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Nutritional
Management of
Digestive Disorders
http://avaxho.me/blogs/ChrisRedfield
Nutritional
Management of
Digestive Disorders
Edited by
Bhaskar Banerjee
Boca Raton London New York
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Library of Congress Cataloging‑in‑Publication Data
Nutritional management of digestive disorders / editor, Bhaskar Banerjee.

p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-4200-8654-6 (hardcover : alk. paper)
1. Gastrointestinal system--Diseases--Diet therapy. I. Banerjee, Bhaskar.
[DNLM: 1. Digestive System Diseases--diet therapy. 2. Nutrition Therapy--methods.
WI 140 N9765 2011]
RC816.N88 2011
616.3’0654--dc22 2010004493
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To my family for their enduring support
throughout my career
Contents
Preface.......................................................................................................................xi
Editor...................................................................................................................... xiii
Contributors.............................................................................................................. xv
Chapter 1 The History of Medical Nutrition Therapy in the Treatment

of Gastrointestinal Disorders................................................................1
Laura S. Harkness
Chapter 2 Assessment of Nutritional Status........................................................ 17

Laura E. Matarese
Chapter 3 Management of Disorders of Deglutition............................................ 37

Ryan F. Porter and C. Prakash Gyawali
Chapter 4 Eosinophilic Esophagitis..................................................................... 59

Alain M. Schoepfer and Alex Straumann
Chapter 5 Management of Chronic Nausea and Vomiting.................................. 73

Gregory S. Sayuk and C. Prakash Gyawali
Chapter 6 Celiac Disease..................................................................................... 91

Peter David Howdle
Chapter 7 Probiotics in Irritable Bowel Syndrome............................................ 113

Eamonn M. M. Quigley and Fergus Shanahan
Chapter 8 The Role of Nutrition in Inflammatory Bowel Disease:

Food for Thought............................................................................... 125
Gerard E. Mullin, Melissa Munsell, and Ashwini Davison
Chapter 9 Probiotics for Antibiotic-Associated Diarrhea and Clostridium

Difficile-Associated Disease............................................................. 149
Mario Guslandi
vii
viii Contents
Chapter 10 Endoscopic Enteral Access and Enteral Nutrition............................ 159

Waqar A. Qureshi and Carol Redel
Chapter 11 Self-Expanding Metallic Stents in the Management of

Malignant Esophageal, Gastric Outlet, and Duodenal
Obstructions.................................................................................. 175
Francis W. Chan and Priya A. Jamidar
Chapter 12 Management of Chronic Malabsorption........................................... 191

Piyush Tiwari, Manreet Kaur, and Bhaskar Banerjee
Chapter 13 Total Parenteral Nutrition: Theory and Application

in Hospitalized Patients.....................................................................205
Dominic Reeds
Chapter 14 Home Nutrition Support.................................................................... 221

Carol Ireton-Jones and David S. Seres
Chapter 15 Intestinal Failure and Liver Disease Related to Parenteral

Nutrition and Intestinal Transplantation........................................... 233
Khalid Khan
Chapter 16 Nutrition in Acute Pancreatitis.......................................................... 253

Rémy F. Meier and Robert Martindale
Chapter 17 Nutrition in Liver Disease................................................................. 271

Mathias Plauth and Tatjana Schütz
Chapter 18 Nonalcoholic Fatty Liver Disease..................................................... 301

Kevin M. Korenblat
Chapter 19 Weight Management Strategies......................................................... 315

Shelby Sullivan
Chapter 20 Bariatric Surgery............................................................................... 327

Alessandrina Freitas and John F. Sweeney
Contents ix
Chapter 21 Obesity and Gastrointestinal Cancers............................................... 343

Yume Nguyen and Bhaskar Banerjee
Chapter 22 Nutrition and Colon Cancer Prevention............................................ 353

Petr Protiva
Index.......................................................................................................................365
Preface
Nutrition is inseparably intertwined with disorders of digestion, and this compact
book, written by many prominent authors, covers not only the traditional areas
of nutrition, but embraces new disorders, novel therapies, and important recent
developments to present a text with a distinctive collection of important, practi-
cal topics.
Chapters are dedicated to nutritional assessment, parenteral nutrition in hospital-
ized patients, and home nutritional support, which is needed for an increasing number
of patients. The scientific basis and management of celiac disease and eosinophilic
esophagitis are thoroughly discussed. Management of conditions that can impact
nutritional status, such as disorders of swallowing and chronic nausea and vomiting,
are described with practical steps in their management.
New and exciting developments, such as the use of probiotics in irritable bowel
syndrome and antibiotic-associated diarrhea, are included, and the role of nutrition
in acute pancreatitis and liver disease extensively discussed.
In addition to presenting the reader with descriptions of established endoscopic
techniques of enteral access and enteral nutrition, a separate chapter is dedicated
to expanding metal stents that are now increasingly used to overcome malignant
obstructions of the upper gastrointestinal (GI) tract.
The epidemic of obesity is introduced by a chapter devoted to weight manage-
ment by diet, exercise, and drugs, followed by a comprehensive account of bariatric
surgery. The often overlooked, but vital topic of nonalcoholic fatty liver disease is
portrayed, along with the relationship between obesity and gastrointestinal cancer as
well as the role of macro- and micronutrients in preventing colon cancer. To contrast
this, the role of nutrition and dietary supplements in inflammatory bowel disease is
described, followed by a chapter on the short bowel syndrome, adverse effects of
parenteral nutrition on the liver, and small intestine transplantation. To put these
recent developments into perspective, the book begins with a chapter that recounts
the history of nutritional therapy in gastrointestinal disorders.
Nutritional Management of Digestive Disorders not only covers the traditional
areas of nutrition, but includes new and emerging fields to produce a unique blend of
topics in a compact text. I am extremely grateful to all the outstanding authors who
have made this work possible.
Bhaskar Banerjee
xi
Editor
Bhaskar Banerjee, MD, AGAF, received
his medical degree from the University of
London, England, in 1983. He is the chief
of gastroenterology at the University of
Arizona College of Medicine in Tucson. Dr.
Banerjee is a professor of medicine, optical
sciences, and biomedical engineering at the
University of Arizona and is the director of
the Gastroenterology Fellowship program.
Prior to his current position, he was a profes-
sor of medicine in the division of gastroen-
terology, Washington University School of
Medicine in St. Louis. Throughout his career,
Dr. Banerjee has been involved in the educa-
tion of medical students, residents, and gas-
troenterology fellows. He has lectured and
published widely and serves on the editorial boards of scientific journals. His clinical
interests are in the luminal gastrointestinal diseases, particularly the detection and
management of gastrointestinal cancer and its relationship to obesity. Dr. Banerjee’s
research interests are in the use of biomarkers in gastrointestinal cancer and in devel-
oping novel optical techniques of early cancer detection. He has discovered a unique
method of detecting cancer cells using the optical properties of an intracellular
molecule and is working on other techniques of cellular imaging in gastrointestinal
disease. Dr. Banerjee is a fellow of the American Gastroenterological Association
and a member of the Educational Affairs Committee of the American College of
Gastroenterology.
xiii
Contributors
Bhaskar Banerjee, MD Carol Ireton-Jones, PhD, RD, LD,
Section of Gastroenterology CNSD
University of Arizona Professional Nutrition Therapists
Tucson, Arizona Dallas, Texas
Francis W. Chan, MD Priya A. Jamidar, MD

Section of Digestive Diseases Section of Digestive Diseases
Yale University School of Medicine Yale University School of Medicine
New Haven, Connecticut
Ashwini Davison, MD
Manreet Kaur, MD
The Johns Hopkins Hospital
Washington University School of
Baltimore, Maryland
Medicine
Alessandrina Freitas, MD St. Louis, Missouri
Department of Surgery
Emory University School of Medicine Khalid Khan, MD
Atlanta, Georgia Department of Surgery
University of Arizona College of
Mario Guslandi, MD, FACG Medicine
Gastroenterology Unit Tucson, Arizona
San Raffaele University Hospital
Milan, Italy Kevin M. Korenblat, MD
Division of Gastroenterology
C. Prakash Gyawali, MD, MRCP Washington University School of
Division of Gastroenterology Medicine
Washington University School of St. Louis, Missouri
Medicine
St. Louis, Missouri Robert Martindale, MD, PhD
Division of General Surgery
Laura S. Harkness, PhD, RD
Oregon Health Sciences University
Nutrition Sciences
Pepsico Nutrition Portland, Oregon
Pepsico R&D
Valhalla, New York Laura E. Matarese, PhD, RD, LDN,
FADA, CNSD
Peter David Howdle, BSc, MD, FRCP Thomas Starzl Transplantation
Leeds Institute of Molecular Medicine Institute
St. James’s University Hospital University of Pittsburgh Medical Center
Leeds, United Kingdom Pittsburgh, Pennsylvania
xv
xvi Contributors
Rémy F. Meier, MD Waqar A. Qureshi, MD

Gastroenterology, Hepatology, and Baylor College of Medicine
Nutrition Department Houston, Texas
Medical University Clinic
Liestal, Switzerland Carol Redel, MNS, MD
Pediatric Gastroenterology, Hepatology,
Gerard E. Mullin, MD and Nutrition
Integrative GI Nutrition Services GROW and Feeding Disorders Clinic
The Johns Hopkins Hospital Baylor College of Medicine
Baltimore, Maryland
Houston, Texas
Melissa Munsell, MD
Dominic Reeds, MD
The Johns Hopkins Hospital
Division of Geriatrics and Nutritional
Baltimore, Maryland
Science
Yume Nguyen, MD Washington University School of
Division of Gastroenterology Medicine
Washington University School of St. Louis, Missouri
Medicine
St. Louis, Missouri Gregory S. Sayuk, MD, MPH
Division of Gastroenterology
Mathias Plauth Washington University School of
Klinik für Innere Medizin Medicine
Dessau, Germany St. Louis, Missouri
Ryan F. Porter, MD Alain M. Schoepfer, MD

Washington University School of Department of Gastroenterology
Medicine Inselspital/Bern University Hospital
St. Louis, Missouri Bern, Switzerland
Petr Protiva, MD Tatjana Schütz

Division of Gastroenterology Gastroenterologie/Hepatologie/
Yale University School of Medicine
Endokrinologie
Charité Universitätsmedizin
and
Berlin, Germany
Breslow Lab
Rockefeller University
David S. Seres, MD, PNS
New York, New York
Medical Nutrition and Nutrition
Eamonn M. M. Quigley, MD, FRCP, Support Service
FACG, FACG, FRCPI Division of Preventative Medicine and
Alimentary Pharmabiotic Centre Nutrition
Department of Medicine Department of Medicine
University College Cork Columbia University Medical Center
Cork, Ireland New York, New York
Contributors xvii
Fergus Shanahan, MD, BSc, FRCP John F. Sweeny, MD, FACS

(UK); FRCPI, FRCP, FRCP (C), Division of General and
FACG Gastrointestinal Surgery
Alimentary Pharmabiotic Centre Emory University School of Medicine
Department of Medicine Atlanta, Georgia
University College Cork
Cork, Ireland Piyush Tiwari, MD
Department of Medicine
Alex Straumann, MD University of Arizona
Department of Gastroenterology Tucson, Arizona
Kantonsspital Olten
Olten, Switzerland
Shelby Sullivan, MD
Washington University School of
Medicine
St. Louis, Missouri
1 The History of Medical
Nutrition Therapy
in the Treatment of
Gastrointestinal Disorders
Laura S. Harkness
Contents
1.1 Introduction.......................................................................................................1
1.2 Dietary Treatment of Gastrointestinal Diseases................................................2
1.2.1 Peptic Ulcer Disease..............................................................................2
1.2.2 Gastrointestinal Disorders and Diet Therapy........................................3
1.3 Postsurgical Diets..............................................................................................4
1.3.1 Dumping Syndrome Diet.......................................................................4
1.4 Enteral Nutrition................................................................................................4
1.4.1 Rectal Feedings.....................................................................................5
1.4.2 Nasal and Gastric Feedings...................................................................5
1.4.3 Small Bowel Feeding.............................................................................6
1.4.4 Development of Enteral Formulas.........................................................6
1.4.5 Modern Enteral Nutrition Therapy........................................................7
1.5 Parenteral Nutrition...........................................................................................8
1.5.1 Glucose in Parenteral Nutrition.............................................................8
1.5.2 Protein....................................................................................................9
1.5.3 Lipid.......................................................................................................9
1.5.4 First Successful Total Parenteral Nutrition......................................... 10
1.5.5 Modern Parenteral Nutrition............................................................... 11
1.6 Conclusion....................................................................................................... 12
References................................................................................................................. 12
1.1 Introduction
Medical nutrition therapy has changed substantially since Hippocrates first empha-
sized the importance of diet to human health in the fifth century bce. In particular,
there have been significant advances in the nutrition management of gastrointes-
tinal diseases and surgical interventions that have enabled patients to return to
health. Yet, despite Hippocrates’ recognition of the importance of diet to help
1
2 Nutritional Management of Digestive Disorders
recovery from illness, the history of dietary treatment from Galen (fourth century
ce) until the mid-1800s has predominantly been treatments of starvation and purg-
ing. Robert Graves, in 1849, decided that rather than starve his patients, to give
them food and beverages during treatments for typhus resulting in an improved
mortality rate.1
The advent of modern medical nutrition therapy has its roots in the work of nutri-
tion pioneers of the nineteenth and twentieth century. In the United States, the names
of scientists Lusk, Chittenden, Mendel, McCollum, Atwater, Rose, Goldberger,
Sherman, and Leverton stand out for their tremendous contributions to the basic
science of nutrition. Key discoveries in the evolution of medical nutrition therapy
include the determination of essential nutrients, advances in body composition anal-
ysis and anthropometry, work on metabolism and energy expenditure during illness
and injury, and refinement of the objective process of nutrition assessment. It was
from this work, as well as others, that the first Recommended Dietary Allowances
was published by the National Research Council to provide a guide for planning nor-
mal and therapeutic diets with a goal toward good nutrition, and the era of modern
medical nutrition therapy was fully here.2
1.2 Dietary Treatment of Gastrointestinal Diseases

1.2.1 Peptic Ulcer Disease
The dietary treatment of peptic ulcer disease has changed substantially over the past
century. Prior to the discovery of Helicobacter pylori and the use of antibiotic regi-
mens, it was thought that excess gastric acid production was the primary cause of
peptic ulcer disease. Dietary treatment was centered on reducing gastric acid produc-
tion and providing symptomatic relief of pain. Perhaps the most widely used dietary
treatment for peptic ulcers was the Sippy Diet, which was prescribed as recently as
the 1970s.3 The Sippy Diet consisted of frequent small feedings of milk or milk and
cream given every hour. As the patient reported less pain, soft cooked eggs, cooked
cereals, custards, cream soups, cottage cheese or cream cheese, and milk toast were
added. It was thought that giving frequent, small feedings to ensure continuous food
in the stomach would neutralize acid. Foods that stimulated gastric acid produc-
tion including meat extracts, tea, coffee, cola-based beverages, spices (pepper, mus-
tard), sugar, and acids (vinegar, pickles, fruit, and fruit juice) were also eliminated.4
In addition, low residue diets were used to reduce risk of mechanical irritation. In
patients with a hemorrhaging peptic ulcer, there were diets specifically prescribed
for bleeding ulcers that consisted of mixing gelatin, glucose, cream, and milk,5 and
in the case of a Danish physician, Meulengracht, a pureed diet of meat, liver, poultry,
fish, eggs, mashed potatoes, vegetables, fruit, custard, ice cream, and puddings.4
As early as the 1950s, there was debate about the usefulness of these diets includ-
ing the Sippy Diet. Schneider, in 1956, published research demonstrating that spices,
such as cloves, cinnamon, paprika, and sage, did not increase gastric acid produc-
tion in patients.6 But, as recent as the 1990s, elimination diets were still being used
to reduce gastric acid production. Diets that eliminated caffeine and theobromine-
containing foods, such as coffee, tea, and chocolate, were prescribed. Today, there is
Medical Nutrition Therapy in the Treatment of Gastrointestinal Disorders 3
no evidence to suggest that specific foods affect the etiology of peptic ulcer disease,
even for foods that are potent inducers of gastric acid.7 The only notable exception
may be for fiber. A high fiber diet is associated with reduced risk of ulcers.7,8
1.2.2 Gastrointestinal Disorders and Diet Therapy

The bland diet was often prescribed for a variety of gastrointestinal disorders and
consisted of low fiber, reduction of foods that stimulate gastric acid secretion, and
neutralization or dilution of gastric contents.9 Foods, including high fiber foods that
were thought to induce mechanical irritation to mucous membranes, were restricted.
Permitted foods included low fiber foods, young vegetables rather than overripe veg-
etables, refined cereals, and cooked or pureed fruits and vegetables, since it was
thought that cooking softened and disintegrated the fiber. Strong flavored or sulfur-
containing vegetables, such as onions, broccoli, cabbage, cucumber, green pepper,
dried beans and peas, corn, Brussels sprouts, and turnips were eliminated. In addi-
tion, since it was not known what foods stimulated gastric acid, many foods were
limited or eliminated from the diet, including meat soups and gravies, smoked meats,
prepared meats (frankfurters, deli meats, sausage), fatty meat, relishes, ketchup, mus-
tard, pepper, horseradish, meat sauces, vinegar, candy, and pickles. For treatment as
a method to reduce gastric acid or to neutralize gastric acid, foods that contained
“highly emulsified” fats were used. These foods included whole milk, cream, butter,
and egg yolk.4,9 Based on the Sippy Diet theory, it was thought that milk had high
buffering properties and became a primary constituent of the bland diet. Patients
were advised to consume one quart of milk per day, including milk or cream at each
meal and in-between meals.
Frequently high protein, low fat, bland, low residue, or high fiber diets are pre-
scribed to treat gastrointestinal diseases. The origins of these diets can be traced
to the 1940s and 1950s. For example, in 1953, a number of case reports of patients
receiving high protein, low fat diets with supplemental vitamins, and minerals for
Crohn’s disease and ulcerative colitis were published.10
More recently the use of these diets, including low fat, low residue, and bland
diets has declined as scientific studies have demonstrated no clinical benefit in treat-
ing gastrointestinal disease.11–14 Low fat diets were frequently prescribed for patients
with conditions including inflammatory bowel disease, gallbladder disease, ulcer-
ative colitis, and Crohn’s disease. A number of studies have demonstrated no associa-
tion between dietary fat intake and symptoms of gallbladder disease.15 In addition,
research during the past 40 years demonstrated that significant fat malabsorption
only occurs when there is massive inflammation or immediate postmassive small
bowel resection.16,17 Of interest, Jeejeeboy and colleagues demonstrated that patients
recovered optimally when given a high kilocalorie (kcalorie), high protein diet with
both fat and carbohydrate as the source of kcalories.18 This was shown in patients
with an intact colon. Previously, it was thought that fat restriction was needed when
the colon was intact due to long chain fatty acid binding with divalent cations.
The most important component of dietary management for gastrointestinal dis-
ease is to provide adequate nutrition to maintain or restore weight. Liberal provision
of kcalories and protein as well as treating any underlying nutritional deficiencies
should be the hallmark of current dietary therapy. The major problem with highly
restrictive diets is that they frequently are inadequate in one or more nutrients includ-
ing kcalories. In addition, they tend to be less appetizing than regular diets and result
in inadequate intake. Specialized diets that restrict fat, fiber, or specific foods should
be reserved for individual cases and liberalized as quickly as possible.
1.3 Postsurgical Diets

1.3.1 Dumping Syndrome Diet
Surgical procedures can often result in impaired digestion and absorption. Truncal
vagatomy with pyloroplasty, truncal vagatomy with antrectomy, gastroduodenos-
tomy, and gastrojejunostomy often lead to dumping syndrome, a condition in which
foods and liquids enter the intestines too rapidly. This leads to severe pain, diar-
rhea, and malabsorption as the digestive and absorptive capacity of the intestine
is overwhelmed. The change in the medical treatment for peptic ulcer disease has
resulted in a striking decrease in surgical intervention, especially truncal vagatomy
with pyloroplasty and truncal vagatomy with antrectomy. Current dietary treatment
for dumping syndrome is aimed at symptomatic control and prevention of malnutri-
tion. The primary focus of nutrition management is to eliminate large volumes of
food and liquids from entering the intestinal tract. Small frequent meals, separating
liquids from solids, and reduced intake of simple sugars to decrease hyperosmolar
load are commonly prescribed. Other interventions include the addition of soluble
fibers, higher protein if needed, and treatment of any underlying nutrient deficien-
cies. This dietary treatment has not changed substantially since the early 1950s when
patients were given high protein and low carbohydrate regimens in six to eight small
meals with liquids 30 minutes after meal consumption.
One notable exception in the dietary treatment history for postsurgical intervention
was prescribed for a brief period in the 1950s. Developed by Pittman and Robinson,
the process consisted of a three-stage approach called “Routines.”19 Routine I, pre-
scribed for one month, consisted of eggs, bacon, lean meat, butter, and margarine.
Routine II followed for one month, allowed the addition of cream, cream cheese, nuts
and limited quantities of bread, cereals, and vegetables. Routine III consisted of sep-
arating liquids from solids with fluids consumed 30 minutes after a meal. In addition,
patients were told to eat regularly and frequently, to relax before and after a meal,
to eliminate all forms of sugar, and to omit milk and milk products until tolerated.
Most of these treatment regimens are no longer used to manage dumping syndrome.
However, patients are still advised to follow parts of Routine III, separating liquids
from solids, limiting simple sugars, and watching for intolerance to milk and fat.
1.4 Enteral Nutrition
The development of enteral nutrition therapy is a notable medical achievement
because it enables provision of nutrients directly into the gastrointestinal tract for
patients who cannot meet their nutrition needs orally. Enteral nutrition therapy has
a long history starting with rectal feedings in ancient Egypt and Greece to modern
day specialty formulas and techniques. It is particularly interesting that the enteral
nutrition solutions used today can be traced to developments from the 1930s and to
delivery techniques that were first introduced in 1910.
1.4.1 Rectal Feedings
Rectal feedings were the preferred route for enteral nutrition until the early part of
the 1900s when gastric and small bowel feedings became the chosen method. The
history of rectal feedings dates to ancient Egypt and Greece, where rectal feeding
consisting of enemas of wine, milk, whey, wheat, and barley broths were used to
promote good health and treat diarrhea.20 There was a belief that reverse peristalsis
could lead to colonic absorption of nutrients and would provide adequate nutrition
to meet the patient’s needs. Rectal feeding devices included a piece of pipe with a
bladder tied to one end, long pieces of rubber tubing attached to funnels or wooden
syringes, and wooden syringes that were used to push solutions into the rectum.21
Rectally fed mixtures included ingredients, such as raw beef, eggs, milk, liquor,
tobacco, wax, red wine, blood, and beef broths.21 Many proponents of rectal feed-
ings advocated using pancreatic glands from a recently slaughtered animal. In fact,
case reports of patients fed rectally include a patient with esophageal stenosis, who
was given enemas of a raw beef mixed with hog’s pancreas.22 This mixture was
pushed into the patient’s rectum twice per day. The physician, in this case, noted
that “the patient was so well fed by that means that he had not visibly lost fluid when
he died, after apoplectic symptoms eight days after the time these enemas had been
first used.” The most famous case of rectal feedings was that of President Garfield
after he was shot during an assassination attempt.23 President Garfield was rectally
infused with peptonized beef broth, beef peptonoid, and whiskey every four hours
during the 79 days that he survived after being shot. President Garfield is reported
to have died from infection and internal bleeding since the surgeons could not locate
and remove the bullet.
1.4.2 Nasal and Gastric Feedings

Historical accounts report that development of gastric feeding devices and solutions
started during the sixteenth century. The first report of enteral feeding was in 1598,
when Capivacceus, a Venetian physician, used a hollow tube to put liquid down a
patient’s esophagus. Other reports include that of Aquapendente, in 1617, who passed
a small silver nasopharyneal tube to feed a patient with tetanus. Von Helmont, in
1646, fashioned a flexible tube using leather for esophageal feeding. And, Boerhave,
in 1710, used Von Helmont’s leather tube to feed into the stomach. In 1790, Hunter
became the first physician to use a nasogastric tube made of a whale bone probe
covered with eel skin and attached to a bladder pump.24
During the eighteenth and nineteenth centuries, one method to provide enteral
feedings was via nasal and oral routes. Feedings were delivered using a rubber tube
or oral feedings using a rigid spout. Feeding solutions, during this time, consisted of
ingredients, such as warm milk, eggs, wine, whiskey, sugar, custard, mashed mutton,
and broth.25–27 For the treatment of children with diphtheria, Morrison in 1895, used
a mixture of cream, brandy, tincture of nux vomica (the seed of an Asian tree that
contains the alkaloids strychnine and brucine), and a digestive ferment that consisted
of liquor of pancreaticus and essence of pepsin.28 The use of nasogastric tubes con-
tinued to increase and became the preferred method by the early part of the twentieth
century, although saline solutions were still infused rectally until 1940. During this
time, Einhorn, developed a nasogastric tube that was weighted on one end to allow
it to pass into the duodenum.29
1.4.3 Small Bowel Feeding

The development of the nasogastric weighted tube was the turning point in the devel-
opment and refinement of enteral nutrition. Several physicians made improvements
to Einhorn’s techniques to help with intolerance to the feeding solution, since patients
were given milk, raw eggs, salt, butter, lactose, and sugar. Morgan and Jones pro-
posed a method to administer the feeding solution drop-by-drop instead of bolus,30,31
and Gross and Held designed a larger tube with a heavier weight that passed to the
duodenum faster than the Einhorn tube.32 In 1918, Andresen introduced jejunal feed-
ing by passing a tube into the jejunum during surgery and feeding a solution of 200
ml peptonized milk, 15 g glucose, and 8 ml whiskey every two hours postsurgery to
reach 2500 kcalories in 24 hours.33
Refinement of the nasojejunal tube and enteral feeding solution can be credited to
two groups: Abbott and Rawson and Stengel and Ravdin. Abbott and Rawson devel-
oped a double lumen tube with one opening in the stomach for suction and one in the
jejunum for feeding.34 Stengel and Ravdin used the Abbott tube to feed patients with
a partially digested solution.35
1.4.4 Development of Enteral Formulas

Refinement to the feeding solutions occurred during the same time as technical
changes were made to the feeding systems and tubes. In the early part of the 1900s,
Morgan heated and strained the food mixtures and, in 1939, Stengel and Ravdin
developed a feeding solution that contained a sterile mix of acidified skim milk,
commercial pepsin, sodium bicarbonate, sodium chloride, dextrose, fish liver oil,
thiamin chloride, nicotinic acid, and vitamin C. In addition, Stengel and Ravdin
designed the first casein hydrolysate. Commercial companies had started to develop
enteral products that could be used to supplement kitchen-prepared mixtures by
the later part of 1930. Companies including Mead Johnson and Wyeth-Ayerst were
producing mixtures of homogenized solid food substances, combinations of supple-
mented dairy products, and elemental food products.21 In 1954, Pareira et al.36 col-
laborated with Mead Johnson to produce a tube feeding solution made of powdered
whole milk, nonfat milk solids, dextrose, eight vitamins, and eight minerals.
It was during this time in the 1950s that Barron and colleagues at Henry Ford
Hospital in Detroit, Michigan, argued that enteral solutions made from food in hos-
pital kitchens were nutritionally superior to commercially prepared formulas.37,38
Hospitals produced tube feeding solutions in their kitchens using standard food
ingredients.39 The Henry Ford Hospital method was much more sophisticated than
the standard hospital-produced solution because it used a food mill that had been
adapted to produce large quantities of liquefied baby food and blenderized hospital
diets. An interesting part of the history of hospital feedings was concern for the
patient being able to feel as if he/she is eating. Patients were initially given alternat-
ing boluses of milk and water and then progressed to tube feeding solutions. The
tube feeding solution was warmed to room temperature and served in a teapot on a
tray, so that the feeding looked like the patient was receiving a standard tray.4
The development of chemically defined enteral solutions parallels the development
of parenteral nutrition solutions in the 1950s and 1960s. Hospitals were increasingly
becoming concerned about two significant issues: malnutrition and infections. These
concerns led to a large-scale study of chemically defined formulas by the National
Institutes of Health and the Vivonex Corporation.40-42 Both animal and human stud-
ies were conducted using purified L-amino acids with procedures to ensure optical
purity, highly purified grades of crystalline glucose monohydrate and sucrose, 16
vitamins analyzed for purity and potency, 15 minerals, and purified ethyl linoleate.
During the 1960s and 1970s, proponents for chemically defined enteral products
continued to promote the benefits of these solutions, but it was during this time that
the first successful animal and human cases of total parenteral nutrition (TPN) were
published.43,44 This resulted in a shift to the use of TPN as the nutrition therapy of
choice for patients who could not ingest food orally.
Advocates for enteral nutrition continued to promote the use of the gastrointes-
tinal tract as the primary way to provide nutrition to patients, even in patients with
minimal intestinal tract. The Codelid Elemental diet (also referred to as the Space
diet, since it was modeled after the U.S. Space Program diet) consisting of 18 purified
amino acids, sucrose, 11 minerals, 12 water soluble vitamins, 3 fat soluble vitamins,
and ethyl linoleate was given to patients with short bowel syndrome secondary to
massive resection, fistulas, pancreatitis, ulcerative colitis, and Crohn’s disease.45,46 In
most cases, the patients recovered. Other studies followed and proved that elemental
diets could be successfully provided to patients with fistulas and short bowel due to
surgical resections via jejunostomy feedings.
1.4.5 Modern Enteral Nutrition Therapy

Enteral nutrition has evolved significantly from the original delivery and feeding
solutions of the 1800s and 1900s. Commercial refinement of enteral formulas, tub-
ing, and pumps continues today with more than 100 commercial products available
and a variety of tubes and pumps for optimizing delivery. However, one of the most
notable achievements that contributed to today’s formulas occurred in 1970. The
Wisconsin formula, which was developed by Gormican and Catli in collaboration
with Gerber Products Company, was designed to provide the energy-yielding nutri-
ents in the ratio found in a regular diet; 30% of the energy as fat, 20% as protein,
50% as carbohydrate.47 This was a marked departure from elemental diets, which
contained minimal fat. The enteral products used today rely on the idea of feeding
the carbohydrate, protein, and fat ratio found in a regular diet. As demonstrated by
Stengel and Ravdin in 1939, the use of protein hydrolysates and lactose-free carbo-
hydrates is still successful today.
The composition of enteral products varies substantially, from intact nutrients for
general use to specialized products for treating clinical conditions. Formulas include
polymeric solutions that provide more intact ingredients, such as whole proteins,
monomeric formulas that require less digestion with proteins in the form of peptides
and carbohydrates as partially hydrolyzed starch, modular solutions to provide sepa-
rate macro- or micronutrients, and specialized formulas to treat metabolic or clini-
cal conditions. Enteral nutrition support is focused on supporting nutritional needs,
weight gain or maintenance, preventing complications associated with malnutrition,
infection, malabsorption, and intolerance as well as modulating the immune system
and the body’s response to injury and illness.
1.5 Parenteral Nutrition

Parenteral nutrition (PN) is a lifesaving therapy for patients who cannot be adequately
nourished by oral or enteral feeding. As a modern therapy, PN has been available
clinically for approximately 50 years, but the history of PN dates back to the early
1600s.44,48 In 1656, Christopher Wren gave intravenous injections (IVs) and infusions
of wine and ale to dogs using a goose quill attached to a pig’s bladder. Wren was
able to demonstrate that the IV solutions caused the same effect as alcohol provided
orally.1,49 During the same time, Lower and King51,52 reported IV feeding and blood
infusions with dogs and, in one case, a young man. The dogs and the young man
reportedly survived. Other early researchers included William Courten who, in 1678,
gave IV olive oil to dogs that did not survive, thus depicting the need for specialized
IV lipid solutions.53 The first successful IV infusion of saline solutions was achieved
by the Scottish physician, Thomas Latta, when he infused salt and water into a chol-
era patient who recovered and survived.54 Hodder, in 1873, reportedly infused milk
into three cholera patients, two who recovered.55 The first total parenteral nutrition
use in humans occurred in 1904 when Friedrich infused subcutaneously peptone,
fat, glucose, and salt.1 Unfortunately for the patients, this method proved to be too
painful and Friedrich abandoned subcutaneous infusion of PN.
1.5.1 Glucose in Parenteral Nutrition

In 1859, Claude Bernard made a key discovery that resulted in numerous experi-
ments with IV glucose administration. He discovered the importance of glucose and
liver glycogen in metabolism, by demonstrating that intravenous glucose was not
immediately excreted in the urine.49 Subsequently, the first infusion of glucose in
humans was reported in 1896 by Beidl and Krauts and was soon followed by a series
of studies by Woodyatt (in 1915).48,56 Woodyatt and colleagues conducted a series of
timed infusions using a pump to ensure constant delivery of solutions. In the experi-
ments, they varied the infusion rate to establish a dose-response relationship. By this
method, Woodyatt determined that an infusion of 0.85 g of glucose/kg/h did not
cause glucosuria. Soon after, Mattas57 used a continuous drip infusion of glucose,
which led to subsequent work by Zimmerman, who gave IV solutions through a
catheter in the superior vena cava.58
Carbohydrates were recognized as a principal component of metabolism, an

inexpensive energy source, and easy to manufacture for PN solutions. This rec-
ognition led to many trials testing differing forms of carbohydrate in PN, which
were largely unsuccessful. Substitutes for glucose were extensively researched
including fructose and invert sugar; however, infusion caused higher levels of
lactate and pyruvate than did infusion of glucose.59 In addition, fructose infusion
resulted in higher urinary electrolyte losses, including phosphate, sodium, and
potassium.60,61 Glycerol was also used as a source of energy and was well tolerated
in animals and humans in small doses, but large doses caused hemolysis, hypoten-
sion, and convulsions.59
During the 1960s and 70s, glucose was used as the primary source of energy for
PN in the United States, since lipid emulsions had not yet been accepted for use in
humans. It was during this time that high doses of glucose were given via central
venous access because it was thought that trauma increased energy needs signifi-
cantly. A number of clinical problems resulted from use of high doses of IV glucose
as the primary energy source, including liver steatosis, fever, essential fatty acid
deficiency, hyperglycemia, and insulin resistance.
1.5.2 Protein
Elman, in 1937, gave the first successful IV infusions of amino acids, as a protein
hydrolysate, in man.62,63 Elman was a student of William Rose, the discoverer of
essential amino acids. Prior to Rose and Elman’s work, Danish physicians Henriques
and Anderson (in 1913) showed that nitrogen equilibrium could be maintained in a
goat with an IV solution of beef protein hydrolysate, glucose, and electrolytes.64 These
studies by Elman, Rose, and Henriques formed the basis for many investigations into
using amino acids in PN solutions. Protein hydrolysates, crystalline amino acids,
and racemic forms of amino acids were all researched following Elman’s work.59
Many of these solutions resulted in side effects, including vomiting, nausea, and
increased ammonia and urea. The initial protein hydrolysates were produced using
an acid treatment, which destroyed tryptophan. This problem was solved in 1944 by
Wretlind when he produced an enzymatic hydrolysate of casein called Aminosol.65
It is particularly interesting that Aminosol contained impurities, which caused trace
element contamination of the solution. This resulted in patients receiving trace ele-
ments as a beneficial effect and leading to fewer deficiencies of trace elements.49
Crystalline amino acid solutions were introduced by Bansi and colleagues in
1964.50 Soon after, Wretlind developed Vamin, a more complete crystalline amino
acid solution that was effective at maintaining postoperative nitrogen balance. In
these solutions, it was technically challenging to include tyrosine, cysteine, cystine,
and glutamine. This problem was solved with the advent of dipeptides in the 1980s,
which improved solubility and stability.66
1.5.3 Lipid
A major effect was undertaken to find methods to prepare fat emulsions since
it was recognized that fat is an excellent kcalorie source. Unfortunately most
experiments with fat emulsions caused severe adverse reactions in animals and
humans. Following the studies of Courten in the late 1600s, researchers contin-
ued to search for methods to successfully infuse fat via IV. From 1920 to 1960,
researchers in the United States and Japan worked diligently to develop lipid infu-
sions that could be tolerated by humans. In Japan, a number of researchers, includ-
ing Yamaka, Sato, and Nomura, tested hundreds of differing lipid solutions and
emulsifiers, particularly using lecithin with good tolerance in animals.49,59 In the
United States, Geyer, Stare, and Meng were working on lipid research during the
same period of time.59,67–69 Meng gave a complete parenteral solution to dogs using
an olive oil emulsion for four weeks with no adverse reactions; nevertheless, this
solution was not tolerated by humans.
It was not until 1960 that the first IV lipid emulsion, called Lipomul, was pro-
duced by the Upjohn Company.70 Lipomul was the result of research conducted by
Meng and Canham (from the U.S. Army Research and Development Command).71
Cottonseed oil was used in Lipomul, which cause significant adverse effects in
humans including chills, fever, vomiting, hypoxia, and hypotension. In 1965, the
entire issue of the American Journal of Clinical Nutrition was devoted to articles
from a symposium on intravenous fat emulsions.71 The high level of toxicity of the
lipid emulsions led to a distrust of lipid infusions in the United States and continued
use of providing kcalories from glucose alone. This reliance of glucose for kcalories
continued until the mid-1970s. Intralipid was the first nontoxic lipid emulsion to be
designed that was made from soybean oil and egg yolk phospholipids, as the emulsi-
fier. It was introduced in 1961 by Wretlind and Schuberth,72 but not available for use
in the United States until 1975. Intralipid, consisting of long-chain fatty acids, made
it possible to use fat-soluble vitamins in TPN solutions.
1.5.4 First Successful Total Parenteral Nutrition

Research conducted during the 1960s by Dudrick, Wilmore, Vars, Rhodes,
and Rhoades at the University of Pennsylvania Harrison Department of Surgery
Research Laboratories on adult dogs and, later beagle puppies, led to a landmark
paper on the first human infant fed with PN.43,73,74 Relying on previous work from
Elman, Geyer, and Zimmerman, among others cited in this chapter, Rhoades and
Dudrick, with colleagues, initiated a series of experiments to successfully develop
and refine PN.75 During the experiments on beagle puppies, the researchers solved
a number of key problems associated with PN; namely, provision of all required
substrates to support normal growth and development, sterilization of the solution,
maintenance of sterility, safe and nonreactive long-term central venous catheters,
and dependable infusion pumps to standup to the activity of a puppy.75 In addition to
solve the problem with the lack of commercially available IV fat soluble vitamins,
the researchers asked the U.S. Vitamin Corporation to develop a water-soluble form
of fat-soluble vitamins.
The first clinical application of the PN in humans was conducted on six malnour-
ished adult surgical patients.75 It was during the care of these patients that several
clinical issues were discovered and remedied. Key observations included noting that
severe hypophosphatemia (a symptom of refeeding syndrome) occurred in a severely
malnourished patient and that gravity-drip infusion was inaccurate and resulted in
hypovolemia, hyperglycemia, and glycosuria. This discovery caused the researchers
to use infusion pumps from the laboratory to deliver continuous steady doses to the
patients and, as a result, led to the use of pumps to infuse IV liquids in critically ill
patients. After successfully treating the six adult patients, the next patient put on PN
was a one-month-old infant.44
In 1968, Wilmore and Dudrick reported on the case of an infant, who had
undergone surgery for atresia, sustained for five months on PN as her sole source
of nutrition.44 This was the first case report of long-term PN being able to support
life. A number of key nutrition insights were gained during this case, including the
need for adequate vitamin D to prevent rickets and the need to provide essential
fatty acids. Fat was provided by feeding the infant’s parents high fat meals, draw-
ing blood from the parents, and infusing the fatty plasma into the infant. Over the
course of the next years, many patients were successfully treated with PN. This led
to parenteral nutrition becoming the primary nutrition therapy during the 1970s
and 1980s for postsurgical patients who could not eat for more than a few days and
who suffered from acute illnesses.76–81 It was during this time that Dr. Rhoades
introduced the term hyperalimination.
1.5.5 Modern Parenteral Nutrition

Parenteral nutrition today is for patients who cannot be fed orally or via enteral
nutrition and require nutrition support during a critical time period. Specific guide-
lines are in place, which help clinicians determine appropriate use of PN. These
criteria are detailed in the American Society for Parenteral and Enteral Nutrition
Guidelines for the Use of Parenteral and Enteral Nutrition in Adult and Pediatric
Patients.81 Parenteral nutrition is no longer a substitute or preferential modality for
enteral nutrition, as enteral nutrition is the appropriate method of nutrition support in
patients with a working gastrointestinal tract. As early as 1980 and continuing to the
present day, clinicians and researchers have recognized that PN frequently resulted
in higher rates of complications in patients.83–90 In fact, a meta-analysis conducted by
Klein et al.91 demonstrated that both preoperative and postoperative enteral nutrition
support results in lower incidence of postoperative complications. Moreover, while
preoperative PN reduced overall risk of complications by 10%, postoperative PN
increases overall risk by 10%.
Current parenteral nutrition solutions and delivery system have been refined to
include all-in-one mixtures infused using electronic pumps. Special care is taken
to prevent infections and bacterial contamination. Solutions include water, glucose
monohydrate, lipid emulsions of soybean oil, triglycerides, and egg yolk phospho-
lipids, and amino acids with vitamins and minerals. Clinical research with PN is
focused on reducing complications, such as hepatic dysfunction, gallstones, meta-
bolic bone disease, bowel function as well as improving patient outcome. Newer
innovations include use of medium chain triglycerides, omega 3 fatty acids, and
short chain fatty acids as well as addition nonessential and conditionally essential
amino acids (taurine, arginine, glutamine) that may be beneficial for patients on PN
or with special clinical needs.
1.6 Conclusion
The nutritional management of gastrointestinal disease has changed markedly in the
past 100 years. Advances in formulations and delivery systems continue as greater
scientific understanding of immune function and disease pathologies is advanced.
Medical nutrition therapy continues to be refined, although it is clear that restrictive
diets, whether as food, beverages, enteral feeding solutions, or parenteral nutrition
solutions, are not useful for most patients and can result in potential deficiencies of
essential nutrients and calories as well as increased complications. Restrictive diets
and feeding prescriptions should be limited to individual cases when it is clear that
there is a therapeutic role. Use of liberal diets and nutritional solutions that provide
adequate calories and nutrients to patients, in combination with medical manage-
ment, result in the best patient outcomes.
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2 Assessment of
Nutritional Status
Laura E. Matarese
Contents
2.1 Introduction..................................................................................................... 17
2.2 Nutritional Assessment Methods..................................................................... 19
2.2.1 Patient History..................................................................................... 19
2.2.1.1 Medical History.................................................................... 19
2.2.1.2 Medications........................................................................... 21
2.2.1.3 Nutrition................................................................................ 22
2.2.1.4 Psychosocial.......................................................................... 22
2.2.2 Nutrition-Focused Physical Exam....................................................... 23
2.2.3 Anthropometry and Body Composition Analysis...............................25
2.2.4 Muscle Function Assessment...............................................................26
2.2.5 Laboratory...........................................................................................26
2.2.6 Micronutrient Status............................................................................28
2.2.7 Subjective Global Assessment............................................................. 29
2.3 Prediction of Complications and Decision to Intervene.................................. 30
2.4 Impact of Nutrition on Disease........................................................................ 31
2.5 Conclusion....................................................................................................... 33
References................................................................................................................. 33
2.1 Introduction
Good nutrition is essential for the well-being and health of the patient with gastro-
intestinal (GI) disease. Nutrition deals with the very crux of existence. Historically,
malnutrition has been associated with poverty, poor sanitation, and lack of resources
often occurring in underdeveloped countries. However, with the abundance of food,
lack of exercise, and overall higher standard of living, obesity and chronic disease
linked to diet has become epidemic and is also considered to be a form of malnutri-
tion. Nutritional health results from an intricate balance between nutrient intake and
requirements. When requirements exceed intake, malnutrition ensues and encom-
passes a wide spectrum of physiological alterations including undernutrition and spe-
cific micronutrient deficiencies. When intake exceeds requirements, malnutrition in
the form of obesity and its co-morbidities result. Malnutrition leads to a sequence of
metabolic and pathological events with physiological alterations, reduced organ and
tissue function, loss of body mass, and eventually death (Figure 2.1). In the setting
17
Nutritional Health
Overnutrition Undernutrition
Nutrient Disequilibrium and

Physiological Adaptation Diminishing Reserves and
Physiological Adaptation
Excess Reserves
Depleted Reserves
Physiologic and Physiologic and

Metabolic Derangements Metabolic Derangements
Nonspecific Signs
Appearance of and Symptoms
Co-morbidities
Functional Changes,
Functional Changes, Failure to Thrive, Organ
Organ System System Dysfunction,
Dysfunction, Illness Illness
Permanent Damage
Permanent Damage
Death Death
Figure 2.1 Development of clinical nutritional disease.
of gastrointestinal disease, nutrient intake may be adequate, but malabsorption and

biochemical alterations can lead to significant nutrient deficiency with biochemi-
cal and physiological changes over a relatively short period of time. Additionally,
nutrient requirements are elevated during periods of active disease states, infection,
postsurgical stress, or general need for repletion; or, oral intake may be reduced in
the face of illness.
Nutritional assessment is an evaluation of the nutritional status of individuals
or populations through measurements of food and nutrient intake and evaluation
of nutrition-related health indicators. The goal is to identify those individuals who
will require nutrition intervention. Since most nutrition interventions carry some
risk, the degree of malnutrition and the potential benefit must be considered when
Assessment of Nutritional Status 19
deliberating the decision to provide these therapies. Nutrition intervention should

be provided to those patients who are most likely to progress to critical malnutri-
tion. The ability to identify individuals at nutritional risk and to effectively augment
their health status through improved nutrition has made nutritional assessment an
important skill for health professions concerned about making healthcare more
cost effective. Despite the abundance of clinical data surrounding the use of sub-
jective and objective assessment tools to identify malnutrition, no single measure
has been proved to be comprehensive, accurate, and cost-efficient in all patients.
This is due in part to the fact that clinically available measures, such as anthro-
pometrics and serum proteins, are frequently distorted by the parallel influences
of malnutrition and disease on body composition and function.1 The predictive
ability of nutritional assessment techniques are also affected by the reproducibil-
ity and error in the measurements themselves as well as narrowly defined stan-
dards for comparison. Ultimately, there is no substitute for good clinical judgment.
Nonetheless, nutritional assessment is an important component in the care of the
patient with GI disease. Nutritional assessment and the provision of nutrition sup-
port should be part of the total integration of care.
2.2 Nutritional Assessment Methods

A comprehensive nutritional assessment encompasses data collection and evaluation
from several different categories: history, physical examination, anthropometry and
body composition analysis, and biochemical evaluation. Within each category are
numerous subcategories of both subjective and objective components. The advan-
tages and limitations of each are presented with a special emphasis on the poten-
tial applications of each method in the assessment of the patient with GI disease.
However, the strength and value of the nutritional assessment lies in the integration
of these components into the overall clinical picture, which is used to identify mal-
nutrition and formulate a treatment plan.
2.2.1 Patient History

The history elicits subjective information from the patient, family, or caregivers and
is the first step in the clinical assessment of nutritional status. Information obtained
from a detailed history contributes to a more accurate assessment of nutritional sta-
tus. Results from the history may prompt the clinician to investigate areas of possible
deficiency and forms the basis for a more focused physical examination and judi-
cious use of laboratory studies. Even after nutrition intervention has been initiated,
ongoing patient histories may provide information as to why the patient’s nutritional
state is not responding to therapy. The historical portion of the nutritional assessment
is divided into medical, medication usage, nutrition, and psychosocial (Table 2.1).
2.2.1.1 Medical History
The medical history is critical in determining the adequacy of nutritional status.
Inadequacies and the potential causes of these deficits are often obtained from a
thorough review of the patient’s medical record and a focused interview with the
Table 2.1
Components of Nutrition-Oriented History
Medical History
• Present and previous illnesses or trauma interfering with nutritional status
• Presence of fever, chills, or myalgias
• Usual level of activity with any remarkable changes
• Diagnostic tests evaluating organ function
• Chronic diseases and/or surgical procedures affecting the GI tract
• Length of the remnant small and large intestine and presence of the ileocecal valve
• Presence and location of GI tubes, surgical drains, stomas, or fistulae
• Hydration status
• Changes in urinary or bowel habits (diarrhea, constipation, steatorrhea)
Medication Usage
• Current prescriptions
• Over-the-counter medications
• Vitamin, mineral or herbal supplements, meal replacements
• Appetite stimulants or suppressants
• Allergies to medications, enteral or parenteral nutrition components, or medical supplies
Nutrition History
• Food habits, eating patterns, diet restrictions, factors influencing nutrient intake, aversions, or
allergies
• Recent weight loss or gain, time frame (≤ six months), stated versus documented, intentional
versus unintentional, has weight stabilized or has patient continued to lose/gain?
• Usual body weight 20% more or less than ideal
• Dysphagia, dysgeusia, anorexia, early satiety, nausea, vomiting, diarrhea, constipation steatorrhea,
gastroesophageal reflux, abdominal pain
• Intake of commercial and/or nonconventional nutritional supplements
• Enteral, parenteral, oral rehydration, or intravenous fluid and electrolyte regimens
Psychosocial Information
• Altered mental states including depression, anxiety, and confusion
• Low education and/or income levels
• Drug or alcohol addiction
• Tobacco use
• Absence of social support
• Housing, finances, ability to purchase and prepare food
• Activity level
patient, family, or caregiver. Understanding the pathophysiology of various disease

states, illness, surgical procedures, and medication interactions is necessary to iden-
tify interactions that may put a patient at nutritional risk. The onset and duration of
the patient’s current health problems provide insight into the changes in GI function
that may possibly alter nutritional status. The configuration of the GI tract for those
patients who have had previous surgeries is important in determining the extent of
Table 2.2
Nutritional Consequences of GI Surgery
Type of Surgery Potential Nutritional Consequences
Esophagus
Resection/replacement • Early satiety
Gastric pull-up • Weight loss due to inadequate intake
• Increased protein loss secondary to catabolism
• Rapid gastric emptying of hypertonic fluids
Colonic interposition • Early satiety
• May need short-term enteral or parenteral nutrition
• May require antidumping diet
Stomach
Partial gastrectomy/vagotomy • Early satiety
• Delayed gastric emptying of solids
• Rapid emptying of hypertonic fluids
• Malabsorption of vitamins and minerals due to achlorhydria
Total gastrectomy • Dumping syndrome
• Malabsorption of vitamins and minerals due to achlorhydria
• Bezoar formation
Bariatric surgery • Malabsorption of vitamins and minerals due to achlorhydria,
nonavailability of bile acids and pancreatic enzymes
Intestine
Ileal resection • Malabsorption of bile salts and vitamin B12
• Poor jejunal adaptation
• Rapid intestinal transit
Extensive bowel resection • Large fluid and electrolyte losses
• Nutrient malabsorption
• Gastic acid hypersecretion
• Rapid gastric emptying
• Rapid intestinal transit
GI dysfunction. Review of operative reports and directed questions to the surgeon

can help to construct an accurate diagram. Although any surgical procedure could
potentially impact nutritional status, operations on the GI tract can have significant
nutritional consequences (Table 2.2).2–10
2.2.1.2 Medications
Prescription and over-the-counter medications as well as vitamin, mineral, and nontra-
ditional medications, such as herbal and alternative remedies, should be reviewed for
polypharmacy, nutrient drug interactions, and potential influence on nutritional status.
Many drugs commonly used in the treatment of GI disorders, such as corticosteroids,
narcotics, immunosuppressants, chemotherapy, antidiarrheals, laxatives, somatostatin
analogues, diuretics, and antibiotics can impact bowel function, appetite, fluid and
electrolyte balance, and overall nutritional status. Unfortunately, there are many GI
patients with chronic disorders who eventually develop narcotic dependence.
2.2.1.3 Nutrition
The nutrition history provides data concerning the patient’s eating habits and patterns,
dietary restrictions, food intolerance, and factors influencing nutrient intake. A thor-
ough nutrition history can provide valuable insight into past dietary interventions and
potential nutrient deficiencies or excesses. Nutrient deficiencies are identified with rela-
tive certainty when a detailed, accurate dietary intake record is compared with care-
fully estimated daily requirements. However, the assessment of dietary patterns may
be skewed by high intraindividual variability in food intake, frequent withholding of
intake for diagnostic testing or surgical procedures, or inaccurate reporting of intake
on behalf of the patient, family, or caregiver. An evaluation of GI symptoms that may
be trigged by oral intake can provide an indication of disease conditions that affect
nutritional status. Key questions, such as the incidence of nausea, vomiting, anorexia,
or early satiety, can clue in the clinician to possible deficiencies. Many patients with
GI disorders will voluntarily restrict oral intake in order to minimize GI output. Oral
intake should be evaluated with reference to GI losses so that adjustments in fluid pro-
visions, antidiarrheal medications, or dietary composition can be implemented.
There are different methods available to perform a dietary assessment. No single
best method exists for measuring dietary intake. There are two techniques that are
generally used in the clinical setting. The first is a dietary history or 24-hour recall
in which the patient is asked to verbally report all foods and beverages consumed on
a typical day. The clinician then asks probing questions to ascertain the frequency
and amounts of consumption of specific foods or food groups in order to evaluate the
reliability of the interview. This is quick to perform, has a low respondent burden,
but does not give data representative of an individual’s usual intake. The second
method is a 24- to 72-hour nutrient intake record or food diary. With this technique
the patient or caregiver is asked to record all foods and beverages consumed during
the specific time frame. The method does not rely on memory, can provide detailed
intake data, but requires a high degree of respondent cooperation. An experienced
registered dietitian can assess the adequacy of overall energy, protein, fluid, and
micronutrient intake based on information obtained from a thorough diet history by
translating foods consumed into nutrient intake. For larger epidemiological studies,
a survey tool is generally employed.
2.2.1.4 Psychosocial
The maintenance of adequate nutrient intake and compliance with nutrition therapy is
often altered in the patient with social, economic, or psychological challenges. These
situations can significantly impact an individual’s ability to comply with medical and
nutritional therapy. Information regarding the patient’s living arrangements, social
support systems, access to medical care, activity level, food purchasing and prepara-
tion capabilities, and religious practices allows the clinician to tailor the nutrition care
plan for optimal success. The use of alcohol, tobacco, and illicit drugs should also be
investigated. For those receiving specialized nutrition therapies, such as home paren-
teral or enteral nutrition, it is important to ensure the patient’s ability to obtain and
safely administer the therapy as directed. Both nutritional and medical therapies will be
enhanced when the patient is evaluated and treated as a whole, including the psychologi-
cal, emotional, and cognitive needs using the skills of a multidisciplinary team.
2.2.2 Nutrition-Focused Physical Exam

The physical examination corroborates and adds to the findings obtained by his-
tory. The addition of the nutrition-focused aspects is valuable in detecting nutritional
deficiencies or excesses. These include both macro- and micronutrient deficiencies
(Table 2.3). The most obvious physical markers of chronic protein-energy malnutri-
tion are temporal or skeletal muscle wasting and loss of subcutaneous fat in the face,
triceps, waist, and thighs. Rapidly proliferating bodily tissues (i.e., hair, skin, nails,
oral cavity, and eyes) tend to respond more promptly to nutrient deficiencies than
other tissues. Thin, dry, easily pluckable hair can signify protein or protein-calorie
deficiency, whereas dryness, scaling, or roughened bumps of the skin may indicate
essential fatty acid deficiency. Protein deficiency is also observed with excessive
bruising, edema, or delayed wound healing. Common manifestations of micronu-
trient deficiencies in GI patients include zinc, magnesium, and B vitamins. This is
often due to impaired ability to digest and absorb as well as the large GI losses from
excessive diarrhea or ostomy effluent.
An evaluation of fluid balance is also an important component of the nutritional
assessment. Malabsorption, chronic illness, and surgery can lead to severe hypoalbu-
minemia and fluid retention presenting as edema, ascites, or anasarca. Dehydration
due to substantial fluid loss from gastric suctioning, vomiting, diarrhea, excessive
ostomy output, and fistula or wound drainage is also possible. This can be physically
detected by assessing skin turgor and examining mucous membranes. Physical find-
ings should be integrated with daily weight changes, laboratory values, intake and
output records, and appearance of urine and stool to ascertain overall fluid balance.
The patient’s subcutaneous adipose stores should be evaluated as these represent
energy reserves and are depleted in chronic malnutrition. This is common in patients
with GI disorders. For those patients who are obese, the location and deposition of
the adipose tissue can signal the potential for other risk factors. Body fat distribution
can be classified into two types: (1) upper body, android, or male type; and (2) lower
body, gynoid, or female type.11 Patients with android obesity or central adiposity
seem to be at greater risk for other diseases. Android obesity has been associated
with co-morbidities, such as cardiovascular disease, insulin resistance, hyperinsu-
linemia, noninsulin-dependent diabetes mellitus, hypertension, hyperlipidemia,
stroke, and even increased mortality.12–15
An evaluation of the functional capacity of the GI tract is especially important
for any patient with a history of GI disease. This can be accomplished using tech-
niques of inspection, auscultation, percussion, and palpation. Bowel sounds, level
of abdominal distention, and presence of tenderness is assessed to rule out ileus or
bowel obstruction. Data from the physical assessment of bowel function should be
combined with radiologic and laboratory tests along with a history of early satiety,
postprandial pain, nausea, vomiting, flatus, diarrhea, or constipation to provide a
comprehensive evaluation along with a treatment plan.
Table 2.3
Physical Signs of Macronutrient and Micronutrient Deficiency
Protein Ascorbic acid (Vitamin C)
• Mental confusion, hyperirritability, apathy • Perifollicular hyperkeratosis
• Thinning, dull, easily pluckable hair; traverse • Hemorrhage
depigmentation of hair • Corkscrew hair
• Edema, anasarca • Swollen, retracted, bleeding gums
• Delayed wound healing, decubitus ulcers • Poor wound healing
• Traverse ridging of nails Vitamin A
• Hepatomegaly • Night blindness
• Decreased baseline temperature • Bitot’s spots
• Cellophane appearance of skin • Xerosis
Protein-energy • Hyperkeratosis of skin
• Dry, dull hair Vitamin D
• Hollowed cheeks • Osteomalacia
• Mottled teeth with cavities • Rickets
• Loss of balance • Tetany
• Muscle weakness and overall wasting Vitamin E
Essential fatty acids • Hemolytic anemia
• Xerosis (scaly, flaky dermatitis of the • Neuropathy
extremities) Vitamin K
• Thrombocytopenia • Bleeding
• Follicular hyperkeratosis • Increased prothrombin time (PT)
• Dry, dull hair Iron
• Nasolabial seborrhea • Hypochromic microcytic anemia
Thiamine (Vitamin B1) • Weakness
• Wernicke’s-Korsakoff encephalopathy • Cheilosis
• Peripheral neuropathy • Pale conjunctiva
• Ophthalmoplegia Zinc
• Heart failure • Apathy
• Edema • Alopecia
• Pour wound healing, pressure ulcers • Poor wound healing
Riboflavin (Vitamin B2) • Dysgeusia
• Angular stomatitis • Skin rash
• Cheilosis • Nasolabial seborrea
• Atrophic lingual papillae Copper
• Glossitis • Microcytic hypochromic anemia, leukopenia,
Pyridoxine (Vitamin B6) neutropenia
• Angular stomatitis • Menke’s syndrome
• Cheilosis Chromium
• Glossitis • Glucose intolerance
• Peripheral neuropathy • Peripheral neuropathy
• Metabolic encephalopathy
Table 2.3 (Continued)
Physical Signs of Macronutrient and Micronutrient Deficiency
Cobalamin (Vitamin B12) Selenium
• Megaloblastic anemia • Dilated cardiomyopathy
• Pernicious anemia • Keshan’s disease
• Angular lingual papillae • White nails
• Dementia
• Ataxia
Folate
• Pancytopenia
• Glossitis
• Stomatitis
• Atrophic lingual papillae
2.2.3 Anthropometry and Body Composition Analysis

Anthropometry is the measurement of physical parameters that deal with the physical
dimensions, proportions, and composition of the human body as well as the study of
related variables that affect them. Body weight is one of the most important measure-
ments in nutritional assessment. Weight, which is relative to height and frame size, is
often used as a tool to determine nutritional status and risk. Changes in usual body
weight should be ascertained. It is important to note the percent of weight loss as well
as the rate of weight loss. Unintentional weight loss greater than 10% is associated
with a poor clinical outcome.16,17 However, it is often difficult to assess true tissue loss.
Weight fluctuations are common in GI disease due to malabsorption and side effects
of corticosteroid therapy and dehydration. It is especially important to note any sig-
nificant increase or decrease in GI losses via stomas, drains, tubes, or fistulae.
The body mass index (BMI) is calculated as weight in kilograms divided by
height in meters squared. A BMI of 14 to 15 is associated with significant mortal-
ity. However, measurements of body weight in patients in hospitals and intensive
care units and those with liver disease, cancer, and renal failure are confounded by
changes in body water due to dehydration, edema, and ascites. Additionally, healthy
BMI indices will vary for individuals of different populations and cultures.
There are other more sophisticated measures available including isotope dilu-
tion, bioelectrical impedance analysis (BIA), bioelectrical impedance spectros-
copy (BIS), dual-energy x-ray absorptiometry (DXA) neutron-activation analysis,
computerized axial tomography, and magnetic resonance imaging. Although these
methods are accurate, they are not practical in the clinical setting. The only meth-
ods that are available for wide clinical application in nutritional assessment are BIA
and BIS. Both of these techniques have shown that reduced fat-free mass increases
length of stay in hospitalized patients. However, limitations exist in the generaliza-
tion of these equations to the patient with GI disorders, particularly if they have
large fluid losses from high output ostomies. Water and electrolyte disturbances,
which are common in intestinal failure, may skew impedance measurements
leading to over- or underestimation of malnutrition in this population.18,19 Pichard

et al. studied the use of BIA in chronically ill patients and confirmed the need for
disease-specific BIA equations.19
2.2.4 Muscle Function Assessment

In addition to measuring the amount of lean muscle, there is interest in measuring
the functional capacity of the muscle mass. This may provide a more meaningful
evaluation than a static measurement of absolute muscle mass. Deficits in muscle
function have been linked to nutritional depletion and higher incidences of postop-
erative complications among hospitalized patients.20–22
Several methods exist for the assessment of muscle function in the hospital and
ambulatory clinics. One of the simplest functional tests for alert and cooperative
patients is grip strength, measured with a small, portable handgrip dynometer. In a
study of 120 patients undergoing elective major abdominal surgery, the most useful
index to determine postoperative complications was hand-grip dynamometry, which
predicted 90% of those who developed complications.23 A grip strength below 85%
of standard for age and sex was found by Webb et al. to be the most specific predictor
of postoperative risk; however, research has yet to show the benefits of preoperative
nutrition support in the at-risk population.24
Handgrip strength was also found to be significantly less in chronically energy-
deficient and underweight young males as compared to those who were well-nourished
but underweight or of normal weight status.25 This implies a potential use of grip
strength in the differentiation of patients with similar weights, but conflicting nutri-
tional status.
2.2.5 Laboratory
Historically, hepatic transport proteins have been used to assess nutritional status.
These proteins can be categorized into negative and positive acute-phase proteins
(Table 2.4). It is the negative acute phase proteins that are often used as a tool for
nutritional assessment. Serum levels of these proteins are largely affected by varia-
tions in synthesis, degradation, and distribution seen with chronic malnutrition or
acute stress. Despite these confounding factors, they have long been used to evaluate
nutritional status and guide nutrition intervention strategies. There were 12 early
studies published that correlated serum protein concentrations with duration of nutri-
tion support, anthropometric measurements, morbidity, and mortality, and concluded
or assumed that nutrition was the primary causative variable.26 However, these stud-
ies overlooked the influence of inflammatory metabolism as well as the mediators
of inflammatory metabolism.27 Later studies, however, suggested that the changes in
these markers were actually caused by inflammation. There were 11 studies that cor-
related serum proteins concentrations with morbidity and mortality, some inflamma-
tory makers, and concluded that inflammation is the primary causative variable.26
During acute stress and inflammation there are significant changes in protein
metabolism. Albumin levels often fall dramatically in response to increased deg-
radation, decreased synthesis with preferential use of amino acids for production
Table 2.4
Acute Phase Proteins
Negative Positive
Albumin (Alb) Fibrinogen
Transferrin (TFN) Prothrombin
Thyroxine-Binding Prealbumin (TBPA) Antihemophiliac
Rentinol Binding Protein (RBP) Plasminogen
Fibronectin Complement proteins
Insulin-like Growth Factor (IGF) Alpha 1 antitrypsin
Alpha 1 antichymotrypsin
Pancreatic secretory trypsin inhibitor
Haptoglobin
Ceruloplasmin
C-reactive Protein (CRP)
of acute phase proteins, and increased vascular permeability with redistribution of

albumin to extravascular spaces.28 During obligatory muscle and connective tissue
proteolysis, stress depresses albumin levels.29 This proteolysis is mediated by leu-
kocyte pyrogen (IL-1) in sepsis and trauma.30 Nitrogen balance studies have been
used to evaluate protein status. But these equations measure net balance (intake and
output) and do not measure synthesis and breakdown for which an isotopic tracer is
required.31 The issue becomes more complicated when considering total body pro-
tein versus hepatic protein metabolism. In a study of protein metabolism during sep-
sis and multiple injury, hepatic proteins were measured 5, 10, 15, and 21 days after
injury in 24 critically ill patients who were hemodynamically stable and compared
to total body protein metabolism.32 Hepatic proteins returned to normal levels, total
body proteolysis continued, and energy expenditure increased. The authors con-
cluded that normalization of hepatic protein metabolism was independent of total
body protein metabolism.
The degree of inflammation must be considered in assessing nutritional status and
nutrition intervention. Nutrition support alone is inadequate to prevent loss of lean
body mass during inflammation. Many medical conditions are also inflammatory
states. Many conditions that afflict GI patients, such as trauma, infection, pancrea-
titis, cachexia, rheumatoid arthritis, advanced age, obesity, and periodontal disease,
are also considered inflammatory states. Nutrition support during inflammatory
metabolism probably supports acute phase metabolism, although this has not been
proven. In the absence of successful interruption of inflammatory metabolism, the
anabolic phase of recovery is the time for nutritional repletion.
The metabolism of these protein markers is different in uncomplicated conditions
of nutrient intake deficit and may be more clinically useful. In chronic uncompli-
cated starvation, serum albumin concentrations are maintained near normal due to
decreased catabolism and shifts in distribution from extra- to intravascular spaces.33,34
In a study of very low calorie diets with different compositions, obese adults were
given 1,200 and 180 to 500 calorie weight loss diets for 20 days.35 In the 1,200 calorie
group, serum albumin, thyroxine binding prealbumin (TBPA), and retinol binding
protein (RBP) remained the same. However, in the very low calorie group, PAB and
RBP decreased at day 5 and remained constant. Changes in plasma proteins during
acute nutritional deprivation in healthy human subjects were evaluated. Albumin,
transferrin (TFN), and fibronectin concentrations during acute nutrient deprivation
and refeeding in healthy adults were monitored over a 15-day trial, which included
5 days of normal diet, 4 days of nothing but water followed by 10 days of a normal
diet.36 Fibronectin decreased by day 2 of starvation. Albumin and TFN remained
the constant. During refeeding fibronectin normalized, TFN decreased, and albu-
min increased. The authors concluded that the changes in albumin and TFN reflect
changes in intravascular fluid volume. However, fibronectin responded immediately
to both stimuli: starvation and refeeding. In other uncomplicated examples of starva-
tion, such as anorexia nervosa, serum transport protein concentrations remain rela-
tively stable.37, 38
Overall, serum transport protein concentrations do not change in uncomplicated
states of undernutrition. The fast turnover proteins change quickly with deprivation
and feeding, but are obscured by infection. These changes reflect the state of nor-
mal undernutrition versus inflammatory metabolism with or without undernutrition.
During uncomplicated undernutrition (adaptive starvation), lean body mass and pro-
tein loss is minimized, substrate metabolism adapts to increased fat and ketone oxi-
dation. This is reversed by provision of exogenous substrate in the form of nutrition.
During inflammatory metabolism, nitrogen loss is accelerated by muscle catabolism
and hepatic protein metabolism is radically altered. This state cannot be reversed by
exogenous substrate provision (nutrition). During acute phase metabolism, there is a
heightened immune response, tissue repair, and substrate mobilization. Hepatic pro-
tein metabolism is changed to facilitate this process.39 During this period, negative
acute phase proteins decrease synthesis by at least 25%, while positive acute phase
proteins increase synthesis by 25%.
It is enticing to use these proteins as determinates of nutritional status as they
are readily available for general use. They are still important tools to be used clini-
cally. Serum proteins are strong prognostic indicators of morbidity,40 mortality,41
length of hospital stay,42 and surgical risk43 among hospitalized patients. However,
they have little to do with nutritional status. The question becomes what is the best
use of hepatic positive and negative acute phase proteins in nutrition assessment and
monitoring? They do indicate metabolic state. They also indicate the severity of ill-
ness and inflammation. They predict the potential need for nutrition interventions;
not to normalize serum assays, but because acute and chronic illness and trauma
cause anorexia.
2.2.6 Micronutrient Status
Vitamins and trace elements are substances that function as co-enzymes in metabo-
lism and are essential in small quantities. Laboratory assessment of vitamins and
trace elements can be useful in detecting subclinical nutrient deficiencies or excess
before physical signs manifest. For many of these nutrients, tissue or hair analysis
represents the most accurate method of assessment. However, these are not practical
in a clinical setting. For the patient with GI disorders, it may be prudent to mea-
sure serum levels of these micronutrients particularly if the GI disorder results in
decreased intake, malabsorption, or increased GI losses. This is especially important
for those individuals on long-term parenteral nutrition. In these instances, the micro-
nutrient composition of the parenteral nutrition formula can be customized. Even for
those patients not on specialized nutrition support, the abnormal vitamin and trace
levels should be repleted with oral supplementation.
2.2.7 Subjective Global Assessment

