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Background: The importance of early postoperative nutrition in surgical patients and early institution of enteral nutrition in intensive care unit (ICU) patients have recently been highlighted. Unfortunately, institution of enteral feeding in both groups of patients often has to be postponed due to delayed gastric emptying and the need for gastric decompression. The design of current polyvinylchloride (PVC) gastric decompression tubes (Salem Sump [Covidien, Mansfield, MA] in the United States; Ryles [Penine Health Care Ltd, Derby, UK] in the United Kingdom and Europe) make them unsuitable for their subsequent use as either nasogastric enteral feeding tubes or for continued gastric decompression during postpyloric enteral feeding. To overcome these problems, we have designed a range of polyurethane (PU) dual-purpose gastric decompression and enteral feeding tubes that include 2 nasogastric tubes (double lumen to replace Salem Sump; single lumen to replace Ryles). Two novel multilumen nasogastrojejunal tubes (triple lumen for the United States; double lumen for the United Kingdom and Europe) complete the range. By using PU, a given internal diameter (ID) and flow area can be incorporated into a lower outside diameter (OD) compared with that achieved with PVC. The ID and lumen and flow area of an 18Fr (OD 6.7 mm) PVC Salem Sump can be incorporated into a 14Fr (OD 4.7 mm) PU tube. The design of aspiration/infusion ports of current PVC and PU tubes invites occlusion by gastrointestinal mucosa and clogging by mucus and enteral feed. To overcome this, we have designed long, single, widened, smooth, and curved edge ports with no "dead space" to trap mucus or curdled diet. Involving up to 214° of the circumference, these ports have up to 11 times the flow areas of the aspiration ports of current PVC tubes., Conclusion: The proposed designs will lead to the development of dual-purpose nasogastric and nasojejunal tubes that will significantly improve the clinical and nutrition care of postoperative and ICU patients., (© 2014 American Society for Parenteral and Enteral Nutrition.)

Background: Gastrointestinal neuromuscular disorders (GINMD) are an important cause of intestinal failure (IF). We present six cases of IF in whom a diagnosis of GINMD was initially suspected, but in whom psychopathology was discovered to be the primary etiology., Methods: (i) Six consecutive cases referred to our unit with IF, initially presumed to be due to GINMD, were selected. Informed consent was obtained from all patients. Case notes were reviewed for salient clinical information. (ii) A literature search was performed to ascertain the epidemiology of psychopathology in IF and the current evidence for the management of severe functional GI disorders with a multidisciplinary psychiatric approach., Key Results: (i)All six cases required multidisciplinary psychiatric management in a specialized psychiatric unit that included the use of antidepressants, antipsychotics, mood stabilizers, and Electroconvulsive therapy in addition to nutritional support via enteral or parenteral routes. (ii) The evidence base for the treatment of severe FGIDs is sparse., Conclusions & Inferences: There is a need for additional reporting of such cases and further research. Our experience would suggest that a delay in the involvement of a specialist liaison psychiatrist has the potential to be life threatening in such cases. This may be more likely with greater severity, where the apparent predominance of 'physical' symptoms generates reluctance in both patient and physician to consider a psychiatric etiology and also appears to occur due to a lengthier investigative process than existed previously. We therefore propose that the provision of a specialist psychiatric assessment for all patients presenting with IF is indicated at the point of initial clinical contact, based upon the substantial clinical benefit it has the potential to confer upon a significant minority. This process need not delay investigation, which can continue as indicated in parallel, but can be life-saving., (© 2011 Blackwell Publishing Ltd.)

Nutrition support is an important link in the chain of therapy for intensive care unit patients. The early institution of nutrition support significantly reduces the incidence of septic complications, reduces mortality, and shortens hospital stay. Unfortunately, impaired gastrointestinal function, particularly gastric atony, restricts the use of nasogastric enteral tube feeding, and the use of this route of administration in these patients can lead to regurgitation, aspiration, and the development of pneumonia. Postpyloric enteral feeding was heralded as a means of overcoming many of these problems. Overall, the results of controlled studies do not support a role of postpyloric duodenal feeding in reducing the incidence of aspiration pneumonia. As a consequence, post-ligament of Treitz nasojejunal enteral feeding is proposed as the technique of choice in these patients. Feeding tube design must incorporate a gastric aspiration port to overcome problems of gastroesophageal acid reflux, duodenogastric bile reflux, and increased gastric acid secretion, problems that occur during "downstream" jejunal feeding. Tube placement technique will need to be refined and patients will need to receive a predigested enteral diet. In postoperative surgical patients in the intensive care unit, there is also a need for a newly designed dual-purpose nasogastric tube capable initially of providing a means of undertaking gastric aspiration and decompression and subsequently a means of initiating nasogastric enteral feeding.

