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Query: UMLS:C0036690 (sepsis)
 59,461 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Sepsis is commonly associated with or complicates short bowel syndrome (SBS). The purpose of the present study was to investigate the effects of endotoxemia on intestinal adaptation in a rat model of SBS. Male Sprague-Dawley rats were divided into three experimental groups: Sham rats underwent bowel transection and re-anastomosis, SBS rats underwent 75% small bowel resection, and SBS-LPS rats underwent bowel resection and were given lipopolysaccharide. Bowel weight, organ weights, and parameters of intestinal adaptation (bowel and mucosal weights, mucosal DNA and protein, villus height, and crypt depth) were determined on day 15 following operation. The results of this study demonstrate that SBS rats showed a significant increase (vs. Sham) in jejunal and ileal bowel and mucosal weight, mucosal DNA and protein, villus height, and crypt depth. SBS-LPS animals demonstrated lower (vs. SBS rats) final body weight (215 +/- 7 vs. 287 +/- 10 g, P < 0.05), overall weight in duodenum (98+/- 2 vs. 119 +/-5 mg/cm, P < 0.05) and jejunum (144 +/- 9 vs. 189 +/- 16 mg/cm, P < 0.05), mucosal weight in jejunum (54 +/- 5 vs. 69 +/- 5 mg/cm, P < 0.05) and ileum (31 +/- 2 vs. 37 +/- 3 mg/cm, P < 0.05), mucosal DNA in jejunum (89 +/- 11 vs. 120 +/- 11 microg/cm, P < 0.05) and ileum (46 +/- 6 vs. 61 +/- 4 microg/cm, P < 0.05), jejunal crypt depth (152 +/- 19 vs. 189 +/- 12 microm, P < 0.05), and ileal villus height (405 +/- 63 vs. 515 +/- 30 pm, P < 0.05). In addition, the SBS group had no late (second week) mortality, whereas the SBS-LPS group had an 17% late mortality rate. In conclusion, in a rat model of SBS-LPS, endotoxemia appears to inhibit structural intestinal adaptation and increase mortality.
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PMID:Endotoxemia inhibits intestinal adaptation in a rat model of short bowel syndrome. 1255 47

Even with the development of new therapeutic agents, such as infliximab, enteral nutrition (EN) and parenteral nutrition (PN) therapies remain important for the treatment of Crohn's disease because Crohn's patients often require nutritional support. Furthermore, nutritional therapies can be used in the control of disease activity. Elemental diets, which are mainly used in EN therapy, consist of a refined amino acid mixture, glucose or maltodextrins and minimal essential fatty acids. EN therapy can reduce mucosal inflammation by the elimination of dietary antigens, which induce inflammation, and by reductions in fat, which activates inflammation. EN is applied not only as induction therapy, but also as maintenance therapy after remission (home EN). However, the unpalatability of elemental diets, difficulties related to self-intubation and the high cost of EN have limited its application as a primary therapy in western countries. PN is utilized as complete bowel rest supporting nutrition. However, since the therapeutic efficacies of EN and PN are similar, the indications for PN are limited and PN is mainly utilized in patients with bowel obstructions or severe fistulas. PN is also used as home therapy in the treatment of Crohn's patients with short bowel syndrome. However, long-term PN sometimes causes life-threatening complications including catheter-induced sepsis, liver failure and lethal mineral deficiencies. We suggest that gastroenterologists should recognize the advantages and limitations of all therapies and choose carefully or combine various therapies in order to maintain the quality of life in individual patients even if in cases where remission can not be achieved.
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PMID:Enteral and parenteral nutrition therapy for Crohn's disease. 1257 Aug 24

