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To investigate the factors associated with a delayed diagnosis (DD) of acute mesenteric ischemia (AMI). An observational cohort study from an intestinal failure center. The primary outcome was DD >24 hours. Between 2006 and 2015, 74 patients with AMI were included and 39 (53%) had a DD. Plasma lactate <2 mmol/L (odd ratio: 3.2; 95% confidence interval: 1.1-9.1; P = 0.03) and unenhanced computed tomography scan (odds ratio: 5.9; 95% confidence interval: 1.4-25.8; P = 0.01) were independently associated with DD. Suspicion of AMI should no longer be affected by normal plasma lactate levels and should prompt evaluation by a contrast-enhanced computed tomography-scan.

Chronic intestinal pseudo-obstruction (CIPO) is a rare, disabling disorder responsible for motility-related intestinal failure. Because it induces malnutrition, CIPO is a significant indication for home parenteral nutrition (HPN). The objective of the study was to evaluate long-term outcome of CIPO patients requiring HPN during adulthood. In total, 51 adult CIPO patients (18 men/33 women, median age at symptom occurrence 20 (0-74) years, 34/17 primary/secondary CIPO) followed up at our institution for HPN management between 1980 and 2006 were retrospectively studied for survival and HPN dependence rates using univariate and multivariate analysis. Follow-up after diagnosis was 8.3 (0-29) years. Surgery was required in 84% of patients. The number of interventions was 3 +/- 3 per patient (mean +/- s.d.), leading to short bowel syndrome in 19 (37%) patients. Actuarial survival probability was 94, 78, 75, and 68% at 1, 5, 10, and 15 years, respectively. Multivariate analysis showed that lower mortality was associated with the ability to restore oral feeding at baseline (hazard ratio (HR) = 0.2 (0.06-0.65), P = 0.008) and symptom occurrence before the age of 20 years (HR=0.18 (0.04-0.88), P = 0.03). Higher mortality was associated with systemic sclerosis (HR=10.4 (1.6-67.9), P = 0.01). Actuarial HPN dependence was 94, 75, and 72% at 1, 2, and 5 years, respectively. In this large cohort of CIPO adult patients with severe intestinal failure, i.e., those requiring HPN, we found a higher survival probability than previously reported. These results should be taken into account when considering intestinal transplantation.

Our objective was to understand the functional link between the composition of faecal microbiota and the clinical characteristics of adults with short bowel syndrome (SBS). Sixteen patients suffering from type II SBS were included in the study. They displayed a total oral intake of 2661 +/- 1005 Kcal/day with superior sugar absorption (83 +/- 12%) than protein (42 +/- 13%) or fat (39 +/- 26%). These patients displayed a marked dysbiosis in faecal microbiota, with a predominance of Lactobacillus/Leuconostoc group, while Clostridium and Bacteroides were under-represented. Each patient exhibited a diverse lactic acid bacteria composition (L. delbrueckii subsp. bulgaricus, L. crispatus, L. gasseri, L. johnsonii, L. reuteri, L. mucosae), displaying specific D and L-lactate production profiles in vitro. Of 16 patients, 9/16 (56%) accumulated lactates in their faecal samples, from 2 to 110 mM of D-lactate and from 2 to 80 mM of L-lactate. The presence of lactates in faeces (56% patients) was used to define the Lactate-accumulator group (LA), while absence of faecal lactates (44% patients) defines the Non lactate-accumulator group (NLA). The LA group had a lower plasma HCO3(-) concentration (17.1 +/- 2.8 mM) than the NLA group (22.8 +/- 4.6 mM), indicating that LA and NLA groups are clinically relevant sub-types. Two patients, belonging to the LA group and who particularly accumulated faecal D-lactate, were at risk of D-encephalopathic reactions. Furthermore, all patients of the NLA group and those accumulating preferentially L isoform in the LA group had never developed D-acidosis. The D/L faecal lactate ratio seems to be the most relevant index for a higher D-encephalopathy risk, rather than D-and L-lactate faecal concentrations per se. Testing criteria that take into account HCO3(-) value, total faecal lactate and the faecal D/L lactate ratio may become useful tools for identifying SBS patients at risk for D-encephalopathy.