Surgical trauma initiates a complex series of metabolic host responses designed to maintain homeostasis and ensure survival. (1)H NMR spectroscopy was applied to intraoperative urine and plasma samples as part of a strategy to analyze the metabolic response of Wistar rats to a laparotomy model. Spectral data were analyzed by multivariate statistical analysis. Principal component analysis (PCA) confirmed that surgical injury is responsible for the majority of the metabolic variability demonstrated between animals (R² Urine = 81.2% R² plasma = 80%). Further statistical analysis by orthogonal projection to latent structure discriminant analysis (OPLS-DA) allowed the identification of novel urinary metabolic markers of surgical trauma. Urinary levels of taurine, glucose, urea, creatine, allantoin, and trimethylamine-N-oxide (TMAO) were significantly increased after surgery whereas citrate and 2-oxoglutarate (2-OG) negatively correlated with the intraoperative state as did plasma levels of betaine and tyrosine. Plasma levels of lipoproteins such as VLDL and LDL also rose with the duration of surgery. Moreover, the microbial cometabolites 3-hydroxyphenylpropionate, phenylacetylglycine, and hippurate correlated with the surgical insult, indicating that the gut microbiota are highly sensitive to the global homeostatic state of the host. Metabonomic profiling provides a global overview of surgical trauma that has the potential to provide novel biomarkers for personalized surgical optimization and outcome prediction.

Background: Gut microflora-mucosal interactions may be involved in the pathogenesis of irritable bowel syndrome (IBS)., Aim: To investigate the efficacy of a novel prebiotic trans-galactooligosaccharide in changing the colonic microflora and improve the symptoms in IBS sufferers., Methods: In all, 44 patients with Rome II positive IBS completed a 12-week single centre parallel crossover controlled clinical trial. Patients were randomized to receive either 3.5 g/d prebiotic, 7 g/d prebiotic or 7 g/d placebo. IBS symptoms were monitored weekly and scored according to a 7-point Likert scale. Changes in faecal microflora, stool frequency and form (Bristol stool scale) subjective global assessment (SGA), anxiety and depression and QOL scores were also monitored., Results: The prebiotic significantly enhanced faecal bifidobacteria (3.5 g/d P < 0.005; 7 g/d P < 0.001). Placebo was without effect on the clinical parameters monitored, while the prebiotic at 3.5 g/d significantly changed stool consistency (P < 0.05), improved flatulence (P < 0.05) bloating (P < 0.05), composite score of symptoms (P < 0.05) and SGA (P < 0.05). The prebiotic at 7 g/d significantly improved SGA (P < 0.05) and anxiety scores (P < 0.05)., Conclusion: The galactooligosaccharide acted as a prebiotic in specifically stimulating gut bifidobacteria in IBS patients and is effective in alleviating symptoms. These findings suggest that the prebiotic has potential as a therapeutic agent in IBS.

Nasogastric enteral feeding is not tolerated in patients with gastric atony and in many critically-ill patients in whom gastric emptying may be delayed and in whom gastro-oesophageal regurgitation may lead to pulmonary aspiration of enteral feed and the development of pneumonia. Initial attempts to overcome these problems led to the development of post pyloric enteral feeding techniques with the infusion port of the tubes positioned in the duodenum. In many centres this technique is still the most practised post-pyloric enteral feeding technique. Nasoduodenal feeding tubes often retroperistalse into the stomach. The technique of choice, therefore, in these difficult patients is to position the infusion port of the feeding tube well distal to the ligament of trietz (post ligament of trietz nasojejunal enteral tube feeding). While nasogastric and nasoduodenal enteral feeding techniques have been shown to elicit a stimulatory exocrine pancreatic response, distal jejunal enteral feeding does not. During this mode of feeding the ileal brake is activated and pancreatic exocrine pancreatic secretion inhibited by the action of the released peptide YY and glucagon-like peptide-1 hormones, in turn the inhibition of pancreatic secretion being the result of inhibition of trypsin secretion. In the light of the findings showing the absence of a stimulatory pancreatic exocrine response to nasojejunal enteral feeding these patients should receive a predigested rather than a polymeric enteral diet.

