Total Bowel Rest Research Articles

The role of parenteral nutrition in patients with malignant bowel obstruction.

The role of parenteral nutrition in the treatment of malignant bowel obstruction is underestimated since palliative literature mainly focuses on gastric aspiration, nothing per os and antisecretory therapy. The purpose of this review is the appraisal of the literature with a focus on the potential contribution of parenteral nutrition. Literature included in a recent meta-analysis and in a Cochrane review on parenteral nutrition in malignant bowel obstruction and updated through PUBMED until March 2019 has been reviewed. Prompt withholding of food intake, nasogastric aspiration and then the use of antisecretory agents represent the milestones of treatment which are applied to all patients with malignant bowel obstruction. After this initial approach, excluding few surgical patients and those defined as imminently dying, there is a heterogeneous group of patients achieving a benefit in a few days but with a prompt recurrence of symptoms as they attempt to reassume some food intake. Parenteral nutrition in hospital or at home addresses to these patients provided their life expectancy is likely to depend on progressive nutritional deterioration due to the prolonged starvation more than on the tumour spread. These patients on home parenteral nutrition can survive a few months with some indefinite benefit on quality of life whereas untreated patients have a survival of few weeks. Parenteral nutrition should be considered in selected patients who benefit from standard palliative treatment of malignant obstruction and are obliged to maintain a total bowel rest for weeks or months.

Nutritional management in chyle leaks and chylous effusions

Chyle leaks occur when there is interruption to the lymphatic ducts that transport chyle around the body. The loss of this protein-rich, calorie-rich fluid can cause serious complications including dehydration, malnutrition and immunosuppression. Treatment of chyle leaks depends on the underlying cause, which may be surgical, secondary to malignant invasion or the result of a medical condition. Nutritional support is vital and leads to spontaneous leak closure in many cases. Nutritional management options include total bowel rest with parenteral nutrition, enteral feeding with specialized formula, or oral diet with supplementation. At present there is no consensus regarding which approach is superior. In reality, most patients with chyle leaks are managed with a combination or oral and enteral feeding, but further work is needed to clarify the optimum management strategy.

Neutropenic Enterocolitis in Adult Patients with Acute Leukemia: A Single Center Experience

