Ileostomy Fluid Research Articles

Moving towards in pouch diagnostics for ostomy patients: exploiting the versatility of laser induced graphene sensors

The development of a 3D printed sensor for direct incorporation within stoma pouches is described. Laser induced graphene scribed on either side of polyimide film served as the basis of a 2 electrode configuration that could be integrated within a disposable pouch sensor for the periodic monitoring of ileostomy fluid pH. The graphene sensors were characterised using electron microscopy, Raman spectroscopy, DekTak profilometry with the electrochemical properties investigated using both cyclic and square wave voltammetry. Adsorbed riboflavin was employed as a biocompatible redox probe for the voltammetric measurement of pH. The variation in peak position with pH was found to be linear over pH 3–8 with a sub Nernstian response (43 mV/pH). The adsorbed probe was found to be reversible and exhibited minimal leaching through repeated scanning. The performance of the system was assessed in a heterogeneous bacterial fermentation mixture simulating ileostomy fluid with the pH recorded before and after 96 h incubation. The peak profile in the bacterial medium provided an unambiguous signal free from interference with the calculated pH before and after incubation (pH 5.3 to 3.66) in good agreement with that obtained with commercial pH probes.Graphical abstract

Artificial intelligence applied to model the sulphur absorption process - a possible application in cure with sulphurous mineral water

The presence of Sulphur in human body is estimated to be around .25 percent from total body weight. The modern therapy includes among others the usage of Sulphur us spring waters as crenotherapy or external use like - therapeutic and preventive treatment for a large category of diseases. High levels of hydrogen sulphide are extremely toxic and as result the model of absorption of Sulphur could be useful as predictor in a daily treatment during a cure with sulphurous mineral water. This quantity of chemical elements from a specific diet rich in these elements absorbed in human organism is one of the most important characteristics of a benefic cure in medical diseases. The most studied mechanisms of absorption were studied for Zinc, Magnesium, Iron and Calcium. The most common way to develop a mathematical model is to use the pharmacokinetic equations based on Michaelis-Menten approach (first order model) and to develop it thereafter for quantitative relations. In some cases, only experimental data can exists and the pharmacokinetic model is not completely elucidated or a simplified model doesn’t exist yet. A model based on genetic programming is proposed in order to discover a mathematical relationship between dietary sulphate (mmol/day) and total sulphate in ileostomy fluid (mmol/day) using experimental data published in literature. The set of terminals that are used in genetic programing – GP (using Polish notation) is reduced to basic operation (sum, difference, multiplication and division) along with the most plausible operations that could have physical meaning: rooted square, exponential and power. The formulas discovered by GP using experimental proved a good fit of data with discovered mathematical formula, e.g. the rooted mean square error below 1.5% and R2  94.36%. Mathematical formulas discovered by genetic programming can be used as an alternative to pharmacokinetic model in order to predict sulphate and sulphite absorption and excretion. The usage of this method is especially efficient when the mechanism of absorption in not elucidated enough to provide a compartmental model given by a set of equations. A correlation with pharmacokinetic equations in the case that these exist will help the improvement of terminals and alphabet used by genetic programming in order to have a model closer to one that have a physical meaning

Small intestinal microbiota composition and the prognosis of infants with ileostomy resulting from distinct primary diseases

