Energy absorption as a measure of intestinal failure in the short bowel syndrome

Personalized exercise intervention in HPN patients - A feasibility study

BACKGROUND

Physical health status may be predictive of readmissions, psychological health and mortality in patients with short bowel syndrome.

AIMS

This study aimed to investigate the feasibility and effect of an individualized exercise intervention and secondary, oral nutrition intake counseling on Timed-Up-and-Go (TUG) and 30 s Chair Stand Test (CST) as well as body-composition and EuroQol (EQ)-5D-5L, in patients with chronic intestinal failure (IF) type III receiving HPN and/or fluid therapy.

METHODS

A 12-week individualized exercise intervention consisting on three weekly home based sessions, and nutrition counselling focusing on protein intake and reducing high stoma output, was performed. Weekly follow-up by phone was done on motivation to exercise.

RESULTS

The study invited 71 patients, 44 accepted the invitation (62%), 37(52%) were included, and 31 (84%) completed the intervention. The exercise intervention was well tolerated. TUG improved from 8.9(SD 5.5) to 7.7(SD 3.8) (p = 0.033). CST improved by four repetitions (<0.001∗). A statistical, however not clinically relevant improvement was seen in muscle mass. No improvement was seen in (EQ)-5D-5L total, but insignificantly (p = 0.055) for physical function only. Protein intake improved by 10.6 g/day (p = 0.008).

CONCLUSIONS

A 12 weeks individualized exercise intervention showed very feasible and beneficial in HPN patients. Physical function improved statistically and clinically, and oral protein intake improved. QoL overall did not improve, however COVID-19 was an uninvited partner throughout the study period, which may have influenced general QoL. As only 62% accepted the invitation to participate, home based exercise intervention may not apply to all patients.

Perioperative Dietary Therapy in Inflammatory Bowel Disease

BACKGROUND AND AIMS

The incidence of inflammatory bowel disease [IBD] is rising worldwide and no cure is available. Many patients require surgery and they often present with nutritional deficiencies. Although randomised controlled trials of dietary therapy are lacking, expert IBD centres have long-established interdisciplinary care, including tailored nutritional therapy, to optimise clinical outcomes and resource utilisation. This topical review aims to share expertise and offers current practice recommendations to optimise outcomes of IBD patients who undergo surgery.

METHODS

A consensus expert panel consisting of dietitians, surgeons, and gastroenterologists, convened by the European Crohn's and Colitis Organisation, performed a systematic literature review. Nutritional evaluation and dietary needs, perioperative optimis ation, surgical complications, long-term needs, and special situations were critically appraised. Statements were developed using a Delphi methodology incorporating three successive rounds. Current practice positions were set when ≥80% of participants agreed on a recommendation.

RESULTS

A total of 26 current practice positions were formulated which address the needs of IBD patients perioperatively and in the long term following surgery. Routine screening, perioperative optimisation by oral, enteral, or parenteral nutrition, dietary fibre, and supplements were reviewed. IBD-specific situations, including management of patients with a restorative proctocolectomy, an ostomy, strictures, or short-bowel syndrome, were addressed.

CONCLUSIONS

Perioperative dietary therapy improves the outcomes of IBD patients who undergo a surgical procedure. This topical review shares interdisciplinary expertise and provides guidance to optimise the outcomes of patients with Crohn's disease and ulcerative colitis. taking advantage of contemporary nutrition science.

Nutritional Therapy in Adult Short Bowel Syndrome Patients with Chronic Intestinal Failure

Intestinal failure (IF) is the reduction of gut function below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, such that parenteral support (PS) is required to maintain health and/or growth. This article critically revises the gaps in and evidence for providing general nutritional therapy recommendations in the Short Bowel Syndrome-IF population. It addresses the need for an individualized approach, aiming to reduce or even eliminate the need for PS, and emphasizes a need to focus on effects of dietary interventions on the quality of life of these patients.

