The Differentiation of Intestinal-Failure-Associated Liver Disease from Nonalcoholic Fatty Liver and Nonalcoholic Steatohepatitis

Intestinal failure-associated liver disease (IFALD), formerly known as parenteral nutrition-associated liver disease has often been listed in textbooks as an example of nonalcoholic fatty liver disease (NAFLD). However, the etiology, pathophysiology, epidemiology, histology, and progression differ substantially between the conditions defined as NAFLD and the disease, IFALD. Therefore, IFALD should not be defined or considered as a type or a cause of nonalcoholic fatty liver or nonalcoholic steatohepatitis, but rather as a distinct disease.

Choline Deficiency Is Associated With Increased Risk for Venous Catheter Thrombosis

BACKGROUND

Patients with intestinal failure who require long-term parenteral nutrition (PN) develop catheter thrombosis as a complication. This patient group may also develop choline deficiency because of a defect in the hepatic transsulfuration pathway in the setting of malabsorption. This study was undertaken to determine whether choline deficiency is a risk factor for development of catheter thrombosis.

METHODS

Plasma free and phospholipid-bound choline concentrations were measured in a group of 41 patients that required long-term PN. Episodes of catheter thrombosis from onset of PN to the time of blood testing were recorded.

RESULTS

Sixteen (39%) patients developed catheter thrombosis, and 5 of these had recurrent catheter thrombosis. Plasma free choline was 7.7 +/- 2.7 nmol/mL in patients with no history of catheter thrombosis and 6.2 +/- 1.7 nmol/mL in patients with previous catheter thrombosis (p = .076 by Wilcoxon rank-sum test). The partial correlation between plasma free choline concentration and the frequency of clots after controlling for catheter duration was r = -0.33 (p = .038). The relative risk for catheter thrombosis in subjects with a plasma free choline concentration <8 nmol/mL was 10.0, 95% confidence interval (1.134-88.167). Plasma phospholipid-bound choline concentration was 2191.7 +/- 679.0 nmol/mL in patients with previous catheter thrombosis and 2103.3 +/- 531.2 nmol/mL in patients without history of catheter thrombosis (p = NS).

CONCLUSION

Choline deficiency is a significant risk factor for development of catheter thrombosis in patients with intestinal failure who require PN.

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.

Risk factors for the development of catheter-related bloodstream infections in patients receiving home parenteral nutrition

BACKGROUND

Risk factors for development of catheter-related bloodstream infections (CRBSI) were studied in 125 adults and 18 children who received home parenteral nutrition (HPN).

METHODS

Medical records from a national home care pharmacy were reviewed for all patients that had HPN infused at least twice weekly for a minimum of two years from January 1, 2006-December 31, 2011. Infection and risk factor data were collected during this time period on all patients although those patients who received HPN for a longer period had data collected since initiation of HPN.

RESULTS

In adults, 331 central venous catheters (CVCs) were placed. Total catheter years were 1157. Median CVC dwell time was 730 days. In children, there were 53 CVCs placed. Total catheter years were 113.1. Median CVC dwell time was 515 days. There were 147 CRBSIs (0.13/catheter year;0.35/1000 catheter days). In children there were 33 CRBSIs (0.29/catheter year;0.80/1000 days; P < .001 versus adults). In adults, univariate analysis showed use of subcutaneous infusion ports instead of tunneled catheters (P = .001), multiple lumen catheters (P = .001), increased frequency of lipid emulsion infusion (P = .001), obtaining blood from the CVC (P < 0.001), and infusion of non-PN medications via the CVC (P < .001) were significant risk factors for CRBSI. Increased PN frequency was associated with increased risk of CRBSI (P = .001) in children, but not in adults. Catheter disinfection with povidone-iodine was more effective than isopropyl alcohol alone. There were insufficient patients to evaluate chlorhexidine-containing regimens.

CONCLUSION

Numerous risk factors for CRBSI were identified for which simple and current countermeasures already exist.