Surgery plays a key role in the management of both acute and, less frequently, chronic intestinal failure. Acute intestinal failure frequently requires surgical treatment when it arises as a consequence of intestinal fistulation or obstruction. In specialised clinical practice approximately 50% of acute intestinal failure is associated with intestinal fistulas and in approximately 50% of patients, this condition arises as part of the natural history or complicating treatment for Crohn's disease. A considerable proportion of such patients have abdominal infection and present complex nutritional and metabolic problems. The most important aspect of the surgical management of patients with acute intestinal failure associated with intra-abdominal infection is management of sepsis, since recovery is unlikely in the presence of active infection. Moreover, effective nutritional support and restoration of body composition is not possible if sepsis remains unresolved. Surgical strategies to deal with intra-abdominal infection may involve percutaneous drainage, laparotomy and resection of fistulating segments of intestine and, when infection is persistent and contamination extensive, laparostomy (a technique in which the abdomen is left open and allowed to heal by secondary intention). Surgical treatment should not only be timely and effective, but also aimed at preventing secondary damage to the small intestine, in order to minimise the risk of short bowel syndrome. In some cases a proximal defunctioning stoma may be required, with prolonged nutritional support, using either home total parenteral nutrition or feeding via the defunctioned distal gut (fistuloclysis), pending restoration of intestinal continuity. The role of surgical treatment for patients with short bowel syndrome is less clear. While surgery is frequently required for the management of complications of short bowel syndrome (including gallstones and possibly peptic ulcer disease), the role of intestinal lengthening and tapering procedures (to increase functional intestinal length), and artificial valves, reversed segments and colonic interposition (to reduce intestinal transit) remains controversial. For some patients with short bowel syndrome and, in particular, those with combined intestinal and hepatic failure, intestinal transplantation may become the treatment of choice as long-term results continue to improve.
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PMID:Surgical management of intestinal failure. 1469 6

Long-term parenteral nutrition (PN) and intestinal transplantation (IT) are life-saving therapies for patients with short bowel syndrome (SBS). However, indications and timing of these therapies are controversial. In this study we aimed to evaluate the indications for IT. Forty-two patients, each with <100 cm of small bowel, were divided into three groups according to the length of remnant: group I patients (n = 18): colon plus 50 to 100 cm of small bowel (SB); group II patients (n = 14): colon plus <50 cm of SB; and group III patients (n = 10): <50 cm of SB without colon. One-year mortality rates for groups I, II, and III were 50%, 72%, and 100%, respectively. All group I survivors developed intestinal adaptation, returning to regular oral feedings at 1 year. Interestingly, three of four surviving patients in group II developed adaptation and were fed an oral short bowel diet (SBD) at 1 year. None of the group III patients survived >1 year, dying due to multiorgan failure in the early postoperative period or from sepsis within 1 year. We conclude that patients with a very short bowel are candidates for IT when stable. If the colon is intact, however, regardless of small bowel remnant length, the patient should be given a chance to develop intestinal adaptation before making the decision for permanent PN or IT.
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PMID:Evaluation of the outcomes of short bowel syndrome and indications for intestinal transplantation. 1469 78

Macroscopic generalized necrotizing enterocolitis (G-NEC) is associated with a very high mortality in neonates. In some instances, however, multiple bowel segments are necrotic, with most of the remaining small bowel damaged but viable. In these selected patients morbidity can be reduced and survival increased with an aggressive and early surgical approach. We have termed this approach damage control laparotomy (DCL). Over a 5(1/2)-year period, all neonates with G-NEC with adequate length of viable small bowel were subjected to DCL. The procedure is characterized by a resuscitative period of a few hours followed by laparotomy and resection of dead/perforated bowel. The bowel ends are either anastomosed or tied, and the bowel is returned to the abdomen to allow full tissue demarcation. Re-look laparotomy is performed 3-4 days later, at which time any new necrotic bowel is excised and re-joined, to achieve small bowel continuity. In this prospective study, 104 neonates with G-NEC underwent operation; 27 neonates (26%) were considered to have an adequate potential length of viable bowel and were selected for DCL. Nineteen neonates survived in the follow-up period. Early mortality was due to sepsis syndrome in 6 patients, and late mortality in 2 neonates was secondary to the short bowel syndrome. The DCL procedure is another step toward improving survival in surgical G-NEC; this technique avoids proximal stomas and their complications, and at the same time it preserves the best possible bowel length.
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PMID:Damage control laparotomy for generalized necrotizing enterocolitis. 1472 62

