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Patients with intestinal failure often need long-term home parenteral support (PS). We aimed to determine how the underlying diagnosis, complications and survival had changed over the last 36 years in the UK's largest IF centre.978 adult home PS patient records were analysed from January 1979 until October 2016. The age, sex, underlying aetiology, complications and survival was compared over 5-year periods.Pre-1990 to 2011-2016, numbers increased from 29 to 451, the mean age of patients increased from 31 ± 16.5 to 52 ± 17.6 years. The percentage of patients with IF due to surgical complications increased (3.4%-28.8%, p 0.001)), while those with inflammatory bowel disease decreased (37.9%-22.6%, p 0.001). Complication of home PS reduced: catheter related blood stream infections (CRBSI) 71.4% to 42,2%, CVC thrombosis 34.5%-5.3%. Intestinal failure associated liver disease (IFLAD) 10.3%-1.8%. Patients with dysmotility, scleroderma and a congenital aetiology had the highest incidence of CRBSI and CVC Thrombosis. Overall survival was greater pre-1995 [HR 0.2-0.4 (p = 0.02)] most likely associated with an increase in mean age. Survival for patients without malignancy was 90%, 66%, 55%, 45%, 33% and 25% at 1,5, 10, 15, 20 and 30 years respectively. Multivariate analysis demonstrated a relationship between survival and age of starting home PS; type of home PS; presence or absence of the colon in continuity; and underlying aetiology.Demand for home PS is increasing in particular for advanced malignancy, post-surgical complications and older more co-morbid patients. Complications of home PS are reducing over the last 30 years and 10-year survival for non-malignant aetiologies improving. Survival and changes in aetiology in intestinal failure.

BACKGROUND Patients with a jejunostomy or high output stoma may need a glucose-sodium oral rehydration solution drink to maintain hydration. These solutions are unpalatable and a new flavoured pre-packaged solution was developed. METHODS After 8 h of fasting, 27 patients took 500 mL of the modified World Health Organization (WHO) cholera solution or Glucodrate® (Vitaflo) on two occasions in a cross-over random order and urine and stomal output was collected for 6 h. RESULTS There was a small but significant difference in net sodium absorption in favour of the modified WHO cholera solution (10 ± 28 mmol modified WHO cholera solution vs. -1 ± 26 mmol Glucodrate®, p = 0.01). However the Glucodrate® was more palatable, with 24 patients (89%) preferring it to the modified WHO cholera solution (p

Adult patients with severe chronic small intestinal dysmotility are not uncommon and can be difficult to manage. This guideline gives an outline of how to make the diagnosis. It discusses factors which contribute to or cause a picture of severe chronic intestinal dysmotility (eg, obstruction, functional gastrointestinal disorders, drugs, psychosocial issues and malnutrition). It gives management guidelines for patients with an enteric myopathy or neuropathy including the use of enteral and parenteral nutrition.

A high-output stoma (HOS) or fistula is when small bowel output causes water, sodium and often magnesium depletion. This tends to occur when the output is >1.5 -2.0 L/24 hours though varies according to the amount of food/drink taken orally. An HOS occurs in up to 31% of small bowel stomas. A high-output enterocutaneous fistula may, if from the proximal small bowel, behave in the same way and its fluid management will be the same as for an HOS.The clinical assessment consists of excluding causes other than a short bowel and treating them (especially partial or intermittent obstruction). A contrast follow through study gives an approximate measurement of residual small intestinal length (if not known from surgery) and may show the quality of the remaining small bowel.If HOS is due to a short bowel, the first step is to rehydrate the patient so stopping severe thirst. When thirst has resolved and renal function returned to normal, oral hypotonic fluid is restricted and a glucose-saline solution is sipped. Medication to slow transit (loperamide often in high dose) or to reduce secretions (omeprazole for gastric acid) may be helpful. Subcutaneous fluid (usually saline with added magnesium) may be given before intravenous fluids though can take 10–12 hours to infuse. Generally parenteral support is needed when less than 100 cm of functioning jejunum remains. If there is defunctioned bowel in situ, consideration should be given to bringing it back into continuity.

Catheter-related bloodstream infections (CRBSIs) commonly arise from a parenteral nutrition catheter hub. A target for a Nutrition Support Team is to have a CRBSI rate of less than 1 per 1000. The diagnosis of CRBSI is suspected clinically by a temperature shortly after setting up a feed, general malaise or raised blood inflammatory markers. It is confirmed by qualitative and quantitative blood cultures from the catheter and peripherally. Treatment of inpatients may involve central venous catheter removal and antibiotics for patients needing short-term parenteral nutrition, but catheter salvage is generally recommended for patients needing long-term parenteral nutrition, where appropriate.

Introduction Patients with a high output ileostomy often have hypomagnesaemia. Oral magnesium therapy may be unsuccessful. Topical magnesium therapy may offer a novel mode of replacement. This phase II clinical study using BetterYou magnesium oil spray primarily aimed to determine if the spray will maintain or increase serum magnesium in these patients. Methods Outpatients with an ileostomy formed more than 6 months prior to inclusion and having chronic hypomagnesaemia (serum magnesium level less than (a) a further outpatient serum magnesium (Mg+2) level (b) needing regular intravenous magnesium infusions at least once every 6 weeks for more than 18 weeks, were recruited. Exclusion criteria included severe hypomagnesaemia ( Recruits applied 10 sprays twice daily for 6 weeks, delivering a topical elemental magnesium dose of 150 mg/day. Serum and whole cell Mg+2 levels were measured at enrolment, and at weeks 1, 3 and 6. Vitamin D levels were measured at enrolment; 24 hour urinary magnesium levels were measured at enrolment and week 6. Treatment response is defined as a serum Mg+2 level rise >0.10 mmol/L at week 6, or the avoidance of a planned magnesium infusion during the trial without a fall in serum Mg+2. Patients with serum Mg+2 Results 7 patients entered the study. 6 patients completed it; 1 was withdrawn at week 4 due to hospitalisation for Crohn’s disease. All 6 patients had normal enrolment vitamin D levels (>45 nmol/L), and 5 of 6 had 24 hour urinary magnesium levels below the minimum detection limit ( 1 of the 6 patients avoided their planned six-weekly magnesium infusion, maintaining a stable serum Mg+2 level (0.59 mmol/L at enrolment, 0.62 mmol/L at week 6) and increased 24-urinary magnesium output. 2 of the remaining 5 patients were treatment successes, with a serum Mg+2 rise of 0.27 and 0.13 respectively. No patient had a fall in serum Mg+2 of greater than 0.07 mmol/L between enrolment and week 6. Serum and whole cell Mg+2 correlation is strong and near linear (Pearson’s r=0.92, p Conclusions 3 of 6 patients were treated successfully with BetterYou magnesium oil spray. Serum magnesium is a reliable surrogate for whole cell magnesium.