Short Bowel Syndrome: Clinical Guidelines for Nutrition Management

Intestinal failure is a condition in which inadequate digestion or absorption of fluid, electrolytes, and nutrients leads to dehydration or malnutrition. The most common cause of intestinal failure is short bowel syndrome (SBS) defined as <200 cm of functional small intestine. SBS may result from congenital abnormalities or from surgical resection. For the past 3 decades, patients with severe SBS were managed with home parenteral nutrition (HPN). With the emergence of new therapies, the clinician now has multiple options to treat these patients. These include intestinal rehabilitation regimens whereby patients are treated with specialized oral diets, soluble fiber, oral rehydration solutions (ORS), and trophic factors to enhance absorption. There are also a variety of surgical techniques available to preserve intestinal length. Small bowel and multivisceral transplantation has evolved during the last decade to be a valid therapeutic option for those patients who cannot be rehabilitated or who fail HPN. These are interrelated services designed to offer the patient the best therapeutic options to meet their individual needs. This article reviews the principles associated with the nutrition management of this very complex and diverse group of patients.

Extensive Intestinal Resection Triggers Behavioral Adaptation, Intestinal Remodeling and Microbiota Transition in Short Bowel Syndrome

Extensive resection of small bowel often leads to short bowel syndrome (SBS). SBS patients develop clinical mal-absorption and dehydration relative to the reduction of absorptive area, acceleration of gastrointestinal transit time and modifications of the gastrointestinal intra-luminal environment. As a consequence of severe mal-absorption, patients require parenteral nutrition (PN). In adults, the overall adaptation following intestinal resection includes spontaneous and complex compensatory processes such as hyperphagia, mucosal remodeling of the remaining part of the intestine and major modifications of the microbiota. SBS patients, with colon in continuity, harbor a specific fecal microbiota that we called “lactobiota” because it is enriched in the Lactobacillus/Leuconostoc group and depleted in anaerobic micro-organisms (especially Clostridium and Bacteroides). In some patients, the lactobiota-driven fermentative activities lead to an accumulation of fecal d/l-lactates and an increased risk of d-encephalopathy. Better knowledge of clinical parameters and lactobiota characteristics has made it possible to stratify patients and define group at risk for d-encephalopathy crises.

A practical approach to the management of high-output stoma

The development of a high-output stoma (HOS) is associated with water, electrolyte and nutritional complications. Prompt, careful assessment and management is required to avoid rapid clinical deterioration in this patient population. A multidisciplinary approach to management ensures the best possible outcome and quality of life for patients who experience HOS. This article outlines the important considerations in the identification and pathophysiology of HOS. A systematic approach to the management of the condition is outlined, considering fluid and electrolyte requirements, nutrient deficiencies and manipulation of gastrointestinal absorption, motility and secretions using medical and surgical therapies.

Serum citrulline is a simple quantitative marker for small intestinal enterocytes mass and absorption function in short bowel patients

BACKGROUND

To investigate the clinical significance of serum citrulline in evaluating the remnant small bowel enterocytes mass and absorptive function in short bowel (SB) patients.

MATERIALS AND METHODS

Serum citrulline concentrations were determined using high-performance liquid chromatography (HPLC) in 22 SBS patients and 33 healthy controls. Five-hour urine D-xylose excretion and digestive protein absorption were measured using HPLC and micro-Kjeldahl method, respectively. Small bowel length and surface area were assessed on X-ray radiograph. Correlations between serum citrulline levels and small bowel length, small bowel surface, and nutritional substrate digestive absorption percentage were analyzed. For six patients receiving bowel rehabilitation therapy, serum citrulline, D-xylose excretion, and intestinal protein absorption were measured pre- and immediately postmanagement, and their correlations were analyzed.

RESULTS

Serum citrulline levels were significantly lower in SB patients compared with healthy controls. In SB patients, they correlated well with remnant small bowel length (r = 0.82, P < 0.001), surface area (r = 0.86, P < 0.001), 5-h urine D-xylose excretion (r = 0.56, P = 0.007), and digestive protein absorption (r = 0.48, P = 0.046). The increased percentage of serum citrulline level in six patients receiving rehabilitation therapy followed a trend of correlating with that of intestinal protein absorption (r = 0.79, P = 0.063) and urine D-xylose excretion (r = 0.81, P = 0.053).

CONCLUSIONS

In patients with short bowel syndrome, serum citrulline is a simple and accurate biomarker for the severity of intestinal failure and may be a candidate marker for the gut-trophic effects of bowel rehabilitation therapies.

Survival rate and prognostic factors in patients with intestinal failure

BACKGROUND

Intestinal failure impairs nutritional status and survival expectance. Though intestinal adaptation and enteral independence may be achieved, artificial nutrition is needed in about half of the patients.

AIMS

This study is aimed at assessing the causes of death, survival rate, enteral independence in time, and factors affecting the clinical outcome in a group of patients with intestinal insufficiency.

