Gallstones during octreotide therapy

Metabolic and Nutritional Issues after Lower Digestive Tract Surgery: The Important Role of the Dietitian in a Multidisciplinary Setting

Many patients undergo small bowel and colon surgery for reasons related to malignancy, inflammatory bowel disease (IBD), mesenteric ischemia, and other benign conditions, including post-operative adhesions, hernias, trauma, volvulus, or diverticula. Some patients arrive in the operating theatre severely malnourished due to an underlying disease, while others develop complications (e.g., anastomotic leaks, abscesses, or strictures) that induce a systemic inflammatory response that can increase their energy and protein requirements. Finally, anatomical and functional changes resulting from surgery can affect either nutritional status due to malabsorption or nutritional support (NS) pathways. The dietitian providing NS to these patients needs to understand the pathophysiology underlying these sequelae and collaborate with other professionals, including surgeons, internists, nurses, and pharmacists. The aim of this review is to provide an overview of the nutritional and metabolic consequences of different types of lower gastrointestinal surgery and the role of the dietitian in providing comprehensive patient care. This article reviews the effects of small bowel resection on macronutrient and micronutrient absorption, the effects of colectomies (e.g., ileocolectomy, low anterior resection, abdominoperineal resection, and proctocolectomy) that require special dietary considerations, nutritional considerations specific to ostomized patients, and clinical practice guidelines for caregivers of patients who have undergone a surgery for local and systemic complications of IBD. Finally, we highlight the valuable contribution of the dietitian in the challenging management of short bowel syndrome and intestinal failure.

Dumping Syndrome: Pragmatic Treatment Options and Experimental Approaches for Improving Clinical Outcomes

Dumping syndrome is a common complication after esophageal, gastric and bariatric surgery and has a significant negative impact on the quality of life of patients. This narrative review describes the clinical syndrome, pathophysiology, diagnosis and reports on standard and pragmatic therapeutical treatment options in order to improve the clinical outcome of patients with dumping syndrome. Dumping syndrome consists of early and late dumping symptoms and can be diagnosed using clinical parameters with the help of the Sigstad's score, questionnaires or by provocative testing. The prevalence of dumping syndrome varies depending on the employed definition of dumping syndrome. Overall, dumping syndrome is more frequent nowadays due to increasing numbers of upper gastrointestinal and bariatric surgeries being performed. First treatment step includes dietary adjustment and dietary supplements, which are often sufficient to manage symptoms for the majority of patients. Next step of therapy includes acarbose, which is effective for late dumping symptoms, but the use is limited due to side effects. Somatostatin analogues are indicated after these two steps have failed. Somatostatin analogues are very effective for controlling early and late dumping, also in the long term. Glucagon like peptide-1 receptor agonists, endoscopic and surgical (re)interventions are reported as treatment options for refractory dumping syndrome; however, their use is not recommended in clinical practice due to the limited evidence on and uncertainty of outcomes. These alternatives should be considered only as last resort options in patients with otherwise refractory and invalidating dumping syndrome.

How to manage a high-output stoma

A high-output stoma (HOS) or fistula is when small bowel output causes water, sodium and often magnesium depletion. This tends to occur when the output is >1.5 -2.0 L/24 hours though varies according to the amount of food/drink taken orally. An HOS occurs in up to 31% of small bowel stomas. A high-output enterocutaneous fistula may, if from the proximal small bowel, behave in the same way and its fluid management will be the same as for an HOS. The clinical assessment consists of excluding causes other than a short bowel and treating them (especially partial or intermittent obstruction). A contrast follow through study gives an approximate measurement of residual small intestinal length (if not known from surgery) and may show the quality of the remaining small bowel. If HOS is due to a short bowel, the first step is to rehydrate the patient so stopping severe thirst. When thirst has resolved and renal function returned to normal, oral hypotonic fluid is restricted and a glucose-saline solution is sipped. Medication to slow transit (loperamide often in high dose) or to reduce secretions (omeprazole for gastric acid) may be helpful. Subcutaneous fluid (usually saline with added magnesium) may be given before intravenous fluids though can take 10-12 hours to infuse. Generally parenteral support is needed when less than 100 cm of functioning jejunum remains. If there is defunctioned bowel in situ, consideration should be given to bringing it back into continuity.

