 5.9% despite prior GI malignancy. A total of 11.8% of patients had a history of benign GI neoplasms before starting teduglutide. A total of 5.9% of patients had posttreatment formation of colon polyps.

CONCLUSION

In a large American database, the teduglutide prescription is rare. Only a minority have postsurgical anatomy associated with the most robust response to teduglutide. Serious adverse events appear rare, but a substantial number of patients are at risk for adverse effects because of the presence of comorbid heart failure or GI neoplasm.

Changes of Drug Pharmacokinetics in Patients with Short Bowel Syndrome: A Systematic Review

BACKGROUND AND OBJECTIVES

Short bowel syndrome is a clinical condition defined by malabsorption of nutrients and micronutrients, most commonly following extensive intestinal resection. Due to a loss of absorptive surfaces, the absorption of orally administered drugs is also often affected. The purpose of this study was to systematically review the published literature and examine the effects of short bowel syndrome on drug pharmacokinetics and clinical outcomes.

METHODS

Studies were identified through searches of databases MEDLINE, EMBASE, Web of Science, and SCOPUS, in addition to hand searches of studies' reference lists. Two reviewers independently assessed studies for inclusion, yielding 50 studies involving 37 different drugs in patients with short bowel syndrome.

RESULTS

Evidence of decreased drug absorption was observed in 29 out of 37 drugs, 6 of which lost therapeutic effect, and 14 of which continued to demonstrate clinical benefit through drug monitoring.

CONCLUSIONS

The influence of short bowel syndrome on drug absorption appears to be drug-specific and dependent on the location and extent of resection. The presence of a colon in continuity may also influence drug bioavailability as it can contribute significantly to the absorption of drugs (e.g., metoprolol); likewise, drugs that have a wide absorption window or are known to be absorbed in the colon are least likely to be malabsorbed. Individualized dosing may be necessary to achieve therapeutic efficacy, and therapeutic drug monitoring, where available, should be considered in short bowel syndrome patients, especially for drugs with narrow therapeutic indices.

Intestinal Failure: Epidemiology, Catheter-Related Sepsis and Challenges

Background

The Leicestershire intestinal failure team (LIFT) service provides specialist intestinal failure care to patients in Leicestershire and surrounding counties.

Aims

To study the epidemiology of intestinal failure (IF) cases referred to the service and review outcomes particularly the indications and delivery of parenteral nutrition (PN). To review catheter-related sepsis (CRS) rates and identify areas for improvement.

Methods

Service data from January 2016 to November 2017 was analysed retrospectively. Descriptive and inferential statistical analysis was carried out. Chi-square/Fisher Exact tests were used to identify significance on categorical data and non-parametric settling was used for qualitative data analysis.

Results

A total of 365 patients were referred to the service from January 2016 to November 2017. 58% patients had grade I intestinal failure. 34% and 24% referrals were made by the colorectal and hepato-pancreato-biliary (HPB) units, respectively. Gut rest (27%) and small bowel obstruction (25%) were the most common indications for nutritional support. Duration of PN requirements varied greatly, but most patients (39%) required it for up to seven days. Single lumen PICC line (64%) and cephalic vein (54%) were the most commonly used catheter and site of vascular access, respectively. Chronicity of IF and number of vascular catheters required to provide PN were significantly associated with rates of CRS.

Conclusion

CRS was found to be statistically significantly associated with chronic IF and number of vascular access catheters required to provide PN. Cost implication and morbidity of CRS could be analysed further to identify other ways to provide safer and cost-efficient parental nutrition for patients with intestinal failure.

Expression, purification and molecular dynamics simulation of extracellular domain of glucagon-like peptide-2 receptor linked to teduglutide

Teduglutide is the only drug approved for long-term treatment of short bowel syndrome (SBS). This drug exerts its pharmacological effects via binding to the GLP-2 receptors (ECD-GLP2R) located in intestinal tissue. The three dimensional (3D) structure of ECD-GLP2R hasn't been determined yet and hence its mode of interaction with agonists/antagonists is not clear. Therefore, it would be of great importance to develop a structural scaffold for investigation of ECD-GLP2R interactions with its binders. For this, the current study aimed to produce fusion protein of ECD-GLP2R-teduglutide. The ECD-GLP2R-teduglutide protein was expressed in bacterial expression system and purified using affinity and size exclusion chromatography techniques. Using circular dichroism the secondary structure content of purified protein was determined which was comparable to that of theoretical calculations. The low structural stability of purified protein (ΔG = 3.64 kJ.mol^-1) was elucidated by monitoring its fluorescence emission at the presence of various concentrations of GdnHCl as a denaturant. Finally, a 3D model for ECD-GLP2R-teduglutide protein was generated and validated using molecular dynamics simulation whose information alongside the experimental studies can be useful for providing new insight into the mode of interaction of ECD-GLP2R with its specific ligands in order to design potent and specific GLP2R agonists.

Designing Novel Teduglutide Analogues with Improved Binding Affinity: An In Silico Peptide Engineering Approach

INTRODUCTION

Short bowel syndrome (SBS) is a disabling condition that occurs following the loss of substantial portions of the intestine, leading to inadequate absorption of nutrients and fluids. Teduglutide is the only drug that has been FDA-approved for long-term treatment of SBS. This medicine exerts its biological effects through binding to the GLP-2 receptor.

METHODS

The current study aimed to use computational mutagenesis approaches to design novel potent analogues of teduglutide. To this end, the constructed teduglutide-GLP2R 3D model was subjected to the alanine scanning mutagenesis where ARG²⁰, PHE²², ILE²³, LEU²⁶, ILE²⁷ and LYS³⁰ were identified as the key amino acids involved in ligand-receptor interaction. In order to design potent teduglutide analogues, using MAESTROweb machine learning method, the residues of teduglutide were virtually mutated into all naturally occurring amino acids and the affinity improving mutations were selected for further analysis using PDBePISA methodology which interactively investigates the interactions established at the interfaces of macromolecules.