AbstractAbstract 4324 IntroductionNeutropenic enterocolitis (NEC), a complication associated with chemotherapy induced neutropenia, is defined by abdominal pain and fever with bowel wall thickening observed on imaging studies. The published literature regarding this complication comes from case reports and small, predominantly pediatric, series. We conducted a single center retrospective chart review to examine the clinical features of NEC in adults treated with chemotherapy for acute leukemia or myelodysplastic syndrome (MDS). MethodsA key word search of radiology records for “acute leukemia” and “neutropenic enterocolitis” or “typhilitis” identified a total of 20 cases which occurred during the period of 1/2008 to 3/2012. Only cases with documented fever (T >38°C), abdominal pain, neutropenia (<500/mm3), and findings of submucosal edema, pericolonic inflammation or bowel wall thickening on computed tomographic imaging plus a diagnosis of acute myeloid leukemia (AML), acute lymphoid leukemia (ALL) or high risk MDS were included. All 20 cases identified by the record search met these criteria. ResultsMale: female ratio was 1:1 and the mean age was 51.5 years (range 25 to 82). There were 15 patients (pts) with AML, 3 with ALL, 1 with acute promyelocytic leukemia (APL) and 1 with high risk MDS. 10 pts developed NEC during hospitalization for newly diagnosed disease, 8 during relapsed disease, and 2 during remission consolidation therapy. 17 pts received anthracycline-based therapy prior to the development of NEC; 16 received cytarabine, of which 5 received high dose cytarabine. 13 pts had diarrhea. 5 pts had documented Clostridium difficile infection during the same admission. 11 pts had positive blood cultures during the course of NEC: Enterococcus faecium (6), E. coli (4), and Klebsiella species (1). All pts received broad spectrum antibiotics. 11 pts received a carbapenem antibiotic, 5 pts received an aminoglycoside antibiotic, 18 received anaerobic coverage, and 19 received antifungal coverage. 9 pts were placed on total bowel rest, 11 kept on a clear liquid diet, 13 received a proton pump inhibitor (PPI), 1 received an H2 blocker, and 13 received filgrastim to facilitate recovery of the neutrophil count. 3 pts died; the cause of death was attributed to NEC in all 3. The mean duration of time from the onset of symptoms to the time of documentation of NEC by means of imaging studies was 5.6 days (range 0–15), the mean overall duration of symptoms was 16.4 days (range 0–46), and the mean duration of neutropenia prior to the diagnosis of NEC was 10.9 days (range 0–32). The 3 pts who died had a shorter mean duration of time from the onset of symptoms to the time of documentation of NEC by imaging studies (1.7 days), shorter mean duration of symptoms (7.3 days), and shorter mean duration of neutropenia prior to diagnosis of NEC (6 days). Among the 17 pts who recovered from NEC these durations were 6.3 days, 17.9 days, and 11.7 days, respectively. The mean age of the 3 pts who died was 72 years (range 67–82); while the mean age of the 17 pts who recovered was 47 years (range 25–69). All 3 pts who died had AML, 2 receiving induction therapy and 1 remission consolidation therapy at the time of NEC. All 3 pts had involvement of the cecum on imaging. 1 had associated Clostridium difficile infection and 2 pts had positive blood cultures: Klebsiella species (1), Enterococcus faecium (1). 2 of the 3 pts who died had received a PPI and filgrastim. None of the 20 pts required surgical intervention. DiscussionNEC is a life threatening complication of treatment of acute leukemia and high risk MDS. This is the largest single institution retrospective case study of NEC developing in adult patients with acute leukemia. 17 of 20 pts recovered. The 3 pts who died as a result of NEC had a shorter duration of symptoms and neutropenia prior to the diagnosis of NEC, suggesting an aggressive form of the disease with rapid development of symptoms. Older age may be a risk factor for poor outcome. 11 of the 17 pts who survived were kept on a clear liquid diet, suggesting that complete bowel rest may not be necessary for the successful treatment of NEC. NEC remains a dreaded complication of acute leukemia therapy and further studies in the adult population are needed to establish guidelines for the diagnosis and optimal management of NEC. Disclosures:No relevant conflicts of interest to declare.

Tricho‐hepato‐enteric syndrome: A case of hemochromatosis with intractable diarrhea, dysmorphic features, and hair abnormality

We report on a female infant with congenital iron storage disease, facial dysmorphism, intractable diarrhea, and hair abnormalities. The intractable diarrhea failed to resolve despite total parenteral nutrition and complete bowel rest for more than 3 weeks. The patient also had elevated liver enzymes and failure to thrive. Histopathologic examination of the liver revealed marked iron deposits in hepatocytes with portal edema, fibrosis, and septal formation. No metabolic abnormalities could be detected. She died at the age of 10 months. We suggest that this case could have a specific iron storage syndrome that is similar to the two sibs reported by Stankler et al. [1982; Arch Dis Child 57:212-216] and Verloes et al. [1997; Am J Med Genet 68:391-395]. The condition was called the tricho-hepato-enteric (THE) syndrome.

Intestinal Failure–Associated Liver Disease: What Do We Know Today?