Background & Aims: Severe ileostomy dysfunction with high ileostomy volumes or severe diarrhea after panproctocolectomy and restorative ileo-anal pouch formation are a rare but serious development after surgery for ulcerative colitis (UC). The incidence, severity, morbidity, and mortality are poorly documented in the literature., Methods: We describe the case of a patient who developed life-threatening diarrhea after surgery for UC and review the literature., Results: Eight cases have now been described in the literature. Small-bowel disease has developed up to 17 months after colectomy. Most cases responded to corticosteroid therapy. A single case in which this treatment was delayed was fatal., Conclusions: This is a rare sequel to colectomy for UC, but one which is serious and can be fatal. If the diagnosis is made promptly, a full response to treatment can be expected and the long-term outlook is excellent.

Background: Enteral nutrition can be associated with gastrointestinal side effects and fibre supplementation has been proposed as a means to normalize bowel function., Aim: To evaluate systematically the effects of fibre supplementation of enteral feeds in healthy volunteers and patients both in the hospital and community settings., Methods: Electronic and manual bibliographic searches were conducted. Controlled studies in adults or children, comparing fibre-supplemented vs. fibre-free formulae given as the sole source of nutrition for at least 3 days, were included., Results: Fifty-one studies (including 43 randomized-controlled trials), enrolling 1762 subjects (1591 patients and 171 healthy volunteers) met the inclusion criteria. Fibre supplementation was generally well tolerated. In the hospital setting, the incidence of diarrhoea was reduced as a result of fibre administration (OR 0.68, 95% CI: 0.48-0.96; 13 randomized-controlled trials). Meta-regression showed a more pronounced effect when the baseline incidence of diarrhoea was high. In both patients and healthy subjects, fibre significantly reduced bowel frequency when baseline frequency was high and increased it when it was low, revealing a significant moderating effect of fibre., Conclusions: The review indicates that the fibre-supplemented enteral formulae have important physiological effects and clinical benefits. There is a need to use a consistent approach to undertake more studies on this issue in the community setting.

Background and Aims: Chronic idiopathic intestinal pseudo-obstruction (CIIP) is a severe motility disorder associated with significant morbidity. Several histopathological (neuropathic and myopathic) phenotypes have been described but only a single adult with jejunal smooth (circular) muscle alpha-actin deficiency. We present a prospective multinational case series investigating smooth muscle alpha-actin deficiency as a biomarker of this disease., Methods: A total of 115 fully clinically and physiologically (including prolonged (24 hour) ambulatory jejunal manometry) characterised CIIP patients from three European centres were studied. Immunohistochemical localisation of actins and other cytoskeletal proteins were performed on laparoscopic full thickness jejunal biopsies and compared with adult controls. Distribution of alpha-actin was also characterised in other gut regions and in the developing human alimentary tract., Results: Twenty eight of 115 (24%) CIIP patient biopsies had absent (n = 22) or partial (n = 6) jejunal smooth muscle alpha-actin immunostaining in the circular muscle layer. In contrast, smooth muscle alpha-actin staining was preserved in the longitudinal muscle and in adult jejunal controls (n = 20). Comparative study of other adult alimentary tract regions and fetal small intestine, suggested significant spatial and temporal variations in smooth muscle alpha-actin expression., Conclusions: The ability to modulate alpha-smooth muscle actin expression, evident in development, is maintained in adult life and may be influenced by disease, rendering it a valuable biomarker even in the absence of other structural abnormalities.

Chronic intestinal pseudo-obstruction (CIP) has been defined as a rare and severe, disabling disorder, which is characterised by recurring episodes or continuous symptoms and signs of bowel obstruction, including radiological features of obstruction. It is suggested that the diagnosis should be broadened to include patients with severe gastrointestinal symptoms who do not have radiological features of obstruction but who have manometric features of CIP and/or have demonstrable end organ list of pathological features described in CIP. A case of pseudo-pseudo-obstruction is described in this issue of the Journal. Originally the patient was thought to have CIP, and a mechanical cause of obstruction was suspected based on small intestine manometric features, suggesting a distal mechanical obstruction and a worsening of symptoms when treated with a prokinetic agent. As patients with CIP can develop mechanical obstruction and episodes of mechanical obstruction can mimic CIP, small intestine manometry and trials of prokinetic therapy should be undertaken in all difficult cases of obstruction and particularly in patients with documented CIP.

