Increased Stool Output Research Articles

322: PHARMACIST OPTIMIZATION OF BOWEL PREPARATIONS IN THE CRITICALLY ILL: THE POOPY STUDY

Introduction: Critically ill patients undergo stressful states while in the intensive care unit (ICU) and thus have alterations in bowel habits, including constipation in 20-83% and diarrhea in 3.3-78%. Patients frequently receive opioid analgesics to assist with sedation and pain control. Appropriate bowel management is essential to prevent further complications during the ICU stay. The purpose of this study is to examine the various bowel preparations (BP) used in ICU patients, time to first bowel movement after initiation or escalation of a BP, and reason for BP discontinuation. Methods: This multi-center, multi-ICU, retrospective observational review evaluated tele-critical care pharmacist interventions documenting initiation or change in BP from January 2, 2021 to June 30, 2021. Interventions were excluded if the BP was renewed, duplicate therapy and/or change in formulation. Descriptive statistics were used to describe the data. Results: One hundred ninety-six unique patients had at least one BP intervention. Baseline characteristics include 55% male, average age of 64 years, a BMI of 32.9, and 66% COVID-19 positive. One hundred seventy-four unique patients had a BP initiated or added on to current therapy, while 62 unique patients had current therapy escalated. The median days to first bowel movement after initiation or addition of a BP was 5.4 days (range 0-19). Ninety-eight percent of patients received an opioid, either continuous infusion or oral, and 90% received enteral nutrition. Docusate and senna were the primary BPs added when a regimen was initiated. Then, polyethylene glycol was added as the next BP. Lactulose and bisacodyl suppositories were added as 4th line treatment if the patient had not experienced a bowel movement. Methylnaltrexone was used in 1 patient. Fifty-two unique patients had one or more medications from their current bowel regimen discontinued due increased stool output, diarrhea, multiple bowel movements within last 24 hours, or the patient refusing the medication. Conclusions: Initiation of BPs in critically ill patients, especially if receiving an opiate, may be delayed. Bowel regimen initiation should be considered when the patient is placed on opiate therapy. If the patient continues to have a delayed response to therapy, prompt escalation of therapy may be warranted.

SLC26A6-selective inhibitor identified in a small-molecule screen blocks fluid absorption in small intestine.

SLC26A6 (also known as putative anion transporter 1 [PAT1]) is a Cl–/HCO3– exchanger expressed at the luminal membrane of enterocytes where it facilitates intestinal Cl– and fluid absorption. Here, high-throughput screening of 50,000 synthetic small molecules in cells expressing PAT1 and a halide-sensing fluorescent protein identified several classes of inhibitors. The most potent compound, the pyrazolo-pyrido-pyrimidinone PAT1inh-B01, fully inhibited PAT1-mediated anion exchange (IC50 ~350 nM), without inhibition of the related intestinal transporter SLC26A3 (also known as DRA). In closed midjejunal loops in mice, PAT1inh-B01 inhibited fluid absorption by 50%, which increased to >90% when coadministered with DRA inhibitor DRAinh-A270. In ileal loops, PAT1inh-B01 blocked fluid absorption by >80%, whereas DRAinh-A270 was without effect. In colonic loops, PAT1inh-B01 was without effect, whereas DRAinh-A270 completely blocked fluid absorption. In a loperamide constipation model, coadministration of PAT1inh-B01 with DRAinh-A270 increased stool output compared with DRAinh-A270 alone. These results provide functional evidence for complementary and region-specific roles of PAT1 and DRA in intestinal fluid absorption, with PAT1 as the predominant anion exchanger in mouse ileum. We believe that PAT1inh-B01 is a novel tool to study intestinal ion and fluid transport and perhaps a drug candidate for small intestinal hyposecretory disorders such as cystic fibrosis–related meconium ileus and distal intestinal obstruction syndrome.

Predictor Factors for Emergency Department revisiting of children with acute gastroenteritis: Case-control study.