BACKGROUND: Globally, >300 million patients have surgery annually, and ≤20% experience adverse postoperative events. We studied the impact of both cardiac and noncardiac adverse events on 1-year disability-free survival after noncardiac surgery. METHODS: We used the study cohort from the Evaluation of Nitrous oxide in Gas Mixture of Anesthesia (ENIGMA-II) trial, an international randomized trial of 6992 noncardiac surgical patients. All were ≥45 years of age and had moderate to high cardiac risk. The primary outcome was mortality within 1 postoperative year. We defined 4 separate types of postoperative adverse events. Major adverse cardiac events (MACEs) included myocardial infarction (MI), cardiac arrest, and myocardial revascularization with or without troponin elevation. MI was defined using the third Universal Definition and was blindly adjudicated. A second cohort consisted of patients with isolated troponin increases who did not meet the definition for MI. We also considered a cohort of patients who experienced major adverse postoperative events (MAPEs), including unplanned admission to intensive care, prolonged mechanical ventilation, wound infection, pulmonary embolism, and stroke. From this cohort, we identified a group without troponin elevation and another with troponin elevation that was not judged to be an MI. Multivariable Cox proportional hazard models for death at 1 year and assessments of proportionality of hazard functions were performed and expressed as an adjusted hazard ratio (aHR) and 95% confidence intervals (CIs). RESULTS: MACEs were observed in 469 patients, and another 754 patients had isolated troponin increases. MAPEs were observed in 631 patients. Compared with control patients, patients with a MACE were at increased risk of mortality (aHR, 3.36 [95% CI, 2.55-4.46]), similar to patients who suffered a MAPE without troponin elevation (n = 501) (aHR, 2.98 [95% CI, 2.26-3.92]). Patients who suffered a MAPE with troponin elevation but without MI had the highest risk of death (n = 116) (aHR, 4.29 [95% CI, 2.89-6.36]). These 4 types of adverse events similarly affected 1-year disability-free survival. CONCLUSIONS: MACEs and MAPEs occur at similar frequencies and affect survival to a similar degree. All 3 types of postoperative troponin elevation in this analysis were associated, to varying degrees, with increased risk of death and disability.

Patients who have a bowel resection for mesenteric infarction may require parenteral nutrition (PN). This study primarily aimed to determine the aetiological factors for a mesenteric infarction and the effects of restoring bowel continuity on the long-term PN requirements.A retrospective review of data on patients treated for mesenteric infarction from 2000 to 2010.A total of 113 patients (61 women, median age 54 years) were identified. Seventy-four (65%) had a superior mesenteric artery thromboembolism, 25 (22%) had a superior mesenteric vein thrombosis, and 4 (3%) had superior mesenteric artery stricture or spasm. Patients younger than 60 years most commonly had a clotting abnormality (n = 23/46, 50%), whereas older patients had a cardiological risk factor (n = 11/17, 65%). All patients with a jejunostomy required long-term PN. Fifty-seven (49%) patients had restoration of bowel continuity (colon brought into circuit). After this, PN was stopped within 1 year in 20 (35%), within 2 years in 29 (50%) patients and within 5 years in 44 (77%) patients (P = 0.001).A thrombotic tendency is the main etiological factor in most patients younger than 60 years. An anastomosis of the remaining jejunum to the colon can allow PN to be stopped.

Introduction Standard management of type 3 intestinal failure (IF) is long-term parenteral support (PS). While it is clear that PS is lifesaving treatment for IF, it carries significant morbidity and mortality, both dependent and independent of the underlying aetiology of the IF. We report the largest single-centre series assessing the long-term survival of adult patients on all forms of home PS (parenteral nutrition and parenteral fluids) for type 3 IF. Method Clinical records of 978 adult patients receiving home parenteral support for IF at our tertiary referral centre were analysed from January 1979 until October 2016. Demographic data, underlying aetiology, intestinal length, colonic continuity, complication rates and survival was recorded. Differences between groups were analysed by chi-squared tests. Kaplan-Meier and Cox’s regression models were used to assess factors affecting survival. Results Overall probability of survival for all patients on PS was 86%, 63%, 52%, 43%, 31%, 24% at 1, 5,10, 15, 20 and 30 years respectively. When active malignancy is excluded as a cause of IF, survival rates were 90%, 66%, 55%, 45%, 33% and 25% (graph 1). There is a significant difference in survival dependent on underlying IF aetiology. The worst 1 year survival of 62% was seen for malignancy and the best with pseudo-obstruction (excluding scleroderma) at 93%. Multivariate analysis demonstrated a significant relationship between survival and the following factors; age at start of PS; HR 1.03 (p Conclusion Our data have shown that several factors are associated with long-term survival. A better prognosis was associated with an earlier age of onset of type 3 IF and the presence of colonic continuity, while a worse prognosis was associated with underlying aetiologies such as malignancy and radiation enteritis. To our knowledge, this is the largest single-centre case series looking at survival in type-3 IF to date and adds to our current understanding of the long-term outcomes in type 3 IF. Disclosure of Interest None Declared