The rationale for antidepressants in the treatment of functional gastrointestinal disorders (FGDs) has been the subject of much interest. However, because of our incomplete understanding of FGDs, this rationale remains unclear. A key point is whether the high degree of psychiatric co-morbidity associated with FGDs (40-90%) represents a shared pathophysiology or the ascertainment bias of tertiary referral patients. Our aims were four-fold: (i) to review the current rationale for antidepressant therapy in FGDs; (ii) to review the studies comparing the characteristics of FGDs with both organic gastrointestinal disease and psychiatric disorders; (iii) to propose a model of FGDs which explains the high psychiatric co-morbidity; (iv) to compare the treatment regimes and effectiveness of antidepressants in FGDs and psychiatric illnesses. The review highlights two important observations. Firstly, the characteristics of FGDs are similar to those of affective disorders and dissimilar to those of organic disease. Secondly, although antidepressants benefit FGD sufferers, their benefits in psychiatric illnesses are greater. We conclude that, in view of the degree of similarity between FGDs and affective disorders, FGDs could be considered as affective disorders in their own right and, if the prescription of antidepressants conformed to their use in affective disorders, FGD morbidity would be reduced.

Benign pneumoperitoneum is a complication of percutaneous endoscopic gastrostomy (PEG) feeding tube placement. The rate of occurrence is reported as up to 25%. It is usually an incidental finding that arises immediately following the procedure. We report a case of pneumoperitoneum that developed a significant time after the initial procedure. The patient developed intractable vomiting and had to be fed parenterally. The pneumoperitoneum resolved and the gastrostomy tube feed was re-started.

With the aim of improving end organ treatment, we describe a new system of classifying irritable bowel syndrome (IBS) according to clinical features into four groups, spastic colon syndrome (SCS), functional diarrhea (FD), diarrhea-predominant spastic colon syndrome (DPSCS), and midgut dysmotility (MGD). The aim of the study was to investigate fasting and postprandial distal colonic motility in the four groups of patients and to compare the results with normal controls. Distal colonic motility studies were performed in the unprepared colon. 2.5-hr recordings were made from four channels with a standard meal administered at 0.5 hr. The intubated colon was treated as a study segment and data analyzed for study segment activity index (SSAI) and number and mean amplitude of pressure peaks over 30-min epochs. Patients with SCS had significantly higher (P < 0.05) mean amplitude of pressure peaks (60 min, 120 min) and SSAI (120 min) than controls and patients with FD, DPSCS, and MGD. In contrast, patients with FD and DPSCS had significantly (P < 0.05) lower postprandial SSAI than controls and patients with SCS (60 min, 120 min). With the exception of raised postprandial mean amplitude of pressure peaks (120 min), MGD patients had normal distal colonic motility. Division of IBS patients into subgroups has highlighted significant differences in distal colonic motility that provide insights into etiopathogenesis and should assist targeting of current and newly developed therapies, particularly receptor active agents.

Background and Aims: Fibres with varying fermentability may improve bowel function during enteral feeding. Two studies in healthy volunteers aimed to 1) investigate effects of Nutrison Multi Fibre (NMF) on gastrointestinal function, and 2) compare effects of NMF administered orally and nasogastrically on distal colonic motor activity., Methods: (1) Ten subjects were randomly assigned to 3x7 days self-selected diet (SSD), 2 litres Nutrison Standard (NS), or 2 l NMF. Objective and subjective indices were measured. (2) Two groups (n=6) received 2x250 ml boluses of NMF 2 hourly either nasogastrically or orally. Distal colonic motility was measured for 8 h (3 pre/5 post) first bolus., Results: Whole gut transit time was prolonged during NS (P<0.05) compared with SSD or NMF. Stool wet weight was higher during SSD (P<0.05) than during NS or NMF. Bowel frequencies were comparable. NMF was well tolerated. 2. Colonic activity index was maintained after oral administration with no associated diarrhoea. Activity index decreased after nasogastric bolus (P<0.05), but recovered to higher than fasting levels (P<0.05). 5 subjects had watery stools., Conclusions: Oral NMF is well tolerated, normalises whole gut transit time and maintains colonic motility. Recovery of colonic activity after nasogastric bolus suggests a putative protective effect of NMF over a longer period of feeding., (Copyright 2001 Harcourt Publishers Ltd.)

