Serum vitamins in adult patients with short bowel syndrome receiving intermittent parenteral nutrition

Neurological complications in patients undergoing general surgery: A literature review

Surgical procedures are extremely burdensome for patients, as in addition to complications directly related to the intervention, they expose the patient to further complications resulting from the disturbance of key functions of homeostasis in the body's systems, particularly the circulatory, respiratory, and nervous systems. Furthermore, they may contribute to the exacerbation of symptoms of underlying chronic diseases. This paper focuses on the most common possible neurological complications that may occur after surgical procedures and includes topics such as stroke, chronic pain, neuropathy, and delirium. The risk factors for neurological deficits, their known or possible etiology, the most characteristic symptoms, and potential preventive actions are discussed. The paper analyzes articles from the PubMed, ResearchGate, and Scopus databases. A surge0on's knowledge of possible complications that may occur in the perioperative period enables early recognition and effective reduction of their negative impact on the patient's functioning and quality of life after surgery, contributing to better overall treatment outcomes.

Short Bowel Syndrome in Adults

Short bowel syndrome (SBS) is a rare disorder characterized by severe intestinal dysfunction leading to malabsorption of macronutrients and micronutrients that often results in permanent need of parenteral nutrition support. Patients can develop SBS because of massive intestinal resection or loss of intestinal function and consequently experience significant morbidity and increased healthcare utilization. The remaining anatomy and length of bowel after intestinal resection have important prognostic and therapeutic implications. Because patients with SBS constitute a heterogenous group, management is complex and multifaceted, involving nutrition support, fluid and electrolyte management, and pharmacologic therapies in particular to control diarrhea. Surgical interventions including intestinal transplantation may be considered in selected individuals. Successful care of these patients is best accomplished by a multidisciplinary team that is experienced in the management of this syndrome.

New insights into intestinal failure-associated liver disease in adults: A comprehensive review of the literature

Intestinal failure-associated liver disease (IFALD) remains one of the most common and serious complications of parenteral nutrition (PN), causing a wide spectrum of hepatic manifestations from steatosis and mild cholestasis to portal hypertension and end-stage liver failure. The prevalence of IFALD depends on the diagnostic criteria and ranges from 4.3% to 65%. Moreover, many factors are shown to contribute to its development, including nutrient deficiencies, toxicity of PN, infections, and alterations of bile acid metabolism and gut microbiota. Prevention and management of IFALD aim at ameliorating or eliminating the risk factors associated with IFALD. The use of PN formulations with a lower ratio omega-6-to-omega-3 polyunsaturated fatty acids, cycle PN, optimization of enteral stimulation and prevention and early treatment of infections constitute the main therapeutic targets. However, failure of improvement and severe IFALD with end-stage liver failure should be considered as the indications of intestinal transplantation. The aim of this review is to provide an update of the epidemiology, pathophysiology, and diagnosis of IFALD in the adult population as well as to present a clinical approach of the therapeutic strategies of IFALD and present novel therapeutic targets.

Vitamin C in Home Parenteral Nutrition: A Need for Monitoring

To date, there are no recommendations about screening plasma vitamin C concentration and adjust its supplementation in patients on long-term home parenteral nutrition (HPN). The aim of this study was to evaluate vitamin C status and determine if a commercial multivitamin preparation (CMVP) containing 125 mg of vitamin C is sufficient in stable patients on HPN. All clinically stable patients receiving HPN or an intravenous fluid infusion at least two times per week for at least 6 months, hospitalized for nutritional assessment, were retrospectively included, for a total of 186 patients. We found that 29% of the patients had vitamin C insufficiency (i.e., <25 µmol/L). In univariate analysis, C-reactive protein (CRP) (p = 0.002) and intake of only 125 mg of vitamin C (p = 0.001) were negatively associated with vitamin C levels, and duration of follow-up in our referral center (p = 0.009) was positively associated with vitamin C levels. In multivariate analysis, only CRP (p = 0.001) and intake of 125 mg of vitamin C (p < 0.0001) were independently associated with low plasma vitamin C concentration. Patients receiving only CMVP with a low plasma vitamin C level significantly received personal compounded HPN (p = 0.008) and presented an inflammatory syndrome (p = 0.002). Vitamin C insufficiency is frequent in individuals undergoing home parenteral nutrition; therefore, there is a need to monitor plasma vitamin C levels, especially in patients on HPN with an inflammatory syndrome and only on CMVP.

Subacute combined degeneration associated with vitamin E deficiency due to small bowel obstruction: A case report

RATIONALE

There have been a few reported cases of subacute combined degeneration (SCD) associated with vitamin E deficiency, but the period of intestinal malabsorption was more than several years. We present a rare case of acute onset SCD that occurred in a relatively short period of several weeks with vitamin E deficiency related to small bowel obstruction.

