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Abstract
Gastroparesis (GP) is commonly seen in hospitalized patients. Refractory vomiting and related dehydration, electrolyte abnormalities, and malnutrition are indications for hospital admission. In addition, tube feeding intolerance is a common sign of gastric dysmotility in critically ill patients. The diagnosis and management of GP in the hospital setting can be quite challenging. Diagnostic tests are often deferred because of patient intolerance of the oral meal for standard scintigraphy or severity of the primary disease. The diagnosis of GP is often established on the basis of clinical scenario and risk factors for gastric motor dysfunction. Medical therapy in GP is directed toward controlling nausea and vomiting by prokinetic and antinausea medications and correcting nutrition risks or treating malnutrition with nutrition therapy. Enteral nutrition is the preferred nutrition intervention for patients with GP. Delayed gastric emptying in critically ill patients has a negative impact on the timely delivery of enteral feeding and meeting the energy and protein goals. Measures to improve gastric tolerance or provide feeding beyond the stomach are often needed, since early enteral nutrition has been an important target of therapy for critically ill patients. This review will address the current understanding of the mechanisms of GP and feeding intolerance in critical illness, diagnostic workup, drug therapies, and interventions to improve the provision of enteral nutrition in hospital settings when gastric dysmotility is present or suspected.
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Affiliation(s)
- Vikram Rangan
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Andrew Ukleja
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Shimizu K, Ogura H, Matsumoto N, Ikeda M, Yamamoto H, Mori M, Morii E, Shimazu T. Interstitial cells of Cajal are diminished in critically ill patients: Autopsy cases. Nutrition 2020; 70:110591. [PMID: 31751930 DOI: 10.1016/j.nut.2019.110591] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 04/20/2019] [Accepted: 09/11/2019] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Gastrointestinal dysmotility in critically ill patients is important as enteral nutrition is crucial. However, normal gut motility is impaired under conditions of critical illness subsequent to severe insult. Interstitial cells of Cajal (ICC) form an extensive network associated with the myenteric plexus in the enteric nervous system. There are few reports about ICC distribution in critically ill patients. The aim of this study was to evaluate ICC in critically ill patients. METHODS Postmortem colon harvest was obtained from critically ill patients. Control specimens were obtained from patients without bowel movement problems who underwent hemicolectomy. The tissues were stained with c-Kit for ICC. The number of ICC was identified by counting from 10 high-power fields (HPFs). RESULTS Specimens from six patients were analyzed and compared with those from six control patients. All patients had abnormalities of crypt architecture and inflammatory cell infiltrations. Mucosal thickness tended to be lower in the critically ill patients than in the controls (147 ± 47 versus 231 ± 127 μm; P = 0.15). Muscle layer thickness tended to be higher in the critically ill patients than in the controls (494 ± 163 versus 394 ± 258 μm; P = 0.44). ICC in the critically ill patients were almost depleted in the colon compared with those in the controls. Significantly fewer ICC were present in the critically ill patients than in the controls (0.45 versus 7.25 cells/HPF; P < 0.05). CONCLUSIONS Critical illness is associated with diminished numbers of ICC in the colon. This finding could have implications for dysmotility in critically ill patients.
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Gokhale A, Kantoor S, Prakash S, Manhas Y, Chandwani J, Mahmoud AE. Bedside placement of small-bowel feeding tube in Intensive Care Unit for enteral nutrition. Indian J Crit Care Med 2016; 20:357-60. [PMID: 27390461 PMCID: PMC4922290 DOI: 10.4103/0972-5229.183909] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Enteral nutrition is the preferred mode of nutrition in critically ill patients whenever feasible as it has a number of advantages over parenteral feeding. Both gastric and small-bowel feeding can effectively deliver calories. In patients with gastroparesis, small-bowel feeding can help avoid parenteral feeding. We carried out a retrospective observational study to assess the ability to insert the Tiger 2 tube into the small bowel at the bedside in 25 patients who failed to tolerate gastric feeds. The time taken, rate of successful insertion, and ability to feed these patients using a standardized feeding protocol were noted. Success rate of insertion was 78% and feeding could be established. This method reduced the delays and risks associated with transportation and dependence on other specialties.