Introduction Intestinal failure (IF) occurs when there is reduced intestinal absorption causing malnutrition and/or dehydration. The management of this condition has changed since the very first patients were started on long-term parenteral support in the form of parenteral nutrition in the 1960s. At our unit our first patient was started on long-term parenteral support in the 1970’s. We now care for the largest number of HPN patients in the UK. We describe changes in aetiology as seen in our unit over the last 36 years. Method Clinical records of 974 adult patients receiving home parenteral support for IF at our tertiary referral centre were analysed from a period from January 1979 until October 2016. Demographic data including age, sex, underlying aetiology, complication rates and survival was recorded. Difference between groups were analysed by with chi-squared tests, and the Cox’s regression model was used to assess survival. Results The mean age of patients treated at our unit has increased from 31±16.5 to 52±17.6 years from pre 1989 to 2010–2016. During the same period there has been a change in the underlying aetiology, with a greater percentage of patients with IF due to surgical complications (3.4% to 28.8%% (p Conclusion At our institution there has been a significant change in the underlying aetiology and demographics of patients with IF. The age of initiation of home parenteral support is increasing, and there has been a reduction in the proportion of patients with IBD as the underlying cause of IF with an increase in surgical complications and malignancy. Our data also shows that there has been a reduction in the rates of complications related to IF including catheter related blood stream infection rates and rates of central venous thrombosis. Notably survival outcomes were significantly better in the period pre 1995, which is likely explained by the fact that we now are treating older patients with complex underlying conditions associated with poorer outcomes. Disclosure of Interest None Declared

Aim Patients with a high-output stoma (HOS) (> 2000 ml/day) suffer from dehydration, hypomagnesaemia and under-nutrition. This study aimed to determine the incidence, aetiology and outcome of HOS. Method The number of stomas fashioned between 2002 and 2006 was determined. An early HOS was defined as occurring in hospital within 3 weeks of stoma formation and a late HOS was defined as occurring after discharge. Results Six-hundred and eighty seven stomas were fashioned (456 ileostomy/jejunostomy and 231 colostomy). An early HOS occurred in 75 (16%) ileostomies/jejunostomies. Formation of a jejunostomy (defined as having less than 200 cm remaining of proximal small bowel; n = 20) and intra-abdominal sepsis? obstruction (n = 14) were the commonest causes identified for early HOS. It was possible to stop parenteral infusions in 53 (71%) patients treated with oral hypotonic fluid restriction, glucose-saline solution and anti diarrhoeal medication. In 46 (61%) patients, the HOS resolved and no drug treatment was needed, 20 (27%) patients continued treatment, six (8%) of whom went home and continued to receive parenteral or subcutaneous saline, and nine died. Twenty-six patients had late HOS. Eleven were admitted with renal impairment and four had intermittent small-bowel obstruction. Eight patients were given long-term subcutaneous or parenteral saline and two also received parenteral nutrition. All had hypomagnesaemia. Conclusion Early high output from an ileostomy is common and although 49% resolved spontaneously, 51% needed ongoing medical treatment, usually because of a short small-bowel remnant.

Introduction Adalimumab is effective in inducing and maintaining response/remission in patients with Crohn's disease either naive to biological therapies or after secondary failure of infliximab. Aim To present the first ‘real-life’ survey data from England and Ireland on the use of adalimumab. Method A retrospective audit conducted through a web-based questionnaire in England/Ireland. Results We analysed data on 61 patients (35 female, 26 male) with a median age of 33 years (range 17–71 years) and an average follow-up of 8 months. The maximal maintenance dose was 40 mg every other week in 84% of patients, 40 mg weekly in 13% and 80 mg weekly in 3%. Maintenance adalimumab achieved remission in 57% of patients. The ongoing response rate was 83.6%. An additional 8% had a secondary loss of response after an average of 8.4 months (range 2–17). Adverse effects were observed in 23% of patients: of which there was local pain in 29%, infection in 36%, headaches in 14%, leucopenia (on azathioprine) in 7%, a painful rash in 7% and serum-sickness-type reaction in 7%. Adverse events led to discontinuation in two patients. Conclusion This English/Irish audit shows an acceptable response/remission and safety profile of adalimumab in the treatment of Crohn's disease. In contrast to earlier data from Scotland, dose escalation was only observed in 16% of patients. The majority of responders were steroid-free at follow-up.

Summary Background & aims Complications resulting from home parenteral nutrition (HPN) reduce a patient's quality of life. The major complications of catheter-related sepsis, venous thrombosis and chronic liver disease are well recognised. This study aimed to determine if there were other minor, but common complications that caused patient distress. Methods All patients (45) from four HPN centres were asked if they had suffered any side effects of parenteral nutrition and whether these side effects related to the timings of the feed or required specific intervention. Results Muscle cramps were the most common minor side effect [12/45 (27%)]. A greater proportion of HPN patients (51%) suffered from muscle cramps than did a control group of patients with inflammatory bowel disease (24%) [p = 0.0001]. In the HPN patients, no significant difference in serum electrolyte concentration or in feed composition was noted between those patients with and those without cramps in relation to feeds. Cramps were of sufficient severity to warrant pharmacological intervention in 9 of 12 patients who had cramps in relation to feeds, and parenteral nutrition administration was slowed in 2 of the 12. Conclusion Muscle cramps have a high prevalence in patients receiving home parenteral nutrition.

Six patients with short intestine (jejunal length 25-70 cm) on long-term parenteral nutrition, needing 4-5 L of intravenous fluid daily, were given octreotide (a somatostatin analogue, SMS 201-995) to investigate whether it would reduce beneficially their secretory diarrhoea (3.6-6.9 kg/day). They consumed the same diet for 2 control days, followed by 2 test days. Octreotide was given intravenously, initially in a dose of 50 micrograms b.d. through the central feeding line. There was a significant reduction of daily stomal output (0.5-5.0 kg) and daily sodium and potassium output; however there was no significant change in energy absorption. The response to octreotide was greatest in those patients who absorbed least nutrients. A dose increase to 100 micrograms t.d.s. gave no further measurable benefit though the patients found it smoothed-out the post-prandial rise in stomal output. Two patients were continued on long-term octreotide therapy, which allowed for a daily reduction in intravenous fluid of 1 and 1.5 L. Octreotide's anti-secretory effect was found to have been maintained when it was retested in one patient after a year of continuous therapy.