Assessment of nutritional status is complex. Unfortunately, no single parameter
is able to consistently determine the degree and type of malnutrition in all types
of patients. Baker et al.44 and Detsky et al.45 developed the technique of subjective
global assessment (SGA) based on the principle that findings from a routine clini-
cal examination can correlate with objective measurements and predict clinical out-
comes with greater accuracy than objective measurements in a wide range of patient
populations.46,47 The SGA classification is described as follows:
1. History
• Weight change
• Change in dietary intake patterns over time
• Presence of gastrointestinal symptoms persisting for more than two
weeks
• Change in functional capacity over time
• Primary diagnosis and level of metabolic demand
2. Physical
• Degree of loss of subcutaneous fat
• Degree of muscle wasting
• Degree of edema
• Degree of ascites
• Presence of mucosal, cutaneous, or hair abnormalities
3. Subjective Global Assessment Rating
• A = well nourished
• B = moderately (or suspected of being) malnourished
• C = severely malnourished
This subjective approach defines malnourished patients as those who are at

increased risk for medical complications and who will most likely benefit from
nutritional intervention. The basis of this assessment is to determine whether nutri-
ent metabolism has been altered because of reduced food intake, maldigestion, or
malabsorption; whether any effects of malnutrition on organ function and body
composition have occurred; and whether the patient’s disease process influences
nutrient requirements. Unlike traditional methods that rely on objective anthro-
pometric and biochemical data, SGA is based on four elements of the patient’s
history (recent weight loss, changes in usual diet, presence of significant gastroin-
testinal symptoms, and the patient’s functional capacity) and three elements of the
physical examination (loss of subcutaneous fat, muscle wasting, and presence of

edema or ascites).
SGA is relatively simple to use. Additionally, despite the subjective nature,
the results are reproducible when used by trained clinicians. The interrater
reproducibility among nurses and medical residents using SGA was 91% agree-
ment,46 and among medical residents and specialists in clinical nutrition with 79%
agreement.48
The ability of SGA to predict outcome and adequately assess nutritional status
has been compared to other traditional methods. In a prospective analysis of 59
surgical patients, the predictive value of SGA was compared to different standard
techniques.45 Preoperative SGA was a better predictor of postoperative infectious
complications than serum albumin, TFN, delayed cutaneous hypersensitivity, anthro-
pometry, creatinine height index, and the prognostic nutritional index. Combining
SGA with some of the traditional markers of nutritional status increased the ability
to identify patients who developed complications from 82 to 90% and also increased
the percentage of patients who were identified as malnourished but who did not
develop postoperative complications from 25 to 30%. Thus, by increasing sensitiv-
ity, the number of patients who might receive unnecessary nutrition intervention is
reduced.
The ability of SGA to predict body composition was evaluated in a study, which
compared SGA to bioelectrical impedance (BIA) measurements of fat-free mass
(FFM). FFM was significantly lower in patients classified as severely malnourished
by SGA than in those classified as well nourished by SGA.49 However, SGA classi-
fication did not correlate with BIA measurements of FFM in a study of 47 intestinal
failure patients receiving home parenteral nutrition.50 The authors concluded that
SGA in combination with a weight history would be sufficient for the assessment of
malnutrition in this population.
SGA also has been shown to be a powerful predictor of postoperative complica-
tions. Several studies have reported successful use of the SGA to predict compli-
cations in general surgical patients,48 patients on dialysis,51–53 and liver transplant
patients.54 In each of these studies, significantly more complications were observed
in the severely malnourished versus moderate and mildly malnourished patients.
2.3 Prediction of Complications and

Decision to Intervene
Can nutritional assessment predict which patients will have complications and
which patients will benefit from nutrition intervention? There is a clear distinction
between prediction of complications and prediction of those who will benefit from
nutrition intervention. While many of the tools for nutritional assessment predict
potential complications, they may not be able to adequately identify patients who
would benefit from nutrition support. Since nutritional support therapies do carry
some risk, the potential benefit-to-risk ratio must be considered before instituting.
Some of the assessment tools identify patients who have had reduced intake, other
tools demonstrate the degree of illness. The exact impact of nutrition on disease
outcome has not been clearly demarcated in all disease states. Yet, there is no clini-
cal condition that benefits from malnutrition. It seems intuitive that the provision
of nutrition to malnourished patients would produce positive outcomes. However,
to date, there have not been any prospective controlled clinical trials demonstrat-
ing that providing nutrition support to malnourished patients influences outcome.
A retrospective subgroup analysis of a large multicenter trial found that parenteral
nutrition given preoperatively to severely malnourished patients or those at nutri-
tional risk decreased postoperative complications.55
2.4 Impact of Nutrition on Disease

There is an intimate relationship between nutrition and GI disease. GI disease may
result in undernutrition or frank malnutrition as a consequence of loss of appetite,
maldigestion, malabsorption, or increased metabolic demand. It is clear that an
inadequate intake of food over time will result in the physiological, body compo-
sition, functional, cognitive, and psychological changes that together constitute a
state of malnutrition. Malnutrition can result in an increase in the risk of disease.
Conversely, malnutrition can be a consequence of GI disease either by increased
metabolic demand or reduced nutrient intake.
When intake is poor or absent for a prolonged period, weight loss is associated
with organ failure and death (see Figure 2.1). Life-threatening undernutrition is
classified as a loss of about one-third of body weight or a BMI ≤ 15 kg/m 2. Death
will ensue when 40% of lean tissue is lost during acute starvation and 50% is
lost during chronic starvation.56 During the Irish Republican Army (IRA) hunger
strikes, previously healthy lean individuals survived between 57 and 73 days with-
out food.57 The mean weight loss of the group was 38% and one-third of them died.
Thus, in the absence of disease, one can anticipate that previously normally nour-
ished adults may die of starvation in approximately 60 days. Superimpose illness
and injury onto this, and one can anticipate death much sooner in the hospitalized
patient. Studley showed that if patients lost more than 20% of their body weight
prior to surgery for peptic ulcer disease, they had a 33% mortality compared with
4% if less than 20% body weight had been lost.58 Keys and colleagues conducted a
number of studies on conscientious objectors to World War II to evaluate the physi-
ological effects of starvation and refeeding.59 Thirty-two male volunteers were
semistarved during a six-month period with an average consumption of 1,570 kcal,
50 gm of protein, and 30 gm of fat. The resulting decline in organ system func-
tions was systematically recorded. Nutritional deprivation had a negative impact
on every organ system studied including the GI tract. The subjects developed diar-
rhea, peptic ulcers, changes in gastric motility, and even changes in the position
of the stomach.
The effects of undernutrition on the GI tract are particularly important. Apart
from its role in digestion and absorption, the GI tract constitutes a major immune
organ, acting as a barrier to prevent the translocation of bacteria into the body.
Adequate nutrition is important to preserve gut barrier function. The intestine is
unique in that it is nourished by two mechanisms, from the circulation and from
nutrients passing directly through the lumen.60 The epithelial cells of the gut have
extraordinary turnover and are renewed every two to three days. Luminal nutrients
are the most potent stimulus for mucosal cell proliferation and intestinal adaptation.
Interestingly, luminal and systemic starvation can occur separately as when a patient
is supported with parenteral nutrition, but receives no nutrition via the enteral route.
Alternatively, a patient may be chronically depleted, but may be able to maintain a
minimal enteral intake in the form of diet or tube feeding. The diet may or may not
contain all the necessary nutrients or the patient may not receive adequate amounts
of tube feeding to maintain the health of the GI tract.
The effects of acute and chronic undernutrition in the presence of disease relate
to the end result of altered immune function, impaired wound healing, and over-
all decrease in functional status. This ultimately translates into increased length of
stay (LOS), increased hospital costs as well as greater morbidity and mortality. The
associations between malnutrition and poor outcome are not confined to the general
surgical population. Similar findings have been demonstrated in GI and liver disease.
Alberino and colleagues studied 212 hospitalized patients with liver cirrhosis clini-
cally for two years or until death.61 Severe depletion of muscle mass and body fat
were found to be independent predictors of survival. The inclusion of anthropomet-
ric measurements in the Child–Pugh score, the prognostic score used most with liver
disease, improved its prognostic accuracy. These data demonstrate that malnutrition
is an independent predictor of survival in patients with liver cirrhosis.
In a prospective study of 1,053 cirrhotic patients, Child–Pugh classification as
well as clinical and biochemical variables were used to assess the severity of cirrho-
sis and to determine whether malnutrition was a risk factor for mortality in cirrhotic
patients.62 Nutritional status was evaluated both by anthropometric and clinical mea-
surements. In the univariate analysis, the presence of muscle depletion and/or reduc-
tion in fat deposits was associated with a higher risk of mortality.
There are data to suggest that a significant proportion of patients undergoing liver
transplantation are nutritionally compromised and that this affects patient infec-
tion, susceptibility, graft function, and mortality, which may possibly be improved
by nutritional intervention. In a prospective study, the effect of nutritional status
on outcome in 102 consecutive adult patients undergoing elective orthotopic liver
transplantation was examined. Midarm muscle circumference was calculated.63
Patient outcome variables included time spent in the intensive care unit, total time in
hospital, infectious complications, and mortality. Graft outcome variables included
early graft function, peak aspartate transaminase, alkaline phosphatase, bilirubin,
and prothrombin time. There were significantly more bacterial infections in the
malnourished group and a difference in mortality up to six months postoperatively.
Additionally, there were significant differences between the malnourished and the
well-nourished patients for peak alkaline phosphatase and peak prothrombin. In
a retrospective analysis of 99 orthotopic liver transplants, severely malnourished
patients require more blood products during surgery and have prolonged postopera-
tive length of stay in hospital.64
Severe preoperative malnutrition has a positive predictive value for mortality
in patients with gastric cancer. In a prospective study of 40 patients with gastric
adenocarcinoma treated surgically, patients who died presented with a signifi-
cantly greater preoperative cellular immunosuppression than those who survived.65
Postoperative mortality correlated significantly with hypoalbuminemia and weight

loss. Clearly there is evidence that nutrition impacts the clinical course of the patient
with GI disease.
2.5 Conclusion
Malnutrition produces a wide range of physiological effects ranging from biochemi-
cal alterations, clinical manifestations, and, ultimately, death. Although, the full
extent of the relationship between nutrition and disease has not been fully elucidated,
there is no clinical condition that benefits from a state of malnutrition. Malnutrition
also increases the need for healthcare and healthcare resources. The more severe
the malnutrition, the more costly the intervention required and the greater the risk
in providing the intervention. The goal of nutritional assessment is to identify those
patients who are or may become malnourished. Assessment of nutritional status at
first glance appears intuitive. But it is a complex process and encompasses all body
systems. Once malnutrition has been identified, a plan for safe and effective inter-
vention must follow. The nutritional assessment must continue during the nutrition
therapy in order to ensure safe and effective therapy.
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3 Management of
Disorders of Deglutition
Ryan F. Porter and C. Prakash Gyawali
Contents
3.1 Definitions....................................................................................................... 38
3.2 Evaluation........................................................................................................40
3.2.1 Oropharyngeal Dysphagia...................................................................40
3.2.1.1 Clinical Bedside Evaluation.................................................. 41
3.2.1.2 Videofluoroscopic Examination............................................ 41
3.2.1.3 Nasal Endoscopy................................................................... 42
3.2.1.4 Imaging Studies.................................................................... 42
3.2.1.5 Electrodiagnostic Techniques............................................... 42
3.2.1.6 Laboratory Tests................................................................... 42
3.2.2 Esophageal Dysphagia......................................................................... 43
3.2.2.1 Upper Endoscopy..................................................................44
3.2.2.2 Barium Studies......................................................................44
3.2.2.3 Esophageal Manometry........................................................ 45
3.2.2.4 Imaging Studies.................................................................... 45
3.3 Management.................................................................................................... 45
3.3.1 Oropharyngeal Dysphagia................................................................... 45
3.3.1.1 Swallowing Therapy and Feeding........................................ 45
3.3.1.2 Surgical Therapy...................................................................46
3.3.1.3 Dilation................................................................................. 47
3.3.1.4 Pharmacotherapy.................................................................. 47
3.3.2 Esophageal Dysphagia......................................................................... 47
3.3.2.1 Esophageal Strictures........................................................... 47
3.3.2.2 Food Impaction..................................................................... 48
3.3.2.3 Gastroesophageal Reflux Disease......................................... 49
3.3.2.4 Malignant Dysphagia............................................................ 49
3.3.2.5 Eosinophilic Esophagitis...................................................... 49
3.3.2.6 Achalasia............................................................................... 50
3.3.2.7 Spastic Disorders.................................................................. 50
3.3.3 Odynophagia........................................................................................ 51
References................................................................................................................. 51
37
3.1 Definitions
Dysphagia is the sensation arising from impediment or obstruction to the passage
of food from the mouth to the stomach.1,2 Dysphagia is typically described as food
“hanging up” or “sticking” on attempted swallowing. A careful history can lead to
the cause of dysphagia in greater than 80% of patients with up to 80% accuracy.3,4
Odynophagia refers to pain during the act of swallowing.1 Globus is distinct from
dysphagia and describes a sensation of fullness, discomfort, or a lump in the throat
that is constant and does not interfere with swallowing.1 In fact, globus may actu-
ally improve during swallowing. Most patients with globus do not have evidence of
organic oropharyngeal or esophageal disease despite exhaustive investigation.1
There are two categories of dysphagia: oropharyngeal dysphagia and esophageal
dysphagia.1 Oropharyngeal or transfer dysphagia results from impairment of the
transfer of food from the mouth into the proximal esophagus.1,5 This can result from
poor oral preparation of the bolus, weak pharyngeal contraction, inadequate opening
of the upper esophageal sphincter (UES), and/or lack of coordination between pha-
ryngeal contraction and UES relaxation. Skeletal muscles involved in these events
are innervated by the lower cranial nerves. Consequently, neuromuscular dysfunc-
tion related to cerebrovascular accidents or Parkinson’s disease is the most frequent
mechanism of oropharyngeal dysphagia. Structural obstructive processes, such as
webs, luminal narrowings, extrinsic compression, and tumors are much less fre-
quent.1,6 Common causes of dysphagia and odynophagia are:
Oropharyngeal or Transfer Dysphagia

Neuromuscular Diseases
Central Nervous System Diseases
Cerebrovascular accident
Parkinson’s disease
Amyotrophic lateral sclerosis
Central nervous system tumor
Dementia
Spinocerebellar degeneration
Cranial Nerve Diseases
Diabetes Mellitus
Paraneoplastic syndromes
Toxins, e.g., lead poisoning and other neurotoxins
Myopathic Disorders
Inflammatory myopathies (e.g., polymyositis, dermatomyositis, col-
lagen vascular disorders)
Muscular dystrophies
Thyroid dysfunction (hyperthyroidism, myxedema)
Myasthenia gravis
Amyloidosis
Primary cricopharyngeal dysfunction
Structural Lesions
Mucosal and luminal lesions
Management of Disorders of Deglutition 39
Oropharyngeal and proximal esophageal carcinoma

Benign esophageal tumor
Esophageal web and stricture
Corrosive damage
Head and neck surgery
Foreign body ingestion
Radiation related changes
Extrinsic Lesions
Thyroid enlargement
Cervical vertebral osteophytes
Lymph node enlargement
Vascular anomalies
Esophageal Dysphagia
Structural Lesions
Mucosal and Luminal Lesions
Gastroesophageal reflux disease
Peptic stricture
Eosinophilic esophagitis
Esophageal tumors (benign and malignant)
Congenital esophageal webs and strictures (e.g., Schatzki ring)
Radiation related stricture
Corrosive and pill related esophagitis
Postsurgical change (postfundoplication, anastomotic stricture)
Foreign body
Radiation changes
Extrinsic Lesions
Vascular anomalies (dysphagia lusoria, dysphagia aortica)
Thoracic vertebral osteophytes
Mediastinal tumors (lymph node enlargement, benign and malig-
nant tumors)
Obstructing lesions of the gastric cardia
Neuromuscular Diseases
Spastic and Hypermotility Disorders
Achalasia
Diffuse esophageal spasm
Nonspecific spastic disorders
Isolated incomplete LES relaxation
Hypomotility Disorders
Idiopathic hypomotility
Hypomotility associated with systemic disorders (e.g.,
connective tissue disease, scleroderma, diabetes mellitus,
hypothyroidism)
Odynophagia
Infectious esophagitis
Candida albicans
Herpes simplex
Cytomegalovirus
Varicella
Foreign body ingestion
Corrosive ingestion
Pill esophagitis
Reflux esophagitis
Neoplasms
Esophageal dysphagia refers to dysphagia arising from disorders in the tubular

esophagus, particularly the distal two-thirds, which consists of smooth muscle inner-
vated by intramural neural plexuses with central control.1,2 Preprogrammed neural
mechanisms of esophageal peristalsis are usually robust and are infrequently affected
by systemic or central nervous system disorders. Therefore, structural etiologies are
more common causes of esophageal dysphagia than neuromuscular disorders (see
list above). Mucosal or intrinsic esophageal lesions that narrow the lumen of the
esophagus, and conditions in the mediastinum that compress or encase the esoph-
agus can result in esophageal dysphagia. Disorders that disrupt peristalsis in the
smooth muscle esophagus or impair lower esophageal sphincter (LES) relaxation are
encountered less frequently.1,7 Organic dysphagia refers to dysphagia from a demon-
strable structural abnormality, in contrast to functional dysphagia where symptoms
exist, but no organic etiology is identified even after extensive investigation.
Impaired swallowing can lead to malnutrition, weight loss, and dehydration.8
Older patients are particularly prone to these complications. Although benign causes
of dysphagia can also result in malnutrition and weight loss, these symptoms are
more marked and progress more rapidly with malignant dysphagia. Body weight and
nutritional status of the patient are indirect indicators of disease duration and sever-
ity and need to be assessed during physical examination.
3.2 Evaluation
3.2.1 Oropharyngeal Dysphagia
At the outset, it is important to accurately assess structural and physiologic mechanisms
responsible for oropharyngeal dysphagia, and when possible, determine the underlying
cause. Additionally, the safety and practicality of oral feeding needs to be addressed.1
A careful history and physical examination complemented with videofluoroscopic
swallowing evaluation are essential initial steps. Associated symptoms originating in
the oral cavity or oropharynx are common, consisting of drooling, spillage of food or
saliva from the mouth because of poor muscular tone, inability to chew, and difficulty
in propelling the food bolus into the pharynx. Symptoms of pharyngeal dysfunction
include nasal regurgitation of food, tracheal aspiration with coughing, choking episodes
or aspiration pneumonia, the need to swallow repeatedly to clear food from the pharynx,
dysarthria, and dysphonia. Dysphagia occurring within a second of attempted swallow-
ing is usually oropharyngeal in origin. Symptoms related to xerostomia, or dry mouth,
can be mistaken for oropharyngeal dysphagia if a careful history is not obtained.1 The
physical examination should assess for evidence of lower cranial nerves palsies, stroke,
Parkinson’s disease, and muscular dystrophies. Patients with myasthenia gravis may
complain of fatigability, with worsening symptoms as the day progresses.1,8
Assessments for oral and neck masses, lymph nodes, goiters, evidence of previous
tracheostomy, head and neck surgery, and radiotherapy are also important. Specific
treatments are available for toxic and metabolic myopathies, myasthenia gravis,
inflammatory polymyopathies, and certain neoplasms.8 These conditions should be
identified and treated appropriately.
3.2.1.1 Clinical Bedside Evaluation

The first step in the evaluation of oropharyngeal dysphagia is a clinical bedside
swallowing evaluation, which consists of clinical assessment of the structural and
functional integrity of the oropharyngeal swallowing mechanism, and cranial nerve
function.6 The oral mucosa is inspected to determine salivation and state of denti-
tion. Integrity of cranial nerves is assessed with a careful neurologic examination.
Bedside clinical assessment can detect aspiration during the swallowing of liquids
with a sensitivity of 97% and a specificity of 69%.9 In stroke patients, the following
six clinical features have been associated with a risk for aspiration when compared to
documented aspiration on videofluoroscopy: (1) dysphonia, (2) dysarthria, (3) abnor-
mal volitional cough, (4) abnormal gag reflex, (5) cough on trial swallow, and (6)
voice change on trial swallow.6,10 The presence of two of these six features has an
accuracy of 92% in identifying aspiration risk, while the presence of four features
increases specificity.10–12 The occurrence of dysphagia within the first 24 hours after
a stroke increases the risk for aspiration pneumonia.13 In patients with amyotrophic
lateral sclerosis and other degenerative disorders, the presence of dysarthria may
correlate with oropharyngeal dysphagia.14 Formal testing of swallowing and inter-
vention to prevent aspiration pneumonia is indicated in these instances.
3.2.1.2 Videofluoroscopic Examination
A modification of the barium swallow is the standard in the evaluation of oropha-
ryngeal dysphagia. This consists of a dynamic videofluoroscopic examination of
the swallowing mechanism, using boluses of varying consistencies.8,15 Aspiration
of the administered bolus into the airway can be easily identified (Figure 3.1). This
Figure 3.1 Aspiration of barium on modified barium swallow: A modified barium swal-
low in a stroke victim showing a trickle of barium in the larynx and trachea (solid arrow),
anterior to the barium column in the esophagus (open arrow). On testing with multiple food
consistencies, aspiration occurred with liquids but not with thickened and viscous foods.
examination may be combined with nasal endoscopy for real-time visualiza-

tion of the pharynx during the act of swallowing and involves the use of special
techniques, such as swallowing maneuvers and postures to correct dysfunction.
Detailed analysis of physiologic events associated with normal swallowing is
performed, along with measurement of bolus transit times.15 Identification of
postdeglutitive pharyngeal residue during videofluoroscopy correlates with an
increased aspiration risk.16 In one series, 90% of 608 dysphagic patients had evi-
dence of aspiration or other swallowing abnormalities resulting in a change in
management in 83%.17
3.2.1.3 Nasal Endoscopy
Endoscopic assessment is of immense value in assessing the structural integrity
of the oropharynx, and addressing aspiration risk with better accuracy compared
to clinical examination. A small videoendoscope is introduced through the nos-
tril to assess the pharynx, larynx, and nasopharynx in patients presenting with
symptoms suggestive of oropharyngeal dysphagia.18,19 Flexible endoscopic evalua-
tion of swallowing with sensory testing (FEESST) consists of transnasal fiberoptic
endoscopy of the naso- and oropharynx with assessment of laryngopharyngeal
sensory discrimination thresholds, using an endoscopically delivered pulse of air
to stimulate the mucosa innervated by the superior laryngeal nerve. The technique
is safe and well tolerated.18,19
3.2.1.4 Imaging Studies

When structural lesions are suspected, computerized tomography (CT) and mag-
netic resonance imaging (MRI) scans are useful, particularly in the evaluation for
central nervous system (CNS) tumors, head and neck tumors, but also CNS lesions,
such as stroke, that may be responsible for oropharyngeal neuromuscular dysfunc-
tion.1 Invasion of nerves and musculature responsible for the initiation of swallowing
can also be ascertained.
3.2.1.5 Electrodiagnostic Techniques
Distinction between neurogenic and myogenic causes of muscle weakness is some-
times required, and can be achieved with electromyography of the submental mus-
cle, and sometimes the cricopharyngeus.20 Piezoelectric sensors can be used to study
movements of the larynx during swallowing.
3.2.1.6 Laboratory Tests
Blood tests are useful in the diagnosis and follow-up of toxic and metabolic myopa-
thies.1 The diagnosis of myasthenia gravis can be confirmed by detection of serum
acetylcholine receptor antibodies. Serum creatinine phosphokinase is elevated in
inflammatory disorders of muscle; erythrocyte sedimentation rate, C-reactive pro-
tein, and antinuclear antibody may also be abnormally elevated. Elevated thyroid
hormone levels in association with low thyroid-stimulating hormone levels suggest
hyperthyroidism or thyrotoxicosis.
3.2.2 Esophageal Dysphagia
As with oropharyngeal dysphagia, careful clinical assessment should precede inves-
tigative procedures in the evaluation of esophageal dysphagia. Structural disorders,
which predominate as causes of esophageal dysphagia, impair passage of a food
bolus, and therefore the initial symptom is usually dysphagia to solids (see above
list in Section 3.1). Fixed narrowings from intrinsic esophageal or extrinsic lesions
may leave enough patency in the esophageal lumen to allow unimpaired passage
of liquids.1,21 Mild dysphagia to solids can be overcome by chewing food well and
drinking liquids to push down the solid bolus. Heartburn is reported by up to 75%
of patients with a peptic esophageal stricture; patients with adenocarcinoma associ-
ated with Barrett’s esophagus also report long-standing heartburn.22,23 Although, the
absence of heartburn does not exclude these conditions, as 25 to 30% of patients
with dysphagia from peptic strictures or esophageal adenocarcinoma may have no
heartburn at presentation.24,25 Immunosuppressed patients are prone to esophagitis
from opportunistic infections, and may present with dysphagia and odynophagia.26
Common infections include candida, herpes simplex, and cytomegalovirus, but
reflux esophagitis remains in the differential diagnosis. Pill esophagitis can present
with dysphagia and odynophagia,21 and the usual culprits are doxycycline, potassium
chloride, alendronate, nonsteroidal antiinflammatory agents, and quinidine.
Disorders that affect esophageal peristalsis can result in dysphagia to both solids
and liquids. A long history of dysphagia and regurgitation is seen with achalasia, the
prototypical neuromuscular disorder of the tubular esophagus. Chest pain and aspira-
tion pneumonia can occur, and weight loss is common in later stages of the disease.7
Collagen vascular diseases (typically scleroderma and CREST syndrome, but also
rheumatoid arthritis and systemic lupus erythematosus) can be associated with esoph-
ageal hypomotility resulting in dysphagia. Severe hypomotility of the esophageal
body and hypotonicity of the lower esophageal sphincter can predispose to signifi-
cant gastroesophageal reflux disease (GERD), sometimes complicated by esophageal
strictures, Barrett’s esophagus, or even adenocarcinoma.21,27 Physical examination
is usually not particularly revealing, but may demonstrate evidence of collagen vas-
cular disease, or scleroderma (e.g., arthritis, calcinosis, telangiectasia, sclerodactyly,
rashes). Lymph nodes, especially in the supraclavicular area, may be seen in neoplas-
tic disorders and oral thrush can be a marker of esophageal candidiasis.21
Dysphagia from a benign etiology is generally static or only slowly progressive
without significant nutritional impairment or weight loss. Benign esophageal webs
or strictures may result in intermittent, short-lived, discrete, symptomatic episodes
separated by symptom-free intervals lasting varying periods. In contrast, signifi-
cant weight loss may occur from dysphagia due to neoplasms.21,28 The acute onset
of esophageal-type dysphagia during a meal suggests food impaction.1 However,
acute onset with symptoms and signs of neurologic impairment may be seen with
acute stroke. Both of these situations may result in aphagia or inability to swallow.
Dysphagia from obstructive processes in the tubular esophagus may be localized to
a point in the chest either above or at the level of the lesion causing the obstruction.
Pharyngeal lesions causing dysphagia are typically localized to the front of the neck.
Localization of symptoms correspond to the actual site of the lesion in as many as
74% in one series,29 but localization to the suprasternal notch has limited value in
predicting the site of the obstructing lesion. While localization to the cervical region
does not necessarily indicate an oropharyngeal process, oropharyngeal dysphagia is
never localized to the retrosternal region.8,21
3.2.2.1 Upper Endoscopy
Upper endoscopy is preferred as the initial investigative study, and is the test of
choice when biopsies or therapeutic dilations are contemplated.30,31 Since GERD and
benign obstructions are the most common diagnoses in dysphagic patients, endos-
copy is a reasonable initial test of choice in the primary care setting.32 In addition to
establishing the diagnosis of dysphagia in most instances, endoscopy allows detailed
visual inspection of mucosal lesions, enables collection of tissue samples for histo-
pathologic analysis, and offers therapeutic potential.30 Endoscopy is more sensitive
than barium studies in the evaluation of esophageal mucosal lesions and esophagitis.
In cost comparisons, initial endoscopy with therapeutic intent is more cost effective
than barium swallows if benign obstructive processes are suspected.32
3.2.2.2 Barium Studies
Barium upper gastrointestinal studies are more sensitive than endoscopy in detecting
subtle esophageal strictures; sensitivity further improves with solid bolus swallows,
such as a marshmallow or a 13-mm barium pill.33,34 Barium studies also have an
advantage in patients with Zenker’s diverticulum, epiphrenic diverticula, and para
esophageal hernias. Barium studies provide a “road map” for subsequent endoscopy
in patients with complex esophageal strictures, where the length and tightness of

Figure 3.2 Esophageal stricture: (A) A tight midesophageal stricture on a barium swal-
low in an elderly patient who had undergone radiation therapy for lung cancer. The barium
study has provided a road map for subsequent endoscopic stricture dilation. (B) Upper endos-
copy demonstrates significant narrowing of the esophageal lumen. Since the barium swallow
showed a relatively straight strictured segment, a guide wire could be positioned through the
stricture and bougie dilation was successfully performed. Also note the rare patches of whit-
ish exudates representing esophageal candidiasis.
the stenosed segment can be easily assessed (Figure 3.2).30 Barium studies are less
expensive than endoscopy for the diagnosis of esophageal disorders, but the cost
benefit is lost if therapeutic endoscopy is subsequently performed. Barium studies
performed under fluoroscopy can demonstrate certain esophageal motility disorders,
particularly achalasia and diffuse esophageal spasm.35
3.2.2.3 Esophageal Manometry
Esophageal manometry is used for the evaluation of unexplained dysphagia, after
luminal or obstructive lesions have been excluded with a negative endoscopy or
barium swallow.36 In this setting, esophageal motor abnormalities were detected in
90% of patients in one series, but a change in management based on manometric
findings is reported in only half the patients referred for this procedure.37 Advances
in this technique include the use of multiple recording sites with computerized data
acquisition and topographic display, a technological advance termed high resolution
manometry that improves the sensitivity and diagnostic accuracy.38 The procedure is
well tolerated with no serious side effects.19 Esophageal manometry is the gold stan-
dard for the diagnosis of esophageal motor disorders, particularly achalasia, diffuse
esophageal spasm, and esophageal hypomotility associated with connective tissue
disorders.36,37 Manometry is less useful in the diagnosis of disordered UES function,
but special pharyngeal recording leads can sometimes assist in the characterization
of oropharyngeal dysfunction.
3.2.2.4 Imaging Studies

Cross-sectional imaging studies (CT, MRI) are useful in evaluating extrinsic com-
pression of the esophagus and esophageal neoplasia. Positron emission tomography
(PET) and endoscopic ultrasound (EUS) are useful in the staging of esophageal
neoplasia.
3.3 Management
3.3.1 Oropharyngeal Dysphagia
General measures that can be implemented prior to establishing a diagnosis include
assessment of feeding and nutritional needs.1 Specific pharmacologic, endoscopic, and
surgical therapy are only available for a limited number of conditions. Management
decisions regarding timing of feeding intervention and route of administration
require consideration of the degree of swallowing dysfunction, outcome of swal-
lowing therapy, course of underlying disease process, and patient preferences.8 The
aims of management are to establish oral intake if possible without aspiration using
compensatory swallowing techniques, and to concurrently build strength and coor-
dination in oropharyngeal musculature toward eventual unhindered oral intake.39
3.3.1.1 Swallowing Therapy and Feeding

Videofluoroscopic analysis is an important tool in assessing swallowing dysfunction
and implementing swallowing therapy techniques that may reduce the risk of aspi-
ration.8,19 These techniques include swallowing maneuvers, postural adjustments,
facilitatory techniques, and dietary modifications.8 Indirect swallowing therapy

methods include exercises to enhance the tone and function of muscles involved
in swallowing and the swallowing reflex. These methods are more effective when
used in conjunction with direct swallowing therapy, consisting of compensatory
techniques, such as head and neck positioning during swallowing, supraglottic swal-
lowing, effortful swallowing, and the chin-tuck maneuver.8,40,41 Despite only modest
changes in end-of-trial dysphagia rates, these nonspecific interventions may signifi-
cantly improve the nutritional state as well as the chances of successful oral feeding
in stroke patients. When correctly applied, these measures may allow reversion to
oral feeding and removal of gastrostomy feeding tubes thus improving the quality of
life in these patients.42–44
Oropharyngeal dysphagia is common among patients with stroke, wherein first-
year mortality from aspiration pneumonia approaches 20% and subsequent annual
mortality remains elevated at 10 to 15%.45 Formal dysphagia screening of acute
stroke patients reduces pneumonia rates.46 Early behavioral swallowing intervention
(e.g., suprahyoid muscle strengthening exercises) improves their ability to resume
normal diet and regain swallowing function.47,48 Aspiration of thin liquids observed
videofluorographically can be eliminated in the short term with postural adjustments
and thickened liquids.49 Furthermore, fluid intake may be deficient in stroke patients
with dysphagia, and the use of prethickened fluids may help maintain adequate fluid
intake while simultaneously addressing nutritional needs.50 One trial suggests a
nonsignificant trend toward lower case fatality with nutritional supplementation in
the management of acute stroke.42 However, it is unclear if postural adjustments or
dietary modifications translate into a reduced incidence of aspiration pneumonia.51
Despite the paucity of data supporting the reduction of mortality or pneumonia risk,
potential benefits at relatively low cost drive recommendations for continued use of
these postural and dietary adjustments.8,45,52
Early initiation of enteral feeding through an endoscopically placed feeding tube
(percutaneous endoscopic gastrostomy, PEG) may be superior to nasogastric (NG)
tube feeding in the management of acute stroke and dysphagia.42,53,54 Intolerance
of an orally administered pureed diet 14 days after an acute stroke may predict the
necessity for enteral feeding using PEG,55 thereby improving nutritional status as
assessed by weight, midarm circumference, and serum albumin when compared to
NG tube feeding.42,54 Further, PEG feeding may prolong survival and reduce treat-
ment failures when compared to NG tube feeding.42,53,54 However, the reported
PEG-related survival benefit may potentially only reflect a higher proportion of
survivors with poor outcomes.56 An alternative to traditional swallowing therapy,
neuromuscular electrical stimulation (NMES) is available, but results are variable.57
Vitamin deficiencies may occur in patients with oropharyngeal dysphagia treated
with oral feedings,58 which can remain undiagnosed unless specific vitamin levels
are assessed, particularly cobalamin. Tube-fed patients are less likely to develop
these vitamin deficiencies.
3.3.1.2 Surgical Therapy
Surgical intervention is available for Zenker’s diverticulum, cricopharyngeal bars,
and cricopharyngeus muscle dysfunction. Cricopharyngeal myotomy combined with
resection of the diverticulum is a safe and effective procedure that can be performed
with relative ease for Zenker’s diverticulum.59,60 Endoscopic diverticulostomy of a
moderate-sized Zenker’s diverticulum with an endoscopic stapling device or CO2
laser are effective therapies with good patient results.61 Patients with manometric
evidence of defective upper esophageal stricture opening or elevated cricopharyn-
geus muscle tone benefit from cricopharyngeal myotomy, particularly in the pres-
ence of a symptomatic response to a botulinum toxin injection.62,63 When aspiration
of oropharyngeal secretions and saliva is intractable and continues despite enteral
feeding through a PEG tube, laryngotracheal separation or total laryngectomy are
options.64 Relocation of salivary ducts or resection of submandibular salivary glands
are rarely performed for hypersalivation.64
3.3.1.3 Dilation
Benign proximal esophageal webs and stenoses are effectively disrupted with large
caliber (18 to 20 mm) bougie dilation, typically performed over a guide wire.65 This
approach can also be used for elevated UES resting pressures or impaired UES
relaxation during swallowing, allowing resumption of oral feeding.66
3.3.1.4 Pharmacotherapy
Drug therapy of the causative disorder may improve symptoms in certain myopathic
disorders, especially myasthenia gravis and inflammatory myopathies. Myasthenia
gravis is amenable to therapy with anticholine esterase agents, oral immunosup-
pressives, and plasmapheresis.67 Inflammatory myopathies, such as polymyositis and
dermatomyositis also respond to anti-inflammatory and immunosuppressive agents.68
Conditions associated with excessive salivation and drooling may benefit from anti-
cholinergic medication, especially transdermal scopolamine.69 There are no data to
evaluate the impact of these therapies on dysphagia as a symptom. Cricopharyngeus
muscle spasm or hypertonicity and cricopharyngeal achalasia may improve with bot-
ulinum toxin injection into the cricopharyngeus.70 This approach may also provide
long-term benefit in neurogenic dysphagia from altered upper esophageal sphincter
opening in the presence of preserved pharyngeal contraction.71 A response to botuli-
num toxin injection helps confirm the diagnosis in these patients.70,72
3.3.2 Esophageal Dysphagia
General measures recommended for all patients with esophageal dysphagia include
advice to chew food well and to avoid hurried meals. Patients with esophageal nar-
rowing from strictures or neoplasia benefit from a soft or pureed diet. Nutritional
supplementation is recommended when dysphagia results in weight loss, in the form
of liquid nutritional supplements, enteral tube feedings, or even parenteral nutrition.
Specific management depends on the etiology of dysphagia.1,21
3.3.2.1 Esophageal Strictures
Intermittent endoscopic dilation is effective in the therapy of peptic esophageal
strictures, esophageal webs, and rings.73,74 Approximately 35% of strictures require
repeated dilation within one year.75 Injection of steroids (triamcinolone 40 to 80 mg)
into mucosal rents created by stricture dilation can sometimes prolong the inter-
vals between repeat dilations.74,76 Benign idiopathic and congenital distal esophageal
rings, such as Schatzki rings, can be treated with electrosurgical incision or bougie
dilation. Both are safe and effective options, but long-term outcome data are lack-
ing.77–80 Rings require less frequent dilation; initial dilation with larger caliber dila-
tors and rubber bougies is a common practice.21,81,82
Peptic esophageal strictures are treated with intermittent esophageal dilation and
aggressive management of reflux disease.73,81,83 The addition of proton pump inhibitor
therapy improves GERD-related symptoms for both peptic strictures and Schatzki
rings.77,81 The decision to use mercury-filled bougies over stiffer polyvinyl bougies
placed over endoscopically placed guide wires or balloon dilators depends on the
complexity, length, and tortuosity of the stricture.74,84 Dilations are usually performed
progressively to 40 to 60 Fr (13 to 20 mm), and relief of dysphagia is achieved with
residual luminal diameters of >15 mm.2,85 The “rule of threes” is generally followed,
wherein no more than three further sizes of bougies or balloons are employed after
resistance is encountered during dilation.86,87 Perforations occur at a rate of 0.1 to
0.5%, and are most common when blind bougie dilation is attempted for complex
strictures.85,86,88 Repeat dilations are performed as necessary in patients with recur-
rent symptoms. Endoscopic incision and steroid injections are reserved for strictures
refractory to adequate antisecretory therapy and requiring frequent dilation.74,89
In addition to aggressive acid suppression, fundoplication has also been used as a
mode of definitive reflux therapy for peptic strictures, without a higher risk of residual
dysphagia on follow-up.90 Endoscopic dilation is effective in relieving symptoms in
about two-thirds of cases of postfundoplication dysphagia when the fundoplication
appears intact on endoscopy or barium studies.91 The use of a large-caliber esopha-
geal bougie across the gastroespophageal junction during fundoplication appears to
reduce the incidence of postoperative dysphagia.92 Even in the absence of obstruction
on upper endoscopy and barium studies, empiric dilation using a 50 Fr bougie may
improve dysphagia.93 Such empiric dilation may be more beneficial for patients with
solid food dysphagia than those with both solid and liquid food dysphagia.94
3.3.2.2 Food Impaction
Mechanical impediment to the passage of a food bolus can sometimes result in food
bolus impaction at the site of obstruction. Symptoms are rapid in onset, usually occur
during a meal, and consist of total or near total dysphagia, chest pain, and severe
retching. Patients are often unable to swallow their own saliva. A trial of smooth
muscle relaxants, such as glucagon or nitroglycerine, can be considered, but impac-
tions rarely resolve spontaneously, and endoscopy with mechanical dislodgement
are frequently necessary.95 The management of food bolus obstruction has changed
with the recognition of eosinophilic esophagitis as a frequent cause of food impac-
tion.96 Dilation can increase the risk of mucosal tearing or perforation in patients
with eosinophilic esophagitis. Therefore, in young patients with clinical history or
endoscopic findings suggestive of eosinophilic esophagitis, gentle bolus disimpaction
and biopsy are recommended, and dilation is considered unsafe. However, dilation at
the time of food disimpaction is safe in discrete strictures not related to eosinophilic
esophagitis, particularly with Schatzki rings or peptic strictures.95
3.3.2.3 Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is initially treated with acid suppression.75
Aggressive acid suppression with proton pump inhibitors improves dysphagia and
decreases the need for subsequent esophageal dilation in patients with reflux dis-
ease.81,83,97 Surgery also offers adequate therapy of reflux-induced dysphagia even
when a stricture is not found, although a loose fundoplication is performed when
esophageal peristalsis is feeble on preoperative esophageal manometry.94,98
3.3.2.4 Malignant Dysphagia
Whenever possible, neoplastic disorders are managed with curative surgery.
Palliation with radiotherapy or chemotherapy are options when curative measures
are not possible.99 Dilation or stent placement may be necessary to allow oral intake.
Endoscopic laser therapy or argon plasma coagulation has a low complication rate in
alleviating malignant dysphagia, and is particularly useful when the life expectancy
is estimated to be short. This can be combined with the use of plastic and metal
stents. Endoscopically placed self-expanding metallic and plastic stents provide
comparable relief of dysphagia in patients with esophageal cancer, with benefits at
times lasting for over a year.100–102 Stent placement for esophageal malignancy is a
cost-effective treatment option that improves quality of life compared to other pallia-
tive alternatives and complications are rare.103 While plastic stents may be less expen-
sive, metallic stents may contribute to improved quality of life. The safety of these
stents is documented at locations as proximally as the upper esophageal sphincter
and as distally as the gastroesophageal junction.104,105 Recurrent ingrowths of tumor
through the stent can be effectively treated with endoscopic laser therapy or argon
plasma coagulation.101 Endoluminal stents can also be used in malignant extrinsic
compression of the esophagus, though stent migration may be a complication. Newer
esophageal stents fitted with an antireflux valve intended to lower gastroesophageal
reflux are available, albeit without clear demonstration of a consistent benefit.106,107
Further stent design modifications are encouraging and the safety of these new class
of stents is validated.108,109 The cost of single-dose brachytherapy and stent placement
in the palliative treatment of esophageal cancer are comparable.110
3.3.2.5 Eosinophilic Esophagitis
Eosinophilic esophagitis is becoming more recognized as a cause for solid food
dysphagia, particularly in young adult males.111 Eosinophilic infiltration of the
esophageal mucosa occurs with mucosal edema and reduced compliance of the
esophageal wall. The esophagus may be of small caliber, but may appear normal
on barium swallow. Endoscopy may demonstrate edema, erythema, vertical fur-
rows, and whitish exudates. Histopathology typically reveals ≥15 eosinophils/high
power field.111–113 Treatment options include systemic and topical corticosteroids,
elimination of dietary allergens when identified, mast cell stablizers, and anti-IL5
antibodies, but there is no consensus on optimal therapy at present.113,114 Dysphagia
refractory to topical corticosteroids may be amenable to endoscopic dilation, which
needs to be performed with care to reduce the risk of perforation.114 Long-term
outcome studies are lacking.
3.3.2.6 Achalasia
Therapies for achalasia are aimed at reducing (LES) pressure to facilitate esophageal
emptying by gravity.74,115 Isosorbide dinitrate and calcium channel blockers sublin-
gually or orally immediately prior to meals can transiently relax smooth muscle and
facilitate LES opening.115 Compared to placebo, controlled trials have not demon-
strated consistent clinical benefit with these agents, and side effects can be trouble-
some.116,117 Botulinum toxin injection into the LES during upper endoscopy reduces
LES pressure by inhibiting acetylcholine release from nerve endings.42,115,118 Although
this approach can be remarkably effective in the short term, recurrence of symptoms
is greater than surgical myotomy or pneumatic dilation.7,119,120 Nevertheless, it can
effectively improve symptoms when more invasive therapies are contraindicated or
it can be used as a short-term bridge to durable therapy.121
Disruption of the LES with pneumatic dilation or surgical myotomy are the only
definitive treatments that consistently improve esophageal emptying in achalasia.
Recommendations for individual patients depends on available institutional exper-
tise. Surgical myotomy is offered to otherwise healthy patients who can tolerate lap-
aroscopic surgery, reserving pneumatic dilation for patients who decline surgery or
have other risk factors for surgery.122,123 Both treatments are safe and effectively abate
symptoms.122–125 Patients who fail pneumatic dilation can subsequently undergo sur-
gical myotomy if necessary.126 Pneumatic dilation uses a specially designed balloon
dilator that distends the LES to a diameter of 3 to 4 cm disrupting LES muscle
fibers.115,120 An important complication is perforation, requiring emergency surgical
repair, seen in less than 5% of cases.115,120 Surgical myotomy is performed laparo-
scopically with good success and a lasting symptomatic benefit.120,127 Concurrent
fundoplication effectively reduces reflux symptoms; a partial fundoplication (e.g.,
Dor or Toupet) is associated with less dysphagia compared to 360-degree Nissen
fundoplication.128 Computer-enhanced robotic laparoscopic Heller myotomy holds
promise to lower surgical complications, but cost-effectiveness is unclear.129
3.3.2.7 Spastic Disorders
Spastic motor processes, such as diffuse esophageal spasm and nonspecific spastic
disorders, can have obstructive and/or perceptive symptoms, the latter associated
with esophageal hypersensitivity.130 Smooth muscle relaxants have been used, but
conclusive literature supporting this approach are lacking.115,131 In the absence of
other pharmacologic alternatives, a therapeutic trial may be considered using either
nifedipine or nitrates.131 Nifedipine reduces esophageal peristaltic amplitude and
may improve chest pain in nonspecific spastic disorders, but efficacy has not been
conclusively demonstrated in controlled trials.131 Nitrates have also been used, but
results are inconsistent.131 Case reports demonstrate symptomatic relief and nor-
malization of spastic motor abnormalities with sildenafil.132 Pneumatic dilation and
surgical myotomy are reserved for refractory obstructive situations, though there
are no controlled trials addressing these therapeutic measures. Perceptive symptoms
and esophageal hypersensitivity may benefit from therapy with low dose trazodone
or tricyclic antidepressants. Concurrent reflux disease needs to be managed with
antisecretory therapy, as reflux episodes can trigger perceptive esophageal symp-

toms in spastic motor disorders.133
3.3.3 Odynophagia
Odynophagia is encountered less often compared to dysphagia, although it can some-
times coexist with dysphagia.1 The mechanism of symptom production is thought to
relate to deep mucosal infiltration with inflammatory processes or neoplasia, or to
sensory stimulation from profound mucosal inflammation or infection. Historical
clues to the diagnosis include: immunosuppressive diseases or therapies, radiation
exposure, caustic ingestion, and foreign body ingestion. Direct mucosal visualiza-
tion and tissue biopsies are often required.1 Infectious esophagitis can be seen in
a wide range of patients with immunocompromised states, including AIDS, organ
transplants, antibiotic use, malignancy, diabetes mellitus, steroid therapy, and other
immunosuppressive therapies.1,2 Esophageal candidiasis is the most common oppor-
tunistic process; other frequently encountered opportunistic infections include her-
pes simplex and cytomegalovirus infections. Viral esophagitis can rarely be seen
in the immunocompetent host, most commonly from herpes simplex virus infec-
tion. In immunocompromised states, the presence of oral thrush in the setting of
odynophagia can prompt empiric therapy for esophageal candidiasis.134,135 Therapy
with either fluconazole 100 to 200 mg/d or itraconazole 200 mg/d for 14 to 21 days
is recommended as initial therapy;75 however, a poor response requires further
investigation.
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4 Eosinophilic Esophagitis
Alain M. Schoepfer and Alex Straumann
Contents
4.1 Introduction, Definition, and Diagnostic Criteria............................................60
4.2 Epidemiology...................................................................................................60
4.3 Immunopathogenesis....................................................................................... 61
4.4 Clinical Manifestations of Eosinophilic Esophagitis...................................... 62
4.4.1 Symptoms in Children......................................................................... 62
4.4.2 Symptoms in Adults............................................................................ 62
4.5 Natural History of Eosinophilic Esophagitis................................................... 62
4.6 Diagnostic Measures in EoE........................................................................... 63
4.6.1 Endoscopy............................................................................................ 63
4.6.2 Biopsy Procurement and Evaluation.................................................... 63
4.6.3 Intraesophageal pH Monitoring...........................................................64
4.6.4 Motility Studies................................................................................... 65
4.6.5 Radiography......................................................................................... 65
4.6.6 Histopathologic Features of Eosinophilic Esophagitis........................ 65
4.6.7 Allergologic Evaluation in EoE........................................................... 65
4.6.8 Laboratory Analyses in Eosinophilic Esophagitis..............................66
4.6.8.1 Peripheral Eosinophil Count.................................................66
4.6.8.2 Total IgE, Aeroallergen-Specific IgE, Food-Specific
IgE......................................................................................... 67
4.6.8.3 Skin Prick Testing for Antigen Sensitization and Atopy
Patch Testing......................................................................... 67
4.6.8.4 Eotaxin-3 Measurements...................................................... 67
4.7 Treatment of Eosinophilic Esophagitis............................................................ 67
4.7.1 Proton Pump Inhibitors....................................................................... 67
4.7.2 Corticosteroids..................................................................................... 67
4.7.3 Leukotriene Receptor Antagonists and Mast Cell Stabilizers............ 68
4.7.4 Biologicals........................................................................................... 68
4.7.5 Dietary Treatment................................................................................ 68
4.7.6 Esophageal Dilation............................................................................. 69
4.8 Monitoring of Patients with Eosinophilic Esophagitis.................................... 69
4.9 Outlook/Future Research................................................................................ 69
References................................................................................................................. 70
59
4.1 Introduction, Definition, and Diagnostic Criteria

Eosinophilic esophagitis (EoE) is rapidly emerging as a distinctive disorder in pedi-
atric and adult gastroenterology. EoE is a chronic inflammatory esophageal disease,
characterized clinicopathologically by (1) esophagus-related symptoms and (2) a
dense esophageal eosinophilia, both of which persist despite prolonged treatment
with proton pump inhibitors. Of note, EoE is neither defined by one single marker,
e.g., number of eosinophils in the esophagus, nor by endoscopic findings.
Up until now, several different names, such as primary eosinophilic esophagi-
tis (PEE), allergic eosinophilic esophagitis (AEE), and idiopathic eosinophilic
esophagitis (IEE), have been used in the literature, but today most researchers favor
the simple term eosinophilic esophagitis (EoE or EE).
Esophageal eosinophilia is not exclusively found in EoE. Among other diseases
that are associated with esophageal eosinophilia are gastroesophageal reflux dis-
ease (GERD), Crohn’s disease, collagen vascular disease, infectious esophagitis (e.g.,
herpes, Candida), drug-induced esophagitis, eosinophilic gastroenteritis, and hyper
eosinophilic syndromes.
Summarized, the diagnostic guidelines for EoE encompass the following four items:
1. Clinical symptoms of esophageal dysfunction

2. Esophageal histology with ≥15 eosinophils in at least one high-power-field
3. Lack of response to high-dose proton pump inhibitors (PPIs) or normal
pH-monitoring
4. Exclusion of other conditions that cause esophageal eosinophilia
(Table 4.1)
4.2 Epidemiology
EoE affects males two to three times more frequently than women.1–13 The disease is
found mainly in industrialized countries, such as the United States, Canada, Europe,
and Australia, although there have been reports from all continents except Africa.
Currently there is a lack of data to verify the geographic variations of prevalence and
it is unclear whether EoE is associated with an ethnic or racial group. Socioeconomic
distribution as well as seasonal variation in EoE have not been systematically exam-
ined. EoE is likely to be a relatively “new” disease as there is strong evidence that
it had not been seen prior to the early 1980s. Whether the increased recognition
Table 4.1
Diagnostic Guidelines for Eosinophilic Esophagitis
• Clinically: Symptoms of esophageal dysfunction
• Histologically: ≥15 eosinophils in one high-power field
• Exclusion of GERD = either lack of response to high-dose PPIs or normal pH-monitoring of the
distal esophagus
• Exclusion of other conditions that cause esophageal eosinophilia
Eosinophilic Esophagitis 61
is due to a true increase of the incidence of EoE or to an increased awareness is

debatable. However, there is strong evidence to suggest that the prevalence of EoE is
increasing. A population-based, long-term study performed in Switzerland revealed
an increase in prevalence from 2 per 100,000 to 27 per 100,000 inhabitants over a
16-year period.14 In accordance with these findings, Noel et al. identified a fourfold
increase in the prevalence of EoE in children in the Midwest United States from
2000 to 2003.15 A few reports have suggested a familial clustering, but it is unclear
whether this is due to genetic predisposition or common environmental exposure.16
In a recently published paper where sporadic EoE patients were compared to famil-
ial EoE patients, a familial form was identified in 4 of 26 (15%) of families. The
familial EoE characteristics (clinical, endoscopic, pathologic, and global esophageal
transcript expression profile analysis) were similar to sporadic EoE, leading to the
estimation that both forms share a comparable pathogenesis.17 The gene encoding
the eosinophil-specific chemoattractant eotaxin-3 is the most highly induced gene in
EoE patients compared to its expression level in healthy individuals and its presence
may indicate genetic predisposition to EoE.18
4.3 Immunopathogenesis
The underlying pathogenesis of EoE is not completely understood. Under healthy
conditions, the esophagus is devoid of eosinophils. In contrast, eosinophils are resi-
dents of the lower sections of the gastrointestinal tract and they establish themselves
early during embryonic development. This process is mainly regulated by eotaxin.19
Eotaxin also has a central role in the antigen-mediated eosinophil recruitment.20
Eosinophilic infiltration of the gastrointestinal tract can be observed as a consequence
of a variety of inflammatory or infectious conditions, such as gastroesophageal
reflux disease (GERD), inflammatory bowel disease, or exposure to food allergens.21
The association of EoE with allergies leads to the hypothesis that the eosinophilic
recruitment in EoE patients may be a response to environmental antigens. However,
it is unclear whether it is due to food antigens coming in direct contact with the
esophageal mucosa or if the antigens exert their effect outside of the esophagus. In
a murine model with sensitized airways, Mishra and colleagues have shown that
intranasal administration of allergens induced esophageal eosinophilia, whereas oral
or intragastric application of the same allergens did not.22 Besides eotaxin, interleu-
kin-5 (IL-5) has an important role in eosinophil recruitment with subsequent selec-
tive Th2 response.23,24 This is supported by the observation that IL-5-deficient mice
are resistant to EoE.25 However, the variable response to measures aimed at limiting
antigen exposure suggests that other mechanisms may be involved. Eosinophils in
the esophagus can persist there through the release of eosinophil chemoattractants,
such as Interleukin-3 (IL-3), IL-5, and granulocyte macrophage-colony stimulating
factor (GM-CSF).26 The eosinophils themselves may cause local inflammation by
release of major basic protein, a cytotoxic cationic protein.27 Active eosinophilic
esophageal inflammation may cause dysphagia due to motility disorders in the
absence of an esophageal narrowing. IL-5 appears to mediate eosinophil-induced
esophageal remodeling.28
4.4 Clinical Manifestations of Eosinophilic Esophagitis

As in many other diseases, there exist some age-related differences in EoE present-
ing symptoms between children and adults.1-13
4.4.1 Symptoms in Children
In neonates and infants, food refusal is a common symptom of EoE and may denote
dysphagia, which cannot be easily expressed in this age group. Children often com-
plain of GERD-like symptoms, such as heartburn and reflux (range 5 to 82%), vom-
iting (range 5 to 68%), and abdominal pain (range 8 to 100%). Dysphagia and food
impaction are reported increasingly with age. However, children less frequently
present with failure to thrive, chest pain, and diarrhea.
4.4.2 Symptoms in Adults
In contrast to children, EoE in adolescents and adults presents with a narrow spectrum of
symptoms. The two leading complaints are dysphagia for solids (range 29 to 100%) and
food impaction (range 25 to 100%). A minority of patients report GERD-like symptoms,
nonswallowing-related chest pain, and upper abdominal pain. Many adults will have a
history of recurrent food impaction prior to the diagnosis of EoE. Table 4.2 compares the
symptoms in children and adolescents to the adults. In contrast to the very characteristic
history, the physical examination is usually normal in patients with EoE.
Therefore, EoE should be considered in young children with GERD-like symptoms
and feeding problems, whereas in older children and adults, a history of food impac-
tion, dysphagia for solids, or refractory retrosternal pain should raise suspicion.
4.5 Natural History of Eosinophilic Esophagitis

Four studies have been performed to elucidate the natural history of EoE. Straumann
and colleagues described the longest follow-up of 30 adults with EoE.2 The present-
ing symptom was mostly dysphagia with food impaction and the diagnostic delay
Table 4.2
Symptoms Pointing at Eosinophilic Esophagitis
Children Adults
Feeding aversion/intolerance Dysphagia
Vomiting/regurgitation Food impaction
“GERD refractory to therapy” “GERD refractory to therapy”
Food impaction/foreign body impaction
Epigastric pain
Dysphagia
Failure to thrive
was on average 4.6 years (range 0 to 17 years). With follow-up of up to 11.5 years,
23% of patients reported increasing dysphagia and 36.7% reported stable symptoms.
Potter et al reported on 29 patients, presenting primarily with dysphagia and with
“refractory GERD” symptoms.4 The majority of patients showed evidence of tissue
remodeling at endoscopy. In 86% of patients, rings, strictures, or small caliber esoph-
agus were found, whereas radiographic studies showed narrowing in 67%. Of note,
the small caliber esophagus that was observed endoscopically was missed radio-
graphically in four patients. Croese et al reported on 31 patients with EoE (24 men,
mean age 34 years, range 14 to 77 years), mostly presenting with bolus impaction or
dysphagia.6 Mean diagnostic delay was 54 months (range 0 to 180 months). Strictures
were present in 57% and were localized to the proximal esophagus; dilation caused
longitudinal tears in 77% of patients, but there was no perforation. Liacouras and
colleagues examined the largest longitudinal study of 381 children with EoE (66%
male, mean age 9 years).12 Most patients presented with symptoms of GERD refrac-
tory to acid suppression treatment or with dysphagia. Endoscopy showed rings in
12% and one patient required esophageal dilation.
There have been no reports of a causal association between EoE and Barrett’s
esophagus or esophageal carcinoma. Although long-term data is limited, careful
follow-up of what is a chronic disease is recommended.
In summary, EoE is a chronic inflammatory disease that harbors relevant long-
term risks and substantially impairs the quality of life of affected individuals. The
major long-term complications of chronic eosinophilic esophagitis are esophageal
strictures and a narrowed esophageal lumen resulting in food impaction.
4.6 Diagnostic Measures in EoE

4.6.1 Endoscopy
Although there is neither a pathognomonic endoscopic sign nor a typical pattern
of abnormalities related to EoE, upper endoscopy is the first diagnostic step in the
evaluation of an individual with suspected EoE. A number of endoscopic features
associated with EoE have been described, including longitudinal furrows, white
exudates, edema, longitudinal shearing, friability, crêpe paper mucosa, small cali-
ber esophagus, Schatzki ring, corrugated or ringed esophagus, and solitary rings
(Figure 4.1a-d).1–6,11–12,29–31 These findings are suggestive of the diagnosis of EoE,
but the endoscopic suspicion needs confirmation by histology. There are some
early studies reporting normal appearing mucosa in EoE. With increasing aware-
ness and experience, more endoscopists will recognize subtle mucosal changes
that may have been overlooked in the past. However, in any patient with dysphagia
or food impaction, esophageal biopsies should be obtained, even if the mucosa
appears normal.
4.6.2 Biopsy Procurement and Evaluation

Histological findings are a cornerstone in establishing the diagnosis of EoE. It is
therefore mandatory to take mucosal biopsies, fixed in formalin, from all patients

(A) (B)

(C) (D)
Figure 4.1 (See color insert following page 112) Endoscopic findings associated with
EoE. (A) Mucosal rings representing transient contractions or fixed structures, this aspect is
also called trachealization, feline esophagus, or corrugated esophagus. (B) After esophageal
dilation a deep mucosal laceration is seen representing a typical finding (“longitudinal shear-
ing”). (C) Whitish exudates scattered across the mucosal surface, representing eosinophilic
microabscesses. (D) Esophageal furrowing representing mucosal edema and thickening.
in whom EoE is suspected, e.g., those with dysphagia or food impaction, even if
themucosaappears normal. Of note, in a study of 381 children with EoE, 30% had
a normal appearing mucosa on endoscopy.12 Regarding the patchy nature of the
eosinophilic infiltration, the question is how many biopsies must be taken to achieve
an appropriate sensitivity. Gonsalves and colleagues showed that with a histological
cut-off value of 15 eos/HPF, the procurement of one single biopsy specimen had a
sensitivity of 55% for diagnosing EoE, whereas the analysis of five biopsy specimens
resulted in an almost 100% sensitivity.32 Areas of gross endosopic abnormalities as
well as proximal and distal esophageal mucosa should be assessed histologically.
Furthermore, biopsy specimens also should be obtained from stomach and duode-
num to rule out other diseases, such as eosinophilic gastroenteritis.
4.6.3 Intraesophageal pH Monitoring
There exists a critical overlap between EoE and GERD. When the diagnosis of gas-
tro‑esophageal reflux disease versus EoE is not apparent despite endoscopy and histol-
ogy, intraesophageal pH monitoring may be of use in excluding pathologic reflux as
the reason for esophageal eosinophilia. Alternatively, an upper endoscopy after six to
eight weeks of high-dose PPI treatment can help determine the etiology of esophageal
eosinophilia.
4.6.4 Motility Studies
Nonspecific motor abnormalities have been described in patients with EoE, but these
are not diagnostic.
4.6.5 Radiography
In patients with dysphagia, an upper gastrointestinal (GI) contrast study may show
a narrowed esophageal lumen. It might also be beneficial for children presenting
with vomiting to rule out anatomic etiologies, such as malrotation. The radiographic
information is also important for the subsequent upper endoscopy because it may
alert the endoscopist to use a smaller caliber endoscope and prepare the endoscopist
for the possible need for a dilatation. In contrast to patients presenting with dys-
phagia, an upper GI contrast study is generally not useful in patients presenting with
symptoms typical of GERD, e.g., heartburn.
4.6.6 Histopathologic Features of Eosinophilic Esophagitis

The key diagnostic criterion for diagnosing EoE is an increased number of intraepi-
thelial eosinophils. Values between >5 Eos/HPF up to >30 Eos/HPF have been used
by the different research groups. In a consensus conference, a cut-off value of ≥15
Eos/HPF in any biopsy was recommended as diagnostic criterion.33 The eosinophils
are counted under 400 fold magnification. The peak and not the mean number of
eosinophils is used for diagnosis. Of note, relevant intraepithelial counts of eosino-
phils (>20/HPF) have also been reported in adults with GERD.34
In addition to their abundance in EoE, eosinophils often form microabscesses5
and can accumulate in the superficial layers of the squamous epithelium.10 Most
investigators report a basal zone hyperplasia, which occupies more than 20% of the
epithelium.5,11 Papillary lengthening was variably defined and was reported in 50
to 100% of cases of EoE.10,11,13 Epithelial ulcers were rarely reported, and lamina
propria fibrosis is seldom reported, probably due to the absence of lamina propria
in most esophageal pinch biopsy specimens.35 Figure 4.2a,b demonstrates the typi-
cal histologic findings of EoE. Beside eosinophils, mast cells and lymphocytes are
frequently found in eosinophilic esophagitis.
4.6.7 Allergologic Evaluation in EoE

EoE affects mainly patients with preexisting atopic conditions, such as aller-
gic rhino-conjunctivitis, asthma, oral allergy syndrome, and atopic dermatitis.12
The knowledge of an individual pattern of sensitizations is important, particu-
larly if elimination diet therapy is considered. In some cases, a complementary
examination by an allergist regarding other atopic diatheses may be useful (weak
evidence).33
100µm
(A)
(B)
Figure 4.2 (See color insert following page 112) Eosinophilic esophageal inflam-
mation in EoE. (A) The low-power field (Hemalaun-Eosin, 200-fold magnification) of
the epithelium demonstrates an increased number of eosinophils, basal zone hyper-
plasia, elongated rete papillae, and subepithelial fibrosis. (B) The high-power field
(Hemalaun-Eosin, 400-fold magnification) of the epithelium demonstrates a large number
of eosinophils, some of them are marked by a green star. (Micrographs courtesy of CH.
Bussmann, Kantonhospital, Luzern, Switzerland.)
4.6.8 Laboratory Analyses in Eosinophilic Esophagitis

4.6.8.1 Peripheral Eosinophil Count
Between 10 and 50% of adults and 20 to 100% of the children with EoE have a mild
eosinophilia on their differential blood count.2,9 The values seldom exceed 1500 eos/
mm3. The determination of a differential blood count, therefore, may provide sup-
portive evidence for the presence of EoE, but a peripheral eosinophilia is not diag-
nostic nor does it correlate with the disease activity.
4.6.8.2 Total IgE, Aeroallergen-Specific IgE, Food-Specific IgE

More than 70% of EoE patients have elevated total immunoglobulin E (IgE) val-
ues.10,13 So far, there is no evidence for the role of total IgE as a surrogate marker for
disease progression or resolution; patients with high total IgE levels do not readily
respond to corticosteroids compared to patients with normal values.42
With our present limited understanding of the pathogenic role of food and aero
allergens, the value of measuring specific IgE levels is limited.
4.6.8.3 Skin Prick Testing for Antigen Sensitization and Atopy Patch Testing
The combination of prick skin tests and atopy patch testing has shown promising
results with regard to food elimination diets and food reintroduction in patients with
EoE. However, its use should be reserved until its role in the diagnosis and manage-
ment of EoE is determined.33
4.6.8.4 Eotaxin-3 Measurements
One study documented twofold elevated eotaxin-3 levels in the peripheral blood of
EoE patients compared to normal controls and controls with chronic noneosinophilic
esophagitis.17 Eotaxin-3 expression and its genetic variation seem to be promising
markers of distinguishing EoE from other causes of esophagitis. Future research
concerning the reversibility of eotaxin-3 levels with therapy and their prognostic
significance deserve investigation. Until now, assessment of eotaxin-3 remains a
research tool and correlations with disease severity and activity remain to be further
evaluated.33
4.7 Treatment of Eosinophilic Esophagitis

The optimal treatment for EoE has not been defined, as experience has been limited
largely to case series and small controlled trials.38 Similarly, it is currently uncer-
tain whether treatment of symptoms alone is sufficient or whether resolution of
the eosinophilic inflammation is required. Thus, patients should ideally be treated
within the context of a clinical study. Following are the data regarding efficacy and
safety of known EoE treatments.
4.7.1 Proton Pump Inhibitors

Acid suppression with PPIs is almost mandatory as a part of fulfilling the diagnostic
criteria for EoE.10,12 In addition, it may be used for patients with established EoE
who have symptoms due to concomitant GERD. Nevertheless, PPI treatment should
not be considered as a primary treatment for patients with EoE, rather as co-therapy
because it sometimes alleviates symptoms in part.
4.7.2 Corticosteroids
Several clinical trials and many case series have demonstrated that systemic and
topical corticosteroids are highly effective in resolving symptoms and signs of acute
flares of EoE in both children and adults.39–42 A comparison of topical with sys-
temic corticosteroids has shown that there is no significant difference regarding
the efficacy of these two different forms. However, when topical or systemic cor-
ticosteroids are discontinued, the disease generally recurs within a few weeks. In
general, topical corticosteroids are used as first line medications. They are well tol-
erated and, with the exception of oropharyngeal Candidiasis, are almost free of side
effects. The use of systemic corticosteroids, therefore, may be limited to emergent
cases, such as dysphagia requiring hospitalization, dehydration because of swallow-
ing difficulties, or if the inflammation persists despite adequate dosage and correct
application of topical corticosteroids. On the basis of expert opinion and the current
literature, suggested starting doses range from 440 to 880 µg/day for children and
880 to 2000 µg/day for adolescence/adults. The drug is administered by mouth and
can be given in two or four doses per day.33 It is very important to familiarize the
patient with the method of administration; patients should be instructed to adminis-
ter the medication without the use of a spacer. The spray or dose inhaler should be
inserted into the mouth and sprayed with lips sealed around the device. The spray or
powder should then be swallowed and not rinsed. It is important to instruct patients
not to eat or drink for 30 minutes after each dose in order to ensure a long contact
time of the esophagus with the steroid. Duration of treatment for flares is between
2 to 12 weeks. Afterwards, patients are often treated with a maintenance regimen
with lower doses of topical corticosteroids up to one year. There is an urgent need
for studies to clarify treatment schedules and pharmacodynamic of topical cortico
steroid treatment.43
4.7.3 Leukotriene Receptor Antagonists and Mast Cell Stabilizers

Cromolyn sodium has no apparent therapeutic effect for patients with EoE.
Leukotriene receptor antagonists have been shown to induce symptomatic relief at
high dosages; however, its use has not been shown to have any effect on esopha-
geal eosinophilia. The measurements of mucosal leukotriene levels do not suggest a
potential therapeutic benefit. The use of these drugs for the treatment of EoE is not
supported by the current literature and, therefore, should be omitted.33
4.7.4 Biologicals
Novel biologic agents, such as monoclonal antibodies directed against IL-5 (e.g.,
mepolizumab) or TNF-alpha blocking agents (e.g., infliximab) present a unique
opportunity for certain patients with EoE.44 These molecules await larger clinical
trials and cannot be recommended for routine use at the present time.33
4.7.5 Dietary Treatment

Individual adjusted elimination diet, semiadjusted six-food elimination diet (removal
of the six most common allergenic foods, such as dairy, eggs, wheat, soy, peanuts,
fish/shellfish), and protein-free elemental diet have shown to be effective in the treat-
ment of children and adults diagnosed with EoE.36,37,45 When deciding on the use of
a specific dietary therapy, the patient’s lifestyle and family resources also need to
be considered. So far, dietary treatment has been more effective in children than in
adults. The use of dietary therapy in adults requires further evaluation.33
4.7.6 Esophageal Dilation
Esophageal dilation is useful for patients with symptoms not responding adequately
to medical therapy, mainly patients presenting with a functional narrowing of
the esophagus.46 This condition may occur as a sequela of the chronic, untreated
eosinophilic inflammation. There is a substantial risk of mucosal tearing and frank
perforation, especially if rigid procedures are performed.47 Because the responsive-
ness of strictures cannot be predicted on endoscopic appearance, we recommend
whenever possible to perform a therapeutic attempt with topical corticosteroids or
with an elimination/elemental diet, prior to dilation. We prefer Savory bougienage
because the effect is exerted along the entire length of the esophagus. Respecting
the abnormal fragility of the EoE mucosa, an inspection of the esophagus should be
done following dilation to assess for laceration. One study has shown that dilations
increasing the initial esophageal diameter up to 3 mm per session can be regarded
as safe.48 Therefore, several sessions may be necessary until the EoE patients benefit
from dilation therapy.
4.8 Monitoring of Patients with

Eosinophilic Esophagitis
In children, as in adults with EoE, regular visits are recommended focusing on symp-
toms, adherence to therapy, and adverse effects. The goal is to improve the recogni-
tion of complications associated with chronic esophageal eosinophilia. Follow-up
endoscopies are indicated in patients with refractory or relapsing symptoms or if
therapeutic decisions have to be performed.
4.9 Outlook/Future Research
Despite the fact that our knowledge of EoE has increased enormously during the last
decade, there are still many unresolved issues:
• Our understanding of the natural history is very limited.