Intestinal failure-associated liver disease develops in 40% to 60% of infants who require long-term total parenteral nutrition (TPN) for intestinal failure and 15% to 40% of adults on home parenteral nutrition. The clinical spectrum includes hepatic steatosis, cholestasis, cholelithiasis, and hepatic fibrosis. Progression to biliary cirrhosis and the development of portal hypertension and liver failure occurs in a minority but is more common in infants and neonates than in adults. The pathogenesis is multifactorial. In infants it is related to prematurity, low birth weight, duration of PN, short bowel syndrome requiring multiple laparotomies, and recurrent sepsis. Other important mechanisms include lack of enteral feeding, which leads to reduced gut hormone secretion; reduction of bile flow and biliary stasis, which leads to the development of cholestasis; and biliary sludge and gallstones, which exacerbate hepatic dysfunction. In adults, IFALD is less common and related to age, length of time on PN, total caloric intake, and lipid or glucose overload. In preterm infants, a deficiency of taurine or cysteine may play a role, whereas in both adults and children, choline deficiency may exacerbate IFALD. Lipid emulsions, choline deficiency, and manganese toxicity are associated with both hepatic steatosis and cholestasis in adults and children. Management strategies for the prevention of intestinal failure-induced liver disease include early enteral feeding, a multidisciplinary approach to the management of parenteral nutrition, and aseptic catheter techniques to reduce sepsis. The addition of choline, taurine, and cysteine to PN solutions may also play a role. Oral administration of ursodeoxycholic acid may improve bile flow and reduce gallbladder stasis. Survival after either isolated small bowel or combined liver and small bowel transplantation is approximately 50% at 5 years, making this an acceptable therapeutic option in adults and children with irreversible liver and intestinal failure.

Nutrition support during acute pancreatitis

Studies have shown that protein catabolism increases by 80% and energy expenditure by 20% in acute pancreatitis, indicating that nutritional requirements are elevated. Other studies have associated the resolution of negative nitrogen balance by nutrition support with improved outcome. Consequently, the need for effective nutrition is one cornerstone of management of acute pancreatitis. Concerns that feeding may exacerbate the disease process by stimulating the synthesis of proteolytic enzymes in the acinar cell and perpetuating autolysis has led to the widespread use of total parenteral nutrition (TPN) and bowel rest. Unfortunately, the use of TPN in clinical practice has been associated with major metabolic and infective complications, possibly because 1) patients with acute pancreatitis are intolerant of glucose due to coexistent pancreatic endocrine dysfunction and 2) the disease causes immune suppression. This has led to the search for alternatives. Based on physiologic studies, infusion of nutrients into the distal jejunum bypasses the stimulatory effect of feeding on pancreatic secretion. Many controlled trials have compared TPN with jejunal feeding. No study has shown that jejunal feeding exacerbates the disease. Further, jejunal feeding is associated with fewer infectious and metabolic complications. These observations and the fact that enteral feeding is one-tenth the cost of TPN has resulted in the general acceptance of jejunal feeding as the preferred mode for maintaining nutrition in patients with acute pancreatitis.

Closure of Proximal Colorectal Fistulas Using Fibrin Sealant

Fibrin glue has been used in upper gastrointestinal and perianal fistula disease, but its success in proximal colorectal pathology has not been widely documented. This report describes the use of endoscopically injected fibrin glue as a successful adjunct to traditional methods in accelerating the closure of colorectal fistulas. A retrospective review was performed on cases of colon and rectal fistulas treated with fibrin glue using an endoscopic technique of injection. Fistulas were injected via a flexible fiberoptic endoscope with fluoroscopic guidance (three) or directly with a rigid proctoscope (one). Fibrin glue was mixed directly from cryoprecipitate, thrombin, and calcium (one) or using a Tisseel kit (three) (Baxter, Deerfield, IL). Four patients were identified and included: two J-pouch fistulas, a colocutaneous fistula, and a complex rectocutaneous fistula. The median duration of fistula was 33 days (range 4-365 days). Total parenteral nutrition and bowel rest were used in two patients and three required drainage of an abscess. All fistulas were obliterated and patients required a mean of one application of fibrin glue (range one to two). The mean time to resuming a regular diet postinjection was 2 days (range 1-5). No complications were identified. Fistula resolution was documented in all cases with a contrast enema and no patient has had a fistula recurrence at a median follow-up of 12 months (range 6-65). This preliminary series demonstrates that fibrin glue can be used to obliterate proximal rectal, colonic, and pouch fistulas. Endoscopy and fluoroscopy may aid in administering the fibrin glue. This adjunctive technique may shorten the time to fistula closure and may allow some patients to avoid further surgery.