Parenteral nutrition may be needed to give nutritional support to patients with severe acute (temporary or reversible) or chronic intestinal failure. Parenteral nutrition needs to be given only by health workers trained in its use otherwise life-threatening complications (especially sepsis) may occur.

A new definition of intestinal failure is of reduced intestinal absorption so that macronutrient and/or water and electrolyte supplements are needed to maintain health or growth. Severe intestinal failure is when parenteral nutrition and/or fluid are needed and mild intestinal failure is when oral supplements or dietary modification suffice. Treatment aims to reduce the severity of intestinal failure. In the peri-operative period avoiding the administration of excessive amounts of intravenous saline (9 g NaCl/l) may prevent a prolonged ileus. Patients with intermittent bowel obstruction may be managed with a liquid or low-residue diet. Patients with a distal bowel entero-cutaneous fistula may be managed with an enteral feed absorbed by the proximal small bowel while no oral intake may be needed for a proximal bowel enterocutaneous fistula. Patients undergoing high-dose chemotherapy can usually tolerate jejunal feeding. Rotating antibiotic courses may reduce small bowel bacterial overgrowth in patients with chronic intestinal pseudo-obstruction. Restricting oral hypotonic fluids, sipping a glucose-saline solution (Na concentration of 90–120 mmol/l) and taking anti-diarrhoeal or anti-secretory drugs, reduces the high output from a jejunostomy. This treatment allows most patients with a jejunostomy and >1 m functioning jejunum remaining to manage without parenteral support. Patients with a short bowel and a colon should consume a diet high in polysaccharides, as these compounds are fermented in the colon, and low in oxalate, as 25% of the oxalate will develop as calcium oxalate renal stones. Growth factors normally produced by the colon (e.g. glucagon-like peptide-2) to induce structural jejunal adaptation have been given in high doses to patients with a jejunostomy and do marginally increase the daily energy absorption.

Epidermal growth factor (EGF) is a potent mitogenic peptide produced by salivary glands. We examined whether EGF enemas are an effective treatment for active left-sided ulcerative colitis and ulceration limited to the rectum (proctitis).In a randomized, double-blind clinical trial conducted at Leicester Royal Infirmary, 12 patients with mild-to-moderate left-sided ulcerative colitis received daily enemas of 5 microg of EGF in 100 ml of an inert carrier and 12 received daily enemas with carrier alone for 14 days. All also began to receive 1.2 g of oral mesalamine per day or had their dose increased by 1.2 g per day. Patients were assessed clinically at 0, 2, 4, and 12 weeks and by sigmoidoscopy and biopsy at 0, 2, and 4 weeks. The primary end point was disease remission (defined by a St. Marks score of 4 or less without sigmoidoscopic evidence of inflammation) at two weeks. Secondary end points were clinically significant improvements in disease activity (defined by a decrease of more than 3 points in the St. Marks score or the ulcerative colitis disease-activity index) at two and four weeks. Analyses were performed according to the intention-to-treat principle.After two weeks, 10 of the 12 patients given EGF enemas were in remission, as compared with 1 of 12 in the control group (83 percent vs. 8 percent, P0.001). At the 2-week assessment, disease-activity scores, sigmoidoscopic score, and histologic scores were all significantly better in the EGF group than in the placebo group (P0.01 for all comparisons), and this benefit was maintained at 4 weeks and at 12 weeks.This study provides preliminary data suggesting that EGF enemas are an effective treatment for active left-sided ulcerative colitis.

Short bowel syndrome most commonly results after bowel resections for Crohn's disease. The normal human small intestinal length ranges from about 3 to 8 m, thus if the initial small intestinal length is short, a relatively small resection of the intestine may result in the problems of a short bowel. Two types of patient with a short bowel are encountered in clinical practice: those with their jejunum anastomosed to a functioning colon, and those with a jejunostomy. Both types of patient have problems absorbing adequate macronutrients, and both need long-term vitamin B12 therapy. Patients with a jejunostomy also have major problems with large stomal losses of water, sodium, and magnesium. This high-volume jejunostomy output is treated by restricting oral fluids, giving a glucose-saline solution to drink, and using drugs that either reduce gastrointestinal motility (loperamide or codeine phosphate) or secretions (H2 antagonists, proton pump inhibitors, or octreotide). Patients whose jejunal length is less than 100 cm, and whose stomal output is greater than their oral intake, benefit most from antisecretory drugs. In patients with a retained colon, bacterial fermentation of unabsorbed carbohydrate in the colon results in energy being salvaged. However, they have increased oxalate absorption and a 25% chance of developing calcium oxalate renal stones. Thus patients with a colon are advised to eat a high-energy diet rich in carbohydrate but low in oxalate. Patients with a jejunostomy need a high-energy iso-osmolar diet with added salt. Both patient types have a 45% prevalence of gallstones. With current therapy most patients with a short bowel have a normal body mass index and a good quality of life.

Summary Background & aims Refeedinghypophosphataemia (RH) can result in sudden death. This study aimed to compare the incidence of RH between patients fed enterally and those fed parenterally. Methods The risk of RH in adult patients fed parenterally (PN) or nasogastrically (NG) was assessed by comparison of patient records with the UK NICE guidelines for refeeding syndrome, between December 2007 and December 2008. A fall in serum phosphate to less than 0.6 mmol/L was indicative of RH. Results Of 321 patients,92 were at risk of RH. Of these, 23 (25%) patients developed RH ( p = 0.003). 18 (33%) of NG fed, ‘at-risk’ patients developed RH vs 5 (13%) fed parenterally ( p = 0.03). Death within 7 days and RH were not associated. The sensitivity and specificity of the NICE criteria for defining patient’s risk of RH was calculated: 0.76 and 0.50 respectively for NG feeding; 0.73 and 0.38 respectively for parenteral feeding. Conclusion Patients fed by NG tube and deemed at risk of RH are more likely to develop RH than patients fed by PN. The higher risk with NG feeding may be due to the incretin effect from absorption of glucose. The UK guidelines lack specificity.