• We have no predictive factors to identify patients who are at risk of develop-
ing esophageal remodeling.
• We need methods to distinguish between pure EoE and GERD-associated
esophageal eosinophilia.
• Noninvasive markers to monitor disease activity must be developed and
validated.
• The long-term medical management is still not defined.
• The management of patients’ refractory to standard therapies is still
controversial.
• The management of asymptomatic patients with esophageal eosinophilia

is unclear.
Further joint efforts of clinical researchers and basic scientists addressing these
issues are urgently needed in order to improve the lives of affected children and
adults with eosinophilic esophagitis.
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inhaled corticosteroids. J Pediatr Gastroenterol Nutr 1998; 27: 90–93.
41. Lipworth BJ, Systemic adverse effects of inhaled corticosteroid therapy: a systematic
review and meta-analysis. Arch Intern Med 1999; 159: 941–955.
42. Konikoff MR, Noel RJ, Blanchard C, et al. A randomized double-blind, placebo-
controlled trial of fluticasone proprionate for pediatric eosinophilic esophagitis.
Gastroenterology 2006; 131: 1381–1391.
43. Aceves SS, Bastian JF, Newbury RO, et al. Oral viscous budesonide: a potential
new therapy for eosinophilic esophagitis in children. Am J Gastroenterol 2007; 102:
2271–2279.
44. Simon D, Braathen LR, Simon HU. Anti-interleukin-5 antibody therapy in eosinophilic
diseases. Pathobiology 2005; 72: 287–292.
45. Spergel JM, Andrews T, Brown-Whithehorn TF, et al. Treatment of eosinophilic
esophagitis with specific food elimination diet directed by a combination of skin prick
and patch tests. Ann Allergy Asthma Immunol 2005; 95: 336–343.
46. Schoepfer AM, Gschossmann J, Scheurer U, Seibold F, Straumann A. Esophageal stric-
tures in adult eosinophilic esophagitis: dilation is an effective and safe alternative after
failure of topical corticosteroids. Endoscopy 2008; 40: 161–164.
47. Straumann A, Bussmann C, Zuber M, Vannini S, Simon HU, Schoepfer A. Eosinophilic
esophagitis: analysis of food impaction and perforation in 251 adolescent and adult
patients. Clin Gastroenterol Hepatol 2008; 6: 598–600.
48. Aceves SS, Newbury RO, Dohil R, et al. Esophageal remodeling in pediatric eosino-
philic esophagitis. J Allergy Clin Immunol 2007; 119: 206–212.
5 Management of Chronic
Nausea and Vomiting
Gregory S. Sayuk and C. Prakash Gyawali
Contents
5.1 Introduction..................................................................................................... 74
5.2 Functional Nausea and Vomiting.................................................................... 74
5.2.1 Definition and Diagnostic Criteria...................................................... 74
5.2.2 Epidemiology....................................................................................... 75
5.2.3 Pathogenesis......................................................................................... 75
5.2.4 Clinical Manifestations....................................................................... 76
5.2.5 Natural History.................................................................................... 76
5.2.6 Diagnostic Measures............................................................................ 77
5.2.7 Management........................................................................................ 77
5.2.8 Monitoring........................................................................................... 78
5.3 Cyclic Vomiting Syndrome............................................................................. 78
5.3.2 Epidemiology....................................................................................... 79
5.3.3 Pathogenesis......................................................................................... 79
5.3.5 Natural History....................................................................................80
5.3.6 Diagnostic Measures............................................................................80
5.3.7 Management........................................................................................ 81
5.3.8 Monitoring........................................................................................... 81
5.4 Delayed Gastric Emptying............................................................................... 82
5.4.2 Epidemiology....................................................................................... 82
5.4.3 Pathogenesis......................................................................................... 83
5.4.5 Diagnostic Measures............................................................................84
5.4.6 Management........................................................................................84
5.4.6.1 Nutrition................................................................................84
5.4.6.2 Pharmacologic Therapy........................................................84
5.4.6.3 Gastric Electrical Stimulation............................................... 85
5.4.6.4 Other..................................................................................... 85
5.4.6.5 Monitoring............................................................................ 85
References................................................................................................................. 86
73
5.1 Introduction
Nausea is a subjective awareness of an impending urge to vomit. It is always unpleas-
ant and can either precede vomiting or occur on its own. Patients use terms, such
as “sick to the stomach” or “queasy,” when describing this symptom. Vomiting or
emesis consists of rapid, retrograde, forceful ejection of gastric contents through the
mouth. Repetitive contraction of abdominal wall muscles, termed retching, generates
the pressure gradient necessary for the retrograde evacuation of stomach contents.
Retching can occur without vomiting and, therefore, without evacuation of gastric
contents. Vomiting can occur without preceding nausea in certain situations.1
Vomiting must be distinguished from regurgitation and rumination. Regurgitation
refers to passive retrograde movement of esophageal or gastric contents into the
mouth, typically not associated with nausea or retching. Rumination consists of
effortless regurgitation of recently ingested food into the mouth, sometimes followed
by rechewing and reswallowing or spitting out. This usually occurs soon after a
meal, may be repetitive, and may be a voluntary pleasurable experience.1
Nausea and vomiting can be classified as acute or chronic based on symptom
duration. Acute nausea and vomiting consist of symptoms of <1 month duration. This
designation is important, as etiologies and management strategies differ between
acute and chronic nausea and vomiting. When encountered in the acute setting, most
of the causes of nausea and vomiting usually fall into one of the following catego-
ries: medication induced (including chemotherapy-related symptoms), postoperative,
acute systemic infections, central nervous system disorders (including raised intrac-
ranial tension), gastrointestinal obstruction, gastrointestinal inflammatory disorders,
metabolic disorders, and pregnancy. In addition to treatment of the causative disor-
der, judicious use of antiemetic medications and attention to hydration, electrolytes,
and nutrition is typically sufficient in early management.
This chapter will focus on chronic nausea and vomiting encountered in gastroen-
terology practice. The following conditions will be discussed: functional nausea and
vomiting, cyclic vomiting syndrome, and delayed gastric emptying.
5.2 Functional Nausea and Vomiting

5.2.1 Definition and Diagnostic Criteria
Chronic nausea and/or vomiting (experienced on average at least once a week over
the preceding several months) in the absence of any structural or metabolic expla-
nation is regarded as functional nausea and vomiting. As defined by the Rome III
Diagnostic Criteria for the functional gastrointestinal disorders (FGIDs),1 functional
nausea and vomiting can be further subdivided into: (1) chronic idiopathic nausea,
(2) functional vomiting, and (3) cyclic vomiting syndrome. The specific diagnostic
criteria as established by the consensus of Rome III Committee are listed below.
Chronic Idiopathic Nausea

1. Bothersome nausea occurring at least several times per week
2. Not usually associated with vomiting
Management of Chronic Nausea and Vomiting 75
3. Absence of abnormalities at upper endoscopy or metabolic abnormali-

ties that explain the nausea
Functional Vomiting
1. On average one or more episodes of vomiting per week
2. Absence of criteria for an eating disorder, rumination, or major psychi-
atric disease according to DSM-IV
3. Absence of self-induced vomiting and chronic cannabinoid use and
absence of abnormalities in the central nervous system or metabolic
disease to explain the recurrent vomiting
Cyclic Vomiting Syndrome
1. Stereotypical episodes of vomiting regarding onset (acute) and duration
(less than one week)
2. Three or more discrete episodes in the past year
3. Absence of nausea and vomiting between episodes
Note: All of the criteria must be fulfilled to satisfy the diagnosis, and must be present
for the last three months with symptom onset at least six months prior to diagnosis.
Previously, chronic idiopathic nausea was regarded as having significant overlap
with functional dyspepsia (Rome II), but has since been recognized as a separate
condition given the lack of responsiveness of this syndrome to typical dyspepsia-
specific therapeutic approaches.1 Historically, functional nausea and vomiting has
also been called “psychogenic vomiting” in recognition of the substantial overlap
of these conditions with other psychiatric and functional co-morbidities.2–4 For the
purpose of this discussion, cyclic vomiting syndrome will be addressed separately
given its unique stereotypical pattern of presentation and responsiveness to specific
treatment strategies.
5.2.2 Epidemiology
Functional nausea and vomiting generally is regarded as an uncommon condition.
One tertiary care center reported a 5% prevalence of functional nausea and vomiting
following an extensive evaluation of other potential explanations of symptoms.5 No
clear gender predominance in seen in these conditions, and most commonly these
syndromes present in younger adults in their 20s or 30s, though initial presentations
can occur through the sixth decade of life.6
5.2.3 Pathogenesis
Inherent in the diagnosis of chronic idiopathic nausea and functional vomiting is a
lack of any structural abnormalities or biological derangements to explain symptom
experiences. Hence, the pathogenesis of functional nausea and vomiting has not been
fully elucidated. Early on, these disorders were regarded as being purely psychoso-
matic in origin, which is almost certainly an oversimplified explanation for these
disorders. Epidemiologic evidence supports a likely genetic contribution to these
disorders, though attempts to identify specific genes responsible for these disorders
to date have been disappointing.7 This is likely due to an important influence of both
early environmental learning and psychosocial factors in the expression of these

conditions. The potential for abnormal gastroduodenal motility underlying func-
tional nausea and vomiting has been examined, but unfortunately such abnormalities
are not consistently present in either chronic idiopathic nausea or functional vomit-
ing, and moreover these motor abnormalities at best only partially correlate with
symptoms.8,9 Visceral hypersensitivity holds potential in explaining not only func-
tional nausea and vomiting, but other functional gastrointestinal (GI) disorders (i.e.,
irritable bowel syndrome). Visceral sensitivity implies either a lower threshold to
abnormal gastroduodenal stimuli (visceral hyperalgesia) or increased sensitivity to
normal foregut stimuli (allodynia).10,11 This visceral hypersensitivity likely involves
the “brain–gut axis,” and reflects either an enteric sensitization at the level of the gut
or an overamplification of the afferent sensory signaling in the higher brain centers
responsible for the emotional, cognitive, and sensory interpreting of these ascending
visceral signals.12
5.2.4 Clinical Manifestations
Chronic idiopathic nausea (CIN) typically presents as significant nausea symptoms
that occur on several occasions throughout the week. CIN usually is not associated
with emesis. Functional vomiting patients typically complain of vomiting symptoms
at least once a week. These symptoms should be distinguished from the nausea and
vomiting that can occasionally be present with functional dyspepsia, often experi-
enced concomitantly with epigastric abdominal discomfort in the latter case. Chronic
idiopathic nausea and functional vomiting are chronic conditions, and are typically
present for at least six months. Usually, functional nausea and vomiting symptoms
are not associated with historical red flag features, such as weight loss or gastrointes-
tinal bleeding, and often patients do not experience symptoms that awaken them from
sleep. The presence of any such features should raise suspicion for another potential
cause of the patient’s nausea and vomiting (see Section 5.2.1). Importantly, func-
tional nausea and vomiting often co-exist with other functional disorders, both gas-
trointestinal (irritable bowel syndrome) nongastrointestinal (fibromyalgia, migrane
headache), as well as psychiatric conditions (depression, anxiety, somatization). The
presence of these co-morbidities should elevate one’s suspicion of the potential pres-
ence of a functional nausea and vomiting disorder to explain these symptomatic com-
plaints.13 Moreover, the presence of major depression or a conversion disorder alone
may predispose an individual to continuous vomiting symptom experiences.3
5.2.5 Natural History
The natural history of chronic idiopathic nausea and functional vomiting has not
been examined systematically. Often these conditions follow a waxing and waning
course wherein patients experience regular low grade symptoms with periodic exac-
erbations, typically lasting months to years. In contrast to cyclic vomiting syndrome
(Section 5.3), stereotypic asymptomatic periods lasting weeks to months are not typi-
cally reported.
5.2.6 Diagnostic Measures

Evaluation should exclude the presence of other important causes of chronic nausea
and vomiting, most notably gastroparesis, intestinal obstruction, or pseudo-obstruc-
tion, as well as central nervous system processes and metabolic derangements.
Appropriate testing usually includes an upper endoscopic examination, and a
small bowel x-ray (small bowel follow through, computerized tomography (CT)- or
magnetic resonance (MR)-enterography) to exclude small bowel inflammation or
obstruction. Scintigraphic gastric emptying study can be performed to assess for
gastroparesis. A limited biochemical evaluation should include serum chemistries,
thyroid testing, pancreatic enzyme assays, and assessment of adrenal function.
Performance of a serum or urinary beta-hCG to exclude pregnancy in women of
child-bearing age is warranted. A head CT should be pursued to exclude a central
nervous system (CNS) lesion. Further testing should be directed by the presence of
additional symptoms. Gastroduodenal manometry can be performed to assess for
an underlying enteric neuropathy, but typically must be performed at a tertiary care
center with considerable expertise, and as such, it is not routinely performed for
functional nausea and vomiting symptoms. In the absence of any overt abnormalities
following this focused diagnostic evaluation, a diagnosis of functional nausea and
vomiting is likely. It should be explained to the patient that any diagnostic evaluation
is not being performed to confirm the cyclic vomiting syndrome (CVS) diagnosis,
but rather is undertaken to exclude other less likely diagnoses.14
5.2.7 Management
Treatment recommendations for the management of functional nausea and vomiting
symptoms derive largely from anecdotal experience and small, nonrandomized ret-
rospective studies.15 First-line approaches typically implement traditional antiemetic
or prokinetic agents, which can be useful for symptom relief. Preferred agents include
the dopamine receptor antagonists prochlorperazine (5 to 10 mg PO/IM/IV q6h prn)
and chlorpromazine (10 to 50 mg PO/IM/IV q8h prn). These agents are generally
well tolerated, but have the potential for the development of side effects, which are a
consequence of the action of these agents on CNS dopamine receptors, and include
sedation, insomnia, mood lability, confusion, dystonia, and tardive dyskinesia. The
prokinetic agent metoclopramide (5 to 20 mg PO/IM/IV q6h prn), via its effects on
both 5-HT4 and peripheral dopamine receptors also can be used for acute symp-
tom relief. While its prokinetic effects may attenuate with continued use, metoclo-
pramide may continue to exert a central antiemetic effect. Similar potential for side
effects exist with this agent, particularly with long-term use, and include anxiety,
tremor, and Parkinsonian symptoms. The 5-HT3 receptor antagonists ondansetron
(4 to 8 mg PO/IV q8h) and granisetron (1 mg PO q12h) may also be used for acute
symptom relief of functional nausea and vomiting. While these agents are associated
with fewer side effects, their regular use may be cost-prohibitive. Domperidone, a
peripheral dopamine receptor antagonist, is a potent prokinetic agent with overlap-
ping antiemetic properties, and is another therapeutic option. As this drug does not
have substantial blood–brain barrier penetration, CNS side effects including mood
changes and dystonias are less common.16 At present, this medication is not available
in the United States, necessitating patient acquisition of this agent over the Internet
from international pharmacies.
The use of low doses of antidepressants, particularly the tricyclic antidepressants,
has been described as a prophylactic regimen for functional nausea and vomiting.
Agents, such as amitrityline, nortriptyline, and desipramine, at a maintenance dose
of 10 to 50 mg at bedtime, have been shown to be effective at suppressing functional
nausea and vomiting symptoms in retrospective analysis.17 Empirically, the selective
serotonin reuptake inhibitors (such as fluoxetine, sertaline, and citalopram), bupro-
pion, an inhibitor of neuronal dopamine and norepinephrine reuptake, and the anxi-
olytic buspirone may also provide suppressive relief of chronic nausea and vomiting
symptoms.18 However, randomized, controlled studies of these agents in this setting
currently are lacking.
Anecdotal and small clinical trial experiences have demonstrated that a host
of other alternative therapies, including ginger, hypnosis, psychotherapy, biofeed-
back, and acupuncture may be of adjunct benefit in functional nausea and vomiting
patients.19–21 In patients who remain medically refractory despite the above mea-
sures, the use of a gastric stimulator device (Enterra, Medtronic, Inc.), a pacemaker
device that delivers rapid electrical stimulation to the gastric wall via implanted
electrodes, can be considered. Recent data suggest that this device may be of benefit
to patient quality of life regardless of the presence of underlying delays in gastric
emptying.22 In the United States, placement of this device requires U.S. Food and
Drug Administration (FDA) humanitarian use approval and thus is performed only
in expert centers.
5.2.8 Monitoring
Monitoring of functional nausea and vomiting patients typically includes a periodic
assessment of serum electrolytes via a basic metabolic panel as hypernatremia and
elevated blood urea nitrogen (BUN) and creatinine may suggest a state of dehydration.
Contraction alkalosis with associated hypokalemia may also be present with more
severe, prolonged emesis. Patients should monitor weights at home on a regular basis
to allow for early detection of significant fluctuation in weight. Fortunately, these
objective features are more unusual in cases of functional nausea and vomiting.
5.3 Cyclic Vomiting Syndrome

Cyclic vomiting syndrome (CVS) is a chronic vomiting syndrome manifested by
stereotypical episodes of intractable vomiting, both in terms of onset and duration.
At least three such episodes should be documented before a diagnosis of CVS is
entertained. Importantly, the diagnosis of CVS implies a complete absence of vom-
iting symptoms between these acute episodes, typically lasting weeks to months.
Following a focused evaluation to assess for other biochemical or structural expla-
nations for these symptoms, no objective explanation is found. As such, CVS is
regarded as a functional GI disorder. Diagnostic criteria have been offered by the

Rome III Committee1 (see Section 5.2.1). Similar to other FGIDs, substantial overlap
exists with CVS and other psychiatric disorders, such as anxiety and depression.23
5.3.2 Epidemiology
Some important epidemiologic distinctions exist in comparing CVS to functional
vomiting and chronic idiopathic nausea. First, CVS is reported to affect males and
females equally. Whereas functional vomiting and chronic idiopathic nausea almost
uniformly are diagnosed in adulthood, a significant proportion of CVS patients are
diagnosed in childhood.24 Indeed, CVS was first described in pediatric populations,
and was later recognized in adult gastroenterology populations. When manifesting
in an adult population, CVS typically presents at an older age compared to other
functional vomiting disorders, often in the third or fourth decade of life. CVS is a
rare diagnosis, affecting <1% of individuals seeking gastroenterology consults at
referral centers.25
5.3.3 Pathogenesis
As with chronic idiopathic nausea and functional vomiting, a lack of overt structural
or biochemical abnormalities is implicit in the diagnosis. The specific pathophysi-
ologic mechanisms underlying CVS, however, remain poorly understood. This lack
of an appreciation of the etiology of this condition derives in part from the lack of
large patient cohorts to study. Present thinking implicates similar abnormalities in
visceral hypersensitivity and brain–gut function as in the case of chronic idiopathic
nausea and functional vomiting. Specific infectious, food product, hormonal (men-
ses), and psychosocial stressors may serve as triggering events that sensitize the indi-
vidual to such central dysfunction. Both physical and psychiatric factors that trigger
acute vomiting episodes have been described in a full two-thirds of pediatric CVS
cases.26,27 A multitude of other mechanisms to explain the pathogenesis of CVS have
been proposed, including abnormalities in autonomic neurotransmission28 and gas-
tric emptying,29,30 mitochondrial dysfunction,31 and derangements of the cortisol and
prostaglandin pathways.32–34 No single hypothesis, however, has been sufficient to
explain the biological basis of CVS.
The hallmark of CVS is stereotypical episodes of vomiting (“emetic phase”) with
interposed, asymptomatic periods (“well phase”). The acute vomiting episodes
experienced during the emetic phase of CVS can be quite intense, and will fre-
quently precipitate a visit to an emergency or urgent care setting for dehydration
and intravenous (IV) antiemetics. In contrast to functional vomiting, abdomi-
nal pain frequently accompanies the vomiting symptoms in as many as 70% of
patients.25,27,34 Prior to the onset of vomiting symptoms, 30% of CVS patients will
describe a prodromal phase, manifested by nausea, anorexia, lethargy, and head-
ache. As with migraineurs (those who experience migraines), a subset of patients
with antecedent prodromal symptoms will report aura-like symptoms. These pro-
dromal symptoms may last a few minutes to a few hours, and when present are
important to recognize as they provide a window of opportunity to intervene medi-
cally, and, in so doing, hopefully preventing more of the full-blown emetic phase
of the condition.
Early in the course, CVS patient symptoms are often incorrectly ascribed to an
infectious gastroenteritis until a pattern becomes more apparent. On average, these
acute vomiting attacks last three to five days, but may range from as short as a day
to as long as two weeks.25,34 The duration of episodes may be longer in adult subjects
compared to their pediatric counterparts.27 Given the relative rarity of this condition
and the varying frequency with which CVS patients experience vomiting attacks
(average every three months), CVS patients commonly experience a significant delay
in diagnosis and incorrect diagnoses prior to recognizing CVS.27,29 Patients with
CVS often are mislabeled as malingerers, psychiatric patients, and drug seekers. In
one study, patients had experienced symptoms for 6.3 (±1.8) years before a diagnosis
of CVS was made.25 Other conditions associated with CVS include migraine head-
aches, mood disorders (anxiety and depression, in particular), and other functional
GI disorders. A significant number of CVS patients will have overlapping diabetes
mellitus, distinct from the gastroparesis often associated with this condition. Chronic
marijuana use is also seen in CVS, with 42% of adult patients using marijuana in one
study.35 It remains unclear whether this is a causative factor or whether CVS patients
turn to marijuana for its purported antiemetic properties.
5.3.5 Natural History
No long-term follow-up studies have been performed on CVS patients to estab-
lish the expected course of this condition over time. The authors have followed
several patients with CVS with symptoms for more than 30 years, suggesting that
CVS patients can be intermittently symptomatic over the span of several decades.
Given the severity and duration of symptoms experienced during acute attacks, and
the cyclical nature of these symptoms, what is clear is the substantial social and
financial burdens that are imposed by this diagnosis, and CVS patients are often
on disability.

The differential diagnosis for CVS includes a host of gastrointestinal conditions,
including intermittent partial bowel obstruction, chronic intestinal pseudo-obstruction,
gastroparesis, cholecystitis, biliary dyskinesia, and peptic ulcer disease. Non-GI
conditions that might mimic CVS include CNS abnormalities (CNS lesion or hydro-
cephalus) as well as metabolic disorders (adrenal insufficiency), and a host of sys-
temic conditions (systemic lupus erythematosis, vasculitis, systemic mastocytosis,
hereditary angioedema, for example). The diagnostic evaluation should include the
basic evaluation as detailed in Section 5.2.6 above. Additional work-up beyond the
scope of this chapter may be indicated based on suspected diagnoses.
5.3.7 Management
The aggressive use of an effective abortive regimen is important in the prodromal and
emetic phases of CVS to minimize the severity and duration of symptoms. Patients
should have a prescribed antiemetic regimen on hand at all times to use at the ear-
liest signs of symptom onset. If symptoms progress in spite of the use of oral and
suppository agents, prompt attention in an urgent care or emergency room setting for
IV administration is appropriate. To facilitate this care, a detailed letter describing
the nature of the condition, previous evaluation, and the description of an effective
abortive regimen is provided by the authors to CVS patients. This is an effective
approach in minimizing superfluous testing and unnecessary delays in medical care.
The antiemetic agents described above in the management of functional nausea and
vomiting are indicated. Also potentially effective are the use of IV benzodiazepines,
such as lorazepam 1 to 2 mg IV every two hours as needed. A subset of patients,
particularly those with associated migraine headaches will respond well to the use of
5-HT1D agonists (sumatriptan, zolmitriptan).36 In cases where pain is a predominant
symptom, use oral or IV narcotics, such as fentanyl 50 to 100 mcg or dilaudid 0.5 to
1 mg q one to two hours as indicated. Provision of a quiet, stress-free environment
is indicated, and, in some cases, a warm bath or shower may be helpful. Supportive
care measures to consider in the acute phase include IV hydration with D5 ½ NS
and correction of any electrolyte deficits. Empirically, many experts also advocate
the use of a PPI (either orally or IV) to decrease gastric secretions and pH during the
emetic phase.37
Prophylactic therapy is the other important component to the medical manage-
ment of CVS. A prophylactic agent is worth considering in patients experiencing
more than two to three episodes of major vomiting per year. Though perhaps less
effective than in functional nausea and vomiting, the tricyclic antidepressants
(TCAs) are the authors’ first line prophylactic agents for CVS, and have the most
data in support of their use.25,38,39 Typically started at very low doses (25 to 50
mg at bedtime), and slowly titrated over weeks to months to doses in the moder-
ate range (75 to 150 mg at bedtime), 59 to 93% of patients will receive at least a
partial response, with a full quarter obtaining remission at higher doses.25,35 When
TCAs are not effective or not tolerated, other agents including the beta blocker
propranolol (40 mg twice daily)40 or the contemporary anticonvulsants zonisamide
(100 to 400 mg daily) or leveiracetam (500 to 2000 mg a day in divided doses) can
be considered as alternative agents.41 When acute symptoms are clearly linked to
menses, the use of oral contraceptives or leuprolide injections can be used.42 Given
the chronic, and often debilitating nature of this condition, many patients benefit
from the education and support resources available through the Cyclic Vomiting
Syndrome Association (www.cvsaonline.com).
5.3.8 Monitoring
Careful assessment of volume status and frequent monitoring of electrolytes is nec-
essary during the emetic phase as biochemical derangements are common during
periods of intense emesis. As treatment goals often are focused on the decrease of
emetic phase duration, severity, and frequency rather than a complete remission of
symptoms, it is important that an open line of communication exists between the
gastroenterologist so that the CVS course can be documented and closely monitored
in order to make objective assessments of therapeutic progress.
5.4 Delayed Gastric Emptying

The term gastroparesis is loosely used for all situations of delayed gastric emptying
encountered on a solid phase gastric emptying study. Common symptoms include
nausea, vomiting, and abdominal pain; patients may also complain of bloating, early
satiety, abdominal distension, and weight changes.43–45 In mild cases, weight and
nutrition may be maintained with minor dietary modification with or without medi-
cations. In moderate cases, sometimes termed compensated gastroparesis, dietary
and lifestyle adjustments allow for adequate nutrition with concurrent pharmaco-
logic agents. When severe, patients are symptomatic despite pharmacotherapy and
dietary adjustments, and are unable to maintain nutrition and body weight with oral
intake. These patients may require frequent hospitalization and enteral feeding distal
to the stomach.43
5.4.2 Epidemiology
In the absence of mechanical gastric outlet obstruction, symptomatic abnormal delay
in emptying of the stomach in the postprandial state can be encountered in up to 4%
of the general population, predominantly in females.43,44 There is considerable over-
lap between true gastroparesis related to neuromuscular dysfunction of gastric emp-
tying and functional dyspepsia with associated delayed gastric empyting. Therefore,
the true prevalence of gastroparesis is difficult to estimate. Dyspeptic symptoms
compatible with delayed gastric emptying, including nausea and vomiting, can be
encountered in 11 to 18% of diabetics.46,47 The prevalence of delayed gastric empty-
ing as documented by a gastric emptying study is thought to be much higher, docu-
mented in as many as 48 to 65% of diabetics at a tertiary care center.48 This suggests
that a delay in gastric emptying in diabetics, although frequent, may be asymptom-
atic and not require pharmacologic therapy. Further, nausea and vomiting symptoms
correlate poorly with the degree of gastric emptying delay in diabetic patients in
both short- and long-term follow-up.48–50 Therefore, it is likely that the majority of
diabetic patients with nausea and vomiting have a functional etiology for symptoms.
As many as a third of patients with functional dyspepsia have been demonstrated to
exhibit gastric emptying delays, especially in the presence of postprandial fullness
and vomiting.51,52 Heightened visceral sensitivity associated with gastric distension
may trigger symptoms in both diabetics and patients with functional dyspepsia.53,54
For these reasons, clinically significant “gastroparesis” needs to be distinguished
from functional dyspeptic symptoms that could potentially improve with neuromod-
ulator therapy. When nutrition, body weight, and fluid balance are impacted by a true
mechanical impact of delayed or absent gastric emptying, alternate routes of feeding
need to be considered; this is typically achieved with enteral feeding distal to the
pylorus by means of a jejunostomy tube.
5.4.3 Pathogenesis
Normal gastric emptying requires relaxation and tonic contraction of the gastric fun-
dus to accommodate food and to set gastric tone, coordinated phasic distal gastric
and antral contractions to break down food particles to 1- to 2-mm sized particles,
pyloric relaxation in between antral contractions to allow these small particles to
exit the stomach, and adequate antropyloroduodenal coordination to ensure smooth
motor function.45,55 Migrating motor complexes (MMC) ensure emptying of non-
digestible solids, wherein coordinated contraction of the distal stomach is associ-
ated with persistent pyloric relaxation.56 Disruption of these physiologic mechanisms
can result from autonomic neuropathy, enteric nerve abnormalities, and dysfunction
of the interstitial cells of Cajal (ICC).57,58 In diabetics, vagal autonomic neuropathy
may lead to abnormal postprandial gastric accommodation, incoordinated antroduo-
denal contractions, and sometimes pylorospasm.55,59 Fluctuations in blood glucose,
especially hyperglycemia can affect gastric motor function.60,61 Viral illnesses can
sometimes trigger acute onset of symptoms, wherein motor abnormalities including
antroduodenal incoordination and abnormal fundic accommodation can be demon-
strated.62 Psychosomatic factors have also been associated with gastric motor abnor-
malities in patients with functional dyspepsia.63,64 In a subset of patients, no clear
precipitating mechanism can be elucidated for similar pathophysiologic alterations
when the delayed gastric emptying is designated idiopathic.65
Presenting symptoms of delayed gastric emptying include nausea, vomiting, post-
prandial abdominal fullness and bloating, early satiety, abdominal pain, and weight
loss. Nausea and vomiting are the most frequently reported presenting symptoms,
reported by 92% and 84% of 146 patients with gastroparesis in one series.65 In the
same series, 89% had abdominal pain or discomfort, 75% had abdominal bloating,
and 60% had early satiety. These symptoms have considerable overlap with func-
tional dyspepsia. Complications of gastric emptying delay and gastroparesis can
include a propensity for gastroesophageal reflux and esophagitis, Mallory–Weiss
tears at the gastroesophageal junction from retching and emesis, formation of bezo-
ars in the stomach, fluid and electrolyte abnormalities from associated emesis, and
nutritional deficiencies including weight loss and vitamin deficiencies.45,66
One of the first steps in the evaluation of the patient with suspected delayed
gastric emptying is to rule out mechanical obstruction at the gastric outlet or far-
ther distally. This can be achieved with endoscopic examination or radiographic
upper gastrointestinal series, specifically looking for pyloric stenosis, peptic ulcer
disease, and neoplasia. Further, the presence of retained gastric food residue or
bezoars after an overnight fast suggests delayed emptying.15,45 A small bowel
x-ray series or cross-sectional imaging of the abdomen can exclude small bowel
processes associated with proximal small bowel obstruction. Manifestations of
functional and cyclic nausea and vomiting can overlap with those from delayed
gastric emptying, and a careful history can help distinguish these conditions as
described in the sections above.17,25

The finding of food residue in the stomach after an overnight fast on upper endo-
scopic examination can suggest delayed gastric emptying. Quantification of empty-
ing of a solid phase meal using gastric emptying scintigraphy is considered the gold
standard for the diagnosis of delayed gastric emptying.55,67 However, the value of
gastric emptying scintigraphy in directing management remains in question.68 The
test is typically performed using 99 mTc sulfur colloid labeled egg sandwich or egg
whites after an overnight fast.67,69 Scintigraphic imaging is continued for at least 90
to 120 minutes; extending the test to four hours is thought to improve the accuracy
and specificity in the identification of delayed gastric emptying.70
A 13C-labeled breath test can indirectly estimate gastric emptying. A 13C-labeled
medium chain triglyceride (octanoate)-based breath test has been demonstrated to be
reproducible, and may correlate with solid phase scintigraphic scans.55 13C-labeled
spirulina, a protein-rich blue-green algae is being validated as an alternate substrate
for breath testing. Antroduodenal manometry can help differentiate between neuro-
pathic and myopathic mechanisms of gastric motor dysfunction, while electrogas-
trography assesses gastric myoelectrical activity; these techniques have little value in
patient management, but may help elucidate pathophysiologic mechanisms leading
to delayed gastric emptying.45,55
5.4.6 Management
Diabetic patients with delayed gastric emptying benefit from good control of blood
sugars, since hyperglycemia may promote gastric motor abnormalities.
5.4.6.1 Nutrition
Liquids leave the stomach quicker than solids, and emptying is passive relative to
gastric tone. Dietary fiber and high fat content retard gastric emptying. Therefore,
patients with delayed gastric emptying are advised to consume frequent, small meals
that have low fat content and minimal fiber. Liquids and soups are beneficial. If
weight loss or nutritional deficiencies persist despite maximal dietary and pharma-
cologic therapy, enteral feeding distal to the pylorus needs to be entertained. This
is best achieved through an endoscopically or surgically placed jejunostomy tube.
A venting gastrostomy tube may be necessary to relieve gastric retention in these
situations. Total parenteral nutrition is rarely indicated, usually when small bowel
feeding is not tolerated.55
5.4.6.2 Pharmacologic Therapy

Metoclopramide is a dopamine and serotonin receptor antagonist that has both anti-
emetic and prokinetic properties. While the antiemetic effects are central, prokinetic
effects are from local effects on cholinergic neurons, dopamine, and muscarinic
receptors in the proximal gut.55 While short-term efficacy is documented, tachyphy-

laxis ensues, and long-term utility in the management of delayed gastric emptying has
not been proved.71,72 Central nervous system side effects, particularly jitteriness, tremor
and extrapyramidal deficits can be limiting, and can be seen in some form in as many
as 40% of patients.72 Domperidone, an alternate dopamine receptor antagonist, may be
better tolerated,73,74 but is only available in the United States by direct import through
an FDA-approved investigational new drug (IND) process.55 Erythromycin induces gas-
tric emptying by stimulating motilin and cholinergic receptors, and is most effective
when used intravenously for short periods.75 Oral administration is less effective, and
may be associated with side effects. Cisapride accelerates gastric emptying and small
bowel transit, but has been withdrawn because of the risk of fatal cardiac arrhythmias.76
Tegaserod was also studied as a potential prokinetic agent in delayed gastric emptying,
but has also been withdrawn from the market due to risk of vascular events.77
Improvement of chronic vomiting can be expected in 75% of patients with sup-
pressive therapy using low dose tricyclic antidepressants. In an open label study, a
similar benefit was achieved regardless of the presence of delayed gastric emptying.78
The mechanism of action is unknown, but may be related to effects on central neural
pathways involved in the process of vomiting.79
5.4.6.3 Gastric Electrical Stimulation

High-frequency electrical stimulation of the stomach using an implantable device is
reported to improve nausea and vomiting, but does not necessarily accelerate gastric
emptying.80 Open label studies suggest a decreased need for nutritional support with
the electrical stimulator, mainly from decreased frequency of emesis and fewer hospi-
talizations. Improvement in nausea and vomiting was noted in 60 to 75% of subjects in
open label trials; a multicenter study with one year follow-up suggested a 50% reduc-
tion in nausea and vomiting.80,81 Diabetics responded more favorably compared to idio-
pathic gastroparesis in a double-blind cross-over study.82 However, data are insufficient
for a more robust recommendation of this device, and human trials are hampered by
inconsistency in diagnosis of gastroparesis and the invasive nature of the device.80
5.4.6.4 Other
Intrapyloric injection of botulinum toxin has been reported to improve gastric emp-
tying of solids in open label studies,83,84 but symptomatic benefit was lacking in a
double-blind placebo-controlled cross-over study.85 Near-total gastrectomy has been
rarely performed for patients with significant gastric stasis, with reported symptom-
atic benefit in 43%, but with a complication rate of 40%.86
5.4.6.5 Monitoring
Patients with delayed gastric emptying and gastroparesis need to be monitored for
fluid, electrolyte, and nutritional deficiencies. Hospital admissions may be neces-
sary for correction of fluid and electrolyte imbalances. It is estimated that 2 to 5%
of patients require multiple hospitalizations for management of refractory or ongo-
ing symptoms.87 Ongoing management hinges on adequate symptom suppression
and maintenance of oral nutrition, without overt attempts to improve gastric motor
physiology.78
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6 Celiac Disease
Peter David Howdle
Contents
6.1 Introduction and History................................................................................. 91
6.2 Epidemiology...................................................................................................92
6.3 Small Intestinal Pathology in Celiac Disease..................................................94
6.4 Pathogenesis of Celiac Disease.......................................................................96
6.4.1 The Environmental Factor...................................................................96
6.4.2 Genetic Predisposition.........................................................................97
6.4.3 The Mucosal Immune Response.........................................................97
6.5 Clinical Features of Celiac Disease................................................................. 98
6.5.1 Celiac Disease in Childhood...............................................................99
6.5.2 Celiac Disease in Adults......................................................................99
6.6 Associated Diseases....................................................................................... 100
6.7 Diagnosis of Celiac Disease.......................................................................... 101
6.7.1 Celiac Antibody Tests........................................................................ 101
6.7.2 Small Intestinal Biopsy...................................................................... 102
6.8 Diagnostic Pathway....................................................................................... 102
6.9 Treatment of Celiac Disease.......................................................................... 104
6.10 Response to Treatment with a GFD............................................................... 105
6.11 Compliance with a GFD................................................................................ 105
6.12 Prognosis of Celiac Disease.......................................................................... 105
6.13 Follow-Up of Celiac Disease......................................................................... 105
6.14 Complications of Celiac Disease................................................................... 106
6.14.1 Refractory Celiac Disease................................................................. 106
6.14.2 Ulcerative Jejunitis............................................................................ 107
6.14.3 Small Intestinal Malignancy............................................................. 107
6.15 Future Developments in Celiac Disease........................................................ 108
6.16 Conclusions.................................................................................................... 108
References............................................................................................................... 108
6.1 Introduction and History

Physicians have been aware for centuries of a clinical condition that was probably
celiac disease. The word celiac is derived from a Greek word meaning “belonging
to the belly” and it is claimed to have first been used for a medical condition by
Aretaeus from Cappadocia (now part of modern Turkey) who practiced in Rome
in the second century ad. However, the first accurate description was published in
91
1888 by Samuel Gee1 of St. Bartholomew’s Hospital in London. His description of

the clinical features remains remarkably accurate even when we now know so much
about the disease. He was also percipient in that he said that “if the patient can be
cured at all, it must be by means of diet.”1 During the subsequent 60 years, few
advances were made although many dietary manipulations were tried, including the
famous “banana diet.” Some of these diets worked because, unknown to the recom-
mending physician, the patients were obtaining carbohydrates from elsewhere and
avoiding wheat to a large extent.
In 1950, Willem Dicke, a pediatrician in Holland, showed that wheat was impli-
cated in causing the clinical symptoms of celiac disease (CD).2 It is said that he
formed this opinion partly out of his observation that when wheat and rye were
unavailable in Holland during World War II his young patients improved, only to
relapse when these cereals became available at the end of the war. Dicke and co-
workers went on to show that the gluten fraction of wheat produced evidence of
malabsorption in children with CD.3
Two other major advances were made during the 1950s. John Paulley provided an
accurate description of the typical gastrointestinal lesion from operative specimens
from patients with CD.4 The development of peroral biopsy instruments enabled
small intestinal mucosal biopsies to be obtained without abdominal surgery.5,6
Since these seminal findings our understanding of CD has increased markedly.
Much is known about the genetics of the disease, the moiety in gluten that is involved,
the detail of the mucosal abnormality, and the immunopathogenesis.
Celiac disease can be defined as that disorder in predisposed individuals in which
there is an abnormality of the small intestinal mucosa manifested by contact with the
gluten fraction of wheat and the similar fractions in rye and barley. It is important to
note that this definition refers to a predisposition (the genetics of the disease), to an
abnormality of the small intestinal mucosa (but does not state the degree or type of
abnormality since we now know this is very variable), and to fractions of three cere-
als: wheat, rye, and barley (but not a specific “toxic” peptide). Some explanation of
all these caveats will be given in Section 6.3 and Section 6.4.
6.2 Epidemiology
Many patients with celiac disease remain undiagnosed, partly because they have
minimal symptoms and partly because, unfortunately, many clinicians fail to con-
sider the diagnosis. Hence, the true prevalence is unknown. However, there are many
recent studies estimating the prevalence in developed countries using serological
tests in normal populations (e.g., blood donors). The estimates range from 1:100
to 1:400;7–10 these figures are considerably higher than those previously quoted at
1:100011 and 1:300012 and reflect the fact that many people with minimal or no symp-
toms are never diagnosed. In the United Kingdom, there is good evidence that the
prevalence is 1:100,7,13 but clinical estimates suggest only 1:800 are diagnosed. These
figures have led to the concept of the “celiac iceberg” (Figure 6.1).14
At the tip of the iceberg there are diagnosed patients with clinical disease with
a known abnormal small intestinal mucosal biopsy. Their symptoms may be gas-
trointestinal or nongastrointestinal (often called atypical, e.g., anemia, osteopenia).
Celiac Disease 93
Abnormal mucosal biopsy

Diagnosed CD
serology
Positive
Silent CD
HLA-DQ2/8
Normal mucosal biopsy

Potential / Latent CD
Negative
serology
Healthy individuals
Figure 6.1 (See color insert following page 112) The Celiac Iceberg. (From Maki M,
Collin P. Coeliac disease. Lancet 1997, 349, 1755–1759. With permission.)
Beneath them, below the waterline, are patients who are undiagnosed; they have
few, if any, recognized clinical features, but do have an abnormal mucosa on biopsy
(silent CD). Both of these groups of patients would be expected to have a positive
serological test. Beneath them, there are individuals who are likely to develop evi-
dence of celiac disease. Those with potential CD have a normal small intestinal
mucosal biopsy, but may have a positive serological test and a predisposition to
develop the disease, e.g., a blood relative with CD. Those with latent CD constitute
a very small number of individuals who have a normal mucosal biopsy while taking
a normal (gluten containing) diet, but at some other time, either previously or later,
have an abnormal mucosa that responds to gluten withdrawal.15 They also may have
a positive serological test. This latter group provides evidence of the dynamic nature
of gluten sensitivity in some individuals. Finally, at the base of the iceberg is a large
number of healthy individuals with normal small intestinal mucosa and negative
serology who never develop CD, but who have the same predisposing HLA (human
leukocyte antigen) genes as the other groups who have CD.
These epidemiological findings are mainly reported for Caucasian populations
of European decent, i.e., Europe, Australia, the Americas. The reported prevalences
reflect the genetic inheritance, the developed healthcare systems, and the frequency
of wheat use in the diet. The prevalence in the United States is said to be variable,
which may reflect the diverse racial mix and varying dietary traditions. It certainly
seems that from an evolutionary viewpoint the prevalence of the disease reflects
the spread of wheat cultivation from the fertile crescent in the Middle East where
agriculture began. The disease is rare in countries with traditionally rice or maize-
based diets. It is described in those Asian countries where wheat is commonly used
in the diet, but rarely, if ever affects those of purely African Caribbean, Chinese, or
Japanese decent. These latter groups presumably inheriting a slightly different HLA
genotype irrespective of the traditional cereal component of their diets.
The disease is frequently reported to affect adult females more than males (2:1),
although the sex ratio in children is equal. This may reflect the willingness of women
to seek medical investigation.
In many developing countries diagnostic facilities are almost nonexistent, mal-
nutrition is common and many gastrointestinal symptoms are due to infectious dis-
eases; hence, CD will not be considered nor regarded as a major medical issue.
6.3 Small Intestinal Pathology in Celiac Disease

The definition of CD given above includes an abnormality of the small intestinal
mucosa. It is in the upper portion of the small intestine that the classical abnormali-
ties were described and which are sought in order to make the diagnosis. In modern
medical practice biopsies of the upper small intestine (distal duodenum beyond the first
part) are easily obtained using a routine gastroscope. Ideally, four mucosal biopsies
should be obtained and orientated correctly for histological examination. In CD, it is
the mucosa only that is usually affected and when there are major abnormalities these
can be seen under the dissecting microscope where, in CD, the surface looks flat, often
with a mosaic appearance. There is an absence of villi and the entrances to the crypt
vestibules are obvious. A comparison with normal mucosa is seen in Figure 6.2a,b.
Histological sections confirm the absence of villi or loss of villous height with
an increase in crypt depth and in inflammatory cells. A comparison with normal
mucosa is seen in Figure 6.3a,b. In CD, the surface enterocytes are cuboidal rather
than columnar and have a much more immature appearance. The crypt cells have a
normal appearance in CD, but have a greatly increased cell turnover with a reduced
cell cycle time, as reflected by the crypt hyperplasia.
As well as these villus—crypt changes, the mucosa has a large increase in inflam-
matory cells. There is an early increase in intraepithelial lymphocytes (IELs) (pre-
dominantly CD8+ve) accompanied by increases in lymphocytes (predominantly
CD4+ve), plasma cells, macrophages, polymorphs, eosinophils, and mast cells in
the lamina propria. Together with the crypt hyperplasia, this means that the mucosal
thickness is similar to normal, despite the loss of villous height.
a b
Figure 6.2a/b (See color insert following page 112) (a) Untreated celiac mucosa
at dissecting microscopy (×10); (b) normal mucosa at dissecting microscopy (×10). (From
Howdle PD. Encyclopedia of Food Sciences and Nutrition, Elsevier, Amsterdam, 2003. With
permission.)
Celiac Disease 95
a b
Figure 6.3a/b (See color insert following page 112) (a) Histological section of
untreated celiac mucosa (×40); (b) histological section of normal mucosa (×40). (From
Howdle PD. Encyclopedia of Food Sciences and Nutrition, Elsevier, Amsterdam, 2003. With
permission.)
Electron microscopic examination of the enterocytes in CD reveals degenera-
tive changes including shortened and distorted microvilli on the brush boarder (see
Figure 6.4a,b for comparison with normal).
Marsh, in a series of elegant studies, showed how dynamic these changes were
in the mucosa, particularly in relation to the amount of gluten present.16 He graded
the pathological features on a scale of 0 to 4. Type 0 was “preinfiltrative” where the
mucosa is normal, but the patient may have positive serology. Type 1 was “infiltra-
tive” with an increase in IELs but normal architecture. Type 2 was “infiltrative/
hyperplasic” with an increase in IELs and LP lymphocytes as well as crypt hyper-
plasia, but villi of normal height. In Type 3, “flat destructive,” there is villous atrophy
as well as the other features. Types 2 and 3 represent those features commonly seen
in newly diagnosed celiac patients. Type 4 “atrophic hypoplastic” is very rare and
irreversible. There is not only villous atrophy but total hypoplasia of the mucosa. It
leads to severe malabsorption and is normally untreatable and often fatal.
Routine biopsies of the duodenum in untreated celiac disease do show variability
in the mucosal changes. Hence, the lesion is said to be “patchy.”17 This emphasizes
the need for several diagnostic biopsies.
The mucosal changes are more severe proximally in the small intestine, so that
in most patients there is a length of mid to lower small intestine that is normal. This
partly explains the variety and severity of symptoms between patients. Nevertheless,
the distal mucosa is gluten sensitive and typical changes occur if gluten is instilled
in the ileum.
a b
Figure 6.4a/b (a) Electron micrograph of microvilli on an untreated celiac entero-

cyte (×40,000); (b) electron micrograph of microvilli on a normal enterocyte (×40,000).
(From Howdle PD. Your Guide to Coeliac Disease. Hodder Arnold, London. 2007. With
permission.)
Treatment of celiac disease with a gluten-free diet (GFD) results in reversal of the
changes described with the mucosa returning toward normal.
6.4 Pathogenesis of Celiac Disease

CD has been a good clinical model allowing a greater understanding of intestinal
mucosal immunology. There are three factors involved in the pathogenesis of celiac
disease, as suggested in the definition of the disease: the environmental factor (glu-
ten), the genetic predisposition, and the mucosal immune system.18,19
6.4.1 The Environmental Factor

CD can only occur in populations and individuals who consume wheat and related
cereals as part of their diet. Dicke and co-workers in the 1950s showed that it was
the gluten content of wheat that was responsible for inducing the disease.3 Gluten is
the water-insoluble component of wheat flour and is a complex mixture of proteins.
When cooked, gluten gives food the texture that is very palatable. Gliadin is the
alcohol-soluble fraction of gluten, whereas glutenin is the insoluble fraction. There
are similar fractions in the related cereals rye and barley, the gliadin equivalents
being secalin and hordein, respectively. The phylogenic relationships of the cereals
are shown in Figure 6.5. The triticeae branch contains the celiac-inducing cereals,
and it can be seen that those more distantly related cereals are safe for celiac patients
to consume. Most investigations into the relevant pathogenetic fractions have been
performed on gliadins. The gliadin genes have large allelic variation so that the glia-
dins in a single wheat variety comprise a complex mixture.
The gliadins can be separated on the basis of molecular weight into α, β, γ, and ω
fractions, and the amino acid structure of several of these proteins has been described.
Several peptides from an α-gliadin have been shown to be immunologically active in
celiac disease. Interestingly, these are rich in proline and glutamine and are particu-
larly resistant to intestinal peptidases.18,20
Gramineae
Pooideae Bambusoideae Panicoideae
Triticeae Aveneae Oryzeae Andropogoneae Paniceae

Wheat, Rye, Oats Rice Maize (corn), Millet
Barley Sorgum
Figure 6.5 Taxonomic relationships of cereal grains. Celiac-inducing cereals are in the
triticeae group; oats, the most closely related is safe for the vast majority of celiac patients.
Other cereals are distantly related and are safe for celiac patients.
Celiac Disease 97
6.4.2 Genetic Predisposition

Involvement of the human leukocyte antigen region (HLA) on chromosome 6 has
been known for some time.21 More detailed analysis has revealed that almost 95% of
celiac patients have the genes that encode for HLA-DQ2 and the remaining 5% for
HLA-DQ8.22 These findings imply that possession of HLA-DQ2 or DQ8 is neces-
sary but not sufficient for the development of celiac disease, since 30% of the healthy
population also possess these genes. The genetic basis of CD is supported by the
clinical findings that 10% of blood relatives have the disease and that there is at least
70% concordance in monozygotic twins.23 Several non-HLA genes are also associ-
ated with CD, although their role has yet to be determined.24,25
6.4.3 The Mucosal Immune Response

Immune responses to gliadin peptides form the basis of the pathological changes
seen in CD, both innate and adaptive immune systems are involved. Certain gliadin
peptides (e.g., p31-43 from A-gliadin) have been shown to induce interleukin-15 in
enterocytes.26 IL-15 is involved in T-cell activation, in the activation of IELs express-
ing the NK-G2D natural killer cell receptor, and in the expression of the stress mole-
cule MIC-A on enterocytes. Interaction between enterocyte MIC-A and lymphocyte
NK-G2D results in direct enterocyte killing and is one way in which early damage
to the villi occurs.27,28 Such damage may also enhance the permeability of gliadin
peptides into the lamina propria.29
IL-15 activation of T-cells also relates to the adaptive immune response. In
this system, antigen-presenting cells (APC) expressing HLA DQ2/8 surface recep-
tors preferentially take up gliadin peptides, which have been deamidated by tis-
sue transglutaminase in the lamina propria.30,31 This deamidation of glutamine to
glutamic acid in the gliadin peptides increases their immunogenicity. The APCs
process the peptide and present it on the surface bound to the DQ2/8 receptors in
order to activate gliadin-sensitive CD4 + T-cells. This results in the release of a
variety of cytokines and other mediators involved in the inflammatory response
and results in the villous damage and crypt hyperplasia typical of CD (Figure 6.6).
As part of this cascade, B-cells are activated into plasma cells specifically pro-
ducing celiac-relevant antibodies (e.g., antigliadin, antiendomysial, antitissue
transglutaminase).18
The current understanding of the immune pathogenesis of the disease and its asso-
ciation with other autoimmune diseases, probably via a common genetic predisposi-
tion, has led to CD being considered an autoimmune disorder. The specific autoantigen
is unknown, but is probably a complex involving elements of a gliadin peptide and
tissue transglutaminase, against which specific antibodies are produced.32
It is important to note that other factors may have a role in the development of
CD by influencing the immune response. For example, breast feeding of infants and
the timing of the introduction of gluten into the diet may affect the development of
the disease.33 Certain gastrointestinal infections (e.g., rotavirus) may also increase
the risk.34
MICA Cytokines
IL15
Gliadin CD4
peptides APC
T cell
in lumen
Tissue
transglutaminase B cell
Antibodies
Figure 6.6 Pathogenesis of celiac disease. Wheat is digested in the lumen to gliadin
peptides. Resistant to further breakdown, they cross the epithelial layer stimulating IL-15
from enterocytes in the innate response. Gliadin peptides in the lamina propria are deami-
nated by tissue transglutaminase and processed by antigen-presenting cells for presentation
via HLA-DQ2/8 molecules to the T-cell receptor of CD4 cells. These initiate the adaptive
immune response leading to the characteristic mucosal pathology.
6.5 Clinical Features of Celiac Disease

Since CD is a disease affecting mainly the small intestine with varying severity, this
results in a number of clinical effects. There may be gastrointestinal symptoms, or
more systemic symptoms believed to result from the malabsorption of a variety of
dietary nutrients and from the underlying autoimmune nature of the disease. Thus,
patients can have a wide variety of clinical features of varying severity. Those with
predominantly gastrointestinal symptoms are said to have “classical” CD, those with
more general, mainly nongastrointestinal symptoms, are said to have “atypical” CD,
and those with no symptoms have “silent” CD. All of these patients would have the
characteristic features in a small intestinal biopsy. These clinical presentations are
reflected in the “iceberg” phenomenon described in Section 6.2. Clinical effects can
occur at any age, but there are two peaks of incidence, one in early childhood and
the other in middle age.14,19
Celiac Disease 99
6.5.1 Celiac Disease in Childhood

Approximately 30% of all patients who are eventually diagnosed with CD will have
had symptoms attributable to the disease in childhood, although not all of them
will have had the diagnosis made as children. The majority of children who are
diagnosed develop quite marked symptoms early in life between six months and two
years of age. Boys and girls are equally affected. Symptoms develop only after the
introduction of cereals to the diet. Longer breast feeding and later introduction of
cereals may reduce the risk of developing the disease.33
Affected infants develop diarrhea, vomiting, and a swollen abdomen. They are
generally unwell and irritable and fail to thrive. This is in marked contrast to their
initial progress.
In later childhood (2 to 10 years), children have more minor gastrointestinal symp-
toms, but may be shorter in height than expected with delayed growth and puberty.
They may be lacking in energy and have behavioral or learning difficulties. Anemia
and nutritional deficiencies may be detected. Some children are now detected follow-
ing screening of family members.
It is not known why CD is diagnosed less frequently in teenagers. Those who have
been diagnosed as children often find a gluten-free diet very difficult to maintain.
However, despite frequently consuming large amounts of gluten, they often have
none or few symptoms. Why this is the case is not known.
6.5.2 Celiac Disease in Adults

The clinical features of newly diagnosed adults with CD have changed consider-
ably in the past 25 years. Previously patients presented with marked gastrointestinal
symptoms and major weight loss. Nowadays, the majority of patients have few symp-
toms and are frequently diagnosed because of anemia or an incidental deficiency on
a routine blood test. This is mainly because clinicians are more aware of the disease,
there is a sensitive serological test and it is being diagnosed earlier.35,36
The peak age for diagnosing CD in adults is 40 to 55 years, although it can be
diagnosed at any age. More patients are being diagnosed over 65 years of age for
the first time. General lethargy is a common, and sole, presentation. The ratio of
diagnosed female to male adult patients is 2:1 and, although the reason for this is
unknown, it may reflect men’s reluctance to seek medical attention. Thirty percent
will have had symptoms in childhood, which could be attributable to the disease and
10% will have a family history.
Gastrointestinal symptoms are now seen less frequently at diagnosis, these are the
“classical” symptoms of diarrhea, abdominal bloating, and weight loss (Table 6.1).
Of people diagnosed with irritable bowel syndrome, at least 5% will have CD.37
Rather than being underweight, 30% of patients will be clinically overweight when
first diagnosed.38
More usually patients will present with “atypical” features (Table 6.1). Usually
these will be lethargy and a finding of anemia. Chronic symptoms with no clinical
diagnosis can lead to depression and anxiety. Patients may present with muscle and
joint pains, ataxia, and peripheral neuropathy. These neurological findings, although
Table 6.1
Classical and Atypical Presenting Clinical Features in CD
Classical Atypical
Diarrhea Fatigue
Abdominal discomfort Anemia
Abdominal swelling Vitamin deficiencies
Weight loss Osteopenia/osteoporosis
Indigestion Arthritis/arthralgia/myalgia
Mouth ulcers Ataxia
Nausea/vomiting Peripheral neuropathy
Constipation Epilepsy
Irritable bowel syndrome Reduced fertility
Delayed development Obesity
Childhood history suggestive of CD Depression/anxiety
Family history of CD
Incidentally positive serology or duodenal biopsy
rare are increasingly recognized. Epilepsy and cerebral calcification have been
reported, particularly in children, but these are rare. Osteopenia and osteoporosis
are common findings in untreated celiac disease, and, conversely, in patients with
“idiopathic” osteoporosis, 5 to 10% will be found to have CD.39
Problems with fertility have been reported in CD. In adolescent girls, puberty
may be delayed and women with a chronic disease have reduced fertility and an early
menopause. Well-treated female patients should have none of these problems and
fertility is normal in such patients, although celiac women tend to have their children
at a slightly later age than average.40
On clinical examination very few abnormal physical signs will be found in the
celiac patient, reflecting the nonspecific nature of many of the presenting symptoms.
For these reasons there are still many patients where it takes a long time for the
diagnosis to be made; this delay contributes to the psychological features of chronic
ill health.
6.6 Associated Diseases
There are several diseases or conditions that are associated with CD and which
occur more commonly in celiac patients than would normally be expected. These
are listed in Table 6.2. The more common of these are dermatitis herpetiformis,
insulin-dependent diabetes mellitus, thyroid disease, and immunoglobulin A (IgA)
deficiency. Many of those listed have an autoimmune basis that perhaps reflects a
common genetic basis for the diseases.41 Five to 10 percent of celiac patients may
develop type I diabetes mellitus (DM) or thyroid disease and these should be borne
in mind in the follow-up of celiac patients.42,43
IgA deficiency occurs in 1:40 of celiac patients compared to 1:400 of the general pop-
ulation. Thus, celiac patients may be prone to more minor infections, but these are not
Celiac Disease 101
Table 6.2
Conditions Associated with CD
Dermatitis herpetiformis
Type I diabetes mellitus
Autoimmune thyroid disease
IgA deficiency
Inflammatory bowel disease and microscopic colitis
Sjogren’s syndrome and other connective tissue disorders
Addison’s disease
Pulmonary fibrosis
Down’s syndrome
Turner’s syndrome
Cardiomyopathy
Sarcoidosis
Primary biliary cirrhosis
Persistent abnormal liver function
Chronic thrombocytopenic purpura
usually of any practical significance. The main practical problem is that IgA deficiency
may have a misleading effect on the antibody tests for CD (see Section 6.7.1 below).
Dermatitis herpetiformis (DH) is a rare skin disease characterized by intensely
itchy blisters on elbows, knees, buttocks, and torso.44 At least 90% of patients have
small intestinal mucosal abnormalities identical to those of celiac disease. Patients
also have the same HLA genotype and serological profiles as celiac disease. DH
patients have few if any gastrointestinal symptoms reflecting the relatively mild
nature of the small intestinal mucosal abnormalities normally seen in DH. The skin
lesion responds to treatment with dapsone, but also to a gluten-free diet, which is
also recommended for the small intestinal disease. DH patients can develop the same
complications or associated conditions as those with celiac disease. The pathogen-
esis of DH is not understood, but there is now evidence that a particular type of tissue
transglutaminase, which is specific to the skin, may be involved, presumably render-
ing gliadin more immunogenic for the skin.
6.7 Diagnosis of Celiac Disease

In view of the wide variety of symptoms and range of severity (including “silent”
disease), clinicians must have a high index of suspicion for CD. Routine blood tests
may show anemia, evidence of vitamin and mineral deficiency, or features of a
hyposplenic blood film, but none of these are specific for CD.
6.7.1 Celiac Antibody Tests

Serological tests have been available for some years, but have become more reliable
recently. Such tests usually measure IgA antibodies, but it should be remembered
Table 6.3
Range of Published Sensitivities and Specificities for
Serological Tests in CD
Serological Test Sensitivity Specificity
IgA antigliadin antibodies (AGA) 75–90% 82–95%
IgA endomysial antibodies (EMA) 85–98% 97–100%
IgA tissue transglutaminase antibodies (tTG) 90–98% 94–97%
that IgA deficiency is more common in CD, so that IgA levels should be measured or
IgG antibodies also assayed where there is any doubt. Antigliadin antibodies (AGA)
are present in CD, but the sensitivity and specificity are not sufficient for a reliable
clinical test.45 Recently antibodies to deamidated gliadin have been measured that
may develop into a more reliable test. Antiendomysial antibodies (EMA) are very
specific for CD and have a high sensitivity, hence, this is a reliable clinical test. The
endomysium is an element of connective tissue and it is now known that the antigenic
component of endomysium against which the antibodies develop is the enzyme tissue
transglutamase. Measurement of these antibodies (tTG) is also highly sensitive and
specific for CD. Therefore, this is also a reliable clinical test. Anti-tTG antibodies
are easily measured in the laboratory and, if positive, a confirmatory EMA is usually
also performed.45,46
The range of sensitivities and specificities of these tests using IgA antibodies is
shown in Table 6.3. Since none of these serological tests is 100% accurate, the diag-
nosis should always be confirmed by small intestinal biopsy.
6.7.2 Small Intestinal Biopsy

As already mentioned, when seeking to diagnose CD, four small intestinal biopsies
from the second/third part of the duodenum should be obtained via a routine upper
gastrointestinal endoscopy. These should be carefully orientated and the histological
sections reported by a pathologist with experience of celiac pathology. The charac-
teristic changes have already been described and are represented in Figure 6.3a.
6.8 Diagnostic Pathway
The diagnostic pathway for CD includes the use of both serological tests and mucosal
biopsy. Figure 6.7 shows a logical progression. Before proceeding with this scheme,
the clinician should ensure that the patient is taking a diet containing gluten.
When following such a diagnostic scheme, there is always a small number of
patients on the borderline. These cases should always be reviewed and investiga-
tions repeated if there is doubt or discrepancy. Where other causes of villous atrophy
(Table 6.4) are being considered specialist follow-up is necessary.
There are three further points to note. A follow-up biopsy 6 to 12 months after
starting a gluten-free diet was previously thought to be mandatory in order to show an
Celiac Disease 103
Clinical suspicion
of celiac disease
WEAK STRONG
Serology Serology and
(EMA, tTG, lgA) biopsy
Serology Serology Biopsy Biopsy positive, Biopsy Biopsy

negative, positive positive, serology negative, negative,
CD very serology negative. serology serology
unlikely positive - Consider positive, negative,
Biopsy CD confirmed other mucosal potential CD - CD
disease. Review excluded
See Table 6.4
Negative
Positive
Potential CD -
CD confirmed
Review
Figure 6.7 The diagnostic pathway. If the clinical suspicion of CD is weak (e.g., no sug-
gestive symptoms), serology is performed first. If the suspicion is strong, both serology and
a biopsy are performed. In patients with an abnormal biopsy (biopsy positive), but nega-
tive serology, other causes of villous atrophy (Table 6.4) must be considered. If excluded or
unlikely, the patient should be treated as CD with “false” negative serology. Follow-up biop-
sies will be needed to assess the mucosal response to gluten withdrawal.
Table 6.4
Causes of Villous Atrophy other Than CD
Infections: giardia, tuberculosis, HIV, Whipple’s disease, gastroenteritis in children
Tropical sprue
Eosinophilic gastroenteritis
Small bowel bacterial overgrowth syndrome
Crohn’s disease
Arterial disease
Drug and radiation damage
Zollinger–Ellison syndrome
Severe malnutrition
Immunodeficiency states, e.g., common variable immunodeficiency
Food intolerance, e.g., cow’s milk, soya protein, especially in children
improvement in the mucosal abnormalities and, therefore. to confirm the diagnosis.

