Fat-soluble Vitamin Deficiency Research Articles

Vitamin E status among bariatric surgery patients: a systematic review.

Vitamin E, a fat-soluble vitamin with antioxidant properties, is thought to modulate enzymes involved in signal transduction, affect gene expression, and have immunomodulatory capabilities. Severe vitamin E deficiency is associated with neuronal disorders, impaired immune response, hemolytic anemia, and oxidative-based disorders. Patients who undergo bariatric surgery (BS), especially malabsorptive procedures, are at greater risk of developing fat-soluble vitamin deficiencies. Current data on vitamin E statuses among BS patients are limited. Therefore, this systematic review has summarized the scientific literature on vitamin E and examined its status among patients following different types of BS. Searches of the MEDLINE and Embase databases were performed, followed by hand-searching of reference lists from all relevant papers. Of the 671 initially identified articles, 24 met the inclusion criteria: 1 study on adjustable gastric banding patients (n = 21), 4 studies on sleeve gastrectomy patients (n = 173), 12 studies on Roux-en-Y gastric bypass patients (n = 689) and 12 studies on biliopancreatic diversion with or without duodenal switch (n = 799) or single anastomosis duodeno-ileal bypass with sleeve gastrectomy patients (n = 163). Results suggest that patients who undergo malabsorptive procedures are at higher risk of developing vitamin E deficiency, although clinical manifestations of vitamin E deficits following BS are rarely documented. The optimal dose of vitamin E supplementation required for prevention of deficiency or for treatment following BS has yet to be established. Future observational and intervention studies are needed to bridge the gaps in existing knowledge.

Effect of Fat-Soluble Vitamins A, D, E and K on Vitamin Status and Metabolic Profile in Patients with Fat Malabsorption with and without Urolithiasis.

Patients with intestinal fat malabsorption and urolithiasis are particularly at risk of acquiring fat-soluble vitamin deficiencies. The aim of the study was to evaluate the vitamin status and metabolic profile before and after the supplementation of fat-soluble vitamins A, D, E and K (ADEK) in 51 patients with fat malabsorption due to different intestinal diseases both with and without urolithiasis. Anthropometric, clinical, blood and 24-h urinary parameters and dietary intake were assessed at baseline and after ADEK supplementation for two weeks. At baseline, serum aspartate aminotransferase (AST) activity was higher in stone formers (SF; n = 10) than in non-stone formers (NSF; n = 41) but decreased significantly in SF patients after supplementation. Plasma vitamin D and E concentrations increased significantly and to a similar extent in both groups during intervention. While plasma vitamin D concentrations did not differ between the groups, vitamin E concentrations were significantly lower in the SF group than the NSF group before and after ADEK supplementation. Although vitamin D concentration increased significantly in both groups, urinary calcium excretion was not affected by ADEK supplementation. The decline in plasma AST activity in patients with urolithiasis might be attributed to the supplementation of ADEK. Patients with fat malabsorption may benefit from the supplementation of fat-soluble vitamins ADEK.

S1584 Autoimmune Exocrine Pancreatic Insufficiency: A Novel Paraneoplastic Mechanism for Diarrhea in Patients With Thymoma

