Jejunal efflux in short bowel syndrome

doi:10.1016/0140-6736(90)93238-K

The Lancet

Volume 336, Issue 8718, 29 September 1990, Pages 765-768

https://doi.org/10.1016/0140-6736(90)93238-K Get rights and content

Abstract

24 h oral intake and intestinal output were studied in 15 patients with a short residual length of jejunum and no colon. 8 patients showed a net secretory, and 7 a net absorptive response to food. In secretors, daily intestinal output exceeded oral intake (mean 2·3 kg wet weight, and 233 mmol sodium). Long-term parenteral fluid and electrolyte replacements were needed only in those with a secretory response. Jejunal length inversely correlated with net intestinal output of fluid, sodium, potassium, and with percentage energy absorption. A secretory response was observed if jejunal length was less than 100 cm and was reduced by gastric antisecretory drugs and octreotide.

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Cited by (174)

ESPEN guideline on chronic intestinal failure in adults – Update 2023
2023, Clinical Nutrition
In 2016, ESPEN published the guideline for Chronic Intestinal Failure (CIF) in adults. An updated version of ESPEN guidelines on CIF due to benign disease in adults was devised in order to incorporate new evidence since the publication of the previous ESPEN guidelines.
The grading system of the Scottish Intercollegiate Guidelines Network (SIGN) was used to grade the literature. Recommendations were graded according to the levels of evidence available as A (strong), B (conditional), 0 (weak) and Good practice points (GPP). The recommendations of the 2016 guideline (graded using the GRADE system) which were still valid, because no studies supporting an update were retrieved, were reworded and re-graded accordingly.
The recommendations of the 2016 guideline were reviewed, particularly focusing on definitions, and new chapters were included to devise recommendations on IF centers, chronic enterocutaneous fistulas, costs of IF, caring for CIF patients during pregnancy, transition of patients from pediatric to adult centers. The new guideline consist of 149 recommendations and 16 statements which were voted for consensus by ESPEN members, online in July 2022 and at conference during the annual Congress in September 2022. The Grade of recommendation is GPP for 96 (64.4%) of the recommendations, 0 for 29 (19.5%), B for 19 (12.7%), and A for only five (3.4%). The grade of consensus is “strong consensus” for 148 (99.3%) and “consensus” for one (0.7%) recommendation. The grade of consensus for the statements is “strong consensus” for 14 (87.5%) and “consensus” for two (12.5%).
It is confirmed that CIF management requires complex technologies, multidisciplinary and multiprofessional activity, and expertise to care for the underlying gastrointestinal disease and to provide HPN support. Most of the recommendations were graded as GPP, but almost all received a strong consensus.
Six-month outcomes of teduglutide treatment in adult patients with short bowel syndrome with chronic intestinal failure: A real-world French observational cohort study
2020, Clinical Nutrition
Citation Excerpt :
Our results also highlighted that more patients could be weaned from PS in patients with colon in continuity. This is quite understandable as their baseline PS volume needs are generally lower compared to those of patients with end-jejunostomy (Group 1) and consistent with the substantial evidence that preserving the colon as an energy salvage organ is essential for reducing the need for PS in SBS patients [15–17]. Finally, eight patients showed no or insufficient response after 6 months of drug exposure, of whom seven were patients with colon in continuity.
Teduglutide, a GLP-2-analog, has proven effective in two placebo-controlled studies in reducing parenteral support (PS) in patients with short bowel syndrome-associated intestinal failure (SBS-IF) after 24 weeks. The aim of this study was to describe in a real-life situation the effects of teduglutide treatment and their predictive factors.
We included 54 consecutive SBS-IF patients treated with teduglutide in France for at least 6 months from 10 expert centers. Small bowel length was 62 ± 6 cm and 65% had colon in continuity. PS was 4.4 ±0 .2 infusions per week, started 9.8 ± 1.2 years before. Response (PS reduction ≥ 20%) and PS discontinuation rates were assessed at week 24. Adjusted p values of factors associated with response and weaning were calculated using a multivariate logistic regression model.