In the majority of patients who respond well clinically and in whom the antibody test
becomes negative, a second biopsy is not necessary. Some patients still prefer such a
biopsy, however, and some clinicians still regard that as the best means to secure the
diagnosis. If symptoms persist or recur, however, further biopsies are always indicated.
In situations where a diagnosis has not been adequately made, for example, where
a patient started a GFD prior to investigation, it may be necessary to reintroduce
gluten in order to make a diagnosis. This process is called a “gluten challenge” and
the situation is probably best managed by a specialist gastroenterologist.
The final point relates to the degree of abnormality in the mucosa, which is neces-
sary to diagnose the disease. In the majority of patients, a Marsh type 2 or 3 lesion
is seen, which would be regarded as diagnostic.16 However, with milder degrees, it is
usually advisable to keep the patient under close review and to repeat mucosal biop-
sies in relation to a gluten-free or a gluten-enhanced diet in order to move toward a
definite diagnosis.
6.9 Treatment of Celiac Disease

Once celiac disease has been properly diagnosed, treatment can begin. The cor-
nerstone of treatment is, of course, life-long adherence to a gluten-free diet
(GFD). Initially, if patients have severe deficiencies or are seriously malnourished,
intravenous replacement may be necessary, but this is very rarely needed. Oral vita-
min supplements should be given initially to replenish any deficiency, but eventu-
ally normal nutrition can be maintained with an adequate GFD. Such a diet should
exclude foods containing products of wheat, rye, or barley. Obviously these cereals
form part of the staple diet in many parts of the world and it is a major step in chang-
ing to a GFD and it has a substantial impact on the daily life of the patient and his
or her family. A GFD can be very healthy, but helping a patient to establish such a
diet requires sensitive and sympathetic handling by medical, nursing, and dietetic
staff. An experienced dietitian is invaluable to a celiac patient.47
It must be stressed that a GFD can be palatable and nutritious. Many natural foods
can be eaten, such as vegetables, salads, pulses (legumes), fruits, nuts, meats, fish,
poultry, cheese, eggs, and milk. Historically, rice, maize (corn), and potatoes were
the substitutes for gluten-containing cereals. A number of grains, seeds, legumes,
and nut flours are now available that offer more variety, improved palatability, and
higher nutritional quality to a GFD.
There is good evidence that oats are safe for celiac patients to eat.48 The main
practical problem is cross-contamination with other cereals during manufacture.49
Oats from specialist suppliers should be pure. There is a very small number of celiac
patients who are sensitive to oats.50
In some European countries, wheat starch is allowed in a GFD, although the very
low level of gluten that may be present is strictly limited and this type of starch for
use in food manufacturing is called Codex wheat starch. There has also been major
European regulation for food labeling, so that now manufactured foods have a clear
indication as to whether wheat or gluten is present.
Celiac Disease 105
6.10 Response to Treatment with a GFD

The vast majority of patients begin to feel better within weeks of starting a GFD.
Even those who had very few or no symptoms initially often report a surprising gen-
eral feeling of good health.
This clinical improvement is reflected in the histological improvement of the
small intestinal mucosa, although this may take several months to improve signifi-
cantly. Positive serological tests will also become negative over this time if a strict
GFD is followed.
There are some clinical problems, however. Weight gain often occurs once absorp-
tion has improved in the small intestine. Some patients become constipated because
they are eating less fiber in trying to avoid gluten-containing cereals.
6.11 Compliance with a GFD

It can be difficult to comply totally with a GFD. Physicians and dietitians recognize
this.47,51 There are several reasons why patients find it difficult; for example, the
diet restricts lifestyle particularly when eating out or traveling. Children and teen-
agers find it particularly difficult to eat different food from their friends. Patients
with “silent” disease may not notice much difference in their few, if any, symptoms
and thus there is no incentive to stick to the diet. A GFD is more expensive than a
normal diet.
6.12 Prognosis of Celiac Disease

The prognosis of treated CD is excellent, with at least 90% of patients leading nor-
mal healthy lives. Well-treated patients have a normal life expectancy.
A small number of patients do not improve on treatment with a GFD. Most of
these have remaining symptoms, but some also have remaining mucosal abnor-
malities on follow-up biopsies. The reasons for a poor response are listed in
Table 6.5.
The most common reason is continuing gluten ingestion, either inadvertently or
knowingly. Hence, the need for follow-up by an experienced dietitian. The gastroen-
terologist should consider the other possibilities, particularly the rare complications
that are described below.
6.13 Follow-Up of Celiac Disease

Regular follow-up of treated celiac patients is recommended by several professional
gastroenterological associations.52 This allows adequate nutritional assessment of
the patient, education about the disease, and assessment of the diet. In particular,
osteopenia and osteoporosis should be assessed and treated if indicated. Routine
vaccination for all age groups should be performed according to national recom-
mendations, but pneumococeal vaccination for celiac patients is also increasingly
recommended.
Table 6.5
Reasons for a Poor Response to GFD
Continuing gluten ingestion
Incorrect initial diagnosis (see Table 6.4)
Lactose intolerance (primary or secondary)
Other food intolerances
Exocrine pancreatic insufficiency
Microscopic colitis
Co-existent irritable bowel syndrome
Complications of celiac disease: refractory CD, ulcerative jejunitis, small intestinal malignancy
6.14 Complications of Celiac Disease

There are three major complications of CD affecting the intestinal mucosa, which
lead to serious disease.
6.14.1 Refractory Celiac Disease

This condition is rare, and occurs in those patients with a symptomatic severe
small intestinal mucosal abnormality, which does not respond either primarily or
secondarily to a strict GFD for at least six months and is not explained by other
causes of a mucosal abnormality. Other causes of a poor response (Table 6.5) have
to be excluded.53 In primary cases, the mucosa never responds to a GFD, whereas
in secondary cases there has been a mucosal response to gluten withdrawal at
some stage.
Clinically these patients probably represent about 1% of the celiac population. Some
continue for many years with chronic ill health reflected by low body weight and per-
sistent lethargy, presumably due to ongoing malabsorption. Others follow a deteriorat-
ing clinical course with severe malnutrition and may require intravenous nutrition.
Refractory CD has now been classified into type 1 where there is a normal intra-
epithelial lymphocyte phenotype, with IELs exhibiting surface expression of CD3,
CD8, and T-cell receptors αβ and γδ, and type 2 where there is an aberrant IEL
population. In this latter type, the IELs express cytoplasmic CD3, but lack surface
expression of CD3, CD8, and the T-cell receptors. Immunohistochemical studies
can be performed on routine formalin-fixed mucosal biopsy specimens from these
patients. This allows differentiation between type 1 and type 2 refractory CD, since
in the former, IELs have a normal CD3 + CD8 + phenotype, whereas in type 2, IELs
have the abnormal CD3 + CD8- phenotype. The delineation of the two phenotypes is
mainly for prognostic purposes because those patients with type 2 and thus aberrant
IELs have a high risk of developing ulcerative jejunitis or enteropathy-associated
T-cell lymphoma (EATL), whereas type 1 patients, with normal IELs, have a much
more benign course.54–56
All patients with refractory CD should be investigated and monitored for the
development of further complications. Treatment has been tried with limited success
Celiac Disease 107
using steroids, azathioprine and cyclosporin. More recently, infliximab and cladrib-
ine (2-clorodeoxyadenosive) have been used, again with limited success.
6.14.2 Ulcerative Jejunitis

Rarely patients with refractory CD present in a severe clinical condition, with
dehydration, abdominal pain, diarrhea, and malnutrition. Not only do they have an
abnormal mucosa on biopsy, but also chronic multiple ulcers throughout the small
intestine. These can perforate, bleed, or cause obstructive features. Barium studies,
CT scanning, extensive biopsies, and laparotomy may be necessary. Histological
examination of the mucosal biopsies shows grossly abnormal features, frequently
with the abnormal IELs of type 2 refractory CD. This condition is probably a precur-
sor to lymphoma (see Section 6.14.3 below). Treatment with intravenous feeding and
major immunosuppression is usually tried, but with limited success. The prognosis
is very poor.
6.14.3 Small Intestinal Malignancy

There is a longstanding belief that celiac patients have a substantially increased
risk of malignancy, particularly small intestinal adenocarcinoma and lymphoma.
This resulted from early cohort studies from specialist centers. These results over-
estimated the risk.57,58 More recent population studies have shown that there is a
moderately increased risk of non-Hodgkin’s and small bowel lymphoma and small
intestinal adenocarcinoma. However, these tumors are all rare, so that the abso-
lute risk in any one celiac patient is still low. Of particular interest is the EATL,
which occurs in celiac disease. This commonly has the CD3 + CD8- phenotype
characteristic of the aberrant IELs in type 2 refractory CD, suggesting there is a
spectrum of clinical disease encompassing refractory CD, ulcerative jejunitis, and
enteropathy-associated T-cell lymphoma.
Patients with small intestinal adenocarcinoma commonly present with weight
loss, abdominal pain, abdominal mass, or anemia. They may have treated CD, which
appears to have relapsed, or they may present de novo, CD being diagnosed concur-
rently with the tumor.
Patients with small bowel lymphoma may present with malaise, anorexia,
weight loss, abdominal pain, or diarrhea. Once again, CD may be known or be
diagnosed concurrently.59
Investigation for small bowel malignancy involves barium studies, CT scan-
ning, capsule endoscopy, laparoscopy, or laparotomy, but it is notoriously difficult
to diagnose.
Treatment involves surgery and chemotherapy and the prognosis depends upon
the stage of the disease, but is generally poor.
There is also a slightly increased risk of cancer of the oropharynx, esophagus,
colon, and pancreatobiliary system in CD, although once again it must be stressed
that these tumors are rare in CD. Interestingly, breast cancer has a reduced incidence,
although the reason for this is as yet unknown.57,58
6.15 Future Developments in Celiac Disease

As a result of the greater understanding of the pathogenesis of CD, several thera-
peutic possibilities have been opened up.18 Bacterial prolyl endopeptidases have
been produced that breakdown immunostimulatory gliadin peptides to immuno-
logically inactive peptides and amino acids. Theoretically, these could be used as
dietary supplements to prevent low-level gluten exposure in patients. The identifi-
cation of dominant wheat gliadin epitopes is the initial step in producing a desen-
sitizing vaccine.
It may be possible to produce genetically modified (GM) cereals that have reduced
or absent T-cell stimulatory peptides, although this will be a major challenge for
plant scientists.
Other therapeutic possibilities include blocking tTG deaminating activity, block-
ing zonulin-mediated intestinal permeability, and blocking innate or adaptive
immune mechanisms.
A useful development will be the development of better screening assays for the
gluten content of foods.
6.16 Conclusions
CD occurs in up to 1% of the population in societies where wheat is a staple in the
diet. Modern serological tests have helped to increase the number of patients diag-
nosed. There is a wide spectrum of clinical presentations and the vast majority of
patients respond well to treatment with a GFD. Complications of the disease are rare
and the prognosis is good.
Recent developments in genetics, immunology, and molecular biology have
unraveled much of the pathogenesis of the disease and opened the way to novel
therapeutic possibilities.
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7 Probiotics in Irritable
Bowel Syndrome
Eamonn M. M. Quigley and Fergus Shanahan
Contents
7.1 Introduction................................................................................................... 113
7.2 Antibiotic Use and IBS.................................................................................. 114
7.3 Postinfectious IBS......................................................................................... 114
7.4 Inflammation and IBS................................................................................... 115
7.5 Qualitative or Quantitative Changes in the Enteric Flora (Microbiota)........ 115
7.6 Efficacy of Antibiotics in IBS........................................................................ 116
7.7 Efficacy of Probiotics in IBS......................................................................... 116
7.8 Conclusions.................................................................................................... 117
References............................................................................................................... 118
7.1 Introduction
While probiotics and prebiotics have been used for decades on an anecdotal basis to
address a variety of the ills that man is prone to suffer from, the scientific study of
probiotics in irritable bowel syndrome (IBS) is more recent and its emergence has
paralleled an emerging interest in the role of the microbiota in intestinal disorders.
The possibility that the enteric flora, or microbiota, could play a role in the patho-
genesis of IBS has only begun to attract concerted scientific attention very recently,
though evidence to suggest a link has been extant for some time and contains several
distinct, and even contradictory, strands:
1. Epidemiological evidence that antibiotic use may predispose to IBS or to

exacerbations thereof.
2. Epidemiological, clinical, and experimental evidence for the existence of
postinfectious IBS.
3. Evidence, both experimental and clinical, for a role for low-grade inflam-
mation (perhaps triggered by luminal bacteria) in IBS.
4. The suggestion that IBS may be associated with small intestinal bacterial
overgrowth (SIBO) or other changes in the gut flora.
5. Evidence to indicate that manipulation of the gut flora, by antibiotics or
probiotics, may ameliorate symptoms in IBS.
113
7.2 Antibiotic Use and IBS

In a survey of 421 subjects in a primary care practice in the United Kingdom, anti-
biotic use was strongly associated with an increased risk of IBS (odds ratio 3.7).1
Privileged childhood living conditions were also an important risk factor, which,
according to the authors, was consistent with an allergic or infectious etiology for
IBS. Other epidemiological studies have come to similar conclusions.2
7.3 Postinfectious IBS

We are now beginning to see real data to directly support the concept of postin-
fectious IBS.3 First reported by McKendrick and Read,4 the occurrence of IBS
following episodes of bacteriologically confirmed gastroenteritis has now been
documented in several studies.5–15 Thabane and colleagues concluded that the
overall risk for the development of IBS was increased sixfold following an episode
of bacterial gastroenteritis with younger subjects, those who have prolonged fever
during the episode of gastroenteritis and those who suffer from anxiety or depres-
sion being at greatest risk.16 These symptoms are not transient; in a Scandinavian
study in which 12% of their subjects had IBS within three months of gastroen-
teritis, 9% still had symptoms five years later.13 Neal and colleagues documented
similar recovery rates for postinfectious and nonpostinfectious IBS in a six-year
follow-up study.17
One study went on to establish a direct link between prior exposure to an infec-
tious agent, persisting low-grade inflammation and IBS.8 In this study, an increase
in the number of chronic inflammatory cells in the rectal mucosa was seen only
among those exposed patients who had developed IBS. Others have demonstrated a
persisting increase in rectal mucosal enteroendocrine cells, T lymphocytes, and gut
permeability in patients with postdysenteric IBS.9,10 These observations are impor-
tant as they indicate a relationship between perturbations of the microbiota, mucosal
inflammation, and IBS, an hypothesis that is amply supported by data from studies
in experimental animal models. The development of IBS has, recently, been linked
with non-GI infections,18 again, perhaps, invoking a role for a systemic inflammatory
response in the mediation of symptoms.
A number of parasites, such as Dientamoeba fragilis, Blastocystis hominis, and
giardia have been associated with the development of chronic gastrointestinal symp-
toms that may mimic IBS;19–20 whether parasitic infections can trigger IBS, per se, is
unknown. Very recently, an outbreak of viral gastroenteritis was associated with the
new onset of an IBS-type syndrome in 24% of affected subjects when interviewed
three months later; subsequent follow-up suggested that postviral IBS was more
transient than its bacterial counterpart.21
Postinfectious IBS may explain only a minority of cases of IBS (1 to 6.7% in one
recent study),22 but it does represent a clear link between exposure to an environmen-
tal agent, inflammation, and IBS in predisposed individuals.
Probiotics in Irritable Bowel Syndrome 115
7.4 Inflammation and IBS

Direct and compelling evidence for a role for mucosal inflammation in IBS was
first provided by Chadwick and colleagues among 77 IBS patients: 31 demon-
strated microscopic inflammation and 8 fulfilled criteria for lymphocytic colitis.
However, among the group with “normal” histology, immunohistology revealed
increased intraepithelial lymphocytes as well as an increase in CD3+ and CD25+
cells in the lamina propria. All, therefore, showed evidence of immune activa-
tion.23 Subsequent studies have provided further evidence of T-lymphocyte24,25 and
mast cell activation26–29 in the mucosa in IBS; others have demonstrated an exten-
sion of inflammation into the myoneural compartments30 and still others cytokine
profiles in peripheral blood mononuclear cells31,32 and serum33 compatible with a
proinflammatory state.
It is reasonable to suggest that these immunological changes could result from
exposure to an exogenous (such as bacterial) antigen challenge.34,35 That IBS patients
may be predisposed to an, albeit contained, inflammatory response to luminal triggers
is, indeed, supported by the finding of polymorphisms in genes that encode for the
production of anti-inflammatory cytokines among IBS patients 36,37 and by the very
recent description of high titers of antiflagellin antibodies in serum derived from IBS
patients.38,39
While the idea that IBS patients may truly harbor inflammatory changes in the
colonic mucosa is increasingly gaining credence,40 many important questions remain
to be answered and it is clear that this is going to be an area of active investigation
for some time to come.
7.5 Qualitative or Quantitative Changes

in the Enteric Flora (Microbiota)
For some time, various studies have suggested the presence of qualitative changes in
the colonic flora in IBS patients; a relative decrease in the population of bifidobacte-
ria being the most consistent finding.41–46 It should be noted, however, that these find-
ings have not always been reproduced and the methods employed have been subject
to question. Nevertheless, qualitative changes in the colonic flora, be they primary
or secondary, could lead to the proliferation of species that produce more gas45,46
and short chain fatty acids and are more avid in the deconjugation of bile acids.
With regard to the former, the displacement of gas-forming species could result in
local changes in gas production, a development that may be poorly tolerated by IBS
subjects who seem to have difficulties with the transport of gas along the intestine
and to be overly sensitive to gas-induced distension. The latter could, in turn, lead
to clinically significant changes in water and electrolyte transport in the colon and
affect colonic motility and/or sensitivity. Similarly, a repopulation of the flora with
the deficient commensal could restore homeostasis. Attractive as this concept may
be, it belies the challenges posed by attempts at a comprehensive description of the
flora in IBS, or in any condition.
Several factors limit the interpretability of prior studies, including the unrepre-
sentative nature of the fecal flora, a failure to describe those bacterial populations
that may be adherent to the mucosal surface and, above all, the recognition that a
very significant proportion of the colonic microbiota cannot be identified by conven-
tional culture methods. Molecular methods are now being applied to this complex
issue and have, indeed, confirmed that IBS patients, regardless of subtype, do exhibit
a fecal flora that is clearly different from control subjects.43,44,47,48 The precise nature
of these differences and their potential to disturb mucosal or myoneural function in
the gut wall, or induce local or systemic immune responses, remains to be defined.
More recently, the role of the gut flora in IBS has been taken a stage farther with
the suggestion that some IBS patients may harbor quantitative changes in the indig-
enous flora in the small intestine: small intestinal bacterial overgrowth (SIBO).49–53
The occurrence of SIBO has been associated with abnormalities in small intesti-
nal motor function54 and its eradication with symptomatic relief.49,50,53,55,56–58 These
striking results have been the target of much criticism on several grounds.59–65 First,
IBS symptoms are nonspecific and may be mimicked by SIBO, regardless of etiol-
ogy; patient selection, therefore, is an issue. Second, the hydrogen breath test, which
has been the test most widely used to make the diagnosis of SIBO in this context, is
subject to considerable error, especially in relation to altered small bowel transit,66,67
and, third, others have failed to confirm these findings.68–71
7.6 Efficacy of Antibiotics in IBS

The principal evidence for a role for antibiotics in IBS comes from studies among the
aforementioned IBS patients with associated SIBO.49,50,53,55,56 In a subsequent study
that did not document bacterial overgrowth, Pimentel and his colleagues treated IBS
patients with the poorly absorbed antibiotic rifaximin;72 some IBS patients, at least,
demonstrated a prolonged response (up to 10 week) to a short course of this antibi-
otic. As pointed out in an accompanying editorial, there are, however, several limita-
tions to this study that reduce its impact.73 In a recently reported multicenter phase
II study, 388 diarrhea-associated IBS subjects were randomized to either rifaximin
in a dose of 550 mg twice a day or placebo for 14 days, followed by another 14 days
on placebo alone and then 2 weeks follow-up. During treatment, at 4 weeks and at
12 weeks, those randomized to rifaximin had a modest 8 to 13% therapeutic gain for
adequate relief of global IBS symptoms and a rather diappointing 4 to 8% gain for
relief of bloating.74,75 However, the eradication of SIBO, as proposed by these authors,
may not be the sole explanation for these responses, which could also be explained on
the basis of a suppression of fermenting bacteria in the colon, as suggested by Dear et
al.46 and supported by the recent report from Sharara et al.76 Finally, one must remain
reluctant, pending long-term studies, to recommend a prolonged course of antibiotic
therapy to any population regardless of the safety profile of a given antibiotic.
7.7 Efficacy of Probiotics in IBS

Given their safety profile, probiotics, if effective, would at first sight appear to be
more attractive as potential manipulators of the gut flora in IBS. Are probiotics
effective in IBS? Several factors complicate the interpretation of clinical trials of

probiotics in IBS: many studies have been underpowered and some earlier studies
were even uncontrolled and not blinded. Furthermore, results between studies are
difficult to compare because of differences in study design, the use of nonvalidated
and differing endpoints, and variations in probiotic dose and strain. Nevertheless,
there has been some, but by no means consistent, evidence of symptom improve-
ment.77–97 Hamilton-Miller, in reviewing earlier studies and while drawing attention
to the shortcomings of prior trials in terms of study design, concluded that there
was, overall, sufficient evidence of efficacy to warrant further evaluation.98 More
recent reviews99,100 have explored the scientific rationale behind the use of probiotics
in IBS and reviewed the clinical results from studies performed over the past two
decades. Outcomes continue to be variable, some studies report little evidence of
efficacy,78,82,87,90 while others document responses only for specific symptoms, or in
selected populations.81,85,88,91,92–96 It is noteworthy that flatulence, bloating, and dis-
tension, common and distressing symptoms in IBS,101 seem especially responsive to
probiotic therapy, given the sensitivity of IBS subjects to gas-induced distension102 and
their difficulties with moving gas along the intestine.103 One probiotic combination
containing Bifidobacterium animalis (lactis) DN-173-010 has been shown to accel-
erate intestinal transit and reduce abdominal girth,97 no doubt explaining its ability
to increase stool frequency in IBS patients with constipation and providing some
objective evidence in support of an effect of probiotics on bloating.91 Some stud-
ies have employed probiotic “cocktails” rather than single isolates, rendering it dif-
ficult to deduce what were the active moieties.85,88,89,91–96 One particular probiotic,
B. infantis 35624 appears to have more global effects in IBS. In the first of two
studies with this organism, this Bifidobacterium was found to be superior to both a
Lactobacillus and placebo for each of the cardinal symptoms of the irritable bowel
syndrome (abdominal pain/discomfort, distension/bloating, and difficult defecation)
as well as for a composite score.31 More recently, these results were replicated in a
much larger, dose-ranging, primary care-based study involving 360 IBS subjects,
where B. infantis, in an encapsulated format and in a dose of 108, was associated with
significant improvements in the cardinal symptoms of IBS as well as in the subjects
global assessment of all symptoms; at study end, over 60% of subjects randomized
to the Bifidobacterium felt better than before therapy, a therapeutic gain of over 20%
over placebo.104 In both studies, a positive impact on IBS symptomatology occurred
independent of any effect on stool frequency indicating that the observed effects
were not attributable to either a laxative or antidiarrheal effect. These studies with
this particular B. infantis strain provide, therefore, evidence for a benefit in IBS for a
clearly defined single-organism probiotic preparation and, thereby, suggest that some
strains may be more effective than others for this indication.
7.8 Conclusions
Many recent findings add to a growing body of evidence to suggest that IBS, like
inflammatory bowel disease (IBD), may, in part at least, result from a dysfunc-
tional interaction between the indigenous flora and the intestinal mucosa, which,
in turn, leads to immune activation in the colonic mucosa. This does not place IBS
within the spectrum of IBD where the intensity and distribution of the inflamma-
tory process are vastly different.105 Some propose a role for bacterial overgrowth as
a common causative factor in the pathogenesis of symptoms in IBS; other evidence
points to more subtle qualitative changes in the colonic flora; both hypotheses
remain to be confirmed, but the likelihood that bacterial overgrowth will prove
to be a major factor in IBS now seems remote. On the other hand, the advent
of molecular techniques for the identification of the composition of the micro-
biota holds great promise for the identification of distinctive aspects of the flora
in IBS. A role for the flora in IBS is further supported by the observation that
short-term therapy with either antibiotics or probiotics does seem to reduce symp-
toms among IBS patients.106–108 It seems most likely that the benefits of antibiotic
therapy are mediated through subtle and, perhaps, localized, quantitative and/or
qualitative changes in the colonic flora. How probiotics exert their effects remains
to be defined, but an antiinflammatory effect seems likely. While this approach to
the management of IBS is in its infancy, it is evident that manipulation of the flora,
whether through the administration of antibiotics or probiotics, deserves further
attention in IBS.
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8 The Role of Nutrition
in Inflammatory
Bowel Disease
Food for Thought
Gerard E. Mullin, Melissa Munsell,
and Ashwini Davison
Contents
8.1 Introduction................................................................................................... 126
8.2 Epidemiology................................................................................................. 126
8.2.1 A Gene Nutrient Interaction.............................................................. 126
8.3 Pathophysiology............................................................................................. 127
8.3.1 Overview of IBD Presentation........................................................... 127
8.3.2 Chronic Inflammation....................................................................... 127
8.3.3 Malnutrition....................................................................................... 128
8.3.4 Mechanisms of Growth Retardation and Malnutrition..................... 129
8.3.5 Implications of Malnutrition.............................................................. 129
8.3.6 Nutrition and Bone Health................................................................. 130
8.3.7 Nutrient Deficiencies......................................................................... 130
8.3.8 Bone Health....................................................................................... 131
8.3.9 Anemia.............................................................................................. 131
8.4 Role of Parenteral Nutrition........................................................................... 132
8.5 Role of Enteral Nutrition............................................................................... 132
8.5.1 Mode of Action of Enteral Nutrition................................................. 133
8.5.2 Glutamine.......................................................................................... 133
8.6 Other Dietary Therapy in IBD...................................................................... 133
8.6.1 Polyunsaturated Fatty Acids.............................................................. 134
8.6.2 Short Chain Fatty Acids, Low Particle Diets, and Polyphenols........ 134
8.7 Phytonutrients in IBD.................................................................................... 135
8.7.1 Resveratrol......................................................................................... 135
8.7.2 Catechins........................................................................................... 135
8.7.3 Curcumin........................................................................................... 135
8.8 Supporting Colonic Microbes........................................................................ 136
8.8.1 Probiotics........................................................................................... 136
8.8.2 Prebiotics........................................................................................... 136
125
8.9 Food Intolerance and IBD............................................................................. 137

8.9.1 Gluten................................................................................................. 137
8.9.2 Fiber................................................................................................... 137
8.10 Summary....................................................................................................... 138
References............................................................................................................... 138
8.1 Introduction
Inflammatory bowel disease (IBD) is a chronic illness characterized by unremit-
ting intestinal inflammation caused by increased oxidative and metabolic stress.
Increased energy, macronutrient, micronutrient, and electrolyte requirements result
from thermodynamic demands of inflammation and tissue losses from intestinal
injury. Consequent protein-calorie malnutrition and micronutrient deficiencies are
common and require close supervision and corrective supplementation. Food har-
bors nutrients that play an important role in attenuating the unresolved inflammation
of IBD while optimizing healing and immunity. Dietary and nutritional strategies
have been studied as primary treatments in IBD. The following chapter reviews the
impact of nutrition on the sequelae and treatment of IBD.
8.2 Epidemiology
8.2.1 A Gene Nutrient Interaction

Incidence rates of IBD in the United States have remained stable over the past 30
years with the prevalence of ulcerative colitis estimated at 214 cases per 100,000
and Crohn’s disease at 174 per 100,000.1,2 In parts of the world such as Asia, it is
unclear if the increased incidence of IBD is due to improved diagnostic methods
or environmental triggers. For example, the increased incidence of IBD in Japan
has been concurrent with the integration of Westernized diets into the culture.3
Diets high in animal fat and sugar, but low in fiber, have been implicated in the
development of IBD.4–6 The exact etiology of IBD has yet to be identified, but it
has been proposed that genetically susceptible individuals develop disease when
there is an exaggerated immune response to an environmental trigger (i.e., infec-
tion, diet) in the gut microbiota. Since IBD is the result of a complex interaction
between genetic, immune, microbial, and environmental factors, it is highly plau-
sible that diet, as an environmental factor, may contribute to the pathogenesis.
For example, elemental diets have been shown to produce symptomatic relief
and objective remission in up to 90% of patients.7 Elemental diets do not contain
intact protein, unlike polymeric diets. In elemental diets, nitrogen is supplied in
the form of amino acids and dipeptides. In animal models of IBD, dietary protein
has increased intestinal permeability, and elemental diets have led to the resolu-
tion of this.8 Nutrition appears to play an integral role in the pathogenesis and
treatment of IBD.
The Role of Nutrition in Inflammatory Bowel Disease 127
8.3 Pathophysiology
8.3.1 Overview of IBD Presentation
Ulcerative colitis (UC) affects the colonic mucosa in a continuous manner and is
characterized by diarrhea, abdominal pain, and hematochezia. Crohn’s disease (CD)
is characterized by transmural inflammation that is discontinuous and may affect
any part of the gastrointestinal tract.9 The most common location of disease involve-
ment for CD is the small bowel where most nutrients are assimilated and absorbed.
Endoscopically, the mucosa is described as cobblestoned with evidence of aphthous
ulcerations. Radiographically, evidence of fistulae or stricturing disease may be
present. Patients with CD often have symptoms of abdominal pain from strictur-
ing disease, which limits nutrient intake, they also suffer from diarrhea because of
severe mucosal injury causing malabsorption of fat and lipid-soluble vitamins. The
loss of fluids, electrolytes, and minerals leads to weight loss and overall malnutrition
in these patients.
8.3.2 Chronic Inflammation
Chronic inflammation in IBD is characterized by the infiltration of monocytes and
polymorphonuclear neutrophils into the intestinal wall.10 The inflammatory response
becomes amplified by these cells that recruit and activate more inflammatory cells
to the lamina propria. It is believed that mononuclear cells mediate this immune
response via secretion of proinflammatory cytokines, such as tumor necrosis factor
(TNF), interferon-γ, interleukins, and eicosanoids (prostaglandin class 2, thrombox-
anes, and leukotriene class 4).11 Activation of NFκB stimulates expression of these
molecules, but also stimulates expression of protective molecules that inhibit inflam-
mation.12 This mechanism is not completely understood, but is thought to play a key
role in the acute and chronic inflammation of IBD.13 Studies have shown that short
chain fatty acids (SCFAs), such as butyrate, polyphenols, and n-3 fatty acids, can
reduce NFκB activity, providing hope that these may become nutraceutical thera-
peutic modalities for IBD.14–16
Linoleic acid is an essential polyunsaturated fatty acid (PUFA) and is a substrate
for eicosanoids. PUFAs are categorized into two main families: n-6 and n-3. Linoleic
acid is the parent compound to proinflammatory n-6 fatty acids and is found in fairly
high concentrations in red meat, corn, soybean, and safflower oils. The other class of
essential fatty acids are n-3 PUFAs of which the parent compound is α-linoleic acid.
These fatty acids play an important role in immunomodulation via the production
of prostaglandin class 3 and leukotriene B5, and the inhibition of arachidonic acid
production.17 The n-3 fatty acids are believed to compete with n-6 fatty acids as pre-
cursors for eicosanoid synthesis.18 N-3 fatty acids also reduce TNFα production by
inhibiting protein kinase C activity.19 N-3 PUFAs are found in flaxseed, canola, wal-
nuts, and oils from deep sea fish. The latter is a more valuable source of n-3 PUFAs
because humans do not readily transform α-linoleic acid to eicosapentaenoic acid
and docosahexaenoic acid, which are the main precursors for desirable eicosanoids.
Fish oil affects the gut immune system by suppressing T cell signaling, inhibiting
proinflammatory cytokine synthesis, reducing inflammatory cell recruitment, and

enhancing epithelial barrier function.20,21
Along with PUFAs, SFCAs are also thought to play a role in IBD pathogenesis.
SCFAs are monocarboxylic hydrocarbons produced when endogenous bacterial flora
in the colon digest nonabsorbable carbohydrates, such as acetate, propionate, and
butyrate.22 These dietary fibers include nonstarch polysaccharides, resistant starch,
cellulose, and pectins.23 Butyrate is a major source of energy for colonocytes and
early studies demonstrate that rectal epithelial cells in patients with UC have impaired
oxidation of butyrate, which may be caused by elevated levels of TNFα.24–26 Other
studies have shown that SCFAs, such as butyrate, may have an antiinflammatory
effect by down-regulating cytokines.27,28 Furthermore, SCFAs may promote colonic
sodium absorption.29 The therapeutic potential of SCFAs has been shown in both
animal and human studies in IBD.30
IBD results from the complex interplay between genetic, immune, and environ-
mental factors, including food and nutrients. Diets high in animal fats or sugar and
low in fiber have been implicated in IBD, but studies on the role of diet in IBD are
challenging to interpret because other lifestyle and environmental factors also play a
role.1 Dietary microparticles have also been theorized to be involved in the etiology
of IBD. Microparticles are bacterial-sized inorganic particles, such as titanium, alu-
minum, and silicone, which are found in Western diets, often as food additives. They
are thought to exacerbate inflammation by increasing intestinal permeability and
allowing for increased exposure to antigens.31,32 Although certain foods aggravate
IBD symptoms, there is no evidence linking specific foods as directly causing IBD.
The diet for patients with IBD should be a well-varied regimen that includes foods
rich in polyphenolsomega-3 fatty acids, and prebiotics. This should be coupled with
a healthy lifestyle in patients with IBD to minimize malnutrition, attenuate inflam-
mation, and optimize healing.
8.3.3 Malnutrition
Hospitalized patients with IBD have a higher prevalence of malnutrition than patients
hospitalized with other benign conditions.33 CD patients, in particular, are suscep-
tible to protein-calorie malnutrition, which contributes both to increased length of
stay and hospital costs.34,35 Protein-calorie malnutrition in IBD is often manifested
clinically by weight loss.36 Up to 70% of adult patients with CD are underweight
while fewer ambulatory patients with UC experience weight loss, as weight loss is
more commonly seen in hospitalized UC patients.37–39
Weight loss is also common in outpatients with Crohn’s disease and is seen in
up to 75% of these patients140–42 CD patients also have significantly lower lean body
mass.43 Even when they are in remission, 20% of patients remain 10% below their
ideal body weight.44 Male patients with CD have a significantly lower percentage
of body fat and hamstring muscle strength compared to healthy controls.38,45 The
reasons for protein-calorie malnutrition in IBD stem from ongoing inflammation
and catabolic proinflammatory cytokine production, hypothalamic pituitary adrenal
(HPA)-axis dysregulation, malabsorption of nutrients, and diminished intake due to
abdominal discomfort.
While weight loss in association with malnutrition is common, obesity can also
lead to protein-calorie malnutrition. Fat is often distributed in mesenteric fat, and
is independent of body mass index. “Creeping fat” is seen in CD and refers to fat
hypertrophy and visceral fat wrapping around the small and large bowel.1 It was
originally thought that creeping fat was simply the result of transmural inflam-
mation. Emerging data shows that mesenteric fat itself is proinflammatory and
produces TNFα along with proinflammatory adipocytokines.46 Hyperinsulinism,
cortisol and catecholamine imbalance, as well as enhanced proinflammatory
cytokines, can lead to obesity in some patients with IBD. Prednisone therapy can
contribute to weight gain by decreasing lipid oxidation and increasing protein oxi-
dation, thereby increasing fat stores and depleting muscle protein.47,48 The com-
bination of hyperinsulinism, corticosteroid use, and obesity can lead to unique
struggles for the patient with IBD.
8.3.4 Mechanisms of Growth Retardation and Malnutrition

Growth impairment in IBD results from poor nutrition, chronic inflammation, and
as a complication of medical or surgical therapy.49,50 Decreased oral intake is fre-
quently seen in those with active disease and may be due to anorexia or sitophobia.50
Even while in remission, patients may have lower daily intake of nutrients, such as
fiber and phosphorus.44 In addition to reduced dietary intake, malnutrition in patients
with Crohn’s disease results from malabsorption, enteric loss of nutrients, and rapid
GI transit time. Disease activity and extent can markedly influence the prevalence
and degree of malnutrition in CD.51 Patients with diffuse small bowel involvement
typically are more at risk for malnutrition. This is due to impaired absorption of
nutrients, similar to what is seen in patients with small bowel resection or bacterial
overgrowth.43,52,53 Genetic susceptibility may also play a role as children with NODII/
CARD15 variants in CD have lower height and weight percentiles.54 Insulin-like
growth factor (IGF)-1 has also been implicated in metabolic derangements in both
children and adults with IBD. Total and free IGF-1 levels are reduced in patients with
both Crohn’s disease and ulcerative colitis when compared to healthy controls. This
may be partially reversed by steroid therapy and TNF inhibitors.55–57 Once inflam-
mation and disease activity is controlled, the nutritional status of patients with CD
usually improves. Biologic therapies improve weight and body mass index (BMI) in
children with active CD who respond to treatment.58 Four to six years after patients
with UC undergo total proctocolectomy with ileal pouch-anal anastomosis, muscular
strength is increased by 11%, total tissue mass by 4.5%, and bone mineral density
by almost 2%.52
8.3.5 Implications of Malnutrition
Malnutrition has many detrimental effects including muscle breakdown, impaired
immunity, and delayed wound healing.59 In children, malnutrition leads to stunted
growth, and it leads to weight loss in patients of all ages.60,61 Patients with CD,
especially ileal or ileocolonic disease, have a greater loss of muscle than fat.40
They can develop hypoalbuminemia because of increased protein catabolism and
decreased synthesis. Once again this is due to ongoing inflammation, intestinal

protein loss, reduced hepatic protein synthesis, malabsorption, and anorexia.62
Villous atrophy and increased intestinal permeability may occur as a result of
malnutrition leading to poor nutrient absorption.63 Malnutrition on admission to a
hospital has been correlated with longer lengths of stay, higher costs, and increased
mortality when compared to normally nourished individuals.64,65 Patients with
IBD admitted to the hospital with hypoalbuminemia and evidence of malnutrition
require a prompt nutritional evaluation and early intervention. Individuals who
undergo an aggressive correction of their underlying malnutrition in the hospi-
tal setting have improved outcomes, lower morbidity, lower mortality rates, and
shorter hospital stays.66
8.3.6 Nutrition and Bone Health

Malnutrition, systemic inflammation, and corticosteroid use contribute to decreased
bone mineral density in these patients.67,68 The prevalence of osteopenia in patients
with IBD is 50% while the prevalence of osteoporosis is 15%.69 Though both patients
with CD and UC are at risk for decreased bone density, there is a greater risk in CD.70
One study showed that osteopenia is even seen in newly diagnosed patients with
IBD, prior to any steroid therapy.71 This is in contrast to another study demonstrat-
ing that women who developed IBD prior to age 20 are likely to have normal bone
mineral density as adults.72 Though steroid use has often been blamed for reduced
bone mineral density in IBD, it has been shown to be a weak predictor of osteopenia
in patients with CD. Age, body mass index, serum magnesium, and history of bowel
resections appear to be more important predictors for low bone mineral density.73,74
Calcium and vitamin D supplementation has been shown to maintain and increase
bone mineral density in patients with CD.75,76 Vitamin D can help regulate cytokine
responses and dampen inflammatory responses.77 The ability of vitamin D to influ-
ence the immunopathogenesis of IBD has been reviewed elsewhere.78,79 Biologic
therapy with infliximab is associated with increased markers of bone formation
without increasing bone resorption.80 Weight-bearing exercise should be encouraged
and smoking should be avoided. All women with IBD should be supplemented with
calcium and vitamin D according to the dietary reference intakes (DRIs). However,
most experts agree that given the prevalence of vitamin D insufficiency (25(OH) D
levels < 32 mcg/mL) in Crohn’s disease, supplementation should be individualized
to meet individual needs.
8.3.7 Nutrient Deficiencies
Vitamin and mineral deficiencies are commonly seen in IBD, especially that of
calcium and phosphorous These patients also are deficient in niacin, zinc, copper,
and vitamins A and C.81 Increased oxidative stress along with impaired antioxidant
defenses in the form of mucosal zinc, copper, and super oxide dismutase has been
shown in studies of serum and diseased intestinal mucosa.82 Every patient with IBD
should be screened at least annually for vitamin and mineral deficiencies. The body
Table 8.1
Prospective Studies of Short Chain Fatty Acids for Left-Sided Ulcerative Colitis
Study
No. Patients Duration Butyrate
Study Design (Treatment) (wk) Dose Results
Scheppach Single-blind 10 (Butyrate 2 100 mM ↓ Stool frequency,
enema) hematochezia,
↓ Endoscopic histologic
score
Breuer Crossover 10 (Placebo) 6 100 mL bid No change with placebo
Open-label 10 (SCFA 40 mM ↓ Disease activity index
enema) 100 mL bid ↓ Mucosal histology
score
Steinhart Open-label 10 (Butyrate 6 80 mM ↓ Disease activity index
enema) 60 mL qd 60% Response
40% Complete remission
Patz Open-label 10 (SCFA 6 40 mM 5/10 Endoscopic and
enema) 100 mL bid clinical improvement
Vernia Open-label 10 (Butyrate 6 80 mM 7/9 Endoscopic, clinical,
+ 5-ASA 100 mL bid and histologic
enema improvement
Source: Adapted from References 121 to 125.
systems most commonly impacted by nutrient inadequacies in IBD are summarized

in Table 8.1.
8.3.8 Bone Health

The relative risk of fractures is 40% greater in IBD patients than in the general popu-
lation. The risk of fracture is similar in CD and UC, and for both males and females
with IBD. The main nutrients involved in bone health are calcium, vitamin D, vita-
min K, and magnesium. As discussed earlier, vitamin D appears to have a role in
immunomodulation as well and exerts its effects via vitamin D receptors on T-cells
and antigen-presenting cells. Vitamin D can antagonize T-helper 1 proinflammatory
responses by interfering with antigen presentation and Th1 activation, upregulating
Th2 cytokines, and downregulation NFκB in macrophages.85
8.3.9 Anemia
Anemia is frequently seen in patient with IBD and may be due to iron, B12, or folic
acid deficiency. Measurement of serum B12 should be performed annually in patients
with ileal CD.83 Methylmalonic acid can be used as a more sensitive test for the
diagnosis of cobalamin deficiency.84 Hyperhomocysteinemia is seen in IBD and is
associated with decreased levels of vitamin B12 and folate.85
Table 8.2
Probiotics in IBD
Author Year Probiotic Result
Kruis 1997 E. coli Nissle 1917 Equal to mesalamine
Rembacken 1999 E. coli Nissle 1917 Equal to mesalamine
Guslandi 2000 S. boulardii Equal to mesalamine
Ishikawa 2003 Bifidobacterium milk Superior to placebo
Borody 2003 Stool enema Improved
Kruis 2004 E. coli Nissle Superior to conventional
Kato 2004 Bifidobacterium milk Superior to placebo
Furrie 2005 Bifidobacterium + fiber Improved
Source: Adapted from References 150 to 155, 158.
8.4 Role of Parenteral Nutrition

Total parenteral nutrition (TPN) with bowel rest was previously viewed as a primary
therapy for Crohn’s disease. However, a key study in 1988 demonstrated that com-
plete bowel rest was not a major factor in achieving clinical remission.86 The practice
of bowel rest varies from practitioner to practitioner. TPN carries a risk of sepsis,
cholestatic liver disease, and other complications listed in Table 8.2. Overfeeding
can also lead to problems in patients with IBD.87 In animal models, long-term TPN
use is associated with small intestinal atrophy and increased intestinal permeabil-
ity.88,89 A recent study of nationwide patterns of inpatient TPN utilization showed
that usage was associated with higher in-hospital mortality, length of stay, and hos-
pital costs ($51,729 versus $19,563).90 Enteral nutrition can prevent malnutrition in
patients with adequate bowel length and, when feasible, should be favored over TPN
due to preservation of mucosal integrity and a favorable adverse effect profile.91,92
8.5 Role of Enteral Nutrition

The role of enteral nutrition as primary therapy in IBD remains uncertain, par-
ticularly in adults. While enteral nutrition as primary therapy for active CD is less
successful in inducing remission than steroid therapy, it has a better response than
placebo.93,94 Meta-analyses have shown that remission rates with enteral feeds in
Crohn’s disease is approximately 60%.95,102 Oral diet supplementation with low resi-
due nutrition has been shown to improve nutritional status and decrease disease
activity in CD.96,97 One randomized control study showed that patients obtaining
half of their calories from an elemental diet and the remaining half from a poly-
meric diet had a reduced risk of relapse compared to patients receiving all of their
calories from a normal diet.98 Studies like this are difficult to perform because of
large dropout rates from intolerance of the study diet.18 In terms of the type of
enteral feeds, elemental diets have not been shown to be more successful in induc-
ing remission than nonelemental diets.99,104 In children, enteral nutritional support
has a positive effect on growth and development and may help avoid steroid use.100,101
Once again, elemental formulations are not palatable and noncompliance becomes
a major issue.
8.5.1 Mode of Action of Enteral Nutrition

The mechanism by which enteral nutrition affects the inflammatory process in IBD
is not clear. Proposed mechanisms include provision of essential nutrients, reduction
of antigenic load, alteration of bowel flora, and improved immune function.102 The
enteral diet may have an antiinflammatory effect on the gastrointestinal mucosa,
which may be related to the fatty acids in the feed or alteration of gut flora.1,103,104 The
feeds studied (AL110, Modulen IBD. and ACD004 [Nestlé, Vevey, Switzerland]) all
have casein as the protein source, are lactose free. and are rich in the antiinflam-
matory cytokine, transforming growth factor beta (TGF-beta). They have all been
shown to induce clinical remission associated with mucosal healing.105 Modulen
IBD not only led to macroscopic and histological healing of the mucosa, but also
decreased mucosal proinflammatory cytokines. This included interleukin-1 mRNA
in the colon and ileum, interleukin-8 mRNA in the colon, and interferon gamma
mRNA in ileum. It also led to a rise in the regulatory cytokine TGF-beta mRNA in
the ileum. Formulas such as this may be influencing the disease process and allow-
ing for clinical remission via a reduction in inflammation.
Clinical response to enteral nutrition is associated with mucosal healing and
down regulation of proinflammatory cytokines.112 Modulen supplementation pro-
vided statistically significant protection against weight loss, hypoalbuminemia, aci-
dosis, and GI damage in a rat model of IBD.106 Future animal research regarding the
mechanism of action of Modulen’s protective effects is needed before further human
trials are considered.
8.5.2 Glutamine
The nonessential amino acid glutamine is a source of energy for intestinal epithelial
cells and stimulates proliferation of intestinal epithelial cells.107 In animal models of
IBD, glutamine-enriched parenteral nutrition decreased bacterial translocation and
stimulated IgA mucosal secretion.108,109 New animal data has suggested that paren-
teral glutamine may have antiinflammatory effects via the NFκB pathway with anti-
TNFα properties.110 These findings led to the hypothesis that glutamine-enriched
parenteral nutrition may improve outcomes in patients with CD. However, glu-
tamine-enriched parenteral nutrition has failed to show a clinical benefit in patients
with IBD, when compared to standard parenteral nutrition.111 Intestinal utilization of
glutamine appears to be impaired in CD, and this may be why it has not been suc-
cessful as restorative therapy.112
8.6 Other Dietary Therapy in IBD

Although diet has been implicated in the pathogenesis of IBD, there is no defini-
tive evidence linking a specific food or additive as a cause of IBD. Therefore, most
patients are advised to follow a healthy, well-balanced diet. Alternative dietary strat-
egies, however, do warrant consideration.
8.6.1 Polyunsaturated Fatty Acids

One proposed mechanism for the efficacy of low-fat elemental diets is that without suf-
ficient n-6 fatty acids, proinflammatory eicosanoids cannot be synthesized.113 The fam-
ily of n-3 fatty acids have the parent compound α-linoleic acid, which is synthesized
into fatty acids that are important in immunomodulatory and antiinflammatory effects
via the production of prostaglandin class 3 and leukotriene B5, and by inhibiting pro-
duction of arachidonic acid and TNFα production.17–19 These findings would suggest
that a diet rich in n-3 PUFAs may be protective against IBD, while those rich in n-6
PUFAs may promote inflammation. PUFAs may reduce the risk of recurrence in CD
and may also have a role in UC.114,115 One study evaluated a polymeric enteral diet high
in oleate acid (monounsaturated fat) versus an identical diet high in linoleate acid, and
demonstrated that remission rates were improved with the linoleate diet.113 Conversely,
elemental diets with increased amounts of long-chain triglycerides (LCTs) resulted in
lower remission rates in active Crohn’s disease than the same diet with lower LCTs.116
Soybean oil was used as the LCT with the principal fatty acids being oleic acid and
linoleic acid. According to the Cochrane review, omega 3 fatty acids might be effective
for maintenance therapy in CD, though this was not supported in UC (Table 8.3).117,118
Most recently, two randomized, placebo-controlled trials showed omega-3 fatty acids
were not effective in the prevention of relapse in CD.119
8.6.2 Short Chain Fatty Acids, Low Particle Diets, and Polyphenols

In addition to PUFAs, other dietary strategies in IBD include SCFAs, low particle
diets, and polyphenols.15,27,120,123,124 The majority of studies on SCFAs have been
Table 8.3
Prebiotics in Ulcerative Colitis
Author Year Fiber Study Outcome
Fernandez-Banares 1999 Plantago ovata Fiber +/- mesalamine Equal to mesalamine in
seed fiber 10 in patients in maintenance of
grams BID remission remission
Kanauchi 2002 Barley 20–30 Mild to moderately Decreased disease
2003 grams active UC activity
Hallert 2003 Oat bran 60 Patients in remission Decreased abdominal
grams (fiber 20 pain, increased fecal
grams) butyrate
Welters 2002 Inulin 24 grams IPAA Deceased pouch
inflammation
Source: Adapted from References 168 to 171.

Note: IPAA = ileal pouch-anal anastomosis.
conducted in animals, but there is some research on humans. Though the studies,121,122
were small and of a relatively short duration, they demonstrated clinical response or
improvement with SCFA enemas (Table 8.1).123–125 One small, nonrandomized, open-
labeled trial demonstrated a decrease in clinical index activity scores in patients with
ulcerative colitis treated with 30 grams of germinated barley, which increased lumi-
nal butyrate production.29
8.7 Phytonutrients in IBD

8.7.1 Resveratrol
Polyphenols are phytochemicals found in food substances produced from plants,
and they are thought to be involved in immunomodulation.126 Examples of polyphe-
nols include resveratrol, epigallocatechin, and curcumin. Resveratrol is found most
abundantly in the skin of red grapes.127 Resveratrol appears to be antiinflamma-
tory, although its mechanism of action has not been clearly established.15 In rodent
models of inflammatory colitis, resveratrol has been shown to reverse weight loss,
increase stool consistency, improve mucosal appearance, improve gut histology,
decrease inflammatory infiltrate, and decrease mucosal levels of interleukin-1β,
COX-2, and prostaglandin D2.128 To date, resveratrol has not been studied in human
subjects with IBD.
8.7.2 Catechins
Catechins, such as gallocatechin gallate (EGCG), are abundant in green (nonfer-
mented) tea.129 Green tea has been studied in the prevention or treatment of cancers,
such as breast, lung, ovarian, prostate, and stomach, as well as in diseases, such as
hypertension and cardiovascular health.15 EGCG can modulate and inhibit NFκB
activity which may affect inflammation.130 Similar to resveratrol, green tea has
been shown to improve disease activity in murine models of colitis.131,132 An in vitro
study involving human colonic tissues showed that EGCG administration resulted
in decreased proinflammatory cytokine production, but to date, there are no in vivo
human studies in IBD.133
8.7.3 Curcumin
Another phytonutrient studied for its antiinflammatory role is curcumin, the major
chemical component of turmeric. Turmeric, from the herb Curcuma longa, is the
major spice found in curry.134 Curcumin is used orally and topically to treat a vari-
ety of ailments and has an excellent safety profile.135,136 It appears to have multiple
mechanisms of action including the inhibition of NFκB, which likely leads to the
downregulation of proinflammatory genes and cytokines.137 Overall, in animal mod-
els of colitis, curcumin has prevented and ameliorated chemical-induced colonic
injury.138,139 In one randomized, double-blind, placebo-controlled trial, 89 patients
with quiescent ulcerative colitis were given 1 gram of curcumin twice daily or pla-
cebo for six months. They were followed prospectively for relapse of disease. Of the
44 patients who consumed curcumin, only 2 experienced clinical flares while 8 of

the 45 patients taking placebo relapsed (p = 0.049).140
8.8 Supporting Colonic Microbes

8.8.1 Probiotics
Probiotics are defined as “live microorganisms, which when administered in ade-
quate amounts, confer a health benefit on the host.”141 Disturbances in bacterial
intestinal flora have been purported as a triggering factor for IBD.142 Animal mod-
els suggest probiotics may be useful in the treatment of UC and CD.143,144 Based
on these animal models, probiotics alter gastrointestinal flora and ameliorate dis-
ease.145,146 Pouchitis (chronic inflammation of the ileo-anal pouch) is a complication
of surgery for UC and is typically treated effectively with antibiotics, suggesting a
causative role of bacteria.147 In patients with chronic pouchitis induced to achieve
remission with antibiotic therapy, VSL#3 (a high potency probiotic with 450 billion
colony=forming units per dose) was successful in maintaining remission.148 VSL#3
may also have a role as primary prophylaxis of pouchitis in patients with ileal pouch-
anal anastomosis.149
Probiotics have been shown to be efficacious in maintenance therapy in UC
(Table 8.2). Three randomized controlled trials showed that Escherichia coli Nissle
1917 equaled conventional 5-aminosalicylic acid treatment, suggesting that probiot-
ics can be used to maintain remission of disease.150–152 Studies using other probi-
otic species have yielded mixed results.153,154 Probiotics have also been studied in the
treatment of active ulcerative colitis.155 When VSL#3 was used in combination with
low-dose balsalazide, patients had shorter time to remission than balsalazide alone,
suggesting that probiotics can lessen dosage requirements of conventional agents
for UC.156 Of note, the doses of balsalazide used were lower than typically used in
a clinical scenario. Additionally, when probiotics have been used as topical therapy
with E. coli Nissle 1917 enemas, they have led to remission, with the shortest time to
remission occurring with the highest dose of enema.157
Probiotics have been studied in CD as well. One study showed patients using
Saccharomyces boulardii plus mesalazine had fewer relapses than those using
mesalazine alone.158 Other studies, however, have not shown probiotics to be effec-
tive as a maintenance strategy in CD.159,160 In treating active CD, probiotics have not
been shown to significantly have a role in treatment. One study showed that prebiot-
ics may reduce disease activity in active CD.161 Research on probiotics and prebiotics
is limited for a number of reasons, including enrollment of small number of patients,
variability in choice of probiotic or prebiotic used, and variability in patients’ diets.
Larger randomized controlled trials are needed to determine the role of probiotics
and prebiotics in the treatment of IBD.
8.8.2 Prebiotics
Prebiotics are compounds that promote intestinal proliferation of probiotic bacteria
and are metabolized into SCFAs.162 Most prebiotics are from the group of dietary
fibers found in foods, such as legumes, artichokes, onions, garlic, banana, soya,
and other beans.163 Examples of prebiotics are inulin and oligofructose. When these
prebiotics are given in sufficient amounts, they selectively promote the growth of
bifidobacteria.164 Animal models of IBD have shown inulin to reduce inflammatory
mediators and reduce histological damage scores.165 Along with inulin, other prebi-
otics, such as oligofructose and lactulose, have shown antiinflammatory effects in
animal models of IBD.166,167 In clinical studies, inulin as compared to placebo was
associated with improvement in inflammation in UC as well as chronic pouchitis
(Table 8.3).168–171 Combining probiotics and prebiotics as synbiotics may be useful in
the treatment of IBD. In mild ulcerative colitis, a synbiotic preparation (oligofruc-
tose-enriched inulin and Bifidobacterium longum) compared to placebo showed a
trend in reduction of mucosal expression of proinflammatory cytokines (TNFα) and
improvement in inflammation on a histological level.172
8.9 Food Intolerance and IBD

Irritable bowel syndrome (IBS) can be a co-morbid condition in patients with IBD.
Healthcare providers need to recognize this association in order to avoid the use of
IBD therapy to treat symptoms resulting from IBS.173 Patients with an IBS overlap
may have intolerance to certain foods, such as dairy products, caffeine, fried foods,
and high fiber.174 It is important to note that food intolerance is not a true allergic
reaction. If foods cause a true allergic reaction, they need to be completely avoided.
Patients who have intolerance to certain foods should try to avoid these specific trig-
gers in order to minimize their symptoms.
8.9.1 Gluten
Celiac disease has been noted with increased frequency among patients with CD.175
In general, only those with celiac disease or confirmed gluten-sensitivity should
be given a gluten-free diet. There is insufficient data to support or refute a recom-
mendation concerning gluten sensitivity testing for IBD. It is reasonable to suggest
that clinicians query patients as to their possible intolerance to gluten and if sus-
pected, IgG1/IgG4 and antitransglutaminase/antiendomyseal antibody testing should
be considered.
8.9.2 Fiber
IBD, particularly CD, can result in complications of intestinal strictures, fistulae,
high-output ostomy as well as short bowel syndrome. Though patients with non-
stricturing CD do not benefit universally from a low residue diet, most experts in
IBD would recommend a low residue diet in patients who have ongoing intestinal
strictures.176 Insoluble fiber products help serve as prebiotic products to facilitate the
population of beneficial enteric bacteria. Thus, continued intake of adequate fiber is
helpful for patients with both forms of IBD. Patients with intestinal fistula, high-out-
put ostomy, and short bowel syndrome often are difficult to manage from a nutrition
standpoint. Careful management of fluid and electrolyte disturbances is essential,

and parenteral nutrition may be necessary in some cases.177
8.10 Summary
There is no clear evidence that any specific diet is either the cause or a cure for IBD.
Healthcare providers are often faced with the challenge of recommending proper
diets for patients with IBD. There is an ongoing struggle between wanting these
patients to avoid certain foods while allowing them to enjoy meals as well. In order
to prevent food restriction, patients should be encouraged to follow a healthy diet
as tolerated; they should be taught about antiinflammatory diets whenever possible.
Supplementation with polyphenols, probiotics, and fish oils should be considered
as adjuncts to care. Further studies on the role of nutraceuticals used in combina-
tion with conventional medical therapies may facilitate improved outcomes and
less toxicity.
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9 Probiotics for Antibiotic-
Associated Diarrhea and
Clostridium Difficile-
Associated Disease
Mario Guslandi
Contents
9.1 Introduction................................................................................................... 149
9.2 Probiotics in the Prevention of AAD............................................................. 150
9.2.1 Lactobacilli........................................................................................ 151
9.2.2 Saccharomyces boulardii.................................................................. 151
9.2.3 Miscellanea........................................................................................ 152
9.2.4 Meta-Analyses................................................................................... 152
9.3 Probiotics in the Prevention and Treatment of CDAD.................................. 152
9.3.1 Saccharomyces boulardii.................................................................. 153
9.3.2 Lactobacilli........................................................................................ 153
9.3.3 Miscellanea........................................................................................ 153
9.3.4 Prebiotics........................................................................................... 153
9.4 Conclusions.................................................................................................... 154
References............................................................................................................... 154
9.1 Introduction
Antibiotic-associated diarrhea (AAD) is a frequent event, both in outpatients and
especially in hospitalized subjects as well as in residents of long-term institutions,
with incidence ranging from 5 to 30%.1 Broad spectrum antibiotics, such as amoxi-
cillin, cephalosporins, clindamycin, and floroquinolones are the most commonly
involved among antibacterial agents.2,3 Between 20 to 30% of cases of AAD are
linked to the presence of Clostridium difficile,3 a Gram-positive, anaerobic, spore-
forming bacillus that is considered responsible for the large majority of the most
severe form of AAD: pseudomembranous colitis. Occasionally other microorgan-
isms, such as Clostridium perfrigens, Klebsiella oxytoca, and Staphylococcus
aureus can be implicated.4,5
Clostridium difficile-associated disease (CDAD) is especially frequent in elderly
people, hospitalized patients, and in subjects on long-term therapy with either
149
immunosuppressive agents or gastric acid inhibitors, particularly proton pump

inhibitors.6
The incidence of CDAD has been on the rise all over the world.7,8 A report from
the United States shows the incidence of hospitalization due to CDAD doubled from
5.5 cases per 10,000 population in 2000 to 11.2 in 20058 with a consequent, obvious
economic impact on hospital charges and strain on the healthcare system.
Clinical presentation varies. Uncomplicated diarrhea, which may occur either
during antibiotic treatment or up to eight weeks after antibiotics have been discon-
tinued,9 usually lasts one to seven days both in adults and children.10,11 In cases
in whom antibiotic-associated colitis develops, the diarrhea becomes more severe
and is accompanied by abdominal cramps, fever, leukocytosis, and hypoalbumin-
emia, with more pronounced systemic involvement if pseudomembranous colitis
occurs. Diagnosis is based on a positive C. difficile assay (culture or, more com-
monly, finding of toxins A and B in the stools, the latter having a higher sensitivity
and specificity) after other causes of diarrhea (Shigella, Giardia, etc.) have been
ruled out.
Toxins A and B are two large molecular weight toxins responsible for induction
of proinflammatory cytokines, such as IL-8, with consequent polymorphonuclear
leukocyte infiltration, mucosal barrier breakdown. and, ultimately, cell apoptosis.3
Sigmoidoscopy is performed when CDAD is suspected in spite of a negative stool
test or when other intestinal disorders are under consideration.
Identification of pseudomembranes is the main feature of endoscopic diagnosis of
CDAD. In up to 35% of cases, CDAD recurs shortly after treatment is stopped.12
Treatment of CDAD is initially based on discontinuation of the offending anti-
biotics (if diarrhea occurs during antibiotic intake). This measure alone promotes
disappearance of diarrhea in 20 to 30% of cases over two to four days.6 Standard
pharmacological therapy is carried out by administering either metronidazole or
vancomycin. However, both drugs have their drawbacks.
Metronidazole is cheaper, but can be neurotoxic and, recently, high failure rates
in severe cases have been reported, while vancomycin, which is considerably more
expensive (although apparently more effective in severe cases and in patients resis-
tant to metronidazole), has been shown to promote colonization by vancomincin-
resistant enterococci.13,14
Understandably, different avenues of action are being pursued in order to man-
age AAD and, especially, CDAD. In this respect, probiotics constitute a possible,
safer alternative.
9.2 Probiotics in the Prevention of AAD

The rationale for using probiotics in the treatment and/or prevention of AAD and
CDAD is based on the proposed modes of actions of these agents, namely their
ability to inhibit pathogens, strengthen intestinal barrier functions, exert anti-
inflammatory effect through modulation of cytokine production, and decrease
gut permeability. In view of these properties, several probiotic products have
been tested.
Probiotics 151
9.2.1 Lactobacilli
Various randomized controlled studies have investigated the possible effect of
Lactobacilluss spp. in the prevention of AAD.
Lactobacillus rhamnosus GG was found more effective than placebo in pre-
venting AAD in children taking antibiotics.15,16 In particular, in a group of 167
children receiving antibiotics to treat respiratory infections, AAD developed in
only 5% of cases in the Lactobacillus group and in 16% of cases with placebo
(p <0.05).15
In adults, the results with that particular probiotic have yielded conflicting results.
In a small study in erythromycin-treated patients, a Lactobacillus GG yogurt was
found effective in reducing diarrhea as well as flatulence and abdominal discom-
fort,17 whereas, in a large trial enrolling 302 hospitalized, antibiotic-treated patients,
no benefit was observed, the incidence of diarrhea being about 29% both in the pro-
biotic and in the placebo group.18
Probiotic cocktails have also provided variable, although mostly favorable results.
For instance, 63 hospitalized adults taking antibiotics receiving a drink mixture con-
taining Lactobacillus GG, L. acidophilus, and Bifidobacterium bifidus for 14 days
experienced AAD in only 5.9% of cases compared with 27.6% of subjects receiving
placebo.19 Similarly both mixtures of L. casei and L. acidophilus20 and of L. casei,
L. bulgaricus, and S. thermophilus21 were found significantly more effective than
placebo in hospitalized patients taking antibiotics.
In the latter study,21 diarrhea developed in 12% of cases in the probiotic group
and in 34% of the placebo group. None of the subjects receiving probiotics became
C. difficile positive, compared with 17% of patients who were given placebo. The
cost to prevent one case of AAD or CDAD was estimated to be $100 to $120, which
appears to be quite a saving when considering that the additional cost to treat AAD
would have been $3,669.
By contrast, a combination of L. acidophilus and L. bulgaricus proved to be inef-
fective both in adults22 and children23 treated with oral penicillin. Similarly, in a
recent double-blind, placebo-controlled trial carried out in antibiotic-treated chil-
dren, a probiotic cocktail of B. longum PL03, L. rhamnosus KL53A, and L. plan-
tarum was found to be ineffective in reducing the rate of diarrhea, in spite of a
significant reduction of the frequency of stools per day.24
9.2.2 Saccharomyces boulardii