BackgroundStudies of microbiota composition of infants with small intestinal ostomy due to various etiologies are limited. Here, we characterized the intestinal microbiota of neonates with ileostomy resulting from distinct primary diseases.MethodsFifteen patients with necrotizing enterocolitis, eight patients with meconium peritonitis, and seven patients with Hirschsprung’s disease were included in the study. The small intestinal microbiota composition in infants with ileostomy caused by these diseases was studied.ResultsMicrobial diversity in neonatal ileostomy fluid was generally low, and was dominated by members of the Proteobacteria and Firmicutes phyla. At the genus level, the most abundant were Klebsiella, Escherichia-Shigella, Streptococcus, Clostridium sensu stricto 1, Enterococcus, and Lactobacillus. Streptococcus and Veillonella are related to carbohydrate metabolism and immunity, and breastfeeding can increase the proportion of these potentially beneficial bacteria. The proportion of Bifidobacterium in the breastfeeding group was higher than that in the non-breastfeeding group, and incidence of colitis and sepsis was reduced in the breastfeeding group. The proportion of Bifidobacterium increased and incidence of colitis and sepsis decreased in the breastfeeding group compared with the non- breastfeeding group, but there was no significant difference. The increase in body weight in the breastfeeding group was observed to be higher than in the non-breastfeeding group.ConclusionsExcessive Klebsiella and Escherichia-Shigella and low abundance of Streptococcus, Veillonella and Faecalibacterium suggests that the small intestinal microbiota is in an unhealthy state after ileostomy. However, Streptococcus, Faecalibacterium, and Veillonella species were frequently present, suggesting that expansion of these bacteria might assist the development of the immune system after surgery.

Development of an Electronic Skin Wafer for the Minimization of Peristomal Irritant Dermatitis

An ostomy is created in response to a gastrointestinal injury or disease, such as Ulcerative Colitis, Crohn’s disease and cancer. A stoma is created by a surgical opening in the lower abdomen, which allows for a section of the intestine to be brought to the surface to allow for the excretion of waste products. The resulting effluent is collected through an ostomy pouch that is attached to the abdomen via an adhesive skin wafer (baseplate) as indicated in Figure 1A. In recent years there has been a tremendous effort expended in the design and development of ostomy appliances, which has helped to revolutionize stoma care and management. However, despite the numerous advances, peristomal skin damage remains an issue and arises as a consequence of the gradual erosion of the protective skin wafer. This results in the underlying skin being exposed to the caustic ileostomy fluid (Figure 1B) which subsequently compromises the integrity of the skin barrier and inevitably leads to irritation and ulceration. In the USA alone, it is estimated that one million patients deal with the routine care of an ostomy, and at some stage they are likely to have experienced an incidence of peristomal skin complication (PSC). Although, there have been improvements in the development of materials used within ostomy appliances, there has been little technological innovation in regards to the active prevention of PSCs.A novel skin wafer containing a printed electrode array has been designed which can permit the monitoring of the skin pH in situ and thereby alert the patient when the baseplate has been compromised (Figure 1B). The system is based on a conductive carbon layer which has been modified with a range of peptide agents to confer pH selectivity. This electrode layer is integrated within a hydrocolloid (carboxymethylcelluose based gel) which provides a protective layer from the effluent debris that would otherwise compromise the operation of the sensor. As the skin becomes compromised, the pH can be expected to increase and at this point the patient can be alerted to the situation and the pouch appliance replaced before the onset of a PSC. The design and construction of the skin wafer is described and its operation in ileostomy fluid is critically assessed. Figure 1

PTH-232 Retention of the ileocolic sphincter in a modified brooke ileostomy decreases the loss of key electrolytes in ileostomy fluid of patients who have undergone colectomy for ulcerative colitis