Catheter thrombosis and superior/inferior vena cava syndrome are rare complications of long term parenteral nutrition

The objective of this study was to determine the incidence of catheter thrombosis and superior/inferior vena cava (SVC IVC ) syndrome in a large population of patients receiving home total parenteral nutrition (TPN), using retrospective data collection and analysis. 527 patients including 138 children who were discharged on home TPN and followed in the UCLA home TPN program for a minimum of one week between April, 1973 and October, 1991. There was a total of 1154 years of patients follow-up, including 241 years in children. Fifty-seven patients (11%) developed 81 episodes of catheter thrombosis excluding SVC IVC syndrome with an incidence of 0.07 episodes per catheter year. The median catheter duration prior to thrombosis was 7 months. Twenty-one thromboses occured in children with an incidence of 0.09 per catheter year. Eleven percent of thrombotic episodes were associated with catheter sepsis. Thirty-nine percent of patients had a PTT less than control values. Twenty-two patients including 6 children developed SVC IVC syndrome with an incidence of 0.02 per catheter year. SVC IVC syndrome was not associated with catheter sepsis in any patient. Sixty-eight percent of patients had catheter thrombosis at some point prior to developing SVC IVC syndrome. It is concluded that catheter-related thrombotic events are rare complications of home TPN and are uncommonly associated with infection. However, we recommend warfarin anticoagulation following an initial thrombotic event, in the absence of catheter malposition, for all such patients as long as they maintain a central venous catheter.

Plasma citrulline concentration as a marker for disease activity in patients with Crohn's disease

BACKGROUND

Citrulline is a nitrogen end product produced from the intermediary metabolism of glutamine through the enzymatically mediated urea cycle, almost exclusively in the enterocytes of small intestinal epithelium, with some synthesis in colonocytes. Intestinal dysfunction resulting from intestinal diseases or injuries affects intermediary metabolism, which includes citrulline synthesis. We sought to determine whether plasma citrulline was a biomarker for disease activity in patients with Crohn's disease with the hypothesis that citrulline concentration would be reduced during active disease.

METHODS

A total of 81 outpatients aged 18 to 65 years (mean, 40.6±15.4 y) with a known history of Crohn's disease were studied prospectively. Patients with prior small intestinal resection, or renal or hepatic insufficiency were excluded. Crohn's disease activity was measured by Harvey-Bradshaw Index (HBI) and was correlated to the plasma citrulline concentration measured simultaneously (ion chromatography). Spearman correlation coefficients were used to assess for an association between the 2 variables. Subgroup analyses of patients with isolated small intestinal disease and endoscopically or radiologic verified disease activity were also performed.

RESULTS

Twenty-two patients had isolated colonic disease and 59 had small intestinal involvement. Twenty-six of these patients had concurrent endoscopy and/or computed tomography or magnetic resonance imaging. On the basis of HBI scores, 32 patients had active disease (HBI ≥5) and 49 patients had inactive disease. The mean HBI scores were 4.8±5.5. The mean plasma citrulline concentration was normal, although was below normal in some patients. However, it failed to distinguish between active and inactive patients based on the HBI (active 27.8±8.8 μmol/L, inactive 27.8±11.1 μmol/L, P=0.991). There was no significant linear association between the ranks of citrulline and ranks of HBI (rs=0.012, P=0.915). Of the 59 patients with isolated small intestinal disease, there was no association between plasma citrulline concentration and the HBI (Spearman correlation coefficient, 0.073; P=0.583). There was no difference in plasma citrulline concentrations among those with confirmed inflammation by imaging or endoscopy (confirmed, 26.2±11.8; negative, 28.0±10.0; independent t test P=0.583).

CONCLUSIONS

Plasma citrulline concentration was not a marker of disease activity in patients with Crohn's disease. However, all patients studied were outpatients and it is possible that plasma citrulline concentration may be depressed only in patients with more severe disease or extensive small bowel involvement. In addition, plasma citrulline may be increased in the postabsorptional state, and for the most part, our patients were nonfasting. More studies are needed to further elucidate the role of citrulline as a marker of disease activity in patients with Crohn's disease. The possibility also exists that citrulline may be a better marker in patients with previous resection, and this group will require specific evaluation.