Saccharomyces boulardii, a yeast with a complex mode of action, including the inac-
tivation of C. difficile toxins25 has been tested and found significantly superior to
placebo in prevention of AAD in at least six controlled trials carried out in large
adult populations of both outpatients, hospitalized subjects, and intensive care unit
patients.26–31 The only negative results were obtained in a study employing subthera-
peutic doses of S. boulardii.32
A similar, superior efficacy versus placebo has been observed in several ran-
domized clinical trials performed on children33,34 taking various oral antibiotics.
In particular, in a study including 466 children aged 1 to 15 years, S. boulardii
significantly reduced the incidence of ampicillin-sulbactam-induced diarrhea (5.7%

versus 25.6% with placebo; p <0.05), whereas, rather surprisingly, it was ineffective
in azythromicin-treated subjects.34
9.2.3 Miscellanea
A head-to-head comparison of Lactobacillus GG, S. boulardii and L. acidophilus +
B. lactis in the prevention of AAD during Helicobacter pylori eradication treatment,
found all the above probiotics to be more effective than placebo.35
A yogurt preparation with B. longum reduced stool frequency during erythro-
mycin intake36 and so did the use of a combination of B. longum and L. acidophilus
in clindamycin-treated patients.37 On the other hand, Enterococcus faecium SF 68
when compared with placebo was shown to be ineffective.38,39
9.2.4 Meta-Analyses
The use of probiotics as a group of agents in the prevention of AAD has been the
subject of a number of meta-analyses. All found evidence of a benefit for probiot-
ics compared with placebo with odds ratios ranging from 0.37 to 0.43.40–42 Similar
conclusions were reached by a meta-analysis considering only studies carried out in
children.43
A meta-analysis examining only studies employing S. boulardii demonstrated a
significant preventative effect (o.r. 0.43) (Table 9.1).44
9.3 Probiotics in the Prevention

and Treatment of CDAD
The data on the efficacy of probiotics in the prevention of a first episode of CDAD
largely equate those concerning their ability to prevent AAD. A probiotic cocktail
shown to be superior to placebo in preventing development of AAD was also found,
Table 9.1
Probiotics in the Prevention of AAD
Meta-Analysis
Number of Studies Results
D’Sousa (40) 2002 9 Probiotics > Placebo
Cremonini (41) 2002 7 Probiotics > Placebo
Szajewskaa (44) 2005 5 Probiotics > Placebo
Szajewslab (43) 2006 6 Probiotics > Placebo
McFarlandc (42) 2006 25 Probiotics > Placebo
a Children.
b S. Boulardii only.
c Significant for S. Boulardii, L. rhamnosus, and probiotic mixtures.
Probiotics 153
as discussed above, to significantly reduce the appearance of C. difficile toxins in

antibiotic-treated patients.21 Similarly, a trial carried out on 150 elderly hospitalized
patients treated with antibiotics has compared the effects of a mixture of L. acido-
philus, B. bifidum, and placebo. After 20 days, C. difficile toxin was found in 78% of
cases in the placebo group and 46% in the probiotic group.45
9.3.1 Saccharomyces boulardii

When added to metronidazole and/or vancomycin for four weeks in a group of 124
CDAD patients,46 1 g of S. boulardii daily failed to induce significant benefits in the
treatment of the first episode, although this might have been due to a type II statisti-
cal error,47 but proved to be effective in subjects with recurrent CDAD, in whom
relapses during a subsequent four-week follow-up period were reduced by 50%.46
In a second study enrolling only subjects with recurrent CDAD, S. boulardii was
significantly efficacious only in a subgroup of patients treated with high dose vanco-
mycin (the incidence of CDAD being 17 versus 50% with placebo), but not in those
treated with either metronidazole (48.1 versus 50% with placebo) or low-dose vanco-
mycin (51.1 versus 44.7% with placebo).48
9.3.2 Lactobacilli
The possible usefulness of single Lactobacillus species in cases of recurrent CDAD
has been examined mostly in small, open, uncontrolled studies. Small size, controlled
trials versus placebo showed a decrease in recurrence of CDAD in patients receiving
Lactobacillus GG49,50 or L. plantarum51 without reaching statistical significance.
9.3.3 Miscellanea
Other types of therapies have been tested only in pilot, uncontrolled studies, either
administering nontoxigenic Clostridium strains52 or performing rectal instillation of
anaerobe mixtures53 or Escherichia coli Nissle 1917.54 To date the possible efficacy
of these unconventional treatments cannot be established.
9.3.4 Prebiotics
The ability of prebiotics as nutritional factors for useful components of the intesti-
nal flora (e.g., oligofructose is metabolized by Bifidobacteria, thus increasing their
number in the colon) may provide a weak rationale for their possible role in AAD
prevention, but the experience in this area is even more limited.
A large trial where 450 elderly patients treated with broad spectrum antibiotics
were randomized to either oligofructose or placebo, but did not show any significant
difference in terms of both incidence of diarrhea and C. difficile infection.55 Risk
factors for developing diarrhea were cephalosporins, being female, weight loss, and
a long hospital stay.
On the other hand, in a study on 142 in patients with recurrent CDAD,56 relapses
were significantly less frequent with oligofructose (34.3%) than with placebo (8.3%)
Table 9.2
Tentative Guidelines for the Use of Probiotics in AAD and CDAD
Aim of Treatment Probiotic Evidence Comment
Prevention of AAD S. boulardii 1 g/day Good Adults and children
Lactobacillus GG Good Children only
1.2 × 1010 CFU/die
Probiotic cocktails Variable Ideal mixture to be identified
Primary prevention of CDAD Probiotic cocktails Variable Ideal mixture to be identified
Prevention of recurrent S. boulardii 1 g/day Moderate Adults
CDAD
(p >0.001), although the appearance of C. difficile in the stools was similar in the
prebiotic group (30%) and in the placebo group (36%). Thus, no definitive conclu-
sions can be drawn by these preliminary studies with oligofructose.
9.4 Conclusions
As demonstrated in all the published meta-analyses, probiotics, as a group, are sig-
nificantly effective in preventing AAD both in adults and in children. This is par-
ticularly true, according to the largest available meta-analysis42 for Saccharomyces
boulardii, Lactobacillus rhamnosus, and probiotic cocktails. Which probiotic mix-
ture could be more effective remains to be determined. The extreme variety of the
combinations tested in clinical studies makes it impossible to identify the most effec-
tive product.
The efficacy of probiotics in the prevention and treatment of CDAD is less straight-
forward. S. boulardii does not appear to be useful in preventing the first episode of
CDAD, but was shown to reduce the relapse rate in recurrent CDAD.46
Data about Lactobacilli are too limited to provide meaningful information.
Clearly, much work remains to be done in this area, but further, larger controlled
studies are warranted to better define the therapeutic role of probiotics in AAD and
CDAD (Table 9.2).
Probiotics are safer and cheaper that most antibiotics, and their ability to prevent
antibiotic-induced diarrhea deserves a wider use, in order to reduce patients’ dis-
comfort as well as the costs related to diagnosis, treatment, absence from work, and
possible hospitalization.
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10 and
Endoscopic Enteral Access
Enteral Nutrition
Waqar A. Qureshi and Carol Redel
Contents
10.1 Introduction................................................................................................... 159
10.2 Indications for Enteral Feeding..................................................................... 160
10.3 Prophylactic Antibiotics for Enteral Access Procedures............................... 160
10.4 Types of Endoscopic Enteral Access............................................................. 160
10.4.1 Endoscopic Nasoenteric Access........................................................ 160
10.4.2 Endoscopic Percutaneous Enteral Access......................................... 162
10.4.2.1 Percutaneous Endoscopic Gastrostomy (PEG)................... 162
10.4.3 Percutaneous Endoscopic Gastrostomy/Jejunostomy........................ 162
10.4.4 Direct Percutaneous Jejunostomy...................................................... 164
10.4.4.1 The Technique..................................................................... 165
10.5 Enteral Feeding following Feeding Tube Placement..................................... 166
10.5.1 The Decision for Tube Feeding......................................................... 166
10.5.2 Nutrition Assessment......................................................................... 167
10.6 Administration of Enteral Feedings.............................................................. 168
10.6.1 Advancing Feedings.......................................................................... 168
10.6.2 Interval versus Continuous Feedings................................................. 168
10.6.3 Minimizing Aspiration Risk.............................................................. 170
10.6.4 So Now, What Do I Put In This Tube?.............................................. 170
10.6.4.1 Protein Modifications.......................................................... 171
10.6.4.2 Immune Enhancing Nutrients............................................. 171
10.6.4.3 Disease Specific Formulas.................................................. 171
10.7 Conclusions.................................................................................................... 172
References............................................................................................................... 172
10.1 Introduction
Adequate nutrition is essential in patients who cannot eat and is particularly impor-
tant for the critically ill patient. Adequate nutrition improves patient outcomes, fre-
quently getting them through a stay in the intensive care units. Nutrition can be
provided to a patient either intravenously (parenteral nutrition) or delivered by feed-
ing tubes into the gastrointestinal tract (enteral nutrition). When the gastrointestinal
tract is able to function, enteral nutrition (EN) is preferred over parenteral nutrition
(PN) because there is less risk of sepsis and metabolic derangements.1 EN also pro-
motes a healthier gut barrier, an important defense against ingested bacteria.2 There
159
is growing evidence that EN should be used whenever possible and used early as in
severe acute pancreatitis where, until recently, PN or prolonged fasting was com-
monly recommended. Increasingly a feeding tube or other enteral route is sought
when a patient cannot eat in the setting of normal absorptive capability of the diges-
tive tract.
Enteral nutrition can be delivered into the stomach or the proximal small bowel.
Endoscopic gastric and enteral access has become the main method of placement
of feeding tubes in the gastrointestinal tract. When the need for EN is anticipated
to be one month or less, a tube feeding is recommended. If greater that one month,
endoscopic percutaneous access is the technique of choice.
10.2 Indications for Enteral Feeding

The most common reason for enteral feeding is to provide nutrition via a function-
ing gastrointestinal tract for the long term in patients who cannot otherwise eat or
eat enough.
Patients in this group often have neurologic disorders, such as stroke or malignan-
cies of the head, neck, or esophagus. Less commonly, enteral access is desired for
decompression of the stomach in severe gastroperesis or abdominal carcinomatosis
and intestinal obstruction. It may be indicated in severe burns and in patients with
Crohn’s disease.
10.3 Prophylactic Antibiotics
for Enteral Access Procedures
Several studies have shown that prophylactic antibiotics reduce the incidence of per-
istomal wound infection after endoscopic enteral access.3,4 Administering antibiotics
at the time of the procedure has been shown to be a cost-effective strategy.5 There is
some suggestion that percutaneous access wound infections with methicillin-resis-
tant Staphylococcus aureus (MRSA) are more common in patients receiving the
usual prophylactic antibiotics if they happen to have nasopharyngeal colonization
with MRSA. MRSA decolonization has been suggested in such individuals, but this
issue is still being debated.6
10.4 Types of Endoscopic Enteral Access

10.4.1 Endoscopic Nasoenteric Access
Enteral nutrition is sometimes delivered by blind placement of a feeding tube, such
as a Dobbhoff feeding tube into the stomach, ensuring correct placement with the
use of a stethoscope or plain radiograph and will not be discussed any further here.
Sometimes it is necessary to deliver feeding into the jejunum in an attempt to prevent
aspiration in ill patients or patients who have gastroperesis or gastric outlet obstruc-
tion from tumor involvement. Nasojejunal (NJ) feeding tubes are frequently placed
with the aid of an endoscope.
Endoscopic Enteral Access and Enteral Nutrition 161
Endoscopic passage of an NJ feeding tube generally requires conscious sedation.

Some of the more common techniques are described below:
1. The NJ tube with a suture attached to its tip is passed into the stomach
via a nostril. The patient is then endoscoped and the suture at the tip of
the feeding tube is grasped with a forceps and the scope advanced into the
distal duodenum where the NJ tube is released. Sometimes the tube is inad-
vertently pulled back into the stomach when the endoscope is withdrawn.
One way to overcome this is to use a double channel scope and through the
second channel put down an endoclip to attach the suture to the wall of the
intestine before withdrawing the endoscope.
2. The guide-wire technique. In this method the endoscope is advanced
to the distal duodenum or jejunum and a floppy tip 0.035 guide wire is
advanced as far out into the jejunum as possible. The endoscope is then
slowly withdrawn as the wire is fed into the biopsy channel. The NJ tube
is then pushed over the wire into the distal duodenum or jejunum and the
guide wire removed. Sometimes this procedure is easier when done with
fluoroscopic guidance. The NJ tube now requires oral-to-nasal transfer. In
this final maneuver, a short transfer tube, usually supplied with the NJ tube
kit, is passed into a nostril and retrieved from the throat and brought out
of the mouth. The feeding tube or guide wire is threaded into this tube and
advanced so that it comes out from the nostril. The transfer tube is then slid
off the NJ tube or guide wire. Sometimes the guide wire (placed through
the nose) to the jejunum has to be held under tension with a biopsy forceps
while the tube is fed over the stiffened guide wire.
3. Nasal endoscopy with ultrathin endoscope for placement of NJ tube. This
technique avoids the need to perform the oral-to-nasal transfer of the feed-
ing tube since the digestive tract is accessed via the nostril. An ultrathin
endoscope is passed through a nostril into the duodenum and a guide wire
passed through its biopsy channel into the distal duodenum or jejunum. The
endoscope is then removed as the wire is carefully fed into the channel to
keep the wire in place. Next the NJ tube is pushed blindly over the wire into
position in the small bowel.
4. Nasally inserted NJ tubes guided by conventional endoscopes. With an
endoscope in the midesophagus or stomach, NJ tubes with guide wires in
them to stiffen them can be introduced via the nostril and guided by the
endoscope keeping the NJ tube tip well ahead of the scope at all times.
Once the feeding tube is in place, the scope is carefully withdrawn while
the stiffening wires hold the NJ tube in place. Finally the wires are removed
from the feeding tubes.
5. Through the scope jejunal tube placement. Commercial 9 F and 11 F
nasojejunal feeding tubes can be placed through the channel of either a
pediatric colonoscope or therapeutic endoscope. This is quick and easy, but
an extension tube, such as a snare, sometimes has to be used for very deep
jejunal placement because the tube disappears into the channel before the
tip of the scope exits the mouth.
10.4.2 Endoscopic Percutaneous Enteral Access

Percutaneous access is usually preferred if enteral nutrition is likely to be required
for greater than one month. Percutaneous endoscopic gastrostomy (PEG) is the most
commonly performed technique for enteral feeding by the gastroenterologist. In cer-
tain situations, such as recurrent aspiration, severe gastroperesis, or previous gastric
surgery, it may be preferable to deliver the feed directly into the proximal small
intestine. This is achieved either by extending a feeding tube passed through the
PEG tube into the jejunum or placing a feeding tube directly into the jejunum percu-
taneously. These techniques are described below.
10.4.2.1 Percutaneous Endoscopic Gastrostomy (PEG)

Following informed consent, these patients undergo an upper endoscopy generally
requiring sedation. Because of the risk of aspiration, the patients head is elevated to
30o during the procedure. Following a brief examination of the pylorus and duode-
num, the scope is withdrawn to the upper stomach and the abdominal wall palpated
over the potential PEG site area to look for point indentation through the endoscope.
Usually at about the same time, transillumination of light from the scope is seen on
the abdominal wall further allowing the best site selection for PEG. One should avoid
placing a PEG too close to the costal margin or large abdominal scars from previous
surgeries because of the risk of the bowel being adherent to these surgery sites. Once
a site is selected, the skin is marked either with ink or pressure indentation from a
needle cap and the area cleaned with antiseptic. The selected site is anesthetized with
lidocaine to raise a wheal. The needle is frequently slowly advanced into the stomach
under direct vision. Next a 1-cm incision is made in the skin with a scalpel through
which the trocar is pushed into the stomach, again under direct vision. During this
time, a snare is introduced through the scope into the stomach. The guide wire sup-
plied in the PEG kit is then introduced through the trocar sheath after the needle has
been removed. The guide wire tip is grasped in the snare as it enters the stomach and
the endoscope is then pulled out of the patient with the guide wire. Next, depending
on whether one uses a pull-type or a push-type PEG tube, one would either push a
PEG tube over the guide wire or pull it by tying it to the PEG tube and pulling it into
position. Once the PEG tube is in position, an external skin bolster is slid over the
PEG tube and brought against the skin to hold the PEG in place. It is important not
to tighten the bolster because pressure necrosis or, worse still, necrotizing fasciitis
could occur. In fact, it’s good practice to leave a loose fit, i.e., 1- to 2-cm slide for the
PEG tube. The site is then covered with gauze. PEG feeding can be started three to
six hours after PEG placement.7
10.4.3 Percutaneous Endoscopic Gastrostomy/Jejunostomy

In this technique, a jejunal feeding tube is placed through an existing PEG tube
or as a one-step procedure where a PEG is placed in the usual way and a jejunal
tube is placed into position via the PEG. PEG tubes are usually 20F or 24F and
most manufacturers now make jejunal feeding tubes that will fit snuggly onto
these to prevent leakage, which was a problem in the past. Bard Access Systems
Figure 10.1 The jejunal feeding tube is grasped by its string with a biopsy forceps as it
emerges through the percutaneous endoscopic gastrostomy (PEG) dome in the stomach.
(Salt Lake City, Utah) makes a one-piece PEG tube that narrows down to a jejunal
feeding tube.
Various techniques have been described to pass the jejunal feeding tube through
the PEG. It is our preference to use a therapeutic double channel endoscope for this
procedure. Then the PEG tube is grasped as it enters the stomach through the PEG
dome (Figure 10.1) with a biopsy forceps and taken through the pylorus and as far
into the duodenum as possible (Figure 10.2). An endoclip is then introduced through
the second channel of the endoscope and the jejunal tube anchored with a clip to the
distal duodenal or jejunal wall (Figure 10.3 and Figure 10.4). Placing a flexible 0.035
guide wire inside the jejunal feeding tube makes the process easier both in terms
of taking the wire as far as possible into the small bowel, but it also helps hold the
clipped tube in place as the endoscope is withdrawn. Once the endoscope is back in
the stomach, it is necessary to make sure the feeding tube is not looped in the stom-
ach, but goes directly from the PEG dome to the pylorus (Figure 10.5). If not, the
feeding tube needs to be advanced farther into the jejunum.
It is important to make sure that the jejunal tube goes directly from the PEG
through the pylorus and into the distal duodenum. Any significant looping of the
tube in the stomach will cause it to fall back into the stomach. Some endoscopists
prefer to anchor the tip of the jejunal feeding tube in the small bowel before scope
withdrawal. This is done by placing a string loop at the tip of the tube and anchoring
this to the bowel wall with an endoclip.
Figure 10.2 The endoscope is then advanced through the pylorus and the biopsy forceps
advanced farther, taking the feeding tube deeper into the distal duodenum.
Figure 10.3 The feeding tube is now anchored to the jejunal wall with an endoscopically
introduced clip through the second channel of the endoscope.
Figure 10.4 One or more endoscopically placed clips may be required to secure the feed-
ing tube.
Figure 10.5 It is important that the intragastric portion of the jejunal feeding tube does
not loop in the stomach but advances directly from the percutaneous endoscopic gastrostomy
(PEG) dome to the pylorus, otherwise it may in time fall back into the stomach.
10.4.4 Direct Percutaneous Jejunostomy

A jejunal feeding tube is placed directly into the small bowel just distal to the liga-
ment of Treitz using a pediatric colonoscope or an enteroscope. This procedure is
similar to the PEG placement, but is technically more difficult to perform. It is our
practice to have two physicians perform this—the endoscopist, and the assistant or
the “skin” person.
10.4.4.1 The Technique
Following sedation and 0.5 mg glucagon as an antimotility agent, a pediatric colono-
scope or enteroscope is introduced into the patient in the supine or left lateral posi-
tion. Care is taken to minimize the amount of air put into the stomach to make
looping of the scope less likely. Once the scope is advanced in the duodenum, the
“skin” doctor looks for transillumination. The endoscope is advanced until the light
is seen through the abdominal wall or as far as the endoscope will go. If no transillu-
mination is seen, then the endoscopy is slowly withdrawn while looking for the light.
At the same time, poking the left side of the abdomen with the index finger look-
ing for indentation can help localize the potential site for percutaneous endoscopic
jejunostomy (PEJ) placement. It is important to see a discreet point indentation at
the area of transillumination for site selection and the next step. Once this site is con-
firmed, it is marked, cleaned with iodine, and draped. The site is then anesthetized
with 1% lidocaine to raise a wheal. A 22- or 25-G needle that is at least 1.5 inches
is used for this as it is also long enough to enter the jejunum. A 1-cm skin incision
is then made with a scalpel. The introducer trocar needle is then placed through
this cut into the jejunum and caught by the awaiting snare much like during a PEG
placement. The blue loop wire is then inserted through the trocar after the needle in
withdrawn, grasped by the snare, and pulled out of the patient’s mouth. Then, just
like in PEG tube placement, a standard 20F pull-type gastrostomy tube is tied to
the wire and pulled back into position. Some prefer to check the position of the PEJ
dome before terminating the procedure by repeating the endoscopy. Below are a few
“rules of thumb” that we follow:
1. Do not proceed in the absence of good transillumination. This may require

moving the scope tip in all four quadrants within the small bowel to look
for it.
2. Make sure you get a good point indentation with your index finger before
making the final site selection.
3. If you have trouble staying in the jejunum with your needle or trocar, grasp
it with a snare quickly to maintain your position.
The success rates for endoscopic PEJ range from 72 to 100%, this is lowest in
obese patients and highest in patients who have had previous gastrointestinal surgery,
such as Bilroth-II.8–13 Shetzline et al. demonstrated a high rate of success when using
fluoroscopy in oblique views to reach as close to the skin as possible with the ent-
eroscope for site selection. They also used ultrasound to locate solid organs to avoid
complications. In seven patients, they had 100% success with no complications.
The major complication rate in the literature is about 2 to 4% and includes colon perfo-
ration, significant bleeding and abdominal wall abscess, persistent entrocutaneous fistula,
jejuno–colonic fistula, and skin infections. Deaths have occurred from complications.13
Direct percutaneous endoscopic jejunostomy (DPEJ) seems to require fewer endo-
scopic interventions than PEG/J when used long term (greater than six months).14
These DPEJ tubes may be replaced with replacement J-tubes that have a 3 to 5 mL
balloon anchor or internal bolster introduced blindly with a stylet. The DPEJ has
to be at least four weeks old for replacement tubes to be placed so that a tract has
formed and the bowel doesn’t come away from the abdominal wall leading to a “free
perforation” and possible peritonitis.
10.5 Enteral Feeding following Feeding Tube Placement

During the past 40 years, there has been a veritable explosion in the field of clinical
nutrition, based in large part on studies on hospital malnutrition.15,16 Subsequently, the
concepts of nutrition support and nutrition pharmacology have received widespread
attention, spawning the development of (1) evaluative methods for nutrition support,
(2) a broad range of both enteral and parenteral formulas and feeding devices, and (3)
professional organizations devoted to the science of nutrition support. While early
in this growth process, parenteral nutrition was hailed as the innovation that would
reverse all hospital-associated malnutrition, limitations of parenteral nutrition (cost,
infection risk, negative effects on metabolism, and intestinal epithelial cell structure
and function) have relegated it to instances in which enteral nutrition is contraindi-
cated, i.e., with gastrointestinal tract dysfunction. The old adage: “If the gut works,
use it” remains the guiding principal and, thus, the focus has been on enteral support
via a myriad surgically, endoscopically, or manually placed feeding tubes.
10.5.1 The Decision for Tube Feeding

The decision to provide enteral nutrition is generally based on medical diagnosis,
coupled with client history of undernutrition, and/or anticipated or ongoing subop-
timal oral nutrition. Major indications are dysphagia and anorexia, either of which
may be associated with a variety of primary medical diagnoses. The sole contraindi-
cation is mechanical obstruction of the gastrointestinal (GI) tract; in this case, access
and feeding may be possible distal to the point of obstruction.
Enteral nutrition support may be initiated either on an out- or inpatient basis, and
restricted to inhospital use, or continued in the home setting. Medicare coverage
guidelines, frequently followed by third-party carriers, have guidelines for cover-
age of home enteral nutrition, including a projected minimum duration of 90 days.
Although it would appear intuitively obvious, client and/or caregivers should be
screened for the ability to transition enteral care into the home (clean and safe home
environment, knowledge of tube, care/feeding by tube, and ability to troubleshoot
problems). Arrangements with a homecare company with 24-hour availability for
troubleshooting, and visits by a homecare nurse will help ensure independence of the
client and support system. Additional information and support are available from the
Oley Foundation (www.oley.org).
Tube feeding may be delivered into the stomach, duodenum, or jejunum; the site
of administration is related to projected duration of tube feeding and site-specific
gastrointestinal function. For example, for short term (<1 month) support, nasoen-
teric tube feeding may be an option. Feedings may then be delivered into the stom-
ach or more distally. To minimize the risk of aspiration or avoid increasing severity
of gastroesophageal reflux, placement of the tip past the third portion of the duo-
denum or the ligament of Treitz is utilized. A prokinetic agent (erythromycin or
metoclopramide) may be given prior to tube insertion to facilitate small intestinal

tip placement. The primary advantage of nasoenteric tubes is bedside and outpatient
placement. Potential complications are many, from nasal discomfort and clogging of
small bore tubes to the GI tract, or respiratory trauma and perforations.
For other clients for whom nutrition support will be necessary beyond 30 days, the
option of endoscopic, fluoroscopic, or surgical tube placement is considered. Similar
placement sites are utilized, again considering diagnosis and functional assessment
of the gastrointestinal tract.
10.5.2 Nutrition Assessment
Once the decision is made concerning the need for an enteral feeding device, goal
nutrients are determined for the individual client. This task is generally accomplished
by a registered dietitian, and is based on sex, age, activity, oral nutrient intake, preexist-
ing nutritional status/deprivation, and ongoing medical condition and medications.
Dietary Reference Intakes: Recommended intakes for individuals17 are generally the
starting points for determining nutrient requirements. Baseline energy requirement is
calculated using firstly the Harris Benedict Formula, where BEE = basal energy expen-
diture, and ABW = actual body weight:
Males: 66.5 + (13.8 × ABW in kg) + (5 × height in cm) (6.8 × age in

years) = BEE in kcal
Females: 655.1 + (9.6 × ABW in kg) + 1.8 × height in cm) – (4.7 × age in
years) = BEE in kcal.
Alternative (and more easily recalled) formula is the Owen formula:
Males: BEE in kcal/day = 879 + 10.2 × weight

Females: BEE in kcal/day = 795 + 7.2 × weight,
Or the Mifflin formula (more accurate than the Owen over wide range of BMI
values):
Males: BEE in kcal/day = 5 +10 (weight in kg) + 6.25 (height in cm)

– 5 (age in years)
Females: BEE in kcal/day = 161 + 10 (weight in kg) + 6.25 (height in cm)
– 5 (age in years)18
To the basal energy expenditure, activity and/or injury factors are multipliers to
reach total energy expenditure (BEE × AF × IF = TEE):
Activity Factors (AF)

Bed rest: 1.2
Ambulatory: 1.3
Sepsis: 1.6
Injury Factors (IF)

Minor surgery: 1.2
Skeletal trauma: 1.35
Severe burns: 2.1
Baseline protein requirements are based on weight, with modifications for stress.
The adult protein requirement is 0.8 – 1 g/kg/d, but increases to 1 to 2 g/kg/d for
moderate stress, and 2 to 2.5 g/kg/day with severe stress.
For example, a 65-year-old female, currently at her ideal body weight of 110 pounds
(50 kg) for a height of 5’2” (157 cm) is admitted to a hospital from an assisted living
center for the problems of Alzheimer’s disease and anorexia due to acute cholecys-
titis. By the Mifflin formula, her BEE = –161 + 10 (50 kg) + 6.25 (157 cm) – 5(65
years), or 995 kcal/day. Currently on bed rest, her activity factor is 1.2, giving her a
kcal requirement of 1,194 kcal/d. Estimated protein requirement is 40 to 50 g/day.
Various tools are available for the assessment of nutritional deprivation, including
subjective global assessment of malnutrition,19,20 the Waterlow criteria for malnutri-
tion.21 Then using a combination of nutrient requirements for age and sex, together
with a factor for preexisting malnutrition, macronutrient goals exceeding baseline
requirements may be determined.
Despite several available tools for calculation of nutrient repletion, reassessment
of the individual client’s nutritional progress by anthropometrics is vital to preven-
tion of overnutrition or continuing undernutrition.
10.6 Administration of Enteral Feedings

10.6.1 Advancing Feedings
Little data is available on initial rates and volume of feeding. Although initial dilut-
ing of formulas has been employed in the past, there is data pointing to greater risk
of microbial contamination in diluting formulas, as the lower osmolality and higher
pH may contribute to microbial growth.22
In medically stable clients, progression of feeding rates and volumes to reach goal
nutrients may take place over a 24- to 48-hour time period. Conversely, in cases of
medical instability (in particular gastrointestinal instability), or preexisting malnu-
trition, progression to goal nutrition may require greater than one week. In cases of
preexisting malnutrition, care should be taken to avoid refeeding syndrome by care-
ful monitoring and correction of electrolytes and fluid balance.
10.6.2 Interval versus Continuous Feedings

Regardless of enteral feeding device employed, delivery of nutrients is by interval
(bolus) or continuous feedings, or a combination of the two methods. Interval
feedings may be provided by gravity drip or enteral feeding pump, while con-
tinuous feedings are uniformly delivered via pump. Both interval and continuous
feedings have uses and complications, with interval feedings more closely simu-
lating mealtimes.
Interval feedings are generally administered by gravity drip every several hours
throughout the day. The client is able to tolerate volumes of 240 to 400 ml delivered
over 10 to 20 minutes (in adults), and the frequency of feeding is linked to volume
tolerance. This route of administration is easy to teach to caregivers, as there is no
need for training on feeding pump use. In addition, the client is free to ambulate and
engage in physical activity between feedings. This method is the least costly in terms
of dollars and time, as well as least restrictive to the client.
Unfortunately rapid bolus use is associated with significantly lower esophageal
sphincter pressure, allowing reflux of gastric contents;23 this pressure change is not
observed in the continuously fed or slower interval fed population. In addition, bloat-
ing can be the consequence of delayed gastric emptying or gastroparesis, thus limit-
ing the tolerance for rapid bolus feeding.
Gastric residual volumes are checked as a means to prevent overfilling the stom-
ach, which contributes to gastroesophageal reflux, aspiration, and discomfort due to
bloating. At this time, accepting occasional residual volume of 250 ml in an adult has
been recommended due to the observation of increased nutrient delivery using this
value.24 A prokinetic agent may be employed to accelerate gastric emptying, with
either metoclopramide or erythromycin considered.
Data regarding the relationship between gastric residual volume and aspiration
remains insufficiently studied.24 No research has identified a gastric residual volume
associated with either aspiration or gastrointestinal intolerance, and aspiration has
been noted in association with zero residual volume. However, incidence of aspira-
tion is greater in association with GRV >250 ml.25,26 For a more complete discussion
of research concerning gastric residual volume, the reader is referred to the recent
ASPEN Enteral Nutrition Practice Recommendations.27
Interval feedings may also be administered by feeding pump, thus allowing a con-
trolled and slower delivery rate, an alternative useful for patients experiencing nausea,
vomiting, bloating, or abdominal pain with gravity interval feedings. Feedings are
then delivered via enteral feeding pump, with infusion time determined by tolerance.
This method is more restrictive to client movement due to the need for a mechanical
device for feeding delivery. The caregiver requires additional training in use of the
pump and priming the extension tubing for pump use. Rental or purchase fees for the
pump are also considerations, as is the need for an external power source.
Enteral feedings can be delivered via continuous drip to clients intolerant of interval
feedings. This method minimizes diarrhea and aspiration events,28 and the hours of feed-
ings may be linked to sleeping hours, 24 hours continuously, or any duration between.
Due to discomfort (as evidenced by bloating, cramps, diarrhea) with rapid deliv-
ery of hyperosmolar solutions into the jejunum, continuous feedings are preferred
with intrajejunal feeding devices. Continuous drip feedings are also preferred in the
critically ill population as a means to minimize aspiration events.
In instances where intestinal absorptive capacity is compromised, as in the case
of the young child with short bowel syndrome, use of both interval feedings during
the day and nocturnal continuous feedings may allow for improved volume and calo-
rie tolerance, less diarrhea, and overall improved growth rate without subjecting the
child to continuous connection to a pump while awake.
10.6.3 Minimizing Aspiration Risk

Due to the risk of aspiration, gastric feedings should be given in the upright posi-
tion. For clients restricted to bed, a 30- to 45-degree head of bed elevation is rec-
ommended over supine positioning to decrease incidence of aspiration pneumonia.
This angle may not avoid aspiration, as studies have documented aspiration even in
the semirecumbant position.29 A recent prospective study of ventilated clients has
documented a significant decrease in tracheal secretion pepsin when bed elevation is
>30%.30 Additionally in this study, risk of pneumonia was four times greater among
aspirating clients.
In cases where this angle is contraindicated (prone position, unstable spine,
hemodynamic instability), use of transpyloric feeding, or use of a prokinetic agent
may be considered. Although blue dye (FD&C Blue No. 1 and methylene blue) have
traditionally been added to formulas to aid in the diagnosis of aspiration, dye is
insufficiently sensitive in detecting pneumonia, and overdosing has been associated
with increased risk of mortality.30 Testing of tracheal secretions by the glucose oxi-
dase method has additionally fallen out of favor given the presence of glucose in the
tracheal secretions of unfed clients.31
10.6.4 So Now, What Do I Put In This Tube?

Gone are the days when the home blenderized tube feeding diet was the only alter-
native to the two commercially intact protein formulas for tube feeding. Currently
there are many formulas available differing in degree of macronutrient hydrolysis,
special additives, and selected indications. Due to cross-manufacturer similarities in
products, most healthcare institutions stock a limited formulary of items.
With knowledge of the individual’s gastrointestinal anatomy and function, nutri-
ent requirements, and feeding site (gastric versus small intestinal), coupled with any
nutrient modifications imposed by disease state, an enteral formula may be selected.
Commercially available formulas, often termed medical nutritionals, are pre-
ferred to a home-prepared blenderized formula due to concerns of sanitation, nutri-
ent adequacy, and consistency of proximate composition. Many of these products
are designed solely for tube feeding, as palatability is poor. Composed of intact pro-
tein (casein, soy, whey), glucose polymers and/or lactose, and a mixture of long and
medium chain fats, standard formulas are designed to be used as a sole source of
nutrition or as a supplement to oral feedings in clients with functional gastrointes-
tinal tract. Hence, these are generally the first formulas utilized. Standard formulas
provide 1 to 1.2 kcal/ml and are generally isotonic (approximately 300 mOsm) and
low in residue.
Due to the frequency of lactose intolerance in both adults and children, a num-
ber of formulas are lactose-free. Some preparations also contain fiber, which may
be beneficial in clients with fiber-responsive constipation or diarrhea, or irritable
bowel syndrome.
For clients tolerating intact protein, but requiring a more protein-dense formula
(specific indications: postsurgical or trauma, sepsis, promotion of wound healing),
several formulas provide approximately 30% protein. The protein source is generally
casein. These are often suffixed high protein or high nitrogen (HN). Lower osmolal-
ity remains a feature.
In clients, volume restricted or intolerant formulas providing 1.5 or 2.0 kcal/ml
may be used. With these formulas, though, osmolality is increased. Protein concen-
tration is generally greater to allow protein requirements to be met in less volume.
Due to less free water in these formulas, clients should be monitored for hydration
status.
10.6.4.1 Protein Modifications

More specialized formulas may contain hydrolyzed protein (to peptides and/or amino
acids), facilitating use in protein sensitive or allergic patients. Formula osmolality,
as well as cost, increases with protein hydrolysis. Calorie concentration is generally
1 kcal/ml. These products have been marketed for the treatment of gastrointestinal
stress, such as in the treatment of active inflammatory bowel disease (IBD).
The most elemental formulas provide free amino acids as well as glucose polymers,
and either a combination of medium chain triglycerides and long chain fats or negligi-
ble fat. As expected, these are expensive and have limited use due to high osmolality.
Branched chain amino acid fortified formulas are marketed for use in advanced
liver disease. In hepatic encephalopathy, decreased serum branched chain amino
acids (BCAA) and elevated aromatic amino acids have been noted. Use of special-
ized BCAA-supplanted formula is based on the ability of BCAA to interfere with
aromatic amino acid’s ability to cross the blood–brain barrier. Clinical observa-
tion has noted no benefit of these formulas when compared to medical treatment
of encephalopathy with lactulose or neomycin.32 Conversely, benefit upon nitrogen
balance33 and survival of a malnourished population34 has been noted with BCAA
supplemented formulas.
10.6.4.2 Immune Enhancing Nutrients

Recently a number of nutrients have been added to enteral formulas based largely on
animal studies demonstrating benefit: glutamine, arginine, nucleotides, and omega
3 fatty acids.
The amino acid glutamine, a nucleotide precursor, is essential for rapidly divid-
ing cells. Supplementation has been studied in the following scenarios: trauma/burn,
neonatal care, and bone marrow transplantation with varying benefit on infection
rates (benefit seen in BMT,35 trauma/burns;36 however, not in preterm infants.37 The
so-called “immune-enhancing” mixture includes glutamine, arginine, and omega
3 fatty acids. Several costly formulas, including this cocktail, are commercially
available, but data regarding improvement in clinical outcomes remain limited, with
meta-analysis suggesting reduction in infection rate, ventilator days, and length of
stay, but no change in mortality.38–39 On the other hand, a large, well implemented
study found no effect upon outcomes.40
10.6.4.3 Disease Specific Formulas

In diabetic- or glucose-intolerant clients, the option of reduced carbohydrate for-
mula is available. To compensate for the carbohydrate reduction and maintain a kcal
concentration of 1 kcal/ml, a greater percentage of kcal are derived from fat. These
formulas maintain normal osmolality.
For clients with fat malabsorption from bile salt deficiency or lymphatic disor-
der, formula containing medium chain triglycerides (MCT) as the predominant fat
source is utilized. MCT-predominant formula provides intact carbohydrate and fat,
so in cases of compromised gastrointestinal tract function where hydrolysates are
preferred, a negligible fat, hydrolyzed protein and carbohydrate formula may be
more appropriate.
Pulmonary formulas are polymeric, but supply less carbohydrate as a means to
decrease the respiratory quotient. These formulas, like the diabetic formulas are
high in fat, and in addition may provide antiinflammatory omega 3 fatty acids and
increased kcal density of 1.5 kcal/ml.
10.7 Conclusions
Nutritional support is important for good outcomes in the critically ill patients
and those with chronic disease who cannot ingest an adequate diet or have severe
gastroperesis. Early enteral nutrition seems to have better outcomes in all groups
where the gut is functional compared to parenteral nutrition. Endoscopic enteral
access provides a means of delivering nutrition to these patients without the need
for surgery. The techniques for endoscopic enteral access are safe and effective and
should be in the armamentarium of every gastroenterologist. The most appropriate
nutritional formulas require a knowledge of the particular patient’s nutrition and
energy requirements.
References
1. Daly JM, Lieberman MD, Goldfine J, Shou J, Weintraub F, Rosato EF, Lavin P. Enteral
nutrition with supplemental arginine, RNA, and omega-3 fatty acids in patients after oper-
ation: immunologic, metabolic, and clinical outcome. Surgery. 1992 Jul;112(1):56–67.
2. Kudsk KA, Croce MA, Fabian TC, Minard G, Tolley EA, Poret HA, Kuhl MR, Brown
RO. Enteral versus parenteral feeding: effects on septic morbidity after blunt and pen-
etrating abdominal trauma. Ann Surg. 1992 May;215(5):503–11; discussion 511–3.
3. Lipp A, Lusardi G. Systemic antimicrobial prophylaxis for percutaneous endoscopic
gastrostomy. Cochrane Database Syst Rev. 2006 Oct 18;(4):CD005571; review.
4. Ahmad I, Mouncher A, Abdoolah A, Stenson R, Wright J, Daniels A, Tillett J, Hawthorne
AB, Thomas G. Antibiotic prophylaxis for percutaneous endoscopic gastrostomy—
a prospective, randomised, double-blind trial. Aliment Pharmacol Ther. 2003 Jul
15;18(2):209–15.
5. Külling D, Sonnenberg A, Fried M, Bauerfeind P. Cost analysis of antibiotic prophylaxis
for PEG. Gastrointest Endosc. 2000 Feb;51(2):152–6.
6. Horiuchi A, Nakayama Y, Kajiyama M, Fujii H, Tanaka N. Nasopharyngeal decoloniza-
tion of methicillin-resistant Staphylococcus aureus can reduce PEG peristomal wound
infection. Am J. Gastroenterol. 2006;101(2):274–7.
7. Choudry U, Barde CJ, Market R, et al. Percutaneous endoscopic gastrostomy: a ran-
domized prospective comparison of early and delayed feeding. Gastrointest Endosc
1996;44:164–7.
8. Mellert J, Naruhn MB, Grund KE, Becker HD. Direct endoscopic percutaneous jejunos-
tomy (EPJ): clinical results. Surg Endosc. 1994 Aug;8(8):867–9; discussion 869–70.
9. Shike M, Latkany L, Gerdes H, Bloch AS. Direct percutaneous endoscopic jejunosto-
mies for enteral feeding. Gastrointest Endosc. 1996 Nov;44(5):536–40.
10. Bueno JT, Schattner MA, Barrera R, Gerdes H, Bains M, Shike M. Endoscopic place-
ment of direct percutaneous jejunostomy tubes in patients with complications after
esophagectomy. Gastrointest Endosc. 2003 Apr;57(4):536–40.
11. Barrera R, Schattner M, Nygard S, Ahdoot M, Ahdoot A, Adeyeye S, Groeger J, Shike
M. Outcome of direct percutaneous endoscopic jejunostomy tube placement for nutri-
tional support in critically ill, mechanically ventilated patients. J Crit Care. 2001
Dec;16(4):178–81.
12. Maple JT, Petersen BT, Baron TH, Gostout CJ, Wong Kee Song LM, Buttar NS. Direct
percutaneous endoscopic jejunostomy: outcomes in 307 consecutive attempts. Am J
Gastroenterol. 2005 Dec;100(12):2681–8.
13. Shetzline MA, Suhocki PV, Workman MJ. Direct percutaneous endoscopic jejunos-
tomy with small bowel enteroscopy and fluoroscopy. Gastrointest Endosc. 2001
May;53(6):633–8.
14. Fan AC, Baron TH, Rumalla A, Harewood GC. Comparison of direct percutaneous
endoscopic jejunostomy and PEG with jejunal extension. Gastrointest Endosc. 2002
Dec;56(6):890–4.
15. Dark DS, Pingleton SD. Nutrition and nutrition support in critically ill patients. J Int
Care Med 1993;8:16.
16. Robinson G, Goldstein M, Levine GM. Impact of nutritional status on DRG length of
stay. JPEN 1987;11:49.
17. Institute of Medicine. Food and Nutrition Board. Dietary reference intakes: recom-
mended intakes for individuals. National Academy of Sciences, 2004.
18. Frankenfield DC, Rowe WA, Smith JS et al. Validation of several established equations for
resting metabolic rate in obese and nonobese people. J Am Diet Assoc 2003;103:1152.
19. Detsky AS, McLaughlin JR, Baker JP et al. What is subjective global assessment of
nutritional status? JPEN 1987;11:8.
20. Secker DJ, Jeejeebhoy KN. Subjective global nutritional assessment for children. Am J
Clin Nutr 2007;85:1083.
21. Waterlow JC. Classification and definition of protein-calorie malnutrition. Br Med J
1972;3:566.
22. Campbell SM. Preventing Microbial Contamination of Enteral Formulas and Delivery
Systems. Columbus OH: Abbott Laboratories, Ross Products Division, 2000.
23. Coben RM, Weintraub A, DiMarino AJ et al. Gastroesophageal reflux during gastros-
tomy feeding. Gastroenterol 1994;106:13.
24. Kattlemann KK, Hise M, Russell M et al. Preliminary evidence for a medical nutri-
tion therapy protocol: enteral nutrition for critically ill patients. J Am Diet Assoc
2006;106:1226.
25. Metheny NA, Schallom L, Oliver DA et al. Gastric residual volume and aspiration in
critically ill patients receiving gastric feedings. Am J Crit Care 2008;17:512.
26. Metheny NA, Dahms TE, Chang YH et al. Detection of pepsin in tracheal secretions
after forced small-volume aspiration of gastric juice. JPEN 2004;28:79.
27. Bankhead R, Boullata J, Brantley S et al. ASPEN enteral nutrition practice guidelines.
JPEN 2009;33:122–67.
28. Ciocon JO, Galindo-Ciocon DJ, Tiessen C et al. Continuous compared with intermittent
tube feeding in the elderly. JPEN 1992;16:525.
29. Torres A, Serra-Batlles J, Ros E et al. Pulmonary aspiration of gastric contents in
patients receiving mechanical ventilation: the effect of body position. Ann Int Med
1992;116:540.
30. Metheny NA, Clouse RE, Chang YH. Tracheobronchial aspiration of gastric contents
in critically ill tube fed patients: frequency, outcomes and risk factors. Crit Care Med
2006;34:1.
31. Metheny NA, Dahms TE, Stewart BJ et al. Verification of inefficiency of the glu-
cose method in detecting aspiration associated with tube feeding. MedSurg Nursing
2005;14:112.
32. Eriksson LS, Conn HO. Branched chain amino acids in the treatment of encephalopa-
thy: an analysis of variants. Hepatology 1989;10:228.
33. Marchesini G, Dioguardi FS, Bianch GP et al. Long-term oral branched chain amino
acids treatment in chronic hepatic encephalopathy: a randomized double blind casein-
controlled trial. J Hepatol 1990;11:92.
34. Cabre E, Gonzalez-Huiz F, Abad-Lacruz A et al. The effect of total enteral nutrition on
the short-term outcome of severely malnourished cirrhotics: a randomized controlled
study. Gastro 1990;98:715.
35. Schloerb PR, Amare M. Total parenteral nutrition with glutamine in bone marrow trans-
plant and other clinical applications. JPEN 1993;17:407.
36. Houdijk AP, Rijnsburger ER, Jansen J et al. Randomized trial of glutamine-enriched
nutrition on infectious morbidity in patients with multiple trauma. Lancet 1998;
352:772.
37. van den Berg A, van Elburg RM, Westerbeek EA et al. Glutamine enriched enteral nutri-
tion in very-low birth weight infants and effects on feeding tolerance and infectious
morbidity: a randomized controlled study. Am J Clin Nutr 2005;81:1397.
38. Beal RJ, Bryg DJ, Bihari DJ. Immunonutrition in the critically ill: a systemic review.
Crit Care Med 1999;27:2799.
39. Heyland DK, Novak F, Drover JW et al. Should immunonutrition become routine in
critically ill patients? A systemic review of the evidence. JAMA 2001;286:944.
40. Kieft H, Roos AN, van Drunen JD et al. Clinical outcomes of immunonutrition in a
heterogeneous intensive care population. Int Care Med 2005;31:524.
11 Self-Expanding Metallic
Stents in the Management
of Malignant Esophageal,
Gastric Outlet, and
Duodenal Obstructions
Francis W. Chan and Priya A. Jamidar
Contents
11.1 Overview of Esophageal Carcinoma and Malignancies Responsible
for Gastric Outlet Obstruction....................................................................... 175
11.2 Methods of Palliation..................................................................................... 176
11.2.1 Esophageal Obstruction..................................................................... 176
11.2.2 Gastric Outlet and Duodenal Obstruction......................................... 177
11.3 Stents and Characteristics.............................................................................. 177
11.4 Technical Considerations Regarding Placement........................................... 182
11.4.1 Esophageal Obstruction..................................................................... 182
11.4.2 Gastric Outlet and Duodenal Obstruction......................................... 184
11.5 Esophageal Obstruction Outcomes................................................................ 185
11.6 Gastric Outlet and Duodenal Obstruction Outcomes.................................... 186
11.7 Poststent Care................................................................................................ 186
11.8 Conclusions.................................................................................................... 187
References............................................................................................................... 187
11.1 Overview of Esophageal Carcinoma

and Malignancies Responsible for
Gastric Outlet Obstruction
The treatment of upper gastrointestinal tract cancers continues to be a challenge to
clinicians. Esophageal carcinoma and malignancies that cause gastric outlet or duo-
denal obstruction are particularly distressing to both the patient and clinician due
to their frequent late stage of presentation as well as their adverse effects on quality
of life. The incidence of esophageal adenocarcinoma has been increasing world-
wide, while that of esophageal squamous cell carcinoma is decreasing.1,2 Moreover
175
there has been a significant increase in the proportion of patients presenting with
Stage IV adenocarcinoma.3 Consequently, approximately 50 to 60% of patients have
incurable disease at the time of presentation.4 Based on the histologic organization
of the esophagus, squamous cell carcinoma typically occurs in the midesophagus,
whereas adenocarcinoma typically occurs in the distal esophagus. Early esopha-
geal carcinomas typically appear as superficial plaques or ulcerations while more
advanced lesions can present as strictures or ulcerating and bleeding esophageal
masses. Because this malignancy develops as an intraluminal lesion, the advanced
stage malignancies most commonly cause symptoms of dysphagia or odynophagia.
Other presentations include iron deficiency anemia, overt gastrointestinal bleeding,
or tracheoesophageal fistula. In the subset of patients with late stage disease, there-
fore, palliative therapy is focused on relieving symptoms of dysphagia.
Malignancies are the etiology of up to 39% of cases of gastric outlet obstruc-
tion.5 Malignant gastric outlet and duodenal obstruction can be caused by intrinsic or
extrinsic effects of a tumor. Pancreatic adenocarcinoma with extension to the stom-
ach or duodenum can commonly cause extrinsic obstruction, and if invading through
the bowel wall, can also cause intrinsic obstruction of the lumen. The incidence of
pancreatic adenocarcinoma is 7.1 per 100,000 people.6 Of affected patients, retro-
spective reports indicate that gastric outlet obstruction can occur in up to 15 to 25%.7
Other common malignancies that cause gastric outlet obstruction include distal gas-
tric cancer, small bowel neoplasms, gastric lymphoma, and peritoneal carcinomato-
sis. Patients with gastric outlet or duodenal obstruction typically present with severe
nausea and vomiting, abdominal distension, early satiety, and abdominal pain.
11.2 Methods of Palliation
11.2.1 Esophageal Obstruction
Because such a large percentage of patients with esophageal cancer present with
incurable and unresectable disease, the goals of management for these patients typi-
cally focus on palliation of the disease. Modalities that are utilized for palliation
include external beam radiation therapy (EBRT), chemoradiotherapy, brachyther-
apy, endoscopic balloon dilatation, endoscopic laser ablation, and endoscopic stent-
ing with plastic or metal stents.
EBRT and chemoradiotherapy can be successful in 40 to 88% of patients, but
improvements in swallowing function can take up to two months.8,9 For patients
with advanced disease and a limited lifespan, the duration of time required to derive
benefit from this modality may not be acceptable. Brachytherapy is also an effective
palliative modality in greater than 70% of patients. However, similar to EBRT and
chemoradiotherapy, the palliative effect is delayed, with some patients deriving peak
relief of dysphagia 30 days after therapy.10 Moreover, up to 30% of patients subse-
quently develop fibrotic strictures.11 Although laser therapy also has been used suc-
cessfully for treatment of malignant dysphagia, patients frequently require multiple
treatment sessions at four- to six-week intervals, and some patients require esopha-
geal dilatation prior to laser therapy, which confers a 5 to 9% risk of perforation.12,13
Conventional plastic endoluminal stents also have been used to treat esophageal
Self-Expanding Metallic Stents 177
malignant obstruction. The benefits of this type of therapy include rapid relief of
dysphagia symptoms after stent placement and treatment success with single session
therapy. However, plastic stents are often technically challenging to place. Due to the
large external diameters of the delivery systems, patients often require prestenting
esophageal dilatation to accommodate the stent. This consequently incurs a perfo-
ration rate of 5 to 19%.14 The small internal diameters of the stent lumen also may
limit improvement in dysphagia scores. Finally, the procedure-related mortality with
plastic endoluminal stents is high, ranging from 2 to 4% up to 16%.11
The limitations of these alternative modalities have spurred the development
of self-expanding metallic stents (SEMS). The application of SEMS for palliation
of gastrointestinal luminal obstruction was pioneered in the early 1990s and has
revolutionized the management of malignant luminal obstruction. Overall, SEMS
appear to be safer than plastic stents while maintaining equivalent clinical benefits
in regards to the relief of dysphagia. Therefore, SEMS have largely surpassed plastic
stents for palliation of malignant obstruction. In two randomized controlled trials
comparing SEMS and plastic stents, SEMS were found to have lower procedure-
related complication rates including perforation, lower procedure-related mortality,
and lower rates of stent migration.9, 15
11.2.2 Gastric Outlet and Duodenal Obstruction

Malignant gastric outlet and duodenal obstruction are common late complications
of pancreatobiliary and gastric cancers. Because of the late presenting symptoms,
patients frequently have limited management options. At diagnosis, approximately
85% and 40% of pancreatic and gastric cancers, respectively, are inoperable.16 The
few patients that present with early stage, localized disease may be candidates
for curative surgical resection. More commonly, due to its late presentation, this
malignancy is amenable only to palliative therapy. If patients are operative candi-
dates, open or laparoscopic gastrojejunostomy is the primary approach for surgical
palliation. Open and laparoscopic gastrojejunostomy are associated with morbid-
ity and mortality rates as high as 30% and 15%, respectively.17 Studies compar-
ing open versus laparoscopic gastrojejunostomy have shown that the laparoscopic
approach may have a lower morbidity and mortality as well as a shorter length
of hospital stay, and shorter time to oral intake.18–20 Unfortunately, because most
patients present with late stage disease, surgical palliation is frequently not a via-
ble option.
Nonsurgical methods for palliation include radiation therapy, balloon dilata-
tion, laser ablation, and SEMS. In studies comparing SEMS with gastrojejunos-
tomy, SEMS has been found to have lower postprocedure complications, more rapid
resumption of normal oral intake, and shorter lengths of hospital stay.19,21–23
11.3 Stents and Characteristics

SEMS are composed of several different types of metals and are designed specifically
for use in the biliary tree, esophagus, small bowel, and colon. Each stent has differ-
ent performance characteristics that are based on the type of metal alloy, delivery
system, length and diameter of the closed and open stent, radial force exerted by the
open stent, degree of shortening that occurs upon opening of the stent, and the pres-
ence or absence of a stent covering.
SEMS are commonly constructed of nitinol, stainless steel, combination alloys,
or polyester and silicone. The material from which the stent is constructed and the
lattice pattern of the metal contribute to the radial force characteristics of each indi-
vidual stent. Delivery systems also vary with some stents that are deployed through-
the-scope (TTS), while others are non-TTS stents that are placed over-the-wire and
deployed via fluoroscopic guidance. The length and diameter (open and closed) vary
and can be selected based on the dimensions and characteristics of the obstructing
mass. The degree of shortening that may occur with stent expansion should be taken
into account when selecting the appropriate stent length. Lastly, the selection of cov-
ered versus uncovered stents has important implications in regards to migration risk,
tumor overgrowth, and the presence or absence of an enteric fistula.
Currently, in the United States there are three companies who manufacture U.S.
Food and Drug Administration (FDA)-approved esophageal stents. Conventionally,
FDA-approved esophageal stents also have been used for gastric outlet and duode-
nal obstruction. Boston Scientific (Natick, Massachusetts) produces the Wallflex®
Duodenal and the Wallstent® Colonic and Duodenal Stent (Figure 11.1), the Ultraflex®
NG (covered and uncovered), and the Polyflex® Esophageal stents (Figure 11.2).
Cook Medical (Bloomington, Indiana) produces the Esophageal Z-Stent® in cov-
ered, uncovered, and antireflux versions (Figure 11.3) and the Evolution Controlled
Release Stent® (Figure 11.4). Alveolus (Charlotte, North Carolina) produces the
Alimaxx-E®. The characteristics and specifications of these stents vary in regards to
their deployment diameter, length, flanges, covered versus bare metal construction
as well as some additional factors (Table 11.1).
The Wallstent Colonic and Duodenal uncovered stent can be used for lesions in
both the upper and lower gastrointestinal tract. It is manufactured from Elgiloy®,
which is a cobalt–chromium–nickel-based alloy that is compressed into a 10 French
delivery system. The stent is available with fully expanded diameters of 20 and 22
mm. Both of these diameters are available in 60 or 90 mm lengths.
Figure 11.1 Boston Scientific Stents. (A) Wallflex Duodenal Stent; (B) Wallstent Colonic
and Duodenal covered and Wallflex Duodenal uncovered stent.
Figure 11.2 Boston Scientific Stents. (A) Ultraflex NG covered stent; (B) Polyflex
Esophageal stent.
A B
C D
Figure 11.3 Cook Medical Stents. (A) Esophageal Z-stent, fully coated; (B) Esophageal
Z-stent, uncoated flange; (C) Esophageal Z-stent, fully coated and uncoated flange with deliv-
ery device; (D) Esophageal Z-stent with Dua Antireflux Valve.
A B
C D
Figure 11.4 Cook Medical Stents. (A and B) Evolution Controlled Release Stent; (C and
D) Evolution Controlled Release Stent with delivery device.
Table 11.1
Esophageal and Duodenal Stents: Specifications and Characteristics
Stent Additional
Stent Composition Stent Diameter Length Characteristics
Boston Scientific
Wallstent Colonic Elgiloy 20, 22 mm 60, 90 mm Through the scope/over
and Duodenal the wire deployment,
Stent reconstrainable up to
79% deployment
Wallflex Duodenal Nitinol 22 mm diam/27 60, 90, 120 Through the scope/over
(nickel- mm flare mm the wire deployment,
titanium) flared distal end,
reconstrainable up to
70% deployment
Ultraflex NG Stent Nitinol 18 mm diam/ 23 70,100, 150 Large Proximal Flare,
System, (nickel- mm flare mm available in proximal
uncovered titanium) and distal release
system, 48–54%
shortening with
deployment
Ultraflex NG Stent Nitinol 18 mm diam/ 23 100, 120, Large Proximal Flare,
System, covered (nickel- mm flare, 150 mm available in proximal
titanium) w/ 23 mm diam/28 and distal release
polyurethane mm flare system, 48–54%
cover shortening with
deployment
Polyflex Polyester w/ 16 mm diam/20 90, 120, 150 Proximal flare,
Esophageal Stent Silicone cover mm flare, mm designed to be
18 mm diam/23 removable, 36–41%
mm flare, shortening with
21 mm diam/25 deployment
mm flare
Cook Medical
Esophageal Stainless steel 18 mm/25 mm 80, 100, Over the wire
Z-Stent Fully flared ends 120, 140 deployment, flared
Coated mm proximal and distal
ends, no shortening
with deployment
Z-Stent Uncoated flared ends 120, 140 deployment, uncoated
Flange mm flared proximal and
distal ends, no
shortening with
deployment
Esophageal and Duodenal Stents: Specifications and Characteristics
Stent Additional
Stent Composition Stent Diameter Length Characteristics
Z-Stent with flared ends 120, 140 deployment, flared
Dual Antireflux mm proximal and distal
Valve ends, pressure-
sensitive “windsock”
at distal end to prevent
reflux, no shortening
with deployment
Evolution Nitinol 20 mm/25 mm 80, 100, Flared proximal and
Controlled (nickel- flared ends 125, 150 distal ends, controlled
Release Stent titanium) w/ mm release with recapture
silicone internal of stent possible up to
and external “point of no return”
cover indicator on
deployment device
Alveolus
Alimaxx-E Nitinol 18, 22 mm 70, 100, 120 Flared proximal and
(nickel- (proximal flare mm distal ends
titanium) 5 mm greater,
distal flare 3
mm greater)
The Wallflex Duodenal uncovered stent is composed of Nitinol, which is a nickel–

titanium alloy that possess thermal elastic memory. This alloy is constructed with a
certain diameter at specific temperatures, then cooled and compressed into a deliv-
ery device. When deployed at body temperature, the stent reexpands in an attempt to
regain its original size, diameter, and configuration. Because of the characteristics
of this alloy, these stents foreshorten when deployed. In addition, they reach their
maximal diameter over the course of several days after the stent has been inserted.
The Wallflex stent is compressed into a 10 French through-the-scope, over-the-wire
delivery catheter. It has a flared distal end with radiopaque markers and clear transi-
tion zone and can be recaptured for repositioning of the stent up to approximately
70% deployment. The stent is available in one diameter with an expanded diameter
of 22 mm with a 27 mm flare and lengths of 60, 90, and 120 mm.
The Ultraflex NG is manufactured from Nitinol and is available in polyurethane
covered and uncovered form. This stent has a proximal flare and, in covered form,
the body is covered while the proximal and distal ends remain uncovered. The
uncovered stent is available in one diameter with a 18 mm diameter body and 23 mm
diameter flare with lengths of 70, 100, and 150 mm.
The covered stent is available in two diameters with an 18 mm diameter body

with 23 mm flare, or 23 mm diameter body with 28 mm flare. Length options for the
covered stent are 100, 120, and 150 mm.
The Polyflex Esophageal stent is not a self-expanding metallic stent. Rather, it is
a new generation of self-expanding plastic stents composed of silicone and polyester.
It has a proximal flare, is designed to be removable, and is packaged in a 12, 13, or
14 mm diameter delivery device. The stent is available with a 16 mm body diameter
with 20 mm flare, 18 mm body with 23 mm flare, or 21 mm body with 25 mm flare.
Each of these sizes is offered in 90, 120, and 150 mm lengths.
The Esophageal Z-stent is composed of stainless steel, flared at the proximal and
distal ends, and is available in three forms: fully coated, uncoated flange, and antire-
flux. This stent features over-the-wire delivery via a 31 French delivery system. It is
available with an 18 mm diameter body with 25 mm flared ends and lengths of 80,
100, 120, and 140 mm.
The Evolution Controlled Release uncovered stent is the newest stent and is com-
posed of Nitinol with a silicone internal and external cover. The primary feature of
this device is the ability to slowly and incrementally deploy this stent while main-
taining the ability to recapture the stent up to a “point of no return” as indicated on
the 8 mm diameter delivery device. The stent is flared at the proximal and distal ends
and is available in a 20 mm diameter body with 25 mm flared ends in lengths of 80,
100, 125, and 150 mm.
Lastly, the Alimaxx-E is an uncovered Nitinol stent with flared proximal and dis-
tal ends. The proximal flare is 5 mm greater and the distal flare is 3 mm greater than
the expanded stent body diameter. It is available in 18 and 22 mm body diameters
with lengths of 70, 100, and 120 mm.
11.4 Technical Considerations Regarding Placement

Once a thorough evaluation and staging of the primary tumor has been completed
and the patient has been deemed a candidate for palliative care, the decision must
be made regarding the desired modality. If endoscopic therapy is chosen, SEMS
placement is most frequently the treatment of choice. Placement of SEMS typically
involves fluoroscopic guidance combined with endoscopic visualization. Before
placement of the stent, exact localization and extent of the tumor must be estab-
lished. In various studies, this initial step has been performed via upper gastrointes-
tinal series with barium contrast or Gastrografin, cross-sectional imaging, or direct
visualization by endoscopy.
11.4.1 Esophageal Obstruction
Both the stricture length and lumen diameter must be assessed. An exact measure-
ment of the stricture length determines the length of the stent that will be inserted.
The techniques utilized to assess stricture length are determined by the degree of
stenosis. If the stenosis is mild to moderate, the length of the stricture can be measured
directly during endoscopy as the endoscope traverses the length of the mass and
stricture. However, if the stenosis is severe, fluoroscopy with contrast dye injection
must often be used to assess the stricture length. A guide wire can be passed through
the stenosis followed by a balloon catheter. Contrast dye is then injected through the
catheter distal to the stricture and examined under fluoroscopy.
Not only is the lumen diameter important for the measurement of stricture length,
but it also determines the feasibility of direct stenting. Each stent is packaged with a
unique delivery device. The diameter of the narrowed lumen must be able to accom-
modate the external diameter of this delivery device in order for the stent to be
accurately and securely inserted. If the lumen diameter does not accommodate the
diameter of the endoscope, an assessment must be made as to whether the lumen
will accommodate the delivery device. In the event that the stenosis does not allow
passage of the delivery device, the stricture will then require predilatation with
either Savary or balloon dilatation. Just as predilatation increases perforation risk
in the placement of plastic endoluminal stents, predilatation for placement of SEMS
may also increase perforation risks over no predilatation. However, this concern is
theoretical as no controlled trials have compared SEMS placement with and with-
out predilatation. This rate, however, is lower than that of predilatation for plastic
stents.9,15 This difference in perforation risk is likely due to the larger diameter deliv-
ery devices of plastic stents.
Because delivery devices are uniquely constructed for each individual stent, they
vary by stent type and medical device manufacturer. The early studies with SEMS
were conducted in the early 1990s when the majority of stent delivery devices did
not utilize through-the-scope delivery systems. Most early stents were developed for
fluoroscopic, over-the-wire delivery and insertion. Contrast was typically injected
into the lumen to outline the location and length of the stricture. Based on the fluo-
roscopic images, radiopaque markers were then placed on the skin to mark the upper
and lower borders of the tumor. These markers then served to guide placement of the
stents. Alternatively, direct fluoroscopy while visualizing the radiopaque borders of
the stent itself has been used to guide placement. Although some current stents still
utilize fluoroscopic, over-the-wire placement, many of the currently available stents
utilize a combination of fluoroscopic, over-the-wire and, through-the-scope delivery
techniques. This maximizes the ability of the endoscopist to accurately place the
stent on the first attempt while minimizing the risk of migration and misplacement.
When choosing a stent, there are several factors that must be taken into consider-
ation: the stent diameter and length, radial force, degree of shortening upon expan-
sion, and the use of covered versus uncovered stents. Because the stent diameter will
determine poststenting lumen diameter, larger stent diameters presumably facilitate
resumption of a more normal diet that includes solid foods. Smaller diameter stents
may continue to limit patients to liquid or semisolid food intake, have a higher risk of
stent migration, tissue overgrowth, and food impaction.24 Therefore, the stent diam-
eter should be maximized while simultaneously conforming to the limits set by the
native diameter of the enteral lumen. However, perforations and fistulas that develop
after stent placement can form due to pressure necrosis that may be more likely with
larger stents.24 Particular care should be taken for stents placed in patients who have
undergone radiation therapy. In at least one report, patients who have undergone
radiation therapy and chemotherapy prior to stent placement have a higher risk of
complications, including perforations.25
The desired length of the stent will be determined by the extent and length of the
esophageal stricture. For mid- to distal-esophageal and gastroesophageal junction
disease, the inserted stent should be approximately 4 cm longer than the stricture,
such that approximately 2 cm of the stent will extend beyond both the proximal and
distal borders of the stricture to maximally reduce tumor overgrowth as well as stent
migration. This is particularly important in stents placed across the gastroesopha-
geal junction. In this location, the distal end of the stent will be freely hanging into
the gastric lumen and will not be in apposition to a mucosal surface. Therefore, only
the proximal end of the stent is in contact with and anchored to normal esophageal
mucosa. Because the stent should extend 2 to 3 cm beyond the borders of the stric-
ture, individual stent characteristics must be known prior to stent selection. Because
there are a number of stents that foreshorten when fully expanded, the closed length
of each individual stent does not necessarily reflect the fully deployed and opened
length of the stent. This degree of shortening must be taken into account when select-
ing the stent length.
Proximal esophageal malignant strictures pose additional challenges. Due to the
proximity of these proximal lesions to the upper esophageal sphincter, there have
been concerns regarding the risk of proximal stent migration and asphyxiation, tra-
cheal compression, pain, and discomfort. Most studies involving esophageal SEMS
for malignant palliation have excluded proximal esophageal lesions. However, there
have been several small studies evaluating stenting of proximal lesions.26,27 In these
studies, success rates were high when the proximal end of the stents were positioned
within the upper esophageal sphincter.
Lastly, the selection of a covered versus uncovered stent has significant implica-
tions. If the primary indication for stent placement is for palliation of a malignant
obstruction or stricture, either a covered or uncovered stent can be used. However, if
an obstruction/stricture exists concurrently with a tracheoesophageal fistula, only a
covered stent can be used.
11.4.2 Gastric Outlet and Duodenal Obstruction