Introduction Previous published work has shown that modifying the traditional Brooke ileostomy (MBI) by retaining the ileocolic sphincter (ICS) preserves a functional high pressure zone which may improve the clinical function of the stoma. The effect of this modification (MBI) on ileal fluid biochemistry has not been reported previously by this group. This study reports the results of this modification on the electrolyte concentration in ileal fluid and also its influence on the reabsorption of urinary electrolytes by way of renal compensation. Method Ileostomy fluid specimens were collected from stoma bags in two groups of patients. Group 1 – ileocolic sphincter retained (MBI); controls – patients undergoing formation of a loop ileostomy (10 cm from the ileocolic junction) as part of an operation for rectal cancer. These samples were collected from patients and controls from stoma bags after an overnight fast. Additionally, 24hr urine collections were made from MBI patients and controls to measure the concentration of routine urinary electrolyes and, in addition, urinary magnesium and calcium. In order to compensate for the changes in urinary volume, which can be accounted for by varied water intake and different kidney efficiency, the urine results for each analyte measured were adjusted against the change in creatinine using a standard formula: adjusted concentration = mmol of analyte/mmol of urinary creatinine. Contemporaneously, routine serum electolytes were collected from patients and controls. This study was approved by the regional ethics committee and statistical analysis was performed using the Wilcoxon paired test where appropriate with p Results 13 MBI patients (mean (SD) age - 52.5(17.8)yrs) were compared with 11 controls age −58.4 (10.9) yrs). Routine serum and urinary biochemistry (except sodium) in both groups was the same. Urinary sodium, calcium and magnesium were raised in patients with a modified Brooke Ileostomy (MBI), when compared to controls: urinary sodium, 8.2 ± 4.5 vs. 4.43 ± 2.19 mmols/mmol creatinine, p Conclusion These results suggest that retention of the ICS in an ileostomy (MBI) has beneficial effects on the retention of ileal sodium, calcium and magnesium by virtue of the reduced reabsorption of these electrolytes from the MBI patients’ urine. Further work is required to confirm this initial finding. Disclosure of interest None Declared.

Inter-subject variability in intestinal drug solubility

Variability in oral drug absorption is a well-known phenomenon, but it is often overlooked for its potential effects in oral drug delivery. Understanding the mechanisms behind absorption variability is crucial to understanding and predicting drug pharmacokinetics. In this study, the solubility of furosemide and dipyridamole – drugs known to have highly variable oral bioavailabilities – was investigated in individual ileostomy fluids from 10 subjects with ulcerative colitis. For comparison, drug solubility was also determined in pooled upper gastrointestinal fluids from healthy human subjects and simulated intestinal fluids. Ileostomy fluid characterization revealed high variability in buffer capacity and to a lesser degree for pH. Drug solubility in ileostomy fluids showed high variability. Correlation analysis revealed that dipyridamole solubility in these fluids is pH-dependent, whereas furosemide solubility was highly correlated to buffer capacity and pH. The implications of these results might partly explain the high variability in bioavailability in vivo, assuming that most of the observed variability is due to the absorption, and not the elimination, process.

Microbiota diversity and stability of the preterm neonatal ileum and colon of two infants

The composition of the microbiota associated with the human ileum and colon in the early weeks of life of two preterm infants was examined, with particular emphasis on the Lactobacillus and Bifidobacterium members. Culturing work showed that bifidobacteria and lactobacilli in the ileostomy changed over time, compared with the colostomy effluent where there was far less variation. The colostomy infant was dominated by two phyla, Actinobacteria and Firmicutes, while in the ileostomy samples, Proteobacteria emerged at the expense of Actinobacteria. Bacteroidetes were only detected following the reversal of the ileostomy in the final fecal sample and were not detected in any colonic fluid samples. Clostridia levels were unstable in the colostomy fluid, suggesting that the ileostomy/colostomy itself influenced the gut microbiota, in particular the strict anaerobes. Pyrosequencing analysis of microbiota composition indicated that bifidobacteria and lactobacilli are among the dominant genera in both the ileal and colonic fluids. Bifidobacteria and lactobacilli levels were unstable in the ileostomy fluid, with large reductions in numbers and relative proportions of both observed. These decreases were characterized by an increase in proportions of Streptococcus and Enterobacteriaceae. Clostridium was detected only in the colonic effluent, with large changes in the relative proportions over time.