The objective of this work is to describe risk factors for reconsultation in patients with an acute gastroenteritis diagnosis, identifiable in their first visit to the Emergency Department. Case-control study, including patients aged between 0-16 years who consulted in the Emer gency Department (ED) of a tertiary hospital for 4 years. The case is defined as the episode with a gastroenteritis diagnosis that reconsulted within 72 hours. A control was selected for each case, which was the first patient to consult after each case with the same diagnosis and not reconsulted later. Epidemiological and clinical variables, and diagnostic-therapeutic interventions carried out during the first visit were studied. Univariate and multivariate analyses of the reconsultation risk were per formed using logistic regression models. Gastroenteritis diagnoses accounted for 5.3% of all ED visits. 745 patients (6.2%) reconsulted within 72 hours. Multivariate analysis found association between reconsultation with each year of increasing age (OR 0.94, 95% CI 0.91-0.97), absence of rotavirus vaccination (OR 1.47, 95% CI: 1.11-1.95), no prior assessment in primary care (OR 1.55, 95% CI 1.09-2.19), increased stool output in the last 24 hours (OR 1.06, 95% CI 1.02-1.10), and stool collection in the ED (OR 1.54, 95% CI 1.05-2.24). Younger patients with an increased stool output are especially susceptible to return to the ED for consultation. Rotavirus vaccination could reduce reconsultation. None of the diagnostic-therapeutic actions carried out seems to reduce the number of visits to the ED.

Soluble Fiber Use in Pediatric Short Bowel Syndrome: A Survey on Prevailing Practices.

In pediatric short bowel syndrome (SBS), adding fiber to enteral feedings is 1 treatment method to manage increased stool output. However, there are no standardized recommendations on the use of fiber in this setting, including type, dosage, titration strategies, etc. OBJECTIVE: The aim of this study is to determine current prevailing practices on the use offiber in thetreatment of chronic high stool output in thepediatricSBS population. An anonymous electronic survey with 13 questions was sent through health professional electronic mailing lists. The survey was completed by healthcare professionals including physicians (primary care, subspecialists, and surgeons), nurse practitioners, and registered dietitians. A total of 94responses were received. The most common supplemental fiber used waspectin (62.8%). The 2 major factors considered when initiating fiber therapy were consistency of stool (74.5%) and volume of stool output (85.1%). The major factor that determined discontinuation of fiber was abdominal distention (67%). A majority of providers waited 2 weeks or less to see improvement following fiber initiation before discontinuing it. The goal of the surveywas to gather more information with regard to fiber use in the management of SBS patients. The data collected can be used to provide future direction on determining best practices for fiber use in SBS patients.

Necrotizing Enterocolitis.

Necrotizing enterocolitis (NEC) is a frequently encountered condition in the premature neonate, which can have devastating effects. The signs and symptoms of NEC are variable and can be confused with those of sepsis. An abdominal radiograph is often obtained for diagnosis, and findings that indicate NEC include pneumatosis and portal venous gas. The treatment of NEC includes gastrointestinal rest, gastric decompression, broad-spectrum intravenous antibiotics, and systemic support. A finding of pneumoperitoneum signifies intestinal perforation, which requires surgical intervention. Long-term sequelae of NEC include short-gut syndrome, intestinal stricture, and neurodevelopmental delays. The presentation of intestinal stricture can be puzzling. It can appear at presentation as a bowel obstruction or, conversely, as increased stool output or diarrhea. The clinician should have a high level of suspicion for intestinal stricture in a patient with a history of NEC.

Endoscopy Following Pediatric Intestinal Transplant.

Biopsies remain the criterion standard in the diagnosis of intestinal transplant (ITx) rejection, and gastrointestinal endoscopy plays a pivotal role in patient management. Herein, we describe a single-center 23-year endoscopic experience in pediatric ITx recipients. A retrospective review of endoscopy and pathology reports of all ITx recipients <18 years old transplanted between 1991 and 2013 was performed with the aim of describing the procedural indications, findings, and complications. A total of 1770 endoscopic procedures within 1014 sessions were performed. A combination of esophagogastroduodenoscopy and ileoscopy was the most common procedure (36%). Increased stool output (35%) and surveillance endoscopy (32%) were the most common indications. A total of 162 episodes of biopsy-proven rejection were diagnosed. The first episode of rejection occurred at a median of 1 month after ITx. Of histology-proven rejections, 45% had normal-appearing endoscopies. The rate of procedural complications, including but not limited to bleeding and perforation, was 1.8%. Endoscopy with biopsy plays a significant role in the care of ITx recipients. Multiple procedures are required for graft surveillance, diagnosis of rejection, subsequent treatment, and follow-up of therapy. The gross endoscopic appearance, particularly in mild to moderate acute cellular rejection, does not correlate well with histology. Complex anatomy, complication rates that are higher than patients with non-ITx pediatric endoscopy, and timely histologic interpretation by experienced pathologists are reasons that these procedures should be performed at centers accustomed to caring for ITx recipients. The field would benefit from the development of a noninvasive biomarker to reliably and efficiently detect rejection.