Like esophageal obstructions, assessing the stricture length and lumen diameter
in gastric outlet obstruction and duodenal obstruction prior to stent placement is
also imperative. The techniques by which this evaluation is performed are similar
and consist of either direct endoscopic visualization or fluoroscopic assessment
with contrast dye injection. Most lesions causing gastric outlet obstruction will be
within reach of a standard upper endoscope. For lesions distal to the second or third
portion of the duodenum, a colonoscope or enteroscope may be required to access
the stricture.
Depending on the severity of the gastric outlet or duodenal obstruction, predilata-
tion may be required prior to advancing the stent delivery device. Dilatation can be
performed with a pneumatic balloon. Because many of the stents that are utilized for
esophageal strictures also are used for gastric outlet and duodenal obstruction, the
techniques used for stent localization are very similar and are based on the individ-
ual stent characteristics and specifications. Localization and insertion is performed
either via fluoroscopy and over-the-wire placement or via fluoroscopy and over-the-
wire/through-the-scope placement.
The stent chosen should be approximately 4 cm longer than the length of the
obstruction to allow an appropriate degree of contact between the stent and the nor-
mal mucosa. Oftentimes stents that are placed across the pylorus into the duodenum
will traverse the ampulla. In these situations, several case series have described a sig-
nificant rate of biliary obstruction in up to 50% of patients.28,29 Therefore, consider-
ation should be given to inserting a biliary stent concurrently with a gastroduodenal
stent. If not performed concurrently, biliary obstruction developing after gastroduo-
denal stent placement may not be able to be managed endoscopically because the
stent overlying the ampulla will frequently impair access to the common bile duct.
In such cases, percutaneous biliary drainage may be required.
11.5 Esophageal Obstruction Outcomes

Stenting of lesions in the esophagus and the gastroesophageal junction (GEJ) with
SEMS has a high technical and clinical success rate and an acceptably low rate of
complications. The majority of studies with SEMS have been performed in Europe
where the stents utilized differ from those that are available and Food and Drug
Administration (FDA)-approved in the United States. As such, much of the data
regarding success rates are based on stents that are not available in the United States.
Moreover, many of the studies that do include FDA-approved stents predate the most
recent iteration of stents produced by the medical device companies. Therefore,
much of the data must be extrapolated from these studies and applied to stents avail-
able in the United States.
In most studies, technical success rates have been defined by the ability to accu-
rately deliver and expand the stent in the desired location on the first procedural
attempt. In most studies evaluating placement of SEMS in the esophagus, technical
success rates have been reported to be greater than 95%.9,25,30–33 For stents placed
in the distal esophagus and across the GEJ, success rates do not differ significantly
from midesophageal stent placement.34
Clinical success rates have largely been measured by patient-reported symptoms.
Most studies utilize a four-stage dysphagia score. A score of 0 corresponded to the
ability to eat a normal diet; 1, the ability to eat some solid foods; 2, the ability to eat
semisolids; 3, the ability to drink liquids only; and 4, complete dysphagia. Most stud-
ies have shown dramatic reductions in dysphagia scores with the majority of patients
improving by 2 grades. Most patients had mean scores of 2 to 3 prior to stenting and
scores of 0 to 1 poststenting.15,31,33,35,36 However, palliation of esophageal stenosis
due to extrinsic malignant compression may have less dramatic improvements in
dysphagia scores.34
The primary procedure related complications that result from SEMS placement
include aspiration in 6 to 20% of patients,30,33,37 pain in up to 25%,32,33 severe bleed-
ing in up to 10%,31,32,35,37 and perforation in up to 6%.31,37 Late complications, such as
stent migration, occur in up to 13%,31,35 and recurrent dysphagia or tumor ingrowth/
overgrowth occurs in up to 30%.9,15,31,33,35,37 In addition to these potential complica-
tions that may occur with esophageal stenting, there are unique challenges and risks
involved when placing stents across the GEJ. Because the distal end of the stent is not
in firm apposition with a mucosal surface, but rather projects into the gastric lumen,
stent migration is more likely.11 In addition, increased rates of bleeding complica-
tions and reflux have been noted with stents placed at the GEJ.34
11.6 Gastric Outlet and Duodenal

Obstruction Outcomes
Similar to esophageal and GEJ stenting, treatment of gastric outlet and duodenal
obstruction with SEMS has a high success rate and low complication rates. The
majority of the data originate from Europe, using stents that either are not available
in the United States or are outdated by newer stent technology.
Like esophageal stenting, technical success is defined by the ability to accurately
deploy the stent in the location of interest on the first attempt. One large systematic
review of palliative stenting for gastric outlet obstruction (GOO) included an analy-
sis of 1,046 patients who underwent stent placement. The overall technical success
rate was 96%.6
Clinical benefit has been defined based on patient symptom scores. The Gastric
Outlet Obstruction Scoring System (GOOSS) score has been used for this purpose
in most studies. In the GOOSS, a score of 0 denotes no oral intake, 1 represents
liquid intake, 2 indicates soft foods, and 3 represents solid food/full diet. Reported
clinical success rates have typically been defined by improvement of one stage in the
GOOSS. These success rates range from 75 to 92%.21,23,28,29,38–40 In one large meta-
analysis, 11% of patients did not experience a clinical improvement after GOO stent-
ing. The primary causes of this failure included progression of disease (61%), early
stent migration (20%), and errors in stent placement and deployment (15%).42
The most common complications of GOO stenting include bleeding in 1.5% of
patients,40 common bile duct (CBD) obstruction in 44 to 71%,21,28 recurrent obstruction
in 9 to 22%,28,29,40–42 perforation in 1 to 6%,29,39–42 and stent migration in up to 1.5 to
14%.21,29,39–42 Recurrent obstruction is most commonly caused by tumor overgrowth or
ingrowth. This typically can be treated successfully by repeat endoscopic intervention.
11.7 Poststent Care

Nutritional guidelines have not been studied or established for patients in whom
SEMS have been placed. Most patients derive clinical benefit within one to seven
days of stent placement. For nitinol stents, in particular, the reduction of dysphagia
may not be immediate due to the physical properties of the nitinol. Because these
stents possess thermal elastic memory, it may take several days for these stents to
reach their maximal diameter. Unlike nitinol, other stents manufactured from other
materials typically take on their maximal diameter upon deployment.
In general, for esophageal, gastric outlet, and duodenal stents, patients are typi-
cally started on clear liquid diets within one day of the stenting procedure. In some
centers, patients undergo an esophagram poststenting to determine the patency of
the stent and to rule out perforation prior to resuming oral intake. A clear liquid diet
is typically initiated 24 hours poststenting. Once patients have proved their ability to
take liquids, they can slowly be advanced to full liquids, puree/semisolid food, and,
if tolerated, a full diet. However, patients should avoid high residue foods, such as
leafy vegetables. Patients should continue to eat whatever foods they tolerate while
avoiding foods that trigger symptoms of dysphagia. As previously mentioned, recur-
rent obstruction due to tumor ingrowth or overgrowth can be as high as ~25%. These
patients who are affected by recurrent dysphagia and obstruction should be evalu-
ated for repeat stenting procedures.
11.8 Conclusions
Self-expanding metal stents have become the standard of care for the treatment of
malignant symptomatic obstructions in the upper gastrointestinal tract for those
patients who are not deemed to be operative candidates. Data regarding the usage of
SEMS indicate that, when used by experienced clinicians in the appropriate candi-
dates, this technology provides rapid clinical improvement with a low complication
rate. The benefits derived from this treatment provide patients comfort and improved
quality of life during their finals stages of life.
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12 Management of Chronic
Malabsorption
Piyush Tiwari, Manreet Kaur, and Bhaskar Banerjee
Contents
12.1 Introduction................................................................................................... 191
12.2 Physiology of Digestion and Absorption....................................................... 192
12.2.1 Fat...................................................................................................... 192
12.2.2 Carbohydrate..................................................................................... 192
12.2.3 Protein................................................................................................ 192
12.2.4 Enterohepatic Circulation.................................................................. 192
12.2.5 Minerals and Vitamins...................................................................... 193
12.2.6 Water and Electrolyte Balance.......................................................... 193
12.3 Etiology of Malabsorption............................................................................. 194
12.4 Diagnostic Evaluation of Malabsorption....................................................... 194
12.5 Management of Malabsorption...................................................................... 197
12.5.1 Control of Diarrhea............................................................................ 197
12.5.2 Correction of Nutritional Deficiencies...............................................200
12.5.3 Treatment of Underlying Disease and Diet Modification..................200
References...............................................................................................................204
12.1 Introduction
Malabsorption is a global term that includes a wide variety of impaired digestive and
absorptive disorders that are found in diverse gastrointestinal diseases. The severity
and breadth of clinical manifestations of malabsorption can differ widely depending
on the unabsorbed nutrients. The clinical features are collectively called the mal-
absorption syndrome. This chapter will provide general guidelines to help detect,
diagnose, and treat malabsorptive disorders and their symptoms. Before discuss-
ing malabsorption, it is important to consider the normal process of digestion and
absorption of dietary food as listed below.1
• Lubrication of food along with its movement through the alimentary tract.
• Mechanical and enzymatic breakdown of fats, proteins, and carbohydrates.
• Reabsorption of nutrients and water, and transportation of nutrients to the
liver via the portal vein and lymphatic system.
• Production of nutrients, such as biotin and vitamin K, by intestinal bacteria.
191
Any disruption in the above steps can result in malabsorption, which is the
impaired ability to digest or absorb nutrients across the intestinal mucosa into the
blood stream.2
12.2 Physiology of Digestion and Absorption

The normal physiology of digestion and absorption is outlined below.
12.2.1 Fat
Dietary fat is largely composed of long chain fatty acids (LCFAs), which esterify
to form triglycerides. Fat is digested to form free fatty acids and monoglycerides
through the process of lipolysis, which is initiated by gastric lipase in an acidic pH
of 4.5 to 6. Most of the lipolysis is performed by pancreatic lipase in the alkaline
medium of the duodenum and jejunum. In order to traverse through the thin aqueous
layer covering intestinal mucous membrane, free fatty acids form hydrophilic mixed
micelles in combination with conjugated bile acids, phospholipids, and cholesterol.
Micelles undergo cellular uptake and disintegrate to individual components, follow-
ing which free fatty acids resterify to generate triglycerides. Along with B lipopro-
tein, cholesterol, and cholesterol ester, triglycerides form chylomicrons that exit into
the lymphatic system to reach the liver. Medium chain fatty acids (present in coconut
oil) do not require lipolysis and subsequent reesterification. Upon mucosal absorp-
tion, they reach the liver via the portal vein.)3 Short chain fatty acids are synthesized
by colonic bacteria from nonabsorbed carbohydrates reaching the colon, and require
absorption through the colonic mucosa with sodium chloride (NaCl) and water.
12.2.2 Carbohydrate
Dietary carbohydrate is found in the form of starch, disaccharides, and glucose.
Salivary amylase, pancreatic lipase, and intestinal mucosal brush border cell surface
disaccharidase, sequentially digest carbohydrates to form monosaccharides (glu-
cose, galactose, and fructose) that are absorbed in the small intestine through an
active sodium (Na)-dependent process with the help of the cell membrane transport
carrier protein SGLT (sodium-dependent glucose transporters). Fructose absorption
is facilitated by GLUT 5 transport protein.
12.2.3 Protein
Dietary protein is ingested as polypeptides and then converted to tripeptides, dipep-
tides, and amino acids by gastric pepsin and pancreatic trypsin prior to absorption
in the small intestine.
12.2.4 Enterohepatic Circulation
Approximately 500 mg of primary bile acids (cholic acid and chenodeoxycholic
acid) are synthesized in the liver daily from cholesterol. Bile acids are conjugated
Management of Chronic Malabsorption 193
with glycine and taurine and secreted into the duodenum. In the small intestine, bile
acids form micelles with digested dietary fat to aid their absorption. The remaining
bile acids are absorbed by the terminal ileum for return to the liver (enterohepatic
circulation). A small amount of conjugated bile acid enters the colon and is rapidly
deconjugated and converted to secondary bile acids (deoxycholic acid and lithocholic
acid) by colonic bacteria, prior to their excretion in stool. The daily fecal loss of bile
acid is compensated by hepatic synthesis, which has a limited capacity. The entire
bile acid pool is recirculated about six to eight times during a 24-hour period.
12.2.5 Minerals and Vitamins

The absorption of fat-soluble vitamin A, D, E, and K occurs with dietary fat absorp-
tion. Fat malabsorption thus disrupts the absorption of fat soluble vitamins. Most
vitamins, including water soluble vitamin B and C, are absorbed mainly in the
jejunum, but vitamin B12 is absorbed in the ileum. Dietary vitamin B12 is liberated
from diet proteins and binds to R-binder protein (present in salivary and gastric
secretion) in the acidic pH of stomach, and later released free again in the alkaline
pH of the duodenum secondary to pancreatic enzymes. Vitamin B12 further binds
to an intrinsic factor (a protein secreted by gastric parietal cells) and reaches the
terminal ileum where this complex is attached to the specific mucosal receptors
for vitamin B12 absorption. An increase in stomach pH4 and/or decrease in duode-
nal pH interferes with the release of vitamin B12 from dietary and R-binder pro-
teins, respectively, and impair vitamin B12-intrinsic factor complex formation, and,
hence, cause vitamin B12 malabsorption.
About 25 to 75% of ingested calcium is absorbed actively in the duodenum.
Through vitamin D derivatives, Ca2+ absorption is adjusted and regulated to body
needs. Calcium absorption is inhibited by phosphates and oxalates, which form
insoluble salts with Ca2+ in the intestine.
Dietary iron is absorbed in the duodenum by a regulated process to maintain body
iron homeostasis as iron excretion is not regulated. Dietary iron exists in the forms
of heme and nonheme, which are present mainly in red meat and in vegetables, cere-
als, and white meat, respectively. Nonheme dietary iron is released by acid digestion
in the stomach, and before mucosal absorption, reduced to the ferrous (Fe2+) ion by
ascorbic acid and an iron-regulated ferric reductase protein (Dcytb, Cybrd1),5 which
is present on the apical membrane of enterocytes.
12.2.6 Water and Electrolyte Balance

Every day the intestines are exposed to about 2,000 ml of ingested fluid and 7,000
ml of secretions from the gastrointestinal secretory glands. Ninety-eight percent of
this fluid is reabsorbed, limiting the daily fluid loss to about 200 ml with stool. Only
small amounts of water move across gastric mucosa, but water movement is bidi-
rectional across the mucosa of the small and large intestines in response to osmotic
gradients, which influences stool volume and consistency.
12.3 Etiology of Malabsorption
Malabsorption may be extensive or partial, depending on the number of malabsorbed
nutrients. Diffuse mucosal pathology or reduced mucosal absorptive surface, e.g., in
celiac disease, may result in extensive malabsorption of almost all nutrients, where
symptoms are readily apparent. Partial malabsorption results from the diseases that
disrupt the absorption of only specific nutrients, e.g., defective B12 absorption in
patients with pernicious anemia. The etiology of malabsorption can be classified in
three categories (Table 12.1).
12.4 Diagnostic Evaluation of Malabsorption

Since malabsorption can be the end result of a variety of disorders, its clinical pre-
sentation may vary. Malabsorption can be approached in following manner:6,7
1. Suspicion of Malabsorption—The classic manifestations of extensive mal-

absorption are diarrhea with pale, greasy, voluminous, foul-smelling stools;
weight loss despite adequate food intake; mild abdominal discomfort; and
distention along with flatus. These symptoms can be attributed to the pres-
ence of unabsorbed fat and carbohydrate that affects intestinal NaCl and
water transport to increase stool volume. Moreover, bacterial fermentation
of unabsorbed carbohydrates releases foul-smelling hydrogen and methane
gas. Partial forms of malabsorption may present solely with the symptoms
that are attributable to the particular nutrient in question. However, many
malabsorptive disorders may only have nonspecific clinical presentations,
such as loose stools and malaise. The suspicion of malabsorption is gener-
ally made based on the patient’s history, clinical features, and routine blood
investigations, and can sometimes be quite subtle. Details are summarized
in Table 12.2.
2. Confirmation of Malabsorption—Once suspicion of malabsorption has
been raised, the next logical step is to confirm its presence. Measuring low
serum level after ingesting a nutrient and/or its decreased urinary excretion
can help confirm malabsorption. Similarly, increased excretion of a nutrient
in stool supports its malabsorption.8 List of tests performed to evaluate and
confirm presence of malabsorption is mentioned in Table 12.3.
3. Finding the Cause of Malabsorption—This often requires more inves-
tigations. Several invasive (endoscopy with biopsy, capsule endoscopy,
ERCP, or EUS) and noninvasive (abdominal CT scan, MRI, ultrasound,
x-rays) tests are used. If history suggests a particular cause, testing can be
directed to confirm the diagnosis. The order of testing and choice of a par-
ticular test should be individualized and according to available resources.
The ultimate goal is to find or to exclude a disease that causes malab-
sorption. A diagnostic algorithm to evaluate malabsorption is shown in
Figure 12.1.9
Table 12.1
Etiological Classification of Malabsorption Based on Pathophysiology
Site of
Malabsorption Pathophysiology Example of Disease Causative Mechanism
Luminal Phase 1. Impaired Chronic pancreatitis, Absent or decreased level of
(Carbohydrates, nutrient pancreatic resection, pancreatic enzyme
proteins, and fats hydrolysis cystic fibrosis pancreatic
are hydrolyzed cancer, congenital
and solubilized pancreatic enzyme
in the lumen by deficiencies
intestinal Zollinger–Ellison Inactivation of pancreatic
mucosal, syndrome enzyme from gastric acid
pancreatic, and hypersecretion
biliary Short bowel syndrome Inadequate mixing of
secretions) nutrients, bile, and
Enterokinase deficiency enzymes
Inability of pancreatic
proenzymes to convert to
active enzymes
2. Impaired Cirrhosis, Parenchymal Decrease hepatic synthesis
micelle liver diseases of bile acid
formation Primary biliary cirrhosis, Decrease bile secretion in
chronic cholestasis, duodenum
Primary sclerosing
cholangitis
Anatomical abnormality Bacterial overgrowth causes
(small bowel deconjugation of bile and
diverticulosis, blind loop, subsequently diminishes
stricture) micelle formation
Impaired motor
abnormality (scleroderma,
diabetic neuropathy),
enterocolic fistula
Terminal ileitis, e.g., Impaired bile absorption
Crohn’s disease, ileal second to ileal mucosal
resection disease
3. Impaired Pernicious anemia, gastric Lack of intrinsic factor
nutrient resection causes vitamin B12
processing and deficiency
availability for Atrophic gastritis Diminished gastric acid
absorption secretion causes vitamin
B12 deficiency secondary to
impaired cleavage of
vitamin B12 and R-binding
protein
Postbillroth II procedure Inadequate mixing and
disorganized enzyme
release
(continued)
Site of
Mucosal Phase 1. Impaired brush Lactase deficiency Acquired disaccharidase
(Carbohydrates, border defect; most common
peptides, and fats hydrolysis cause of intestinal brush
are further border enzyme deficiency
hydrolyzed and Sucrase-isomaltase Congenital disaccharidase
packaged for enzyme deficiency defect
absorption) Acrodermatitis Autosomal recessive
enteropathica metabolic disorder
affecting the zinc uptake
2. Impaired Crohn’s disease, celiac/ Damaged mucosal surface
mucosal collagenous/tropical secondary to inflammation
nutrient sprue, AIDS enteropathy,
absorption chemotherapy and
radiation enteritis,
nongranulomatous
ulcerative jejunoileitis,
eosinophilic
gastroenteritis
Intestinal lymphoma and Mucosal and submucosal
amyloidosis, systemic infiltration affecting
mastocytosis, absorption
immunoproliferative
small intestinal disease
(IPSID)
Bacterial overgrowth, Mucosal and submucosal
Giardiasis, Whipple’s infestation by
disease, microorganism impairs
cryptosporidiosis, absorption
microsporidiosis, and
other parasitic diseases,
mycobacterium
avium-intracellulare,
AIDS enteropathy
Cystinuria Defect in dibasic amino acid
transport
Hartnup disease Defect in neutral amino acid
transport
Site of
Postabsorptive 1. Impaired Intestinal Congenital abnormality,
Phase (Absorbed lymphatic flow lymphangiectasia, Milroy affecting lymphatic flow
nutrients are disease
packaged and Whipple disease, intestinal Acquired abnormality,
exported to vein neoplasm, tuberculosis causing disruption in
and lymphatic lymphatic flow
system to reach
liver)
2. Impaired Abetalipoproteinemia Absent beta lipoprotein
chylomicron causing defect in
absorption chylomicron transport to
lymphatic system
12.5 Management of Malabsorption
The primary goals of managing patients with malabsorption should include:
• Control of diarrhea
• Correction of nutritional deficiencies and maintaining an optimal nutri-
tional status
• Correcting the cause
Because the underlying etiology of malabsorption varies in patients, the following

section details certain general principals of management.
12.5.1 Control of Diarrhea
Diarrhea is usually the most common and troublesome manifestation of malabsorp-
tion. The cause of diarrhea has an impact on its treatment. For example, in steator-
rhea secondary to pancreatic insufficiency, enzyme supplementation with 25,000 to
40,000 units of porcine lipase per meal using pH-sensitive pancreatin microspheres
is recommended (Table 12.4). In case of treatment failure, the dose should be
increased, compliance checked, and alternative causes of malabsorption excluded.
Addition of PPI/H2 blocker therapy may help to increase the efficacy of pancreatic
enzyme supplement.10 Still, in most patients, fat digestion cannot be completely nor-
malized by standard therapy and the diarrhea may not resolve entirely.
Bile salt malabsorption from terminal ileal disease or resection can result in
a secretory choleretic diarrhea that responds to treatment with bile salt-binding
resins (cholestyramine, colestipol).11 These resins can cause flatulence and bloating
that may interfere with compliance and absorption of other oral medications. In
patients that have undergone extensive resection of terminal ileum (usually >100
Table 12.2
Clinical Features and Routine Laboratory Tests Suggesting Nutrient
Deficiency
Clinical Features Nutrient Deficiency
Bleeding Vitamin K, protein malnutrition
Night blindness, xerophthalmia, follicular Vitamin A
hyperkeratosis
Peripheral neuropathy, ataxia Vitamin B12 and thiamine
Dermatitis Vitamin A, zinc, and essential fatty acid deficiency
Anemia Iron, folate, vitamin B12
Tetany, paresthesia, pathologic fracture, positive Calcium, vitamin D, and magnesium
Chvostek and Trousseau sign malabsorption
Glossitis, cheilosis, stomatitis, acrodermatitis Iron, vitamin B12, folate, and vitamin A
malabsorption
Amenorrhea and decrease libido Protein/calorie malabsorption, second
hypopituitarism
Azotemia and hypotension Fluid and electrolyte depletion
Weakness, muscle wasting, weight loss Protein/calorie malabsorption, anemia, electrolyte
depletion
Steatorrhea Fat malabsorption
Seizure Biotin deficiency
Edema, ascites Protein deficiency
Laboratory Tests Nutrient Deficiency
Microcytic anemia, low serum iron and ferritin Iron
level, thrombocytosis
Macrocytic anemia, low vitamin B12 and folate Vitamin B12 or folate
level, increase serum methylmalonic acid, and
homocysteine level
Hypokalemia Potassium and magnesium malabsorption
Low blood urea nitrogen, creatinine and albumin Protein malnutrition
Low serum calcium and vitamin D level, high Calcium, vitamin D, fat, and magnesium
serum alkaline phosphatase
Elevated INR Vitamin K and fat malabsorption
Low carotene level Vitamin A
cm), the loss of bile salt may exceed the liver’s ability to compensate with increased
synthesis, and, hence, treatment with bile salt-binding resins often worsens diar-
rhea12 (in this case, steatorrhea). Definitive treatment comprises the administering
of exogenous bile acids. Synthetic preparations are preferred as they are resistant to
bacterial deconjugation by colonic flora that can contribute to secretory diarrhea.
In the absence of fat or bile acid malabsorption, diarrhea may be secondary
to rapid transit of contents through the intestine. Nonspecific antidiarrheal medi-
cations help prolong the intestinal transit time and increase rectal sphincter tone
(Table 12.4). Dosages of these medications may need to be titrated with careful
Table 12.3
List of Tests to Confirm Malabsorption of Specific Substrate
Test Result
Protein malabsorption Generally not performed due to technical difficulties
Alpha-antitrypsin fecal clearance Suggest protein-losing enteropathy as a cause for protein
malabsorption
Carbohydrate malabsorption After 25 g of D-xylose ingestion, failure of blood
D-xylose absorption test D-xylose levels to rise above 20 mg/100 ml at 1 hour
and above 22.5 mg/100 ml at 3 hours, or failure of
urinary output to exceed 4.5 g in 5 hours suggests
carbohydrate malabsorption secondary to proximal
intestinal dysfunction;17 falsely positives in diabetes
mellitus, renal insufficiency; false negative in small
bowel bacterial overgrowth
Oral glucose, sucrose, lactose tolerance Similar to D-xylose test
test
Breath hydrogen tests Greater than 10–20 ppm breathe hydrogen after ingestion
of specific carbohydrate substrate is consistent with
malabsorption;18 false positive in bacterial overgrowth;
false negative in hydrogen nonexcretors (18% of
population)
Fat malabsorption It is very simple to perform, but commonly the result of
Qualitative fecal fat excretion this test is equivocal, and can have false positive
secondary to medication usage (orlistat, mineral oil,
etc.)
Quantitative fecal fat excretion (48–72 Test is more accurate for fecal fat analysis, but difficult to
hour stool collection) perform; mainly used for fat malabsorption follow-up
study; adherence to an 80- to 100-g/daily fat diet is
required
Near infrared reflectance analysis of fecal Not used commonly, but may be the test of choice in
fat19 future
Vitamin B12 malabsorption It is mainly used to evaluate function of ileum in patients
Schilling test with diarrhea or malabsorption
Bile acid malabsorption
Quantitative fecal bile acid excretion “Gold standard,” but difficult to perform
SeHCAT (selenium-75-labeled Sensitive indicators of ileal bile acid malabsorption, but
taurohomocholic acid) test difficult to perform;20 false positive in diarrhea
Bacterial overgrowth test These tests are performed more commonly. Every test
14C-glycocholic acid breath test performed in this category works on the principle that
14C-xylose breath test bacterial overgrowth will metabolize nutrients more
Glucose (lactose) breath hydrogen test rapidly, and would release substrates, which would be
absorbed and expired, but these tests have low
sensitivity and specificity
Quantitative culture of jejunal aspirate “Gold standard” test for this diagnosis
(>105 CFU/ml)
(continued)
List of Tests to Confirm Malabsorption of Specific Substrate
Test Result
Tests for exocrine pancreatic
insufficiency Low concentration in presence of steatorrhea is
Stool chymotrypsin concentration suggestive of pancreatic insufficiency
Fecal elastase test Low level of stool elastase is sensitive only for advance
state pancreatic insufficiency
Serum trypsinogen level Although not specific, but very low level <20 ng/ml is
sensitive for pancreatic insufficiency
Secretin/CCK tests (direct pancreatic Complex analysis, but more accurate test; performed only
stimulation) at a few centers
attention to potential adverse effects, such as dry mouth, urinary retention, dizzi-
ness, and drowsiness.
12.5.2 Correction of Nutritional Deficiencies

An important goal of managing patients with malabsorption is detecting the early
and often subtle signs of nutrient malabsorption. The individual with malabsorption
also must be monitored for signs of dehydration and loss of calories. Malabsorption of
dietary fat can lead to deficiency of fat soluble vitamins (A, D, E, and K), which often
occur in a cluster. Diffuse ileal disease can lead to deficiency of one or more water
soluble vitamins. Iron and folic acid supplementation are usually required in celiac
disease.13 Calcium and magnesium supplementation are required after extensive
small intestinal resection or in any setting where there is severe fat malabsorption.
The daily requirement of vitamins and nutrients, along with common manifesta-
tions of deficient states are given in Table 12.5. Patients with ongoing malabsorp-
tion and deficient states may require nutrient supplementation with several times the
daily requirement to replete body stores. For example, patients with gastric resec-
tion and Whipple’s procedure are at increased risk for iron, vitamin D, and calcium
deficiency, which can lead to metabolic bone disease. Weekly doses of 50,000 IU of
vitamin D administered for four to six weeks is required to replete levels and attenu-
ate cortical bone loss. Serum levels of 25(OH) vitamin D, calcium, and parathyroid
hormone levels should be checked following the initial supplementation and annu-
ally thereafter along with bone mineral density of the hip and lumbar spine.14
12.5.3 Treatment of Underlying Disease and Diet Modification

Dietary restrictions can prove beneficial in alleviating diarrhea in patients with malab-
sorption. Specific dietary restriction varies with the underlying conditions as follows.
• Gluten-free diet in celiac sprue.

• Fat restriction in exocrine pancreatic insufficiency.
Clinical findings suggesting malabsorption (steatorrhea, loose stools, weight loss, malaise)
Initial inquiry
- History: include drug intake, traveling and food intake
- Family history e.g. Celiac sprue or autoimmune diseased
- Examination: look for signs of malabsorption
- Stool: volume, appearance, presence mucus, blood, parasites, sudan stain
- Blood: complete blood count, calcium, albumin, alkaline phosphatase, Mg, Iron, vitamin
B12, folate, and cholesterol.
Malabsorption supported by initial inquiry
Yes No, but still suspected No
Anti antigliadin, Anti Endomysial, and/or Anti tissue

transglutaminase antibodies for celiac disease 72-hour stool collection
No further test
for quantitative fat
needed
Stool evaluation for giardia lamblia, enteropathogenic excretion
bacteria (Aeromonas spp. and Plesiomonas shigelloides
etc.), parasites and ova.
Abdominal ultrasound / CT scan Steatorrhea No steatorrhea

H2-breath tests for carbohydrate malabsorption (e.g.,
lactose, fructose)
Specific etiology suspected by above

laboratory and imaging studies
Yes No D-xylose absorption

test
Small bowel
disease
Pancreatic Normal Abnormal
insufficiency
Mucosal Bacterial Vitamin B12

disease overgrowth deficiency Small
syndrome Elastase or bowel
chymotrypsin in disease
stool
EDG and EDG with small Schilling-
Colonoileoscopy bowel aspirate test CT scan, MRCP,
with mucosal ERCP.
biopsy Glucose-H2-test Parietal
cell and Secretin- Mucosal Bacterial
Alpha 1- Small bowel intrinsic pancreozymin-test disease overgrowth
antitrypsin barium contrast factor syndrome
clearance study antibody Pancreatic enzyme
test supplementation
CT abdomen 14C-xylose trial
angiography breath test
Figure 12.1 Diagnostic algorithm for evaluation of malabsorption. (From Porter, R. (Ed.).
Merck Manual of Diagnosis and Therapy, 18th ed. Hoboken, NJ: John Wiley & Sons, 2008.
With permission.)
• Removal of a particular carbohydrate from the diet in patients with isolated

disaaccharidase deficiencies (lactose intolerance, fructose intolerance).
• Consumption of daily calories in six small meals in patients with rapid
intestinal transit.
• Patients with steatorrhea, who have an intact colon, benefit from a diet
restricted in long chain triglycerides (e.g., most of the dietary fat). Medium
chain triglycerides (in coconut oil) do not require bile salts for absorption
and are a useful caloric supplement in these patient populations.
Table 12.4
List of Medicines Commonly Used for Treatment of Diarrhea
Medications and Dosages
Antidiarrheals
Diphenoxylate/ Atropine (Lomotil) 2.5 mg/.025 mg tab PRN, maximum daily dose 8 tabs
Loperamide (Imodium) 2 mg capsule, maximum daily dose 16 mg
Deodorized Tincture of Opium: 0.6 ml Q4H PRN
Pancreatic enzyme supplements

Viokase, Creon, Pancrease, etc.:25,000–40,000 units of lipase with meals; titrate as needed
Bile salt-binding resins

Cholestyramine: 4 to 8 gm in divided doses; max daily dose 24 gm
Colestid (Colestipol) 2 to 16 gm per day in divided doses
Bile salt supplements

Cholyl sarcosine (synthetic preparation): 2 to 4 gm with meals
Dessicated ox bile (available without prescription)
Similarly, resolution of symptoms can be achieved by treating specific disease

processes causing malabsorption:
• Antibiotics, such as rifaximin, a poorly absorbed antibiotic to treat bacterial

overgrowth.15
• Oral 5-ASA, corticosteroids, anti-TNF (tumor necrosis factor) to treat
Crohn’s disease.
• Long-term antibiotics (tetracycline) and folic acid for six months to treat
tropical sprue Supplements, such as B12, iron, and other vitamins may also
be needed.16
• Protease and lipase supplements are helpful in pancreatic insufficiency.
• Proton pump inhibitor (PPI) therapy and surgical resection of sporadic gas-
trinoma in Zollinger–Ellison syndrome.
• Long-term antibiotics (e.g., trimethoprim-sulphamethoxazole for one year)
to treat Whipple’s disease.
The goal of management is maintaining adequate nutritional status with oral

intake while avoiding parenteral nutrition. Some patients may require nutritional
supplements if they are unable to maintain ideal body weight. Management of
chronic malabsorption can be challenging and requires multiple attempts at dose
adjustments of medications and dietary modifications before arriving at a success-
ful regimen.
Table 12.5
Daily Recommended Dose Supplement of Nutritional Substrates
Nutrient RDA /AI Manifestations of Deficiency State
Vitamin A 900 µg/d Night blindness
Follicular hyperkeratosis
Vitamin D
20–49 yrs 5 µg/d (200 IU) Osteomalacia /osteoporosis
50–69 yrs 10 µg/d (400 IU) (Monitor serum 25(OH) vitamin D levels
> 70 yrs 15 µg/d (600 IU) during replacement)
Vitamin E 15 mg/d Spinocerebellar ataxia
Myopathies
Vitamin K 120 µg/d Petechiae ecchymosis
Vitamin B12 2.4 µg/d Anemia (megaloblastic)
Peripheral neuropathy
Folate 400 µg/d Anemia (megaloblastic)
Vitamin B6 1.3–1.7 mg/d Seborrhoeic dermatitis
Atrophic glossitis
Angular cheilitis
Niacin 14–16 mg/d Dermatitis
Pellagra (diarrhea, dermatitis, and dementia) in
severe cases
Thiamine 1.1–1.2 mg/d Peripheral neuropathy
Encephalopathy
Riboflavin 1.1–1.3 mg/d Angular cheilitis
Scaly dermatitis
Iron
Females 18–50 yrs 18 mg/d Anemia
> 51 yrs 8 mg/d Koilonychia (“spoon nails”)
Males 8 mg/d
Calcium Tetany
Males and females 1000 mg/d Muscle weakness
20–50 yrs 1200 mg/d Fractures
> 51 yrs Osteoporosis
Magnesium 300–400 mg/d Required for normal calcium levels
Zinc 8–11 µg/d Acrodermatitis
Selenium 55 µg/d Osteoarthropathy
Mental retardation (deficiency extremely rare
in United States)
Copper 900 µg/d Anemia
Pancytopenia
Peripheral neuropathy
Ataxia
References
1. Phillips, SF. The growth of knowledge in human digestion and absorption.
Gastroenterology 1997;112:1404.
2. Riley, SA, Marsh, MN. Maldigestion and malabsorption. In Gastrointestinal and
Liver Disease. Feldman, M, Scharschmidt, BF, Sleisenger, MV (Eds), WB Saunders,
Philadelphia 1998, p. 1501.
3. Jeppesen, PB, Mortensen, PB. The influence of a preserved colon on the absorption of
medium chain fat in patients with small bowel resection. Gut 1998;43:478–83.
4. Marcuard, SP, Albernaz, L, Khazanie, PG. Omeprazole therapy causes malabsorption of
cyanocobalamin (vitamin B12), Ann of Int Med. 1 Feb 1994;120;3:211–15.
5. McKie AT, Barrow D, Latunde-Dada GO, Rolfs A, Sager G, Mudaly E, Mudaly M,
Richardson C, Barlow D, Bomford A, Peters TJ, Raja KB, Shirali S, Hediger MA,
Farzaneh F, Simpson RJ. An iron-regulated ferric reductase associated with the absorp-
tion of dietary iron. Science. 2001 Mar 2;291(5509):1755–59. Epub 2001 Feb 1.
6. Romano TJ, Dobbins JW. Evaluation of the patient with suspected malabsorption.
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7. Harewood GC, Murray JA: Approaching the patient with chronic malabsorption syn-
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their contribution to diagnosis, management, and understanding the pathophysiology of
specific disease states. Crit Rev Clin Lab Sci. 1997;34:141. (PMID: 9143817)
9. Beers MH Berkow, R. The Merck Manual of Diagnosis and Therapy, 18th ed., Robert
Porter (Ed). Hoboken, NJ: John Wiley & Sons, 2008. Available at: http://www.merck.
com/mmpe (accessed on October 1, 2009).
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exocrine pancreatic insufficiency: implications of gastrointestinal physiology and prop-
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Gastroenterol 1995 Sep; 90(9):1383–93.
11. Schiller LR. Management of diarrhea in clinical practice. Rev Gastroenterol Disorders
2007;(suppl 3):S27–38.
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13 Total Parenteral Nutrition
Theory and Application
in Hospitalized Patients
Dominic Reeds
Contents
13.1 Introduction...................................................................................................206
13.2 Nutritional Assessment..................................................................................206
13.2.1 Plasma Proteins.................................................................................206
13.2.2 Body Weight......................................................................................206
13.2.3 Subjective Global Assessment...........................................................207
13.3 Macronutrient Needs.....................................................................................207
13.3.1 Effect of Changes in Body Weight....................................................208
13.3.2 Protein Requirements........................................................................208
13.3.3 Fat......................................................................................................209
13.3.4 Carbohydrate.....................................................................................209
13.4 Parenteral Nutrition.......................................................................................209
13.4.1 TPN Solutions.................................................................................... 210
13.4.1.1 Amino Acid Formulation.................................................... 210
13.4.1.2 Carbohydrate....................................................................... 210
13.4.1.3 Fat....................................................................................... 210
13.4.2 TPN Use............................................................................................. 211
13.4.2.1 TPN Regimens.................................................................... 211
13.4.2.2 Catheter Care...................................................................... 211
13.4.2.3 Complications..................................................................... 211
13.5 Case Studies................................................................................................... 212
13.5.1 Case 1................................................................................................ 212
13.5.1.1 Management Plan............................................................... 212
13.5.1.2 Follow-Up Evaluation......................................................... 213
13.5.1.3 Management Plan............................................................... 213
13.5.2 Case 2................................................................................................ 214
13.5.3 Case 3................................................................................................ 214
13.5.3.1 Management........................................................................ 215
13.5.3.2 Management Plan............................................................... 215
13.5.4 Case 4................................................................................................ 216
13.5.4.1 Management........................................................................ 216
205
13.5.5 Case 5................................................................................................ 217

13.5.5.1 Management........................................................................ 217
References............................................................................................................... 218
13.1 Introduction
Most hospitalized patients are able to meet their nutritional needs through voluntary
consumption of a regular diet. Determining which hospitalized patients may ben-
efit from nutrition support (NS) is challenging. This chapter will provide guidance
in the assessment of nutritional status, macronutrient requirements, the use of total
parenteral nutrition (TPN), and clinical cases. Where possible, these suggestions
have been made using evidence-based medicine; however, for many issues in nutri-
tion support, there are no prospective clinical trials to provide guidance and, thus,
conclusions have to be drawn from a synthesis of the literature.
13.2 Nutritional Assessment
There are no simple, clinically available methods for accurately determining nutri-
tional status in hospitalized patients. Practitioners are forced to rely on surrogate
measures, many of which lack objective data to support their use.
13.2.1 Plasma Proteins

Plasma protein markers have been purported to reflect nutritional state since the
1950s.1 The value of these measurements may be as prognostic factors rather
than measures of nutritional status.2,3 Plasma albumin and prealbumin concen-
tration are affected by many clinical factors including inflammation, hepatic and
renal function, clinical acuity, and fluid shifts4 making interpretation impossible.
Further, calorie or protein restriction in healthy patients does not appear to affect
the plasma concentration of albumin and prealbumin. Patients who undergo bar-
iatric surgery maintain normal plasma albumin concentration despite up to 35%
weight loss5 and patients with anorexia nervosa typically have normal concentra-
tions of plasma proteins despite very low body mass index (BMI). At this time, the
plasma concentration of albumin and prealbumin concentration should not be used
to determine “nutritional status” or to guide changes in protein or calorie delivery
in patients receiving NS.
13.2.2 Body Weight

Body weight is also often used as a surrogate measure of nutritional status. It is often
assumed that patients who have a low BMI (<18.5 kg/m2) are underweight and are
at greater risk for development of complications related to malnutrition. Similarly,
patients who are overweight or obese are often felt to be at low risk for develop-
ing malnutrition due to large energy stores in adipose tissue. It is clear that obese
people are normally able to tolerate starvation for longer periods of time than leaner
Total Parenteral Nutrition 207
patients. A 70 kg (154.3 lb) man provided fluids and electrolytes has sufficient fat
stores to tolerate ~60 days of fasting before death, whereas the longest documented
case of a supervised fast is that of an obese patient who fasted for 382 days without
complications.6 BMI is not always accurate in identifying patients with malnutrition.
Extremely obese patients with excessively rapid weight loss (for example, through
gastric bypass with complications) may have signs and symptoms consistent with
severe malnutrition despite being obese. While measurement of body weight would
seem to be a simple measurement, it is often unreliable in a hospital setting due to
rapid changes in body fluid status and methods of weighing (bed weight versus bed-
side weight).
Weight change may be the most helpful clinical measure. Clinical data indicates
that an unintentional weight loss of >10% in the six months prior to hospitalization
is associated with worse clinical outcomes.7 It is not clear, however, whether this is
because of malnutrition itself or whether weight loss is a surrogate marker of more
severe or chronic underlying illness. Nevertheless, it is reasonable to regard patients
with an unintentional weight loss of more than 10% in the six months prior to hos-
pitalization as at increased risk of complications and to consider earlier use of NS
in this setting.
13.2.3 Subjective Global Assessment

This process involves the combination of a focused history and physical exam to
assess recent macronutrient intake and the impact that macronutrient deficiency has
had on body composition and function.8 The findings from this assessment rank
patients as well nourished, moderately malnourished, or severely malnourished.
These criteria may predict the likelihood of developing postoperative complications.8
Again, it should be noted that these medical complications may not be due directly to
malnutrition or modified by institution of TPN, but rather identify patients at greater
risk of morbidity and mortality.
13.3 Macronutrient Needs
Prior to considering the use of any form of nutrition support, it is critical to under-
stand caloric requirements and macronutrient needs. In adults, caloric needs are
determined primarily by basal metabolic rate, which represents the number of
calories that are required to meet the energetic needs of maintaining homeostasis
(e.g., brain activity, heart contraction). In most people, activity makes only a minor
contribution (~20%) to daily energy expenditure. Daily resting energy expenditure
may be estimated by a predictive equations, the most widely used of which is the
Harris–Benedict (HB) equation:9
Men: 66 + (13.7 × weight in kg) + (5 × height in cm) – (6.8 × age

in years)
Women: 665 + (9.6 × weight) + (1.8 × height) – (4.7 × age)
The energy expenditure of a noncritically ill adult with a BMI of 20 to 25 kg/m2

may be estimated by adding 10 to 20% to the HB equation to account for activity,
and results in an energy requirement of 25 to 30 kcal/kg/day. Providing excessive
amounts of calories increases the risk of metabolic abnormalities including hyper-
glycemia, hyperlipidemia, and acidosis, and the risk of infectious complications. In
critically ill adults, it is especially important to minimize the risk of overfeeding and
TPN should provide calories equal to, or perhaps less than that predicted by HB.
Government guidelines suggest that energy expenditure be increased by 300 kcal/
day during pregnancy.10
13.3.1 Effect of Changes in Body Weight

As patients become progressively more obese, most of the weight gain (75%) is adi-
pose tissue and only a minor component is skeletal muscle. Both adipose tissue and
skeletal muscle have relatively low energy requirements compared to visceral tissues.
While resting, energy expenditure increases with increasing adiposity, the number of
calories per kg body weight per day actually declines. Therefore, in obese patients,
an adjusted body weight should be used to prevent overfeeding:
Adjusted body weight = ideal body weight + (actual ideal body weight × 0.25)
In patients who are underweight, the majority of body weight is made up of

lean, metabolically active tissue, so while their absolute daily energy expenditure
is lower than that of a larger person, the relative number of calories per kg body
weight per day increases as BMI becomes smaller. A patient with a BMI <15 kg/
m 2 may have energy requirements of 35 to 45 kcal/kg/day or 300 to 500 kcal
greater than that predicted by HB. Energy needs supplied by TPN may be deter-
mined using BMI-based regimens.11
13.3.2 Protein Requirements

Critically ill patients may lose up to 1% of their lean body mass per day12 and the pri-
mary goal of NS is to attenuate these losses. The amount of protein that is required by a
patient is dependent upon endogenous needs (determined by the amount of lean body
mass), exogenous protein losses (e.g., chylothorax, nephrotic syndrome), and clinical
status. Protein requirements should be calculated on the basis of ideal body weight
(IBW), even in obese patients. In healthy patients, 0.8 g/kgIBW/day of protein will
meet estimated protein needs for ~98% of the population. Most hospitalized patients
should receive protein intake of 0.8 to 1.5 g/kgIBW/day; however, several common
clinical conditions increase protein requirements including hemodialysis (1.2 to 1.4
g/kg IBW/day) and peritoneal dialysis (1.3 to 1.5 g/kgIBW/day). The number of non-
protein calories supplied also affects protein needs. As caloric intake declines (such
as in hypocaloric feeding), protein needs increase, and it is critical to remember that
if the decision is made to feed a patient hypocalorically that protein intake should be
liberalized (up to 2 g/kg IBW/day). Providing more than 1.5 g/kgIBW/day of protein
per day does not appear to attenuate negative nitrogen balance in most hospitalized
patients who are being fed eucalorically.12 Protein intake may need to be restricted
in patients with chronic renal failure who are not being dialyzed, acute renal failure
(0.8 to 1.0 g/kg IBW/day) and in patients with hepatic encephalopathy.11 Patients who
have exogenous protein losses (e.g., chylothorax , surgical drains) should have the
daily volume and the concentration of protein in fluid losses measured to estimate
additional protein needs.
13.3.3 Fat
Adipose tissue is the largest energy storage depot in adults and during illness these
lipids are mobilized to supply fuel to vital organs. It is recommended that patients
receive more than 5% of total daily calories from fat to prevent deficiency of the
essential fatty acids linoleic and linolenic acid.13 At a minimum, 2% of total energy
should be obtained from linoleic acid and 0.5% from linolenic acid.11
13.3.4 Carbohydrate
There is no absolute requirement for carbohydrate because glucose can be synthe-
sized from precursors including glycerol and gluconeogenic amino acids. Most
body tissues rely on fatty acid oxidation during starvation; however, several body
tissues including bone marrow, white and red blood cells are dependent on glucose.
Glycogen stores are exhausted in ~24 hours of starvation and, subsequently, hepatic
gluconeogenesis is increased and insulin sensitivity is reduced to promote sparing of
glucose for glucose-requiring tissues. Insulin resistance promotes release of gluco-
neogenic amino acids from skeletal muscle and hydrolysis of triglycerides to release
fatty acids and glycerol. During prolonged periods of starvation, the kidneys and
liver are the major sources of glucose and patients with renal or hepatic dysfunction
are at increased risk of life-threatening hypoglycemia.
13.4 Parenteral Nutrition

In patients who are unable to receive enteral feeding, parenteral nutrition may be a
life-saving intervention. It is often not clear when TPN should be initiated because
it is not known when negative caloric balance becomes clinically harmful. While
cross-sectional studies suggest that failure to meet caloric needs is associated with
worse outcomes,14 it is not clear whether the caloric deficit itself contributes to mor-
bidity or more likely whether failure to tolerate feeding is a predictor of poorer
outcomes. Conversely, some data suggests that in obese patients, caloric restriction
(permissive underfeeding) during critical illness may be beneficial, causing shorter
ICU stays and reduced antibiotic use.15 The period of time that each patient will
tolerate starvation is highly variable and depends on body fat reserves, muscle mass,
weight history, and clinical scenario. Parenteral nutrition is generally initiated when
a patient with normal body weight has been, or it is anticipated will be, unable to
meet 25% of their energy intake for 10 to 14 days; however, there is no prospective
data to support this cutoff.
13.4.1 TPN Solutions
TPN solutions provide macro- and micronutrients, trace elements, and vitamins to
meet the estimated needs of each patient. In general, these solutions are provided as
a single bag that contains all of these substrates.
13.4.1.1 Amino Acid Formulation

Most standard TPN solutions contain amino acids at a concentration between 3 and
15%, at a ratio of ~50:50 between “essential” and “nonessential” amino acids. Most
commercially available formulas lack the nonessential amino acids glutamine, glu-
tamate, aspartate, asparagine, tyrosine, and cysteine. It is not known whether this
deficiency affects the efficacy of TPN. Modified formulations of TPN have been mar-
keted for use in patients with specific disease states, such as solutions with greater
amounts of branched-chain amino acids for patients with hepatic encephalopathy or
greater amounts of essential amino acids for patients with renal dysfunction. These
formulations allow for provision of greater amounts of protein without development
of encephalopathy in patients with severe underlying liver disease.16 The benefit of
TPN supplemented with essential amino acids in patients with renal failure may not
necessarily provide clinical benefit.17
13.4.1.2 Carbohydrate
Most TPN formulations provide carbohydrate in the form of 5 to 30% dextrose. As
the dextrose is provided as dextrose monohydrate, it provides 3.4 kcal/gram. Infusion
of dextrose stimulates insulin release, inhibits lipolysis, suppresses the release of
amino acids from skeletal muscle, and may be “protein-sparing,” reducing amino
acid oxidation.
13.4.1.3 Fat
TPN provides lipid as a fat emulsion with the lipids from soy or safflower oil. These
lipids provide sufficient linoleic and linolenic acid to prevent fatty acid deficiency.
These fatty acids form lipid micelles that are similar in size to chylomicrons. Recent
focus18 has been placed on the importance of large particle sizes in these emulsions as
particles greater than 1 µm are associated with poorer clearance, and greater uptake
by the reticuloendothelial system, possibly promoting fat buildup in end organs and
immune dysfunction.19 Lipid infusion allows minimization of calories provided as
carbohydrate, which may help prevent development of hyperglycemia and lower the
risk of respiratory acidosis.
Lipid infusion is associated with a number of medical complications including
pulmonary syndromes,20 impaired immune function,21 and hypersensitivity reactions
which may be fatal22 and should not be infused at a rate of greater than 1 kcal/kg/
hour to lessen the chances of complications. Lipid infusion may aggravate hyper-
triglyceridemia, especially in patients with preexisting hyperlipidemia and a plasma
lipid profile should be measured during TPN infusion. If plasma triglycerides are
>400 mg/dl before institution of TPN, interventions should be taken to treat this
condition prior to institution of lipid-containing TPN.
13.4.2 TPN Use
Prior to providing TPN, a full clinical and biochemical assessment of the patient
should be made including current nutritional status and medical co-morbidities.
Close attention should be paid to conditions that affect glucose and lipid metabo-
lism. Biochemical measurement should include a basic metabolic profile, calcium,
glucose, phosphorous, and plasma triglyceride concentration. Body weight and fluid
balance should be monitored daily.
13.4.2.1 TPN Regimens
It is impossible to provide a uniform prescription for TPN that is suitable for all
patients. In general, the first step is to estimate the number of calories that the patient
will require. Sufficient lipid (9 kcal/g) is provided to meet approximately 30% of
total daily calories. Amino acid (4 kcal/g) needs are calculated based on ideal body
weight and co-morbidities. The remaining calories are then provided as carbohy-
drate (3.4 kcal/g).
In patients who are believed to be at low risk of refeeding syndrome (normal
body weight without a recent history of significant weight loss or calorie restric-
tion) and are at low risk for development of volume overload, TPN may generally
be initiated at goal calories infused over a 24-hour period. The duration of infu-
sion of TPN may be tapered to infuse over a 12-hour period in most patients, with
close attention to hyperglycemia, hyperlipidemia, and observation for development
of heart failure. Blood sugars should be monitored before and at regular intervals
during infusion of TPN, with a goal of <150 mg/dl. If during titration of TPN,
the blood glucose (BG) is consistently >200 mg/dl, then the rate of TPN infusion
should not be increased until glycemic control has been achieved. In patients with
type 1 diabetes, insulin may be added to the TPN fluid at a ratio of 1 unit/15 g of
carbohydrate. Higher doses may be necessary in patients with type 2 diabetes,
critical illness, or receiving medications that lower insulin sensitivity. If patients
require an additional corrective dose of insulin during TPN, half of this amount of
insulin should be added to the following days TPN. A plasma triglyceride concen-
tration greater than 400 mg/dl during TPN infusion requires either reduction in the
rate of lipid infusion or removal of lipid altogether.
13.4.2.2 Catheter Care
Careful attention should be paid to the central catheter, with dressing changes every
24 to 48 hours. A 0.22 µm filter should be used in line with lipid-free TPN, and a 1.2
µm filter should be used with lipid-containing TPN. These filters should be changed
whenever the TPN is changed. (Note: TPN should not be disconnected and then
restarted for any reason.) TPN should not be infused through central lines placed
in the groin because of the high risk of infection. Patients receiving TPN should be
monitored by a nutrition support team as this reduces complications.23
13.4.2.3 Complications
TPN is not a risk-free intervention. It carries a clear risk of infection and should be
used cautiously in immunocompromised patients (e.g., chemotherapy, neutropenia,
renal failure). Long-term TPN is associated with development of many complica-

tions including liver failure. The risk of TPN-associated liver disease is greatest
in patients with (1) short residual intestinal length, (2) excess caloric delivery, (3)
patients receiving continuous (noncycled) TPN, and (4) inability to consume any oral
feeding. TPN is also associated with a number of metabolic abnormalities including
osteoporosis, hyperglycemia, hyperlipidemia, and fluid and salt overload.24,25
13.5 Case Studies
13.5.1 Case 1
A 72-year-old woman is admitted to the general hospital ward with a week-long
history of abdominal pain. She lives with her husband who says she has had a good
appetite. Her past medical history is significant for type 2 diabetes, hypertension,
coronary artery disease, dyslipidemia, and obesity. On admission, she is receiving
lisinopril, hydrochlorthiazide, glipizide, simvastatin, and aspirin. She smokes 1 pack
per day and drinks socially. On exam, she is obese, 5 feet, weight 100 kg (220 lb),
blood pressure (BP) 140/100, pulse (P) 110, respiratory rate (RR) 22, temperature
(T) 38.9o C (102° F). Her jugular venous pressure is elevated. Her abdomen is dif-
fusely tender. A CT scan demonstrates a colonic mass with complete obstruction.
She undergoes a colectomy with ileostomy placement. After 24 hours, she is still
unable to eat because of persistent nausea and vomiting. A nasogastric tube is placed
with improvement in symptoms. A request is made by the surgical service for NS
evaluation and consideration of TPN.
13.5.1.1 Management Plan
The initial question is whether TPN will benefit the patient. TPN is not risk free in
this clinical setting as diabetics have a significantly greater risk of central line asso-
ciated gram-negative infections than nondiabetics.26 A record of the patients weight
history would be helpful, as while she is obese, it is possible that she had lost greater
than 10% of her body weight. A clinical assessment should be made to determine
volume status, and to assess for any other potential sources of protein loss, such as
nephrotic syndrome, given her diabetes. If surgical drains are present, then the daily
volume and protein content of the drainage should be measured.
It is commonly believed that (1) metabolic rate is dramatically increased by
critical illness or trauma and (2) routine use of perioperative NS in patients who
are unable to eat after surgery improves outcomes. Several studies suggests that in
the absence of burn injury, head trauma, or the use of sympathomimetic medica-
tions, energy expenditure is not significantly increased in critical illness or with
infection.27,28 It has yet to be proved that patients who undergo surgical procedures,
who had good preoperative nutritional status benefit from routine use of TPN, and
data suggests that conservative care with intravenous (IV) fluids alone may be the
best treatment. One prospective study randomized 300 patients undergoing major
elective surgery to either TPN beginning within 24 hours of surgery or intrave-
nous fluids containing ~500 kcal/day as dextrose.29 Each regimen was continued
until patients were either able to voluntarily meet their caloric needs or until day
15. There was no difference in clinical outcomes between the two groups. When
patients who received TPN were grouped with those who were randomized to
TPN, but were unable to tolerate goal feeding rates, mortality appears to have been
greater in the TPN group. These data suggest that in patients in whom it is pre-
dicted will not be able to eat for up to 15 days, routine use of TPN is of no benefit.
Furthermore, patients who are unable to tolerate goal TPN rates are at increased
risk of poor outcomes.
On the basis of the Case 1 patient’s obesity, stable preoperative weight history,
and lack of significant protein losses, TPN is not recommended at this time and
enteral feeding should be initiated when able.
13.5.1.2 Follow-Up Evaluation
The patient undergoes diuresis and conservative management. Evaluation reveals
only trace proteinuria. After receiving maintenance intravenous fluid and electro-
lytes for a further 10 days, the patient continues to have a postoperative ileus and
fails to tolerate attempts at enteral feeding. The surgical team requests “aggressive”
TPN because the patient has been in negative caloric balance and there is concern
that this increases the risk of poor outcome.
It is not unreasonable to consider TPN in a patient who has been unable to eat for
10 days; however, again it is unlikely that even a further delay in feeding will result
in poorer outcomes. Negative caloric balance has been shown in some studies to
be predictive of poorer clinical outcomes in hospitalized patients, with the greatest
impact in the first week after the insult,14 this may be an associative rather than a
causative relationship.
The goal of TPN in this patient should be to minimize negative nitrogen balance.
Providing calories in excess needs increases the risks of hyperglycemia, hyperlipi-
demia, hepatic steatosis, metabolic acidosis, and a greater risk of infectious complica-
tions. Hypocaloric feeding(i.e., permissive underfeeding) could permit mobilization
of the patient’s endogenous lipid stores, improve insulin sensitivity, and lower the
risk of metabolic complications.27 Cross-sectional studies indicate that providing
between 33 and 67% of predicted energy expenditure is associated with improved
clinical outcomes in critically ill patients.30 Prospective studies have shown that
hypocaloric feeding in obese, critically ill patients does not result in worse clini-
cal outcomes and may reduce antibiotic usage, probably by lowering hyperglycemia
and infection risk.15 Providing additional amounts of protein to patients receiving
hypocaloric diets appears to minimize loss of lean body mass. Providing ~10 to
12 kcal/kg adjusted body weight per day as TPN with 1.5 to 2 g of protein per kg
ideal body weight and 30% of calories from fat would be a reasonable initial TPN
regimen. Prolonged periods (>two to three weeks) of hypocaloric feeding should be
used cautiously in critically ill patients as this intervention has not been shown to be
beneficial for extended periods of time. Blood sugars should be optimized prior to
initiating TPN to prevent severe hyperglycemia. Given preexisting type 2 diabetes,
providing at a ratio of 1 unit of insulin for every 10 grams of carbohydrate in the TPN
will lower the risk of hyperglycemia.
13.5.2 Case 2
An 82-year-old man is transferred to your hospital from a local nursing home after
suffering a stroke. He was found in bed that morning with new onset dysarthria
and confusion. According to the nursing home records, the patient had stable body
weight prior to transfer. His past medical history is remarkable only for hypertension
and Alzheimer’s disease. He takes hydrochlorthiazide and aspirin. He never smoked
or drank alcohol. On exam, he is 5 feet 6 inches tall and weighs 70 kg (154 lb); BP
150/94, P 80, RR 12, T 37o C (98.6° F). He is dysarthric, but in no apparent dis-
tress. He has poor dentition. His neck veins are flat. Lungs are clear. He is normally
ambulatory, but is currently confined to bed. His basic metabolic profile and CBC
are unremarkable. His son, who is an internist, requests that his father receive early
nutrition because he believes that this improves outcomes in hospitalized patients
who are unable to eat.
While early nutrition support is probably indicated in patients with low body
weight, it is not clear that early nutrition support itself improves outcomes in hospi-
talized patients. Recent studies have shown that early protocols to raise the awareness
of the role of early nutrition in ICUs have indeed shortened the time span between
admission and initiation of NS, but no benefit in outcomes occurred.31 The FOOD
trial randomized patients, who suffered a stroke causing dysphagia, to early enteral
nutrition using a nasogastric (NG) tube or late placement (~seven days after admis-
sion).32 As anticipated, the early NG tube placement group received enteral feeding
earlier than the late group and had slightly improved mortality rates. Unfortunately,
the degree of severe morbidity (requiring 24-hour care) was greater in the early
group, corresponding to almost exactly the number of people who may have ben-
efited from early feeding. On the balance of the data, it is unlikely that early enteral
nutrition will improve the outcome in this patient, and could increase the risk of
complications including GI bleeding or aspiration. It is unlikely that TPN will pro-
vide clinical benefit and may increase the risk of infectious complications. The pre-
ferred treatment may be to provide supportive care including intravenous fluids, but
not feeding enterally until the prognosis is more clear.
13.5.3 Case 3
You are asked to provide care to a 22-year-old white female who is admitted for
anorexia nervosa. She reports that she consumes 600 kcal per day and exercises
on a treadmill for one hour per day. She uses alprazolam and caffeine to suppress
her hunger. She denies shortness of breath or swelling, but does feel cold. She has
no significant past medical history other than prior admissions for anorexia. On
exam she appears cachectic; she is 5 feet 2 inches, weighs 34 kg (75 lb), BMI 14.1,
P 40, RR 12, T 35o C (95° F). Her jugular venous distention (JVD) is not elevated,
heart sounds are distant, point of maximal impulse (PMI) is the fifth intercostal
space at the anterior axillary line. Laboratory studies are remarkable for a sodium
of 132 mEq/L, potassium of 3.2 mEq/L, glucose of 42 mg/dl, albumin of 4.3 g/dl,
hematocrit of 28% with a mean corpuscular volume of 72 uL. You are consulted
for management.
13.5.3.1 Management
In order to understand management, an understanding of the changes in body com-
position, organ function, and substrate metabolism is necessary. This patient is at
high risk of refeeding syndrome given her low body weight and chronic starva-
tion.33 This syndrome, which was initially reported in concentration camp victims,
has been reported in patients with starvation who receive aggressive refeeding. This
is manifested with a lowering of serum potassium and magnesium when carbohy-
drate is provided, due to an influx of these salts from the plasma into the intracel-
lular compartment, and is exacerbated by increases in plasma insulin concentration.
Ventricular tachyarrhythmias and sudden death are common in patients with
extremely low BMI and may be preceded by QT prolongation.34 The patient should
receive an EKG and be monitored on telemetry. Also plasma phosphate concen-
tration often declines dramatically following refeeding in malnutrition due to use
in the synthesis of ATP. This may be manifested with EKG abnormalities, muscle
weakness including heart failure, and diaphragmatic weakness precipitating respira-
tory failure.35–37 Glucose intolerance is common in patients who are suffering from
starvation. Prolonged starvation results in hypoglycemia, promotes lipid mobiliza-
tion with increased dependence on fatty acids, and preservation of glucose for use
by glucose-requiring organs. Carbohydrate should be used as necessary to prevent
hypoglycemia, but patients should be closely monitored for subsequent hyperglyce-
mia.38 Fluid management may be challenging in starving patients. Prolonged caloric
restriction may be accompanied by a dilated cardiomyopathy with low cardiac mass,
low stroke volume, and bradycardia. This may be confounded by a reduction in renal
mass inhibiting the ability to excrete a free water load. Further, hyperinsulinemia
during refeeding promotes sodium resorption and places these patients at high risk
for developing volume overload and pulmonary congestion.39 Loss of subcutane-
ous adipose tissue places patients at risk of hypothermia and bedsores from loss of
cushioning over bony prominences. All patients should receive intravenous thiamine
prior to refeeding to prevent development of Wernicke’s encephalopathy.40
Initial treatment should focus on cautious replacement of necessary fluid and elec-
trolytes with close attention to the prevention of development of volume overload.
Patients should receive multivitamins through the intravenous route to ensure ade-
quate absorption. All patients should receive 100 mg of thiamine to prevent the
development of Wernicke’s encephalopathy after carbohydrate administration.
If the patient is willing, enteral nutrition (EN) should be provided as this allows
for more gradual absorption of electrolytes. TPN may be provided if the patient
is unwilling or unable to tolerate EN. Patients should receive intermittent, isotonic
feeds to prevent fasting hypoglycemia and also overwhelming the ability of the body
to metabolize the caloric load. Repletion of potassium and phosphorous should also
be made, preferably through the enteral route. Clinicians should be cautious in reple-
tion of these electrolytes because while total body stores are depleted, as these nutri-
ents are buffered in lean body mass, rapid infusions may cause dangerous increases
in serum levels of these electrolytes.
The precise formulation of EN or TPN is widely variable from patient to patient so

that a universally applicable prescription is not possible, but several key features should
be noted. After ensuring that patients are euvolemic, fluid should be restricted to ~800
ml above insensible losses to prevent heart failure. Unless sodium losses are high (e.g.,
diuretic abuse), sodium should be restricted to ~88 meq (2 g) per day. Body weight
should be measured daily as weight gain of greater than 0.25 kg/day or ~1.25 kg/week
is suggestive of fluid overload. Caloric delivery should initially be ~15 to 20 kcal/kg/
day containing 100 g of carbohydrate to meet the needs of glucose-requiring tissues.
Magnesium, phosphorous, and potassium should also be repleted in patients with nor-
mal renal function. Close attention should also be made to ensure that patients do not
suffer from hypo/hyperthermia and to prevent development of bedsores. Calories may
be advanced at up to 200 kcal/day if electrolyte and volume status remain acceptable.
13.5.4 Case 4
You are asked to provide recommendations for nutritional management of a 62-year-
old man with HIV who is admitted with community-acquired pneumonia. The
patient had a week-long history of malaise, fever, cough, and shortness of breath. His
symptoms persisted despite prescription of oral antibiotics. He has responded slowly
to antibiotics over the last 10 days, but subsequently developed clostridium difficile
colitis. He has been treated with metronidazole orally; however, he has had profound
nausea accompanying this therapy. He is now unable to eat due to persistent nausea
and has refused nasogastric tube placement. Due to his prolonged period of inani-
tion, the admitting team has requested use of TPN. The patient denies recent weight
loss. His past medical history is remarkable for HIV for 15 years, hypertension, and
hypertriglyceridemia. He has gained approximately 120 lb after beginning HAART
(antiretroviral drug therapy) eight years ago. He reports loss of limb and facial fat,
but gain in trunk fat over the last five years. His hypertriglyceridemia has been severe
with triglyceride concentrations of 500 to 1000 mg/dl despite fibrate therapy. He
does not smoke or use alcohol and denies recreational drug use. On exam, he appears
comfortable. He is 5 feet 8 inches, weighs 90 kg (198 lb), BP 130/74, RR 20, T 36.70
C (98° F). He has facial lipoatrophy and prominent veins on his arms and legs. He
has darkly pigmented axillary skin. He has diffuse rhonchi with apical wheezes. He
has abdominal obesity, but no striae, with a liver edge 4 cm below the right costal
margin. His laboratory studies reveal a blood sugar of 250 mg/dl, a white blood cell
count of 17,000. His lipid profile reveals a plasma triglyceride concentration of 750
mg/dl, HDL 24 mg/dl, LDL 100 mg/dl.
13.5.4.1 Management
In order to determine how this patient should be managed, it is important to under-
stand the metabolic changes that are seen in patients with HIV. Prior to the avail-
ability of HAART, patients with HIV had a progressive course of weight loss with
elevated metabolic rate and lipolytic rate, and hypertriglyceridemia, the “HIV wast-
ing syndrome.”41 While use of HAART has improved mortality due to infectious
complications, more than 50% of patients develop metabolic abnormalities includ-
ing loss of adipose tissue on the limbs and/or face (lipoatrophy), gain in trunk fat
(lipohypertrophy), hypertriglyceridemia, low plasma HDL, lipid accumulation in the