PATIENT CONCERNS

A 50-year-old woman had abdominal pain. A small bowel obstruction was suspected and conservative treatment was performed. She underwent bowel surgery after 2 weeks without any improvement. Following the operation, she was in a state of reduced consciousness. She was treated in an intensive care unit. Her consciousness level gradually recovered to alert in a week, but other symptoms such as ataxia, weakness on limbs, severe dysarthria, and dysphagia occurred. Since then, she had spent nearly 6 weeks in a bed-ridden state without improving.

DIAGNOSIS

SCD associated with vitamin E deficiency was confirmed by laboratory investigations, electrophysiologic test, and whole spine magnetic resonance imaging scans.

INTERVENTIONS

For vitamin E supplementation, she was administered a dose of 1200 mg/d. Physical therapy was focused on strengthening exercise, balance, and walker gait training. Occupational therapy was focused on activities of daily living training and dysphagia rehabilitation.

OUTCOMES

After 6 weeks, her muscle strengths and functional level were substantially improved. The vitamin E level was recovered to normal range.

LESSONS

This case suggests that if neurological symptoms occur in patients with intestinal obstruction, clinicians need to consider a deficiency of micronutrients such as vitamin E and vitamin B12. Patients with short clinical courses suffer less neurological damage and achieve faster recovery.

Trends of INR and Fecal Excretion of Vitamin K During Cholestasis Reversal: Implications in the Treatment of Neonates With Intestinal Failure-Associated Liver Disease

BACKGROUND

Vitamin K is a fat-soluble compound that plays important roles in coagulation. In children with intestinal failure-associated liver disease (IFALD), the disrupted enterohepatic circulation can lead to intestinal loss of vitamin K. Fish oil-based lipid emulsion (FOLE) has proven effective in treating IFALD. As biliary excretion is restored during cholestasis reversal, the accelerated vitamin K loss can pose a risk for deficiency.

METHODS

Ten neonates with IFALD and receiving FOLE monotherapy were prospectively enrolled in the study from 2016 to 2018. In addition to weekly measurements of international normalized ratio (INR) and direct bilirubin (DB), ostomy output was collected for determination of fecal concentrations of phylloquinone (PK). Trends of DB, INR, and fecal PK concentrations were summarized with locally estimated scatterplot smoothing.

RESULTS

The median time (interquartile range) from FOLE initiation to cholestasis reversal was 59 (19-78) days. During cholestasis reversal, INR remained relatively unchanged, whereas the mean (95% confidence interval) daily fecal excretion of PK increased from 25.1 (5.0-158.5) ng at the time of FOLE initiation to 158.5 (31.6-1000.0) ng at complete reversal. Examination of individual trends in fecal PK excretion and INR revealed little correlation between the 2 measurements (r = -0.10; P = 0.50).

CONCLUSION

Children with IFALD are at risk for vitamin K deficiency during cholestasis reversal. Close monitoring and quantified supplementation of vitamin K may be warranted during this period. However, this should not be guided by INR alone, as it is a poor indicator of vitamin K status.

A Rare Case of Primary Midgut Volvulus Necessitating Extensive Bowel Resection in an Adult

A cause of acute intestinal obstruction in adults, midgut volvulus can be categorized into two types: primary type with no identifiable underlying cause, and secondary type that occurs in the presence of a predisposing condition such as, postoperative adhesions. Primary midgut volvulus can lead to bowel ischemia and necrosis, making an extensive bowel resection imminent. A potential consequence of bowel resection is short-bowel syndrome - a failure of digestion and absorption by the intestines, leading to malnutrition and other complications. As such, we report the diagnosis and management of primary midgut volvulus - a rare entity in adults - occurring in an adult patient.

Management and Complications of Short Bowel Syndrome: an Updated Review

Short bowel syndrome (SBS) is defined as loss of bowel mass from surgical resection, congenital defects, or disease. Intestinal failure (IF) includes the subset of SBS unable to meet nutrition needs with enteral supplements and requires parenteral nutrition (PN). The parenteral treatment of SBS is now a half-century old. Recent pharmacologic treatment (GLP-2 analogues) has begun to make a significant impact in the care and ultimate management of these patients such that the possibility of reducing PN requirements in formerly PN-dependent patients is a now a real possibility. Finally, newer understanding and possible treatment for some of the complications related to IF have more recently evolved and will be an emphasis of this report. This review will focus on developments over the last 10 years with the goal of updating the reader to new advances in our understanding of the care and feeding of the SBS patient.

