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PURPOSE: The purpose of this study was to determine the mechanisms by which patients with Crohn's disease develop intestinal failure and, in particular, to assess the relative importance of severe primary disease, repeated uncomplicated elective small intestine resection, and resection performed as a consequence of intra-abdominal septic surgical complications. METHODS: This was a retrospective analysis of 41 patients with Crohn's disease referred to a specialized intestinal failure unit between January 1987 and September 1998 for permanent home parenteral nutrition. To compare the surgical activity in patient groups, a resection index was calculated by dividing the number of intestinal resections by the interval in years between the first resection for Crohn's disease and referral for management of intestinal failure. RESULTS: Extensive primary Crohn's disease was responsible for intestinal failure in 7 cases (17 percent). The remainder (n=34, 83 percent) developed intestinal failure after intestinal resection. Nine of the “surgical” Crohn's patients developed intestinal failure after uncomplicated sequential resection, (median small-bowel length 65 (range, 60–120) cm) after a median of 3 (range, 2–8) operations over a median of 17 (range, 3–27) years. By contrast, the other 25 surgical Crohn's patients developed intestinal failure after multiple unplanned laparotomies for intra-abdominal sepsis (median small-bowel length 70 (range, 60–200) cm), with a median of 4 (range, 2–7) laparotomies performed over a median of 0.5 (range, 0.1 to 1.5) years (P

Background Glucose utilization in sepsis is impaired but the mechanisms are unclear. This study examined the effect of sepsis on total glucose utilization, oxidation and storage, and the energetic costs of these metabolic processes. Methods Glucose infusion rate (GIR), glucose oxidation rate (GOR), non-oxidative disposal rate and the energetic cost of glucose storage were studied in 24 patients with abdominal sepsis and in 26 healthy controls, using indirect calorimetry and the euglycaemic hyperinsulinaemic clamp with insulin infusion rates of 40 and 240 mU m−2 min−1. Results Basal GOR was significantly lower in septic patients than in controls (1·5 versus 2·3 mg per kg fat-free mass (FFM) per min, P < 0·001). Septic patients had a significantly lower GIR at 40 mU m−2 min−1 (4·2 versus 9·1 mg per kg FFM per min) and at 240 mU m−2 min−1 (7·5 versus 11·8 mg per kg FFM per min), relative to controls (P < 0·001). GOR was similar in septic and control subjects at both rates of insulin infusion whereas non-oxidative disposal was significantly lower in septic patients (P < 0·001) and accounted entirely for the reduction in GIR. The energetic cost of glucose disposal was unaffected by sepsis. Conclusion Sepsis is associated with selective impairment of glucose storage but the energetic cost of non-oxidative disposal is unaffected.

Between 1980 and 1993, 18 patients underwent formal laparotomy after laparostomy and healing of the peritoneal cavity by granulation. The majority (12 patients) were men and the median age was 47 (range 22–67) years. Intra-abdominal infection following surgery for Crohn's disease (four patients) and necrotizing pancreatitis (six) was the most common primary condition requiring laparostomy. A total of 23 reconstructive operations were carried out on the 18 patients a median of 6 (range 1–18) months after laparostomy. The indication for surgery was for closure and/or resection of an enteric fistula in 13 patients. The site of the fistula included three gastric, two duodenal, 11 small bowel and seven colonic. A further four patients required operation for closure or refashioning of a stoma. Five patients subsequently required a second laparotomy: two for elective restoration of bowel continuity, two for recurrent fistula and one for an acute abdomen. After reconstructive surgery following laparostomy 16 patients were discharged home alive and well, one requiring home parenteral nutrition for short boweksyndrome. In contrast, the two oldest patients in the series died from multiple organ failure immediately after initial reconstructive surgery. Both had pre-existing medical problems and in neither was there evidence of further intra-abdominal infection after reconstruction.

Two commercially available kits have been used to create 25 percutaneous tracheostomies, 20 using the Cook system and five using the Rapitrac system. The operation time and complication rates of these tracheostomies have been compared with those for 16 conventional tracheostomies performed for similar indications. Median operating times were 60 (range 30–105) min for conventional tracheostomy, 15 (range 8–70) min for Cook and 5 (range 3–15) min for Rapitrac systems (P < 0·001). A significantly higher proportion of patients in the Rapitrac group had complications compared with the other two groups (P < 0·05). The complication rate for the Cook group compared favourably with that for the conventional tracheostomy group. The Cook system of percutaneous tracheostomy is a simple, rapid and safe alternative to conventional tracheostomy.

