Prolonged Bowel Rest Research Articles

A case report of refractory congenital chylous ascites in infant – surgical treatment with Fibrin glue

Congenital chylous ascites is a rare disease that results from abnormal development of the intra-abdominal lymphatic system. No gold standard treatment has been described so far, however, a combination of medium–chain triglyceride based diet or total parenteral nutrition along with octreotide and abdominal paracentesis is considered as a conservative management. This treatment is often a challenge to physicians since chylous ascites is often refractory and result in malnutrition and immune deficiency because of the loss of proteins and lymphocytes. We report a four-month old boy with congenital chylous ascites who was refractory to medical treatment with prolonged bowel rest, total parenteral nutrition, octreotide and repeated paracentesis. The baby well responded to surgical treatment with application of fibrin glue on the surface area of the leak site and was discharged after 2 month of hospitalization. When following up the patient had no recurrence of the ascites and he was growing up normally.

Chylous ascites in an infant – Treated surgically with fibrin glue after failed medical treatment - A case report

Abstract Congenital chylous ascites (CCA) is a rare disease that results from mal development of the intra-abdominal lymphatic system and no gold standard treatment described so far. It is defined as the accumulation of triglyceride-rich milky fluid into peritoneal cavity in infant younger than three months. Medium chain triglyceride (MCT)-based diet or total parental nutrition (TPN) with rest to bowel and abdominal paracentesis is the time honoured conservative management. Due to rare incidence of this disorder, the existing literature includes mainly case reports where TPN was used with or without MCT based formulas along with octreotide. This condition is often refractory to therapy and is responsible for serious malnutrition and immunological deficiency because of loss of proteins and lymphocytes. Its treatment is often frustrating and challenge to physician. We report an infant with chylous ascites which was refractory to medical treatment in the form of prolonged bowel rest with TPN, Octreotide and repeated paracentesis. Surgical treatment with application of fibrin glue in the area of paradudenal retroperitoneal lymphatics sealed the lymphatic leak and cured the patient.

Frequency and Predictors of Fasting Orders in Inpatients with Ulcerative Colitis: The Audit of Diet Orders - Ulcerative Colitis (ADORE-UC) Study

Introduction: Studies have demonstrated that physicians may contribute to malnutrition by ordering bowel rest inappropriately. Practice guidelines recommend that patients hospitalized with UC be offered a normal diet or enteral nutrition unless such a diet is not tolerated. There are no published studies assessing compliance with this recommendation. This study aims to assess the frequency of unnecessary bowel rest in hospitalized UC patients and to identify predictors of prolonged bowel rest. Methods: We conducted a retrospective cohort study of ulcerative colitis patients who were admitted to the gastroenterology (GI) service or the general internal medicine (GIM) service at an academic hospital between January 2009 and December 2014, with a length of stay of 2 or more and 30 or fewer days. The frequency and duration of bowel rest orders and the number of meals missed because of these orders were assessed. Bowel rest orders were considered necessary if the patient had intractable nausea or vomiting, pancreatitis, bowel obstruction, toxic megacolon or were awaiting endoscopy. Prolonged bowel rest was defined as being NPO (nil per os) or on a CFD (clear fluids diet) for over 25% of the duration of the admission, and absence of an appropriate indication. Predictors of prolonged bowel rest were assessed using logistic regression. Results: A total of 187 admissions in 158 UC patients were identified during the study period. The median length of stay was 8 days ([IQR] = 4 - 12). Prolonged bowel rest orders were encountered in 82 (43.9%) admissions. The mean duration of prolonged bowel rest was 2.27 days (SD = 1.2) or 36% of admission length (SD = 26). Prolonged bowel rest was encountered in 52 (27.8%) admissions. Significant (p< 0.05) predictors of prolonged bowel rest in the final model were: NPO or CFD diet ordered at admission, odds ratio [OR] 19.5 (95% confidence interval [CI] 7.75 - 49.0); more than one admission during the study period, 8.86 (95% CI 2.16 - 36.27); biologic therapy initiation during admission, 4.25 (95% CI 1.40 - 12.85); and admission to non-GI service 2.64 (1.30 - 6.72). Conclusion: There is a high burden of prolonged bowel rest among hospitalized UC patients. Our findings also suggest that targeted interventions, possibly directed early in admission, are needed to decrease the frequency of inappropriate bowel rest among hospitalized UC patients. Further studies are needed to assess the nutritional impact of prolonged bowel rest on UC patients.