INTRODUCTION: Paraneoplastic syndromes are an exceedingly rare cause of chronic diarrhea. Thymomas have been associated with two known paraneoplastic diarrheal syndromes, namely in the context of hypogammaglobulinemia (Good’s syndrome) or a graft-versus-host disease (GVHD)-like condition. However, exocrine pancreatic insufficiency has yet to be reported as a cause of diarrhea in patients with thymoma. CASE DESCRIPTION/METHODS: A 36-year-old woman with no known medical morbidities presented with postprandial watery diarrhea, emesis, and 100-lb unintentional weight loss over two years. Labs were notable for lymphocytosis up to 8,100/mL with normal flow cytometry and no abnormalities on blood smear. Celiac disease serologies and stool infectious studies were negative. Immunoglobulin G levels were elevated at 3,010 mg/dL, and stool pancreatic elastase levels were low (< 15 mg/g). Additional labs were consistent with fat soluble vitamin deficiency: vitamin A < 5 mcg/dL, 25-hydroxyvitamin D < 4 ng/dL, vitamin E 7 mg/L, vitamin K 69 pg/mL. Computed tomography (CT) of the chest revealed an 11-cm anterior mediastinal mass with pleural and nodal metastases, and biopsy was suggestive of malignant thymoma (Figure 1). CT of the abdomen revealed a normal-appearing pancreas. Subsequent endoscopy and colonoscopy showed healthy-appearing mucosa with no abnormalities (Figure 2). However, colonic biopsies were notable for mild diffuse inflammatory changes including scattered intraepithelial lymphocytes and neutrophils, increased apoptotic bodies, and crypt architectural distortion. Her diarrhea ultimately improved after four cycles of induction chemotherapy. DISCUSSION: GVHD-like colitis in patients with malignant thymoma has been reported in several instances. This has been attributed to alterations in the thymic microenvironment, which lead to dysregulation and loss of anergy. Autoreactive T-cells can mount an immune response that impacts a number of organs, especially in the gastrointestinal tract. Although our patient had histopathological changes reflective of colitis secondary to GVHD, the severity of her diarrhea was out-of-proportion to these findings. The postprandial nature of her symptoms and markedly low stool pancreatic elastase were suggestive of possible pancreatic insufficiency, likely secondary to an autoimmune phenomenon impacting the exocrine glands of the pancreas. This case proposes a possible novel paraneoplastic mechanism for diarrhea in patients with thymoma.Figure 1.: Cross-section image of anterior mediastinal mass.Figure 2.: Normal-appearing duodenal mucosa.

Fat-soluble Vitamin Deficiency is Common in Children With Chronic Pancreatitis Undergoing Total Pancreatectomy With Islet Autotransplantation.

The prevalence of fat-soluble vitamin (FSV) deficiency in children undergoing total pancreatectomy with islet autotransplantation (TPIAT) for chronic pancreatitis (CP) is unknown. We quantified FSV deficiency in 100 children (age ≤18) undergoing TPIAT. FSV levels (vitamins A, E, D) and clinical history were abstracted from medical records. Vitamin A was low in 4% before and 7% at 1 year after TPIAT, vitamin E in 17% and 18%, and vitamin D in 22% and 24%, respectively, regardless of pancreatic enzyme or vitamin supplement dosing. Longer duration of CP was associated with pre-TPIAT vitamin D insufficiency (P = 0.0002). This remained significant in a multivariate regression model (adjusted P = 0.01). On multivariate analysis, there were no significant predictors of low FSV levels post-TPIAT. FSV deficiencies are common among children undergoing TPIAT and patients who have had longer disease duration may be at increased risk. All children should be monitored for FSV deficiency after TPIAT.

Vitamin E supplementation in people with cystic fibrosis.