At week 24, 85% of patients were responders and 24% had been weaned off PS, with a 51% reduction of PS needs and 1.5 ± 0.2 days off PS per week. Response to teduglutide was influenced by a higher baseline oral intake (p = 0.02). Weaning off PS was influenced by the presence of colon (p = 0.04), a lower PS volume (p = 0.03) and a higher oral intake (p = 0.01). There were no differences based on age, bowel length or SBS-IF causes.
Our study confirms the effectiveness of teduglutide in reducing PS needs in SBS-IF patients. We associated reduced parenteral support volume with baseline parenteral volume support, bowel anatomy, and oral intake. These findings underline the role of nutritional optimization when starting the treatment.
Gastrointestinal Tract Reconstruction in Adults with Ultra-Short Bowel Syndrome: Surgical and Nutritional Outcomes
2020, Surgery (United States)
Citation Excerpt :
The highest parenteral support needs in patients with end ostomy or tube decompression is not only associated with absence of a colon and its role on fluid and nutrient absorptive capacity, but also the lack of adequate absorption of gastric, pancreatobiliary, and jejunal secretions. These patients with short gut and end ostomies are considered “net secretors” since their output tends to be higher than their intake.13,16 In addition, patients with type I short bowel syndrome also exhibit accelerated gastric emptying and intestinal transit due to lack of ileal and colonic L cells that produce motility regulatory peptides such as PYY and GLP-1.16
Historically, adults with ultra short bowel syndrome (USBS) have been considered candidates for lifetime parenteral nutrition (PN) or are referred for visceral transplantation. We examined the surgical and nutritional outcomes of adult patients with USBS managed at a single intestinal rehabilitation center.
We retrospectively reviewed data on 588 adult patients referred to our center between January 2013 and December 2018. USBS was defined as residual small bowel (SB) length ≤ 50 cm.
Forty-five patients (7.6%) with a mean age of 46.7 years (range 17-78) were identified. Indications for enterectomy included mesenteric ischemia (n=17) and internal hernias (n=6), followed by large intraabdominal fibroids, trauma, and allograft enterectomies, with five cases each. Median SB length was 18.0 cm; 20 patients (44.4%) had their entire SB resected. Thirteen patients had an intact colon, of which nine had preservation of the ileocecal valve. Patients who underwent autologous reconstruction of their gastrointestinal (GI) tract required a lower total PN volume (29.0 ± 7.6 vs. 40.8 ± 13.2 ml/Kg/day, p=0.002) and presented better short- and long- term survival (p=0.005). Patients with no gut had higher mortality (p=0.036). Hormonal therapy with the glucagon-like peptide-2 analog teduglutide was used in nine patients (20%) five of whom were weaned off TPN. Excluding patients with no gut (n=20), discontinuation of total PN rate for patients with an end ostomy or tube decompression (n= 6), jejunocolostomy (n= 10), and jejunoileostomy (n=9) were 0%, 40%, and 77.7%, respectively. Eleven patients (44%) with some residual small intestine achieved nutritional autonomy in an average of 20 months after GI reconstruction. Fifteen patients were listed for transplantation (33.3%). Seven patients underwent isolated SB transplantation and achieved nutritional autonomy in an average of three months after transplantation. One-year patient and graft survival were 100%. After a 37-month median follow-up period, 36 of 42 patients followed by our center were still alive (85.7%).
Nutritional autonomy can be achieved in a significant number of patients with USBS in specialized centers with surgical and/or hormonal therapy. The presence of an intact colon and ileocecal valve can significantly increase the adaptation rate. Moreover, restoration of GI tract continuity has a positive impact on medical management and survival.
ESPGHAN/ESPEN/ESPR/CSPEN guidelines on pediatric parenteral nutrition: Fluid and electrolytes