Enteral nutrition support

Up to 33% of patients who are admitted to hospitals with hronic disease and trauma also present with moderate to evere malnutrition. This results in depletion of body cell mass, rolonged wound healing, and impaired function [1]. Malnurition is defined as unintentional weight loss of more than 10% f an individual’s body weight. It is classified as mild, modrate, or severe based on body mass index, arm muscle cirumference, skin fold thickness, and depletion of visceral proein stores (e.g., albumin, prealbumin, and retinol-binding rotein). The etiology of malnutrition can be subdivided into our continuous types: 1) decrease in nutrient intake (poor diet, ating difficulty) or excessive losses (long-term diarrhea, abormal bleeding, large draining wounds), 2) nutrient store epletion, 3) increased metabolic demand (i.e., hypercataboism), and 4) cell or tissue damage [1,2]. Prolonged starvation leads to deterioration of intestinal ntegrity. Within a few days of complete bowel rest, proressive atrophy and disruption of the intestinal mucosa ccur. With severe protein deficiency, microvilli of the ntestinal mucosa undergo shortening, resulting in generalzed disruption of the surface architecture [3]. Of particular mportance is the amino acid glutamine which is the prinipal metabolic fuel for intestinal epithelial cells [4]. Lack of luminal nutrient substrates followed by mucosal isruption is also associated with the process of bacterial ranslocation. In critically ill patients, prolonged bowel rest ay lead to loss of endothelial architecture and integrity, hereby allowing the enteric pathogens to migrate across the ffected bowel mucosa and into the systemic circulation [5]. he correction and prevention of malnutrition decreases orbidity, hospital stay, mortality rate, and recovery time rom illness [6,7]. Artificial nutritional support refers to the administration f nutrient solutions by enteral or intravenous (parenteral)

Modulating effects of the feeding route on stress response and endotoxin translocation in severely stressed patients receiving thoracic esophagectomy

Experimental studies have demonstrated that the route of nutritional supply impacts the systemic metabolic responses after surgical injury. Intestinal mucosal atrophy, as induced by total parenteral nutrition (TPN) or prolonged bowel rest, has been reported to enhance bowel endotoxin translocation. The operative procedure for thoracic esophageal cancer, including thoracotomy, laparotomy, and three-field lymph-node dissection, is a particularly stressful surgery that requires long-term aggressive nutritional support and often results in the postoperative hypermetabolic state, leading to perturbation of postoperative immune function. Interleukin-6 (IL-6) plays an important role in host inflammatory responses, whereas IL-10 is linked to suppression of cellular immunity. The aim of this study was to investigate how the antecedent nutritional routes influence systemic IL-6 and IL-10 responses and endotoxin translocation after an operation for thoracic esophageal cancer. Twenty-nine patients who underwent esophagectomy with three-field lymphadenectomy were investigated. They were assigned to groups receiving either TPN ( n = 18) or enteral nutrition (EN; n = 11) providing 35 kcal · kg −1 · d −1 of energy and approximately 1.2–1.5 g · kg −1 · d −1 of amino acids. These nutritional supports were conducted from 1 wk before the operation to 14 d after the operation. Serum IL-6, IL-10, and endotoxin concentration were measured before and during the operation and at 2 h and 1, 3, and 7 d after the operation. IL-6 in sera was significantly higher after the operation in both groups. In the EN group, however, significantly less IL-6 production was observed on the third and seventh postoperative days when compared with those patients in the TPN group. Similarly, serum IL-10 concentration in the TPN group showed a significantly higher level than that in the EN group. Serum IL-6 showed a significant positive correlation with IL-10 at 2 h and at 7 d after the operation, suggesting that the reduced inflammatory responses were related to the inhibition of the development of postoperative immunosuppression. Endotoxin concentration in sera was significantly lower in the EN group after the operation than in the TPN group. Perioperative EN provides better regulation of inflammatory cytokine responses and may contribute less to immunosuppression after major surgery than parenteral nutrition. The attenuated production of endotoxin induced by EN may play an important role in these phenomena.