PATIENTS

Sixty-eight patients with intestinal insufficiency, due to major intestinal resection in 60 cases (short bowel syndrome) (remnant intestine length 101-150 cm in 31 cases, 50-100 cm in 23 cases, <50 cm in 6 cases), and due to chronic idiopathic pseudo-obstruction in 8 cases, were enrolled and followed-up for (median) 36 months (25th and 75th percentile in 12 and 60 months, respectively). In 60 short bowel syndrome patients, the main conditions that led to intestinal failure were ischemic bowel (28), major surgery complications or severe adhesions (17), radiation enteritis (10), Chron's disease, intestinal tuberculosis, small bowel lymphoma and trauma (others).

METHODS

Seventeen variables age, underlying disorders, length of remnant bowel, type of surgery, hospital stay, type of nutrition (hospital and home) and its variations in time, causes of death, survival rate and time were considered. Statistical analysis was carried out by Mann-Whitney U-test, Pearson chi2, Spearman correlation test, Kaplan-Meyer method and Cox's proportion hazards regression model.

RESULTS

At the time of admission to the hospital, none of the patients had nutritional independence, 54 (79.4%) were on parenteral nutrition and 14 (20.6%) were on enteral nutrition. At the time of discharge, 23 (33.8%) patients showed enteral independence, 39 were on home parenteral nutrition, 3 on enteral nutrition + i.v. feeding, 1 on enteral nutrition, and 2 needed oral supplementation with hydroelectrolyte solutions only. After a median value of 36 months, 30 and 2 patients were on home parenteral nutrition and enteral nutrition + i.v. feeding, respectively, 2 on enteral nutrition, 2 on oral supplementation with hydroelectrolyte solutions, and 26 cases reached enteral independence. A significant relationship was detected between the length of remnant bowel and types of nutrition at both admission (r = 0.38; P = 0.001) and discharge (r = 0.48; P = 0.001), parenteral nutrition being more frequent in patients with very short bowel. Twenty-two patients (32.4%) died (4 from newly occurring malignancies), 40 (58.8%) survived, and 6 (8.8%) were lost to the follow-up. Eleven of 22 patients died from conditions related to intestinal failure (8 cases) and/or home parenteral nutrition complications (3 cases). At 12, 24, 36, 48, 60 and 72 months, survival rates were 95.4, 93.3, 88.1, 78.6, 78.6 and 65.5%, respectively, but it was significantly lower for patients with <50 cm of remnant bowel than those with longer residual intestine (P < 0.05), and in patients who started home parenteral nutrition above the age of 45 years (P < 0.02). Survival rate was higher in patients with enteral independence than those with enteral dependence (P < 0.05). Better survival rates were registered in patients with chronic obstructive intestinal pseudo-obstruction and major surgery complications, whereas ischemic bowel and even more radiation enteritis were associated with a lower survival expectance.

CONCLUSIONS

Actuarial survival rate of patients with intestinal failure quotes 88 and 78% at 3 and 5 years, respectively. It is influenced by the length of remnant intestine, age at the start of home parenteral nutrition, enteral independence and, to some extent at least, by the primary disorder. Enteral independence can be achieved in time by about 40% of the patients with intestinal insufficiency, but for home parenteral nutrition-dependent cases, intravenous feeding can be stopped in less than one out of five patients during a median 3-year period.

Experimental approaches: dietary and hormone therapy

Patients who suffer from intestinal failure depend on parenteral support to maintain nutritional equilibrium. In this chapter, recommendations for evaluation the absorptive capacity of patients with intestinal failure are defined, and the evidence and magnitude of the effect of dietary and hormone therapy is given. Regarding dietary advice, the effects of employment of diets with various carbohydrate:fat ratios in short-bowel syndrome (SBS) patients with and without a preserved colon is presented. Focus has been placed on the use of growth hormone but also on the use of a novel intestinotrophic hormone, glucagon-like peptide 2, in the promotion of intestinal adaptation in SBS patients. Overall, the ultimate aim in the treatment of SBS patients is to optimize remnant intestinal function, thereby eliminating the need for parenteral support and improving quality of life in these patients.