Intestinal failure (IF) can be defined as the reduction of functional gut mass below the minimal amount necessary for digestion and absorption adequate to satisfy the nutrient and fluid requirements for maintenance in adults or growth in children. In developed countries, IF mainly includes individuals with the congenital or early onset of conditions requiring protracted or indefinite parenteral nutrition (PN). Short bowel syndrome was the first commonly recognized cause of protracted IF. The normal physiologic process of intestinal adaptation after extensive resection usually allows for recovery of sufficient intestinal function within weeks to months. During this time, patients can be sustained on parenteral nutrition. Only a few children have permanent intestinal insufficiency and life-long dependency on PN. Non-transplant surgery including small bowel tapering and lengthening may allow weaning from PN in some cases. Hormonal therapy with recombinant human growth hormone has produced poor results while therapy with glucagon-like peptide-2 holds promise. Congenital diseases of enterocyte development such as microvillus inclusion disease or intestinal epithelial dysplasia cause permanent IF for which no curative medical treatment is currently available. Severe and extensive motility disorders such as total or subtotal intestinal aganglionosis (long segment Hirschsprung disease) or chronic intestinal pseudo-obstruction syndrome may also cause permanent IF. PN and home-PN remain are the mainstays of therapy regardless of the cause of IF. Some patients develop complications while receiving long-term PN for IF especially catheter related complications (thrombosis, sepsis) and liver disease. These patients may be candidates for intestinal transplantation. This review discusses the causes of irreversible IF and emphasizes the specific medico-surgical strategies for prevention and treatment of these conditions at several stages of IF.
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PMID:Irreversible intestinal failure. 1507 23

BACKGROUND: Short bowel syndrome (SBS) is defined as the malabsorptive state that often follows massive resection of the small intestine. Most cases originate in the newborn period and result from congenital anomalies. It is associated with a high morbidity, is potentially lethal and often requires months, sometimes years, in the hospital and home on total parenteral nutrition (TPN). Long-term survival without parenteral nutrition depends upon establishing enteral nutrition and the process of intestinal adaptation through which the remaining small bowel gradually increases its absorptive capacity. The purpose of this article is to perform a descriptive systematic review of the published articles on the effects of TPN on the intestinal immune system investigating whether long-term TPN induces bacterial translocation, decreases secretory immunoglobulin A (S-IgA), impairs intestinal immunity, and changes mucosal architecture in children with SBS. METHODS: The databases of OVID, such as MEDLINE and CINAHL, Cochran Library, and Evidence-Based Medicine were searched for articles published from 1990 to 2001. Search terms were total parenteral nutrition, children, bacterial translocation, small bowel syndrome, short gut syndrome, intestinal immunity, gut permeability, sepsis, hyperglycemia, immunonutrition, glutamine, enteral tube feeding, and systematic reviews. The goal was to include all clinical studies conducted in children directly addressing the effects of TPN on gut immunity. RESULTS: A total of 13 studies were identified. These 13 studies included a total of 414 infants and children between the ages approximately 4 months to 17 years old, and 16 healthy adults as controls; and they varied in design and were conducted in several disciplines. The results were integrated into common themes. Five themes were identified: 1) sepsis, 2) impaired immune functions: In vitro studies, 3) mortality, 4) villous atrophy, 5) duration of dependency on TPN after bowel resection. CONCLUSION: Based on this exhaustive literature review, there is no direct evidence suggesting that TPN promotes bacterial overgrowth, impairs neutrophil functions, inhibits blood's bactericidal effect, causes villous atrophy, or causes to death in human model.The hypothesis relating negative effects of TPN on gut immunity remains attractive, but unproven. Enteral nutrition is cheaper, but no safer than TPN. Based on the current evidence, TPN seems to be safe and a life saving solution.
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PMID:The effects of long-term total parenteral nutrition on gut mucosal immunity in children with short bowel syndrome: a systematic review. 1568 91