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Affiliation(s)
- Antara Gokhale
- Department of Anesthesia and Adult Intensive Care Unit, Royal Hospital, Muscat, Oman
| | - Sandeep Kantoor
- Department of Anesthesia and Adult Intensive Care Unit, Royal Hospital, Muscat, Oman
| | - Sadanandan Prakash
- Department of Anesthesia and Adult Intensive Care Unit, Royal Hospital, Muscat, Oman
| | - Yogesh Manhas
- Department of Anesthesia and Adult Intensive Care Unit, Royal Hospital, Muscat, Oman
| | - Juhi Chandwani
- Department of Anesthesia and Adult Intensive Care Unit, Royal Hospital, Muscat, Oman
| | - Ashraf Ezzat Mahmoud
- Department of Anesthesia and Adult Intensive Care Unit, Royal Hospital, Muscat, Oman
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Whitehead K, Cortes Y, Eirmann L. Gastrointestinal dysmotility disorders in critically ill dogs and cats. J Vet Emerg Crit Care (San Antonio) 2016; 26:234-53. [PMID: 26822390 DOI: 10.1111/vec.12449] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2013] [Revised: 07/21/2015] [Accepted: 08/30/2014] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To review the human and veterinary literature regarding gastrointestinal (GI) dysmotility disorders in respect to pathogenesis, patient risk factors, and treatment options in critically ill dogs and cats. ETIOLOGY GI dysmotility is a common sequela of critical illness in people and small animals. The most common GI motility disorders in critically ill people and small animals include esophageal dysmotility, delayed gastric emptying, functional intestinal obstruction (ie, ileus), and colonic motility abnormalities. Medical conditions associated with the highest risk of GI dysmotility include mechanical ventilation, sepsis, shock, trauma, systemic inflammatory response syndrome, and multiple organ failure. The incidence and pathophysiology of GI dysmotility in critically ill small animals is incompletely understood. DIAGNOSIS A presumptive diagnosis of GI dysmotility is often made in high-risk patient populations following detection of persistent regurgitation, vomiting, lack of tolerance of enteral nutrition, abdominal pain, and constipation. Definitive diagnosis is established via radioscintigraphy; however, this diagnostic tool is not readily available and is difficult to perform on small animals. Other diagnostic modalities that have been evaluated include abdominal ultrasonography, radiographic contrast, and tracer studies. THERAPY Therapy is centered at optimizing GI perfusion, enhancement of GI motility, and early enteral nutrition. Pharmacological interventions are instituted to promote gastric emptying and effective intestinal motility and prevention of complications. Promotility agents, including ranitidine/nizatidine, metoclopramide, erythromycin, and cisapride are the mainstays of therapy in small animals. PROGNOSIS The development of complications related to GI dysmotility (eg, gastroesophageal reflux and aspiration) have been associated with increased mortality risk. Institution of prophylaxic therapy is recommended in high-risk patients, however, no consensus exists regarding optimal timing of initiating prophylaxic measures, preference of treatment, or duration of therapy. The prognosis for affected small animal patients remains unknown.
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Affiliation(s)
- KimMi Whitehead
- Emergency and Critical Care Department, Oradell Animal Hospital, Paramus, NJ, 07452
| | - Yonaira Cortes
- Emergency and Critical Care Department, Oradell Animal Hospital, Paramus, NJ, 07452
| | - Laura Eirmann
- the Nutrition Department (Eirmann), Oradell Animal Hospital, Paramus, NJ, 07452
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Abstract
Advances in surgery, anesthesia and intensive care have led to a dramatic increase in the number of patients who spend time in our intensive care units (ICU). Gastrointestinal (GI) motility disorders are common complications in the intensive care setting and are predictors of increased mortality and length of the stay in the ICU. Several risk factors for developing GI motility problems in the ICU setting have been identified and include sepsis, being on mechanical ventilation and the use of vasopressors, opioids or anticholinergic medications. Our focus is on the most common clinical manifestations of GI motor dysfunction in the ICU patient: gastroesophageal reflux, gastroparesis, ileus and acute pseudo-obstruction of the colon.