Pentoxifylline and thalidomide fail to reduce hepatic steatosis during total parenteral nutrition and bowel rest in the rat.

We suggested that the continuous translocation of endotoxin from Gram-negative bacterial overgrowth during bowel rest and total parenteral nutrition (TPN) causes the release of tumor necrosis factor (TNF), resulting in liver damage and hepatic dysfunction. Because TPN-induced hepatic steatosis was significantly reduced by the monoclonal antibodies against TNF, we attempted a more clinically applicable approach using pentoxifylline and thalidomide. A control group (group I) fed rat chow and four groups of rats receiving TPN were studied. Group II received TPN only; group III, TPN and 100 mg/kg/d pentoxifylline; group IV, TPN and 200 mg/kg/d pentoxifylline; and group V, TPN and 5 mg/kg/d thalidomide. On day 7, total liver fat was determined. Bowel rest and TPN resulted in a significant (p < .0005) increase in liver fat content that was unaltered by either pentoxifylline or thalidomide. Our results show no role for pentoxifylline or thalidomide in reducing TPN-associated hepatic steatosis.

Complications during home parenteral nutrition in children affected by congenital microvillous atrophy

Among the heterogeneous group of intractable diarrheas in infancy is a now better-identified new clinical entity, intestinal epithelial dysplasia (IED). These forms, together with autoimmune enteropathies, enteropathies described in immunological deficits,2 and those associated to some rare inborn errors of metabolism and/or in some genetical syndromes represent the most severe microvillous atrophies. Intestinal epithelial dysplasias reveal themselves with intractable diarrhea starting in the neonatal period: the diarrhea is severe, watery, with electrolitic losses and without extradigestive manifestations. It is resistent to all the most common dietetic and pharmacological treatments and also to total bowel rest. An histological picture of severe microvillous atrophy with normal or hyperplastic cryptae is always present but is only sometimes associated with microvillous inclusions. These conditions that represent the more typical example of irreversible intestinal failure may be considered today to be one of the more frequent indications to small bowel transplant (Sb-Tx) in childhood. Parenteral nutrition (PN) has completely modified prognosis of this disease assuring to the patients not only survival but also normal growth while waiting for Sb-Tx. In these cases PN is started soon after birth and has a prolonged duration with home parenteral nutrition (HPN) programs. It is a total PN that assures the whole nutritional need and that has to cover the persistent severe fecal losses. In these patients, PN dependence and its complications in particular influence Sb-Tx timing. The aim of this study is to evaluate the complications we observed during HPN in three cases of congenital microvillous atrophy with epithelial dysplasia waiting for Sb-Tx.

10 Nutrition and ulcerative colitis

The role of diet in the aetiology and pathogenesis of ulcerative colitis (UC) remains uncertain. Impaired utilization by colonocytes of butyrate, a product of bacterial fermentation of dietary carbohydrates escaping digestion, may be important. Sulphur-fermenting bacteria may be involved in this impaired utilization. Oxidative stress probably mediates tissue injury but is probably not of causative importance. Patients with UC are prone to malnutrition and its detrimental effects. However, there is no role for total parenteral nutrition and bowel rest as primary therapy for UC. The maintenance of adequate nutrition is very important, particularly in the pen-operative patient. In the absence of massive bleeding, perforation, toxic megacolon or obstruction, enteral rather than parenteral nutrition should be the mode of choice. Nutrients may be beneficial as adjuvant therapy. Butyrate enemas have improved patients with otherwise recalcitrant distal colitis in small studies. Non-cellulose fibre supplements are of benefit in rats with experimental colitis. Eicosapentaenoic acid in fish oil has a steroid-sparing effect which, although modest, is important, particularly in terms of reducing the risk of osteoporosis, but it seems to have no role in the patient with inactive disease. γ-Linolenic acid and anti-oxidants also are showing promise. Nutrients may also modify the increased risk of colorectal carcinoma. Oxidative stress can damage tissue DNA but there are no data published at present on possible protection from oral anti-oxidants. Butyrate protects against experimental carcinogenesis in rats with experimental colitis. Folate supplementation is weakly associated with decreased incidence of cancer in UC patients when assessed retrospectively. Vigilance should be maintained for increased micronutrient requirements and supplements given as appropriate. Calcium and low-dose vitamin D should be given to patients on long-term steroids and folate to those on sulphasalazine.