2018, Clinical Nutrition
Intestinal Failure and Rehabilitation
2018, Gastroenterology Clinics of North America
Citation Excerpt :
Such solutions operate on the principle that sodium and glucose are co-transported into the enterocyte, and water follows as a result of solvent drag.49 Stomal sodium loss in effluent is approximately 90 to 100 mmol/L, and therefore such patients often secrete more sodium than they consume orally.50,51 Therefore, ORS should ideally contain 100 mmol/L of sodium.
Is it possible to stop intravenous ranitidine in children with long-term parenteral nutrition?
2018, Nutrition Clinique et Metabolisme
En raison de l’hypersécrétion gastrique et/ou d’importantes pertes intestinales, certains patients nécessitent un apport en ranitidine dans leur mélange de nutrition parentérale (NP). L’objectif était de réévaluer l’intérêt clinique de la ranitidine dans les prescriptions de NP suite à des tensions d’approvisionnement en ranitidine injectable.
Un suivi clinique prospectif des patients en NP à domicile (NPAD) a été réalisé pendant 4 mois selon trois critères : l’arrêt, la substitution ou le maintien de la ranitidine dans les prescriptions de NP.
Parmi les 109 patients en NPAD, 64 (59 %) bénéficiaient de ranitidine dans leur NP. L’arrêt définitif, tenté chez 23 patients (36 %), s’est soldé par deux échecs avec retour à la prescription initiale. Le relais per os a concerné 22 patients (34 %) et a conduit à quatre échecs. Pour ces 6 patients, des nausées/vomissements et des accélérations du transit intestinal ont été observés. Ces effets secondaires ont concerné des patients atteints d’un syndrome du grêle court (SGC). Enfin, chez 19 patients (30 %) atteint soit d’un SGC sévère, d’une Maladie de Hirschsprung étendue ou d’une Pseudo obstruction intestinale chronique, la ranitidine a dû être maintenue.
Une réévaluation des prescriptions a été menée en respectant les profils cliniques particuliers des patients avec l’arrêt d’un grand nombre de prescription de ranitidine. Cependant, la ranitidine reste indispensable chez les patients présentant de graves troubles digestifs (nausées, vomissements, pertes élevées). Néanmoins, la voie intraveineuse peut être relayée par la voie orale quand cela est possible, associée à un suivi clinique.
Because of gastric hypersecretion and/or high water-electrolytes losses, some patients require ranitidine in their parenteral nutrition (PN) mixture. Our goal was to reassess the clinical utility of adding ranitidine in NP mixtures following tensions in the supply of ranitidine for parenteral injection.
A prospective clinical follow-up of patients on home parenteral nutrition (HPN) over a period of 4 months was carried out according to three criteria: “stopping”, “substituting” or “maintaining” ranitidine in NP prescriptions.
At the beginning of the study, 109 patients were followed on HPN program. Most of them (48 %) having short bowel syndrome (SBS). Initially, 64 patients were receiving ranitidine in association with PN. Attempt to stop IV Ranitidine was achieved in 23 patients (36 %): 2 failures led to reverse to the initial prescription. The change to the oral route involved 22 patients (34 %) with 4 failures. These failures occurred shortly after modifications, with nausea/vomiting, increased water-electrolytes losses in SBS patients. On 19 patients (30 %), ranitidine was maintained, due to insufficient intestinal absorption from children with extreme SBS, extended Hirschsprung Disease, and Chronic Intestinal Pseudo Obstruction.
A review of ranitidine prescriptions was conducted according to specific clinical profiles of patients. Ranitidine appears necessary for patients with severe digestive disorders. Nevertheless, an oral administration of ranitidine can be considered with clinical monitoring.

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Jejunal efflux in short bowel syndrome

Abstract

Lancet

Gastroenterology

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

Aliment Pharmacol Ther

A ballistic bomb calorimeter

Br J Nutr

Effect of different drinks on fluid and electrolyte losses from a jejunostomy

J R Soc Med

Studies of intestinal digestion and absorption in the human

J Clin Invest

Ionic constituents and osmolality of gastric and small intestinal fluids after eating

Am J Dig Dis