People with cystic fibrosis are at an increased risk of fat-soluble vitamin deficiency, including vitamin E. Vitamin E deficiency can cause a host of conditions such as haemolytic anaemia, cerebellar ataxia and cognitive difficulties. Vitamin E supplementation is widely recommended for people with cystic fibrosis and aims to ameliorate this deficiency. This is an updated version of the review. To determine the effects of any level of vitamin E supplementation on the frequency of vitamin E deficiency disorders in people with cystic fibrosis. We searched the Cochrane Group's Cystic Fibrosis Trials Register and also searched international online trial registries for any ongoing clinical trials that were not identified during our register search. Date of last search of the Register: 11 August 2020. Date of last search of international online trial registries: 20 July 2020. Randomised controlled trials and quasi-randomised controlled trials comparing any preparation of vitamin E supplementation to placebo or no supplement, regardless of dosage or duration. Two authors extracted outcome data from each study (published information) and assessed the risk of bias of each included study. They assessed the quality of the evidence using GRADE. Four studies with a total of 141 participants were included in the review, two of these were in children (aged six months to 14.5 years), and two did not specify participants' age. All studies used different formulations and doses of vitamin E for various durations of treatment (10 days to six months). Two studies compared the supplementation of fat-soluble as well as water-soluble formulations to no supplementation in different arms of the same study. A third study compared a water-soluble formulation to a placebo; and in the fourth study a fat-soluble formulation of vitamin E was assessed against placebo. There was limited detail about randomisation and blinding in the included studies which compromises the quality of the evidence base for the review. The heterogeneous mix of the formulations with differing biovailabilities among these studies also limits the generalisability of the data to the wider cystic fibrosis population. None of the studies in either comparison report the review's primary outcomes of vitamin E total lipid ratio or the incidence of vitamin E-specific deficiency disorders, or the secondary outcomes lung function or quality of life. Water-soluble vitamin E Water-soluble vitamin E may improve serum vitamin E levels compared with control at six months, one study (45 participants), mean difference (MD) 19.74 umol/L (95% confidence interval (CI) 13.48 to 26.00) (low-quality evidence). Similar results were also seen at one month, two studies (32 participants), MD 17.66 umol/L (95% CI 10.59 to 24.74) and at three months, one study (45 participants), MD 11.61 umol/L (95% CI 4.77 to 18.45). Only one study (45 participants) reported weight (secondary outcome of growth and nutritional status) at one and six months, but showed no difference between treatment and control at either time point. Fat-soluble vitamin E Two studies (36 participants) reported higher levels of serum vitamin E at one month with fat-soluble vitamin E compared with control, MD 13.59 umol/L (95% CI 9.52 to 17.66); however, at three months one study (36 participants) showed no difference between treatment and control. No studies in this comparison reported on growth or nutritional status. Vitamin E supplementation may lead to an improvement in vitamin E levels in people with cystic fibrosis, although evidence we assessed was low quality. No data on other outcomes of interest were available to allow conclusions about any other benefits of this therapy. In future, larger studies are needed, especially in people already being treated with enteric-coated pancreatic enzymes and supplemented with vitamin E, to look at more specific outcome measures such as vitamin E status, lung function and nutritional status. Future studies could also look at the optimal dose of vitamin E required to achieve maximal clinical effectiveness.

One Anastomosis Gastric Bypass with a Biliopancreatic Limb of 150cm: Weight Loss, Nutritional Outcomes, Endoscopic Results, and Quality of Life at 8-Year Follow-Up.

One anastomosis gastric bypass (OAGB) is now recognized as a mainstream bariatric procedure, nonetheless concerns about the risk of nutritional deficiencies and biliary reflux persist, and the ideal length of the biliopancreatic limb (BPL) is debated. Data of patients who underwent OAGB between May 2010 and December 2010 were collected prospectively and analyzed retrospectively. At an 8-year follow-up, a complete evaluation included clinical examination, blood tests, upper gastrointestinal endoscopy, and quality of life (QoL) assessed through the BAROS score. Overall, 115 patients underwent OAGB with a BPL of 150cm. Thirty-six (31%) were lost at the 8-year follow-up. Mean preoperative weight was 117 ± 20.8kg and mean BMI 43.2 ± 5.8kg/m2. At 8years, weight was 76.5 ± 17.3kg, BMI 28.3 ± 5.8, %TWL 34.8 ± 10.7, and %EWL 84.8 ± 27.1. No patients were readmitted for nutritional complications or underwent revisional surgery for malnutrition; 6 patients were converted to Roux-en-Y gastric bypass for intractable reflux. High rates of vitamin D and A deficiencies and secondary hyperparathyroidism were found at 8years. The BAROS score was > 3 at 8years for 93% of patients. Upper gastrointestinal endoscopy was available for 46 patients and found esophagitis in 6.5% of cases but no cases of Barrett's esophagus. OAGB performed with a 150-cm BPL is an effective bariatric procedure, associated with good long-term outcomes in relation to weight loss, QoL, resolution of comorbidities, and a very low rate of protein-calorie malnutrition. Fat-soluble vitamin deficiencies represent the main long-term concern. Endoscopic findings at 8years are reassuring.

Vitamin K supplementation for cystic fibrosis.