PTH-250 Clinical course and management of norovirus infection following small bowel transplantation in children

<h3>Introduction</h3> Noroviruses are a common cause of acute gastrointestinal illness worldwide and can be life-threatening in immunocompromised patients e.g. intestinal transplantation (ITx).^1,2No treatment is currently available for Norovirus infection. <h3>Method</h3> The Noroviral status of 85 paediatric ITx recipients at Birmingham Children’s Hospital (1993–2014) was recorded and the first episode of gastroenteritis was identified. <h3>Results</h3> 20 patients developed Noroviral gastroenteritis (12F:8M). 7 patients received isolated ITx, 11 combined liver and ITx and 2 multivisceral transplant. The mean age at transplantation was 7.2 yrs (range 11 months – 10 yrs) and at diagnosis of Noroviral infection 10.15 yrs (range 1–17 yrs). The mean time interval of transplantation and Noroviral infection was 2.15 yrs (range 2 months- 15 yrs). The time of hospitalisation varied significantly depending on the co-morbidities (5–114 days). 9 patients received intensified immunosuppression within the last 3 months prior to Noroviral infection due to rejection, PTLD, GvHD or other autoimmune process. All patients presented with increased stool output, while 5 also presented with vomiting and 9 with dehydration. The immunosuppressive regime included Tarolimus and Prednisolone in 13 patients and a combination of Tacrolimus, Prednisolone, MMF, Sirolimus, Infliximab and Azathioprine in the rest. 6 patients developed rejection, 5 had a concomitant stool infection, 2 were diagnosed with PTLD and 7 had a systemic infection. 7 patients required parenteral nutrition (PN) and 14 received oral human immunoglobulins (OHIG) as part of their treatment. The outcome for 2 patients was death (both diagnosed with PTLD). All other patients managed to re-establish enteral feeds with 4 needing extra overnight IV fluids or PN. On average, the children treated with OHIG were younger with a shorter time interval between Noroviral gastroenteritis and ITx. OHIG reportedly shortens the period of diarrhoea³but we did not observe a shortened hospitalisation time. The histopathological appearances of norovirus can mimic rejection²and it is important to correlate clinically. <h3>Conclusion</h3> Norovirus is a significant pathogen in ITx and differentiation from rejection is crucial. OHIG may have a role in the treatment of ITx recipients. <h3>Disclosure of interest</h3> None Declared. <h3>References</h3> Bok K, Green KY. <i>N Engl J Med</i>. 2012;367(22):2126–2132 Kaufman SS, <i>et al</i>. J Pediatr Gastroenterol Nutr., 2005;40(3):328–333 Florescu DF, <i>et al</i>. Pediatr Transplant. 2011;15(7):718–21