Intestinal failure can be the end result of a wide variety of disease processes that impair the ability of the gut to adequately digest and absorb food. Patients with established intestinal failure may require parenteral nutrition support and/or abdominal surgery to reverse the disease process involved. Selected patients with irreversible intestinal failure can be managed in experienced units by home parenteral nutrition.

The place of somatostatin and its analogues in the management of gastrointestinal fistulae is reviewed, drawing attention to the difficulty of assessing treatments that influence spontaneous closure. Sixteen patients with gastric, small bowel, and pancreatic fistulae were randomized to receive octreotide injections (100 micrograms t.i.d.) or placebo for 12 days. Spontaneous fistula closure occurred in 7 at a mean of 37 days after entering the trial. A second study is underway with greater patient numbers recruited from peripheral hospitals and with an increased period of octreotide medication (21 days).

Quality of life was assessed in 37 patients receiving home parenteral nutrition (HPN) for intestinal failure. A questionnaire was developed specifically for this purpose and the results were compared with those obtained by subjective assessment using a simple linear scale. The majority of patients (n = 26, 70.3%) had a good objective quality of life and most (n = 16, 53.3%) of those eligible (n = 30, 81.1%) did not express an interest in intestinal transplantation. Despite the apparent good quality of life enjoyed by patients receiving HPN, there werenumerous areas in which patients with intestinal failure felt that their quality of life left much to be desired: many patients reported significant psychological symptoms (n = 15, 40.5%) sexual (n = 10, 27.0%) and social dysfunction (n = 19, 51.3%) and most patients with intestinal failure were unable to return to work (n = 24, 88.9%). Detailed quality of life assessment reveals that there is much still to be done to ensure that provision of care for patients with intestinal failure involves not only prolongation of life but also an improvement in quality of life.

Between 1977 and January 1991, 400 patients were entered on the United Kingdom Home Parenteral Nutrition (HPN) Register. Almost half suffered from Crohn's disease. Most commenced HPN while between 20–50 years of age. In terms of life quality while on HPN, most (63%) were able to work or look after their families unaided. A further 89 (22%) were able to cope with HPN independently. 221 patients ceased HPN during the study period, mostly (41%) due to intestinal adaptation. Of 69 patients who died, over half (57%) did so due to disease progression. Complications of HPN resulted in death in 22% of this subgroup. In terms of specific disease groups, those with Crohn's disease had the lowest mortality rate (8%).

300 consecutive admissions over 7 years to a purpose-built intestinal failure unit are reviewed. The commonest underlying condition was Crohn's disease (42%), and the commonest complication precipitating admission was intestinal fistula (42%). Total parenteral nutrition was used in 85% and surgery in 50%. A multidisciplinary approach to management gave a high success rate--90% of patients were discharged from hospital, although nearly 25% needed home parental nutrition. These results suggest that chronic intestinal failure should be managed in specialised units in the same manner as other types of organ failure.

Summary Although there is common agreement about the corecases in which there is no alternative to HPN, cultural and economic differences lead to major variations in the types of disease treated, the ages of patients treated, the duration of and prevalence of treatment. It is unlikely that there will be agreement between countries on the extent to which artificial nutritional support will be used.

Home parenteral nutrition services have revolutionized the treatment, and improved the survivial, of patients with prolonged or permanent intestinal failure. Without such a programme, these patients either would be condemned to continuous in-patient parenteral nutrition or to death. The indications for HPN in the UK remain predominantly intestinal failure resulting from inflammatory bowel disease, and major small bowl resection. Nearly 50% of patients receiving HPN will ultimately have normal intestinal function restored and thus be able to return to enteral feeding. This knowledge is reflected in the selection criteria for instituting HPN. The use of HPN in patients with malignant disease poses significant ethical questions. The success of HPN is dependent upon the organization of nutritional units to allow centralization of HPN programmes and to provide the necessary support to patients. It is clear that not all patients will benefit from HPN, and it is only by careful assessment of patients, based on the experience of specialized nutritional units, that a rational HPN service can be provided.