RESULTS

The calculations resulted in D15I, D15L, D15M and N24M mutations, which can improve the binding ability of the ligand to the receptor. The final evaluation of identified mutations was performed by molecular dynamics simulations, indicating that D15I and D15M are the most reliable mutations to increase teduglutide affinity towards its receptor.

CONCLUSION

The findings in the current study may facilitate designing more potent teduglutide analogues leading to the development of novel treatments in short bowel syndrome.

Proteomic biomarkers in short bowel syndrome : are we ready to use them in clinical activity?

Introduction: Short bowel syndrome (SBS) is a clinical condition that can affect childhood and adult patients. Biomarker research is expected to be a new frontier in the clinical application, helpful for patients and health-care systems.Areas covered: SBS is usually a consequence of a massive intestinal resection that leads to an intestinal failure because of the reduction of absorptive surface, bacterial overgrowth, and faster intestinal transit. This new condition requires a multidisciplinary expertise to achieve again digestive autonomy. Parental nutrition (PN) supports nutritional status in SBS patients while the new guidelines on intestinal transplantation confirm its strict indication only for patients at actual risk of death on PN. A PubMed literature review from the 1980s up to date was performed, highlighting proteomic biomarkers and growth factor therapies that have shown so far promising results in SBS patients.Expert opinion: Apart from a few specific biomarkers and growth factors, the discovery of specific molecular events is currently under investigation of the proteomic analysis and could potentially represent fundamental, future changes in prevention, diagnosis, therapeutic management, and experimental practices in SBS.

GLP-1 and Intestinal Diseases

Accumulating evidence implicates glucagon-like peptide-1 (GLP-1) to have, beyond glucose maintenance, a beneficial role in the gastrointestinal tract. Here, we review emerging data investigating GLP-1 as a novel treatment for intestinal diseases, including inflammatory bowel diseases, short-bowel syndrome, intestinal toxicities and coeliac disease. Possible beneficial mechanisms for these diseases include GLP-1′s influence on gastric emptying, its anti-inflammatory properties and its intestinotrophic effect. The current knowledge basis derives from the available GLP-1 agonist treatments in experimental animals and small clinical trials. However, new novel strategies including dual GLP-1/GLP-2 agonists are also in development for the treatment of intestinal diseases.

Endoscopy in Patients With Surgically Altered Anatomy

A comprehensive understanding of gastrointestinal anatomy is essential for performance of any endoscopic procedure. Surgical approaches to therapy have become increasingly common in the past decade, which has resulted in a substantial proportion of patients with surgically altered anatomy who require endoscopy. In parallel with the obesity epidemic, bariatric surgery for obesity management has been widely adopted. In response to these trends, gastroenterologists must become familiar with patient anatomy after these surgical interventions and understand the implications of this altered anatomy on the current array of available endoscopic modalities for diagnosis and therapy. This review describes the range of surgically altered anatomy commonly encountered in the upper gastrointestinal tract. For each foregut location-esophagus, stomach, and small bowel-we describe indications for and specific details of the range of common surgical approaches affecting this regional anatomy. We then provide an endoscopic roadmap through the altered anatomy resulting from these surgical interventions. Finally, we address the impact of postsurgical anatomy on performance of endoscopic ultrasound and endoscopic retrograde cholangiopancreatography, with guidance surrounding how to successfully execute these procedures. Evolution of endoscopic approaches over time might be expected to enhance the safety and efficacy of these interventions in patients with surgically altered anatomy.

Predictors and timing of response to teduglutide in patients with short bowel syndrome dependent on parenteral support

BACKGROUND AND AIMS

This study aimed to identify predictors and estimate time to teduglutide response among adult patients with short bowel syndrome with intestinal failure (SBS-IF) dependent on parenteral support (PS).

METHODS

Post-hoc analysis was performed on individual patient data from teduglutide-treated patients in the phase III teduglutide trial STEPS and the STEPS-2 extension. Response was defined as ≥20% PS volume reduction from baseline for two consecutive visits. Early responders experienced the reduction at 20 and 24 weeks during STEPS while late responders experienced the reduction during STEPS-2. Timing and predictors for response were assessed among the treated population using Cox proportional hazard model. Time to response was compared in aetiological subgroups using Kaplan-Meier analysis. Patient characteristics and time to response were compared between early vs. late responders.

RESULTS

A total of 34 patients were included in this analysis; overall median time to response was 4.3 months. The presence of stoma predicted a positive response to teduglutide (hazard ratio [HR]: 5.6; 95% confidence interval [CI]: 1.4-21.9; p = 0.013). Vascular disease (vs. inflammatory bowel disease [IBD]) as cause of major intestinal resection (HR: 0.2; 95% CI: 0.0-0.8; p = 0.015), presence of ileocecal valve (HR: 0.1; 95% CI: 0.0-0.8; p = 0.047), and female sex (HR: 0.3; 95% CI: 0.1-1.0; p = 0.026) are negatively associated with response. In subgroup analyses, patients with IBD (vs. vascular disease), with (vs. without) a stoma, and without (vs. with) colon-in-continuity had a shorter time to response (all p < 0.05). The mean times to response were 3.6 (standard deviation (SD): 1.1) months for early responders (n = 27) and 10.0 (SD: 6.1) months for late responders (n = 7). Fewer early responders had colon-in-continuity (51.9%) and ileocecal valve (0.0%) compared to late responders (100% and 28.6%, respectively; both p < 0.05). Early responders had a lower mean percentage of colon remaining compared to late responders (24.6% vs. 57.1%, respectively; p = 0.016).

CONCLUSIONS

Time to response to teduglutide depends on bowel anatomy and SBS-IF aetiology. IBD, presence of a stoma, and absence of ileocecal valve were associated with earlier response to teduglutide. These findings may enhance management of patients with SBS-IF; however, due to sample size limitations, additional studies are needed to confirm these findings.