The Evolving Medical Management of Short Bowel Syndrome

management. Physiology of short bowel syndrome Patients with SBS undergo significant metabolic alterations due to the anatomical loss of the small bowel. Malabsorption of nutrients arises due to reduction of the intestinal absorptive area, resulting in nutritional depletion of vital nutrients, weight loss, diarrhea and dehydration. Transient hypergastrinemia may occur, due to loss of the enteric hormonal feedback (protein PYY, glucagon-like peptide-1 (GLP-1), Cholecystokinin (CCK) and secretin) that helps to reduce gastric secretion. Altered motility is seen due to the loss of the ‘ileal brake” that normally would serve to slow transit of nutrients, with reduction of the hormones glucagon-like peptide-2 (GLP-2), peptide YY, GLP-1, and neurotensin. Patients with significant distal ileal resection, >100 cm, are at risk for vitamin B12 deficiency, bile salt diarrhea and development of gallstones. This is due to the loss of the ileal area where vitamin B12 is absorbed and where bile salts are recycled back to the liver via enterohepatic circulation. This will result in increased stool output as bile salts enter the colon, and exert a cathartic action. Oxalate kidney stones may develop due to excessive absorption of oxalate in the colon. Bacterial overgrowth may arise as well. There is also a risk of D-lactic acidosis due to the colonic bacterial fermentation of simple Carbohydrates (CHO). Nutritional management of SBS Intestinal Rehabilitation is an important concept in the management of these complex patients with the aim of facilitating nutrient and fluid absorption and reduction of the need for parenteral support, in order to achieve the best possible quality of life. Nutritional management of SBS includes various interventions, which includes the use of enteral nutrition, therapeutic manipulation of the diet and parenteral nutrition when required. Nutritional interventions for oral intake are individualized and designed to stimulate intestinal adaptation to maximize the function of existing small bowel. The gut has the ability to adapt over the course of 1 to 2 years, (intestinal adaptation), which includes the hypertrophy of the villi leading to a greater absorptive area to optimize nutritional capacity. The known length of the remaining small bowel and whether a colon is present or not determines the nutritional therapies utilized. Enteral nutrition is the favored route. The use of gastrostomy or jejunostomy tubes to facilitate nocturnal feeding should also be considered. Parenteral nutrition (PN), along with intravenous fluids may be required initially until the patient stabilizes. Trophic enteral feeds can be used in conjunction of PN initially and with enteral feed advancement, can help to transition the SBS patient off PN. The use of an isotonic polymeric enteral formula is initially preferred to stimulate intestinal adaptation. If a patient does not adequately tolerate a polymeric enteral formula, then an isotonic elemental enteral formula can be attempted. A variety of polymeric and elemental enteral formulas are available. Patients with 100 cm small bowel or less without a colon or left with 50 cm small bowel with a colon inevitably stay TPN dependent. These patients are referred to as SBS-Intestinal Failure (IF) patients. Parenteral nutrition, however, carries a significant risk of line sepsis, vascular occlusion and liver dysfunction. Reduction and potential weaning of PN is the goal, and is done gradually and is initiated with a modest reduction in caloric provision. The weaning process is individualized, and is dependent on how well the patient progresses with increasing oral intake and/or enteral feeds while stabilizing nutritional parameters, such as weight status, hydration and stool output. The macronutrient composition of the diet will differ between SBS patients that have a colon and those that do not and have end jejunostomies or ileostomies. Overall, a high caloric intake is needed to compensate for the malabsorption of nutrients that may occur initially with SBS.

Effect of retrograded rice on weight control, gut function, and lipid concentrations in rats.

The effects of retrograded rice on body weight gain, gut functions, and hypolipidemic actions in rats were examined. When the retrograded rice was produced by repetitive heating and cooling cycles, it contained significantly higher amounts of resistant starch (13.9 ± 0.98%) than is found in common rice (9.1 ± 1.02%) (P < 0.05). Sprague-Dawley rats were fed either common rice powder or retrograded rice powder, and mean body weight gain was significantly lower in the retrograded rice group (P < 0.05). The liver weight of the retrograded rice group (14.5 ± 0.5 g) was significantly lower than that of the common rice group (17.1 ± 0.3 g, P < 0.05). However, the weights of other organs, such as the kidney, spleen, thymus, and epididymal fat pad were not significantly affected by rice feeding. Intestinal transit time tended to be lower in rats fed retrograded rice when compared to rats fed the common rice, but the difference was not significant. The retrograded rice diet significantly increased stool output when compared to that in the common rice powder diet (P < 0.05), whereas fecal moisture content (%) was significantly higher in the retrograded rice group (23.3 ± 1.2) than that in the common rice group (19.1 ± 1.2) (P < 0.05). The retrograded rice group had significantly lower plasma cholesterol (P < 0.05), liver cholesterol (P < 0.05), and triacylglycerol contents in adipose tissue (P < 0.05) when compared to those in the common rice group. In conclusion, retrograded rice had higher resistant starch levels compared with those of common rice powder, and it lowered body weight gain and improved lipid profiles and gut function in rats.

