Nutrition and the gastrointestinal tract

In this year’s issue, we again have a high-calibre collection of topical reviews. Gracie and Ford commence with an assessment of the role of symbiotics (i.e. probiotics and prebiotics given together) in patients with irritable bowel syndrome. They first review the many randomized trials of probiotics and the significant and persistent reductions in symptoms that (on balance) these yield – that may persist after the end of treatment. Pain, bloating and flatulence are all better than with placebo with a range of different regimens. However, although symbiotics appear promising, their current conclusion is that the evidence for superiority over probiotics alone is lacking. Jin and Vos then consider the pathophysiology of nonalcoholic fatty liver disease and specifically the role of fructose. Their synthesis of the literature includes the conclusion that unregulated lipogenesis is key to nonalcoholic fatty liver disease, linked to generalized increases in visceral adiposity – in turn probably secondary to changes in the intestinal microbiota. Dietary fructose seems an important determinant of these phenomena, and early-in-life exposure appears of most significance. Although dogmatic advice is not justified, continuing to argue for limitation of dietary fructose seems wise. Barrett et al. consider the immune response in patients on artificial nutrition in the current context wherein we aim for enteral nutrition whenever possible – thus recognizing that patients who need parenteral nutrition are then an especially high-risk group. They conclude from AQ3 a wide consideration of animal and human data that the intestinal epithelial barrier is significantly compromised and to a clinically relevant extent in patients on exclusive parenteral nutrition. They encourage targeted new work to exploit the mechanisms that have now been unearthed, such that future parenteral nutrition could be used with fewer adverse immunological consequences. Plank and Russell look at nutrition in liver transplantation incorporating new data from patients with concomitantmorbid obesity. It is of course clear that obesity is a perioperative risk factor but we lack proof that pretransplant weight loss would change this. The main issue here is probably the sarcopenic element, and weight loss without muscle preservation (or growth) would be unlikely to help. As obese patients are AQ4 being transplanted, better data are clearly needed to guide optimal nutritional strategies. After a comprehensive review on the state of the art on gluten sensitivity in the absence of coeliac disease by David Sanders, the issue finishes with a intriguing article by Murphy et al. in which they consider the evidence that chronic disease is made more likely by changes in the gut microbiota driven by a high-fat diet. Although dysbiosis is present and linked to obesity, on present evidence, this falls short of a direct causal relationship. We feel confident that readers will find plenty to provoke thought and hopefully to stimulate research in the many loci where data are sparse or inconclusive

Zn : Cu suhte suurenemine toidus tõstab teist tüüpi diabeedi korral ateroskleroosi riski

Eesti Arst 2023; 102(3):15

Total parenteral nutrition in twin pregnancy after suicide attempt with corrosive

Introduction. Self-poisoning is not frequent during pregnancy. We present the successful treatment of a woman 20 weeks pregnant with twins with self-inflicted poisoning by a caustic substance. Case report. A 34-year old caucasian pregnant woman was admitted to our institution after self-inflicted poisoning with concentrated acetic acid. Initial clinical evaluation showed severe diffuse erythema of the mouth and oropharynx, a systemic inflammatory response syndrome, and dichorionic diamniotic twin pregnancy in the 20th week of gestation confirmed on abdominal ultrasound. An indirect laryngoscopic examination revealed severe generalised hyperemia of the laryngeal mucosa with corrosive changes in the pharyngeal mucosa especially of the posterior pharyngeal wall. Due to pain an urgent esophagogastroduodenoscopy could not be performed, and because of patient refusal a feeding gastrostomy or jejunostomy could not be created. The patient was given "All-in-One" total parenteral nutrition (TPN) in addition to the other supportive therapy. Gradual introduction of enteral nutrition (EN) via a nasoenteric tube placed in the second month of hospitalization failed due to severe vomiting. After almost three months of TPN, EN was however introduced; we then started with oral fluids, increasing gradually to a regular diet, and needed almost half a month to reach an adequate nutritional goal. The delivery was spontaneous at 36 weeks pregnancy and the patient gave birth to two normal healthy girls (46cm/2580gr and 48cm⁄2960gr). Conclusion. TPN can be a safe choice for providing prolonged and adequate nutritional intake even in a twin pregnancy without adverse effects on fetal growth