Treatment of cholera-like diarrhoea with oral rehydration

Cholera diarrhoea remains a major global health problem that has caused seven pandemics. The pathogenesis of cholera is attributable to the production of cholera toxin by the causative pathogen, Vibrio cholerae. The toxin causes increased production of cyclic adenosine monophosphate and this results in massive water and electrolyte secretion into the intestinal lumen. These changes manifest clinically as the painless defecation of voluminous stools that resemble 'rice water', leading to severe dehydration. The cornerstone in the management of cholera diarrhoea is the use of oral rehydration solutions (ORS) to replace the water and electrolytes lost as stools. The World Health Organization recommends the use of ORS of 'reduced osmolarity' for the treatment of acute non-cholera diarrhoea and the use of rice-based ORS for the management of cholera diarrhoea. Although several attempts have been made to improve ORS, studies to evaluate some of the modifications, which include the addition of amylase-resistant starch, the use of amino acids (such as glycine, alanine and glutamine) as sodium cotransporters, and zinc-supplemented ORS, are still needed.

Mesenteric vascular thromboembolism in inflammatory bowel disease: a single center experience

BACKGROUND

Vascular thrombotic complications in inflammatory bowel disease (IBD) are well recognized, although mesenteric vascular thrombotic disease is rare.

METHODS

We describe nine patients in a tertiary care center with IBD that developed thrombosis of the mesenteric arterial or venous vasculature (e.g., mesenteric thrombosis, MT).

RESULTS

Eight subjects developed mesenteric venous thrombosis (five located in the superior mesenteric vein and three located in a branch of the portal vein) and one had a mesenteric arterial embolus, located in the splenic artery. Five subjects had Crohn's disease (CD), and four had ulcerative colitis. The one subject diagnosed with an arterial thrombosis had CD. Mean time from diagnosis of IBD to diagnosis of thrombosis was 24.6 ± 13.5 years. Five of the nine subjects developed mesenteric venous thrombosis while their IBD was clinically in remission. Seven of nine subjects were symptomatic from the development of MT, including bowel infarction that led to development of short bowel syndrome.

CONCLUSION

Mesenteric thrombosis is a rare complication of IBD and may develop during clinical remission, suggesting a potential role for factors other than clinically significant inflammation in its pathogenesis.

Teduglutide, a novel mucosally active analog of glucagon-like peptide-2 (GLP-2) for the treatment of moderate to severe Crohn's disease

BACKGROUND

Teduglutide, an analog of glucagon-like peptide-2 (GLP-2), is associated with trophic effects on gut mucosa. Its role in the treatment of active Crohn's disease (CD) was assessed in a pilot, randomized, placebo-controlled, double-blinded, dose-ranging study.

METHODS

Subjects with moderate-to-severe CD were randomized 1:1:1:1 to placebo or 1 of 3 doses of teduglutide (0.05, 0.10, or 0.20 mg/kg daily) delivered as a daily subcutaneous injection for 8 weeks. The primary outcome measure was the percentage of subjects in each group that responded to treatment, defined as a decrease in Crohn's Disease Activity Index (CDAI) score to <150 or a decrease of > 100 points. At week 8 there was an optional 12-week open-label period of treatment with teduglutide 0.10 mg/kg/d.

RESULTS

One hundred subjects were enrolled and 71 completed the study. The mean baseline CDAI score was 290.8 +/- 57.6 and was similar across groups. There were numerically higher response and remission rates in all teduglutide-treated groups as compared with placebo, although the percentage of subjects who achieved a clinical response or remission was more substantial, and seen as early as week 2 of treatment in the highest dose (0.2 mg/kg/d) group (44% response and 32% remission versus 32% response and 20% remission in the placebo group). Of subjects who had not achieved remission during the 8-week placebo-controlled phase in the higher-dose group, 50% achieved remission during the more prolonged, open-label treatment phase. Plasma citrulline was similar across groups at baseline, but increased substantially over time in all teduglutide groups when compared with placebo at week 8. Adverse events were not different between placebo and active treatment groups.

CONCLUSIONS

Teduglutide is a novel and potentially effective therapy for inducing remission and mucosal healing in patients with active moderate-to-severe CD. Further clinical investigation of this growth factor is warranted.

A randomised placebo-controlled multicentre trial of intravenous semapimod HCl for moderate to severe Crohn's disease

OBJECTIVE

Semapimod, a small molecule known to inhibit proinflammatory cytokine activity, was studied to determine the optimal dose necessary to achieve a response in patients with moderate to severe Crohn's disease (CD).