Metabolomics of Human Intestinal Transplant Rejection

Surveillance endoscopy with biopsy is the standard method to monitor intestinal transplant recipients but it is invasive, costly and prone to sampling error. Early noninvasive biomarkers of intestinal rejection are needed. In this pilot study we applied metabolomics to characterize the metabolomic profile of intestinal allograft rejection. Fifty-six samples of ileostomy fluid or stool from 11 rejection and 45 nonrejection episodes were analyzed by ultraperformance liquid chromatography in conjunction with Quadrupole time-of-flight mass spectrometry (UPLC-QTOFMS). The data were acquired in duplicate for each sample in positive ionization mode and preprocessed using XCMS (Scripps) followed by multivariate data analysis. We detected a total of 2541 metabolites in the positive ionization mode (mass 50-850 Daltons). A significant interclass separation was found between rejection and nonrejection. The proinflammatory mediator leukotriene E4 was the metabolite with the highest fold change in the rejection group compared to nonrejection. Water-soluble vitamins B2, B5, B6, and taurocholate were also detected with high fold change in rejection. The metabolomic profile of rejection was more heterogeneous than nonrejection. Although larger studies are needed, metabolomics appears to be a promising tool to characterize the pathophysiologic mechanisms involved in intestinal allograft rejection and potentially to identify noninvasive biomarkers.

Preparation and characterization of shellac‐coated anthocyanin pectin beads as dietary colonic delivery system

Anthocyanins are connected with various biological activities. A promising way to enhance the availability of anthocyanins for in situ effects in the lower intestine is colon-specific delivery. Shellac and shellac/hydroxypropyl methylcellulose (HPMC) coated anthocyanin amidated pectin beads as dietary colonic delivery systems were successfully prepared by ionotropic gelation and fluid bed Wurster coating with aqueous shellac solution. Release characteristics, studied in vitro and ex vivo using simulated gastric fluid (SGF), ileostomy fluid and colostomy fluid (CF) revealed a retardation of anthocyanins during simulated passage of stomach and ileum as well as the desired release of pigments in the colon. Coating level was identified as an important parameter. By addition of 5 or 15% of the water-soluble polysaccharide HPMC to the shellac film, resistance in SGF was increased due to the plasticizer properties of the polymer. Incorporation of 15% HPMC (w/w based on shellac) into the shellac film additionally led to increased anthocyanin diffusivity and complete release as well as degradation of the formulation in CF. In the used in vitro and ex vivo model system mimicking the human intestinal transit, the potential of shellac and shellac/HPMC coated anthocyanin amidated pectin beads as dietary colon targeting systems was demonstrated.

Paneth Cell Hyperplasia and Metaplasia in Necrotizing Enterocolitis

Paneth cell dysfunction has been suggested in necrotizing enterocolitis (NEC). The aim of this study was to i) study Paneth cell presence, protein expression, and developmental changes in preterm infants with NEC and ii) determine Paneth cell products and antimicrobial capacity in ileostomy outflow fluid. Intestinal tissue from NEC patients (n = 55), preterm control infants (n = 22), and term controls (n = 7) was obtained during surgical resection and at stoma closure after recovery. Paneth cell abundance and protein expression were analyzed by immunohistochemistry. RNA levels of Paneth cell proteins were determined by real-time quantitative RT-PCR. In ileostomy outflow fluid, Paneth cell products were quantified, and antimicrobial activity was measured in vitro. In acute NEC, Paneth cell abundance in small intestinal tissue was not significantly different from preterm controls. After recovery from NEC, Paneth cell hyperplasia was observed in the small intestine concomitant with elevated human alpha-defensin 5 mRNA levels. In the colon, metaplastic Paneth cells were observed. Ileostomy fluid contained Paneth cell proteins and inhibited bacterial growth. In conjunction, these data suggest an important role of Paneth cells and their products in various phases of NEC.