liver (hepatic steatosis), insulin resistance, and skeletal muscle loss.42–45 This patient
has many features of this HIV metabolic syndrome and, as such, is at risk for hyper-
glycemia and hypertriglyceridemia. Prior to considering TPN in this patient, blood
glucose and triglycerides should be brought into control to lower the risk of pancrea-
titis. Use of an infusion of glucose and insulin to achieve euglycemia will suppress
fat release and may rapidly improve hypertriglyceridemia. Discussions should be
made with the patient regarding the risks of TPN, in particular the risk of infection
given the insulin resistance and hyperglycemia. While the patient is not at immedi-
ate risk of development of complications due directly to insufficient calorie intake,
it is not unreasonable to consider the use of TPN. If TPN is initiated, he should
initially be fed hypocalorically given his obesity and hyperglycemia. Patients with
HIV-metabolic syndrome have a reduced capacity to suppress proteolysis during
hyperinsulinemia, and are probably at increased risk of loss of lean body mass with
hypocaloric feeding,46 so protein intake should be 2 g/kgIBW/d. Insulin should be
added to the TPN regimen at a ratio of 1 unit for every 10 g of carbohydrate. He
should initially receive continuous TPN, as infusing the TPN over a shorter period
of time may overwhelm the ability of the body to dispose of glucose. Plasma triglyc-
eride concentration should be measured while receiving TPN.
13.5.5 Case 5
A 45-year-old man with no significant past medical history undergoes endoscopic
retrograde pancreatography to evaluate for episodic abdominal pain. Soon after the
procedure he develops epigastric abdominal pain. A serum lipase level is elevated
and CT reveals pancreatitis. You are consulted by the primary team to provide man-
agement recommendations, specifically whether TPN is necessary. On exam, he is
afebrile and in moderate distress. His BMI is 27 kg/m2, pulse 110, afebrile, RR 12.
On exam, his abdomen is moderately tender.
13.5.5.1 Management
Most patients with mild or moderate acute pancreatitis using Ranson’s criteria do
not require NS and merely require analgesia and intravenous fluids. Clinical care
generally involves preventing oral feeding to minimize pancreatic stimulation.
Occasionally, small bowel feeding tubes are placed beyond the ligament of treitz
to provide enteral feeding into the jejunum. Several studies have shown that jeju-
nal feeding can be safely given to select patients with pancreatitis, even those with
severe disease.47–49 TPN does not appear to confer clinical benefit in patients with
mild or moderate pancreatitis and may increase the risk of bacteremia.47,49,50 Several
trials have compared jejunal tube feeding to TPN.47–49 In patients with mild or mod-
erate pancreatitis, clinical outcomes showed no difference between jejunal feeding
and TPN.47 Indeed, some data suggest that outcomes may actually be better with
jejunal feeding than TPN.48 While providing ~30% of calories as lipid to patients
with pancreatitis appears to be safe and may cause less hyperglycemia, exacerba-
tion of pancreatitis with lipid infusion has been reported.51 Hypertriglyceridemia is
common in patients with pancreatitis, and should be controlled prior to initiation of
TPN. It is likely that this patient will have only mild pancreatitis and he should be
managed conservatively. If his symptoms persist and his pancreatitis remains mild
or moderate, jejunal feeding should be considered to reduce his risk of complications
from TPN.
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tion among incident dialysis patients in the United States. J Ren Nutr, 2008. 18(4):
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4. Klein, S., The myth of serum albumin as a measure of nutritional status. Gastroenterology,
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5. Seres, D.S., Surrogate nutrition markers, malnutrition, and adequacy of nutrition sup-
port. Nutr Clin Pract, 2005. 20(3): p. 308–13.
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10. Gibney, M., H. Vorster, and F. Kok (Eds.) Introduction to Human Nurition. 2002, Oxford,
U.K.: Blackwell, p. 333.
11. Klein, S. , A primer of nutritional support for gastroenterologists. Gastroenterology,
2002. 122(6): p. 1677–87.
12. Griffiths, R.D., Muscle mass, survival, and the elderly ICU patient. Nutrition, 1996.
12(6): p. 456–8.
13. Barr, L.H., G.D. Dunn, and M.F. Brennan, Essential fatty acid deficiency during total
parenteral nutrition. Ann Surg, 1981. 193(3): p. 304–11.
14. Villet, S., et al., Negative impact of hypocaloric feeding and energy balance on clinical
outcome in ICU patients. Clin Nutri, 2005. 24(4): p. 502–9.
15. Dickerson, R.N., et al., Hypocaloric enteral tube feeding in critically ill obese patients.
Nutrition, 2002. 18(3): p. 241–6.
16. Naylor, C.D., et al., Parenteral nutrition with branched-chain amino acids in hepatic
encephalopathy. A meta-analysis. Gastroenterology, 1989. 97(4): p. 1033–42.
17. Kopple, J.D., The nutrition management of the patient with acute renal failure. JPEN J
Parenter Enteral Nutr, 1996. 20(1): p. 3–12.
18. Driscoll, D.F., The pharmacopeial evolution of intralipid injectable emulsion in plastic
containers: From a coarse to a fine dispersion. Int J Pharm, 2008. 368(1–2):193–8.
19. Olivecrona, G. and T. Olivecrona, Clearance of artificial triacylglycerol particles. Curr
Opin Clin Nutr Metab Care, 1998. 1(2): p. 143–51.
20. Skeie, B., et al., Intravenous fat emulsions and lung function: a review. Crit Care Med,
1988. 16(2): p. 183–94.
21. Seidner, D.L., et al., Effects of long-chain triglyceride emulsions on reticuloendothelial

system function in humans. JPEN J Parenter Enteral Nutr, 1989. 13(6): p. 614–9.
22. Hiyama, D.T., et al., Hypersensitivity following lipid emulsion infusion in an adult
patient. JPEN J Parenter Enteral Nutr, 1989. 13(3): p. 318–20.
23. Nehme, A.E., Nutritional support of the hospitalized patient. The team concept. JAMA,
1980. 243(19): p. 1906–8.
24. Daly, J.M. and J.M. Long, III, Intravenous hyperalimentation: techniques and potential
complications. Surg Clin North Am, 1981. 61(3): p. 583–92.
25. Klein, G.L. and J.W. Coburn, Parenteral nutrition: effect on bone and mineral homeo-
stasis. Annu Rev Nutr, 1991. 11: p. 93–119.
26. Sreeramoju, P.V., et al., Predictive factors for the development of central line-associated
bloodstream infection due to gram-negative bacteria in intensive care unit patients after
surgery. Infect Control Hosp Epidemiol, 2008. 29(1): p. 51–6.
27. Jeejeebhoy, K.N., Permissive underfeeding of the critically ill patient. Nutr Clin Pract,
2004. 19(5): p. 477–80.
28. Raurich, J.M., et al., Resting energy expenditure during mechanical ventilation and
its relationship with the type of lesion. JPEN J Parenter Enteral Nutr, 2007. 31(1):
p. 58–62.
29. Sandstrom, R., et al., The effect of postoperative intravenous feeding (TPN) on out-
come following major surgery evaluated in a randomized study. Ann Surg, 1993. 217(2):
p. 185–95.
30. Krishnan, J.A., et al., Caloric intake in medical ICU patients: consistency of care with
guidelines and relationship to clinical outcomes. Chest, 2003. 124(1): p. 297–305.
31. Doig, G.S., et al., Effect of evidence-based feeding guidelines on mortality of critically
ill adults: a cluster randomized controlled trial. JAMA, 2008. 300(23): p. 2731–41.
32. Dennis, M.S., S.C. Lewis, and C. Warlow, Effect of timing and method of enteral tube
feeding for dysphagic stroke patients (FOOD): a multicentre randomised controlled
trial. Lancet, 2005. 365(9461): p. 764–72.
33. Solomon, S.M. and D.F. Kirby, The refeeding syndrome: a review. JPEN J Parenter
Enteral Nutr, 1990. 14(1): p. 90–7.
34. Isner, J.M., et al., Anorexia nervosa and sudden death. Ann Intern Med, 1985. 102(1):
p. 49–52.
35. Silvis, S.E. and P.D. Paragas, Jr., Paresthesias, weakness, seizures, and hypophos-
phatemia in patients receiving hyperalimentation. Gastroenterology, 1972. 62(4):
p. 513–20.
36. Weinsier, R.L. and C.L. Krumdieck, Death resulting from overzealous total parenteral
nutrition: the refeeding syndrome revisited. Am J Clin Nutr, 1981. 34(3): p. 393–9.
37. Hayek, M.E. and P.G. Eisenberg, Severe hypophosphatemia following the institution of
enteral feedings. Arch Surg, 1989. 124(11): p. 1325–8.
38. Wyrick, W.J., Jr., W.J. Rea, and R.N. McClelland, Rare complications with intravenous
hyperosmotic alimentation. JAMA, 1970. 211(10): p. 1697–8.
39. DeFronzo, R.A., et al., The effect of insulin on renal handling of sodium, potassium,
calcium, and phosphate in man. J Clin Invest, 1975. 55(4): p. 845–55.
40. Mattioli, S., et al., Wernicke’s encephalopathy during total parenteral nutrition: obser-
vation in one case. JPEN J Parenter Enteral Nutr, 1988. 12(6): p. 626–7.
41. Nahlen, B.L., et al., HIV wasting syndrome in the United States. Aids, 1993. 7(2):
p. 183–8.
42. Reeds, D.N., et al., Alterations in lipid kinetics in men with HIV-dyslipidemia. Am. J.
Physiol Endocrinol.Metab, 2003. 285: p. E490–E497.
43. Reeds, D.N., et al., Alterations in liver, muscle, and adipose tissue insulin sensitivity
in men with HIV infection and dyslipidemia. Am J Physiol Endocrinol Metab, 2006.
290(1): p. E47–E53.
44. Yarasheski, K.E., et al., Insulin resistance in HIV protease inhibitor-associated diabetes.
J Acquir. Immune. Defic. Syndr., 1999. 21(3): p. 209–16.
45. Carr, A., et al., A syndrome of peripheral lipodystrophy, hyperlipidaemia and insulin
resistance in patients receiving HIV protease inhibitors. Aids, 1998. 12(7): p. F51–8.
46. Reeds, D.N., et al., Whole-body proteolysis rate is elevated in HIV-associated insulin
resistance. Diabetes, 2006. 55(10): p. 2849–55.
47. McClave, S.A., et al., Comparison of the safety of early enteral vs. parenteral nutrition
in mild acute pancreatitis. JPEN J Parenter Enteral Nutr, 1997. 21(1): p. 14–20.
48. Windsor, A.C., et al., Compared with parenteral nutrition, enteral feeding attenuates
the acute phase response and improves disease severity in acute pancreatitis. Gut, 1998.
42(3): p. 431–5.
49. Kalfarentzos, F., et al., Enteral nutrition is superior to parenteral nutrition in severe
acute pancreatitis: results of a randomized prospective trial. Br J Surg, 1997. 84(12):
p. 1665–9.
50. Sax, H.C., et al., Early total parenteral nutrition in acute pancreatitis: lack of beneficial
effects. Am J Surg, 1987. 153(1): p. 117–24.
51. Lashner, B.A., J.B. Kirsner, and S.B. Hanauer, Acute pancreatitis associated with high-
concentration lipid emulsion during total parenteral nutrition therapy for Crohn’s dis-
ease. Gastroenterology, 1986. 90(4): p. 1039–41.
14 Home Nutrition Support
Carol Ireton-Jones and David S. Seres
Contents
14.1 Introduction................................................................................................... 221
14.2 Home Enteral Nutrition................................................................................. 222
14.2.1 Enteral Access................................................................................... 223
14.2.2 Formulas............................................................................................ 223
14.2.3 Initiation of Home EN.......................................................................224
14.2.4 Role of the Hospital and Home Clinicians........................................ 225
14.2.5 Monitoring of Home EN.................................................................... 225
14.2.6 Complications of Home EN............................................................... 225
14.2.7 Long-Term Complications................................................................. 226
14.3 Home Parenteral Nutrition............................................................................. 226
14.3.1 Transitioning to Home....................................................................... 227
14.3.2 Components of Home PN.................................................................. 228
14.3.3 Initiation of Home PN....................................................................... 229
14.3.4 Monitoring......................................................................................... 229
14.3.5 Home PN Reimbursement................................................................. 230
14.3.6 Complications.................................................................................... 230
References............................................................................................................... 231
14.1 Introduction
Enteral and parenteral nutrition are utilized in the hospital when patients cannot take
adequate nutrients orally, but require nutrition to support or improve their nutritional
status. With hospital stays decreasing in length or patients actually initiating nutri-
tion support therapy without hospitalization, provision of enteral nutrition (EN) and
parenteral nutrition (PN) in the home is a very real and viable option for complet-
ing a course of nutrition support or as lifetime therapy. The American Society for
Parenteral and Enteral Nutrition (ASPEN) has developed guidelines that specifically
address the application of home specialized nutrition support (HSNS), stating that
HSNS should be used in patients who cannot meet nutrient needs orally and who are
able to receive therapy outside of an acute care facility.1 Additionally, these guide-
lines state that if HSNS is required, home EN is the preferred route when feasible.
However, home PN should be used when the gastrointestinal (GI) tract is not func-
tional or EN/oral intake insufficient to meet nutritional needs. It is also feasible to
provide dual therapies, EN and PN in tandem, to achieve nutrient goals.
221
There is very little randomized controlled data to draw upon to develop specific
HSNS recommendations and guidelines. Therefore, much of this chapter is based on
the extensive experience of the authors caring for this population and can be consid-
ered Level V data—case series, uncontrolled studies, and expert opinion—as used in
the newest combined Society of Critical Care Medicine (SCCM) and ASPEN guide-
lines.2 The reader should understand that, in the absence of referenced randomized
controlled studies, the contents are meant as suggestions. While this chapter focuses
primarily on adult care, references are provided for pediatric practitioners as well.
Prior to initiating home PN or EN, there are some key components to assess.
These include the patient’s and caregiver’s ability to manage these therapies at home,
the reimbursement options for the patient, and the safety of the home environment.
While the technology is certainly available for providing these therapies at home,
complications are frequent in the period just after discharge and may be due to the
disease process more so than the nutrition therapy.3 Care must be taken to assure
appropriate patient selection and ensure that the selected patient and their caregivers
are aware of the responsibilities that are part and parcel of home EN or PN.
HSNS can be initiated at home, bypassing the hospital. Patients who may be
candidates include those with oncologic diagnoses, certain GI conditions, or
hyperemesis gravidarum. A careful evaluation of the patient’s clinical status, bio-
chemical status, and potential response to therapy are particularly important in
these patients.4 When HSNS is started at home, calories should be kept at a mini-
mum for the first several days and increased to goal once tolerance is established.
HSNS patients started at home on PN should initially receive a formula containing
a low concentration of dextrose, which is increased slowly over the ensuing days
for up to one week.
14.2 Home Enteral Nutrition

Indications for home EN are the same as those applied to hospitalized patients:
inability to meet nutritional needs by mouth for an extended period and without
contraindication. Typical diagnoses include head and neck cancer, stroke or other
neurological disease associated with dysphagia, and gastrointestinal diseases, such
as Crohn’s disease, short bowel syndrome, or pancreatitis. The presence of signifi-
cant gut dysfunction does not necessarily rule out the use of the intestine for home
EN if proper access is obtained and symptoms and absorption problems are aggres-
sively and successfully managed. This may provide a greater challenge when initi-
ating EN in the outpatient setting. Many more people than previously thought may
be managed with home EN, especially in partnership with an experienced home
nursing service. It is unusual, however, that home nursing services related to home
EN are covered by insurance. This continues to present a challenge in managing
complex patients.
It is important to carefully evaluate for a treatable cause for deficient intake prior
to considering home EN. A careful review of systems might elicit treatable symp-
toms. Nausea should be distinguished from symptoms of gastroparesis. In the lat-
ter, patients often report vomiting without much warning as well as postprandial
bloating or pain. Antinauseants frequently do not help patients with gastroparesis,
Home Nutrition Support 223
and prokinetic agents are very poor at treating nausea.5 Although, if a patient is on
maximal antinauseants without resolution of vomiting, a prokinetic agent may be
considered. Similarly, constipation and diarrhea can both add to eating difficulties. It
is also important to ask the patient whether their sense of taste and smell are intact.
For example, the loss of the sense of taste may suggest zinc deficiency.6 The quality
of the food available may make a large difference in intake. Many medications can
decrease appetite and affect gastric emptying as well.
Elderly patients are frequently considered for home EN. It is often the case that
intake may be optimized with hand feeding. Aspiration is rarely an indication for
tube feeding in this population unless the patient is frankly choking. Because dis-
allowing oral intake and initiating EN in patients with aspiration is not believed to
decrease the incidence of aspiration pneumonia, the proper indication for home EN
is that these patients are not meeting their nutritional needs. Attention to feeding
techniques is extremely important in all home EN situations, but especially with
fragile patients at risk for aspiration. Patients demonstrated to have swallowing
dysfunction should receive a thorough evaluation by a qualified speech pathologist
with a request to provide advice on the safest feeding methods as well as evaluation
by an otolaryngologist.
14.2.1 Enteral Access
Access for home EN is best achieved using a permanent or semipermanent device,
such as a gastrostomy or jejunostomy. It is frequent that a home nursing agency, or
skilled nursing home for that matter, will reject patients with a temporary naso-
gastric or nasoenteric tube. If the patient is ambulatory, a gastrostomy is usually
preferred so that nourishment may be given in discrete boluses, allowing the patient
a maximum of independence and time off the feeding. Some patients with jejunosto-
mies are able to tolerate slow bolus feeds, but these are generally thought to be easier
with gastrostomies. Gastrostomies and jejunostomies are both acceptable for infu-
sion feeding (i.e., feeding via a pump), but patients with jejunostomies tend to be less
tolerant of concentrated feeding products. Diarrhea may occur as well, particularly
if a concentrated feed is used (see below).
14.2.2 Formulas
Standard feeding formulas are generally adequate for most patients. Disease-specific
feeding products have very limited usefulness and can increase the cost for the feed-
ing product as much as 15-fold. Unless fluid or electrolyte restriction is needed, con-
centrated and/or renal formulas are not necessary. A moderately concentrated (1.5
kcal/ml) feed may help shorten the delivery time in bolus feeding. As mentioned,
concentrated feeds are hypertonic and may be less well tolerated as boluses or when
fed into the small bowel. Dialyzed patients are unlikely to benefit and may be harmed
by protein restriction. When potassium and phosphorus levels are difficult to control,
an electrolyte-restricted formula may be helpful. Hepatic and pulmonary formulas
have not proved to improve outcomes.
14.2.3 Initiation of Home EN
Patients tolerating in-hospital EN should be carefully assessed for their ability to
manage the feeding process independently at home. If they are unable, or are likely
to be too ill, a family member must be available to administer the feeds. Outpatient
placement of feeding devices is acceptable, but confirmation by x-ray is strongly
recommended before feeding is initiated.
Bolus or nocturnal infusions are the most commonly used feeding schedules for
home EN. Gastric access is most appropriate for bolus feeding, but slow bolus feeds
have been tolerated in the small bowel. The total daily feeding volume is divided
into two to five sessions. Bolus feeds may be administered by gravity or by pump,
and may be the initial feeding method when gastric emptying dysfunction is not
suspected. One method for bolus feeds utilizes a 60 ml catheter-style syringe, with
the piston removed, as a funnel. The syringe is connected to the end of the enteros-
tomy tube and formula and water are poured into the syringe in aliquots. A feeding
session using this method should take 15 to 30 minutes. Most patients will tolerate
approximately 750 ml at each session (500 ml of feeding product and 250 ml of
water). When overfullness and intolerance to volume is encountered, a prokinetic
agent should be considered. Gravity bolus feeds may be administered by attaching
a feeding bag to the enterostomy and allowing the feed to run in by gravity as well.
This usually takes longer, but has the advantage of being relatively hands-free.
Pump infusions may be necessary in patients with jejunostomies and/or marginal
gastric emptying. Scheduling the feeding is flexible and should be individualized.
Infusions may be given over a range of approximately 8 to 24 hours depending on
tolerance and convenience. It is commonly thought that an overnight feed yields
maximal daytime freedom. But nocturnal feeds may disrupt sleep when the infusion
needs attention (feeding bags do not usually exceed one liter) or when nocturia is
induced. With the availability of portable infusion pumps, a daytime-only schedule,
in fact, may be preferable. Further, a daytime schedule may make glycemic regula-
tion easier.
Initiating EN for the first time in the home setting should not be done in the
absence of a responsible observer because vomiting and aspiration may occur. In
the authors’ experience, it is more often the case that patients are admitted for nutri-
tion- or hydration-related problems and feeds are initiated during the hospitalization.
Feeding goals should be discussed with a nutrition practitioner and there is generally
no hurry achieving the goal rate. There are many approaches to assessing tolerance
and increasing rates. It is recommended that rates and incremental increases be more
conservative in the home setting if the patient is bedbound or gastric dysfunction
suspected. A reasonable approach might include starting feeding at 30 to 50% of
goal and then increasing by 30 to 50% every day or two. Technical aspects of home
EN should be explained well, such as assuring the head of the bed is elevated to 30
degrees and that the proper care and administration techniques are adhered to by the
patient or caregiver.
Severely malnourished patients are at risk for refeeding syndrome charac-
terized by hypokalemia, hypophosphatemia, and hypomagnesemia.7 For these
patients, initial feeding goals should be very conservative, for example, 15 to
20 kcal/kg of current weight, until electrolyte stability and tolerance are estab-
lished. It is suggested that laboratory testing be performed after one to two days,
and as often as daily if needed until stable. If there is concern, hospital EN ini-
tiation may be preferable. The lack of coverage for home nursing for EN makes
home initiation all the more challenging for complex patients. Refeeding syn-
drome is even more critical in the home PN patient and will be discussed later
in this chapter.
14.2.4 Role of the Hospital and Home Clinicians

Proper in-hospital preparation and training of the patient and/or caregivers prior to
discharge is crucial. A multidisciplinary assessment should include analysis of the
home situation, insurance coverage for feeding product, and the ability for the patient
or family to administer EN. Discharge planners should ensure that provisions for
continuity of care are in place and communicated to the outpatient provider, particu-
larly when the patient is being discharged from a teaching or hospitalist service that
does not provide postdischarge care. Referral to an academic center and/or nutri-
tion support specialist, such as a registered dietitian, should be considered when the
home EN issues are complex.
14.2.5 Monitoring of Home EN
Patients receiving home EN should be monitored for tolerance of the feeding, bowel
function, weight, and hydration. Monitoring frequency should be individualized,
should be more frequent in the initiation period, may be decreased over time given
stability, and may be accomplished by phone if there is a reliable patient or care-
giver in the home. If the potential for refeeding syndrome is suspected, laboratory
testing will be important during the initiation of EN, and longer term for fluid bal-
ance and electrolyte disturbances. The monitoring that the patient will receive is
often dependent on the home provider of the EN supplies and formula. If a durable
medical equipment (DME) company (also called a home medical equipment [HME]
company) is providing these, monitoring may consist of assuring that adequate sup-
plies are ordered and delivered because a nutrition support clinician is usually not
involved. A home infusion agency that also provides home PN will more likely pro-
vide closer clinical monitoring. Therefore, when choosing a provider, it is important
to determine who will monitor these patients at home and what type of monitoring
will be provided.8
14.2.6 Complications of Home EN
As discussed above in Section 14.2.5, life-threatening electrolyte disturbances
may occur with the initiation of feeding (by any modality) in severely malnour-
ished patients and, in particular, those with preexisting electrolyte deficiencies.4,7
In-hospital initiation may be a safer approach for these patients.
Because normal thirst is often bypassed or depressed, dehydration is a serious
concern in home EN patients. Standard feeding products are maximally 85% water.
Water supplementation during tube feeding serves two purposes: (1) in addition to
hydration, frequent flushing of the feeding tube decreases the risk for clogging, and
(2) adequate hydration further prevents constipation. Acidic fluids, such as soda and
cranberry juice, should be avoided as routine flushing with these may increase the
risk for clogging.
Intolerance to bolus feeding in patients with gastrostomies is quite frequent.
Symptoms of overfullness and bloating are most common. The stomach is pulled
anteriorly and tacked to the abdominal wall when the tube is placed. This may cause
gastric emptying dysfunction. Clinicians caring for a patient on gastric home EN
should be careful to screen for these symptoms. Prokinetic agents, such as metoclo-
pramide, are very helpful in treating these symptoms.5
Diarrhea is a frequent accompaniment to tube feeding. Often multiple feeding
products are tried without benefit. The most frequent cause is either medications
or the concentration of the feeding product.9 Patients receiving home EN are often
receiving antibiotics and prokinetics, both known to cause diarrhea. Medications,
such as H2 blockers and proton pump inhibitors given to decrease acid secretion, are
notorious for causing diarrhea and often overlooked as causative in these patients.
Feeds that are hypertonic (greater than 380 mOsm/l) are more likely to cause diar-
rhea, especially when infused into the small bowel. Finally, the vehicle for any medi-
cation given in a liquid form is often 70% sorbitol. Sorbitol is a nonabsorbable sugar
that acts as an osmotic agent to increase the water content of the stool. It is very
useful in treating constipation in these patients, but can also cause diarrhea if enough
is consumed.
14.2.7 Long-Term Complications
Despite placement of feeding devices, patients receiving home EN will fre-
quently lose significant amounts of weight due to recurrent mild intolerance
causing feeding interruptions. Care must be taken to palliate all gastrointestinal
symptoms. Many of the long-term complications of home EN result from prob-
lems with the feeding device. When patients gain weight, the abdominal wall
thickens. If the bolster holding the enterostomy tube in place is not loosened,
tissue around the device will die and the ostomy will enlarge. This causes leak-
age and is difficult to manage. Alternatively, the bolster may become embedded
in the skin, a so-called “buried bumper.”10 An enlargement of the ostomy also
may occur in patients if the enterostomy tube is pressed to the side, especially in
slender patients.
14.3 Home Parenteral Nutrition

Parenteral nutrition is indicated for patients who are unable to intake or absorb ade-
quate nutrients enterally. Common diagnoses associated with home PN include short
bowel syndrome, bowel obstruction, enterocutaneous fistula, radiation enteritis, and
intractable nausea or vomiting.
For hospitalized patients, PN may be used for a relatively short period of time to
accommodate a nonfunctioning small bowel due to an acute injury or episode with
recovery of bowel function and return to an oral diet prior to discharge. However, in
many cases, the recovery of bowel function is impeded or extended and, therefore,
the acute episode may be complete and the patient ready for discharge, yet requir-
ing PN for adequate nutrient intake. Patients who require a continuation of their PN
therapy or will require long-term or lifetime support, such as patients with short
bowel syndrome, are candidates for home PN therapy. As mentioned previously, a
multidisciplinary assessment of each patient’s clinical status, home environment,
and insurance coverage is essential in the discharge process for home PN. A care-
giver must be present especially in the early stages of home PN management to assist
with all of the logistics of managing the PN therapy and supplies at home.
In preparation for home PN, appropriate access must be obtained. Central par-
enteral nutrition (CPN), that is PN infused into a large vein, usually the superior
vena cava, is most commonly used for patients both in the hospital and at home.
Peripheral parenteral nutrition (PPN) is available for both care settings, but is not
readily applicable to the home care setting in that it is a short-term therapy (usu-
ally less than two weeks) and infused through a midline catheter with limitations
on fluids and solution osmolality. Options for intravenous access for home PN are
listed in Table 14.1.
14.3.1 Transitioning to Home
Patients receiving PN in the hospital are ready to transition to the home care setting
when they are clinically and medically stable. Typically, a home infusion provider will
organize the home infusion needs for the patient and meet the patient at home with
supplies for the infusion therapy on the day of discharge. Patient education regarding
administration of the therapy at home should begin in the hospital and culminate on
Table 14.1
Venous Access Devices
Needle Skin
Puncture
Required for Usual
Device Location Access Durability Benefits
Hickman Under skin No Months to years Infections can often
(Tunneled cuffed and exit site be treated without
catheter) removing device
Port Under skin Yes Months to years No exit site
PICC Under skin No Weeks to months Inexpensive safe
and exit site bedside placement
possible
Source: Reprinted with permission from Coram, Inc., Celebrate Life newsletter.
Note: The table summarizes the characteristics, benefits, and disadvantages of each of these three types
of venous access devices.
the first day home with a delivery of required supplies and the first visit by the home
infusion nurse. The hospital clinicians managing the patient should provide a final
discharge PN order coordinated with the home care/home infusion provider. A home
infusion company may provide infusion therapies only with nursing supplied by a
home health agency or may provide their own nursing. Experienced home infusion
nurses are critical to the success of the home PN therapy as the education received
in the hospital is put into action in the home care setting. Appropriate and thorough
patient education on home PN therapy, administration of the therapy, and complica-
tion prevention (specifically excellent catheter care maintenance) is crucial.
A thorough nutrition assessment should be performed in the home setting as
requirements in the hospital are different from those in the home setting. Nutrient
needs may change at home as the patient may be more active and return to nor-
mal activities while being more sedentary in the hospital or may change as healing
occurs. Baseline labs should be established when home PN is started and observed
for trends over time. Hypoalbuminemia more often reflects the inflammatory pro-
cess and is not a good indicator of nutritional status in acute care; however, trends of
albumin over time may aid in the overall evaluation of response to therapy.11
Determining the home PN formula should take into account the goals of nutri-
tion support (repletion versus maintenance), any preexisting disease process, and
nutritional status. Further, it should take into account the patient’s lifestyle at home
with the goal to infuse less than 24 hours per day, usually 10 to 14 hours per day.
For pediatric home PN patients, needs for both growth and development should be
considered.
14.3.2 Components of Home PN
Protein in the form of amino acids, fat as lipid emulsion, and carbohydrate provided
as dextrose make up the macronutrients in a home PN formula. Protein requirements
may be calculated on a gram per kilogram basis and usually fall into the range of
1.0 to 1.5 gram/kg of body weight (if normal weight). For extremely overweight indi-
viduals or those who are underweight, protein needs should be adjusted accordingly.
An optimal ratio of protein to carbohydrate and lipid can be achieved by including 15
to 20% of total kcals as protein. Fat is provided as 25 to 30% of total kcals/day. Lipid
emulsions should not exceed the 2.5 g of lipid/kg body weight/day or 60% of total
kcals. Currently available commercial lipids in the United States are aqueous emul-
sions of soybean or safflower oil with egg phospholipid as the emulsifier. Patients
with egg allergies may not tolerate lipids and should be tested prior to infusion. Lipid
emulsions also contain phosphorus that may be important for patients with renal
disease as well as a small amount of vitamin K. Carbohydrate serves as the primary
energy source and will make up the balance of kcals after accounting for protein and
fat. Dextrose in sterile water is used in PN solutions and provides 3.4 kcal/gm. When
kcal requirements are balanced (15 to 20 % from protein, 25 to 30% from fat, and
the balance of kcals are from dextrose), then the maximum 24-hour glucose infu-
sion rates will be less than 7 mg/kg/minute, which is appropriate for patients with a
normal glycemic response.12 The use of glucose infusion rates to estimate optimal
dextrose infusion in home infusion patients is questionable because the majority of

home PN patients will receive a cyclic infusion of PN for 10 to 12 hours.
Home PN may be in the form of a Total Nutrient Admixture (TNA), which is a
mixture of dextrose, amino acids, and lipids, or a “standard” solution containing
amino acids and dextrose only with lipids provided by a separate pump or “piggy-
backed” into the central line. Two pumps will be needed if the lipid is not mixed
into the home PN and, therefore, this is an added expense and inconvenience in
the home situation. Pediatric patients often require two pumps due to compatibility
issues when adding lipids to the types of dextrose and amino acid solutions required
for the infant or young child.13
Multivitamins are added by the patient or caregiver prior to infusion of home PN.
The multivitamin content has been developed from standards determined by the
Nutrition Advisory Group of the Department of Foods and Nutrition of the American
Medical Association (NAG-AMA, 1975, revised 1985, mandated by 2004). If a
patient has a documented vitamin or mineral deficiency due to disease state, previ-
ous malnutrition, or higher than normal requirements, additional supplementation of
individual nutrients should be provided. It is important to monitor for adequacy to
assure that the normal dosage is used after supplementation is completed. Long-term
home PN patients may need specific, individual trace-element supplements due to
potential elevations of copper, manganese, and chromium.14
14.3.3 Initiation of Home PN
A majority of patients will be receiving PN in the hospital and will be transitioned
from the hospital to the home. Refeeding syndrome has been addressed in this chap-
ter, but should again be discussed in relation to the initiation of home PN. Refeeding
syndrome has been defined as the “over-vigorous feeding of the severely malnour-
ished patient.” This overfeeding is not helpful and, in fact, is harmful, causing
hypophosphatemia, hypokalemia, and hypomagnesemia, which if left untreated can
result in serious complications including death. The optimal treatment for refeeding
syndrome is prevention. If a patient has been without nutrition for some time and is
malnourished, the first level of care should be replenishment of fluids and electro-
lytes. Then, repletion of nutritional status can occur with a low level of dextrose (100
to 150 g of dextrose) and advanced as tolerated over several days. This rehydration
and repletion does not have to happen in the hospital and can be accomplished in the
home with a capable home infusion provider.4
14.3.4 Monitoring
Home monitoring includes evaluation of laboratory data, physical assessment, as well
as self-monitoring that is completed by the patient.15,16 The frequency of monitoring
should decrease as the patient is stable on home PN. A baseline complete metabolic
panel, phosphorous, magnesium, and complete blood count (CBC) with differen-
tial is obtained initially as a baseline. A basic metabolic profile is needed on an
ongoing basis along with specific labs as needed based on clinical status and symp-
toms. Individual micronutrients may be assessed if deficiency is suspected; however,
interpretation of the results and development of a repletion regimen remains a chal-

lenge.14–17 Patients also will need to self-monitor by checking their weight daily or
every other day initially, then weekly checking their temperature daily initially and
adhering to a glucose monitoring schedule if ordered by their physician. Catheter
maintenance is of utmost importance. The physician will order the catheter-care
maintenance, with the home-care nurse providing the catheter-care education to the
patient. The home nursing provider should provide the catheter care until the patient
or caregiver is independent and can successfully manage the care on his/her own.
This can be a limiting factor to home PN because, if the patient or caregiver cannot
manage the catheter care, alternatives to placement at home should be considered.
Goals of therapy should be established early in the nutrition therapy program and
may need to be revised as the patient progresses. Along with observing for tolerance
of the home PN regimen is the monitoring of the adequacy of home PN intake. This
is particularly important as the patient is transitioning from one nutrition support
modality to another (PN to EN or oral). Additionally, when home EN alone is inad-
equate to support nutrient needs, home PN may be used as well. This is a common
occurrence with pediatric patients.13 The challenge of dual therapies is not in the effi-
cacy of the therapies, but in the need for two to three pumps (one to two for home PN
and one for home EN) and insurance coverage for multiple therapies to accomplish
the same goal. If transition back to an oral diet or to an enteral feeding is the goal,
attention to adequacy of the macro and micronutrient intake during this transition is
key. A registered dietitian is well qualified to manage this transition
14.3.5 Home PN Reimbursement
Most commercial payers include coverage of PN at home as a contracted benefit.
Governmental payers—Medicare and Medicaid—do reimburse for home PN under
specific circumstances. Medicaid reimbursement for home PN varies from state to
state and benefits must be verified individually. Medicare reimbursement for home
PN is complex and requires that two basic criteria be met initially and then further
criteria is evaluated to assure that the therapy will be reimbursed based on clinical
criteria.18 Medicare requires the determination of permanence, which they define as
the need for home PN for a long and indefinite duration, 90 days or a lifetime, and the
presence of malabsorption of nutrients due to small intestinal malabsorption. Further
criteria are used to justify the need for home PN, such as recent massive small bowel
resection, short bowel syndrome, and failure of EN. One of the first steps in the refer-
ral process for home nutrition support for home PN or EN is the verification of the
patient’s benefits whether from commercial or a governmental payer. The hospital
case manager can initiate this or the home care provider can as well upon referral.
These individuals are usually highly qualified to assist the referral clinician and
patient in understanding their reimbursement for therapies at home.
14.3.6 Complications
Complications of home PN can be divided into metabolic, mechanical, infectious, and
psychosocial categories. Metabolic complications include hyper- or hypoglycemia,
electrolyte disturbances, and fluid imbalance. Working with qualified clinicians in

the home care setting can attenuate these challenges and has proved to be effective
in minimizing complications.19 When a patient is clinically at risk for electrolyte or
fluid imbalance, such as a patient with a high output fistula, close clinical monitor-
ing is essential. This includes assessment of labs and careful management of the PN
formulation. If a patient is requiring daily changes to their home PN formulation,
clinical stability is in question and this patient may be best managed in the hospital
or an extended care facility.
Mechanical complications and venous access complications are primarily
related to the home PN catheter. Vascular access device complications can be
minimized by optimal choice in the venous access device to be used related to
the patient’s needs as well as fastidious care of the catheter.20,21 Patients who are
receiving home PN (or home EN) also may be receiving other infusion therapies,
such as antiinfectives, infusion pain management, subcutaneous medications, or
supplemental fluids. Initiation of an antiinfective at home to treat a suspected
catheter-related infection can obviate the need for a hospitalization.19 Assuring
that the home infusion provider is well skilled in teaching catheter care tech-
niques and monitoring for complications is of utmost importance in success-
ful home PN therapy. One study has shown that not only does close clinical
monitoring by a home nutrition support team consisting of a dietitian, nurse, and
pharmacist working with the patient’s physician improve clinical outcomes, but
it also decreases cost.19 Details of catheter placement and care require signifi-
cant attention and are out of the scope of this chapter; however, many excellent
resources are available through the American Society for Parenteral and Enteral
nutrition (ASPEN: www.nutritioncare.org) and the National Home Infusion
Association (NHIA: wwww.nhia.org) as well as The Oley Foundation (800-776-
OLEY; www.oley.org).
Along with clinical management, psychosocial support is also essential, espe-
cially if this will be a lifetime therapy. A support group (The Oley Foundation) is
available specifically for patients receiving home EN or PN and their friends and
family. The Oley Foundation provides telephonic support, a newsletter, resources for
individuals and families, and a network of people across the country who are also
on home EN and PN. Clinicians working with patients on home EN or PN should be
aware of The Oley Foundation and provide the contact information to their patients;
it is a wonderful resource.
Being outside of the hospital and at home can certainly improve the qual-
ity of life of individuals who need continued nutrition therapy. Expert manage-
ment at home is required and, therefore, the agency that will be providing the
home EN or PN should have clinical support and expertise in home nutrition
support management.
References
1. ASPEN Board of Directors and The Clinical Guidelines Task Force. Guidelines for the
use of parenteral and enteral nutrition in adult and pediatric patients. J Parenter Enteral
Nutr 2002;26S:1SA–8SA.
2. Martindale, RD, McClave SA, Vanek VV, et al. Guidelines for the provision and assess-
ment of nutirtion support therapy in the adult critically ill patient: Society of Critical
Care Medicine and American Society for Parenteral and Enteral Nutrition: Executive
Summary. Crit Care Med 2009;37(5):1757–1761.
3. de Burgoa LJ, Seidner D, Hamilton C, at al. Examination of factors that lead to compli-
cations for new home parenteral nutrition patients. J Infus Nurs, 2006:29:74–80.
4. Newton AF, DeLegge MH. Home initiation of parenteral nutrition. Nutr Clin Pract
2007;22:57–64.
5. Reddymasu SC, McCallum RW. Pharmacotherapy of gastroparesis. Expert Opin
Pharmacotherapy 2009;10:469–84.
6. Heyneman, CA. Zinc deficiency and taste disorders. Ann Pharmacother 1996;30:
186–7.
7. Tresley J, Sheean PM. Refeeding syndrome: recognition is the key to prevention and
management. J Am Diet Assoc. 2008;108(12):2105–8.
8. Ireton-Jones C. Home enteral nutrition from the provider’s perspective J Parenter
Enteral Nutr (Suppl.) 2002;26(5):S8–9.
9. Eisenberg P. An overview of diarrhea in the patient receiving enteral nutrition.
Gastroenterol Nurs 2002;25:95–104.
10. McClave S, Neff R. Care and long-term maintenance of percutaneous endoscopic gas-
trostomy tubes. J Parenter Enteral Nutr 2006;30(1): S27–40.
11. Fuhrman P, Charney P, Mueller C. Hepatic proteins and nutrition assessment. J Am Diet
Assoc. 2004;104(8):1258–64.
12. Wolfe RR, O’Donnell TF, Stone MD, et al. Investigation of factors determining the
optimal infusion rate in total parenteral nutrition. Metabolism 1980;29(9):892–900.
13. Nguyen PC, Kerner J. Home parenteral nutrition support in pediatrics, In Handbook
of Home Nutrition Support, Ireton-Jones C and DeLegge M (eds.). Jones and Bartlett:
Sudbury, MA, 2007; 223–251.
14. Howard L, Ashley C, Lyon D, Shenkin A. Autopsy tissue trace elements in 8 long-term
parenteral nutrition patients who received the current U.S. Food and Drug Administration
formulation. J Parenter Enteral Nutr 2007;31(1):388–396.
15. Ireton-Jones C, DeLegge M, Epperson LA, et al. Management of the home parenteral
nutrition patient. Nutr Clin Prac 2003;18:310–317.
16. Siepler J. Principles and strategies for monitoring home parenteral nutrition. Nutr Clin
Prac 2007;22:340–350.
17. Kelly D. Guidelines and available products for parenteral vitamins and trace elements. J
Parenter Enteral Nutr 2002;26(5):S34–36.
18. Wojtylak F, Hamilton K. Reimbursement for home nutrition support, In Handbook of
Home Nutrition Support, Ireton-Jones C and DeLegge M (eds.). Jones and Bartlett:
Sudbury, MA, 2007; 389–412.
19. Ireton-Jones C, Hamilton K, DeLegge M. Improving clinical and financial outcomes
with parenteral nutrition therapy. Support Line 2009;31(1):23–25.
20. Sands MJ. Vascular access in the adult home infusion patient, J Parenter Enteral Nutr
2006;30(1):S57–64.
21. Ryder M. Evidence based practice in the management of vascular access devices for
home parenteral nutrition therapy. J Parenter Enteral Nutr 2006;30(1):S82–93.
15 Intestinal Failure and
Liver Disease Related to
Parenteral Nutrition and
Intestinal Transplantation
Khalid Khan
Contents
15.1 Introduction................................................................................................... 234
15.2 Intestinal Failure and Short Bowel Syndrome............................................... 234
15.2.1 Etiology........................................................................................... 234
15.2.2 Prevalence....................................................................................... 235
15.2.3 Pathophysiology.............................................................................. 235
15.2.4 Pathology and Clinical Spectrum................................................... 235
15.2.5 Enteral Nutrition.............................................................................. 237
15.3 Liver Disease Related to PN.......................................................................... 238
15.3.1 Cholestasis....................................................................................... 239
15.3.2 Hepatic Steatosis............................................................................. 239
15.3.3 Risk Factors: Enteral Intake, Sepsis, and Constituents of PN......... 239
15.3.4 Biliary Sludge and Gallstones.........................................................240
15.3.5 Clinical Features.............................................................................240
15.3.6 Histology......................................................................................... 241
15.3.7 Clinical Management...................................................................... 241
15.3.8 Nontransplant Outcome................................................................... 241
15.3.9 Nontransplant Surgery for SBS....................................................... 241
15.3.10 Isolated Liver Transplants for Intestinal Failure............................. 242
15.4 Intestinal Transplantation.............................................................................. 242
15.4.1 Types of Grafts................................................................................ 242
15.4.2 Patient and Graft Outcome.............................................................. 243
15.4.3 Nutrition..........................................................................................244
15.4.4 Maintenance Immunosuppression and Rejection...........................244
15.4.5 Cost and Quality of Life..................................................................244
References............................................................................................................... 245
233
15.1 Introduction
Intestinal failure refers to a patient’s inability to maintain life with enteral intake.
Short bowel syndrome (SBS), often used synonymously, refers to a malabsorptive
state that results from functional and/or anatomic deficiencies of the small intes-
tine. SBS is broadly dichotomous: Congenital anatomic disorders predominate
in infancy, whereas intestinal disease and mechanical loss are the major causes
of SBS in adults. During intestinal rehabilitation, parenteral fluid, electrolytes,
and nutrients are required to sustain life. In the case of anatomic SBS, the small
intestine has the ability to morphologically change (i.e., undergo adaptation) to
improve function; in addition, surgical options exist for lengthening the intestine
in infants.
Ultimately, some patients have no alternative but long-term parenteral nutrition
(PN). Although PN is a lifesaving therapy, liver disease may develop, particularly in
infants with SBS when the remaining small intestine is extremely short, if no enteral
intake is possible and as their time on PN increases. Control of systemic sepsis, scru-
tiny of the PN content, and progress with enteral feeding may halt or even reverse
liver disease, especially if the patient is able to wean off PN. Despite advances in the
care of this population, the eventual outcome is poor on long-term PN, especially in
infants. Transplantation of abdominal viscera, including the small intestine, makes
it possible to prolong life with good quality.
15.2 Intestinal Failure and Short Bowel Syndrome

15.2.1 Etiology
Intestinal failure is most frequently due to anatomic SBS. The most common under-
lying cause of SBS in adults is small intestinal Crohn’s disease.1 Other causes include
a mesenteric vascular event; an infarction from arterial and venous thrombosis, from
an arterial embolism, from midgut volvulus, or from complications of surgery; exten-
sive resection after trauma or for tumor removal; and radiation injury. Complications
of surgery for obesity are an increasing cause.2
Advances in the care of sick newborns have led to the survival of almost all infants
who undergo extensive resection of the small intestine. The congenital abnormalities
that give rise to most cases of anatomic SBS in infants are gastroschisis, intesti-
nal atresia, and malrotation.3,4 Sophisticated care of severely premature infants has
increased the number of survivors, resulting in an increased proportion of infants
with SBS caused by surgery for necrotizing enterocolitis. Other than SBS, intestinal
failure is also caused by diffuse neuromuscular dysfunction, such as the total agan-
glionic form of Hirschsprung disease. Much less common causes are hollow visceral
myopathy and neuropathy (e.g., pseudo-obstruction), which can affect adults or chil-
dren. Diffuse mucosal disease (e.g., microvillus inclusion disease) is fatal in infancy
without treatment; malabsorption can occur with polyposis.5
Intestinal Failure and Liver Disease 235
15.2.2 Prevalence
There is no data on prevalence of intestinal failure in the United States. Widely
quoted home PN Registry data from 1992 showed that about 40,000 patients required
PN each year during that era in the United States.6 About 26% of the patients had
SBS, although some with malignancy or enteritis from radiation may also have had
SBS. For infants, the incidence of SBS was reported as 1,200 of 100,000 live births
between 2002 and 2005.7 Survival rates in children with SBS range from 73 to 89%,
making it one of the most lethal conditions in early childhood.3
15.2.3 Pathophysiology
In most patients with SBS, the duodenum is intact, although it may be dysfunctional
in those with total aganglionosis or pseudo-obstruction. The jejunum is the site of
fluid, electrolyte, and nutrient movement between the gut lumen and the vasculature.
To achieve such movement, the mucosa comprises long villi and deep crypts for
maximal surface area, the greatest amount of brush border enzyme activity, and
large intraepithelial gap junctions. The jejunum is the major site of carrier-mediated
absorption of nutrients after digestion of food and its conversion into monosaccha-
rides, amino acids, and peptides. The ileum has relatively shorter villi and tighter
gap junctions, resulting in less fluid movement, thereby allowing for better (albeit
slower) nutrient absorption. Vitamin B12 and bile salts are absorbed through specific
receptors in the ileum. Ileal absorption is enhanced by the ileocecal valve, which
slows small intestinal transit and increases time spent by nutrients within the ileum.
The valve prevents reflux of bacteria from the colon into the ileum. The colon has
the ability to reclaim sodium, water, amino acids, and energy from bacterial fermen-
tation of carbohydrates into short-chain fatty acids, which provide colonic mucosal
cells with energy.8,9
Hormones that regulate secretion and motility are released from the proximal
small intestine, most notably, gastrin, gastric inhibitory polypeptide, cholecystokinin,
secretin, and motilin. Because the loss of intestine is distal in patients with SBS,
secretion of these hormones is usually preserved. Hypergastrinemia occurs in
patients with SBS from the loss of negative feedback on gastrin secretion after ileal
resection.10 Gastric acid hypersecretion may lead to peptic ulcers and esophagitis,
and may impair absorption by inactivating pancreatic lipase and deconjugating bile
salts. Gastric acid suppression may improve water absorption in patients with SBS.11
The ability to secrete ileal hormones (e.g., enteroglucagon, glucagon-like peptides
[GLPs] 1 and 2, peptide YY, and neurotensin) may be lost in patients with SBS.12 In
particular, peptide YY and neurotensin are responsible for the ileal “brake” effect of
delaying gastric emptying and slowing intestinal transit time, especially in response
to lipids in the ileum.12,13
15.2.4 Pathology and Clinical Spectrum

The loss of the small intestine in patients with SBS can be primary or resection-
related. Primary loss is common in infants with intestinal atresia or gastroschisis.
Functioning small intestine can be lost as a result of severe small intestinal Crohn’s
disease in adults, but the more likely culprit is repeated surgical resection. Small
intestinal volvulus results in the removal of a variable length of jejunum and ileum.
Ileocolic disease may involve removal of ileum, the ileocecal valve, and a propor-
tion of proximal colon. The major cause of ileocolic disease in infants is necrotizing
enterocolitis; in older children and adults, Crohn’s disease. Most macronutrients are
absorbed within the first 100 to 150 cm of jejunum in adults; marked fluid secretion
in the jejunum in response to hypertonic feeding is reabsorbed, primarily in the
ileum.6,14,15 Major jejunal resection with a stoma, therefore, will result in nutrient
and fluid loss—a loss further complicated by secretion of salt and fluid, which is
stimulated by oral intake.16 A shortened gastric emptying time and rapid transit in
the proximal small intestine unchecked by the lack of ileal hormones results in a net
secretory response to food.17 In adults, removal of 60 cm or more of ileum may cause
vitamin B12 deficiency; removal of 100 cm gives rise to bile salt deficiency and to
fat malabsorption from loss of enterohepatic circulation.18 At least 100 cm of small
intestine is necessary in the absence of the colon to prevent intestinal failure, but
35 to 60 cm may suffice when the colon is intact.19–21 In a pediatric study of mainly
small children, patients with >15 cm of small intestine without an ileocecal valve and
patients with <15 cm of small intestine with an ileocecal valve had most success at
nutritional rehabilitation.22 The plasma citrulline level is a measure of mucosal mass,
therefore the length and adequacy of the remaining small intestine.2
Adaptation is the process of expansion of the luminal surface cell mass by which
the small intestinal absorptive area increases in response to the patient’s nutritional
needs. Data from patients who underwent jejunoileal bypass and from animal stud-
ies indicate that the intestine lengthens and that its diameter and the height of villi
increase, resulting in a larger absorptive surface23—a process that continues for two
years or more.24 Some aspects of adaptation occur without such morphologic changes
as increased absorption of carbohydrates.25 In animal studies, small intestinal adap-
tation is heralded by epithelial hyperplasia within 24 to 48 hours after intestinal
resection.26,27 Although the absorptive area increases, functional immaturity occurs,
but gradually improves.25,26,28 Some nutrients are absorbed much more quickly than
others.29 Gross morphologic change is evident by two to three weeks after intestinal
resection.30 A number of genes whose expression is altered after intestinal resec-
tion may play a role in adaptation.31 Jejunal adaptation is limited to function while
the ileum adapts anatomically and functionally resembles the jejunum.32 The jeju-
num cannot adapt to absorb vitamin B12 after ileal loss. In general, patients with an
extremely short small intestinal remnant or with a high jejunal stoma lack sufficient
length for adaptation, although there are exceptions.
Data from animal studies indicate that intestinal hormones, in particular, GLP-2,
contribute to adaptation.33,34 GLP-2 is secreted from the ileum and pancreas; post-
prandial levels are reduced after ileal resection.35 Animals administered GLP-2 after
ileal resection have shown marked villus hyperplasia, enhanced glucose absorption,
reduced intestinal permeability, and morphologic adaptive changes in jejunal rem-
nants.36 Subcutaneous GLP-2 or synthetic variants increase nutrient and fluid absorp-
tion.33 The effect of hormones may be related to an effect on polyamine metabolism.
Polyamines, (e.g., spermine) are produced by proliferating tissues, particularly
in small intestinal epithelium.37 Prostaglandin analogues have been shown to be

trophic to cells, capable of increasing mucosal mass, and of stimulating adaptation
after intestinal resection.38 Inhibition of prostaglandin synthesis, particularly of the
cyclooxygenase pathway, impedes adaptation.39 Specific hormones may also inhibit
adaptation; octreotide, a somatostatin analogue, reduces cell proliferation after intes-
tinal resection; transforming growth factor-beta 1 reportedly inhibits intestinal cel-
lular growth; ghrelin is reduced in patients with SBS, but leptin has been shown to
increase carbohydrate absorption.40–42
Enteral nutrition is imperative for mucosal health and adaptation. Animal data
show that, after small intestinal resection, PN gives rise to atrophy, whereas enteral
intake stimulates hyperplasia.43 The proposed mechanisms include direct stimula-
tion through stimulated secretion of gut hormones and release of trophic secretions
from the upper intestinal tract. Direct stimulation is more effective when the work-
load is increased, such as when the animal’s body is dealing with complex (versus
simple) carbohydrates.44 The role of stimulated hormones and secretions has been
elegantly described in animal models.45,46 In animals, intravenous arginine and glu-
tamine have been shown to reduce intestinal permeability.47,48 Intravenous glutamine
supplementation reportedly has a trophic effect on gut hypoplasia and on lamina
propria plasma cells that produce immunoglobulin A; it also improves overall gut
immunity.49–51 However, enteral glutamine supplementation appears not to affect
intestinal adaptation in animals.52
In humans, enteral glutamine improves body weight as well as fluid and electro-
lyte absorption when growth hormone is added.53 Long-chain triglycerides, espe-
cially arachidonic acid, stimulate intestinal adaptation, an effect related, in part, to
stimulation of ileal hormone release.54
15.2.5 Enteral Nutrition
The care of patients with SBS includes providing adequate fluid, along with macro-
and micronutrients, to prevent malnutrition and deficiency states and to circumvent
dehydration and acid-base disturbances. In children and adults, an initial period of
PN is warranted immediately after intestinal resection. Adults need about 25 to 35
kcal/kg/day and 1.0 to 1.5 kg/day of protein.6 Enteral nutrition should be started
as soon as possible, and then advanced, as tolerated, to a regular diet. In children
with SBS, continuous, steady administration of enteral nutrition is more likely to be
tolerated than bolus feeding.55 In adults with a stoma, eating an increased amount
may help maintain an adequate nutritional balance.56 In adults, protein absorption
has been shown to improve with a peptide-based diet, but no consensus exists on the
benefit of using elemental supplements.6 In infants, initial enteral feeds consist of
diluted elemental formula. The normal caloric density in infants is 0.67 kcal/ml, in
older children, 1 kcal/ml. Feed volume is increased as tolerated. Elemental formulas
are not necessary unless formula intolerance or allergy is evident. Semielemental
peptide-based formulas with a mixture of long-chain and short-chain fatty acids
can be used. Long-chain fatty acids (in particular, highly unsaturated fatty acids)
have a stimulatory effect on adaptation.54 Age-appropriate solid food should be the
eventual goal.
Diarrhea is often due to the osmotic load generated by malabsorbed simple

carbohydrates. A further osmotic load is created by bacterial action in the colon.
Continuous or small bolus feedings, therefore, enhance absorption. Replacing some
carbohydrate calories with medium-chain triglycerides may help patients with SBS,
especially infants. Small bowel bacterial overgrowth results from abnormal motility
and anatomic changes due to intestinal resection, loss of immune tissue, and loss of
the ileocecal valve. The consequences include deconjugation of bile acids, which
results in increased proximal absorption and in the lack of bile salts for micelle for-
mation and, therefore, leads to diarrhea, colitis and arthritis, D-lactic acidosis, and
competitive deficiency of B12, and other nutrients.57 The usual symptoms are bloat-
ing, cramping, diarrhea, and blood loss. The diagnosis is made through a culture
of duodenal fluid or a hydrogen breath test. Facultative and anaerobic bacteria are
typical. The usual treatment includes broad-spectrum antibiotics. Hypergastrinemia-
related fluid secretions may be reduced by histamine2 antagonists. Cholestyramine
for binding bile acids may be useful for diarrhea after ileal resection; however, after
major resection of the small intestine, it may cause further depletion of bile acids.
Other agents that can be of benefit include octreotide,58 and loperamide or diphenox-
ylate (which may reduce transit time, but, at the same time, may potentiate bacterial
overgrowth). Even when adequate macronutrient intake is maintained, micronu-
trient deficiencies can develop with either enteral nutrition or PN in patients with
SBS.6 Iron deficiency is common, although both macro- and microcytic anemia may
occur. Fat-soluble vitamin deficiency is a concern in patients who have steatorrhea
and problems with bile circulation. Jejunal stomas result in loss of electrolytes, par-
ticularly sodium and magnesium. Sodium replenishment is likely to be inadequate
with hypotonic electrolyte solutions.59 Patients with diarrhea are at risk for zinc and
selenium deficiency, in particular.60 Even with stomas for decompression, patients
with diffuse neuromuscular disease are repeatedly disabled by massive intestinal
dilatation and consequent fluid shifts. Dietary supplementation with soluble fiber
(in particular, pectin) could have an effect on gut adaptation, but the major benefit
of soluble fiber is increasing calories by conversion to short-chain fatty acids in the
colon.61 Careful monitoring, along with dietary restriction of oxalate, may be neces-
sary in symptomatic patients who have lost the ileum.
15.3 Liver Disease Related to PN

PN, a lifesaving treatment for patients with nutritional failure, was introduced into
clinical practice almost five decades ago.62 Short-term PN has few negative conse-
quences, but long-term PN is associated with liver and biliary tract disease, nutri-
tional deficiency, and central venous line complications. Liver disease develops in 40
to 60% of infants with intestinal failure on long-term PN and in 15 to 40% of adults
on home PN.9 The spectrum of disease ranges from gallbladder and biliary disorders
to cholestasis, hepatic steatosis and fibrosis, and end-stage liver disease. Once end-
stage liver disease is established, survival at one year is only 20 to 30%.63 Infants
typically develop cholestasis, steatosis is usual for adults. Cholelithiasis and biliary
sludging occur in both adults and children.9
15.3.1 Cholestasis
Cholestasis is the major effect of PN in infants; however, jaundice and hyperbiliru-
binemia are features of end-stage liver disease in adults and children on PN. Recent
data have confirmed that liver disease in patients on PN is strongly associated with
poor long-term survival; in a cohort study of 78 children with SBS, the survival rate
of patients with cholestasis (direct bilirubin concentration >2 mg/dL) was close to
20%, as compared with 80% in those without cholestasis.22 The mortality rate is
related to the inability to wean off PN.64 In premature infants (as compared with
full-term infants and adults), the bile salt pool is small, hepatic uptake and synthesis
of bile salts are poor, and ileal absorption is reduced.65 Not surprisingly, therefore,
cholestasis is associated with prematurity and low birth weight.66 A factor in the
development of cholestasis is conjugation of bile salts, which involves taurine in pre-
mature infants; sulfation is a more efficient way of solubilizing toxic bile salts, such
as lithocholic acid.67 Lithocholic acid, produced by intraluminal bacterial deconju-
gation of bile acids, is toxic, causing reduced bile flow with subsequent cholestasis,
gallstones, and bile duct proliferation.68 Recurrent sepsis is associated with cholesta-
sis; in fact, a bout of sepsis is often the initial event.69 This is compounded by bacte-
rial overgrowth and bacterial translocation.70 Also associated with the development
of cholestasis are a higher number of laparotomies, lipid emulsions, and the lack of,
or delayed, enteral feeding.9 The relationship between cholestasis and lipid emul-
sions has been described in both adults and children.71,72 A lipid infusion rate of >1
g/day has also been reported in adults on home TPN.72 The mechanism may include
macrophage activation caused by excess w-6 polyunsaturated fatty acids in com-
monly used solutions, leading to an accumulation of hepatic phospholipids and/or
phytosterols.72,73
15.3.2 Hepatic Steatosis
Hepatic steatosis, the accumulation of lipids, may occur for a number of reasons: an
excess of carbohydrate calories (> 8 to 12 mg/kg/d of glucose);74 excess lipid infu-
sions;75 deficiencies of essential fatty acids; deficiencies of choline, taurine, or gluta-
thione;76,77 or the creation of toxic hydroperoxidases from ultraviolet light.78 Steatosis
is reversible with appropriate reduction of calories.79
15.3.3 Risk Factors: Enteral Intake, Sepsis, and Constituents of PN

A total lack of enteral feeding is a risk factor for the development of cholesta-
sis; data indicate a reduction in gastrointestinal hormones in patients on PN who
are not able to feed enterally,80 resulting in intestinal and biliary dysfunction.81
Sepsis also plays a significant role in such patients.81 Intestinal stasis associated
with bacterial overgrowth and bacterial translocation may exacerbate cholesta-
sis especially in infants82 as well as increase the production of lithocholic acid.
Recurrent bacterial sepsis, regardless of the cause, contributes to liver disease
related to PN in patients with intestinal failure, especially SBS,83 and may lead
to progressive liver failure.84 Lack of stimulated cholecystokinin release can

cause biliary sludging.85 Fasting possibly reduces the size of the bile salt pool
and decreases bile formation, compounding the difficulties with gallbladder con-
tractility and sludge formation. Taurine or cysteine levels may be reduced by
enzymatic immaturity, especially in premature infants;86 however, adding taurine
does not affect PN-related liver disease.87 Alternatively, in adults with a choline
deficiency state, choline supplementation does result in reduced steatosis.88 Both
aluminum toxicity and chromium toxicity are well recognized in patients on PN,
but no evidence points to a causal effect in PN-related liver disease.89,90 The toxic
effect of manganese, which is excreted in bile, may be exacerbated in patients with
cholestasis. In a study by Fell et al.,91 high whole-blood manganese concentrations
correlated with liver enzyme levels and with the deaths of 4 of 11 children with
hypermanganesemia and cholestasis. Stopping or reducing manganese resulted in
improvement in nervous system findings and liver function.92 An excess in lipid
emulsions can be expected to lead to hepatic steatosis, hyperlipidemia, and throm-
bocytopenia.93 Removing lipid entirely from PN can have a very brief effect in
reducing bilirubin.94 Similarly, data in adults indicate that use of >1 g/kg/d of
lipid results in cholestasis.72 Mechanisms of injury include toxicity from the lipid
itself, from accumulation of phospholipids or phytosterols, and from inflamma-
tory cytokines.72,74,95
15.3.4 Biliary Sludge and Gallstones

Biliary sludge, gallbladder distention, and gallstones and acalculous cholecystitis are
well known in adults and children on long-term PN.9 Biliary sludge increases with
the duration of PN to 100% at 6 to 13 weeks,96 as does the incidence of gallstone
formation.86 Reduction in cholecystokinin stimulation may be contributory, although
other hormone abnormalities may also be significant.86,97 Endogenous release of
cholecystokinin through pulsed infusions of amino acids or by any rate of enteral
nutrition, helps to reduce cholestasis.98 Infusing cholecystokinin has a limited ben-
efit, and side effects may be bothersome.99
15.3.5 Clinical Features
Liver enzyme elevation may be episodic and related to sepsis, but it eventually
becomes persistent and progressively elevated.70 In 22 children evaluated for com-
bined liver and small intestinal transplantation, bilirubin concentration >12 mg/dL
predicted death from end-stage liver disease within six months in 11 of the chil-
dren.100 Similarly, 6 of 42 patients on home PN developed end-stage liver disease and
died within 10 months of the first bilirubin elevation.101 Overall, a poor prognosis is
associated with cholestatic liver disease in patients on PN.102 Isolated hepatic fibrosis
is also reported with PN, although portal hypertensive features are not prominent.103
In contrast to children, adults typically do not develop cholestasis early, unless they
have biliary or small intestinal obstruction.
15.3.6 Histology
Histopathologic changes in the liver include hepatic steatosis without additional liver
injury. Centrilobular cholestasis may be associated with portal inflammation, necro-
sis, and fatty infiltration that progresses to periportal fibrosis, bile ductular prolifera-
tion, and, eventually, bridging fibrosis. Biliary cirrhosis is a late development that
may be associated with death within six months.103
15.3.7 Clinical Management
Patients with intestinal failure on long-term PN need a dedicated team approach
to their care. In the absence of severe fibrosis, cessation of PN may resolve the
liver disease.104 Even a minimal amount of enteral feeding will improve liver and
biliary function.105 Controlling intake of macromolecules and micronutrients is
clearly important. If cholestasis is severe, restriction of lipid intake and a strat-
egy to alter omega-3 fatty acid levels can be considered, especially in infants with
severe cholestasis.106 Aggressively managing intravenous line sepsis107 and control-
ling bacterial overgrowth, thereby reducing bacterial translocation, are perhaps the
most vital components in preventing advancing disease.108 Adding glutamine has a
number of potential benefits (discussed above in Section 15.2.4). In rats, it reverses
the depression of hepatocyte mitochondrial metabolism seen with endotoxemia,
thereby curing sepsis.109 In premature infants, supplementation of PN with glu-
tamine has improved the time to full enteral feeding110 and reduced the incidence
of infection.111 Enteral administration of the yeast Saccharomyces boulardii has
been proposed to reduce bacterial translocation.112 Cycling PN may be helpful in
reducing its impact on liver disease.113 While the evidence is mixed on oral ursode-
oxycholic acid, it was associated with improved liver function tests in patients on
long-term PN.3
15.3.8 Nontransplant Outcome
In a 1975 to 2000 review from a North American academic center of the outcome of
children on PN for longer than three months, adaptation occurred in the first three
years in 77% of survivors.22 The long-term survival rate at five years on PN approxi-
mates 60%.2
15.3.9 Nontransplant Surgery for SBS