METHODS

A randomised, double-blind, placebo-controlled trial (CD04) was carried out followed by an open-label extension study (CD05). The trial was conducted in international multicentre outpatient clinics and included patients with moderate to severe CD (Crohn's Disease Activity Index (CDAI) 250-400). Placebo was administered for 3 days; 60 mg semapimod intravenously for 1 day with placebo for 2 days; or 60 mg semapimod intravenously for 3 days. Participants who completed CD04 could participate in the open-label extension study, CD05, to receive up to five additional semapimod HCl 60 mg daily doses three times every 6-8 weeks. The main outcome measures were CDAI, Inflammatory Bowel Disease Questionnaire (IBDQ), Crohn's Disease Endoscopic Inflammation Score (CDEIS) and serum C-reactive protein (CRP) concentration.

RESULTS

152 patients were randomised in CD04. Responses for 1 and 3 day regimens were similar to placebo for CDAI (p=0.82), IBDQ (p=0.85), CDEIS (p=0.57) and CRP (p=0.40). The only noteworthy treatment-related safety finding was infusion reaction (phlebitis): 7.3, 34.8 and 62.7% for the placebo and 1 and 3 day semapimod treatment groups, respectively (p<0.001). In the open-label CD05 study (included=119 patients) a posthoc analysis showed that the mean CDAI improved in patients receiving 6 compared with < or = 3 cumulative doses (204.1+/-83 vs 251.4+/-103.05, p=0.006).

CONCLUSIONS

Single and 3 day dosing of semapimod (< or = 180 mg) was ineffective for the treatment of moderate to severe CD. However, cumulative dosing > or = 360 mg was associated with decreased CDAI in a limited number of patients.

Prospective randomized open-label multicenter phase I/II dose escalation trial of visilizumab (HuM291) in severe steroid-refractory ulcerative colitis

BACKGROUND

Visilizumab is a humanized IgG(2) monoclonal anti-CD3 antibody. We evaluated its safety and dose response in severe intravenous steroid-refractory ulcerative colitis (UC).

METHODS

In all, 104 patients were treated. In Stage I, 73 patients were randomly assigned to receive intravenous visilizumab 5, 7.5, 10, or 12.5 microg/kg/day for 2 consecutive days. In Stage II, 33 patients received visilizumab at the optimal clinical dose (OCD) of 5 microg/kg/day for 2 days. Symptomatic response and remission were defined by the modified Truelove-Witts severity index. Clinical response and remission were defined by the Mayo score.

RESULTS

The rates of symptomatic response at day 15 in the 5, 7.5, 10, or 12.5 microg/kg dose groups were 71%, 70%, 50%, and 61%, respectively, in Stage I and in 54% in Stage II. The symptomatic remission rates were 35%, 5%, 22%, and 11% in Stage I and 18% in Stage II. The rates of clinical response at day 30 in the 5, 7.5, 10, or 12.5 microg/kg dose groups were 71%, 65%, 50%, and 67%, respectively, in Stage I and 55% in Stage II. The clinical remission rates were 6%, 5%, 0%, and 11% in Stage I and 6% in Stage II. All patients experienced adverse events. Serious adverse events included abdominal abscess, cytomegalovirus infection, atrial fibrillation, herpes zoster, and esophageal candidiasis.

CONCLUSIONS

Treatment with visilizumab induced symptomatic response and clinical response. Results with 5 microg/kg/day were similar to those observed with higher doses.

Micronutrients in parenteral nutrition: too little or too much? The past, present, and recommendations for the future

This research workshop in 2009 grew out of a concern in the United States, Europe, and other countries with advanced medicine that it was time to revisit the parenteral requirements for a number of micronutrients. Critical questions sought to be answered included the following: Were there micronutrients not routinely added that should be part of a parenteral nutrition (PN) formula? Were other micronutrients present but in inappropriate amounts? How are various micronutrient requirements altered in the critically or chronically ill?