This study aimed to determine whether short small intestine modifies antidepressant concentrations. The Css values and concentration–dose ratios (CDRs) of citalopram or escitalopram, administered orally or intravenously, were determined in patients with short bowel syndrome. Eight patients (6 males and 2 females) were included in the study. High CDRs were obtained in orally treated patients with >180 cm of small bowel and in those with >80 cm of small bowel and 50% of colon. Three patients had low Css values, including 1 patient who received intravenous treatment. The variability of drug absorption and metabolism makes prescribing SSRIs challenging in these patients.

ObjectivesThe standard treatment for short bowel syndrome is home parenteral nutrition. Patients’ strict adherence to protocols is essential to decrease the risk of complications such as infection or catheter thrombosis. Patient training can even result in complete autonomy in daily care. However, some patients cannot or do not want too much responsibility. However, doctors often encourage them to acquire these skills. Based on qualitative investigations with patients, we wanted to document issues of importance concerning perceptions of autonomy in daily care.MethodsSemistructured interviews were conducted with 13 adult patients treated by home parenteral nutrition using a maximum variation sampling strategy. We proceeded to a thematic analysis following an inductive approach.ResultsAfter achieving clinical management of symptoms, a good quality of life is within the realm of possibility for short bowel syndrome patients with home parenteral nutrition. In this context, achieving autonomy in home parenteral nutrition could be a lever to sustain patients’ quality of life by providing better life control. However, counterintuitively, not all patients aim at reducing constraints by reaching autonomy in home parenteral nutrition. First, they appreciate the social contact with the nurses, which is particularly true among patients who live alone. Second, they can feel safer with the nurse’s visits. Regaining freedom was the main motivation for patients in the training program and the main benefit for those who were already autonomous.ConclusionsMedical teams should consider patients’ health locus of control (internal or external) for disease management to support them concerning the choice of autonomy in daily care for parenteral nutrition.

Medications were proton pump inhibitors, oral vitamins, and dietary supplements. 12 months after gastric band removal, the patient had lost 80 kg since before banding (weight 47 kg, BMI 18·6 kg/m2) and came to our clinic with cachexia, liver encephalopathy, hypoglycaemia, sarcopenia, oedema, ascites, and diarrhoea. Specific digestive functions were assessed after parenteral nutrition refeeding, under stable conditions and with high oral intake (2500 kcal per day) (appendix).1 Intestinal failure results from obstruction, dysmotility, surgical resection, congenital defect, or disease-associated loss of absorption, and is characterised by the inability to maintain protein-energy, fluid, electrolyte, or micronutrient balance.2 Because the patient did not need any nutritional support before surgery, we thought that gastrojejunal bypass had profoundly altered absorptive function.

Extensive resection of small bowel often leads to short bowel syndrome (SBS). SBS patients develop clinical mal-absorption and dehydration relative to the reduction of absorptive area, acceleration of gastrointestinal transit time and modifications of the gastrointestinal intra-luminal environment. As a consequence of severe mal-absorption, patients require parenteral nutrition (PN). In adults, the overall adaptation following intestinal resection includes spontaneous and complex compensatory processes such as hyperphagia, mucosal remodeling of the remaining part of the intestine and major modifications of the microbiota. SBS patients, with colon in continuity, harbor a specific fecal microbiota that we called “lactobiota” because it is enriched in the Lactobacillus/Leuconostoc group and depleted in anaerobic micro-organisms (especially Clostridium and Bacteroides). In some patients, the lactobiota-driven fermentative activities lead to an accumulation of fecal d/l-lactates and an increased risk of d-encephalopathy. Better knowledge of clinical parameters and lactobiota characteristics has made it possible to stratify patients and define group at risk for d-encephalopathy crises.

Catheter-related bloodstream infection (CRBSI) is one of the most common and potentially fatal complications in patients receiving home parenteral nutrition (HPN). In order to prevent permanent venous access loss, catheter locking with an antimicrobial solution has received significant interest and is often a favored approach as part of the treatment of CRBSI, but mainly for its prevention. Several agents have been used for treating and preventing CRBSI, for instance antibiotics, antiseptics (ethanol, taurolidine) and, historically, anticoagulants such as heparin. Nonetheless, current guidelines do not provide clear guidance on the use of catheter locks. Therefore, this review aims to provide a better understanding of the current use of antimicrobial locking in patients on HPN as well as reviewing the available data on novel compounds. Despite the fact that our current knowledge on catheter locking is still hampered by several gaps, taurolidine and ethanol solutions seem promising for prevention and potentially, but not proven, treatment of CRBSI. Additional studies are warranted to further characterize the efficacy and safety of these agents.