Short bowel syndrome: treatment options

Introduction Short bowel syndrome (SBS) refers to the malabsorptive state that occurs following extensive intestinal resection and is associated with several complications.

Methods The research for this review was conducted in the Pubmed database. Relevant scientific articles dated between 1991 and 2015 and written in Portuguese, Spanish or English were selected.

Results Several therapies, including nutritional support, pharmacological options and surgical procedures have been used in these patients.

Conclusions Over the last decades new surgical and pharmacological approaches emerged, increasing survival and quality of life (QoL) in patients with SBS. All SBS patients ought to have an individualized and multidisciplinary care that promotes intestinal rehabilitation.

Preoperative Planning of Spiral Intestinal Lengthening and Tailoring: A Geometrical Approach

Short bowel syndrome is a pathological condition resulting from extensive resection of the intestine, generally performed due to congenital abnormalities, Crohn’s disease, mesenteric ischemia, or neoplasms. The main consequence of this syndrome is a reduction of intestinal absorption, which causes malnutrition and dehydration. In the most severe cases, specific and complex surgical procedures are requested to manage the syndrome. Such procedures consist of the intestinal lengthening, with lead to an increase of absorptive mucosal surface and intestinal transit time and an overall enhancement of intestinal absorption. One of the most promising surgical procedures is spiral intestinal lengthening and tailoring, which consists of a spiral incision of the intestinal wall and in the elongation longitudinally of the intestine by sliding one flap over the other. The final intestinal lengthening is strictly dependent on a series of parameters, some of which are defined by the surgeon. The present paper proposes a mathematical model, based on patient specific anatomical data, which aims to help the surgeon in defining the optimal parameters for the intervention and in foreseeing its outcomes from the preoperative planning phase. Such a tool can assist the physician in the surgery room by improving the procedure and reducing surgical times.

[Resected bowel syndrome: clinical course and treatment options]

The current concepts of the short bowel syndrome and malabsorption after intestinal surgery are generally accepted, but do not fully reflect the patients condition, making it difficult to diagnose and treat it.

AIM

The purpose of the study is to analyze the clinical course of the patients after bowel resection, to create a classification based on the variants identified to allow for a differentiated treatment and to introduce the concept of the resected bowel syndrome.

MATERIALS AND METHODS

We observed 239 patients (96 men and 143 women) aged 18 to 80 who underwent intestinal resection for 1 month to 16 years (from 2002 to 2018). The 1st group included 96 patients with small bowel resection (40 men and 56 women). The 2nd group included 39 men and 58 women with small bowel resection, including the resection of the ileocecal valve and the right-hand side of the colon (n=97). The 3rd group included 17 men and 29 women with the resection of the right-hand side of the colon or colectomy (n=46). The survey included the NRS-2002 (Nutritional Risk Screening 2002) screening test to identify nutritional risk, a clinical assessment of the symptoms that occurred after the surgery, instrumental methods (esophagogastroduodenoscopy, colonoscopy with biopsy, ultrasound of the abdominal cavity organs and the kidneys, a plain radiography of the abdominal cavity organs, an X-ray examination of the small intestine and the intestinal passage), serum citrulline and short-chain fatty acids in faeces.

RESULTS

Based on the analysis of the clinical symptoms and the nutritional status of the patients, a new concept is proposed the resected bowel syndrome with two variants of its progression: either with or without the development of nutritional insufficiency of three types: the dehydration type, the protein-energy insufficiency type and a mixed type. Type 1 requires the use of antimicrobials with the control of SCFA concentrations in faeces. Type 2 requires the introduction of an optimal amount of easily digestible protein to correct protein-energy deficit. The 3rd (most severe) mixed type requires prescription of a parenteral nutrition component with the control of citrulline concentration in the blood serum.

CONCLUSION

The proposed concept the resected bowel syndrome makes it possible to improve its diagnosis, take into account the variants of its progression and allow for a differentiated treatment.

Predictors for short bowel syndrome in Crohn's disease

BACKGROUND AND AIM

Patients with Crohn's disease (CD) are at risk for short bowel syndrome (SBS). We investigated independent predictors for SBS in these patients to allow the development of preventive strategies.

METHODS

All adult patients seen at the Nancy University hospital for CD or SBS between 2012 and 2019 were eligible for inclusion in this case-control study. Each CD patient with SBS was matched to 9 controls.

RESULTS

410 CD patients were included (369 without SBS and 41 with SBS). Subjects with SBS underwent significantly more bowel resections (median value of 3 vs 1, p<0.0001) and median time before the first surgery was not different than controls (6 vs 4 years, p=0.59). A higher need for parenteral support was found in end-jejunostomy SBS than in jejunocolic and jejunoileal SBS (70.6% vs 25% and 0%, p=0.0031). Montreal B1 behavior (OR 0.02, CI 95% 0-0.08) and budesonide treated-patients (OR=0.03, CI 95% 0.003-0.2) were at lower risk of SBS, while IV steroid treated-patients were at higher risk (OR=8.5, CI 95% 3.0-24.9).

CONCLUSION

Montreal B1 behavior, IV steroids and budesonide use are influencing predictors for this complication. These predictors should be assessed in daily clinical practice to prevent SBS occurrence.

Kocuria kristinae infection associated with short bowel syndrome: A case report

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Only a few cases of K. kristinae infection have been reported in the literature.

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Patients with short bowel syndrome (SBS) have a risk of opportunistic infections.

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We report a rare case of K. kristinae infection associated with SBS.

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Patients with SBS require careful follow-up for opportunistic infections such as K. kristinae.

Introduction

Only a few cases of K. kristinae infection have been reported in the literature. Patients with short bowel syndrome have an increased risk of opportunistic infections due to decreased bowel immunity and the long-term central venous catheter placement. We report a rare case of K. kristinae infection associated with SBS requiring long-term central venous access port placement.