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Affiliation(s)
- Abimbola Adike
- Department of Medicine, Weill Cornell Medical College, Houston Methodist Hospital, Houston, Texas, USA
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Stupak DP, Abdelsayed GG, Soloway GN. Motility disorders of the upper gastrointestinal tract in the intensive care unit: pathophysiology and contemporary management. J Clin Gastroenterol 2012; 46:449-56. [PMID: 22469641 DOI: 10.1097/MCG.0b013e31824e14c1] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Upper gastrointestinal (GI) dysmotility, an entity commonly found in the intensive care unit setting, can lead to insufficient nutrient intake while increasing the risk of infection and mortality. Further, overcoming the altered motility with early enteral feeding is associated with a reduced incidence of infectious complications in intensive care unit patients. Upper GI dysmotility in critical care patients is a common occurrence, and there are many causes for this problem, which affects a very heterogenous population with a multitude of underlying medical abnormalities. Therefore, it is of utmost importance to identify this widespread problem and subsequently institute a proper therapy as rapidly as possible. Prokinetic pharmacotherapies are currently the mainstay for the management of disordered upper GI motility. Future therapies, aimed at the underlying pathophysiology of this complex problem, are under investigation. These aim is to reduce the side effects of the currently available options, while improving on nutrition delivery in the critically ill. This review discusses the pathophysiology, clinical manifestations, diagnosis, and treatment of upper GI motility disturbances in the critically ill.
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Quigley EMM. Passing the bug—Translocation, bacteremia, and sepsis in the intensive care unit patient: Is intestinal decontamination the answer?*: . Crit Care Med 2011; 39:1202-3. [DOI: 10.1097/ccm.0b013e31820e4625] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Shimizu K, Ogura H, Asahara T, Nomoto K, Morotomi M, Nakahori Y, Osuka A, Yamano S, Goto M, Matsushima A, Tasaki O, Kuwagata Y, Sugimoto H. Gastrointestinal dysmotility is associated with altered gut flora and septic mortality in patients with severe systemic inflammatory response syndrome: a preliminary study. Neurogastroenterol Motil 2011; 23:330-5, e157. [PMID: 21199173 DOI: 10.1111/j.1365-2982.2010.01653.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The gut is an important target organ for injury after severe insult, and resolution of feeding intolerance is crucial for critically ill patients. We investigated gut flora and motility to evaluate the impact of gastrointestinal dysmotility on septic complications in patients with severe systemic inflammatory response syndrome (SIRS). METHODS Sixty-three ICU patients with severe SIRS were divided into two groups depending on their intestinal condition. Patients with feeding intolerance comprised patients who had feeding intolerance, defined as ≥ 300 mL reflux from nasal gastric feeding tube in 24 h, and patients without feeding intolerance comprised patients with no feeding intolerance. We compared fecal microflora, incidences of bacteremia, and mortality between these groups. KEY RESULTS Analysis of feces showed that patients with feeding intolerance had significantly lower numbers of total obligate anaerobes including Bacteroidaceae and Bifidobacterium, higher numbers of Staphylococcus, lower concentrations of acetic acid and propionic acid, and higher concentrations of succinic acid and lactic acid than those in patients without feeding intolerance (P ≤ 0.05). Patients with feeding intolerance had higher incidences of bacteremia (86%vs 18%) and mortality (64%vs 20%) than did patients without feeding intolerance (P ≤ 0.05). CONCLUSIONS & INFERENCES Gut flora and organic acids were significantly altered in patients with severe SIRS complicated by gastrointestinal dysmotility, which was associated with higher septic mortality in SIRS patients.
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Affiliation(s)
- K Shimizu
- Department of Clinical Quality Management, Osaka University Hospital, Suita-City, Osaka, Japan.
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Abstract
Several significant changes occur in the gastrointestinal system with obesity that can effect management in critical illness. This population is at risk for gastroesophageal reflux disease (GERD), abdominal compartment syndrome, nonalcoholic fatty liver disease (NAFLD), and an increased incidence of cholelithiasis. It is important for critical care providers to be aware of these potential complicating factors.