Citrulline in health and disease. Review on human studies

The amino acid L-citrulline (CIT) is safely used from the neonatal period onwards in those with urea cycle defects and carbamyl phosphate synthetase or ornithine transcarbamylase deficiencies, but several lines of enquiry indicate that it might have a much wider therapeutic role. When protein intake is low and there is a catabolic state, endogenous arginine (ARG) synthesis cannot fully be met and its supplementation can prove challenging, particularly in patients with critical and multisystem illness. Supplementary CIT could constitute a safer but still focused means of delivering ARG to endothelial and immune cells as CIT is efficiently recycled into these cells and as kidneys can convert CIT into ARG. Unlike ARG, CIT is efficiently transported into enterocytes and bypasses liver uptake. It also appears to prevent excessive and uncontrolled nitric oxide (NO) production. Animal studies and early human data indicate positive effects of CIT on protein synthesis, in which its contribution is thought mediated through the mTOR pathway. It apperas that CIT is an anabolic pharmaconutrient that can be safely administered even in critically ill patients. Promising results in cardiovascular diseases and in disease-related malnutrition can now be considered sufficient to justify formal clinical exploration in these areas and in sarcopenia in general

Adherence to Mediterranean diet in Crohn’s disease

Purpose: To assess the adherence to MD in patients with Crohn’s disease (CD). Methods: Outpatients with CD were enrolled in this protocol. Medical history, disease activity, dietary intake, habitual Mediterranean diet (MedDiet) score, anthropometric measurements and Inflammatory Bowel Disease Questionnaire (IBDQ) were recorded. Blood samples were collected for quantification of biochemical and inflammatory indices. Results: A total of 86 patients with CD were enrolled: 41 in relapse (5 ≤ Harvey Bradshaw Index ≤ 14) and 45 in remission (Harvey Bradshaw Index ≤ 4). Adherence to MD was greater in patients with inactive disease. The MedDiet score correlated positively with the IBDQ (p = 0.008) and negatively with disease activity (p < 0.001). Conclusions: Adherence to Mediterranean diet is associated with improved quality of life in CD patients. Higher adherence to Mediterranean diet could be of importance in patients with CD to improve quality of life and reduce disease activity

Nonalcoholic fatty liver disease

According to the papers published in this special issue, NAFLD is a serious problem, which each author from their own aspect tried to clarify. Regarding the fact that NAFLD is rarely isolated and that it is correlated with obesity, diabetes type 2, polycystic ovarian syndrome, obstructive sleep apnea, and some cognitive deficits, its pathophysiology and clinical development require more investigations. Suggestions for the treatment by the implantation of the intragastric balloon must be considered as one of the treating solutions in the future

Citrulline and intestinal fatty acid-binding protein as biomarkers for gastrointestinal dysfunction in the critically ill

Currently there is no reliable tool available to monitor gastrointestinal function in the critically ill. Biomarkers are therefore of great interest in this field as the lack of monitoring tools impedes any interventional studies. The potential biomarkers citrulline and intestinal fatty acid-binding protein (I-FABP) are the present focus. Targeted literature searches were undertaken for physiology and pathophysiology, sampling, measurement methods and clinical use of citrulline and I-FABP as biomarkers of intestinal function and injury. Physiology and pathophysiology, specific aspects of sampling and different laboratory assays are summarized and respective pitfalls outlined. Studies in animals and patients outside the ICU support the rationale for these biomarkers. At the same time, evidence in critically ill patients is not yet convincing, several specific aspects need to be clarified, and methodology and interpretation to be refined. We conclude that there are good physiological rationales for citrulline as a marker of enterocyte function and for I-FABP as a marker of intestinal injury, but further studies are needed to clarify whether and how they could be used in daily practice in caring for critically ill patients