Safety of Decanted Enteral Formula Hung for 12 Hours in a Pediatric Setting

Enteral nutrition has been an accepted mode of pediatric care for more than 40 years. Early reports in the literature documented high levels of bacterial contamination in enteral formulas delivered to patients. Safety standards for formula administration have not been universally followed. Evidence demonstrates that increased manipulation of the delivery system contributes to bacterial contamination. A prospective, descriptive study was conducted with 30 pediatric patients. They received continuous enteral feedings using decanted formula over a minimum hang time of 12 hours. Formula was delivered according to current practice recommendations. Cultures were obtained and sent to the laboratory initially and every 4 hours. Cultures from 30 patients (average age 6.4 years) were obtained at baseline, 4, 8, and 12 hours. Nasogastric, nasojejunal, gastrostomy, or gastrojejunostomy feeding tubes were used. Formulas administered were polymeric and peptide based. Of the 119 cultures obtained, 8 were either collected improperly or revealed a contaminant. Of the 111 useable cultures, 100 showed no growth, 6 had growth below the Food and Drug Administration threshold for contamination (95% acceptable), and 5 (5%) in 2 patients were considered positive, with all cultures growing coliforms. No patient had any clinical signs of bacterial gastroenteritis (increased stool output, fever, or clinical deterioration) over the 48 hours after data collection. Decanted enteral formula administered continuously over 12 hours in a pediatric hospital setting has a lower than expected rate of bacterial growth when recommended handling practices are followed.

Corticosterone Mediates Reciprocal Changes in CB 1 and TRPV1 Receptors in Primary Sensory Neurons in the Chronically Stressed Rat

Chronic stress is associated with visceral hyperalgesia in functional gastrointestinal disorders. We investigated whether corticosterone plays a role in chronic psychological stress-induced visceral hyperalgesia. Male rats were subjected to 1-hour water avoidance (WA) stress or subcutaneous corticosterone injection daily for 10 consecutive days in the presence or absence of corticoid-receptor antagonist RU-486 and cannabinoid-receptor agonist WIN55,212-2. The visceromotor response to colorectal distension was measured. Receptor protein levels were measured and whole-cell patch-clamp recordings were used to assess transient receptor potential vanilloid type 1 (TRPV1) currents in L6-S2 dorsal root ganglion (DRG) neurons. Mass spectrometry was used to measure endocannabinoid anandamide content. Chronic WA stress was associated with visceral hyperalgesia in response to colorectal distension, increased stool output and reciprocal changes in cannabinoid receptor 1 (CB1) (decreased) and TRPV1 (increased) receptor expression and function. Treatment of WA stressed rats with RU-486 prevented these changes. Control rats treated with serial injections of corticosterone in situ showed a significant increase in serum corticosterone associated with visceral hyperalgesia, enhanced anandamide content, increased TRPV1, and decreased CB1 receptor protein levels, which were prevented by co-treatment with RU-486. Exposure of isolated control L6-S2 DRGs in vitro to corticosterone reproduced the changes in CB1 and TRPV1 receptors observed in situ, which was prevented by co-treatment with RU-486 or WIN55,212-2. These results support a novel role for corticosterone to modulate CB1 and TRPV1-receptor pathways in L6-S2 DRGs in the chronic WA stressed rat, which contributes to visceral hyperalgesia observed in this model.

Disseminated Histoplasmosis and Pneumocystis Pneumonia in a Child With Crohn Disease Receiving Infliximab

Disseminated Histoplasmosis and Pneumocystis Pneumonia in a Child With Crohn Disease Receiving Infliximab

High diagnostic yield of gastrointestinal endoscopy in children with intestinal failure