The number of enteral diets has increased from a handful in the 1970s to over 100 at present. These can be classified as polymeric, chemically defined, disease-specific, and specialized diets, as well as oral dietary supplements. The properties, indications, pros and cons for the use of these diets are outlined in an effort to assist clinicians in their selection.

This review covers the recent advances that have been made in intestinal motility. Failure to stimulate the cephalic response when enteral tube feeding via the nasogastric route is important in contributing to enteral tube feeding related diarrhoea, which cannot be initially overcome by the use of fibre containing feeds. Dysfunction of the nervous system and visceral hypersensitivity appear to be important in contributing to the symptoms associated with irritable bowel syndrome.

Background & Aims: The maintenance of the intestinal mucosal barrier may be energy dependent. Tacrolimus is a potent immunosuppressive drug that decreases mitochondrial adenosine triphosphate production and increases intestinal permeability in animals., Methods: Twelve liver graft recipients receiving tacrolimus, 9 healthy volunteers, and 5 liver graft recipients not receiving immunosuppression underwent a combined absorption-permeability-mitochondrial function test using 5 g lactulose, 1 g L-rhamnose, 0.5 g D-xylose, 0.2 g 3-O-methyl-D-glucose, 1 mg/kg 2-keto[1-13C]isocaproic acid ([13C]KICA), and 20 mg/kg L-leucine. The respiratory quotient and resting energy expenditure were measured by indirect calorimetry. Tacrolimus pharmacokinetic profiles and levels of endotoxin and IgM and IgG endotoxin core antibodies were determined., Results: Tacrolimus inhibited the decarboxylation of [13C]KICA, the resting energy expenditure, and the respiratory quotient in an exposure-dependent manner, suggesting an inhibition of mitochondrial respiration. Tacrolimus inhibited intestinal absorptive capacity in an exposure-dependent manner. Tacrolimus-treated patients had an increased intestinal permeability and significantly higher endotoxin levels compared with healthy volunteers., Conclusions: Tacrolimus inhibits cellular energy production in humans at clinically relevant doses. This is associated with an increased intestinal permeability, endotoxemia, and an impaired intestinal absorptive capacity.

Malnutrition has been shown to have an adverse effect on the clinical outcome of surgical patients. During the past 25 years, investigators have sought to determine whether clinical outcome can be improved by the administration of pre- or postoperative (perioperative) nutritional support. We conclude that the clinical outcome of severely malnourished surgical patients is improved by perioperative nutritional support and that this should be administered whenever possible via the enteral route. The clinical outcome of less severely malnourished surgical patients, including those who are normally nourished, can be improved by the administration of oral dietary supplements at a time in the postoperative period when patients are ingesting free fluids. Some of these patients may also benefit from early postoperative enteral tube feeding, but further work is required to determine the effects following different types of surgery before this is adopted for routine use. Parenteral nutrition is only indicated in the postoperative period when major complications occur in association with intestinal failure.

Artificial nutritional support may be supplied by several routes. Its many potential complications can be avoided if they are anticipated and help sought early from the nutrition team.

We report a case of a 62-year-old man who developed watery diarrhoea after starting treatment with cimetidine for dyspepsia. Macroscopically, sigmoidoscopy and colonoscopy were normal. Histology revealed features consistent with a diagnosis of collagenous colitis. The diarrhoea is responding to treatment with prednisolone and withdrawal of cimetidine. We conclude that the collagenous colitis may have been drug induced.