Copper and magnesium deficiencies in patients with short bowel syndrome receiving parenteral nutrition or oral feeding

BACKGROUND

Patients with short bowel syndrome have significant fluid and electrolytes loss.

OBJECTIVE

Evaluate the mineral and electrolyte status in short bowel syndrome patients receiving intermittent parenteral nutrition or oral feeding.

METHODS

Twenty two adults with short bowel syndrome, of whom 11 were parenteral nutrition dependent (PN group), and the 11 remaining had been weaned off parenteral nutrition for at least 1 year and received all nutrients by oral feeding (OF group). The study also included 14 healthy volunteers paired by age and gender (control group). Food ingestion, anthropometry, serum or plasma levels of sodium, potassium, phosphorus, magnesium, calcium, zinc, iron and copper were evaluated. PN group subjects were evaluated before starting a new parenteral nutrition cycle.

RESULTS

The levels of sodium, potassium, phosphorus, calcium and zinc were similar between the groups. The magnesium value was lower in the PN group (1.0 ± 0.4 mEq /L) than other groups. Furthermore, this electrolyte was lower in the OF group (1.4 ± 0.3 mEq /L) when compared to the Control group (1.8 ± 0.1 mEq/L). Lower values of copper (69±24 vs 73±26 vs 109±16 µg/dL) were documented, respectively, for the PN and OF groups when compared to the control group.

CONCLUSION

Hypomagnesemia and hypocupremia are electrolyte disturbances commonly observed in short bowel syndrome. Patients with massive intestinal resection require monitoring and supplementation in order to prevent magnesium and copper deficiencies.

Phosphorus and calcium: a review for the adult nutrition support clinician

Phosphorus (P) and calcium (Ca) serve vital roles in the human body and are essential components of nutrition support therapy. Regulation of P and regulation of Ca in the body are closely interrelated, and P and Ca homeostasis can be affected by several factors, including disease states, clinical condition, severity of illness, and medications. Nutrition support clinicians must understand these factors to prevent and treat P and Ca disorders in patients receiving nutrition support therapy. This review provides an overview of P and Ca for the adult nutrition support clinician, with some emphasis on the hospitalized inpatient.

Vitamin D deficiency and low bone mineral density in pediatric and young adult intestinal failure

OBJECTIVES

The aim of the present study was to determine the prevalence and predisposing factors for vitamin D deficiency and low bone mineral density (BMD) in patients with intestinal failure (IF).

METHODS

A retrospective review of patients with IF managed at the Cincinnati Children's Hospital Medical Center. IF was defined as history of parenteral nutrition (PN) >30 days. Vitamin D deficiency was defined as serum 25-hydroxyvitamin D (25 (OH) D) <20 ng/dL. Reduced BMD was defined using dual x-ray absorptiometry z score ≤-2. A binary logistic regression model was used to test for association of significant risk factors and the outcome variables after univariate analyses.

RESULTS

One hundred and twenty-three patients with median age of 4 years (range 3-22 years) were evaluated. Forty-nine (39.8%) patients had at least a documented serum 25 (OH) D deficiency during the study interval, whereas 10 of 80 patients (12.5%) with dual x-ray absorptiometry scans completed had a low BMD z score. Age at study entry was associated with both 25 (OH) D deficiency (P = 0.01) and low BMD z score (P = 0.03). Exclusive PN at study entry was associated with reduced bone mass (P = 0.03). There was no significant association between vitamin D deficiency and low BMD z score (P = 0.31).

CONCLUSIONS

The risk of 25 (OH) D deficiency and low BMD z score increases with age among patients with IF. Strategies for monitoring and preventing abnormal bone health in older children receiving exclusive PN need to be developed and evaluated.

Vitamin K status in patients with short bowel syndrome

BACKGROUND & AIMS

Available evidence suggests that patients with short bowel syndrome (SBS) might be at risk of vitamins A, D, E and B(1) deficiency. However, there is little clinical data describing the vitamin K status. Therefore, in the present study we aimed to assess the body resources of vitamin K in a subset of SBS patients.

METHODS

The study comprised 33 patients aged 1 month to 16 years. PIVKA-II concentrations were determined in all subjects.

RESULTS

In all studied subjects, coagulation parameters were normal. PIVKA-II levels indicative of vitamin K deficiency was found in 3 (9.1%) SBS patients. One patient had been receiving an additional intravenous vitamin K dose of 5 mg/week. In all SBS patients with cirrhosis and cholestasis, PIVKA-II concentrations were low (<2 ng/ml). However, all patients with severe liver disease were receiving vitamin K several times a month.

CONCLUSIONS

Vitamin K deficiency may appear in SBS patients.