Arachidyl amido cholanoic acid (Aramchol) is a cholesterol solubilizer and prevents the formation of cholesterol gallstones in inbred mice

We have recently synthesized fatty acid bile acid conjugates (FABAC) that were able to reduce and retard cholesterol crystallization in model and human biles. When given orally, they prevented the formation of cholesterol crystals in the bile of hamsters. The aim of the present study was to determine whether the FABAC are cholesterol solubilizers, whether they can dissolve pre-existing crystals, whether they can prevent the formation of cholesterol gallstones, and to investigate the optimal type of bond between the fatty acid and bile acid. The presence of cholesterol crystals was determined by light microscopy, and the total crystal mass of precipitated crystals was measured by chemical means. Inbred (C57J/L) mice on a lithogenic diet were used to evaluate cholesterol crystal formation, dissolution, and gallstone formation in vivo. Arachidyl amido cholanoic acid (Aramchol) was the FABAC used in the present experiments. At equimolar amounts, the cholesterol-solubilizing capacity of Aramchol was higher than that of taurocholate and similar to that of phosphatidylcholine. The addition of Aramchol dissolved approximately 50% of pre-existing crystals in model bile solutions. The same phenomenon was demonstrated in human bile ex vivo, with a dose-response effect. All inbred mice developed cholesterol crystals in bile after 10-14 d on the lithogenic diet. Thereafter, supplementation of the diet with Aramchol progressively reduced the proportion of mice with crystals to 25% after 28 d. On the lithogenic diet, 100% of inbred mice developed cholesterol gallstones in the gallbladder by day 21. None of the mice whose diet was supplemented with 0.5 mg or 1.0 mg of Aramchol/d developed stones or crystals. FABAC are a new class of molecules that are cholesterol solubilizers and which are able to dissolve cholesterol crystals in bile. Upon oral administration, they dissolve pre-existing cholesterol crystals and prevent the formation of gallstones in gallstone-susceptible mice.

[Increased bile lithogenicity after simultaneous total parenteral nutrition and octrotide. A model of calcium palmitate Gallstones]

Gallbladder stasis and gallstone formation are well-known complications of both fasting-associated total parenteral nutrition (TPN) and long-term treatment with octreotide. Additive noxious effects to hepatobiliary function may develop when both therapies are given together as treatment of enteric fistulae. The aim of this study was to assess the risk of gallstone formation during treatment with TPN and octreotide separately and in combination. We studied four groups of New Zealand rabbits (n = 32) during a 2-week intervention period: 14 chow-fed controls; 6 fasted and TPN-fed; 6 chow-fed and administered octreotide, and 6 fasted and treated with both TPN and octreotide. After treatment, the bile duct was cannulated and the gallbladder and liver tissue were obtained for histological analysis. Hepatic and gallbladder bile were retrieved for microscopic examination and measurement of biliary lipids, bilirubin, calcium, total protein, and cholesterol nucleation time. The chemical composition of gallstones was also analyzed. The results of the study suggest that simultaneous administration of these two therapies in rabbits has additive effects on gallbladder stasis and bile lithogenicity. The administration of both treatments can play an important role in the formation of calcium palmitate gallstones in these animals.

Hepatolithiasis (intrahepatic stone) during octreotide therapy for acromegaly: a case report

We report a case of hepatolithiasis (intrahepatic stone) complicated by gram-negative sepsis in a 37 year old male with acromegaly being treated with octreotide. As a child, he had suffered a traumatic injury to his liver requiring the surgical repair of a laceration. This is the first reported case of hepatolithiasis during octreotide therapy. Gallstones and bile sludge are common side effects of octreotide therapy but rarely become symptomatic or require treatment. Hepatolithiasis is uncommon in western countries but is quite prevalent in East Asia and is often associated with a predisposing condition that causes intrahepatic bile stasis (eg. bile duct stricture). In addition to its known effect on gallbladder stasis, octreotide alters bile acid composition and may thus hasten intrahepatic sludge and stone formation. Extra caution should be taken in using octreotide or its long-acting analog in patients otherwise predisposed to intrahepatic bile stasis.

Nutrition and enterocutaneous fistulas

Enterocutaneous fistulas (ECFs) are a complex topic in terms of classification. ECF-related morbidity and mortality can be high due to fluid loss and electrolyte imbalance, sepsis, and malnutrition. Most prognostic factors influencing the outcome of ECF are now well-known. ECF treatment is complex; and, based on various situations, it can be surgical or conservative/ medical. Depending on fistula site and nutritional status, clinicians have to decide whether total parenteral or enteral nutrition should be established. In cases where total parenteral nutrition alone for 7 days has failed to influence the high output fistulas, overall data support the use of adjuvant drug, somatostatin, or its synthetic analogue, octreotide. Somatostatin 250 microg/d and octreotide 300-600 microg/d have been tried along with total parenteral nutrition to decrease the healing time of ECFs and to reduce the number of complications.

Somatostatin stimulates the brush-tailed possum sphincter of Oddi in vitro and in vivo

BACKGROUND & AIMS

Somatostatin, a neuropeptide and hormone, is found in the biliary tract of several species. The aim of this study was to map the distribution of somatostatin-like immunoreactive nerve fibers in the extrahepatic biliary tract of the Australian possum and to determine the pharmacological effects of somatostatin 1-14 on sphincter of Oddi activity in vitro and in vivo.