Crohn's disease often involves the stomach, yet a permanent enterocutaneous fistula does not usually occur, after a percutaneous endoscopic gastrostomy is removed from a patient with Crohn's disease. This is because the factors that are related to the non-closure of a fistula are absent or have been treated (distal bowel obstruction, abdominal sepsis, undernutrition, poor gastric blood supply or abnormal serum levels of C-reactive protein and albumin). Gastric involvement in patients with Crohn's disease is common. Enterocutaneous fistulas from the stomach are rare. Percutaneous endoscopic gastrostomy (PEG) insertion and subsequent removal rarely cause problems in patients with Crohn's disease. Endoscopic removal of a PEG is advised in patients with Crohn's disease. Steroids may delay gastric adhesion to the anterior abdominal wall.

24 h oral intake and intestinal output were studied in 15 patients with a short residual length of jejunum and no colon. 8 patients showed a net secretory, and 7 a net absorptive response to food. In secretors, daily intestinal output exceeded oral intake (mean 2.3 kg wet weight, and 233 mmol sodium). Long-term parenteral fluid and electrolyte replacements were needed only in those with a secretory response. Jejunal length inversely correlated with net intestinal output of fluid, sodium, potassium, and with percentage energy absorption. A secretory response was observed if jejunal length was less than 100 cm and was reduced by gastric antisecretory drugs and octreotide.

Nine patients with short bowel syndrome and high intestinal output received octreotide either intravenously (50-100 micrograms t.i.d.) or subcutaneously (100 micrograms b.i.d.) on 2 test days. In the 6 patients with net secretory output, there was a reduction in mean daily intestinal output of 0.5-5.0 kg; total daily intestinal output of sodium and potassium was also reduced significantly. Of the 3 patients with a net absorptive state, there was a worsening of output in 2 and no improvement occurred in the other. Two patients with net secretory output received long-term octreotide therapy, allowing a reduction in daily intravenous fluid intake of 1.0-1.5 litres.

Objectives This pilot study aimed to determine if an elemental diet could be used to treat patients with active rheumatoid arthritis and to compare its effect to that of oral prednisolone. Methods Thirty patients with active rheumatoid arthritis were randomly allocated to 2 weeks of treatment with an elemental diet (n = 21) or oral prednisolone 15 mg/day (n = 9). Assessments of duration of early morning stiffness (EMS), pain on a 10 cm visual analog scale (VAS), the Ritchie articular index (RAI), swollen joint score, the Stanford Health Assessment Questionnaire, global patient and physician assessment, body weight, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and haemoglobin, were made at 0, 2, 4 and 6 weeks. Results All clinical parameters improved in both groups (p Conclusions An elemental diet for 2 weeks resulted in a clinical improvement in patients with active rheumatoid arthritis, and was as effective as a course of oral prednisolone 15 mg daily in improving subjective clinical parameters. This study supports the concept that rheumatoid arthritis may be a reaction to a food antigen(s) and that the disease process starts within the intestine.

Introduction Long-term central venous catheters for home parenteral nutrition (HPN) carry a risk of recurrent bacterial colonisation and catheter related sepsis (CRS). 1 Spinal infections following an episode of CRS are uncommon but may be underreported or overlooked due to the high incidence of osteoporotic fractures in this cohort. 2 We aimed to determine the frequency and describe cases of spinal infections in HPN patients at our institution. Method We performed a retrospective review of all spinal infections presenting in our HPN patients between January 2010 and October 2013, a cohort of approximately 270 patients. Data were extracted on basic demographics, indication for and duration of HPN, means of venous access, history of presentation and management. Results The CRS rate was 0.9 per 1000 catheter days. Six patients were identified (mean age 65 years, 5 male) with spinal infection, a rate of 0.02 per 1000 catheter days. Duration with current CVC ranged from 5 months to 2 years. All patients presented with spinal pain; 5/6 cervical, 1/6 thoracic. All patients had a normal white cell count and differential, and in only 1 case was the CRP elevated. In 4 cases an organism was isolated at the time of presentation from blood cultures taken centrally and/or peripherally – commonly staphylococcal species. All patients had contrast-enhanced magnetic resonance imaging (MRI) with features compatible with spinal infection and in two patients a repeat MRI demonstrated resolution of changes. In three patients a disc biopsy was performed yielding one negative culture, one microbiological correlation with blood cultures and a single positive culture (unknown isolate). All patients received three months of intravenous antibiotic therapy augmented with surgery or conservative management on a case-by-case basis. The CVC was removed in 4/6 patients at presentation, with salvage in the remaining two. Conclusion Spinal infections associated with long-term CVC for HPN should be considered in patients presenting with spinal pain. They are often of insidious onset and may present with normal inflammatory markers which may contribute to delayed or missed diagnoses that together with differences in the definition of CRS 1 may partially explain the poor representation in the current HPN-related literature. 3 Gold-standard imaging is with contrast-enhanced MRI with formal biopsy decided on an individual basis. Management should involve prolonged antibiotics and liaison with microbiology and neurosurgery. Multidisciplinary discussion on CVC salvage is important especially in cases of difficult vascular access. Disclosure of interest None Declared. References Reimund JM, et al. Clin Nutr. 2002;21(2):33–38 Haderslev KV, et al. JPEN 2004;28(5):289–294 Huard G, et al. J Clin Med Res. 2014;6(4):272–277