Nutritional management of short bowel syndrome in adults

Short bowel syndrome (SBS) comprises the sequelae of nutrient, fluid, and weight loss that occurs subsequent to greatly reduced functional surface area of the small intestine. Signs and symptoms of SBS include electrolyte disturbances; deficiencies of calcium, magnesium, zinc, iron, vitamin B12, or fat-soluble vitamin deficiency; malabsorption of carbohydrates, lactose, and protein; metabolic acidosis, gastric acid hypersecretion; formation of cholesterol biliary calculi and renal oxalate calculi; and dehydration, steatorrhea, diarrhea, and weight loss. Thorough nutritional management is the key factor in achieving an optimal outcome in SBS. Total parenteral nutrition is necessary in the early stages, as is replacement of excess fluid and electrolyte losses. Nutritional management of SBS has traditionally been divided into three phases: an acute phase when total parenteral nutrition is usually begun, an adaptation phase, and a maintenance phase. Recommendations regarding the need for parenteral nutrition vary depending on the presence or absence of certain factors: the ileocecal valve, jejunum, and functional colon. Patients with residual small bowel length of 100 cm or less usually require the administration of parenteral nutrition at home with good results. The total parenteral nutrition diet should consist of a majority of calories from fat, followed by protein, and the remaining as carbohydrates. Vitamins, minerals, and trace elements should also be added accordingly. Although total parenteral nutrition is initially necessary, treatment goals should focus on early transition to enteral nutrition followed by oral feeds. Other recent advances in the medical management of SBS include pharmacologic treatment and the use of specific nutrients and growth factors to stimulate intestinal absorption and adaptation. Both animal studies and clinical trials in humans have shown much promise in supplementation with growth factors and hormones. This strategy is likely to play a greater role in the treatment of SBS in the future.

Management of patients with a short bowel

There are two common types of adult patient with a short bowel, those with jejunum in continuity with a functioning colon and those with a jejunostomy. Both groups have potential problems of undernutrition, but this is a greater problem in those without a colon, as they do not derive energy from anaerobic bacterial fermentation of carbohydrate to short chain fatty acids in the colon. Patients with a jejunostomy have major problems of dehydration, sodium and magnesium depletion all due to a large volume of stomal output. Both types of patient have lost at least 60 cm of terminal ileum and so will become deficient of vitamin B₁₂. Both groups have a high prevalence of gallstones (45%) resulting from periods of biliary stasis. Patients with a retained colon have a 25% chance of developing calcium oxalate renal stones and they may have problems with D (-) lactic acidosis. The survival of patients with a short bowel, even if they need long-term parenteral nutrition, is good.

Postabsorptive plasma citrulline concentration is a marker of absorptive enterocyte mass and intestinal failure in humans

BACKGROUND & AIMS

No blood marker assessing the functional absorptive bowel length has been identified. Plasma citrulline, a nonprotein amino acid produced by intestinal mucosa, is one candidate. We tested this hypothesis in adult patients with the short-bowel syndrome, whose condition can lead to intestinal failure.

METHODS

In 57 patients, after a minimal follow-up of 2 years subsequent to final digestive circuit modification, postabsorptive citrulline concentration was measured and parenteral nutrition dependence was used to define permanent (n = 37) and transient (n = 20) intestinal failure. Absorptive function, studied over a 3-day period, was evaluated by net digestive absorption for protein and fat (n = 51). Relations between quantitative values were assessed by linear regression analysis and cutoff citrulline threshold, for a diagnosis of intestinal failure by linear discriminant analysis. Cox model was used to compare citrulline threshold and anatomic variables of the short bowel as indicators of transient as opposed to permanent intestinal failure.

RESULTS

In patients with short-bowel syndrome, citrulline levels were lower than in controls (n = 51): 20 +/- 13 vs. 40 +/- 10 micromol/L (mean +/- SD), respectively (P < 0.001). After multivariate analysis, citrullinemia was correlated to small bowel length (P < 0.0001, r = 0.86) and to net digestive absorption of fat, but to neither body mass index nor creatinine clearance. A 20-micromol/L threshold citrullinemia, (1) classified short bowel patients with permanent intestinal failure with high sensitivity (92%), specificity (90%), positive predictive value (95%), and negative value (86%); and (2) was a more reliable indicator (odds ratio, 20.0; 95% confidence interval, 1.9-206.1) than anatomic variables (odds ratio, 2.9; 95% confidence interval, 0. 5-15.8) to separate transient as opposed to permanent intestinal failure.