Presentation of case

A 70-year-old woman presented with fever of approximately 39 °C to our hospital for examination. She has undergone total hysterectomy and radiation therapy for cervical cancer 36 years ago. Five years ago, she developed multiple small bowel perforations, and a jejunostomy was constructed at the oral end of the perforation and approximately 110 cm from the ligament of Treitz because of the difficulty in dissecting the adhesion. She developed short bowel syndrome, and the central venous port was constructed four years ago due to poor enteral nutrition.

K. kristinae was detected in the central venous catheter tip and in two blood cultures. We administered intravenous vancomycin. After seven days of antibiotic treatment, both fever and inflammatory reaction improved, and the blood culture was negative. After 16 days of antibiotic treatment, we performed central venous port construction on the side opposite to the previous site.

Conclusion

Patients with short bowel syndrome have an increased risk of K. kristinae infections due to decreased bowel immunity and the long-term central venous port, and therefore, these patients should be followed up carefully.

Short Bowel Syndrome and Kidney Transplantation: Challenges, Outcomes, and the Use of Teduglutide

Among patients with short bowel syndrome who commonly have kidney disease, kidney transplantation remains challenging. We describe the clinicopathologic course of a 59-year old man with short bowel syndrome secondary to Crohn's disease who underwent a deceased donor kidney transplant that was complicated by recurrent acute kidney allograft injury due to volume depletion from diarrhea, ultimately requiring the placement of permanent intravenous access for daily volume expansion at home resulting in the recovery of allograft function. Teduglutide treatment at 1.8 years post-transplant led to a dramatic decrease in diarrhea. A literature review of similar cases yielded 18 patients who underwent 19 kidney transplants. Despite high rates of complications, at the time of last follow-up (median 2.1 years [0.04-7]), 94% of the patients were still alive and 89% had functioning allografts, with a median eGFR of 37.5 [14-122] ml/min/1.73m². In conclusion, despite high rates of complications, kidney transplantation in patients with short bowel syndrome is associated with acceptable short- and midterm outcomes. Further, we report for the first time the effects of the glucagon-like peptide-2 analogue teduglutide for short bowel syndrome in a kidney transplant recipient.

Scheduled Empiric Antibiotics May Alter the Gut Microbiome and Nutrition Outcomes in Pediatric Intestinal Failure

BACKGROUND

In this study, we aim to determine the effect of scheduled antibiotics on gut microbiome in pediatric intestinal failure (IF) and to evaluate the effect of the gut microbiome on nutrition outcomes in IF.

METHODS

Fecal samples were collected at regular intervals from pediatric patients with IF for gut microbiome comparison between 2 cohorts: (group 1) those on scheduled prophylactic antibiotics and (group 2) those who were not on scheduled antibiotics. Gut microbiome composition and diversity were compared among the 2 cohorts. The association among gut microbiome composition, diversity, and nutrition outcomes (mainly ability to decrease parenteral nutrition [PN] energy requirement and ability to attain positive growth) was also determined.

RESULTS

The microbiome of patients with IF on scheduled antibiotics differed significantly from those not on scheduled antibiotics. Abundance of certain Gram-negative and pathogenic bacteria (Pseudomonas, Prevotella, and Sutterella) was higher in the scheduled cohort. Patients with decreased Enterobacteriaceae demonstrated a greater ability to demonstrate a reduction in PN requirement, as well as attain positive growth.

CONCLUSION

Scheduled antibiotics may alter the gut microbiome in children IF, which in turn may have an influence on important nutrition outcomes in pediatric IF. Further larger, multicenter studies are needed to determine the effect of scheduled antibiotics on the gut microbiome in this patient population and their overall effect on nutrition outcomes.

Engineering transplantable jejunal mucosal grafts using patient-derived organoids from children with intestinal failure

Intestinal failure, following extensive anatomical or functional loss of small intestine, has debilitating long-term consequences for children1. The priority of patient care is to increase the length of functional intestine, particularly the jejunum, to promote nutritional independence2. Here we construct autologous jejunal mucosal grafts using biomaterials from pediatric patients and show that patient-derived organoids can be expanded efficiently in vitro. In parallel, we generate decellularized human intestinal matrix with intact nanotopography, which forms biological scaffolds. Proteomic and Raman spectroscopy analyses reveal highly analogous biochemical profiles of human small intestine and colon scaffolds, indicating that they can be used interchangeably as platforms for intestinal engineering. Indeed, seeding of jejunal organoids onto either type of scaffold reliably reconstructs grafts that exhibit several aspects of physiological jejunal function and that survive to form luminal structures after transplantation into the kidney capsule or subcutaneous pockets of mice for up to 2 weeks. Our findings provide proof-of-concept data for engineering patient-specific jejunal grafts for children with intestinal failure, ultimately aiding in the restoration of nutritional autonomy.

Long-term outcome of patients with Crohn's disease on home parenteral nutrition

OBJECTIVES

In patients with Crohn's disease (CD) and intestinal failure, home parenteral nutrition (HPN) is a necessary lifesaving treatment. The aim of this study was to investigate the long-term outcomes of patients with CD after initiation of HPN.

METHODS

This study included patients with CD receiving HPN for intestinal failure. The patients were treated at Osaka University Hospital between January 2000 and December 2019. Patients' demographic characteristics, HPN dependence and complications, and mortality were analyzed. HPN dependence was estimated using the Kaplan-Meier method. Cox regression analysis was used for between-group comparisons.

RESULTS

Twenty-one patients with CD received HPN. HPN dependence rates were 85%, 75%, 75%, and 64%, respectively, at 2, 5, 10, and 15 y after HPN initiation. Patients who weaned off HPN exhibited lower rates of immunomodulator therapy and additional intensive CD treatment (P < 0.05). Multivariate analysis revealed that not requiring additional intensive CD treatment was a significant factor in weaning off HPN. Two patients (9%) died, at a median of 14.9 y after HPN initiation, due to HPN-related liver disease and CD-associated carcinoma. Among all patients, 61% experienced catheter-related bloodstream infections (CRBSIs), with an incidence of 0.32/1000 catheter-days. Methicillin-resistant bacteria and Candida spp. each accounted for 27% of all pathogens detected in CRBSI.