Treatment of Duodenocutaneous Fistula with Somatostatin Analog in a Child with Dermatomyositis

SummaryA 6‐year‐old girl with juvenile dermatomyositis complicated by five duodenal perforations is described. The treatment consisted of suture closure of the perforations, reinforcement of the suture line with an omental graft, and adequate drainage of the closure site. The use of a somatostatin analog was successful in promptly arresting a leak from the duodenal perforations that had persisted for 3 months after the operation despite prolonged bowel rest and total parenteral nutrition. On follow‐up observation 2 months later, the patient had no abdominal complaints and was tolerating oral intake without problems.

Treatment of Duodenocutaneous Fistula with Somatostatin Analog in a Child with Dermatomyositis

A 6-year-old girl with juvenile dermatomyositis complicated by five duodenal perforations is described. The treatment consisted of suture closure of the perforations, reinforcement of the suture line with an omental graft, and adequate drainage of the closure site. The use of a somatostatin analog was successful in promptly arresting a leak from the duodenal perforations that had persisted for 3 months after the operation despite prolonged bowel rest and total parenteral nutrition. On follow-up observation 2 months later, the patient had no abdominal complaints and was tolerating oral intake without problems.

Total Parenteral Nutrition and Bowel Rest Modify the Metabolic Response to Endotoxin in Humans

Intestinal mucosal atrophy, as induced by total parenteral nutrition (TPN) and/or prolonged bowel rest, is hypothesized to enhance bowel endotoxin (LPS) translocation and may alter host responses to infection. To examine the effect of TPN-induced bowel atrophy on the response to LPS, 12 healthy volunteers were randomized to receive either enteral feedings (ENT, n = 6) or seven days of TPN without oral intake (TPN, n = 6). Enteral or TPN feedings were terminated 12 hours before the study period when a constant dextrose infusion (50 mg/kg/hour) was initiated and continued throughout the subsequent study period. After placement of arterial, hepatic vein, and femoral vein catheters, metabolic parameters were determined before and for six hours after an intravenous E. coli LPS challenge (20 U/kg). Subsequent peak levels of arterial glucagon (ENT, 189 +/- 39 pg/mL; TPN, 428 +/- 48; p less than 0.01), arterial epinephrine (ENT, 236 +/- 52 pg/mL; TPN, 379 +/- 49; p less than 0.05) and hepatic venous cachectin/tumor necrosis factor (cachectin/TNF) (ENT, 250 +/- 56 pg/mL; TPN, 479 +/- 136; p less than 0.05) were significantly higher in the TPN group than in the ENT group. The extremity efflux of lactate (ENT, -16 +/- 4 micrograms/min-100cc tissue; TPN, -52 +/- 13; t = 2 hours; p less than 0.05) and of amino acids (ENT, -334 +/- 77 nmol/min-100cc tissue; TPN, -884 +/- 58; t = 4 hours; p less than 0.05) were higher in the TPN subjects after the endotoxin challenge. Circulating C-reactive Protein (CRP) levels measured 24 hours postendotoxin were also significantly higher in the TPN subjects (ENT, 1.7 +/- 0.2 mg/dL; TPN, 3.2 +/- 0.3; p less than 0.01). Hence the counter-regulatory hormone and splanchnic cytokine responses to LPS were enhanced after TPN and bowel rest. This is associated with a magnified acute-phase response, peripheral amino acid mobilization, and peripheral lactate production. Thus antecedent TPN may influence the metabolic alterations seen in infection and sepsis via both an exaggerated counter-regulatory hormone response as well as an enhanced systemic and splanchnic production of cytokines.