Malabsorption and deficiency of fat-soluble vitamins K may occur in cystic fibrosis, a genetic disorder affecting multiple organs. Vitamin K is known to play an important role in both blood coagulation and bone formation, hence the role of supplementation of vitamin K in this category needs to be reviewed. This is an updated version of the review. To assess the effects of vitamin K supplementation in people with cystic fibrosis and to investigate the hypotheses that vitamin K will decrease deficiency-related coagulopathy, increase bone mineral density, decrease risk of fractures and improve quality of life in people with CF. Also to determine the optimal dose and route of administration of vitamin K for people with CF (for both routine and therapeutic use). We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. Most recent search: 12 August 2019. Randomised controlled trials of all preparations of vitamin K used as a supplement compared to either no supplementation (or placebo) at any dose or route and for any duration, in patients with cystic fibrosis. Two authors independently screened papers, extracted trial details and assessed their risk of bias. The quality of the evidence was assessed using the GRADE criteria. Three trials (total 70 participants, aged 8 to 46 years) assessed as having a moderate risk of bias were included. One trial compared vitamin K to placebo, a second to no supplementation and the third compared two doses of vitamin K. No trial in either comparison reported our primary outcomes of coagulation and quality of life or the secondary outcomes of nutritional parameters and adverse events. Vitamin K versus control Two trials compared vitamin K to control, but data were not available for analysis. One 12-month trial (n = 38) compared 10 mg vitamin K daily or placebo in a parallel design and one trial (n = 18) was of cross-over design with no washout period and compared 5 mg vitamin K/week for four-weeks to no supplementation for four-weeks. Only the 12-month trial reported on the primary outcome of bone formation; we are very uncertain whether vitamin K supplementation has any effect on bone mineral density at the femoral hip or lumbar spine (very low-quality evidence). Both trials reported an increase in serum vitamin K levels and a decrease in undercarboxylated osteocalcin levels. The cross-over trial also reported that levels of proteins induced by vitamin K absence (PIVKA) showed a decrease and a return to normal following supplementation, but due to the very low-quality evidence we are not certain that this is due to the intervention. High-dose versus low-dose vitamin K One parallel trial (n = 14) compared 1 mg vitamin K/day to 5 mg vitamin K/day for four weeks. The trial did report that there did not appear to be any difference in serum undercarboxylated osteocalcin or vitamin K levels (very low-quality evidence). While the trial reported that serum vitamin K levels improved with supplementation, there was no difference between the high-dose and low-dose groups. There is very low-quality evidence of any effect of vitamin K in people with cystic fibrosis. While there is no evidence of harm, until better evidence is available the ongoing recommendations by national CF guidelines should be followed.

Treatment of rickets and dyslipidemia in twins with progressive familial intrahepatic cholestasis type 2

BackgroundProgressive Familial Intrahepatic Cholestasis Type 2 (PFIC2) is a rare congenital cholestatic liver disease that progresses to end stage liver disease. It is associated with fat soluble vitamin D deficiency rickets and severe dyslipidemia; however, treatment of these secondary effects remains a challenge.Case presentationOne year old twin males born to a mother with intrahepatic cholestasis during pregnancy presented with jaundice, pruritus and failure to thrive. Lab evaluation revealed significant transaminitis, direct hyperbilirubinemia and normal gamma glutamyl transferase (GGT). Genetic studies confirmed PFIC2. Further evaluation for fat soluble vitamin deficiencies revealed severe vitamin D deficiency rickets. High dose vitamin D replacement therapy using Ergocalciferol (Vitamin D2) 50,000 IU three times a week over 10 weeks led to the improvement of Vitamin D, 25-Hydroxy (25-OH) serum levels and resolution of rickets. Dyslipidemia with very low high density lipoprotein-cholesterol (HDL-C) and high triglycerides was more profound in our patients compared to what has been described in the literature thus far. The dyslipidemia improved 2 months after internal biliary diversion.ConclusionsHigher doses of Vitamin D therapy are needed for treatment of rickets secondary to cholestasis. Extremely low HDL-C levels are characteristic of PFIC and improve with treatment of underlying cholestasis. Maternal intrahepatic cholestasis during pregnancy can be an early warning sign.

Celiac Disease and Obesity: Is Bariatric Surgery an Option?