The addition of choline to parenteral nutrition

Choline is a quaternary amine endogenously synthesized from the amino acid methionine or absorbed via the portal circulation. It is ubiquitous in the diet, although it has a greater presence in organ meats. Choline is an essential component of all cell membranes, and has been considered a required dietary nutrient since 1998 by the US Institute of Medicine's Food and Nutrition Board. Choline is necessary for DNA repair, mediated by its role as a methyl donor. It also serves as the precursor for the neurotransmitter acetylcholine. Evidence has accumulated that hepatic steatosis, which occurs during parenteral nutrition therapy, develops as a result of choline deficiency because endogenous production of choline from parenterally infused methionine is deficient. In addition, memory deficits and skeletal muscle abnormalities have been described, and choline deficiency appears to activate cellular apoptosis. Provision of intravenous choline ameliorates hepatic steatosis associated with parenteral nutrition infusion.

Oral rehydration solutions in non-cholera diarrhea: a review

The use of oral rehydration solution (ORS) has revolutionized the management of acute diarrhea. The implementation of the standard World Health Organization ORS (WHO-ORS) has resulted in decreased mortality associated with acute diarrheal illnesses in children, although in general stool volume and diarrhea durations are not reduced. Decreased morbidity and mortality have occurred because of improved hydration status. Decreased morbidity has also been described in adults who used this therapy. Various modifications to the standard ORS have been derived. These modifications have included hypo-osmolar or hyperosmolar solutions, use of rice-based ORS, zinc supplementation, and the use of amino acids, including glycine, alanine, and glutamine. Some of these variations have been successful, some have not, and others are still under investigation. ORS has been used for travelers' diarrhea and to decrease intravenous (IV) fluid requirements in patients with short bowel syndrome (SBS) who require parenteral nutrition (PN). This paper reviews the standard WHO-ORS and its mechanism of action, followed by more contemporary reduced osmolarity ORS and rice-based ORS in non-cholera diarrhea. Various modifications to improve ORS are also discussed.

Efficacy and safety of tacrolimus in refractory ulcerative colitis and Crohn's disease: a single-center experience

BACKGROUND

The published experience regarding the use of tacrolimus in Crohn's disease (CD) and ulcerative colitis (UC) refractory to more commonly used medical therapy has been fairly limited. Our objective was to describe our experience with its use in a cohort of patients which, to our knowledge, represents the largest North American cohort described to date.

METHODS

This was a retrospective, single-center chart analysis. Patients were identified by compiling all hospital discharges with principle diagnoses of ICD-9 codes for 555.0-555.9 (regional enteritis) and 556.0-556.9 (ulcerative colitis) from January 1, 2000, to October 31, 2005, and then cross-referencing the electronic charts for tacrolimus serum concentrations ordered during this time period. Additional patients were identified through verbal communication with participating clinicians. Information abstracted included proportion with clinical response and remission (using a modified disease activity index), ability to wean from steroids, need for surgery / time to surgery, and side-effect profile.

RESULTS

In all, 32 UC patients and 15 CD patients were identified. The mean disease duration was: UC 81 months (range, 1 month to 37 years), CD 100 months (range, 1 month to 35 years). The disease distribution for UC was: pancolitis 12 (37.5%), extensive colitis 6 (18.8%), left-sided 11 (34.4%), and proctitis 3(9.4%). For CD this was: TI 2 (13.3%), small bowel 2 (13.3%), colonic 3 (20.7%), ileocolonic 7(46.7%), and perianal 1 (6.7%). The duration of tacrolimus treatment for UC was mean, 29 weeks. For CD it was mean, 9.9 weeks. In all, 30/32 UC and 7/15 CD patients were on steroids; 4/30 UC and 0/7 CD patients were able to subsequently wean off steroids. In all, 12/32 UC patients proceeded to colectomy. Mean time to colectomy was 28 weeks and 6/15 CD patients proceeded to a resective surgery. The mean time to surgery was 22 weeks. In all, 22/32 UC patients achieved a clinical response; 3/32 achieved remission and 8/15 CD patients achieved a clinical response; 1/15 achieved remission. Adverse reactions were generally mild. In 6 patients the drug had to be discontinued because of an adverse reaction. There were no opportunistic infections identified, no cases of renal insufficiency related to drug administration, and no deaths while on the medicine.

CONCLUSIONS

Our experience with tacrolimus in UC and CD indicates that it is safe and relatively well tolerated, although its clinical efficacy is quite variable. More prospective studies assessing its use are necessary.