CONCLUSIONS

In patients with short-bowel syndrome, postabsorptive plasma citrulline concentration is a marker of functional absorptive bowel length and, past the 2-year adaptive period, a powerful independent indicator allowing distinction of transient from permanent intestinal failure.

Intestinal failure defined by measurements of intestinal energy and wet weight absorption

BACKGROUND AND AIMS

Intestinal failure defined by the minimal energy and wet weight absorption required to avoid home parenteral nutrition (HPN) is not well described. Thus the aim of this study was to identify the minimal level of gut function necessary to avoid parenteral support using objective measurements of intestinal function.

METHODS

Energy (bomb calorimetry) and wet weight absorption were measured during 48 hour balance studies in 45 HPN patients with intestinal failure and in 44 non-HPN borderline patients with a short bowel or malabsorption exceeding 2 MJ/day.

RESULTS

In the non-HPN patients, the lower 5% confidence interval of the absorption of energy was 84% of the basal metabolic rate (BMR, the Harris-Benedict equations), equivalent to 4.9 MJ/day. Wet weight absorption was 1.4 kg/day. The HPN patients absorbed less of either or both. The non-HPN patients absorbed 24-86% (range) of the energy and 23-95% of the wet weight. Absorption in the HPN patients ranged from below 0% (net secretion) in patients with very short bowels to 100% absorption of an insufficient oral intake in patients with pseudo-obstruction. Non-HPN patients who absorbed less than half of their intake avoided HPN by hyperphagia (200-400% of BMR equivalent to 10-24 MJ/day, and 3-7 kg/day of wet weight).

CONCLUSION

Intestinal failure was accurately measured as absorption below 1.4 kg/day of wet weight and 84% of the calculated BMR (depending on weight, sex and age), which is equal to 4.9 MJ/day. Intestinal absorption, expressed as a percentage of intake, did not discriminate between patients with and without intestinal failure, except for patients who absorbed less than 25% of their intake.

Colonic digestion and absorption of energy from carbohydrates and medium-chain fat in small bowel failure

Gut function and the degree of intestinal insufficiency or failure in short bowel patients can be quantified with respect to wet weight and energy absorption by the use of balance studies. This enables the physician to distinguish patients with extreme intestinal failure inconsistent with the restoration of intestinal autonomy by dietary manipulation from short bowel patients with borderline gut failure in whom dietary manipulations may result in the weaning from parenteral support. A high-carbohydrate, low long-chain fat diet and a diet where long-chain fat has been replaced by medium-chain triglycerides increase absorption of energy in patients with small bowel failure, provided that they have a preserved colon in continuity. This is due to the ability of the colonic flora to ferment carbohydrates malabsorbed in the small bowel to the short-chain fatty acids (SCFAs). These SCFAs are easily absorbed across the colonic mucosa resulting in a salvage of carbohydrate energy that otherwise would have been lost in feces. In contrast, long-chain fatty acids are not absorbed by the colon, and long-chain fat malabsorbed in the small bowel of short bowel patients are not retained in the large bowel. Recent work has indicated that the water soluble medium-chain fatty acids are effectively absorbed in the large bowel similar to the SCFAs. This may explain an almost complete absorption of medium-chain triglycerides in short bowel patients, even in patients with virtually no absorption of long-chain fat, and why this only occurs in patients with a colon in continuity. Manipulation of the dietary fat:carbohydrate ratio is much less efficacious in short bowel patients with no colonic function, and the use of medium-chain triglycerides has no proven effect on overall energy absorption from short bowel patients without a large bowel in continuity. Hence, the colon has increasingly important digestive functions as small bowel failure proceeds, not only when it comes to absorption of water and sodium, but also of energy from carbohydrates and medium-chain fat.

Body composition changes measured by dual-energy X-ray absorptiometry in patients receiving home parenteral nutrition

BACKGROUND

To monitor changes in body composition in patients receiving home parenteral nutrition (HPN) and to ascertain whether changes were related to the amount of energy supplied by HPN, we studied prospectively patients with gut failure maintained on HPN.

METHODS

Patients were subjected to repeated measurement of body composition by dual-energy X-ray absorptiometry (DXA), the second investigation being performed after a mean period of 20 (range, 11-26) months. Thirty-two patients were included, one patient was excluded, and five patients died during the study period. At inclusion, the patients had received HPN for a mean period of 30 (range, 6-216) months. The indication for HPN was inflammatory bowel disease (n = 16), abdominal cancers (n = 5), and scleroderma and others (n = 11). The fat-free mass (FFM), fat mass (FM), and total body mineral content (TBMC) were measured by DXA.