Introduction Patients with mesenteric infarction can have intestinal failure due to a short bowel thereby needing parenteral nutrition. A short bowel and parenteral nutrition can increase the risk of chronic cholestasis. Restoring bowel continuity after a mesenteric infarction results in reduction or stopping parenteral nutrition requirements. The aims of this study are to determine the prevalence and the effect of restoring bowel continuity on chronic cholestasis. Method A retrospective review of patients with a short bowel due to mesenteric infarction from 2000–2012. We defined chronic cholestasis as two of bilirubin, alkaline phosphatase and gamma-glutamyl transferase being 1.5 times the upper limit of normal for more than 6 months. Results One hundred and four (55 females, median age 54 years) patients were identified. Seventy three (70%) patients had bowel continuity restored while 31 (30%) patients did not have bowel continuity restored. The prevalence of chronic cholestasis was 29%. Fifteen (21%) of 73 patients had chronic cholestasis. Following restoration of bowel continuity, 8 (53%) of 15 patients had a return of liver biochemistry to normal range within a year. Univariate analysis showed restoring bowel continuity (p = 0.002) was associated with a reduced risk of chronic cholestasis. Multivariate analysis showed cessation of PN was a significant factor in reducing chronic cholestasis (p = 0.02). Conclusion The prevalence of chronic cholestasis is 29% for patients with a short bowel receiving parenteral nutrition. Chronic cholestasis resolves in over half patients after continuity is restored. Disclosure of interest None Declared. References Cavicchi M, Beau P, Crenn P, et al. Prevalence of liver disease and contributing factors in patients receiving home parenteral nutrition for permanent intestinal failure. Ann Intern Med. 2000;132(7):525–32 Lloyd DAJ, Zabron AA, Gabe SM. Chronic biochemical cholestasis in patients receiving home parenteral nutrition: prevalence and predisposing factors. Aliment Pharmacol Ther. 2008;27(7):552–60 Nightingale JM. Management of patients with a short bowel. World J Gastroenterol. 2001;7(6):741–51 Salvino R, Ghanta R, Seidner DL, et al. Liver failure is uncommon in adults receiving long-term parenteral nutrition. J Parenter Enter Nutr. 2006;30(3):202–8

1.1 Aim These guidelines aim to help clinicians manage patients who have had an intestinal resection that leaves a short length (about 2 m or less) of small bowel remaining. ### 1.2 Development The preliminary guidelines were compiled from the literature and a first document was drafted by Dr J Nightingale and modified by members of the Small Bowel and Nutrition Committee under the chairmanship of Dr B Jones. A section on “intestinal transplantation” was written by Dr Woodward and added with the approval of the Small Bowel and Nutrition Committee. The resulting document was shown to clinicians at the intestinal units of Hope and St Mark’s Hospitals. Professor A Forbes made recommendations, which have been incorporated. The article was reviewed by the patient organisation PINNT (patients on intravenous or nasogastric nutritional therapy) and modifications made to result in the current document. The guidelines conform to the North of England evidence based guidelines development project.1 The grading of each recommendation is dependant on the category of evidence supporting it. Recommendations based on the level of evidence are presented and graded as: ### 1.3 Scheduled review The content and evidence base for these guidelines should be reviewed within five years of publication. We recommend that these guidelines are audited and request feedback from all users. ### 1.4 Service delivery Patients with a short bowel are not common but should be managed by a multidisciplinary team headed by a clinician with expertise in …

Background A 56-year-old Caucasian woman with a history of Crohn's disease and multiple bowel resections resulting in a loop jejunostomy was referred to our Nutritional Unit from a neighboring district general hospital for further management. She was first seen in October 2001, and initial assessment indicated that she was malnourished with fluid depletion, evidenced by the high volume of stomal fluid produced. There had been no sudden change in her medication, her Crohn's disease was quiescent and there was no evidence of any intra-abdominal sepsis. Despite a high calorific intake through her diet, she continued to lose weight. Investigations Serum urea and electrolytes; magnesium; C-reactive protein; full blood count; urinary spot sodium; anthropometric measurements. Diagnosis High-output stoma with malabsorption as a consequence of repeated small-bowel surgery. Management The patient was treated with oral hypotonic fluid restriction (0.5 l/day), 2 l of oral glucose–saline solution per day, high-dose oral antimotility agents (loperamide and codeine phosphate), a proton-pump inhibitor (omeprazole) and oral magnesium replacement. A year later, the patient's loop jejunostomy was closed and an end ileostomy fashioned, bringing an additional 35 cm of small bowel into continuity; macronutrient absorption improved but her problem of dehydration was only slightly reduced. She was stabilized on a twice-weekly subcutaneous magnesium and saline infusion and daily oral 1α-hydroxycholecalciferol.

A hospital-based nutrition support team (NST) may need to demonstrate cost savings and quality benefits. The primary aim of this study was to determine whether an NST could show tangible cost savings (equipment, investigations, and medication costs) from managing patients considered for parenteral nutrition (PN). Secondary aims related to the quality issues of placement of PN catheters, catheter-related sepsis (CRS), duration of parenteral nutrition, and mortality.An NST was formed in 1999 and worked in all adult areas of a university hospital (Leicester Royal Infirmary). Comparative data about all patients given PN were collected for 2 consecutive years (a retrospective pre-NST year and a prospective NST year).In the pre-NST year there were 82 PN episodes (54 patients), 665 PN days, and a CRS rate of 71% (seven infections/100 PN days). In the NST year, there were 133 referrals for PN but only 78 PN episodes (75 patients, 59% of referrals), 752 PN days, and a decreased overall CRS rate of 29% (three infections/100 PN days, P0.05) but a rate of 7% (0.6 infection/100 PN days) in the final 3 mo of the NST year. Tangible cost savings for the NST year were derived from 55 avoided PN episodes (42741 pounds sterlings) and 35 avoided CRS episodes (7974 pounds sterlings). Thirty-nine percent of PN catheters were inserted by the NST with no insertion-related complications. Competency-based training of ward nursing staff decreased the CRS rate. Mean duration of PN increased from 8 to 10 d (P not significant). In-hospital mortality for patients who had PN was 23 of 54 (43%) in the pre-NST year compared with 18 of 75 (24%) in the NST year (P0.05).Although the number of PN days increased with an NST, tangible cost savings of 50715 pounds sterlings were demonstrated within the NST year by avoided PN episodes and a decreased incidence of CRS. These savings justify the salaries of a nutrition nurse specialist and a senior dietitian.