CONCLUSIONS

Patients with CD receiving HPN had a good prognosis, despite frequent CRBSIs in which methicillin-resistant bacteria and fungi were common pathogens. Some patients with CD can wean off HPN, even after a long period of HPN treatment. A stable disease condition during HPN might be an important factor for weaning off HPN.

Quantitative Evaluation of D-Lactate Pathophysiology: New Insights into the Mechanisms Involved and the Many Areas in Need of Further Investigation

In contrast to L-lactate, D-lactate is produced in minimal quantities by human cells, and the plasma D-lactate concentration normally is maintained at a concentration of only about 0.01 mM. However, in short bowel syndrome, colonic bacterial production of D-lactate may lead to plasma concentrations >3mM with accompanying acidosis and neurological symptoms - a syndrome known as D-lactic acidosis. Minor increases in plasma D-lactate have been observed in various gastrointestinal conditions such as ischemia, appendicitis and Crohn's disease, a finding touted to have diagnostic utility. The novel aspect of this review paper is the application of numerical values to the processes involved in D-lactate homeostasis that previously have been described only in qualitative terms. This approach provides a number of new insights into normal and disordered production, catabolism and excretion of D-lactate, and identifies multiple gaps in our understanding of D-lactate physiology that should be amenable to relatively simple investigative study.

R-Spondin 1 (RSPO1) Increases Mouse Intestinal Organoid Unit Size and Survival in vitro and Improves Tissue-Engineered Small Intestine Formation in vivo

Introduction: Cell therapy and tissue engineering has recently emerged as a new option for short bowel syndrome (SBS) treatment, generating tissue engineered small intestine (TESI) from organoid units (OU) and biodegradable scaffolds. The recombinant human R-Spondin 1 (rhRSPO1) protein may be a key player in this process due to its mitogenic activity in intestinal stem cells.

Objective: Aiming at optimizing the TESI formation process and advancing this technology closer to the clinic, we evaluated the effects of rhRSPO1 protein on OU culture and TESI formation.

Methods: Intestinal OU were isolated from C57BL/6 mice and cultured in Matrigel in the presence or absence of recombinant human rhRSPO1. Throughout the culture, OU growth and survival rates were evaluated, and cells were harvested on day 3. OU were seeded onto biodegradable scaffolds, in the presence or absence of 5 μg of rhRSPO1 and implanted into the omentum of NOD/SCID mice in order to generate TESI. The explants were harvested after 30 days, weighed, fixed in formalin and embedded in paraffin for histological analysis and immunofluorescence for different cell markers.

Results: After 3 days, rhRSPO1-treated OU attained a larger size, when compared to the control group, becoming 5.7 times larger on day 6. Increased survival was observed from the second day in culture, with a 2-fold increase in OU survival between days 3 and 6. A 4.8-fold increase of non-phosphorylated β-catenin and increased relative expression of Lgr5 mRNA in the rhRSPO1-treated group confirms activation of the canonical Wnt pathway and suggests maintenance of the OU stem cell niche and associated stemness. After 30 days of in vivo maturation, rhRSPO1-treated TESI presented a larger mass than constructs treated with saline, developing a more mature intestinal epithelium with well-formed villi and crypts. In addition, the efficiency of OU-loaded rhRSPO1-treated scaffolds significantly increased, forming TESI in 100% of the samples (N = 8), of which 40% presented maximum degree of development, as compared to 66.6% in the control group (N = 9).

Conclusion: rhRSPO1 treatment improves the culture of mouse intestinal OU, increasing its size and survival in vitro, and TESI formation in vivo, increasing its mass, degree of development and engraftment.

[Clinicopathologic features and postoperative outcome of the radiation-induced enteritis: a retrospective study of 41 patients]

INTRODUCTION

Surgery is required in patients with symptoms of chronic radiation-induced enteritis (CRE) resistant to medical therapy. The study aimed to correlate histopathologic features of CRE to the clinical presentation and the postoperative recurrence.

MATERIAL AND METHOD

All patients with small bowel resection performed for CRE between 2006 and 2017 were studied. Histological data were retrospectively correlated to initial clinical data and to postoperative recurrence of CRE (occlusion, need for parenteral nutrition) observed during a median follow-up of 32 months.

RESULTS

Forty-one patients were studied (39 women and 2 men, median age 62 yo at time of radiation for pelvic cancer, 80% gynecologic). Median time to surgery after radiation was 3 years. Ileocaecal resections (80% of patients) removed 60cm (median length). Histologically, a diffuse obliterative arteriopathy was present in 24 (59%) patients, highly associated to amyotrophy, villous atrophy and ulceration observed in 66, 63 and 34% of patients respectively (P<.05). Diffuse arteriopathy was uncorrelated with patient's age and vascular risk factor (tobacco, diabetes, hypertension, dyslipidemia). Median time to surgery after radiation was longer in patients presenting with obliterative arteriopathy (13 years vs. 2.6 years, P=0.0002). During follow-up, half of the patients had a recurrence of CRE, uncorrelated to the arteriopathy.

CONCLUSION

Radiation-induced enteritis requiring late surgery after radiation presented histologically with a diffuse obliterative arteriopathy and ischemic features. In our center, half of the patients were cured by surgery. The arterial injury was not a risk factor for postoperative recurrence.

Prevalence of Bloodstream Infections in Children With Short-Bowel Syndrome With a Central Line Presenting to Emergency Department With Fever

BACKGROUND

Children with short-bowel syndrome (SBS) have significant morbidity and mortality from bloodstream infections (BSIs). We studied the prevalence of BSI in children with SBS and identified possible predictors of BSI.