Intestinal transit and systemic metabolism of apple polyphenols

Apples are the most widely consumed fruits in Germany and various other countries. Positive health effects of apple-derived polyphenols in vivo depend on their absorption, metabolism, distribution, and elimination from the body after consumption. Data on the metabolism of these polyphenols in humans are scarce. In order to study the intestinal transit and metabolism of apple polyphenols in humans, a variety of experiments were carried out. Polyphenols were incubated with saliva (for 5 min), simulated gastric or duodenal juice (4 or 10 h, respectively), or rat hepatocytes (4 h) under aerobic conditions, and with ileostomy fluid under aerobic conditions for 10 h. The polyphenol profile in human serum (8 h later) and renal elimination in urine (24 h later) were also investigated after consumption of 1 L apple juice. Polyphenols and their metabolites were identified and quantified by high-performance liquid chromatography with diode array detection (HPLC-DAD), HPLC-electrospray ionization-tandem mass spectrometry (ESI-MS/MS), and gas chromatography (GC)-MS. In the presence of native saliva or ileostomy fluid, β-glycosides of phloretin and quercetin were hydrolyzed, to varying degrees depending on the sugar moiety, and to much lesser degrees in the presence of antibiotics. In the gastric milieu, almost complete degradation of procyanidin B(2) to (-)-epicatechin was observed. In the presence of artificial duodenal juice flavan-3-ol epimerization occurred. Quercetin was completely converted to phloroglucinol, 3,4-dihydroxybenzoic acid, and 2,4,6-trihydroxybenzoic acid. Formation of isomeric products of hydroxycinnamic acid esters and their corresponding methyl esters was also observed, and similar results were obtained after incubation with rat hepatocytes. Products of phase II metabolism, two phloretin O-glucuronides and eight (methyl) quercetin O-glucuronides, were identified in the hepatocyte samples. Following enzymatic hydrolysis, 5-caffeoylquinic acid, 4-p-coumaroylquinic acid, caffeic acid, (-)-epicatechin, phloretin, and quercetin were recovered in both serum and urine (5.3% and 3.5% of the amounts consumed, respectively). In addition, 19.5% of the polyphenols consumed were identified in the urine in the form of hydroxylated phenolic and hippuric acids. The findings relating to the absorption, metabolism, and systemic availability of polyphenols in vivo should contribute to our understanding of their biological effects, and the characterization of newly formed metabolites should facilitate further studies.

Flavan‐3‐ol C‐glycosides – Preparation and model experiments mimicking their human intestinal transit

In order to study the human intestinal transit of flavan-3-ol C-glycosides, several C-glycosyl derivatives were prepared by non-enzymatic reaction of (+)-catechin with α-D-glucose, α-D-galactose and α-D-rhamnose, respectively. In contrast to literature data, we propose that the reaction mechanism proceeds in analogy to the rearrangement of flavan-3-ols during epimerization under alkaline conditions. Four of the 12 synthesized flavan-3-ol C-glycosides were incubated under aerobic conditions at 37°C using saliva (2 min) and simulated gastric juice (3 h). To simulate human intestine, the C-glycosides were also incubated under anaerobic conditions at 37°C both in human ileostomy fluid (10 h) and colostomy fluid (24 h), respectively. The flavan-3-ol C-glycosides under study, i.e. (+)-epicatechin 8-C-β-D-glucopyranoside (1a), (+)-epicatechin 6-C-β-D-glucopyranoside (1d), (+)-catechin 6-C-β-D-galactopyranoside (2b), (+)-catechin 6-C-β-D-rhamnopyranoside (3b) were analyzed in the incubation samples by HPLC-DAD and HPLC-DAD-MS/MS. They were found to be stable in the course of incubation in saliva, simulated gastric juice and ileostomy fluid and underwent degradation in colostomy fluid. While the 6-C-β-D-glucopyranoside 1d was completely metabolized between 2 and 4 h, decomposition of the 6-C-β-D-galactopyranoside 2b reached only 16 ± 2% within 4 h of incubation. Linear degradation rates of 1d and 2b in colostomy fluid differed significantly. As microbial metabolism of flavan-3-ols is known not to be influenced by the stereochemistry of the aglycon, varying degradation rates are ascribed to the effect of the sugar moiety. Based on these results we assume that flavan-3-ol C-glycosides pass through the upper gastrointestinal tract (oral cavity, stomach and small intestine) unmodified and are then metabolized by the colonic microflora.