Dysplasie épithéliale intestinale : une nouvelle entité

Among the heterogeneous group of intractable diarrheas in infancy is a now better-identified new clinical entity, intestinal epithelial dysplasia (IED). These forms, together with autoimmune enteropathies, enteropathies described in immunological deficits,2 and those associated to some rare inborn errors of metabolism and/or in some genetical syndromes represent the most severe microvillous atrophies. Intestinal epithelial dysplasias reveal themselves with intractable diarrhea starting in the neonatal period: the diarrhea is severe, watery, with electrolitic losses and without extradigestive manifestations. It is resistent to all the most common dietetic and pharmacological treatments and also to total bowel rest. An histological picture of severe microvillous atrophy with normal or hyperplastic cryptae is always present but is only sometimes associated with microvillous inclusions.These conditions that represent the more typical example of irreversible intestinal failure may be considered today to be one of the more frequent indications to small bowel transplant (Sb-Tx) in childhood. Parenteral nutrition (PN) has completely modified prognosis of this disease assuring to the patients not only survival but also normal growth while waiting for Sb-Tx. In these cases PN is started soon after birth and has a prolonged duration with home parenteral nutrition (HPN) programs. It is a total PN that assures the whole nutritional need and that has to cover the persistent severe fecal losses. In these patients, PN dependence and its complications in particular influence Sb-Tx timing.The aim of this study is to evaluate the complications we observed during HPN in three cases of congenital microvillous atrophy with epithelial dysplasia waiting for Sb-Tx.

The effect of intravenous lipids on gastric emptying in rats subjected to total parenteral nutrition

Total parenteral nutrition (TPN) is indicated in a number of clinical situationsinvolving obstructive disorders of the gastrointestinal tract or when total bowel rest is required. However, little is known of its effects upon the physiology of gastric storage and emptying. A study of the effects of lipid nutrient content of TPN on the gastric emptying of a non-energy liquid test meal in male and female conscious rats (250–280 g) was undertaken. Five experimental groups were set up according to the percentage of total non-protein energy administered in the form of different lipids: A (lipid-free: 100% of non-protein energy as glucose); B (5% long-chain triglycerides (LCT), 95% glucose); C (40% LCT, 60% glucose); D (5% LCT and medium-chain triglycerides (MCT) in 1:1 proportion, 95% glucose); and E (40% LCT and medium-chain triglycerides (MCT) in 1:1 proportion, 60% glucose). Animals were maintained on TPN for 24 h and for 3 and 4 days, after which gastric emptying was measured by the phenol red method. 40% lipid TPN was found to accelerate gastric emptying as infusion was prolonged, although the type of lipid had no effect.

Antitumor necrosis factor antibodies reduce hepatic steatosis during total parenteral nutrition and bowel rest in the rat.