Antibiotic-associated diarrhoea

Diarrhoea is a common complication of antimicrobial therapy. The term antibiotic-associated diarrhoea (AAD) is often considered synonymous with Clostridium difficile. In fact, AAD can develop through a variety of mechanisms and manifest through a broad range of clinical signs and symptoms. For improved prevention and recognition of AAD, it is important to understand the pathophysiology and risk factors for AAD. Although Clostridium difficile continues to be the most common identifiable pathogen of AAD, many patients with AAD can be managed through a variety of conservative measures. This review focuses on some of the important distinctions between nonspecific AAD and antibiotic-associated colitis. In addition, the most recent data on important risk factors for the development of AAD are summarised. Given its pathogenicity, there will be an emphasis on the early diagnosis, treatment and prevention of Clostridium difficile-associated diarrhoea. AAD is a common clinical problem that can progress to severe, life-threatening disease if not recognised quickly. Better awareness of risk factors can lead to the most efficacious treatment of this disorder: primary prevention.

Use of percutaneous endoscopic gastrostomy or percutaneous endoscopic jejunostomy in short bowel syndrome

Patients who have short bowel syndrome (SBS) and concomitant intestinal failure have insufficient functional capacity to absorb sufficient nutrients, electrolytes, and/or fluid to sustain independent life. As such, these patients require specialized nutritional support. Although parenteral nutrition is often necessary, at least initially, the therapeutic goal should be to enhance intestinal adaption and enteral nutrient assimilation, and thereby reduce parenteral nutrition requirements. The induction of hyperphagia is critical. Enteral intake also can be enhanced through enteric tube feeding. There are, however, insufficient data to recommend the universal use of a peptide-based formula (versus a polymeric formula), although the use of such a formula may be considered in individual patients in whom the clinician has compared nutritional outcome with the two types of formulas.

Voluntary childlessness is increased in women with inflammatory bowel disease

BACKGROUND

The women's health aspect of inflammatory bowel disease (IBD) is a newer area of study; childbearing issues have received little attention despite the fact that IBD affects women predominantly during their childbearing years. The aim of this study was to better understand patients' considerations about pregnancy-related issues and to examine trends in childbearing so that physicians are able to better tailor their advice to IBD-specific concerns.

METHODS

Data were gathered from specific questions in 3147 surveys mailed anonymously to all members of the Crohn's and Colitis Foundation of America (CCFA) Illinois Carol Fisher chapter. The subjects were provided a pre-addressed, pre-stamped return envelope and were instructed to return their completed surveys with no identifying information. Subjects were from the Illinois community. Females IBD patients were 15-44 of age and were members of the CCFA Illinois Carol Fisher chapter.

RESULTS

In this study, 169 females age 15-44 years with IBD, 110 with Crohn's disease (CD) and 59 with ulcerative colitis (UC), were identified. Most subjects were white. IBD patients had a higher rate of voluntary childlessness (CD 18%, UC 14%) than the 6.2% seen in the general population (P = 0.001 for CD, P = 0.08 for UC). Women with UC had a lower rate of temporary childlessness (CD 28%, UC 13.6%) than the general population (33%) (P = NS and P < 0.0001 for UC). The rates of nonvoluntary childlessness in IBD were similar to the general population. Women with IBD also had fewer children than their state and national counterparts. The state of the patients' IBD, including those who had gone through a previous pregnancy with IBD, did not alter their resolve to have children. The educational level of our subjects was higher than the nationwide and statewide levels; 76% of the subjects used contraception before diagnosis of IBD, and 82% used it after diagnosis. The most common choices were oral contraception, barrier methods, and abstinence. This study was unable to compare the lifetime rates of complications of pregnancy with population-based controls because such data were unavailable. Furthermore, their findings in this study may not be generalized to all ethnic groups because our population was mostly white.

CONCLUSIONS

Women with IBD had a higher rate of voluntary childlessness and fewer children than the general population. These observations are likely attributable to a higher educational achievement and to racial background of the patients rather than to IBD-related reasons. Although contraception use in patients with IBD was lower that in the general population, use was higher after the diagnosis of IBD than before the diagnosis. Contraceptive choices and adoption rates were similar to the general population. Women with CD were more affected by miscarriages after diagnosis with IBD than those with UC.