Objective : The normal adult human small intestinal length, measured surgically or at autopsy from the duodeno-jejunal flexure, ranges from 275 to 850cm. The length is generally shorter in women than in men. Patients with a short bowel have often had relatively little bowel resected and the majority of patients are women. We aimed to determine whether patients with a short bowel had a short small intestinal length before any resections. Patients and methods : In 11 patients (six men and five women) with Crohn's disease and less than 200cm residual small intestine, both the residual length of small intestine and the amount resected were measured. Results : Patients had a median of four resections (range 1-5). The median length of small bowel resected was 120 cm (range 60-165cm) and the medium length of small bowel remaining was 125 cm (range 90-185 cm). Thus, the calculated median original small intestinal length was 240 cm (range 205-315 cm). Conclusion : Although there may have been some bowel shortening as a result of Crohn's disease, the original small intestinal length before any resections was short. It is therefore more important, after performing a bowel resection, to measure the remaining than the resected bowel length. Patients with Crohn's disease and a short bowel may have had a short but 'normal' small intestinal length before any bowel was resected.

Abnormal liver function tests in patients with intestinal failure (IF) may be due to the underlying disease, IF or the treatments given (including parenteral nutrition (PN)). PN-related liver disease in children usually relates to intrahepatic cholestasis and in adults to steatosis. Steatosis may be consequent upon an excess of carbohydrate, lipid or protein, or upon a deficiency of a specific molecule. Pigment-type gallstones are common in adults and children with IF; these develop from biliary sludge that forms during periods of gallbladder stasis. Ileal disease/resection, parenteral nutrition, surgery, rapid weight loss and drugs all increase the risk of developing gallstones. Gallstone formation may be prevented by reducing gallbladder stasis (oral/enteral feeding or prokinetic agents), altering bile composition, or by means of a prophylactic cholecystectomy. Calcium oxalate renal stones are common in patients with a short bowel and retained functioning colon and are consequent upon increased absorption of dietary oxalate; they are prevented by a low-oxalate diet. An osteopathy may occur with long-term parenteral nutrition.

Patients with undernutrition to a degree that may impair immunity, wound healing, muscle strength, and psychological drive are common in UK hospital populations.1 These individuals cope poorly with modern medical and surgical interventions and, on average, stay in hospital for approximately five days longer than the normally nourished, incurring approximately 50% greater costs.2,3 Hospitals should therefore aim to provide at least adequate nutrition to all patients. In the majority, this can be achieved by the catering services if they offer good food and care is taken to avoid missed meals and to provide physical help with eating, as necessary. However, even if these ideals are met, many hospital patients do not or cannot eat adequately. Some of these will benefit from oral supplements but others will need active nutritional support. This can usually be provided by enteral tube feeding (ETF). This document contains guidelines covering the indications, benefits, administration, and problems of ETF in adult hospital practice. The guidelines were commissioned by the British Society of Gastroenterology (BSG) as part of an initiative in several areas of clinical practice. They are not rigid protocols and should be used alongside clinical judgement, taking local service provision into account. These guidelines were compiled from the relevant literature by the authors in discussion with dietitians and specialist nutrition nurses. They were subsequently reviewed by the BSG small bowel/nutrition committee and dietetic, nursing, pharmacy, and medical representatives of the British Association of Parenteral and Enteral Nutrition (BAPEN). The strength of evidence used is as recommended by the North of England evidence based guidelines development project.4

Introduction The public demand for flexible access to health information and services is growing, encouraged by Intnet trends and policies promoting patient involvement. Patients Know Best® (PKB) is an electronic patient centred system providing a secure forum for patients to interact with healthcare teams. With increasing use of this system by our home parenteral nutrition patients we aimed to assess patient satisfaction with a survey. Methods PKB was introduced to patients during routine clinic visits and verbal consent obtained. We recorded the frequency of use, total number of electronic discussions held and the number of additional carers (other healthcare staff or family members) involved in their personal health record. We distributed a 10 question survey to all users. Results 119 patients (50 male, 69 female) were registered over a period of 18 months with a median age of 49 years (range 17–85 years, mean 48 years). A total of 5015 unique electronic conversations were recorded. These would usually have occurred via telephone. PKB has been used for 4 patients transitioning from paediatric to adult services and 2 patients from abroad. Other patients invited included 128 outside clinicians (eg local nutrition nurses and dietitians, transplant coordinators) and 29 carers. There were 58/119 (48.7%) responses including 1 incomplete dataset (61% female). 31/57 patients (54.4%) were over 50 years of age. 42/57 (73.7%) received parenteral nutrition and 13/57 (22.8%) fluids and electrolytes. 51/58 (87.9%) patients felt at least “somewhat confident” working online with their healthcare team and the same number felt that having access to the results was at least “somewhat helpful” – 32 (62.7%) of these responding “very/extremely helpful”. 30/58 (51.7%) use PKB a few times a month, 4/58 (6.9%) a few times a week and the remainder less frequently. The more useful features of PKB included Discussions (ie contacting the St Mark’s Nutrition team electronically) and Monitoring (ie test results). Patients use PKB to contact doctors/nutrition nurses more than dietitians/administrators. Conclusion Our survey suggests that our patient cohort find this a useful facility to contact us and improve the management of their long-term conditions. Not all patients access PKB regularly and they only had a short period in which to respond to the survey. This may explain the 49% response rate in an otherwise motivated patient population. This is an emerging and effective way for patients to interact with their healthcare teams and we have not found it has increased our workload. The ability to communicate seamlessly between different healthcare professionals reduces the current difficulties which exist when transferring information between multiple care providers (eg HIFNET). Disclosure of Interest None Declared.