RESULTS

Mean body mass index decreased from 21.18 to 20.96 kg/m2 (P = 0.36). The mean FFM showed a small, insignificant increase to 37.68 kg (P = 0.71). Mean TBMC was unchanged at 2.28 kg, and mean FM decreased from 19.25 to 18.17 kg (P = 0.055). During the study period the mean daily energy supply by HPN was reduced from kcal 1195 to kcal 959 (P = 0.004). There was a direct positive correlation between the individual changes in HPN energy supply and body weight and FFM (r = 0.437, r = 0.410, P < 0.05).

CONCLUSION

The body composition of HPN patients was stable, with no change in mean FFM, FM, or TBMC. Individual changes in body weight and FFM correlated with change in HPN energy supply.

Review article: practical management of the short bowel

A shortened small intestine may end at a stoma or be anastomosed to the colon. Patients with a jejunostomy, but not those with a colon, lose large amounts of sodium. The intake and absorption of sodium can be increased by sipping a sodium-glucose solution; stomal loss can be reduced by restricting water or low-sodium drinks. If a stoma is situated less than 100 cm along the jejunum, a constant negative sodium balance may necessitate parenteral saline supplements. Gastric anti-secretory drugs or a somatostatin analogue reduce jejunostomy losses in such patients but do not restore a positive sodium balance. Loperamide or codeine phosphate benefit some patients. Magnesium deficiency can usually be corrected by oral magnesium oxide supplements. An elemental or hydrolysed diet is not beneficial. Patients with a jejunostomy can maintain a normal diet without fat reduction. When the colon is present, unabsorbed carbohydrate is fermented to absorbable short chain fatty acids. Unabsorbed long chain fatty acids and bile salts cause watery diarrhoea and increased colonic oxalate absorption with hyperoxaluria. Such patients benefit from a high carbohydrate, low-fat and low-oxalate diet. Parenteral nutrition is needed only by the few patients unable to maintain health or avoid socially disabling diarrhoea despite these measures.

Intestinal absorption of free oral hyperalimentation in the very short bowel syndrome

Ten adult ambulatory patients with the nonactive digestive disease short bowel syndrome were prospectively studied to quantitatively assess their free oral intake and their net digestive absorption of total calories, fat, protein, and carbohydrate during a 3-day period at least 6 months after a resection. The remaining portions of small bowel had a mean length of 75 cm (range, 0-200 cm); the remaining colon lengths had a mean of 67% of normal (range, 0%-100%). The experimental diets were formulated according to a home dietary inquiry. During the study period, pooled intakes and digestive losses were measured for total calories, fat, and protein using the bomb calorimetry, Van de Kamer, and Kjeldahl techniques, respectively. The ingested diet provided 58 +/- 14 kcal.kg-1.day-1 (mean +/- SD) and consisted of 46% carbohydrate, 31% fat, and 23% protein. Net digestive absorption was 67% +/- 12% for total calories, 79% +/- 15% for carbohydrate, 52% +/- 16% for fat, and 61% +/- 19% for protein. The larger net digestive absorption of carbohydrate (P less than or equal to 0.004) compared with fat and protein suggests salvage of colonic cholesterol in short bowel syndrome patients. It is concluded that these patients with the short bowel syndrome adapted to a hypercaloric, hyperprotein diet to compensate for increased fecal losses and that this hyperphagia does not seem to have impaired their net digestive absorption.

The effects of octreotide, soy polysaccharide, codeine and loperamide on nutrient, fluid and electrolyte absorption in the short-bowel syndrome

Four agents, which could delay intestinal transit, were tested in six short-bowel patients (jejunal length 30-120 cm) on long-term nutritional/electrolyte replacement therapy. Intestinal transit time of a liquid test meal and nutrient, water and sodium absorption were measured during a control study and with each test agent on separate days. Soy polysaccharide tended to increase transit time, but decreased the absorption of water, sodium and nutrients. Codeine phosphate and loperamide caused inconsistent and clinically unimportant changes. Octreotide, a long-acting analogue of somatostatin, delayed transit and increased water, sodium and calorie absorption from the meal. Octreotide appears to have the potential to reduce the need for electrolyte and nutritional supplements in patients with the short-bowel syndrome.