The fibrinolytic activity of blood draining from the stomachs of patients with gastroduodenal disease has been compared with the fibrinolytic acitivity of blood in the systemic venous circulation and with the blood draining from normal stomachs. Gastric venous blood from normal and diseased stomachs contains greater amounts of plasminogen activator than simultaneously sampled systemic venous blood. However, gastric venous fibrinolytic activity does not differ between the normal and diseased stomachs and thus indicates that increased gastric venous fibrinolysis is not just a characteristic of the diseased stomach. The studies suggest that stress may cause activation of the fibrinolytic system in gastric venous blood with the release of small amounts of free plasmin. It is postulated that local fibrinolysis may play a part in potentiating gastric hemorrhage.

This registry describes a multicentre experience of Home Parenteral Nutrition (HPN) in nine European countries covering 27 centres and 194 patients. The main purpose of this study was to evaluate the quality of life and prognosis of patients on HPN. Patients started HPN at 44 +/- 1 years old (mean +/- SEM), and received 200 courses of HPN for a mean of 12 +/- 1 months representing a cumulative duration of 207 years. The four commonest indications for HPN were inflammatory bowel disease (30%), mesenteric vascular disease (21%), malignancy (17%) and radiation enteritis (13%). The nutritional status during HPN was clinically normal or subnormal in 93% of cases. The yearly incidence of catheter related complications leading to a catheter change was 0.74, sepsis accounting for half of this. The duration of hospital readmission for HPN complications was 4 +/- 1% of time spent at home, which represents 2 weeks per year and 41% of the total readmission time. Mortality was mainly influenced by the underlying disease since only 3% of patients died of HPN complications. A good social rehabilitation was observed in 52% of patients who during treatment recovered their pre-HPN occupational status. The poorest social rehabilitation was observed in patients over 65 years of age, and patients with malignancies and radiation enteritis, who also had the poorest prognosis. Caution seems necessary before recommending HPN in these patients.

Although home parenteral nutrition (HPN) is an established treatment in the management of chronic intestinal failure [l], much remains to be learned about its biochemical and nutritional consequences. There is a paucity of nutritional data relating to virtually all aspects of long-term intravenous nutrition (IVN). The requirements for energy substrates and amino-acids are reasonably well established from oral dietary studies and a range of suitable preparations are available [2]. On the other hand, a recent study of trace element provisions to patients on home intravenous nutrition concluded that none of the presently available commercial preparations was ideal for use in this patient population [3]. In particular, zinc provision from commercial preparations generally required further supplementation, copper requirements were variable, and manganese and chromium provision was excessive in many cases. None of the preparations contained selenium. Few centres have sufficient patient numbers to conduct studies into efficacy of particular preparations. For this reason data are often pooled from several centres, but this is complicated by local variation in feeding regimens and solutions used. The Nutrition Unit, Hope Hospital, Salford is the largest UK centre for HPN [4]. We have evaluated the recently developed trace element preparation Additracea (Kabi Vitrum, Stockholm) (Table 1) in 24 patients requiring longterm intravenous nutrition.

The methods of provision of essential trace elements to patients receiving long-term home intravenous nutrition in the U.K. have been reviewed and their trace element status has been assessed. Over a 2 year period, 57 patients based on 15 hospitals throughout the country were studied. Although biochemical abnormalities of trace element status were frequent, related clinical complications were apparently rare. Zinc provision from commercial preparations generally required further supplementation. Copper requirements were variable. Manganese provision from trace element mixtures and chromium provision from contaminants of other parenteral nutrient solutions were excessive in many cases. Aluminium contamination is not significant in the nutrient solutions currently used in the U.K. The most common depletion state is for selenium which should probably be provided on a routine basis. The clinical consequences of long-term under- or over-provision of trace elements by the intravenous route requires further study.

Serum carnitine levels have been measured in 178 samples from 75 normal volunteers. We report a wide range of values (10-70 μmol/liter and 8-74 μmol/liter for free and acetylated carnitine, respectively) and a distinct difference between the ranges for males and females (p < 0.001). There is also substantial, seemingly random fluctuation in any one individual's levels, when measured serially over several weeks. (Journal of Parenteral and Enteral Nutrition12: 143-146, 1988)

Assessment of the plain abdominal roentgenogram in thirty patients with acute pancreatitis showed the presence of radiologic signs in two-thirds. Although it was confirmed that dilatation of the first part of the duodenum and the first loop of the jejunum was a common sign, isolated dilatation of the transverse colon was demonstrated to be the most frequent accompaniment of acute pancreatitis, being present in one-third of the cases.