In previous studies, we demonstrated the overgrowth of gram-negative bacteria in the gut and an enhanced release of tumor necrosis factor (TNF) by peritoneal macrophages, suggesting that endotoxin, TNF, or both, may act as hepatotoxins to produce hepatic steatosis during total parenteral nutrition (TPN) and bowel rest. The present study attempts to better define the role of each of these two mediators. The first part examines the LD50 for various doses of endotoxin in TPN-treated rats compared with free-feeding and free-feeding saline-infused rats. In the second part we repeatedly administered anti-TNF monoclonal antibodies to rats subjected to TPN and bowel rest. In the first set of experiments, 87 male Sabra rats were randomized into three groups: free-feeding, infused with normal saline, and infused with TPN. On day 7 of the experiment, all rats received an IV injection of endotoxin at various doses (1.5, 2.5, 5.0, 7.5, and 10 mg/kg). The LD50 in the three groups and at the various doses of lipopolysaccharide tested was determined at 24 hours postinjection. In the second set of experiments, 38 male Sabra rats were randomized into three groups: infused with normal saline and fed rat food ad libitum, infused with TPN, and infused with TPN but also receiving monoclonal antibodies against TNF. Lower endotoxin doses were required to achieve LD50 in the two IV-infused groups (2.5 to 5.0 mg/kg) compared with the free-feeding group (7.5 mg/kg) (p < .03). These findings suggest a moderate increase in susceptibility to the lethal effect of endotoxin in IV-treated rats. The total hepatic fat and triglyceride levels, which were markedly increased in TPN rats, were significantly reduced by using anti-TNF antibodies. Enhanced TNF production by peritoneal macrophages during TPN was completely eliminated by anti-TNF antibodies, probably the result of suppressed TNF production. The continuous translocation of endotoxin from gram-negative bacterial overgrowth in the gut during TPN and bowel rest results in enhanced release of TNF by macrophages. TNF causes hepatic dysfunction, portrayed in the present experimental model as hepatic steatosis. TPN-induced hepatic steatosis was significantly reduced by the administration of monoclonal antibodies against TNF-alpha.

Diverting colostomy induces mucosal and muscular atrophy in rat distal colon.

The progress of adaptive changes in the left colon after diverting colostomy was studied in rats using stereological techniques. Standardised segments of left colon proximal and distal to the colostomy was examined after 0, 1, 2, 4, or 12 weeks. In excluded colon the mucosal weight was reduced by 37% (p < 0.01) and the luminal surface area by 47% (p < 0.01) after four weeks and reached a steady state at this point of time, as no further reduction was seen from 4 to 12 weeks. The number of proliferating crypt cells was determined immunohistochemically after in vivo labelling with bromodeoxyuridine and was compared with the total number of colonocytes. Total bowel rest leads to a reduction in the number of proliferating epithelial cells and not to a reduced average life span. The weight of the muscularis propria decreased by 32% after four weeks (p < 0.01) and by 48% after 12 weeks (p < 0.001), whereas the weight of the submucosa was unchanged. No adaptive changes were found in segments proximal to the colostomy. These results show that the wall composition of defunctioned colon in rats is radically changed resulting from a mucosal and muscular atrophy, and from a reduction in luminal surface area.

Enteral nutrition as primary therapy in Crohn's disease.

The developments in enteral feeding for Crohn's disease in the past decade are critically reviewed. The advent of amino acid based chemically defined elemental diets signalled the end of 'total bowel rest' in the management of these patients. Subsequently, controlled clinical trials showed that elemental diets were as effective as corticosteroids in inducing clinical remission in patients with acute exacerbations of Crohn's disease. The later use of peptide based elemental diets, in Crohn's disease produced somewhat conflicting results. The initial uncontrolled studies suggest that polymeric whole protein diets might also be effective in the management of acute exacerbations of the disease, casting in turn doubts concerning the role of dietary antigens in the pathogenesis of Crohn's disease. Results of controlled studies comparing the use of elemental and polymeric diets as primary therapy in Crohn's disease have, however, also produced conflicting results. The results of one recent controlled trial in which the use of polymeric diet was compared with that of corticosteroids does, however, suggest that these diets may have a primary therapeutic effect in Crohn's disease. An analysis of the composition of some of the enteral diets used in different trials suggest that the effectiveness of enteral diets in treating active Crohn's disease might relate more to their fat than nitrogen composition. A hypothesis is proposed that the effectiveness of enteral nutrition in the primary therapy of acute exacerbations of Crohn's disease occurs because the successful diets used contain insufficient precursors for arachidonate derived eicosanoid synthesis.