Celiac disease is an immune-mediated enteropathy associated with malabsorptive syndrome and fat-soluble vitamin deficiencies. Celiac disease affects 1% of individuals but is largely underdiagnosed, as its multifaceted clinical presentations create challenging diagnostic scenarios. With the rise of the obesity epidemic, doctors are increasingly seeing celiac disease patients with overweight or obesity, which raises the question of bariatric surgery. However, few studies so far have investigated bariatric surgery in this patient population. Here, we provide a comprehensive review of the literature on celiac disease, its nutritional consequences and complications, and we discuss the possible impact of bariatric surgery on weight loss, nutritional deficiencies, response to gluten-free diet, and long-term post-operative complications. We also review the effect of bariatric surgery on the incidence of celiac disease.

A111 SEVERE FAT MALABSORPTION IN A PATIENT POST ILEAL POUCH ANAL ANASTAMOSIS: A RARE PRESENTATION OF MICROSCOPIC ENTERITIS

Abstract Background Microscopic enteritis (ME) is a rare enteropathy characterized by malabsorptive diarrhea and lymphocytic infiltration +/- collagen deposition in the subepithelial layer of the small bowel. Its etiology is unclear. Aims To elucidate a rare cause of fat malabsorption and vitamin deficiency in a patient with ulcerative colitis and an ileoanal pouch. Methods A 74 yo male with a prior IPAA was referred to Internal Medicine in August 2018 for a 36 kg weight loss over 18 months and &amp;gt;16 bowel movements (BM) per day (baseline 6, no history of pouchitis). Celiac serology and infectious workup were negative. Medical management and nutritional supplements did not result in weight gain or improvement of diarrhea. He was admitted in June 2019 with ongoing weight loss, AKI, and signs of fat-soluble vitamin deficiency. A 72-hour fecal fat analysis showed an average fecal weight of 2100 g/d (ref &amp;lt;250 g/d), and excretion of 70% of daily fat intake (ref &amp;lt;7%). His fecal elastase (FE) was 147 µg/g, consistent with moderate pancreatic insufficiency (PI) with mild atrophy on CT. EGD and pouch endoscopy were macroscopically normal, with histological findings of intraepithelial lymphocytosis and mild villous blunting in the duodenum and afferent limb. CT enterography excluded small bowel abnormalities. He was started on pancreatic enzyme replacement and discharged. He returned with worsening diarrhea and AKI. He was treated with supportive care and sent home. In the ensuing 3 weeks, he had up to 24 BM per day and 4 kg of weight loss. He returned in August 2019 with AKI, lack of PO intake and worsened nutritional status. Re-examination of duodenal biopsies from June 2019 revealed an added finding of focal subepithelial collagen thickening. Budesonide was started. Results On budesonide, his symptoms improved within days. BMs decreased to baseline, and his ability to sustain PO intake improved. At his 4-week follow-up visit, BMs were stable with a 6 kg weight gain and no ensuing laboratory abnormalities. Conclusions ME is a rare enteropathy that presents with malabsorption. Fat-soluble vitamin deficiencies can develop with widespread physiological disruption of the mucosal surface. This patient was a diagnostic challenge. His steatorrhea and reduced FE levels led clinicians down a diagnostic pathway of PI. FE is the most common test used in the diagnosis of PI. Levels &amp;lt;200 µg/g are abnormal. Specificity is highest in chronic pancreatitis; however, this decreases in the presence of mucosal atrophy (i.e. IBD and diffuse small bowel disease). Thus, FE could not delineate the cause of steatorrhea in our patient. We can surmise that he likely has diffuse disease that was underestimated on duodenal biopsy. This is supported by his response to budesonide. This case highlights the heterogeneity of clinical presentations of ME. Awareness can reduce patient morbidity. Funding Agencies None

A276 TOTAL PANCREATIC LIPOMATOSIS AND EXOCRINE PANCREATIC INSUFFICIENCY IN A PATIENT WITH CELIAC DISEASE: AN UNUSUAL ENTITY