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Affiliation(s)
- Doyle D Ashburn
- Department of Critical Care Medicine, Geisinger Medical Center, 100 North Academy Avenue, Danville, PA 17822, USA
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Abstract
The objective of this article is to describe adverse drug events related to the liver and gastrointestinal tract in critically ill patients. PubMed and other resources were used to identify information related to drug-induced acute liver failure, gastrointestinal hypomotility, constipation, diarrhea, gastrointestinal bleeding, and pancreatitis in critically ill patients. This information was reviewed, and data regarding pathophysiology, common drug causes, and guidelines for prevention and management were collected and summarized. In cases in which data in critically ill patients were unavailable, data were extrapolated from other patient populations. Drug-induced acute liver failure can be caused by many drugs routinely used in the intensive care unit and may be associated with significant morbidity and mortality. Drug-related hypomotility and constipation and drug-related diarrhea are reported with many drugs, and these are common adverse drug events in critically ill patients that can substantially complicate the care of these patients. Drug-induced gastrointestinal bleeding and drug-induced pancreatitis occur less frequently, can range in disease severity, and can be associated with morbidity and mortality. Many drugs used in critically ill patients are associated with adverse drug events related to the liver and gastrointestinal tract. Critical care clinicians should be aware of common drug causes of drug-induced acute liver failure, gastrointestinal hypomotility, constipation, diarrhea, gastrointestinal bleeding, and pancreatitis, and should be familiar with the prevention and management of these diverse conditions.
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Abstract
Delay in gastric emptying is common in the critically ill, and can lead to abdominal distension, diarrhoea or constipation, and vomiting, and may contribute to increased incidence of reflux and nosocomial infection. Prokinetic agents increase the rate of luminal transit as well as the force of contraction, and are commonly used in the intensive care unit. This article summarises the current state of knowledge about the use of prokinetics and explores potential agents which might be used in the future in this group of patients.
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Affiliation(s)
- Katherine Grant
- Trainee Doctor in Anaesthetics, North Hampshire Hospital, Basingstoke
| | - Richard Thomas
- Consultant in Anaesthesia and Intensive Care, Royal Hampshire County Hospital, Winchester
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Abstract
INTRODUCTION We studied the clinical course of elderly patients acutely hospitalized for various diseases, assessing any differences between patients with and without esophagitis. STUDY A case-control study on the presence of esophagitis was conducted on the clinical records of all in-patients undergoing gastroduodenoscopy at Padova Geriatric Hospital from 1997 to 2001. Data were examined on 338 sex-matched patients: 169 with a diagnosis of esophagitis and 169 with a negative endoscopy. RESULTS Admissions for acute respiratory disorders [odds ratios (OR) 2.68; 95% confidence interval (CI) 0.89-8.01], a remote diagnosis of esophagitis (OR 11.34; 95%CI 2.68-48.07), obesity (OR 3.36; 95%CI 0.91-12.48), and being bedridden (OR 6.84; 95%CI 3.27-14.29) were found to be independent risk factors for the presence of esophagitis. The symptoms prompting the endoscopic diagnoses included: gastrointestinal bleeding (OR 7.61; 95%CI 2.76-21.0), heartburn (OR 4.58; 95%CI 1.86-11.28), and cough (OR 3.59; 95%CI 1.34-9.62). Steroids (OR 2.68; 95%CI 1.11-6.44) and calcium antagonists (OR 1.50; 95%CI 0.79-2.87) were associated with esophagitis as risk factors, whereas proton pump inhibitors (OR 0.46; 95%CI 0.25-0.87), nitrates (OR 0.14; 95%CI 0.02-0.78), and sucralfate in males (OR 0.09; 95%CI 0.01-0.92) were associated as protective factors. Patients with esophagitis were discharged with an endocrinologic/metabolic-type diagnosis. Deaths were significantly higher among patients with esophagitis (25 vs. 9); more severe esophagitis was characterized by a higher Charlson comorbidity index and a greater presence of anorexia and nausea. CONCLUSIONS These findings seem to substantiate the theory that esophagitis is a characteristic which exacerbates frailty in hospitalized elderly people and its identification may be helpful in these patients.
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Affiliation(s)
- Fabrizio Cardin
- Geriatric Department, Division of Geriatric Surgery, University of Padova, Padova, Italy.
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Abstract
While, in the past, gastrointestinal motility may have been viewed as a narrow and restricted field, confined to the study of twitches in muscle baths and squiggles on smoke drums, it has, of late and belatedly, entered into the mainstream of gastroenterology and medicine. As a consequence, this field, now more correctly and appropriately described as neurogastroenterology, concerns itself with a vast spectrum of clinical disorders of varying pathophysiology, presentation and management. Never before has this area offered so many opportunities to the budding academician and researcher.
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