METHODS

This retrospective cohort study included patients with SBS who presented to Holtz Children's Hospital from April 1, 2009, to June 30, 2014, with fever or reported fever. Data including vital signs, white blood cell (WBC) count, C-reactive protein (CRP) levels, and blood and urine cultures were reviewed. We calculated the prevalence of BSI and its confidence level. We also assessed the odds of BSI with increases in WBC and CRP values.

RESULTS

A total of 246 encounters were evaluated. The adjusted calculated prevalence rate for BSI in children with SBS and fever was 55% (95% CI, 42.3%-65.4%). There were 114 gram-negative infections (72.6%), 46 gram-positive infections (29.3%), and 17 fungal infections (10.8%). Using the regression model, each additional 10 units above 20 mg/L CRP increased the odds of BSI by 26%. There was no association between WBC count and the presence of BSI.

CONCLUSION

Children with fever and SBS are at high risk for BSI with gram-positive and gram-negative organisms as well as fungus. WBC count at presentation is a poor predictor of BSI. Though elevated CRP increased the odds of BSI, its low negative predictive value made it a poor predictor of BSI in these patients. Children with SBS and fever should be treated urgently with broad-spectrum antibiotics.

Micronutrients in paediatric Intestinal Failure Patients receiving home parenteral nutrition

BACKGROUND & AIMS

Children with intestinal failure (IF) receive parental nutrition to ensure adequate growth and development. The aim of this study was to assess micronutrient status in paediatric IF patients receiving home parenteral nutrition (HPN) in comparison to a group of healthy children.

METHODS

An observational cross-sectional study was performed at Oslo University Hospital and at the Department of Nutrition, University of Oslo from January to September 2017. All children with IF, aged two to 18 years, were invited to participate. A reference group of healthy children was recruited through social media advertisement. Dietary intake was assessed by a four-day food record, and enteral and parenteral provision was recorded. Blood samples were analysed for vitamins, minerals and haematology to assess iron status. Two spot urine samples from each subject were analysed for iodine concentration (UIC) and creatinine.

RESULTS

Nineteen children with IF and 50 healthy children were included. The mean age of the participants was 10.0 years. IF-patients received a median of 76% of their estimated energy requirements from parenteral nutrition (PN). Recommended intake (RI) for iodine from the diet was reached by 16% of IF patients and 28% of healthy children. In the IF group there was a significant positive correlation between UIC and the percentage of iodine intake from oral diet and enteral nutrition support (r = 0.57, p = 0.03). Although the IF patients had a median parenteral iodine supply of more than twice the ESPGHAN recommendation, the median UIC was 89 μg/L indicating insufficient iodine status. This may suggest that the ESPGHAN recommendation for iodine in paediatric parenteral nutrition is too low. The healthy children had sufficient iodine status according to the median UIC (133 μg/L). IF patients had significantly lower total provision of iron compared to the healthy children, 4,9 vs 8,4 mg/day (p = 0.01) with 21% of IF patients and 28% of healthy children reaching RI for iron. The prevalence of anaemia was higher in IF patients than in the healthy children (40 vs.10%, p = 0.016).

CONCLUSION

The study indicates an insufficient iodine and iron status among paediatric IF patients. Iodine status was associated with enteral provision and patients had insufficient status even if they received the ESPGHAN recommendation of iodine.

TRIAL IDENTIFICATION NUMBER

Clinical Trials AEV2017/1. 2016/391/REK sør-øst B.

Management of Five Hundred Patients With Gut Failure at a Single Center: Surgical Innovation Versus Transplantation With a Novel Predictive Model

OBJECTIVE(S)

To define the evolving role of integrative surgical management including transplantation for patients gut failure (GF).

METHODS

A total of 500 patients with total parenteral nutrition-dependent catastrophic and chronic GF were referred for surgical intervention particularly transplantation and comprised the study population. With a mean age of 45 ± 17 years, 477 (95%) were adults and 23 (5%) were children. Management strategy was guided by clinical status, splanchnic organ functions, anatomy of residual gut, and cause of GF. Surgery was performed in 462 (92%) patients and 38 (8%) continued medical treatment. Definitive autologous gut reconstruction (AGR) was achievable in 378 (82%), primary transplant in 42 (9%), and AGR followed by transplant in 42 (9%). The 84 transplant recipients received 94 allografts; 67 (71%) liver-free and 27 (29%) liver-contained. The 420 AGR patients received a total of 790 reconstructive and remodeling procedures including primary reconstruction, interposition alimentary-conduits, intestinal/colonic lengthening, and reductive/decompressive surgery. Glucagon-like peptide-2 was used in 17 patients.

RESULTS

Overall patient survival was 86% at 1-year and 68% at 5-years with restored nutritional autonomy (RNA) in 63% and 78%, respectively. Surgery achieved a 5-year survival of 70% with 82% RNA. AGR achieved better long-term survival and transplantation better (P = 0.03) re-established nutritional autonomy. Both AGR and transplant were cost effective and quality of life better improved after AGR. A model to predict RNA after AGR was developed computing anatomy of reconstructed gut, total parenteral nutrition requirements, cause of GF, and serum bilirubin.

CONCLUSIONS

Surgical integration is an effective management strategy for GF. Further progress is foreseen with the herein-described novel techniques and established RNA predictive model.

Understanding short bowel syndrome: Current status and future perspectives

Short bowel syndrome (SBS) is a rare malabsorptive disorder as a result of the loss of bowel mass mostly secondary to surgical resection of the small intestine. Other causes are vascular diseases, neoplasms or inflammatory bowel disease. The spectrum of the disease is widely variable from single micronutrient malabsorption to complete intestinal failure, depending on the remaining length of the small intestine, the anatomical portion of intestine and the function of the remnant bowel. Over the last years, the management of affected patients has remarkably improved with the increase in patients' quality of life and survival, mainly thanks to advances in home-based parenteral nutrition (PN). In the last ten years new treatment strategies have become available together with increasing experience and the encouraging results with new drugs, such as teduglutide, have added a new dimension to the management of SBS. This review aims to summarize the knowledge available in the current literature on SBS epidemiology, pathophysiology, and its surgical (including intestinal lengthening procedures and intestinal transplantation) and medical management with emphasis on the recent advances. Moreover, this review attempts to provide the new understanding and recent approaches to SBS complications such as sepsis, catheter thrombosis, and intestinal failure-associated liver disease.