PurposeChildren with intestinal failure (IF) often have gastrointestinal (GI) symptoms, including bleeding, increased stool output, and feeding intolerance. The use of endoscopic assessment of these symptoms has not been previously reported. This report evaluates the diagnostic yield of GI endoscopy in the setting of IF. MethodsAfter institutional review board approval, we reviewed the medical records (including endoscopy, pathology and microbiology data) of patients with IF who underwent GI endoscopies between September 1999 and March 2007. ResultsTwenty-seven patients underwent 61 GI endoscopies: 34 esophagogastroduodenoscopies, 17 colonoscopies, 7 flexible sigmoidoscopies, and 3 ileoscopies. Indications for endoscopy, which were not mutually exclusive, included chronic diarrhea (39%, n = 24), GI bleeding (36%, n = 22), suspected bacterial overgrowth (36%, n = 22), and suspected peptic disease (15%, n = 9). Based on gross endoscopic appearance, histopathology, or microbiology, 43 (70%) procedures yielded abnormalities. These included infectious (20%, n = 12), anatomical (18%, n = 11), peptic (15%, n = 9), allergic (15%, n = 9), and other (2%, n = 1) findings. Eleven (73%) of 15 duodenal cultures grew a spectrum of 17 bacterial species. Overall, 24 (89%) of 27 patients had gross endoscopic, histopathologic, or microbiologic abnormalities. ConclusionsIn pediatric patients with IF, diagnostic upper and lower GI endoscopies yield high rates of abnormalities and can help guide clinical management.

Efficacy of probiotic use in acute diarrhea in children: a meta-analysis.

Our objective was to determine the efficacy of probiotic use in reducing the duration of increased stool output in children with acute diarrheal illness. Eligible studies were limited to trials of probiotic therapy in otherwise healthy children <5 years old with acute-onset diarrhea. The main outcome variable was difference in diarrhea duration between treatment and control groups. Our meta-analysis of 18 eligible studies suggests that coadministration of probiotics with standard rehydration therapy reduces the duration of acute diarrhea by approximately 1 day [random-effects pooled estimate = -0.8 days (-1.1, -0.6), P < 0.001]. Differences in treatment effect between studies was assessed by calculating the Q statistic (Q = 204. 1, P < 0.001). In subsequent analyses limited to studies of hospitalized children, to double-blinded trials, and to studies evaluating lactobacilli, the pooled estimates were similar (-0.6 to -1.2 days, P < 0.001). In conclusion, bacterial probiotic therapy shortens the duration of acute diarrheal illness in children by approximately one day.

Effects of wheat bran and olestra on objective measures of stool and subjective reports of GI symptoms

OBJECTIVE: The aim of this study was to compare the effects of two nondigested, nonabsorbed dietary components on objective and subjective measures of gastrointestinal (GI) function. METHODS: A placebo-controlled parallel study compared the effects of wheat bran (20 g/day or 40 g/day in cereal), a well-known dietary fiber, with those of olestra (20 g or 40 g/day in potato chips), a nonabsorbed fat, on stool output, stool apparent viscosity (log peak force for extrusion [PF]), stool water content, and GI symptoms. Sixty subjects resided on a metabolic ward for 9 days: 3 days baseline and 6 days treatment. RESULTS: Compared with placebo, consumption of 20 g/day wheat bran for 6 days resulted in a rapid (within 38 h) increase in mean (±SE) stool output (placebo, 150 ± 29 g/day; bran, 246 ± 35 g/day, p < 0.05), a directional increase in mean stool water content (placebo, 81.2 ± 0.8%; bran, 83.9 ± 0.8%), stool water output (placebo, 159 ± 54 g/day; bran, 238 ± 30 g/day), and bowel movement frequency (BM/day) (placebo, 2.2 ± 0.4; bran, 2.6 ± 0.4), and no stool-softening effect (placebo log PF, 2.9 ± 0.1 g; bran log PF, 2.9 ± 0.1 g). Wheat bran 40 g/day results were not significantly different from wheat bran 20 g/day. Compared with placebo, consumption of olestra 20 g/day and 40 g/day for 6 days showed no significant difference in mean stool output (151 ± 18 g/day and 204 ± 28 g/day, respectively), mean BM frequency (1.8 ± 0.2 BM/day and 2.1 ± 0.3 BM/day, respectively), and stool water output (138 ± 13 g/day and 184 ± 31 g/day, respectively), a significant ( p < 0.05) decrease in stool water content (75.5 ± 1.7% and 72.6 ± 2.2%, respectively), and either no effect on stool apparent viscosity (olestra 20 g/day, mean log PF, 3.0 ± 0.1 g) or a gradual stool-softening effect beginning study day 6 (olestra 40 g/day, log PF, 2.7 ± 0.1 g). None of the treatment groups showed a significant increase in GI symptoms compared with placebo. CONCLUSIONS: Consumption of wheat bran in excess of levels in a typical Western diet significantly increased stool output, but did not soften normal-viscosity stool nor result in an increase in common GI symptoms. The observed plateau effect for wheat bran at 40 g/day suggests a maximal mechanical stimulatory effect. Consumption of olestra in excess of usual snacking conditions did not result in a significant increase in stool output or common GI symptoms. At the highest level tested, olestra resulted in a gradual stool-softening effect after several days of consumption.