Nutrition and Inflammatory Bowel Disease

Nutritional support, whether enteral or parenteral, is an important part of the treatment of IBD. Inadequate oral intake, malabsorption, and increased gastrointestinal losses all contribute to malnutrition. Weight loss, cachexia, abnormal body composition, and multiple micronutrient deficiencies are common. Acute repletion of body weight and correction of specific nutrient deficiencies improve the patients' sense of well-being and decrease morbidity, especially in the perioperative period. If a short period of bowel rest (10 to 14 days) is part of the medical therapy of acute exacerbations of IBD, TPN should be administered to prevent further nutritional deficiencies. Chronic undernutrition, and growth failure in children, usually are best treated by intensive enteral supplementation. Prolonged bowel rest and TPN (4 to 6 weeks) have not been shown to improve outcome but may be appropriate in carefully selected patients. Long-term home TPN may be necessary for patients who have short gut syndrome. The mainstay of treatment for IBD is medical therapy including corticosteroids. Timely and appropriate surgery is equally important and should not be considered a last resort. Careful nutritional management is essential but is adjunctive rather than primary therapy.

Endoscopic, radiographic, and clinical response to prolonged bowel rest and home parenteral nutrition in Crohn's disease.

Total parenteral nutrition is widely used as a therapeutic measure in patients with severe, active Crohn's disease unresponsive to conventional medical management. We have reviewed our experience with 10 patients with nonfistulous Crohn's disease treated by home parenteral nutrition (HPN) and bowel rest (nothing-by-mouth) assessing the nutritional, radiologic, endoscopic, and clinical responses. After a mean of 4.1 months of treatment, all patients had a marked improvement in nutritional status and resolution of gastrointestinal symptoms; 90% reduced their corticosteroid dose. Eight of nine patients had endoscopic and/or radiographic evidence of mucosal healing. Although 60% of patients were able to avoid surgery and tolerate refeeding, all six patients continue to require steroids to control symptoms. Our study suggests that HPN and bowel rest is a useful therapeutic approach to selected patients with active Crohn's disease, which permits a reduction in corticosteroid dosage and partial healing of mucosal lesions in most. Further studies are required to determine which patients should receive HPN and its optimal duration.

Dietary fructose in the management of intractable diarrhea of infancy.

Carbohydrate digestion/absorption was evaluated in 11 infants with intractable diarrhea while they were receiving a carbohydrate-free soy-isolate formula. Seven patients were fed within 48 h of admission. Enteral feedings were initiated in the remainder after they had gained 1 kg while receiving parenteral nutrition. All feedings were initially administered by continuous nasogastric infusion. Nine patients were initially fed formula with polymeric glucose; two received fructose as the carbohydrate source, based on a documented history of polymeric glucose intolerance. Five of the nine developed watery, acidic stools while receiving polymeric glucose. All were switched to fructose, which resulted in improvement in stool pH and consistency. Glucose tolerance was normal 1 month after discharge in all seven fructose-requiring infants. Three of six infants have shown a persistent inability to hydrolyze sucrose. Several putative mechanisms of polymeric glucose intolerance are discussed, as well as the apparent association with primary sucrase-isomaltase deficiency in three of the patients. Fructose is an effective alternative carbohydrate source in infants unable to tolerate polymeric glucose, and early initiation of fructose may obviate the need for total parenteral nutrition and prolonged bowel rest.

Dietary Fructose in the Management of Intractable Diarrhea of Infancy

SummaryCarbohydrate digestion/absorption was evaluated in 11 infants with intractable diarrhea while they were receiving a carbohydrate‐free soy‐isolate formula. Seven patients were fed within 48 h of admission. Enteral feedings were initiated in the remainder after they had gained 1 kg while receiving parenteral nutrition. All feedings were initially administered by continuous nasogastric infusion. Nine patients were initially fed formula with polymeric glucose; two received fructose as the carbohydrate source, based on a documented history of polymeric glucose intolerance. Five of the nine developed watery, acidic stools while receiving polymeric glucose. All were switched to fructose, which resulted in improvement in stool pH and consistency. Glucose tolerance was normal 1 month after discharge in all seven fructose‐requiring infants. Three of six infants have shown a persistent inability to hydrolyze sucrose. Several putative mechanisms of polymeric glucose intolerance are discussed, as well as the apparent association with primary sucrase‐isomaltase deficiency in three of the patients. Fructose is an effective alternative carbohydrate source in infants unable to tolerate polymeric glucose, and early initiation of fructose may obviate the need for total parenteral nutrition and prolonged bowel rest.