Model experiments mimicking the human intestinal transit and metabolism of D‐galacturonic acid and amidated pectin

In order to study the human intestinal transit and metabolism of D-galacturonic acid and amidated pectin a number of model experiments were carried out. Both substrates were incubated under aerobic conditions at 37 degrees C using saliva (2 min) and simulated gastric juice (4 h). Under anaerobic conditions the substrates were incubated at 37 degrees C using human ileostomy and colostomy fluids, each obtained from three different donors, for 10 and for 24 h, respectively. D-Galacturonic acid, SCFA (acetic acid, propionic acid, and butyric acid), as well as methanol were analyzed photometrically after carbazole reaction, GC-flame ionization detection (GC-FID), and headspace solid-phase microextraction GC/MS (HS-SPME-GC/MS), respectively. D-Galacturonic acid and amidated pectin were found to be stable during incubations with saliva and simulated gastric juice, whereas both substrates underwent degradation in the course of human ileostomy and colostomy fluid incubations. D-Galacturonic acid was practically completely decomposed within 10 h and SCFA, with acetic acid as the major representative, were formed up to 98% of the incubated substrate in colostomy effluent. The amidated pectin was only degraded in part, revealing stable amounts of 22-35% and 3-17% in ileostomy (after 10 h) and colostomy fluid (after 24 h), respectively. SCFA were generated up to 59% of the applied amidated pectin. In parallel, 19-60% and 52-67% of the available methyl ester groups were cleaved in the course of incubations with ileostomy and colostomy fluids, respectively. The results demonstrate for the first time that D-galacturonic acid and amidated pectin are stable in human saliva and simulated gastric juice. The degradation of both compounds during incubation with ileostomy effluent is highlighted, providing evidence for a considerable metabolic potential of the small intestine.

Impaired Luminal Processing of Human Defensin-5 in Crohn's Disease: Persistence in a Complex with Chymotrypsinogen and Trypsin

Human defensin (HD)-5 is an antimicrobial peptide expressed in small intestinal Paneth cells, and alterations in HD-5 expression may be important in Crohn's disease (CD) pathogenesis. Levels of HD-5 in Paneth cells and ileostomy fluid from control and CD patients were studied by quantitative immunodot analysis, immunohistochemistry, acid urea-polyacrylamide gel electrophoresis and sodium dodecyl sulfate-polyacrylamide gel electrophoresis Western blotting, reverse phase-high performance liquid chromatography, N-terminal amino acid sequencing, and ES-QToF mass spectrometry. In both control and CD patients, HD-5 in Paneth cell extracts was present almost exclusively in the precursor form. HD-5 levels in ileostomy fluid were lower in CD patients (n = 51) than in controls (n = 20): median (range), 7.9 (5.5 to 35.0) microg/ml versus 10.5 (6.0 to 30.4) microg/ml; P = 0.05; this difference was most marked in CD patients with homozygous/compound heterozygous mutations in NOD2 (P = 0.03). In control ileostomy fluid, HD-5 was present in the mature form only. In contrast, CD patient ileostomy fluid contained both precursor and mature forms of HD-5, with the majority present in a complex with trypsin, chymotrypsinogen/chymotrypsin, and alpha1-anti-trypsin. Pro-HD-5 was not associated with trypsin or chymotrypsinogen in Paneth cell extracts. In conclusion, pro-HD-5 in the intestinal lumen is processed by trypsin in a complex in which chymotrypsinogen is also cleaved for activation. The persistence of this complex in CD may be attributable to increased luminal levels of proteinase inhibitors such as alpha1-anti-trypsin.

Human intestinal hydrolysis of phenol glycosides – a study with quercetin and p‐nitrophenol glycosides using ileostomy fluid