Total parenteral nutrition and bowel rest result in change of cecal flora

Total parenteral nutrition and bowel rest result in change of cecal flora

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.

Total parenteral nutrition and complete bowel rest in the management of Crohn's disease.

The role of parenteral nutrition with complete bowel rest in the management of active Crohn's disease was evaluated retrospectively in 100 patients who were otherwise refractory to conventional medical management. Ninety patients received complete nutrient replacement and 10 received protein-sparing therapy. In 77 patients, a clinical remission was achieved. Analysis of subgroups revealed that the remission rate was equivalent in patients with subacute bowel obstruction (76%), inflammatory mass (82%), and otherwise uncomplicated severe active disease (89%). However, those patients with fistulae responded less well (63%). The location of the intestinal involvement with the disease did not influence the remission rate (73% in those with small bowel disease only and 78% in those with combined small and large bowel disease). All six patients with only large bowel involvement achieved a remission. In 81% of those patients with a remission, no corticosteroids were given, or the dose prior to TPN was maintained. The serum albumin improved significantly (p less than 0.001) from 3.2 +/- 0.1 to 3.6 +/- 0.1 g/dl with total parenteral nutrition, but there was no significant effect on the hematocrit (p greater than 0.5). The percentage of patients still in remission after 3 months and 1 yr of follow-up was 75 to 79 and 58 to 61%, respectively, in the three nonfistulous groups, and 46 and 36%, respectively, in those with fistulous disease. Thus total parenteral nutrition with complete bowel rest appears to be an effective therapeutic modality in the primary management of complicated Crohn's disease.

Effect of diverting colostomy on collagen metabolism in the colonic wall: Studies in the rat

The effect of total bowel rest by colostomy on collagen metabolism was studied. Fecal diversion led to a marked decrease of collagen and protein synthesis in the excluded colon. These changes were accompanied by a decrease in the amount of collagen and noncollagenous components. In the colonic part proximal to the colostomy site, a less marked decrease in collagen content was observed. It was concluded that stimulation of intraluminal bulk might be important as a regulating factor for collagen turnover. It remains to be determined if the observed changes in collagen metabolism affect colonic healing.

ENTEROCOLITIS FOLLOWING SURGERY FOR TOTAL COLONIC AGANGLIONOSIS (T. C. A.)-A SYNDROME DUE TO BACTERIAL OVERGROWTH

Enterocolitis is evolving as a common entity in patients after surgery for T.C.A., irrespective of the surgical procedure. The syndrome is characterized by diarrhea, cachexia,and abdominal distention. We evaluated 3 childrens with this syndrome, aged 13 months, 14 months, and 6 years. Patients had evidence of marked small and large bowel dilatation on xray, confirmed on barium studies. Stool cultures were negative for all currently known enteropathogens and rotovirus. All patients had malabsorption as indicated by iron deficiency anemia, an abnormal stage 2 Schillings test, and abnormal lactose hydrogen breath test. Colitis and enteritis were documented on biopsy. Duodenal fluid cultures were negative for bacterial pathogens. Treatment: All patients were placed on hyperalimentation and total bowel rest. T.P.N. alone did not alleviate their symptoms. Metronidazole and Sulfasalizine therapy however induced remission in all 3 patients. Conclusions: Enterocolitis is common following surgery for T.C.A. 2. Malabsorption occurred in all 3 patients. 3. T.P.N., Sulfasalizine, and Metronidazole therapy resulted in remission in all 3 patients, supporting the role of bacterial overgrowth in the pathogenesis of this syndrome.