Abstract Background Exocrine pancreatic insufficiency (EPI) is characterized by maldigestion and malabsorption of nutrients and is most commonly caused by diseases of the pancreatic parenchyma including chronic pancreatitis and cystic fibrosis (CF). However, EPI is also observed in other conditions including celiac disease (CD). Aims We report a case of EPI in a patient with CD found to have total fatty replacement of the pancreas. Methods A case report and review of the literature were performed. Results Case Report: A 42-year-old man with CD on gluten-free diet (GFD) presented with a two-year history of increasing bowel frequency (4–6 times daily) and steatorrhea. Quantitative fecal fat over 72 hours confirmed fecal fat excretion of 101g/day; N &amp;lt; 7g) and total stool weight of 3761g. Nadir weight was 67.6 kg. There was a dramatic response to pancreatic enzyme replacement therapy (PERT) with marked improvement in bowel habits and weight gain to 74.8 kg over half a year. There is no history of pancreatitis, abdominal pain or alcohol abuse. He does not smoke but drinks 1–2 units of alcohol per week at most. Family history is negative for pancreatitis and pancreatic malignancy. On examination, following PERT, the patient appeared well-developed and nourished. He did not have clinical features or biochemical evidence of fat-soluble vitamin deficiency following PERT. Anti-tTG was equivocal (7.6 U/mL; N &amp;lt; 7 U/mL). IgG subclasses were normal. Chromogranin was mildly elevated (100mcg/L; N &amp;lt; 94mcg/L), but gastrin (15ng/L) and 24-hour urine for 5-hydroxyindoleacetate [5-HIAA] (23umol/d) were normal. Endoscopic evaluations including upper endoscopy, colonoscopy, and capsule endoscopy demonstrated intact duodenal villous architecture without inflammation, no microscopic colitis, and no small bowel mucosal disease, respectively. CT of the abdomen revealed total fatty replacement of the pancreas with no pancreatic parenchyma (Figure 1). Sweat sodium test was positive (67 mmol/L, N &amp;lt; 60 mmol/L) but CFTR gene sequencing was negative. There was no evidence of diabetes, hyperlipidemia, hyperferritinemia, Cushing’s syndrome, or hepatic disease on biochemical investigations. Literature Review: Total pancreatic lipomatosis (TPL), or fatty replacement of the pancreas, is a rare cause of EPI which leads to maldigestion, malabsorption, and malnutrition. The pathogenesis of TPL is poorly understood but predisposing factors include obesity, diabetes mellitus, hyperlipidemia, malnutrition, Cushing’s syndrome, hemochromatosis, chronic pancreatitis and CF. EPI can also manifest in patients with CD due to active small bowel inflammation or chronic pancreatitis. Last but not least, there appears to be higher prevalence of CD in CF patients. Conclusions Persistent steatorrhea with weight loss despite GFD in patients with CD should prompt other considerations of EPI and trial of PERT. Funding Agencies None

Fat-soluble vitamin deficiency and subsequent coagulopathy in a cat with exocrine pancreatic insufficiency

This report describes the clinical signs, diagnostic findings and treatment of a female spayed Domestic Shorthair with exocrine pancreatic insufficiency (EPI) who presented in shock due to severe gastrointestinal haemorrhage...

Identification of fat-soluble vitamins deficiency using artificial neural network

The fat-soluble vitamins (A, D, E, K) deficiency remain frequent universally and may have consequential adverse resultants and causing slow appearance symptoms gradually and intensify over time. The vitamin deficiency detection requires an experienced physician to notice the symptoms and to review a blood test’s result (high-priced). This research aims to create an early detection system of fat-soluble vitamin deficiency using artificial neural network Back-propagation. The method was implemented by converting deficiency symptoms data into training data to be used to produce a weight of ANN and testing data. We employed Gradient Descent and Logsig as an activation function. The distribution of training data and test data was 71 and 30, respectively. The best architecture generated an accuracy of 95 % in a combination of parameters using 150 hidden layers, 10000 epoch, error target 0.0001, learning rate 0.25.