Efficacy of Milk-based Diets in Persistent Diarrhea: A Randomized, Controlled Trial

Previous studies have shown increased stool output when children with persistent diarrhea (PD) received milk as the predominant source of nutrition. We evaluated the efficacy of milk given in modest amounts as a part of a mixed diet in children with PD. One hundred sixteen children 3 to 24 months of age with diarrhea for between 14 days and 12 weeks were allocated to milk-based (n = 60) or milk-free (n = 56) cereal dietary regimens. The two diets were isocaloric (86.9 calories/100 g for < or = 9 months; 95.6 cal/100 g for > 9 months) consisting of puffed rice cereal, sugar, and oil differing in only their source of protein, which was either milk or egg white, respectively. An average of 30% of the calories were constituted by milk in the milk-cereal diet. Both diets were offered at the rate of 150 kcal/kg per day. Children receiving milk-cereal consumed an average of 1.9 g/kg lactose per day. The baseline characteristics in the two groups were similar. Comparable amounts of diet were consumed in both groups. The milk-cereal group did not have higher median (range) stool output (g/kg/h) compared with the milk-free group during a 0- to 48-hour (milk-cereal, 1.7 [0.2 to 8.7]; milk-free, 1.5 [0.1 to 6.6]) or 0- to 120-hour (milk-cereal, 1.6 [0.4 to 7.2]; milk-free, 1.3 [0.1 to 7.6]) period. The percentage of weight gain was similar in the two groups, and there were no significant differences in the duration of diarrhea. Overall, 23 children had treatment failures, 10 (17%) in the milk-cereal and 13 (23.6%) in the milk-free groups. Our findings suggest that modest intakes of milk are well tolerated as a part of mixed diet during PD.

Octreotide acetate in refractory bone marrow transplant-associated diarrhea.

To evaluate the effectiveness of octreotide acetate in the treatment of refractory bone marrow transplant-associated diarrhea. Case series encompassing 30 months. A 12-bed bone marrow transplant unit at a tertiary care medical center. Twenty-four patients with bone marrow transplant-associated diarrhea who did not improve with supportive or attapulgite therapy. Patients received subcutaneous octreotide acetate at doses ranging from 50 to 250 micrograms 2 to 3 times daily. Concurrent treatment with antimotility or antisecretory agents did not occur. The number of bowel movements and stool volumes were recorded daily. Complete response to octreotide therapy was defined as a reduction of both stool output and stool frequency by more than 50% within 72 hours. Partial response was defined as a reduction of either stool output or stool frequency by more than 50% within 72 hours. Treatment failure occurred if neither of the two parameters decreased by 50% within the designated time period. Twenty-eight treatment challenges were initiated in the 24 patients evaluated. Diarrhea completely or partially subsided in 23 of 28 challenges (82.1%) within 72 hours. Stool output decreased from 1143 +/- 595 at baseline to 252 +/- 356 mL/d within 72 hours (p < 0.005). Stool frequency decreased from a baseline of 7.5 +/- 3.4 to 2.7 +/- 2.2 stools per day within 72 hours (p < 0.005). Adverse effects associated with octreotide were pain or burning at the injection site (24.1%), abdominal pain (13.8%), and increased stool output (6.9%). These data suggest octreotide acetate significantly reduces stool output and frequency in patients with refractory bone marrow transplant-associated diarrhea. Additional research is necessary before this agent can be recommended for routine use in this patient population.