Clonidine reduces diarrhea and sodium loss in patients with proximal jejunostomy: a controlled study

BACKGROUND

Patients with short bowel syndrome have significant fluid losses. This represents a significant management problem, especially in patients with minimal residual intestine. We determined whether clonidine, an alpha2-adrenergic agonist, is effective in decreasing fecal water and sodium (Na) losses in patients with proximal jejunostomy. Eight parenteral nutrition (PN)-dependent subjects (3 men, 5 women), aged 49.9+/-10.2 years, with a residual small bowel length of 71.8+/-152.0 cm that ended in a jejunostomy, were studied.

METHODS

Subjects were admitted to the North-western General Clinical Research Center (GCRC) for a 2-day equilibrium period while receiving a self-selected 100 g fat diet with protein 1.5 g/kg/d and 30 kcal/kg/d and 1 L/d of oral rehydration solution. A D-xylose test was performed after an overnight fast. On days 3-5, all stool and urine were collected for volume, weight, fat, nitrogen, energy, sodium, magnesium, potassium, and calcium. Meals were provided in duplicate and the equivalent portions consumed by each patient were analyzed for fluid volume, fat, nitrogen, energy, sodium, magnesium, calcium, and potassium in order to calculate nutrient balances. At the conclusion of the stool and urine collections (day 6), a clonidine (0.3 mg) patch was applied to the shoulder. Subjects were restudied after 1 week.

RESULTS

Daily fecal volume and weight were 4.514+/-1.769 L/d and 4394+/-1727 g/d, respectively, at baseline. Five subjects were net "secretors" in that excreted fecal volume exceeded oral intake. Fecal volume decreased by 427+/-562 mL/d (8.9%, p=.07). Fecal weight decreased by 438+/-527 g/d (9.4%, p=.05). Urine volume correspondingly increased by 747+/-1934 mL (18.9%, p=not significant [NS]). The increase in urine output was weakly and negatively correlated with the decrease in fecal volume and weight (r=-0.37 and -0.41, respectively, p=NS). Oral fluid intake decreased slightly from 3.328+/-1.246 L/d baseline to 3.203+/-1.119 L/d with clonidine therapy (-3.8%, p=NS). Fecal Na loss was significantly decreased from baseline (887+/-996 mg/d, 11.2+/-12.3%; p=.036). This was not related to decreased oral Na intake, which actually increased from baseline (3.799+/-2.271 g/d) to 3.933+/-1.314 g/d after clonidine therapy (p=NS). No patient developed hypotension.

CONCLUSIONS

Our results show the transdermal administration of clonidine is associated with a modest but clinically significant decrease in fecal output in patients with short bowel syndrome and high-output proximal jejunostomy that require chronic parenteral fluid infusion. This is accompanied by decreased fecal Na loss.

Total Parenteral Nutrition: Challenges and Practice in the Cirrhotic Patient

Patients with cirrhosis develop metabolic derangements of protein, carbohydrate, and lipid metabolism. Malnutrition is commonplace and is associated with morbidity and mortality. Specific nutrient deficiencies may occur and enteral or parenteral nutritional support may improve outcome in appropriately selected patients. Parenteral nutrition itself has been associated with hepatic dysfunction, although the preponderance of evidence suggests that hepatic dysfunction is more a function of the underlying disorder and malabsorption. Intravenously infused organic nutrients may be metabolized differently than the same nutrient consumed enterally. The pathophysiology of total parenteral nutrition-associated liver disease is discussed as well as potential management options.

Nutritional support in patients with chronic liver disease

Malnutrition is highly prevalent among patients with chronic liver disease and is nearly universal among patients awaiting liver transplantation. Malnutrition in patients with cirrhosis leads to increased morbidity and mortality rates. Furthermore, patients who are severely malnourished before transplant surgery have a higher rate of complications and a decreased overall survival rate after liver transplantation. In light of the high incidence of malnutrition among patients with chronic liver disease and the complications that result from malnutrition in these patients, it is essential to assess the nutritional status of all patients with liver disease, and to initiate treatment as indicated. This review addresses the etiologies of malnutrition, methods used to assess nutritional status, and appropriate treatment strategies.