Six patients with jejunostomies and residual jejunal lengths of 105 to 250 cm took the same food and water each day for eight study days. In random order, three methods of salt replacement were tested, each over 48 hours, against a period without added salt. During the three test periods the patients took 120 mmol of sodium chloride daily, as salt in gelatine capsules, as an isotonic glucose electrolyte (280 mOsmol/kg; 30 kcal) solution, and as a glucose polymer (Maxijul) solution (280 mOsmol/kg; 200 kcal). The daily stomal output remained constant for each patient during the four test periods but varied between patients from 0.60 to 2.84 kg (daily intestinal fluid balance 0.74-2.61 kg). Without a salt supplement, three patients lost more sodium from the stoma than they took in by mouth (-25, -94, and -101 mmol/day) and the mean sodium balance for all six subjects was -16 mmol (range -101 to 79) daily. Extra salt was absorbed with each form of supplement (p less than 0.05); no patient with the glucose electrolyte solution (mean 96, range 0 to 226 mmol), but one patient with the glucose-polymer solution (mean 96, range -25 to 164 mmol) and two with the salt capsules (mean 66, range -8 to 145 mmol) were in negative balance. Two patients vomited with the salt capsules. There was only a small increase in energy absorption (mean 115 kcal) with the glucose polymer solution compared with the glucose electrolyte solution. A sipped glucose electrolyte solution seems to be the optimal mode of sodium replacement in patients with a high output jejunostomy.

Controlled trials have shown that bleeding peptic ulcers can be successfully treated by endoscopy and injection of adrenaline, with or without sclerosant. However, these trials have been done in major research centres, and endoscopic treatment of upper gastrointestinal bleeding has not yet become routine in general hospitals. We have done a prospective, randomised, controlled trial of injection treatment for bleeding peptic ulcers in a district general hospital. Between April, 1989, and June, 1991, all patients with acute upper gastrointestinal bleeding (n = 555) underwent endoscopy by an experienced endoscopist within 24 h of admission. 98 patients were found to have an ulcer with a visible vessel, of whom 93 were randomised to injection (n=48) or standard treatment alone (n=45). Injection treatment consisted of 1-2 ml of 1 in 10 000 adrenaline injected at four to six sites around the ulcer. Adrenaline and 5% ethanolamine oleate (1-2 ml) were then injected directly into the vessel. The medical team managing the patient was unaware of the endoscopic treatment given. The two groups were similar for age, initial haemoglobin concentration, shock, and ulcer site. Rebleeding (injected 8 [16·7%] vs control 21 [46·7%], p=0·011) was significantly reduced in treated patients. The treated group also had lower mortality (4 [8·3%] vs 9 [20%]), requirement for surgery (4 [8·3%] vs 8 [17·8%]), and mean blood-transfusion requirement (5 vs 7·5 units). Endoscopic injection treatment in our patients significantly reduced rebleeding rate and may have other benefits. This cheap and widely applicable treatment can be used routinely in the management of patients with bleeding peptic ulcers who are at high risk of rebleeding.

Background & aims: The detection, prevention and treatment of undernutrition in hospitals is often poor. This study assesses the knowledge about undernutrition of staff in a UK teaching hospital. Methods: Twenty nine doctors, 65 final year medical students, 45 nurses, 11 dietitians, and 11 pharmacists anonymously completed a questionnaire of 20 multiple choice questions. One of five possible answers was considered correct. Twelve questions were about adult nutritional assessment and requirements, five about oral/enteral nutrition and three about parenteral nutrition. Results: Dietitians scored significantly more (median 16) than the other groups (doctors: seven, medical students: eight, nurses: seven and pharmacists: nine) (P Examples of areas in which knowledge could be improved are: 67% respondents thought the prevalence of hospital undernutrition to be less than 30%. While 91% of respondents correctly chose a well 70 kg man to need about 2000 kcal/day, only 23% knew that approximately the same amount was needed for a febrile post-operative patient. Sixteen percent knew antibiotic treatment to be the most common reason for enteral feeding-related diarrhoea. Conclusions: Knowledge about the assessment and management of undernutrition among doctors,medical students, nurses and pharmacists was poor. This questionnaire provides a framework for teaching and auditing the effectiveness of an educational program.

BACKGROUND: Short bowel patients with a jejunostomy have large volume stomal outputs, which may in part be due to rapid gastric emptying of liquid. Short bowel patients with a preserved colon do not have such a high stool output and gastric emptying of liquid is normal. AIMS: To determine if differences in the gastric emptying rate between short bowel patients with and without a colon can be related to gastrointestinal hormone changes after a meal. SUBJECTS: Seven short bowel patients with no remaining colon (jejunal length 30-160 cm) and six with jejunum in continuity with a colon (jejunal length 25-75 cm), and 12 normal subjects. METHODS: The subjects all consumed a 640 kcal meal; blood samples were taken for 180 minutes for measurement of gastrointestinal hormones. RESULTS: Patients with a colon had high fasting peptide YY values (median 71 pmol/l with a colon; 11 pmol/l normal subjects, p < 0.005) with a normal postprandial rise, but those without a colon had a low fasting (median 7 pmol/l, p = 0.076) and a reduced postprandial peptide YY response (p < 0.050). Motilin values were high in some patients without a colon. In both patient groups fasting and postprandial gastrin and cholecystokinin values were high while neurotensin values were low. There were no differences between patient groups and normal subjects in enteroglucagon, pancreatic polypeptide, or somatostatin values. CONCLUSIONS: Low peptide YY values in short bowel patients without a colon may cause rapid gastric emptying of liquid. High values of peptide YY in short bowel patients with a retained colon may slow gastric emptying of liquid and contribute to the "colonic brake'.