Background: Previous work has shown that the administration of oral dietary supplements to patients who have undergone gastrointestinal surgery results in clinically significant short term benefits., Aims: This study aimed firstly to re-evaluate these short term effects, and secondly to establish whether there are any long term benefits., Subjects: One hundred patients admitted for elective moderate or major gastrointestinal surgery., Methods: In the inpatient phase, patients were randomised to receive a normal ward diet postoperatively, or the same diet supplemented with an oral dietary supplement. In the outpatient phase, patients were further randomised to receive their home diet, or their home diet supplemented with the oral dietary supplement for four months., Results: During the inpatient phase, patients treated with oral supplements had a significantly improved nutritional intake and lost less weight (2.2, 95% confidence interval (95% CI) 0.9 kg) compared with control patients (4.2 (0.78) kg, p < 0.001). Supplemented patients maintained their hand grip strength whereas control patients showed a significant reduction in grip strength (p < 0.01). Subjective levels of fatigue increased significantly above preoperative levels in control patients (p < 0.01) but not in the supplemented group. Twelve patients in the control group developed complications compared with four in the supplemented group (p < 0.05). In the outpatient phase, supplemented patients had improved nutrient intakes but there were no significant differences in indices of nutritional status or wellbeing between the groups., Conclusions: The prescription of oral dietary supplements to patients who have undergone gastrointestinal surgery results in clinically significant benefits. These benefits, however, are restricted to the inpatient phase.

Diarrhoea is a common complication of enteral feeding. Previous studies have demonstrated a secretion of water and electrolytes in the ascending colon during intragastric but not intraduodenal enteral feeding. The cause of this secretion is likely to be neurohumoral in origin. This study was designed to examine the hormonal responses to enteral feeding. In vivo segmental colonic perfusion studies were undertaken. Before and at hourly intervals during these studies serum was taken for estimations of neurotensin (NT), pancreatic glucagon (PG), peptide YY (PYY) and vasoactive intestinal polypeptide (VIP). During fasting there was a median ascending colonic absorption of water in all groups. During feeding there was a net secretion in the ascending colon in both gastric groups and in the high load duodenal group, but not in the low load duodenal group. During these studies the PYY levels remained unchanged from fasting in the low and high load gastric groups. In the low and high load duodenal groups the PYY levels increased. The NT levels increased only in the high load duodenal group. There were no other changes in NT or in PG or VIP levels either between fasting and feeding, or between the gastric and duodenal groups. PYY is known to stimulate intestinal absorption. The absence of a rise during intragastric feeding may be important in the underlying mechanisms of enteral feeding-induced colonic secretion and hence enteral feeding-related diarrhoea.

Concerned with reports in the literature of a rising incidence of enteral feeding tube clogging, we initiated a design programme in an attempt to improve the clinical efficacy of nasogastric and nasoenteric enteral feeding tubes. Tube design has been based on a remodelling of the outflow part of a polyurethane feeding tube previously developed in our unit. The tip of the newly designed 8F enteral feeding tube is shorter in length with a rounded end to minimize discomfort during intubation. The port itself incorporates a tapered outflow design with the side walls now extending below the mid-point of the internal flow lumen resulting in a 28% increase in port area compared to the equivalent and originally designed tube. The performance of the newly designed polyurethane feeding tube was assessed under controlled trial conditions using as references two widely used 8F polyurethane nasogastric feeding tubes whose design has been based on different principles (Flexiflo, weighted tip, open-ended with two side ports; Freka, occluded tip, two simple large side ports). Eighty-eight of 90 patients entered into the study were successfully intubated with no significant differences being noted in intubation times in the three groups. Significantly less discomfort occurred during intubation of patients with the Radius tube as compared to the Freka tube (P < 0.05). Although there were no clear differences between the Flexiflo and Freka tubes either in regard to the number of attempts required for intubation or aspiration or discomfort during intubation or ease of aspiration, fewer attempts at insertion and aspiration were needed and intubation and aspiration were easier for patients randomised to the Radius group than those to the Flexiflo and Freka groups (P < 0.05). We conclude that the clinical performance of the newly designed Radius enteral feeding tube compares favourably with that of the reference tubes. Only one of the new tubes (3.3%) blocked during the course of the study. High rates of non-elective extubation were observed in the three study groups (Radius 80.0%, Flexiflo 73.3%, Freka 73.3%). Design modifications are unlikely to influence non-elective nasogastric feeding tube extubation rates which remain a major clinical problem.