In order to study the influence of sugar moiety, aglycon structure and microflora concentration on the human ileal hydrolysis of phenol glycosides, various quercetin and p-nitrophenol glycosides were incubated under anaerobic conditions (37 degrees C for 0, 0.5, 1, 2, 4, 6, 8, 10 and 24 h) with ileostomy fluids from three different donors. The glycosides, i.e. beta-D-glucopyranosides, beta-D-galactopyranosides, alpha-L-arabinofuranosides, beta-D-xylopyranosides and alpha-L-rhamnopyranosides as well as the liberated aglycones were identified by HPLC-DAD and HPLC-ESI-MS/MS. Among the quercetin glycosides under study, the 3-O-beta-D-glucopyranoside showed with 0.22 micromol/h the highest hydrolysis rate, followed by the 3-O-beta-D-galactopyranoside, the 3-O-beta-D-xylopyranoside and the 3-O-alpha-L-arabinofuranoside (0.04 and each 0.03 micromol/h, respectively). Quercetin 3-O-alpha-L-rhamnopyranoside was found to be stable for the entire incubation period. Using quercetin 3-O-beta-D-glucopyranoside as a representative example, linear hydrolysis rate was observed from 75 to 2500 microL ileostomy fluid corresponding to its microflora content (log 0.68 up to 21.9 colony forming units). Studies performed in the presence of antibiotics did not reveal any hydrolysis. The p-nitrophenol glycosides were hydrolyzed faster than the corresponding quercetin glycosides. The hydrolysis rate decreased from the beta-D-glucopyranoside (0.41 micromol/h), to the beta-D-galactopyranoside (0.21 micromol/h), the beta-D-xylopyranoside (0.12 micromol/h), the alpha-L-arabinofuranoside (0.09 micromol/h) to the alpha-L-rhamnopyranoside (0.06 micromol/h). These results demonstrate that the human ileal hydrolysis of phenol glycosides depends on the sugar and the aglycon structure as well as the microflora.

C difficile Enteritis in Ileostomy Patients: Report of Three Cases and Review of the Literature

C. difficile (CD) is the most common cause of nosocomial infectious diarrhea and is generally considered a colonic pathogen. CD small bowel enteritis (CDSBE) has only rarely been reported. We describe the clinical course and treatment of 3 ileostomy patients with diarrhea due to CD. Case #1: 48 YOM s/p colectomy and ileostomy for Crohn's disease 2 yrs previously presented with fever, nausea, vomiting, abdominal pain, increased ileostomy output, and marked dehydration. Antibiotics had been administered 3 months previously. Ileostomy CD toxin was positive by ELISA. He responded to a standard course oral metronidazole and vancomycin with resolution of symptoms and negative repeat CD toxin after treatment. Case #2: 72 YOM s/p colectomy and ileostomy for ulcerative colitis 24 yrs earlier presented with a low-grade fever and non-bloody diarrhea of 1-month duration. There was no antecedent antibiotic use. Ileostomy CD toxin was positive by ELISA. He was initially treated with metronidazole, which was switched to oral vancomycin. He responded to 2 weeks of vancomycin, but relapsed following discontinuation and received a 1-month course of vancomycin with clearance of the toxin. Case #3: 39 YOM with severe acute alcoholic pancreatitis required a total abdominal colectomy and ileostomy for colonic ischemia. He required multiple courses of antibiotics and subsequently developed a high ileostomy output. Ileostomy fluid CD toxin was positive and he responded to a standard course oral metronidazole and vancomycin Discussion: CDSBE has been reported in 20 patients in the literature, but only previously in ten ileostomy patients, most of whom were detected in the early post-operative period ( < 90 days). In only 3 cases in the literature was CDSBE diagnosed > 90 d following surgery in ileostomy patients. We report 2 more such cases, and a third in the early post-operative period. Most patients have a history of antibiotic use and present with increased ileostomy output. Most respond to standard therapies (oral metronidazole or oral vancomycin). Relapses may occur. Conclusion: C. Difficile enteritis is a potential cause of high ileostomy output and should be in the differential diagnosis. Treatment with oral metronidazole or vancomycin is generally effective.