Intestinal failure is most commonly treated by the administration of total parenteral nutrition (TPN). In some patients, however, surgical therapy may increase the ability to use the intestine for nutrition and thereby decrease the complications of TPN therapy. A multidisciplinary comprehensive intestinal failure program was initiated at the University of Nebraska Medical Center in October 2000. Here we describe the surgical approaches to patients with short bowel syndrome and the subsequent impact on the need for TPN and on survival. Fifty patients (children=30, adults=20) underwent surgical procedures to restore intestinal continuity (n=5), repair enterocutaneous fistulas (n=5), resect dysmotile or strictured/obstructed bowel segments or mesenteric desmoid tumors (n=7), stricturoplasty (n=2), Bianchi tapering and lengthening (n=20), serial transverse enteroplasty (n=8), and other operations (n=8). Of these 50 patients, three patients did not require TPN after surgical intervention and seven had remnant small bowel anatomy that precluded TPN weaning (e.g., end duodenostomy) and were listed for transplantation or continued on full TPN support. Of the 40 remaining patients, most received the majority of calories from TPN at the time of referral, i.e., mean calories from TPN=90%. Subsequent to the surgical and medical therapy, 26 (65%) have been completely weaned off TPN. In addition, 10 had substantial decreases in their TPN requirements (i.e., from 85% of calories from TPN at onset decreased to a median 35% of required calories at most recent follow-up). Four patients remained on the same amount of TPN support. Four of the seven patients listed for transplantation underwent successful transplantation. Despite the complications of short bowel syndrome, 86% (n=43) of the patients are alive and well at a mean follow-up of 2 years. Patient deaths occurred primarily in those listed or eligible for transplantation and were related to advanced liver disease (n=3), gastrointestinal hemorrhage (n=1), or line sepsis (n=1). Two other patients died, one from influenza A infection and one from unknown cause at home, months after complete discontinuation of TPN. In this series of patients with short bowel syndrome, surgical intervention led to weaning or discontinuation of TPN support in 85% of patients. An organized multidisciplinary approach to the patient with short bowel syndrome is recommended.
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PMID:A multidisciplinary approach to the treatment of intestinal failure. 1569 12

Intestinal failure is characterised by inability of the intestine to absorb sufficient nutrients to maintain the integrity and function of the body. This can be caused by malabsorption due to too short an intestine or an abnormality of the mucosa, or by a severe motility disorder. In addition to dietary measures, the prescription of total parental nutrition (TPN) at home is sometimes necessary. This treatment is a burden on the patient and the risk of complications must be reduced to a minimum. The risks of long-term parenteral nutrition can be limited and the quality of the provision of services can be increased if the co-ordination is in the hands of a centre for home parenteral nutrition. In the Netherlands there are two centres for home-TPN: the St Radboud University Medical Centre in Nijmegen and the University Medical Centre (AMC) in Amsterdam. In both children and adults, the most common indications are the short bowel syndrome and motility disorders. However, the syndromes that cause this are clearly different in the different age groups. Parenteral nutrition can be given for long periods of time. A large variety of complications can occur, related especially to the equipment or the nutrients. When the nutrition is given via a central venous catheter, then sepsis is a serious and possibly life-threatening complication. In case of administration via an arteriovenous shunt, thrombosis of the shunt is the most frequent problem. If the treatment by means of home-TPN fails, then transplantation of the small intestine should be considered.
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PMID:[Treatment of intestinal failure by total parenteral nutrition at home in children and adults]. 1575 16

Three children, 2 boys aged 5 and 4 years, and 1 girl aged 2 years, who suffered from intestinal failure as a result of a short bowel syndrome and who were dependent on total parenteral nutrition (TPN), were screened for small bowel transplantation. The girl also had progressive liver failure. Each child had a clear indication for either isolated small bowel or combined small bowel/liver transplantation. All three children were enrolled in an intestinal rehabilitation program because they were referred early. The intestinal rehabilitation consisted of a systematic analysis of the absorptive capacity of the residual intestine, optimizing enteral and parenteral feeding, prevention of catheter sepsis and further deterioration of liver function. The rehabilitation was performed in an in-patient setting. All three children were partially weaned from TPN, while their growth improved. None of the children were consequently listed for small bowel transplantation. When a child is initially referred for small bowel transplantation, intestinal rehabilitation should be considered as part of an intestinal transplantation program.
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PMID:[Intestinal rehabilitation for children with short bowel syndrome]. 1575 21


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