We performed a prospective randomised study of two different sized percutaneous endoscopic gastrostomy (PEG) tubes to determine if tube size influenced the incidence of PEG-related complications. Patients were given prophylactic cefuroxime, if not already on antibiotics at the time of PEG insertion. Fifty-two PEGs were successfully placed, 26 in each group. Most patients who required a PEG had suffered a cerebrovascular event (82.7%). There were no procedure-related deaths. The mean ages (standard deviation) for the 12 and 20 French Gauge (FG) groups were 78.7 (8.9) and 73.9 (14.4) years, respectively, with no statistical difference. There were no significant differences in mortality (9 deaths in the 12 FG and 11 deaths in the 20 FG groups), number of peristomal infections (8 infections in the 12 FG and 12 infections in the 20 FG groups), episodes of leakage (12 leakages in the 12 FG and 17 leakages in the 20 FG groups) or tube blockage (2 blockage episodes in the 12 FG and 1 blockage episode in the 20 FG groups) between the two groups over a follow-up period of 190 days. The incidence of insertion- and feeding-related complications was thus not influenced by tube size. As the smaller PEG tubes were easier and less traumatic to insert we conclude that there are grounds for considering the more widespread use of the narrower diameter 12 FG PEG tubes.

Background: Collagenous colitis and lymphocytic colitis present with a similar clinical picture. Whether these conditions are separate entities or whether they represent different pathological stages of the same condition is an unresolved issue., Patient: This is a case of collagenous colitis following a fulminant course in which a colectomy was necessary. In the operative specimen the thickened collagen plate, which had been present only two weeks preoperatively had been lost and the pathology was of a lymphocytic colitis. Six months postoperatively this patient developed a CREST syndrome and primary biliary cirrhosis., Conclusions: This case shows the lability of the collagen plate and the common ground between collagenous and lymphocytic colitis, and presents evidence that these two conditions are different manifestations of the same disease. It also describes for the first time an association between collagenous colitis and CREST syndrome and primary biliary cirrhosis.

The development of in-patient malnutrition often begins long before hospital admission. The aim of this retrospective study was to assess the time period taken from when patients first present to their General Practitioners to surgery. Patients undergoing elective intraabdominal surgery over a 3 month period in a district general hospital were divided into two groups: One for those with underlying gastrointestinal malignancy requiring resection (n = 27), and the other in those with chronic biliary disease requiring laparoscopic cholecystectomy (n = 24). Patients with malignant disease presented to the GP at a mean of 3.0 months (SD 2.4) after symptom onset, and those with biliary disease at 3.5 months (SD 2.6). Those with malignancy were then referred and seen by the hospital within a mean of 2.8 weeks (SD 1.3), investigated in 3.3 weeks (SD 2.3) and operated on within 2.7 weeks (SD 1.2). The group with biliary disease were seen in hospital at 6.2 weeks (SD 1.9), investigated in 7.5 weeks (5.8) and operated on at 7.6 weeks (SD 2.1). Overall, the length of time it took from symptom onset to surgery in those with malignant disease was 26 weeks (SD 19), and in those with biliary disease 65 weeks (SD 35). This time period will inevitably lead many patients to become malnourished prior to admission, and this may have implications on the incidence of complications and length of in-patient stay.

Irritable bowel syndrome (IBS), which affects up to 25% of the population in western countries and accounts for up to 50% of referrals to gastroenterologist, remains mainly a diagnosis of exclusion. We have studied, for the first time, prolonged ambulatory motility recordings from the oesophagus, small intestine and colon of a patient who was referred to us with a 12-year history of abdominal pain and a presumptive diagnosis of IBS. The results indicated that the diagnosis was pseudo-obstruction syndrome rather than IBS. Wider clinical use of the new techniques of prolonged ambulatory intestinal motility monitoring in IBS would offer considerable potential not only in achieving a greater understanding of its pathophysiology but also in providing a more precise definition of clinical and therapeutic subgroups.

Objective: To determine how artificial nutrition support is used in hospitals in the United Kingdom and to determine whether there have been any alterations in practice when compared to similar studies in 1988 (1) and 1991 (2)., Design: A 94-question survey about artificial nutrition support (ANS) was sent to all district dietitians registered with the British Dietetic Association on 1 January 1994. Information was collected additionally from pharmacists, nutrition nurses and clinicians., Results: 66.6% of questionnaires distributed were returned with analysable information. Of the respondents, 37.3% had access to nutrition support teams, compared with 27% in 1988. The documentation of usage of nutrition support was poor, only 33% of respondents being able to accurately quantify administration of enteral nutrition (EN), and 53% parenteral nutrition (PN)., Conclusions: Despite increasing awareness about the role of artificial nutrition support, and the value of nutrition support teams there has only been a modest increase in the provision and monitoring of NSTs in the last 3 years. This has important implications when considering audit of such practices.