Immune Response to Influenza Vaccine in Pediatric Patients With Inflammatory Bowel Disease

The aim of this study was to compare response to inactivated influenza vaccine in healthy children and pediatric patients with inflammatory bowel disease (IBD). A prospective, open-label, controlled clinical trial during influenza seasons of 2002-2004 was performed. Single-dose inactive trivalent influenza vaccine was administered. Immune response to vaccination was measured by pre-immunization and postimmunization hemagglutinin inhibition titers. A postimmunization hemagglutinin inhibition titer of 40 or higher was considered protective against influenza. IBD activity and adverse events were recorded. Eighty subjects were enrolled (29 healthy controls, 51 IBD patients). One patient did not complete the study. Patients were divided into 3 subgroups: infliximab and immunomodulatory (16), immunomodulatory (20), and anti-inflammatory therapy (14). Immunomodulatory therapy included corticosteroids, 6-mercaptopurine, or methotrexate. Overall, there was a statistically significant decrease in immune response in patients compared with healthy controls who received 1 influenza vaccine antigen (B/Hong Kong, P = .0125). Patients receiving infliximab and immunomodulatory therapy were less likely to respond to 2 influenza vaccine antigens (A/New Caledonia/20/99 and B/Hong Kong/330/2001, P = .018 and .0002, respectively). Fifteen subjects (19%) reported 19 mild adverse events: 11 (14%) reported soreness at the site, 4 (5%) reported having a cold, 3 (4%) reported flu-like symptoms, and 1 (1%) reported a headache. The clinical activity of IBD was not affected by vaccination. The serologic conversion rate to influenza vaccine in patients with IBD ranged from 33% to 85%. Patients on concomitant infliximab and immunomodulatory therapy are at risk of inadequate response to vaccination. The vaccine was safe and did not affect IBD activity.

A new appliance for collecting ileostomy and jejunostomy fluid in the postoperative period

A new lightweight two-piece ileostomy appliance was tested in 11 patients with newly established ileostomies and jejunostomies. Seven of the patients presented difficult stoma care problems. The appliance was fitted in theatre on completion of the operation and the patient was followed until discharge from hospital. The appliance remained in place for an average of 4.8 +/- 1.2 days. In a total of 204 patient-days the pouch became dislodged from the flange on 10 occasions and there was leakage under the body flange on 7 occasions. All but one of the patients continued to use the appliance on discharge. No patient was allergic to the appliance nor complained of odour. It is concluded that this new appliance represents an important advance in postoperative stoma care.

Cause and management of high volume output salt-depleting ileostomy

Ileostomy function was studied in 12 patients with an established ileostomy following proctocolectomy, in 6 of whom minimal amounts (less than 9 cm) and in 6 significant amounts (30-120 cm, mean 60 cm) of terminal ileum had been removed. Patients who had undergone significant ileal resection had daily faecal volumes considerably greater than those with minimal ileal resection (1202 +/- 284 ml versus 401 +/- 92 ml, P less than 0.001), and also greater daily outputs of sodium (146 +/- 53 mEq versus 43 +/- 12 mEq) and potassium (12.7 +/- 9.0 mEq versus 4.0 +/- 0.99 mEq). The percentage water content of the ileostomy fluid was greater in patients who had had the ileum resected (93.1 +/- 1.8% versus 89.8 +/- 2.5%). In addition, the sodium/potassium ratio in the urine in patients with a properly acting ileostomy after ileal resection was low. It is concluded that when recurrent inflammatory bowel disease, partial small bowel obstruction and intraperitoneal sepsis have been excluded there remains a number of patients whose high ileostomy output is due entirely to the amount of ileum resected. The management of patients with a high output ileostomy with codeine phosphate, Lomotil and oral administration of sodium chloride tablets is discussed.

Dysarthria in a patient with probable acquired chloridorrhea

The authors encountered a patient who had profound hypochloremic metabolic alkalosis after developing profuse diarrhea related to rejection of her small bowel transplant. Her ileostomy fluid showed massive electrolyte losses and was exceptionally high in chloride content. She improved with volume substitution and a proton pump inhibitor, although she subsequently required repeat small bowel transplant. The authors speculate that an impaired “downregulated in adenoma” gene (DRA) that enclodes an apical Cl-/HO-(HCO3) exchanger may have contributed to an acquired chloridorrhea in this patient.