METHODS

Tissue was harvested for immunohistochemistry and sphincter of Oddi for circular or longitudinal muscle contractility. In anesthetized possums, sphincter of Oddi motility was measured by manometry, and transsphincteric flow was measured gravimetrically.

RESULTS

Somatostatin immunoreactivity was evident in gallbladder ganglia nerve cell bodies and in nerve fibers of the common bile duct and sphincter of Oddi. Somatostatin 1-14 increased circular and longitudinal muscle contraction amplitude 3-4-fold (P < 0.05), but only the longitudinal muscle contraction amplitude was tetrodotoxin sensitive. Somatostatin 1-14 stimulated spontaneous sphincter of Oddi motility in a tetrodotoxin-insensitive manner, increasing basal pressure, contraction frequency, and amplitude 2-4-fold (P < 0.05) and reducing transsphincteric flow to 25% of control (P < 0.0001).

CONCLUSIONS

Somatostatin-like immunoreactivity is present in the extrahepatic biliary tree, and somatostatin 1-14 stimulates sphincter of Oddi smooth muscle and nerves. The major action is direct stimulation of sphincter of Oddi circular muscle, which reduces transsphincteric flow.

Cirrhosis: a new, but expected cause of biliary sludge

BACKGROUND/AIMS

Biliary sludge is increasingly recognized as a natural stage in gallstone formation. Logically, cirrhosis, a well-documented cause of black pigment cholelithiasis, should be another condition predisposing to the development of sludge. The aim of this study was to assess the prevalence of biliary sludge in an unselected population and to test the hypothesis that cirrhosis could be one of the causes of sludge.

METHODS

We reviewed the clinical findings and ultrasonograms of 2138 patients, hospitalized or not, consecutively seen in our department between January 1993 and December 1994. Sonograms showing biliary sludge mixed with stones were excluded. Three hundred and eighty-eight of the 2138 were cirrhotic patients.

RESULTS

The overall prevalence of biliary sludge was 4%. Sludge was found in 44 of 388 (11%) of the cirrhotic patients (alcoholism, n = 39; chronic viral B hepatitis, n = 3; hemochromatosis, n = 1; and cryptogenic, n = 1), compared with 42 of 1750 (2%) noncirrhotic patients (p < 0.000001). Thirteen cirrhotic patients received intravenous alimentation for 2 to 17 days, 8 were given somatostatin for variceal bleeding, and 7 have previously had 1 to 5 sessions of endoscopic sclerotherapy of esophageal varices with polidocanol.

CONCLUSIONS

This study convincingly demonstrates that cirrhosis must be added to the growing list of conditions associated with biliary sludge.

Is octreotide a new hope for enterocutaneous and external pancreatic fistulas closure?

BACKGROUND

Octreotide is a long-acting analogue of somatostatin that exhibits good subcutaneous absorption. It reduces gastrointestinal and pancreatic secretions as well as relaxes the intestinal musculature. It has been hypothesized that octreotide could decrease fistula output, thus facilitating fluid and electrolytes management and possibly hasten fistula closure.

DATA SOURCES

Relevant articles were identified from a MEDLINE search of the literature. Because of the scarcity of well-designed studies on the use of octreotide to promote enterocutaneous and pancreaticocutaneous fistulas closure, all case series and controlled trials were reviewed.

CONCLUSIONS

Octreotide as an adjuvant to standard fistula management diminishes fistula output, but its shortening of the time to fistula closure remains to be proven by well-designed comparative trials. For recent onset fistulas (less than 8 days old), octreotide does not seem better than the recommended management, including parenteral nutrition. Octreotide can effectively prevent postoperative complications and fistula formation in patients undergoing elective pancreatic resection.

A radical view of gallstone aetiogenesis

It is proposed that gallstones stem from insufficiency of micronutrient antioxidants relative to the load of oxidants and/or oxidation-prone substrates within hepatocytes in such a way that ancillary hepatobiliary resources, including bilirubin with lactoferrin and mucin, are mobilized to combat oxidative stress but inadvertently promote lithogenesis. Aberrant activities of hepatic cytochrome P450 mono-oxygenases and of haem oxygenase are integral to this template, because differential inhibition or activation of these enzymes would help to rationalize the spectrum of human gallstone composition and also the different outcomes when animals are fed the same lithogenic diets. The hypothesis is based on a decade of work on another lithogenic disease, chronic pancreatitis. It accommodates observations on human and experimental gallstones, it is testable and, as shown by studies of chronic pancreatitis, has implications for primary disease prevention.