Fat soluble vitamins deficiency in pediatric chronic liver disease: The impact of liver transplantation

BackgroundChildren affected with chronic liver disease are at risk for fat-soluble vitamins (FSV) deficiency, in this scenario the role of liver transplant has been only partially explored. AimsThis study aimed to evaluate the prevalence of FSV deficiency in a cohort of paediatric patients awaiting liver transplant, analyze relationships between plasma vitamin concentrations and risk of acute rejections and liver fibrosis and assess the impact of the transplant on vitamin status. Methods166 children candidates for liver transplant were retrospectively evaluated. Vitamin concentrations were measured before and 12 months after transplantation. ResultsBefore transplant vitamin A, vitamin E and vitamin D deficiency was found in 66.6%, 40.6% and 36.3% of patients, respectively. 12 months after surgery, the prevalence of deficiency decreased to 29,5% and 2,6% for vitamin A and E while remained the same for vitamin D (36.3%). No association was found between vitamin status and the risk of acute rejections or the severity of liver fibrosis. ConclusionLiver transplant was effective to improve vitamin A and E, but it did not affect vitamin D. A consensus is needed to define optimal nutritional management of these patients in order to prevent deficiencies.

WITHDRAWN: Fat soluble vitamins deficiency in pediatric chronic liver disease: The impact of liver transplantation.

The Publisher regrets that this article is an accidental duplication of an article that has already been published, https://doi.org/10.1016/j.dld.2019.10.005. The duplicate article has therefore been withdrawn. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.

1381 Bile Reinfusion in Obstructive Jaundice

INTRODUCTION: Bile acid and salts depletion from percutaneous transhepatic cholangiodrainage (PTCD) in obstructive jaundice can lead to fat malabsorption causing malnutrition and fat-soluble vitamin deficiencies, dehydration, acute kidney injury (AKI) and electrolyte abnormalities. Bile reinfusion (BR) is a method of enteral feeding of biliary drain secretions for restoration of bile salts in the gut. We describe a case of oral BR in a patient with PTCD for choledocholithiasis. CASE DESCRIPTION/METHODS: A 64 year-old Caucasian woman with history of gastric adenocarcinoma requiring subtotal gastrectomy and roux-en-y gastric reconstruction presented with nausea, vomiting, and epigastric pain. Imaging showed a stone in the mid common bile duct (CBD) measuring 0.7 × 0.6 cm causing mild biliary dilation. An endoscopic retrograde cholangiopancreatography (ERCP) was attempted with unsuccessful cannulation due to abnormal anatomy from prior surgeries. Hence, an open CBD exploration was performed for stone extraction and a 14 French percutaneous T-tube was placed for PTCD. Post-operatively, she developed large volume output (∼1-2 L/day) from the T-tube, loose stools and AKI with rise in creatinine from 1.12 to 2.96 mg/dL. She was started on BR 4 times/day by mouth (mixed with juice in 1:1 ratio). Over the next few weeks, she had resolution of diarrhea with a slow renal recovery. DISCUSSION: BR has shown variable success as reported in a few case reports and small studies mainly focusing on patients with pancreatitis with enteric fistulae, and obstructive cholangiocarcinoma. 1,2 Tripathy et al. demonstrated that it is a cost-effective method for hastened renal recovery, a common complication in patients with obstructive jaundice. 3 In conclusion, BR should be considered in patients with PTCD as an alternate to exogenous bile salt administration for improved enterohepatic equilibrium.

Management of pancreatic exocrine insufficiency.

Pancreatic exocrine insufficiency (PEI) is one of the well known causes of malabsorption syndrome. An insufficient secretion of pancreatic enzymes and bicarbonate secondary to different pancreatic diseases and upper gastrointestinal and pancreatic surgery leads to maldigestion and malabsorption of nutrients. Patients with PEI may present with symptoms of malabsorption and different nutritional deficiencies. Recent data support the high clinical relevance of PEI and its treatment. Deficiencies of fat-soluble vitamins, proteins, micronutrients and antioxidants in patients with PEI are associated not only with an increased risk of osteoporosis and sarcopenia but also of cardiovascular events and mortality. Pancreatic enzyme replacement therapy (PERT) allows improving fat and protein digestion, relieving maldigestion-related symptoms, normalizing the nutritional status, and improving quality of life of patients with PEI. Recent data support the efficacy of PERT on survival in patients with pancreatic cancer. Dose of oral pancreatic enzymes should be adequate to normalize the nutritional status of PEI patients. Increasing evidence supports the relevance of PEI management by dietary advice and appropriate PERT. Well designed and powered randomized, placebo-controlled clinical trials are needed to further evaluate the clinical impact of PEI and its treatment in clinical practice.