Objective: To describe the case of a women with cholestatic jaundice induced by the spontaneous fragmentation of an oestrogen implant., Patient: A 48-year-old woman, who presented with jaundice, pruritus and a flu-like illness 2 weeks after the insertion of a 100 mg oestradiol implant into her right buttock., Interventions: At presentation the implant was removed and found to be fragmented. Investigations revealed an oestradiol level of 1548 pmol/l and an oestrogen-induced cholestatic jaundice., Results: After removal of the implant and progesterone therapy, the patients symptoms resolved., Conclusion: This is the first reported case of cholestatic jaundice induced by a subcutaneous oestrogen implant.

Background: Dietary fiber is known to influence bowel habit and gastrointestinal mucosal cell morphology and function. large-bowel function is particularly influenced by insoluble, poorly fermentable fiber sources, whereas mucosal function is affected by fiber sources that are soluble and highly fermentable. The aim of the present study was to compare bowel function during consumption of a self-selected diet, a fiber-free enteral diet, and three polymeric enteral diets, each supplemented with a fiber with different fermentation characteristics. The fiber sources used were oat, soy oligosaccharide, and soy polysaccharide., Methods: Seven healthy subjects consumed four diets in random order for 4 to 7 days. These were a self-selected diet, a 2-L polymeric enteral diet, and a 2-L polymeric enteral diet supplemented with 15 g of total dietary fiber per liter derived from either soy oligosaccharide fiber (75 g/L) or oat fiber (15 g/L). An additional six healthy subjects were randomly assigned to three diets (4 to 7 days): a self-selected diet, a 2-L polymeric enteral diet, or the same 2-L polymeric enteral diet supplemented with 20 g of soy polysaccharide fiber per liter (15 g of total dietary fiber per liter). Bowel function was assessed by measuring whole-gut transit time, mean daily stool wet weights, and bowel movement frequency per day. Fermentation characteristics of the different fiber sources were determined quantitatively and qualitatively by measuring short-chain fatty acids produced during in vitro stool culture., Results: Total short-chain fatty acid and butyric acid production with soy oligosaccharide fiber were significantly higher compared with values observed for soy polysaccharide fiber (p < .003), oat fiber (p < .005), and self-selected (control) diet (p < .003). Compared with the fiber-free diet, consumption of the soy polysaccharide, oat, and soy oligosaccharide-fiber-supplemented enteral diets did not significantly (p > .05) alter whole-gut transit time or stool wet weight. However, bowel frequency was significantly improved by consumption of the soy polysaccharide-fiber-supplemented diet but not the oat fiber or soy oligosaccharide-fiber-supplemented diets., Conclusion: Compared with a fiber-free polymeric enteral diet, the daily consumption of an enteral diet supplemented with 30 g of total dietary fiber per day derived from a poorly fermentable oat fiber, a highly fermentable soy oligosaccharide fiber, or a moderately fermentable soy polysaccharide fiber has little impact, if any, on bowel function.

Diarrhoea complicating enteral feeding is a common clinical problem affecting up to 25% of patients. Its pathogenesis remains unknown. A new technique of human in vivo segmental colonic perfusion was used to investigate colonic water and electrolyte movement in response to enteral feeding. Four groups of studies were performed in which low and high load polymeric enteral diet infusions were undertaken, either intragastrically or intraduodenally (n = 6 each group). Net absorption of sodium, chloride, and water occurred during fasting throughout the colon in all groups. There was a significant net secretion of sodium, chloride, and water in the ascending colon during low load (sodium: -42 mmol/h; 95% confidence limits -52 to -19, Chloride: -18 mmol/h; -50 to +16, water: -174 ml/h; -348 to -30) and high load (sodium: -24 mmol/h; -60 to +8, chloride: -18 mmol/h; -31 to +16, water: -120 ml/h; -246 to +6) gastric feeding, and during high load duodenal feeding (sodium: -12 mmol/h; -22 to -6, chloride; -6 mmol/h; -16 to +3, water: -72 ml/h; -144 to -6). Net secretion persisted in the distal colon only during high load gastric feeding. In the other three groups there was a net absorption in the distal colon. This study identified a significant colonic secretory response to enteral feeding, which is related to the site and load of the diet infusion. This response may play an important part in the pathogenesis of enteral feeding related diarrhoea.