Balance Studies and Polymeric Glucose Solution to Optimize Therapy After Massive Intestinal Resection

The aim of this study was to determine whether fluid homeostasis could be maintained by using a hypo-osmolar (200 to 221 mosmol/kg), relatively low-sodium (50 to 52 mmol/liter) solution that contained a glucose polymer in a 54-year-old patient with high ileostomy output attributed to short-gut syndrome and resultant prerenal azotemia. Sequential balance studies were performed to assess stool and urinary output, stool fat, and urinary electrolytes initially during intravenous rehydration and subsequently during administration of the necessary fluids and nutrients exclusively by oral supplementation. The additional effects of high-fat and low-fat diet, loperamide hydrochloride, and octreotide acetate were evaluated. When the patient sipped a hypo-osmolar oral rehydration solution while she was awake during the day and received a high dose of loperamide and a 40-g fat, disaccharide-free diet, salt and water homeostasis was maintained. The addition of octreotide did not substantially enhance fluid balance; rather, it increased fecal fat and fluid losses from the small bowel. Thus, hypo-osmolar polymeric glucose solutions maintain fluid homeostasis in patients with the short-gut syndrome. In such patients, simple balance studies are useful for assessing the absorptive capacity of the residual intestine, for developing an optimal individualized treatment, and for eliminating the need for costly, long-term home parenteral nutrition.

Enteric bacteriology, absorption, morphology and emptying after ileal pouch-anal anastomosis.

The aim was to determine whether changes in enteric bacteriology, absorption, morphology, and emptying occur after ileal pouch-anal anastomosis for ulcerative colitis, and to relate any changes to the clinical result. Twenty patients were studied 26 +/- 2 months (mean +/- s.e.m.) after operation. Eight patients had a good result, six a poor result, and six a history of recurrent pouch ileitis. Anaerobic and aerobic overgrowth occurred in the jejunum of patients with a poor result, but not in those with a good result or with pouch ileitis. In contrast, ileal pouch bacterial overgrowth occurred in all patients regardless of the clinical result. Patients with jejunal overgrowth had increased 24 h stool volume and stool nitrogen, but other patients did not. The larger the stool volume, the greater the anaerobic overgrowth. Pouch biopsies showed chronic inflammation in all patients, while 45 per cent had colonic metaplasia. Neither the inflammation nor the metaplasia correlated with the clinical result, nor did the clinical result correlate with the efficiency of pouch emptying. In conclusion, jejunal bacterial overgrowth after ileal pouch-anal anastomosis was associated with an increased stool output, azotorrhoea, and a poor clinical result. A distinguishing bacterial, absorptive, morphological, or emptying abnormality was not found in patients with a history of recurrent pouch ileitis.

ADENOVIRUS INFECTIONS AN IMPORTANT CAUSE OF MORBIDITY IN HOSPITALIZED CHILDREN FOLLOWING GASTROINTESTINAL SURGERY

We investigated the effect of enteric adenovirus infections (ETAD) on children who had undergone abdominal surgical procedures resulting in intestinal stomas (ostomies). We studied 58 such children hospitalized in our institution over a 27 month period, 28 of whom had an underlying diagnosis of NEC. A total of 13 (22.4%) of the patients had at least one episode of ETAD during hospitalization documented by enzyme immunoassay during the study period. Ten of the 28 (35.7%) children with NEC had ETAD infections. Four of these children had evidence of two distinct infections with ETAD.All of the children infected with ETAD had evidence of a substantially increased gastrointestinal output associated with their infections. In addition, infection with ETAD was associated with a substantial increase in length of hospitalization, (mean stay 163.8 +/- 42.4 days vs 46.1 +/- 11.8 days in uninfected controls, p < .01). Gastrointestinal infection with adenovirus was not associated with respiratory symptoms or conjunctivitis. Other causes of gastroenteritis such as rotavirus, bacteria, or toxins were not found to be significant gastrointestinal pathogens in this population and increased stool output was only infrequently noted in patients without evidence of ETAD. Adenoviruses appear to be important causes of morbidity in hospitalized patients with ostomies, especially in those with a history of NEC.