54 Lipid nutrition and gut health of pigs

Abstract Lipids and fatty acids play major roles in relation to mucosal immune responses, epithelial barrier functions, oxidative stress and inflammatory reactions. The composition of fatty acids and their molecular structures (chain length and number of double bonds) influences digestion, absorption and metabolism of the dietary fat, as well as the bioactivity of the fatty acids. Piglets post weaning having immature intestines and immune functions are very vulnerable towards invading microorganisms. Manipulation of the milk fatty acid composition via the sow nutrition, or inclusion of dietary fat sources in the feed, may be used as a strategic tool to enhance pig performance and their gut health pre- and post weaning. Medium-chained fatty acids (MCFA) are absorbed directly into the portal blood and may contribute with immediate energy for the piglet. In addition, the MCFA possess antibacterial effects. The essential fatty acids, linoleic and linolenic fatty acids, form the building blocks for the longer –chained polyunsaturated n-3 and n-6 fatty acids. Their conversion into n-3 and n-6 eicosanoids influence the inflammatory reactions and the immune responses upon bacterial challenge. The proportion of unsaturated fatty acids in the cell membranes influence the susceptibility to oxidative stress. Oxidative stress accompanies infectious diseases, and if uncontrolled, the development of the lipid peroxides may be harmful for the epithelial barrier function. The aim of this presentation is to review how dietary fatty acid composition during critical phases of pigs’ lives can support a normal immune system and modulate resistance to infectious diseases of pigs, and influence growth of the pig. Furthermore, factors that can enhance oxidative stress (e.g. polyunsaturated fatty acids), uncontrolled inflammatory reactions (e.g. high ratio of n-6 to n-3 fatty acids in cellular membranes), and limit immune development (such as deficiency of fat-soluble vitamins), and be harmful for the pig gut health are addressed.

Vitamin K and cystic fibrosis: A gordian knot that deserves our attention.

Cystic fibrosis (CF) is an inherited genetic disorder with multiorgan involvement. Gastrointestinal tract dysfunction leads to fat and fat-soluble vitamins (A,D,E,K) malabsorption and deficiency of these vitamins. Subclinical vitamin K (VK) deficiency seems to be a common problem in CF patients. However, despite the rest of fat-soluble vitamins being routinely supplemented, this is not a universal clinical practice for VK. Inefficient levels of VK may have significant effects on blood coagulation and bone formation. There are also some data indicating that VK may play a key role on regulation of inflammation. Supplementing CF patients with VK seems rational, but the appropriate dosing regimens are still a matter of debate. This review will try to delineate the problem and communicate the latest opinions on this controversial issue.

Nutritional and vitamin status in patients with neuroendocrine neoplasms.

Symptoms of gastroenteropancreatic located neuroendocrine neoplasms (GEP-NENs) are often related to food intake and manifest as abdominal pain or diarrhoea which can influence patients nutritional status. Malnutrition is common in cancer patients and influences quality of life, treatment options and survival but is also present in up to 40% of patients with GEP-NENs. As part of malnutrition there are often deficiencies in fat-soluble vitamins, mainly vitamin D. Little knowledge exists on trace elements. Several factors influence the development of malnutrition such as size and localisation of the primary tumour as well as metastases, side effects from treatment but also hormone production of the tumour itself. One of the main influencing factors leading to malnutrition is diarrhoea which leads to dehydration and electrolyte disturbances. Treatment of diarrhoea should be guided by its cause. Screening for malnutrition should be part of routine care in every GEP-NEN patient. Multidisciplinary treatment including dietician support is necessary for all malnourished patients with GEP-NENs.