Nutritional Feeding Strategies in Pediatric Intestinal Failure

Intestinal failure is defined as a critical reduction of the gut mass or function, below the minimum needed to absorb nutrients and fluids. The ultimate goal in intestinal failure is to promote bowel adaptation and reach enteral autonomy while a healthy growth and development is maintained. The condition is heterogeneous and complex. Therefore, recommendations for the type and duration of parenteral, enteral, and oral nutrition are variable, with the child's age as an additional key factor. The aim of this review is to provide an overview of nutritional feeding strategies in this heterogeneous population. Different perspectives on nutritional management, nutrition and adaptation, and microbiome and nutrition will be discussed.

Initial Evaluation and Care of the Patient with New-Onset Intestinal Failure

A total parenteral nutrition (TPN) formula needs to be correctly compounded with the help of a pharmacist and patients cycled to ensure they are tolerating the TPN volume. Selection of and close working relationship with a home infusion company needs to be arranged prior to hospital discharge and can be coordinated with the help of a hospital case manager. For Medicare patients, a certificate of medical necessity must be completed and signed prior to hospital discharge. Patients should undergo education regarding catheter care, infusion pump programming, and preparation of the TPN solution with additives, such as multivitamins and trace elements.

Weaning from Parenteral Nutrition

The ultimate goal of treatment of short bowel syndrome/intestinal failure patients is to achieve enteral autonomy by eliminating parenteral nutrition (PN)/intravenous fluids (IV). After optimization of diet, oral hydration and anti-diarrheal medications, attempt should be made to eliminate PN/IV. Weaning from PN/IV should be individualized for each patient. Although teduglutide is the preferred agent for PN/IV volume reduction or successful weaning, optimal patient selection and long-term safety need further evaluation. Following PN/IV elimination, patients need long-term monitoring for nutritional deficiencies. This article will address clinical considerations before, during, and after PN/IV weaning to facilitate safe and successful PN/IV weaning process.

Generating an Artificial Intestine for the Treatment of Short Bowel Syndrome

Intestinal failure is defined as the inability to maintain fluid, nutrition, energy, and micronutrient balance that leads to the inability to gain or maintain weight, resulting in malnutrition and dehydration. Causes of intestinal failure include short bowel syndrome (ie, the physical loss of intestinal surface area and severe intestinal dysmotility). For patients with intestinal failure who fail to achieve enteral autonomy through intestinal rehabilitation programs, the current treatment options are expensive and associated with severe complications. Therefore, the need persists for next-generation therapies, including cell-based therapy, to increase intestinal regeneration, and development of the tissue-engineered small intestine.

Short Bowel Syndrome

Purpose of Review

Short gut syndrome is life-altering and life-threatening disease resulting most often from massive small bowel resection. Recent advances in understanding of the perturbed physiology in these patients have translated into improved care and outcomes. This paper seeks to review the advances of care in SBS patients.

Recent Findings

Anatomic considerations still predominate the early care of SBS patients, including aggressive preservation of bowel and documentation of remnant bowel length and quality. Intestinal adaptation is the process by which remnant bowel changes to fit the physiologic needs of the patient. Grossly, the bowel dilates and elongates to increase intestinal weight and protein content. Architectural changes are noted, such as villus lengthening and deepening of crypts. In addition, gene expression changes occur that function to maximize nutrient uptake and fluid preservation. Management is aimed at understanding these physiologic changes and augmenting them whenever possible in an effort to gain enteral autonomy. Complication mitigation is key, including avoidance of catheter complications, bloodstream infections, cholestasis, and nutrient deficiencies.

Summary

Multidisciplinary teams working together towards intestinal rehabilitation have shown improved outcomes. Today's practioner needs a current understanding of the ever-evolving care of these patients in order to promote enteral autonomy, recognize complications, and counsel patients and families appropriately.

A Systematic Review of Technical Parameters for MR of the Small Bowel in non-IBD Conditions over the Last Ten Years

Technical guidelines for magnetic resonance imaging (MRI) of the small bowel (SB) in the setting of inflammatory bowel diseases (IBDs) were detailed in a 2017 consensus issued by European Society of Gastrointestinal and Abdominal Radiology (ESGAR) and European Society of Pediatric Radiology (ESPR); however, MRI for non-IBD conditions was not addressed. Hence, we performed a systematic review collecting researches on SB MRI for non-IBDs. The literatures were then divided into morphologic group and functional group. Information about the MRI techniques, gastrointestinal preparation, and details of cine-MRI protocols was extracted. We found that a 1.5 T MRI system, prone positioning, and MR enterography were frequently utilized in clinical practice. Gadolinium contrast sequences were routinely implemented, while diffusion-weighted imaging (DWI) was much less performed. The gastrointestinal preparation varied throughout the studies. No uniform protocols for cine imaging could be established. SB MRI examinations for non-IBDs are far from standardized, especially for functional studies. Recommendations for standard parameters in cine-MRI sequences are difficult to make due to lack of evidentiary support. MRI investigations in non-IBD conditions are needed and the standardization of non-IBD imaging in clinical practice is required.

Readmissions related to short bowel syndrome: a study from a national database

While short bowel syndrome (SBS) is the leading cause of intestinal failure in children, little objective data are available regarding hospital readmissions for children with SBS. This study sought to investigate rehospitalizations related to SBS in young children. Data for study were obtained from the 2013 Nationwide Readmissions Database (NRD). Using data from the 2013 NRD, we identified a total of 1898 hospitalizations in children with SBS aged 1–4 years. A total of 901 index cases and 997 rehospitalizations were noted. Of these, 425 children (47.2%) underwent rehospitalizations. The most frequent diagnoses and procedures associated with readmission of children with SBS were related to infections and intravenous catheter placement. This is the first study to use US nationwide data to report on the incidence of readmissions in children with SBS. The results from this study indicate that improving central line care and providing home healthcare resources to families at discharge may help in preventing SBS-related rehospitalizations.

Inflammatory Bowel Disease and Short Bowel Syndrome

Short bowel syndrome / intestinal failure (SBS/IF) is a rare and debilitating disease process that mandates a multidisciplinary approach in its management. Inflammatory bowel disease (IBD), in particular Crohn's disease (CD), predisposes patients to development of SBS/IF. This review discusses SBS/IF from the perspective of IBD, with an emphasis on prevention and treatment in the setting of CD. The aims of this review are to emphasize the unique treatment goals of the newly diagnosed SBS/IF patient, and highlight the role of both medical and surgical therapies in the management of IBD-related SBS/IF, including intestinal transplantation.

Case Report: Transitioning to a Mixed-Oil Intravenous Lipid Emulsion in an Adult Patient Receiving Home Parenteral Nutrition

A potential risk of long-term parenteral nutrition (PN) is intestinal failure-associated liver disease (IFALD). One recommendation for mitigating risk is limiting the fat dose to reduce the harmful effects of the ω-6 fatty acids, which are the main ingredient in traditional fats. SMOFlipid (SMOF) (Kabi-Fresenius, Bad Homburg, Germany) is a combination of soybean oil, medium-chain triglycerides, olive oil, and fish oil emulsion. This fat source may alleviate the risk of IFALD and improve liver function tests. A patient with a long history of PN reliance and IFALD is presented in this case report. After 4 months on SMOF, total and direct bilirubin levels improved.

Cumulative Inflammation Could Be a Risk Factor for Intestinal Failure in Crohn's Disease

BACKGROUND

Intestinal failure is the most critical complication of Crohn's disease. Intestinal failure requires home parenteral nutrition, which worsens the quality of life of the patients and sometimes causes life-threatening complications.

AIMS

The purpose of this study was to investigate the incidence and risk factors for intestinal failure in Crohn's disease.

METHODS

We performed a retrospective analysis of Crohn's disease patients (162 cases) at Osaka University Hospital between January 2000 and December 2017. Kaplan-Meier analysis was used to investigate the cumulative incidence of intestinal failure. To identify the risk factors of intestinal failure, patient characteristics were analyzed by multivariate analysis, including disease classification, surgical history, medical treatment other than surgery, and cumulative inflammation was calculated using the average C-reactive protein value and disease duration.

RESULTS

The cumulative incidence of intestinal failure 5, 10, and 15 years after Crohn's disease diagnosis was 2.6%, 3.4%, and 8.6%, respectively. Multivariate analysis identified the following as independent risk factors for intestinal failure in Crohn's disease: residual small intestinal length < 200 cm (odds ratio 7.51, 95% confidence interval 2.14-29.96), non-use of anti-tumor necrosis factor-alpha therapy (3.34, 1.22-10.74), and cumulative inflammation (1.01, 1.001-1.038). We created a new predictive nomogram consisting of these risk factors.

CONCLUSIONS

Intestinal failure occasionally occurred during long-term treatment of Crohn's disease. Cumulative inflammation for the first time, in addition to short residual small intestinal length and non-use of anti-tumor necrosis factor-alpha therapy, was shown to be potential risk factors for intestinal failure in Crohn's disease.

Ileostomy for steroid-resistant acute graft-versus-host disease of the gastrointestinal tract

Steroid-resistant acute graft-versus-host disease (GVHD) of the gastrointestinal tract associates with important morbidity and mortality. While high-dose steroids are the established first-line therapy in GVHD, no second-line therapy is generally accepted. In this analysis of 65 consecutive patients with severe, steroid-resistant, intestinal GVHD (92% stage 4), additional ileostomy surgery significantly reduced overall mortality (hazard ratio 0.54; 95% confidence interval, 0.36-0.81; p = 0.003) compared to conventional GVHD therapy. Median overall survival was 16 months in the ileostomy cohort compared to 4 months in the conventional therapy cohort. In the ileostomy cohort, both infectious- and GVHD-associated mortality were reduced (40% versus 77%). Significantly declined fecal volumes (p = 0.001) after surgery provide evidence of intestinal adaptation following ileostomy. Correlative studies indicated ileostomy-induced immune-modulation with a > 50% decrease of activated T cells (p = 0.04) and an increase in regulatory T cells. The observed alterations of the patients' gut microbiota may also contribute to ileostomy's therapeutic effect. These data show that ileostomy induced significant clinical responses in patients with steroid-resistant GVHD along with a reduction of pro-inflammatory immune cells and changes of the intestinal microbiota. Ileostomy is a treatment option for steroid-resistant acute GVHD of the gastrointestinal tract that needs further validation in a prospective clinical trial.

Micronutrient Absorption and Related Outcomes in People with Inflammatory Bowel Disease: A Review

Inflammatory Bowel Disease (IBD) is a chronic disorder associated with immune dysregulation and chronic inflammation of the digestive tract. While it is poorly understood, the role of nutrition and nutrient status in the etiology of IBD and its associated outcomes has led to increased research relating to micronutrient deficiency. This review offers an overview of recent literature related to micronutrient absorption and outcomes in adults with IBD. Although the absorption and IBD-related outcomes of some micronutrients (e.g., vitamin D and iron) are well understood, other micronutrients (e.g., vitamin A) require further research. Increased research and clinician knowledge of the relationship between micronutrients and IBD may manifest in improved nutrient screening, monitoring, treatment, and outcomes for people living with IBD.