The most common surgical therapy for intestinal failure is the placement of feed-
ing devices. Some patients with SBS have a proximal small intestinal stoma even
when the distal small intestine or the colon is present, but not in continuity. Taking
down the stoma allows the intestinal contents to have maximal contact time with
the small and large intestine, improving nutrient, fluid, and electrolyte absorption.
Removing strictures and tapering dilated areas of intestine improve the function
of the small intestine by reducing dysmotility and the potential for bacterial over-
growth. Intestinal lengthening procedures take advantage of the intestinal dilation
that often occurs in the foreshortened remaining small intestine. Longitudinal

intestinal lengthening was described in 1980 by Bianchi et al. and has now been
used widely.114 The dilated segment of small intestine is symmetrically divided in
half longitudinally along the antimesenteric border. The blood flow is preserved by
separating the leaves of mesentery with either limb. The lumen is recreated by the
formation of two narrower channels, which are then reapproximated to each other
in a serial fashion. Results have been favorable.115 The serial transverse entero-
plasty procedure (STEP) was more recently described by Kim et al.116 It can also
be applied to a symmetrically dilated piece of small intestine. It requires no entero-
tomies and preserves intestinal vasculature. The procedure consists of applying a
surgical stapler along the intestine at a 90-degree angle to the mesentery, alternat-
ing sides so as to create a zigzag-shaped channel that is longer and narrower. The
recently created STEP registry reported an increase of 116% in enteral tolerance in
38 patients; nearly half were weaned off PN after a median follow-up time of about
a year.117
15.3.10 Isolated Liver Transplants for Intestinal Failure

An isolated liver transplant in children with SBS has enabled some of them to wean
off PN.118 This result suggests a suppressive effect of liver disease on the process of
adaptation. Alternatively, an isolated liver transplant may facilitate adaptation by
increasing the time available and negative effect of chronic liver disease on growth
in patients who would otherwise die of intestinal failure.
15.4 Intestinal Transplantation

An intestinal transplant (ITx) is a definitive treatment for patients with intestinal
failure. Recognized indications for an ITx in the United States include complications
of PN, particularly those related to central intravenous line infections and sepsis.119
Adults on PN can survive for prolonged periods if such complications are contained.
An ITx also may be considered for indications not related to intestinal failure, such
as a desmoid tumor. The overall mortality rate on the waiting list for intestinal trans-
plant candidates continues to be the highest of all abdominal organs: 25% for adults,
60% for children.120 Waiting time averages 7.7 months.2
15.4.1 Types of Grafts
The graft in any particular case can be adapted according to the indication for the
ITx, the recipient’s anatomy, and the function of the other abdominal organs. The
small intestine can be combined with the liver or with any of the abdominal viscera,
including the abdominal wall if necessary (according to the “cluster” concept origi-
nally proposed by Starzl et al.).121–122 An isolated ITx has two main variants: (1) if
the recipient’s abdominal cavity is normal in size (e.g., in case of intestinal pseudo-
obstruction), the superior mesenteric artery (SMA) and vein are used for grafting;
(2) if the recipient’s abdominal cavity is small (e.g., in SBS), the aorta and the vena
cava are used for grafting.123 For a combined liver and intestinal transplant (LITx),
separate organs are used for adult recipients, and a composite graft is typical for
small children.124,125 The multiviseral transplant (MVT) has two main variants: (1)
the “classic” procedure includes the liver, the stomach with duodenum, the pancreas,
and the small intestine; (2) the modified version excludes the liver, but includes the
stomach with duodenum, the pancreas, and the small intestine.126 If the MVT recipi-
ent’s abdominal domain is limited, the donor needs to be 50 to 75% of the recipient’s
size.127 Given the large number of small children who are prospective recipients,
size-matched organ availability is a problem.128 Using a larger donor is the clearest
option. Under these circumstances, alternatives for abdominal closure include reduc-
ing the recipient’s abdominal contents using nonbiologic or biologic mesh, acellu-
lar dermal matrix, human skin, a rotational flap, and/or a donor abdominal wall
graft implanted into the recipient’s iliac or epigastric vessels.129–132 In some MVT
recipients, the donor’s colon and spleen have been included with reasonable results.
The spleen has been included for technical considerations, the potential of splenic
function, and better tolerance.133 Inclusion of the spleen has been shown to reduce
intestinal rejection and to increase response to the pneumococcal vaccine without
an increase in the incidence of posttransplant lymphoproliferative disease (PTLD)
or graft-versus-host disease.134 The previous standard of using organs from deceased
but heart-beating donors has been expanded by successfully using deceased donors
who underwent prior resuscitation, whose blood group did not match the recipient’s,
who had a positive T-cell cross-match, and who were positive for cytomegalovirus
(CMV) even if their recipient was negative.135
Living donors have also been used successfully for ITx recipients. The technique,
now standard, as described by Gruessner et al.,136 entails using 120 to 150 cm of the
distal jejunum and ileum. The ileocecal valve and a segment of 20 cm of the distal
ileum are preserved in the donor to assure normal intestinal sufficiency after dona-
tion.137 Hence, the arterial supply chosen for the graft is the terminal segment of the
SMA distal to the takeoff of the ileocecal branch. Computed tomography scans with
three-dimensional reconstruction and/or angiography are necessary to accurately
evaluate the vasculature and, in particular, the size of the artery. The first living
donor LITx involved a sensitized two-year-old recipient. A sequential transplant first
used the left lateral segment of the liver from the mother and then the ileal graft,
also from the mother, a week later. The outcome was described as good for both the
child and the mother.138 Few such cases have been done overall. The advantage of
this technique is that it allows time for desensitization.
15.4.2 Patient and Graft Outcome

The most recent estimates suggest a survival rate of 90% in ITx recipients in cen-
ters with the greatest experience.2 The long-term graft survival rate has remained
about 60%; the graft survival rate abruptly worsens in pediatric patients after three
years posttransplant.139 Early deaths are mainly from sepsis (40 to 50%) and rejection
(10%).140 Later deaths are also frequently caused by sepsis and rejection, along with
PTLD (6 to 8%, with a peak incidence at two years posttransplant).141 The outcome
of PTLD has improved with rituximab.142
15.4.3 Nutrition
Most patients (>90%) wean off PN after their ITx.143 Patients are started on PN, then
gradually transitioned to enteral feedings. Lymphatic interruption is the rule in ITx
recipients; however, chylous ascites is rare. Lipids are gradually initiated four to six
weeks after the introduction of a diet. Steatorrhea is usually not a problem. PN is dis-
continued once 50% of the caloric intake is enteral. Some prefer to use an elemental
diet for the first few weeks posttransplant, others have used more liberal protocol
without problems.144 Stoma fluid output is slowed with medication when necessary.
15.4.4 Maintenance Immunosuppression and Rejection

Induction therapy (with IL-2 receptor blockade and/or antilymphocyte or antithymo-
cyte globulin) has resulted in improved graft and patient survival rates in the first
year posttransplant; induction agents are now included in some combination in most
regimens, along with steroids.2,145 Tacrolimus is standard for maintenance immu-
nosuppression, allowing many recipients to wean off steroids; sirolimus has been
used in combination with tacrolimus to prevent severe rejection.146 Notably, alem-
tuzumab has been reduced to only very limited use in children because of a high
rate of side effects.147 In ITx recipients, small intestinal graft acute cellular rejec-
tion (ACR) occurs more frequently and is more severe, as compared with any other
abdominal organ probably related to the amount of transplanted lymphoid tissue.147
Historically, a third of ITx recipients did not experience acute rejection; MVT recipi-
ents, particularly children.148 With newer regimens, ACR is now reported to affect
only a third of ITx and MVT recipients.2 Graft loss occurs from severe intractable
ACR; chronic allograft dysfunction can occur with repeated episodes of less severe
rejection. Subclinical rejection (SCR) has been described; predominantly reported in
adults, SCR significantly affects graft and patient survival rates at five years.149 Graft
survival is reduced in recipients showing early vascular lesions. Although acute vas-
cular rejection (AVR) is not well defined, it is related to panel-reactive antibodies
(PRAs) and to positive T-cell and B-cell cross-matches.150 Antirejection therapy for
refractory AVR includes OKT3 or thymoglobulin. Antiinflammatory monoclonal
antibodies (mAbs) against tumor necrosis factor (TNF)-α have been shown to be
effective for acute rejection and may be useful for chronic enteropathy,151 similar
to the results with alemtuzumab.152 Ultimately, chronic graft loss due to vascular
changes cannot be adequately treated and is responsible for the poor long-term out-
come in most ITx recipients. A recent finding is that mutations in the gene coding for
nucleotide-binding oligomerization domain containing two (NOD2) mutations that
are typically associated with Crohn’s disease, may have a role in rejection.153
15.4.5 Cost and Quality of Life

A poor quality of life (QoL) with associated neuropsychological complications
is typical of patients with intestinal failure on PN. QoL is improved in trans-
plant patients.2 A recent review concluded that, because of the limited number
of studies and the preliminary nature of findings, strong conclusions cannot yet
be drawn regarding QoL in ITx recipients; however, the available limited data
were judged as encouraging.154 The cost of a transplant involving the small intes-
tine has been examined in North America and Europe and is roughly similar.2
An ITx is cost-effective as early as two years posttransplant, as compared with
continued PN.155
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16 Nutrition in Acute
Pancreatitis
Rémy F. Meier and Robert Martindale
Contents
16.1 Introduction................................................................................................... 253
16.2 Outcome Predictors....................................................................................... 254
16.2.1 Nutritional Status............................................................................... 254
16.2.2 Assessment of the Severity of Acute Pancreatitis............................. 255
16.3 Artificial Nutrition in Acute Pancreatitis...................................................... 256
16.3.1 Substrate Metabolism during Acute Pancreatitis.............................. 256
16.3.1.1 Metabolism of Carbohydrates............................................. 256
16.3.1.2 Protein Metabolism............................................................. 257
16.3.1.3 Lipid Metabolism................................................................ 257
16.3.2 Exocrine Pancreatic Stimulation by Macronutrients....................... 257
16.3.3 Total Parenteral Nutrition or Enteral Nutrition?.............................. 258
16.3.4 Energy Requirements.......................................................................260
16.4 Clinical Approach for Nutritional Support in Acute Pancreatitis................260
16.4.1 Nutritional Support in Mild to Moderate Pancreatitis..................... 261
16.4.2 Nutritional Support in Severe Acute Pancreatitis............................ 262
16.4.2.1 Route of Feeding............................................................... 262
16.4.2.2 Choice of Optimal Formula.............................................. 263
16.4.2.3 Oral Refeeding..................................................................264
16.5 Nutritional Support in Patients with Pancreatic Surgery............................. 265
16.6 Summary...................................................................................................... 265
References...............................................................................................................266
16.1 Introduction
Acute pancreatitis can be a life-threatening inflammatory disease with an incidence
of about 50 to 80 cases per 100,000 population per year.1,2
The clinical patterns of acute pancreatitis varies from mild disease to severe
necrotizing pancreatitis with local and/or systemic complications. Classifying acute
pancreatitis by the Atlanta criteria (definition of severity) of 1992, approximately 80%
of patients will have a mild, self-limited disease with a mortality rate below 1%.3,4
The morbidity and mortality increases up to 50% if the disease progresses to severe
necrotizing pancreatitis and can further increase up to 80% if sepsis occurs.5,6
253
Severe acute pancreatitis is usually accompanied by systemic inflammatory

response syndrome (SIRS), which results in hypermetabolism and significant pro-
tein catabolism. These patients often develop nutritional deficiencies during the pro-
longed and complicated course of the disease. This prolonged caloric and nutrient
deficit can have fatal consequences especially in patients malnourished at the time
of the initial episode of pancreatitis.7
Until recently, use of the gastrointestinal (GI) tract to deliver nutrients during
an episode of pancreatitis has been relatively contraindicated as it was thought to
further stimulate the exocrine pancreatic secretion and the exacerbation of autodi-
gestive processes. These concerns were the basis of placing patients on bowel rest
and using intravenous nutritional support to bypass the stimulatory effect of oral or
enteral nutrition until the patients recovered.
There is still an ongoing debate on the optimal nutritional support in patients with
acute pancreatitis, but today, nutritional support is guided by the nutritional status of
the patients, the severity of the disease, and the tolerance to enteral nutrition.
16.2 Outcome Predictors
There is evidence that not all patients need specific nutritional support.8 In
uncomplicated mild attacks, most patients recover rapidly and can start eating
after a few days. Whether this is true for patients with preexisting malnutrition
is not known.
Two main factors predict the outcome of acute pancreatitis: the nutritional status
and the severity of the disease.
16.2.1 Nutritional Status
Malnutrition is a common problem in patients with acute pancreatitis. It has been
estimated that 50 to 80% of chronic alcoholics are malnourished.7 Protein calo-
rie malnutrition can arise or worsen during the pancreatitis episode secondary to
depletion of nutrients and the hypermetabolic state. In mild acute pancreatitis, the
clinical course is usually uncomplicated. This form of acute pancreatitis has little
impact on the nutritional status or on energy and substrate metabolism. Patients
with severe acute necrotizing pancreatitis are hypermetabolic. Energy expenditure
and protein catabolism is increased. Pain and inflammatory response modulated by
numerous proinflammatory cytokines initiated by the autodigestive processes are
involved. The inflammatory process results in a significant increased energy expen-
diture.9 Patients with severe pancreatitis often have a nonsuppressible gluconeogen-
esis despite sufficient caloric intake, increased ureagenesis, and an accentuated net
protein catabolism, which can be as high as 40 g nitrogen/day.9,10 Exogenous glucose
supply cannot completely inhibit intrinsic gluconeogenesis and the status of acute
catabolism. Generally speaking, the increased metabolic demand increases linearly
with the severity of pancreatitis. Despite this, resting energy expenditure in these
patients can be 77 to 158% of what is predicted.11 In severe acute pancreatitis, the
Harris–Benedict equation is not sensitive enough to estimate caloric expenditure
and indirect calorimetry is recommended to avoid over- or underfeeding. If energy
Nutrition in Acute Pancreatitis 255
expenditure is measured daily by indirect calorimetry, the values show a wide range
according to the severity of acute pancreatitis.11 If sepsis develops, 80% of patients
have an elevation in protein catabolism with an increased nutrient requirement.9,10
Protein catabolism and proteolysis of skeletal muscle increases by 80% (compared
to healthy controls). The plasma levels of aromatic amino acids increase and the level
of branched chain amino acids decrease. Negative nitrogen balance has an impact
on the nutritional status and the clinical outcome. Sitzmann et al. reported a tenfold
increased mortality rate when the nitrogen balance was negative compared to those
patients with a positive balance.12 It is not clear whether negative nitrogen balance
is the principle factor that determines outcome. The relationship between nitrogen
balance and the outcome may only reflect the association between nitrogen balance
and the severity of the disease as none of the studies were stratified according to the
disease severity.13
In clinical practice, therefore, it is crucial to assess the severity of the disease and
to implement an optimal nutritional support in these patients to avoid severe nutri-
tional depletion.
16.2.2 Assessment of the Severity of Acute Pancreatitis

Several scoring systems, clinical, laboratory, and radiological criteria are available
to predict the course of this disease.14–20
The Atlanta classification for severity defines severe acute pancreatitis on the
basis of standard clinical manifestation: a score of three or more Ranson criteria or
a score of eight or more APACHE II criteria, and the evidence of organ failure and
intrapancreatic pathological findings (necrosis or interstitial pancreatitis).3
The Balthazar score predicts severity based on computerized tomography (CT)
appearance, including presence or absence of pancreatic necrosis. Failure of pan-
creatic parenchyma to enhance during the arterial phase of intravenous, contrast-
enhanced CT indicates necrosis, which predicts the severity of the pancreatitis if
more than 50% of the gland is involved.17 Mortele and colleagues modified the CT
severity index. Extrapancreatic complications, such as vascular or gastrointestinal
tract involvement, were included in this modified score and the assessment of the
extent of pancreatic necrosis was simplified.21 It is generally recommended that a
CT study should be performed with the aim of staging the severity of acute pan-
creatitis not earlier than 48 to 72 hours of the onset of symptoms. This time frame
allows adequate time for the pancreatic necrosis to develop and increases the accu-
racy of prediction.
Other markers, such as concentration of serum C-reactive protein (CRP) or uri-
nary trypsinogen activation peptide (TAP), are useful in clinical practice. CRP is the
most widely used marker for inflammatory diseases. In acute pancreatitis, it reaches
its peak serum concentration between 72 to 96 hours after symptom onset. There is
general agreement that a cut-off level of 150 mg/l within the first 48 hours of onset
of symptoms indicates acute necrotizing pancreatitis with a high specificity of >80%
and an accuracy of 86%.22–26 CRP is a useful marker to predict severity, but has
limitations to detect infected necrosis. Procalcitonin seems to be a more suitable
marker for detection of pancreatic infections.27,28 The specificity is influenced by the
fact that it also can be increased by other severe extrapancreatic infections. Urinary
TAP, which is released during activation of trypsinogen to trypsin, has shown to
accurately predict severity of acute pancreatitis 24 hours after onset. Urinary TAP is
suggested to be used as a single marker for severity assessment, but it is still not used
as a routine test today.19 The sepsis-related organ failure assessment (SOFA) was also
proposed to predict mortality. Mortality is higher if the SOFA score is >3.20
16.3 Artificial Nutrition in Acute Pancreatitis

Pancreatitis patients in the past were either fasted or the nutrients were given by
the parenteral route supporting the concept of the day when it was felt the pancreas
should be “rested” during inflammation. Oral or enteral nutrition was believed
to have a negative impact on the progression of the disease due to stimulation of
exocrine pancreatic secretion and the consequent worsening of the autodigestive
processes. Oral feeding is also known to increase abdominal pain in patients with
acute pancreatitis.
In the past 20 years, the opinion dramatically changed. Patients with mild
to moderate acute pancreatitis can usually start with an oral diet within a few
days of onset if their pain and the pancreatic enzymes return to normal. In this
population of mild to moderate pancreatitis, there is no benefit from early enteral
or total parenteral nutrition (TPN).8 However, this is not the case in patients
with severe acute pancreatitis, where adequate enteral or TPN has been shown
to improve outcome.8 The nutritional management has shifted from parenteral to
enteral feeding. Enteral feeding can reduce catabolism and the loss of lean body
mass. In addition, enteral feeding may modulate the acute phase response and
preserve visceral protein metabolism with the potential to downregulate splanch-
nic cytokine response.29
16.3.1 Substrate Metabolism during Acute Pancreatitis

During acute pancreatitis, as in other patients with critical illness, the metabolism of
the macronutrients can be altered.
16.3.1.1 Metabolism of Carbohydrates
Glucose metabolism in acute pancreatitis is determined by an increase in energy
demand. Endogenous gluconeogenesis is increased as a consequence of the meta-
bolic response to the severe inflammatory process. Glucose is an important source of
energy and can only partially counteract the intrinsic gluconeogenesis from protein
degradation. This can influence, to a certain degree, the deleterious and unwanted
effect of protein catabolism.30 During hypermetabolism, the maximum rate of glu-
cose oxidation is approximately 4 mg/kg/min. The administration of glucose in
excess can be harmful because of lipogenesis and glucose recycling. Furthermore,
hyperglycemia and hyperkapnia can occur. Hyperglycemia is a major risk factor
for infections and metabolic complications. Monitoring and blood glucose control,
therefore, is essential.
16.3.1.2 Protein Metabolism

A negative nitrogen balance is often seen in severe acute pancreatitis. The protein
losses and the muscle wasting should be minimized and the increased protein turn-
over must be compensated. Therefore, a protein supply of at least 1.2 to 1.5 g/kg/
BW/d is highly recommended.
16.3.1.3 Lipid Metabolism
Hyperlipidemia is a common finding in acute pancreatitis. Increases in cholesterol
and free fatty acid serum concentrations also have been reported. The mechanism
associated with the changes in lipid metabolism is not entirely clear. Both altered
lipid oxidation and lipid clearance may play a role. In the majority of cases develop-
ing hyperlipidemia following an acute episode of pancreatitis, serum lipid concen-
tration returns to normal. It is also well reported that in some patients with severe
hyperlipidemia acute pancreatitis can develop.31 Several mechanisms have been
described to explain the adverse influence of hyperlipidemia on the pancreas, but no
single mechanism has been supported by significant scientific data.32,33
16.3.2 Exocrine Pancreatic Stimulation by Macronutrients

For nutritional intervention, the administration of glucose, protein, and fat are neces-
sary; historically, enteral applications were considered to be harmful because of the
potential stimulation of the exocrine pancreatic enzyme secretion.
Enteral glucose perfusion into the jejunum is a very weak stimulus for exocrine
pancreatic secretory response. Jejunal perfusion of elemental diets containing
defined amounts of protein or amino acids are well tolerated and do not stimulate
exocrine pancreatic secretion.34,35 Vu et al. studied the nutrient induced activation of
pancreatic secretion in healthy volunteers.36 They found no significant increase over
basal duodenal outputs of pancreatic enzymes during the continuous administration
of a mixed liquid meal when the tube was located 60 cm distal to the ligament of
Treitz. These findings were confirmed by Kaushik et al. in a study of 36 healthy vol-
unteers.37 This group compared fasting, duodenal, jejunal, and intravenous nutrient
delivery and reported that duodenal delivery stimulated trypsin secretion, whereas
fasting, midjejunal, and intravenous feeding did not. These data are in contrast with
another study by O’Keefe et al.38 They studied the stimulatory effects of enteral or
parenteral feeding on the synthesis and turnover of trypsin. Thirty healthy volunteers
were studied during fasting, intravenous feeding, postpyloric enteral feeding into
the duodenum (polymeric or elemental diet), and into the jejunum (elemental diet).
Compared to fasting, enteral feeding increased the rate of appearance and secre-
tion of newly labeled trypsin and expanded zymogen stores. These differences per-
sisted whether the feedings were polymeric or elemental, duodenal, or jejunal. Only
intravenous feeding had no effect on the trypsin synthesis and turnover. Whether
these findings in healthy volunteers can be extrapolated to patients with severe acute
pancreatitis is still not entirely clear. There is evidence that the secretion of pan-
creatic enzymes, especially trypsin and lipase, is decreased in patients with acute
pancreatitis. This disease-induced alteration of pancreatic function would be another
explanation for the observation that enteral feeding is well tolerated in patients with
acute pancreatitis.
The stimulation of the exocrine pancreatic secretion by enteral administration of
lipids depends on the anatomic side of administration. If the lipids are delivered into
the distal jejunum, no stimulation of the exocrine pancreatic secretion occurs.36 In
addition, no negative side effects were reported in patients fed with lipid-containing
diets by the jejunal route during a severe acute attack of pancreatitis.8
As discussed above in this section, intravenous administration of macronutrients
(glucose, amino acids, and lipids) does not stimulate exocrine pancreatic function
and appears safe in pancreatitis.39,40 The main risk of intravenous glucose in acute
pancreatitis is hyperglycemia. Hyperglycemia also can be aggravated by the insulin
resistance, which is well described in critical ill patients.
All these findings have changed the nutritional concept in acute pancreatitis. In
current critical care settings, enteral feeding in the jejunum is regarded to be safe and
effective without major stimulation of autodigestive processes. Enteral nutritional
support has now been shown to be important in maintaining the gut integrity by
modulating the gastrointestinal tract systemic immunity.
16.3.3 Total Parenteral Nutrition or Enteral Nutrition?

Traditionally, TPN was used to avoid stimulation of the exocrine pancreatic secre-
tion. In mild to moderate pancreatitis, two prospective studies comparing TPN with
a naso-jejunal feeding regimen41 or no nutritional support42 showed no difference in
outcome. However, TPN was more expensive41 or was accompanied by an increase
in catheter-related infections and longer hospital stay.42 Furthermore, TPN was asso-
ciated with more hyperglycemia and other metabolic disturbances. In the past 10
years, it has become clear that these complications were often the consequence of
overfeeding and hyperglycemia.43 In 2001, van den Berge et al. showed, irrespective
of the route of nutritional support, that the control of hyperglycemia with insulin
reduced mortality in critical ill patients.44
Several studies in patients with trauma, thermal injury, and major gastrointestinal
surgery showed a reduction in septic complication with enteral feeding.45,46 Enteral
nutrition helps to maintain mucosal function and limits the absorption of endotoxin
and cytokines from the gut.47,48 In animals with experimentally induced pancreatitis,
enteral nutrition prevents bacteria translocation.49 Whether bacterial translocation
is of clinical evidence in patients with acute pancreatitis is still unclear.50 Following
roughly 20 years in which TPN was considered the standard nutritional support in
severe acute pancreatitis, enteral nutrition was introduced and is now the standard of
care in the management of severe acute pancreatitis. Several prospective, random-
ized clinical trials have been performed comparing enteral with parenteral nutrition
in patients with acute pancreatitis. In the first prospective study by McClave et al.,
patients with mild to moderate acute pancreatitis were randomized to either total
parenteral nutrition or to total enteral nutrition via a naso-jejunal tube.41 Both groups
received an isocaloric, isonitrogenious enteral solution within 48 hours of admis-
sion to the hospital. The outcome in both groups revealed no statistical differences
in infectious complications, length of intensive care unit stay, and length of hospital
stay or days to oral food intake. In the TPN group, a significantly higher glucose
concentration in the first five days was found. The caloric goal was reached in 82%
of the patients with enteral feeding compared to 96% of patients with TPN.41 A
second prospective, randomized study compared either a naso-jejunal tube feeding
with a semielemental diet or TPN within 48 hours of admissions in patients with
severe necrotizing acute pancreatitis.51 Enteral feeding was well tolerated without
adverse effects on the course of the disease, but patients who received enteral feed-
ing experienced fewer septic complications and fewer total complications compared
to those receiving parenteral nutrition. Furthermore, the costs of nutritional sup-
port were three times higher in the patients receiving TPN. This study showed that,
in severe acute pancreatitis, enteral nutrition support was beneficial compared to
patients with mild or moderate pancreatitis.41 These findings are supported by two
other studies. Windsor et al.52 compared parenteral nutrition with enteral nutrition in
patients with acute pancreatitis with all levels of severity. This study demonstrated
that enteral nutrition attenuates the acute phase response in pancreatitis, improves
disease severity and clinical outcome, despite the fact that the pancreatic injuries
were virtually unchanged on a CT scan. In the enteral feeding group, SIRS and
sepsis were reduced, resulting in a beneficial clinical outcome (APACHE II-score
and C-reactive protein). In this study, unfortunately, only a few patients had severe
pancreatitis and the total amount of nutrient received revealed marked differences
between the enteral and the parenteral group. Unfortunately, these positive results
of the Windsor study could not be confirmed by Powell et al. on the inflammatory
response in patients with prognostically severe acute pancreatitis.53
Abou-Assi et al. selected 156 patients with acute pancreatitis over a one-year
period.54 During the first 48 hours, all the patients were treated with intravenous
(i.v.) fluid and analgesics. In this study, 87% of patients had mild, 10% moderate,
and 3% severe disease. Those patients who improved during this first 48-hour period
were fed orally. The nonresponders were randomized to receive nutrients either by
a naso-jejunal tube or by TPN. Seventy-five percent of the initially enrolled patients
improved with the oral regimen and were discharged within four days; 54% of the
enteral group (n = 26) and 88% of the TPN group (n = 27) received inadequate
energy intake. The patients in the enteral group were fed for a significantly shorter
period (mean 6.7 days versus 10.8 days [TPN]), and had significantly fewer meta-
bolic and septic complications. Hyperglycemia requiring insulin therapy was sig-
nificantly higher in the parenteral fed patients. Despite fewer complications in the
enteral group, the mortality was similar in the two groups. The authors concluded
that hypocaloric enteral feeding is safer and less expensive than parenteral feeding
and bowel rest in patients with acute pancreatitis.
Today, there is no doubt that enteral nutrition should be the first attempt to feed
patients with severe acute pancreatitis. The first meta-analysis from McClave et al.
showed that the use of enteral nutrition was associated with a significant reduction
in infectious morbidity, a reduction of hospital length of stay, and a trend toward
reduced organ failure when compared with the use of parenteral nutrition. There
was no effect on mortality.55 Compared to this meta-analysis, a new systemic review
showed a reduction in mortality using enteral nutrition when only patients with
severe acute pancreatitis were included.56 This report emphasizes that the greater the
severity of the disease, the greater is the benefit of the enteral nutrition.
16.3.4 Energy Requirements
For enteral or parenteral nutrition, 25 to 35 kcal/kg/BW/d is recommended.8
Overfeeding and hyperglycemia should be avoided. Blood glucose concentration
should not exceed 10 mmol/l (180mg/dl). Insulin treatment is recommended, but the
dose should not be higher than 4 to 6 units/h. The impaired glucose oxidation rate
cannot be normalized by insulin administration. Normally, 3 to 6 g/kg/BW/d of car-
bohydrates can be recommended. The optimal goal of protein supply is between 1.2
to 1.5 g/kg/BW/d. Lower protein intake should only be given to patients with renal or
severe hepatic failure. Fat can be given up to 2 g/kg/BW/d, but triglyceride levels must
be carefully monitored. Triglycerides are tolerated up to 12 mmol/l (1068 mg/dl).8
In general, the nutrient recommendations are easier to reach with TPN than
with enteral nutrition as intolerance is not an issue. Enteral solution contains fixed
amounts of the macronutrients. The enteral intake of the different nutrients only can
be regulated by changing the rate of delivery. Current recommendations support
continuous jejunal feeding in severe acute pancreatitis.8,57
16.4 Clinical Approach for Nutritional

Support in Acute Pancreatitis
If the patient meets criteria for supplemental enteral nutrition support, continuous
jejunal feeding would be the first choice. Four prospective studies have shown that
jejunal delivery is possible in most patients with acute pancreatitis.41,58–60 Rarely,
proximal migration of the feeding tube and the subsequent pancreatic stimulation
has been reported to aggravate acute pancreatitis.61 If the jejunal tube cannot be
placed blindly at the bedside or with the aid of fluoroscopy, adequate endoscopic
placement is usually feasible. A new approach was recently introduced by using a
self-propelling naso-jejunal feeding tube. The tube was introduced into the stomach,
and gastrointestinal motility was stimulated by metoclopramide. In 56 of 92 patients,
the tube successfully migrated to the ligament of Treitz. Of the 36 patients with an
initial failed placement, endoscopic placement of the tube was successful in 80%.62
Although tube feeding appears to be possible in most prospective trials, in more
general studies, dealing with larger patient populations including all treated patients,
this was not the case. Oleynikov et al. reported that tube feeding was not possible in
most (25 out of 26) patients with severe acute pancreatitis (mean APACHE II-score
17.2 and mean Ranson score 4.3 on admission). This inability to successfully feed
was thought to be secondary to severe retroperitoneal inflammatory changes.63 On the
other hand, tube feeding is possible in the presence of ascites and pancreatic fistulas.
Therefore, parenteral nutrition is indicated when side effects during tube feed-
ing occur or the caloric goal cannot be reached. If parenteral nutrition is started, it
also would be useful to combine it with small volumes of enteral feeds if tolerated.
There is substantial evidence that enteral feeding in severe acute pancreatitis can
downregulate the systemic inflammatory response and promote beneficial effects on

gastrointestinal functions. The impaired gut motility may facilitate the colonization
of the intestine with pathogenic bacteria and may contribute to bacterial transloca-
tion in the intestinal wall, with subsequent superinfection of the pancreatic necrosis.
For this reason, if possible, a low volume of enteral feeding continuously perfused
to the jejunum is recommended to supplement TPN when full enteral nutrition is not
possible (e.g., prolonged paralytic ileus).8
16.4.1 Nutritional Support in Mild to Moderate Pancreatitis

There is no evidence that the nutritional support (enteral or parenteral) has a benefi-
cial effect on outcome in patients with mild pancreatitis.8 Enteral nutrition is unnec-
essary, if the patients can consume normal food within five to seven days of onset of
the pancreatitis episode (ESPEN guidelines: grade B).8 Enteral or parenteral nutri-
tion within five to seven days has no positive effect on the course of the disease and,
therefore, is not recommended (ESPEN guidelines: grade A).8 Early enteral nutri-
tional support can be of importance in patients with preexisting severe malnutrition
or in patients when early refeeding in five to seven days is not possible. Figure 16.1
shows a frequently used approach for these patients.
Assessment of severity of acute pancreatitis
mild to moderate
fasting (2–5 days)

• analgesics
• i.v. fluid/electrolytes
no pain, enzymes
refeeding (3–7 days)

• diet rich in CH
• diet moderate in
protein/fat
normal diet
Figure 16.1 Management for mild to moderate acute pancreatitis.

16.4.2 Nutritional Support in Severe Acute Pancreatitis

In patients with severe pancreatitis, who have complications or need for surgery,
early nutritional support is necessary to prevent the adverse effect of nutrient depri-
vation. In severe necrotizing pancreatitis, continuous early enteral nutrition over 24
hours is indicated as soon as possible (ESPEN Guidelines: Grade A).8,57 Early enteral
nutrition has been shown in many studies to be safe and well tolerated. In patients
with severe necrotizing pancreatitis, intolerance to the enteral feeding commonly
limits delivery of full nutrient requirements. If complete enteral nutrition is not pos-
sible, the enteral nutritional support should be supplemented with parenteral nutri-
tion to meet caloric goals. Usually, the combined nutritional support allows that the
patient reach the nutritional goals. The administration of lipids in parenteral nutri-
tion can be regarded as safe, if hypertriglyceridemia (<12 mmol/l [1068 mg/dl]) is
avoided.8 A practical approach for nutrition in severe acute pancreatitis is outlined
in Figure 16.2.
16.4.2.1 Route of Feeding
The route of nutrient delivery (parenteral/enteral) should be determined by patients’
tolerance. Tube feeding is possible in the majority of patients, but some patients
need a combination with parenteral nutrition (ESPEN Guideline: Grade A).8 Placing
Assessment of severity of acute

pancreatitis
severe
early continuous enteral nutrition enteral nutrition is

(naso-jejunal tube) not possible
• elemental diet or
• polymeric diet or
• immune-enhancing diet
• TPN
and
• continuous small amount
nutritional goal not reached
of an enteral diet
(10-30 ml/h) infused into
the jejunum
add parenteral nutrition

• all in one or
single component solutions
(CH, protein [amino acids], fat)
Figure 16.2 Management for severe pancreatitis.

a jejunal feeding tube distally to the ligament of Treitz can be performed safely
and consistently. Several single or multilumen tubes are available. The tubes can
be placed either with fluoroscopic help, using self-propelling tubes, or with the
endoscope. Partial ileus is not a contraindication for enteral feeding because these
patients frequently tolerate continuous low-volume jejunal nutrients. If surgery is
required in pancreatitis, an intraoperative naso-jejunal tube can be directly placed
into the jejunum by the surgeon by manipulating the tube passed into the stomach by
the anesthesia provider, around the C-loop of the duodenum to the jejunum. A surgi-
cal jejunostomy for postoperative tube feeding is also feasible.64
Whether the jejunal feeding is absolutely necessary is not completely clear.
Minimizing stimulation of the exocrine pancreatic secretion would support the
jejunal feeding route. It is, however, controversial whether stimulation of pancreatic
secretion is important for the outcome in this disease. Recently, two randomized
studies comparing naso-gastric versus naso-jejunal feeding in severe acute pan-
creatitis were published.65,66 In these studies, naso-gastric feeding was as safe as
naso-jejunal feeding; little difference was documented between the two methods
with respect to pain, analgesic requirements, serum CRP concentration, or clinical
outcome. Also here, no clear recommendation can be given. If a multilumen tube is
used for tube feeding, feeding through the gastric port can be initially attempted. If
this is not possible, one can then switch to the jejunal port. More clinical trials using
such concepts are warranted.
16.4.2.2 Choice of Optimal Formula

Most studies have been done using semielemental or peptide-based formulae. The
use of peptide-based formulae showed beneficial effects (ESPEN Guidelines: Grade
A).8 Nowadays, in most institutions, polymeric formulae are used. A direct compari-
son of a peptide-based formula with the polymeric formula showed that there was no
difference on outcome.67 Today, it is common to start with a standard polymeric for-
mula and, if this is not tolerated, a peptide-based formula is tried. Several published
trials also used formulae containing immune-modulating substrates (glutamine,
arginine, n-3 polyunsaturated fatty acids) or pre- and probiotics.57 No specific for-
mula can be recommended for pancreatitis as inadequate comparative studies have
been done. The concept of using pre- and probiotics to prevent intestinal bacterial
translocation is very attractive. Two studies by Oláh et al. examined the efficacy of
enteral administration of probiotics in patients with severe acute pancreatitis.68,69 In
the first study, 22 patients received live lactobacillus plantarum and oat fiber, and
23 patients, the same formulation with heat-killed bacteria. In the group with live
bacteria, they found fewer positive cultures (p = 0.23), reduced need for antibiotics,
and a reduction in pancreatic infections requiring surgical intervention (p = 0.046).
Furthermore, the length of hospital stay was shorter (13.7 days versus 21.4 days).68 In
the second study, 62 patients with acute pancreatitis who were fed with a naso-jeju-
nal tube and randomized to receive enteral nutrition with fiber (29 patients) or enteral
nutrition with fiber and a combination of four different lactobacilli (34 patients). The
probiotic group again had significantly lower complication rates (p = 0.049) and the
control group had higher rates of multiorgan failure, pancreatic septic complications,
surgical intervention, and mortality.69
These observations were exciting until the large multicenter controlled trial by
Besselink et al. was published.70 They randomized 298 patients with severe acute
pancreatitis with either a combination six probiotics (four strains lactobacilli and
two strains bifidobacteria) or placebo. A multifiber enteral solution was given in both
groups by a naso-jejunal tube. There were no differences in infectious complications
between the probiotic and placebo group (30% versus 28%). Unfortunately, mortal-
ity was significantly higher in the probiotic group (16% versus 6%). Nine patients
in the probiotic group developed bowel ischemia. At the moment, it is not clear if
these complications are due to the combination of probiotics administered to the
gut or if other underlying factors played a role and the two groups cannot be fully
compared. Organ failure during admission was more common in the probiotic group
than in the placebo group (27.0% versus 16.0%; p = 0.02). Intestinal ischemia also
can be found more often during vasopressor treatment. In the probiotic group, more
patients received vasopressor drugs than in the placebo group. This could be another
explanation for the developing of bowel ischemia. In the Besselink study, no adverse
events were shown in the group receiving only prebiotics. This is in line with a
new study published by Karakan et al.71 They found that naso-jejunal enteral nutri-
tion with prebiotic fiber supplementation in patients with severe acute pancreatitis
reduced hospital stay, duration of nutrition therapy, acute phase response, and overall
complications compared to standard enteral nutrition. For the moment, probiotics in
severe acute pancreatitis cannot be recommended until more trials have shown that
pobiotics are effective and safe.
Several studies were done by supplementation of TPN with n-3 polyunsaturated
fatty acids or glutamine. Wang et al. found that patients treated with n-3 polyun-
saturated fatty acids had significantly higher eicosapentaenoic acid (EPA) plasma
concentrations, lower CRP levels, and better oxygenation index after five days of
TPN than the control group. In addition, the number of days of continuous renal
replacement therapy was significantly decreased.72 All of the glutamine studies
demonstrated beneficial effects.8,55 This was recently confirmed by the study from
Fuentes-Orozco et al.73 The group with glutamine supplementation had a significant
increase in serum IL-10 levels, total lymphocyte and lymphocyte subpopulations
counts, and albumin serum levels. Nitrogen balance improved to positive levels in
the study group and remained negative in the control group. Infectious morbidity
was more frequent in the control group. The duration of hospital stay and the mortal-
ity were similar between the two groups. It appears from this early work that in the
future adding n-3 polyunsaturated fatty acids and/or glutamine to parenteral nutri-
tion in patients with severe acute pancreatitis may prove beneficial.
16.4.2.3 Oral Refeeding
There are only few data available on oral refeeding. Oral feeding with normal
food and/or oral supplements can be progressively attempted once gastric outlet
obstruction has resolved, provided it does not result in pain, and if complications
are under control. Tube feeding can be gradually withdrawn as intake improves.
Currently, there are only two studies investigating oral refeeding.74,75 In the study
of Lévy et al., 21% of patients experienced a pain relapse on the first and second
day of refeeding. Serum lipase concentration >3 times the upper limit of the normal
range and higher Balthazar’s CT-scores at the onset of refeeding were identified as
risk factors for pain relapse.74
16.5 Nutritional Support in Patients

with Pancreatic Surgery
After surgery, either a naso-jejunal tube or a needle catheter jejunostomy are
used. Both types of feeding are safe, well tolerated and depend on the surgeon
preference.
Postoperative feeding with a needle catheter jejunostomy was successful in
several small studies.59,64,76 Hernández-Aranda et al. found no difference between
groups of patients who received postoperative parenteral nutrition or enteral nutri-
tion via jejunostomy.76 Furthermore, in patients undergoing surgery for severe acute
pancreatitis, needle catheter jejunostomy for long-term enteral nutrition was safely
applied with no nutritional risk.64 In general, in these patients, nutritional support has
to be planned before the operation according to the clinical situation and, the course,
of the disease.
16.6 Summary
Acute pancreatitis occurs in different clinical patterns ranging from a mild to severe
necrotizing disease with local and systemic complications. The major pathologi-
cal processes in acute pancreatitis are inflammation, edema, and necrosis of the
pancreatic tissue as well as inflammation and injury of extrapancreatic organs; 75
to 80% have mild, edematous and about 20 to 25% experience severe necrotizing
pancreatitis. The mortality rate for mild to moderate pancreatitis is less than 1%.
The mortality rate for severe pancreatitis increases up to 30%, but can approach
50% if necrosis of the gland is greater than 50% and can further increase up to
80% if sepsis occurs.
For nutritional interventions, it is essential to assess the severity of the disease.
Patients with severe acute pancreatitis are hypermetabolic. The more severe the acute
pancreatitis is, the more excessive the hypermetabolism.
There is no evidence that a nutritional support (enteral or parenteral) has a
beneficial effect on clinical outcome in patients with mild acute pancreatitis.
Nutritional intervention is unnecessary if the patients can consume normal food
within five to seven days of onset of disease. In patients with severe acute pan-
creatitis, who have complications or need surgery, early nutritional support is
necessary to prevent the adverse effect of nutrient deprivation. Early continuous
enteral nutrition by a naso-jejunal tube is recommended as the first line of sup-
port. If enteral nutrition is not possible, parenteral nutrition should be added.
Peptide-based formula or polymeric formula can be used according to the toler-
ance of the patient. The use of enteral or parenteral formulae containing immune-
modulating substrates (glutamine, arginine, n-3 polyunsaturated fatty acids) is
promising, but more data are needed. Pre- and probiotics should not be used until
new studies prove safety and efficacy.
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50. Kotani J, Usami M, Nomura H, et al. Enteral nutrition prevents bacterial translocation
but does not improve survival during acute pancreatitis. Arch Surg 1999;134:287–92.
51. Kalfarentzos F, Kehagias J, Mead N, Kokkinis K, Gogos CA. Enteral nutrition is supe-
rior to parenteral nutrition in severe acute pancreatitis: results of a randomized prospec-
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52. Windsor AC, Kanwar S, Li AG, et al. Compared with parenteral nutrition, enteral feed-
ing attenuates the acute phase response and improves disease severity in acute pancrea-
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53. Powell JJ, Murchison JT, Fearon KC, Ross JA, Siriwardena AK. Randomized controlled
trial of the effect of early enteral nutrition on markers of the inflammatory response in
predicted severe acute pancreatitis. Br J Surg 2000;87:1375–81.
54. Abou-Assi S, Craig K, O’Keefe SJ. Hypocaloric jejunal feeding is better than total par-
enteral nutrition in acute pancreatitis: results of a randomized comparative study. Am J
55. McClave SA, Chang WK, Dhaliwal R, Heyland DK. Nutrition support in acute
pancreatitis: a systematic review of the literature. JPEN J Parenter Enteral Nutr
2006;30:143–56.
56. Jafri NS, Mahid SS, Gopathi SK, et al. Enteral nutrition is superior to parenteral nutri-
tion in severe acute pancreatitis: a systemic review and meta-analysis. Gastroenterology
2008;134:4:A141.
57. Meier R, Beglinger C, Layer P, et al. ESPEN guidelines on nutrition in acute pancreati-
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58. Cravo M, Camilo M, Marques A, Printo Correia J. Early tube feeding in acute pancrea-
titis: a prospective study. Clin Nutr 1989:A8–A14.
59. Kudsk KA, Campbell SM, O’Brien T, Fuller R. Postoperative jejunal feedings following
complicated pancreatitis. Nutr Clin Pract 1990;5:14–7.
60. Nakad A, Piessevaux H, Marot JC, et al. Is early enteral nutrition in acute pancreatitis
dangerous? About 20 patients fed by an endoscopically placed nasogastrojejunal tube.
Pancreas 1998;17:187–93.
61. Scolapio JS, Malhi-Chowla N, Ukleja A. Nutrition supplementation in patients with
acute and chronic pancreatitis. Gastroenterol Clin North Am 1999;28:695–707.
62. Joubert C, Tiengou LE, Hourmand-Ollivier I, Dao MT, Piquet MA. Feasibility of self-
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67. Tiengou L, Gloro R, Pouzoulet J, et al. Semi-elemental formula or polymeric formula: is
there a better choice for enteral nutrition in acute pancreatitis? Randomized comparative
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68. Oláh A, Belágyi T, Issekutz A, Gamal ME, Bengmark S. Randomized clinical trial of
specific lactobacillus and fibre supplement to early enteral nutrition in patients with
acute pancreatitis. Br J Surg 2002;89:1103–7.
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and infection in severe acute pancreatitis: a prospective, randomized, double blind study.
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17 Nutrition in Liver Disease
Mathias Plauth and Tatjana Schütz
Contents
17.1 Introduction................................................................................................... 272
17.2 Nutritional Risk in Liver Disease Patients.................................................... 272
17.3 Effect of Nutritional State on Liver Disease.................................................. 273
17.3.1 Undernutrition.................................................................................... 273
17.3.2 Overnutrition..................................................................................... 273
17.4 Effect of Liver Disease on Nutritional State.................................................. 274
17.4.1 Acute Liver Disease........................................................................... 274
17.4.2 Cirrhosis............................................................................................. 274
17.4.3 Surgery and Transplantation.............................................................. 274
17.5 Pathophysiology and Nutrient Requirement in Liver Disease....................... 275
17.5.1 Energy................................................................................................ 275
17.5.1.1 Acute Liver Failure (ALF).................................................. 275
17.5.1.2 Cirrhosis.............................................................................. 275
17.5.1.3 Surgery and Transplantation............................................... 276
17.5.2 Carbohydrate Metabolism................................................................. 276
17.5.2.1 Acute Liver Failure............................................................. 276
17.5.2.2 Cirrhosis.............................................................................. 276
17.5.3 Fat Metabolism.................................................................................. 277
17.5.3.2 Cirrhosis.............................................................................. 277
17.5.4 Protein and Amino Acid Metabolism................................................ 278
17.5.4.2 Cirrhosis.............................................................................. 278
17.5.5 Vitamins and Minerals...................................................................... 279
17.6 Disease-Specific Nutrition Therapy..............................................................280
17.6.1 Acute Liver Disease...........................................................................280
17.6.1.1 Acute Hepatitis....................................................................280
17.6.1.2 Acute Liver Failure.............................................................280
17.6.2 Chronic Liver Disease....................................................................... 281
17.6.2.1 Alcoholic Steatohepatitis (ASH)......................................... 281
17.6.2.2 Nonalcoholic Steatohepatitis (NASH)................................ 282
17.6.2.3 Liver Cirrhosis.................................................................... 282
271
17.7 Perioperative Nutrition.................................................................................. 285

17.8 Liver Transplantation..................................................................................... 285
References............................................................................................................... 286
17.1 Introduction
Nutrition has long been recognized as a prognostic and therapeutic determi-
nant in patients with chronic liver disease1 and, therefore, has been included as
one of the variables in the original prognostic score introduced by Child and
Turcotte.2 Yet, not all hepatologists consider nutrition issues in the management
of their patients. In this chapter, the scientific and evidence base of nutrition
management of patients with liver disease is reviewed to give recommendations
for nutrition therapy.
17.2 Nutritional Risk in Liver Disease Patients

Understanding adequate nutrition as a complex action that in healthy organisms is
regulated in a condition-adapted way, the assessment of nutritional risk of patients
must include variables indicative of the physiologic capabilities—the nutritional
status—and the burden inflicted by the ongoing or impending disease and/or
medical interventions. Thus, a meaningful assessment of nutritional status should
encompass not only body weight and height, but information on energy and nutri-
ent balance as well as body composition and tissue function reflecting the meta-
bolic and physical fitness of the patient facing a vital contest. Furthermore, such
information can best be interpreted only when available with a dynamic view (e.g.,
weight loss over time).
Numerous descriptive studies have shown higher rates of mortality and complica-
tions, such as refractory ascites, variceal bleeding, infection, and hepatic enceph-
alopathy (HE) in cirrhotic patients with protein malnutrition as well as reduced
survival when such patients undergo liver transplantation.3–11 In malnourished cir-
rhosis patients, the risk of postoperative morbidity and mortality is increased after
abdominal surgery.12,13
In cirrhosis or alcoholic steatohepatitis (ASH), poor oral food intake is a predic-
tor of an increased mortality. In nutrition intervention trials, patients with the lowest
spontaneous energy intake showed the highest mortality.14–20 Dietary intake should
be assessed by a skilled dietitian, and a three-day dietary recall can be used in out-
patients. Appropriate tables for food composition should be used for the calculation
of proportions of different nutrients. As a gold standard, food analysis by bomb calo-
rimetry may be utilized.18,21
Simple bedside methods like the Subjective Global Assessment (SGA) or anthro-
pometry have been shown to adequately identify malnutrition.4,6,11 Composite scor-
ing systems have been developed based on variables, such as actual/ideal weight,
anthropometry, creatinine index, visceral proteins, absolute lymphocyte count,
delayed type skin reaction, absolute CD8+ count, and handgrip strength.14–16 Such
systems, however, include unreliable variables, such as plasma concentrations of
Nutrition in Liver Disease 273
visceral proteins or 24-hour urine creatinine excretion and do not confer an advan-
tage over SGA.
Accurate measurement of nutritional status is difficult in the presence of fluid
overload or impaired hepatic protein synthesis (e.g., albumin) and necessitates
sophisticated methods, such as total body potassium counting, dual energy x-ray
absorptiometry (DEXA), in vivo neutron activation analysis (IVNAA)22,23 and iso-
tope dilution.24 Among bedside methods, the measurement of phase angle alpha or
determination of body cell mass (BCM) using bioimpedance analysis is considered
superior to methods, such as anthropometry and 24-h creatinine excretion,25–27
despite some limitations in patients with ascites.28,29
Muscle function is reduced in malnourished chronic liver disease patients23,30,31
and, as monitored by handgrip strength, is an independent predictor of outcome.16,32
Plasma levels of visceral proteins (albumin, prealbumin, retinol-binding protein)
are highly influenced by liver synthesis, alcohol intake, or acute inflammatory
conditions.33,34 Immune status, which is often considered a functional test of mal-
nutrition, may be affected by hypersplenism, abnormal immunologic reactivity,
and alcohol abuse.34
17.3 Effect of Nutritional State on Liver Disease

17.3.1 Undernutrition
Severe malnutrition in children can cause fatty liver,35–37 which in general is fully
reversible upon refeeding.37 In children with kwashiorkor, there seems to be a malad-
aptation associated with less efficient breakdown of fat and oxidation of fatty acids38,39
compared to children with marasmus. An impairment of fatty acid removal from the
liver could not be observed.40 Malnutrition impairs specific hepatic functions like
phase-I xenobiotic metabolism,41,42 galactose elimination capacity,43 or plasma levels
of c-reactive protein in infected children.44,45 In nutritional intervention trials in cir-
rhotic patients, quantitative liver function tests improved more, or more rapidly in
treatment groups. This included antipyrine,19 aminopyrine,46 and ICG clearance47 as
well as galactose elimination capacity.48,49 It is unknown whether fatty liver of mal-
nutrition can progress to chronic liver disease.
Quantitative liver function tests seem to be useful for monitoring the effects of
nutritional intervention on liver function. They are not useful, however, for identifi-
cation of patients who will benefit from nutritional intervention because none of the
tests can distinguish between reduced liver function due to reduced hepatocellular
mass versus reduced liver function due to lack of essential nutrients. A simple test is
needed that can distinguish between these two alternatives, in analogy to the intra-
venous (i.v.) vitamin K test, in order to estimate the potential benefit of nutritional
support in individual patients.
17.3.2 Overnutrition
In obese humans subjected to total starvation, or weight reducing diets or small-
bowel bypass, the development of transient degenerative changes with focal necrosis
has been described nearly four decades ago.50 Nonalcoholic steatohepatitis (NASH)
has initially been described in weight-losing individuals51 and, to date, insulin resis-
tance and obesity are the most common causes.52 It is estimated that, in Europe, 20%
of the population with moderate or no alcohol consumption have nonalcoholic fatty
liver (NAFL) of whom 20% progress from NAFL to NASH.53 Analyses of dietary
habits in NASH patients do not show a uniform pattern. Increased consumption of fat
and n-6 fatty acids54,55 and increased consumption of carbohydrate and energy56 have
been observed. Body mass index and total body fat are predictors for the presence of
NASH in the obese,54,57 and, in patients undergoing bariatric surgery, the prevalence
of NASH is 37% (24 to 98%).58 Furthermore, the key role of obesity is illustrated by
the observation that weight reduction, regardless of whether it is achieved by dietary
counseling, bariatric surgery, or drug treatment, has the potential to ameliorate or
even cure NASH.59–63
17.4 Effect of Liver Disease on Nutritional State

17.4.1 Acute Liver Disease
In general, acute liver disease induces the same metabolic effects as any disease
associated with an acute phase response. The effect on nutritional status depends on
the duration of the disease and on the presence of an underlying chronic liver dis-
ease, which may have already compromised the patients’ nutritional status.
17.4.2 Cirrhosis
Mixed-type protein energy malnutrition with coexisting features of kwashiorkor-
like malnutrition and marasmus is commonly observed in patients with cirrho-
sis.64,65 Prevalence and severity of malnutrition are related to the clinical stage
of chronic liver disease increasing from 20% of patients with well compensated
disease up to more than 60% of patients with severe liver insufficiency.66 Patients
with cirrhosis frequently suffer from substantial protein depletion and the resulting
sarcopenia is associated with impaired muscle function23 and survival.6 Recovery
from this loss in BCM can be achieved by the control of complications, such as
portal hypertension and adequate nutrition.67,68 Etiology of liver disease, per se,
does not seem to influence the prevalence and degree of malnutrition and protein
depletion23,65,66 and the higher prevalence and more profound degree of malnu-
trition in alcoholics obviously result from an unhealthy lifestyle and low socio-
economic conditions.
In hospitalized cirrhotics, fatigue, somnolence, or psychomotor dysfunction often
lead to insufficient oral nutrition even in the absence of overt HE.69,70
17.4.3 Surgery and Transplantation

A large number of patients, in whom normal liver function has been restored by liver
transplantation show an enormous weight gain in the first year after surgery71,72 and,
unfortunately, a considerable number put their regained health in jeopardy by the
development of full-blown metabolic syndrome.73 In the first year after transplanta-

tion, patients expand their body fat mass while there is no gain in lean body mass71,74
and there is persisting impairment of nonoxidative glucose disposal in skeletal mus-
cle.75,76 There is growing evidence that, in solid organ-transplanted patients, skeletal
muscle deconditioning persists from the time of decreased physical performance
prior to transplantation31,77–79 that should be addressed by appropriate comprehensive
rehabilitation programs including physiotherapy. Taken together, these observations
indicate that upon restoration of hepatic function and cessation of portal hyperten-
sion full nutritional rehabilitation is possible.
17.5 P
athophysiology and Nutrient
Requirement in Liver Disease
17.5.1 Energy
17.5.1.1 Acute Liver Failure (ALF)
In healthy individuals, hepatic energy expenditure contributes 25% to whole body
energy expenditure80 and, in ALF, one would expect a reduction in oxygen-consuming
processes like hepatic ketone body production and lactate elimination81,82 due to
the loss of functional hepatocyte mass. Indirect calorimetry in patients with ALF,
however, showed an increase in resting energy expenditure (REE) by 18 to 30% in
comparison with healthy controls.83 Most likely, the accompanying systemic inflam-
matory response syndrome has caused an increase in energy expenditure that more
than outweighs the reduced oxygen consumption of hepatocytes. Thus, in terms of
energy expenditure, patients with ALF are not different from critically ill patients
with other etiologies.
17.5.1.2 Cirrhosis
On average, measured REE is of the same magnitude as energy expenditure pre-
dicted by use of formulae (Harris and Benedict).84–87 Likewise, in ASH patients, one
study showed the same relationship between measured REE and predicted REE as
in healthy individuals.88 Whenever available, indirect calorimetry should be used to
measure REE because in the individual patient measured REE may differ consider-
ably from estimated values.89
The question of hypermetabolism has been addressed in cirrhosis and ASH
patients. ASH patients may be considered hypermetabolic when measured REE is
related to their reduced muscle mass.88 Measured REE is higher than predicted REE
in up to 35% of cirrhotic patients (hypermetabolism) and below the predicted value
in 18% of the patients.85–87 In cirrhosis, hypermetabolism has been shown associated
with reduced event-free survival and unfavorable outcome after transplantation10,87
and seems to regress with improvement of body composition68 and after liver trans-
plantation.90 For the diagnosis of hypermetabolism, however, indirect calorimetry is
required so that in daily practice most clinicians cannot use this approach.
Measurements of total energy expenditure indicate that the 24-hour energy
requirement of cirrhosis patients amounts to about 130% of the basal metabolic
rate.21,91 Diet-induced thermogenesis92–94 and the energy cost of defined physical

activity in stable cirrhosis patients95–97 also show no deviation from values obtained
in healthy patients. However, the spontaneous physical activity level is consider-
ably lower in patients with cirrhosis. Obviously, the increased energy requirement
in advanced illness is balanced by diminished physical activity reflecting the poor
physical condition.20,97
In cirrhotics without ascites, the actual body weight should be used for the cal-
culation of the basal metabolic rate using formulae, such as that proposed by Harris
and Benedict.84 In patients with ascites, the ideal weight according to body height
should be used, despite the suggestion from a series of 10 patients with liver cirrhosis
of whom only 4 were completely evaluated,98 in which it was suggested that ascites
mass should not be omitted when calculating energy expenditure by use of body
weight.
17.5.1.3 Surgery and Transplantation

Liver transplant patients on average have the same energy requirements as the major-
ity of patients undergoing major abdominal surgery. In general, nonprotein energy
provision of 1.3 × REE is sufficient.99,100 In a longitudinal study, postoperative hyper-
metabolism peaked on day 10 after the transplantation at 124% of the predicted
REE.74 By 6 to 12 months posttransplant there was no longer a difference between
the measured and predicted REE.74,101
17.5.2 Carbohydrate Metabolism
17.5.2.1 Acute Liver Failure
Hypoglycemia is a clinically relevant and common problem in ALF102,103 resulting
from a loss of hepatic gluconeogenetic capacity, lack of glycogen, and hyperinsu-
linism.103 As a standard procedure, hypoglycemia is treated by infusing glucose
at a rate of 1.5 to 2 g · kgBW–1 · d–1.104,105 Cerebral edema probably resulting from
astrocyte swelling and infection are the two key factors in the prognosis of ALF.
Therefore, the rigorous control of blood glucose and closer metabolic monitoring
may prove beneficial in this condition where the central organ of metabolism is
failing. Considering the facts: (1) glucose infusion is aimed to provide the critically
ill with oxidative fuel essential for vital tissues, such as the central nervous system
and erythrocytes; (2) exogenous insulin at rates above 4 IU/h cannot increase glu-
cose oxidation;106 and (3) in ALF there is insulin hypersecretion, hyperinsulinemia,
and insulin resistance;103 there seems to be little reason for insulin administration
above 4 IU/h in order to control glycemia.
17.5.2.2 Cirrhosis
The utilization of oxidative fuels is characterized by an increased rate of lipid oxi-
dation in the fasting state and the frequent occurrence of insulin resistance (even
in Child–Pugh class A patients)85,107–109 In the postabsorptive state, glucose oxida-
tion rate is reduced and hepatic glucose production rate is low despite increased
gluconeogenesis due to a depletion of hepatic glycogen.110 Insulin resistance affects
skeletal muscle metabolism: glucose uptake and nonoxidative glucose disposal, such
as glycogen synthesis are reduced, while glucose oxidation and lactate production
are normal after glucose provision.75,93,110 It is not known to what extent glucose
deposition as glycogen is impaired just in skeletal muscle or in both muscle and
liver.111,112 Some 15 to 37% of patients develop overt diabetes, indicating an unfavor-
able prognosis.113,114

In the early postoperative phase, there is often a disturbance of glucose metabolism
associated with insulin resistance. In this situation, hyperglycemia should be man-
aged by reducing glucose intake because higher insulin doses are unable to increase
glucose oxidation.106
17.5.3 Fat Metabolism

The oxidation of fatty acids and ketogenesis are the main energy yielding processes
for hepatocytes.115 Thus, adequate provision of lipid would be a plausible therapeutic
objective provided there is sufficient oxygen supply to the hepatic tissue. It must be
kept in mind, however, that some cases of ALF, in particular those with microvesicu-
lar steatosis and mitochondrial dysfunction, are caused by an impairment of hepatic
beta-oxidation. In such a case, exogenous lipid, even from administering propofol
as a sedative, cannot be metabolized and may be harmful.116,117 Unlike the situation
in septic patients, the splanchnic organs of ALF patients do not take up, but rather
release, free fatty acids.81 This may result from either mobilization of mesenteric fat
or, more likely, from the compromised hepatic utilization of fatty acids as a con-
sequence of loss of parenchymal mass. Apart from these physiological data, there
are no systematic studies available regarding the role of fat as a nutrient in ALF.
Anecdotal data118,119 and the European survey data120 demonstrate that exogenous
fat seems to be well tolerated by many patients. A word of caution, however, may be
adequate regarding the use of fat in cases of ALF due to the group of microvesicular
steatosis conditions, where mitochondrial dysfunction may be predominant. In the
absence of data from systematic studies, it is recommended to use plasma triglycer-
ide levels for monitoring fat utilization as the best variable currently available and to
aim for levels no higher than 4 to 5 mmol/l.120
17.5.3.2 Cirrhosis
In the fasting state, the plasma levels of free fatty acids, glycerol, and ketone bodies
are increased and free fatty acid and glycerol concentrations do not fully respond to
low insulin infusion rates as in healthy subjects.121 Lipids are oxidized as the pref-
erential substrate and lipolysis is increased with active mobilization of lipid depos-
its.107,109 There is insulin resistance with regard to the antilipolytic activity.
After a meal, the suppression of lipid oxidation is not uniformly impaired.94,122
Plasma clearance and lipid oxidation rates are not reduced and, thus, the net
capacity to utilize exogenous fat does not seem to be impaired.123,124 Essential and
polyunsaturated fatty acids are decreased in cirrhosis and this decrement correlates
to nutritional status and severity of liver disease.125,126

In hepatic transplant patients, improved functioning of the reticuloendothelial system
was observed when using medium chain triglyceride/long chain triglyceride (MCT/
LCT) emulsions with a lower content of n-6 unsaturated fatty acids compared to pure
soy bean oil emulsions.127
17.5.4 Protein and Amino Acid Metabolism

The plasma levels of amino acids are raised three- to fourfold in ALF. The
amino acid pattern is characterized by a decrease in branched chain amino acids
(BCAAs) and an increase in tryptophan, aromatic and sulphur-containing amino
acids.128–130 More recent data show that in ALF the splanchnic organs do not take
up amino acids in contrast to their net uptake in healthy humans and even in septic
patients.130 Ammonia released from the intestine can no more be extracted suffi-
ciently by the failing liver, and, despite ammonia detoxification by skeletal muscle
hyperammonemia ensues.130–132 Since elevated arterial ammonia levels have been
recognized as an independent predictor of poor outcome in ALF patients,133–135 it
seems prudent to adjust the provision of amino acids according to the ammonia
levels (target: <100 µmol/l) monitored.136
17.5.4.2 Cirrhosis
Protein turnover in cirrhotic patients has been found to be normal or increased. Some
authors mainly focused on the presence of increased protein breakdown, while oth-
ers suggest that a reduced protein synthesis plays the main role.137 Albumin, but not
fibrinogen, synthesis rates correlate with quantitative liver function tests and clinical
stages of cirrhosis.138,139 Nevertheless, stable cirrhotics apparently are capable of effi-
cient nitrogen retention and significant formation of lean body mass from increased
protein intake during oral hyperalimentation.21 Protein catabolism influences the
amino acid imbalance of cirrhosis and indirectly causes nitrogen overload to the liver
leading to hyperammonemia. In cirrhotics, after an overnight fast, glycogen stores
are depleted and metabolic conditions are similar to prolonged starvation in healthy
individuals. It has been shown that a late evening carbohydrate snack was associ-
ated with improved protein metabolism in cirrhotic patients.140–142 Insulin resistance
apparently is without effect on amino acid disposal.143
An explicit and systematic determination of the protein requirement of patients
with liver cirrhosis has been carried out in only a few studies. Patients with stable
cirrhosis were found to have an increased protein requirement leading to the recom-
mendation of 1.2 g · kgBW–1 · d–1 contrasting with the recommended minimal intake
of 0.8 g · kgBW–1 · d–1 in healthy humans.20,21,43,144
Similar to ALF, cirrhotic patients exhibit an altered pattern of plasma amino
acids characterized by the elevation of aromatic (phenylalanine, tyrosine) and sulfur
containing amino acids (methionine) and tryptophane on the one hand and the
decrease in BCAA (leucine, isoleucine, valine) on the other hand.129,145 Decreased
metabolic clearance146 by the failing liver of aromatic and sulfurous amino acids and
increased breakdown in skeletal muscle of BCAA due to portal systemic shunting147
and hyperammonemia130,148–150 are discussed as causal.
Recently, it has been pointed out that, due to the absence of isoleucine from hemo-
globin, blood is a protein source of low biologic value leading to BCAA antagonism
after upper gastrointestinal hemorrhage.151 This BCAA antagonism readily explains
the long-known clinical observation that blood and vegetable protein represent the
two extremes in the hierarchy of food proteins regarding their comagenic potential.
Moreover, this antagonism leading to hyperammonemia could be overcome by the
infusion of just isoleucine.152

After transplantation there is a considerable nitrogen loss and patients remain in
negative nitrogen balance for up to 28 days74,99,153 necessitating an increase in the
provision of protein or amino acids. Protein or amino acid intakes of 1.0 to 1.5
g · kgBW–1 · d–1 have been reported.8,154 The determination of postoperative urea
nitrogen excretion has proved helpful in the assessment of individual nitrogen
requirements.
17.5.5 Vitamins and Minerals

No recommendation on the requirement of micronutrients can be made on the
basis of controlled studies. As in other diseases, the administration of micronu-
trients has no proven therapeutic effect apart from the prevention or correction of
deficiency states.
Body composition of cirrhotics is altered profoundly and characterized by pro-
tein depletion and accumulation of total body water even in Child–Pugh class A
patients.22,23 This goes hand-in-hand with salt retention, which does not usually lead
to hypernatremia. On the contrary, depletion of potassium, magnesium, phosphate,
and other intracellular minerals frequently occurs. In an early study comparing par-
enteral nutrition versus oral diet in cirrhotic patients with ascites, the response to
diuretics was poorer in those patients receiving parenteral nutrition.155
Zinc and selenium deficiencies have been observed in alcoholic and nonalcoholic
liver disease.156–159 An impressive association between HE and zinc deficiency has
been described in case reports.160,161 A deficiency in water soluble vitamins, mainly
group B vitamins, is common in cirrhosis, especially that of alcoholic origin.162,163
Deficiency in fat soluble vitamins has been observed in cholestasis-related steator-
rhea, bile salt deficiency, and in alcoholics.164,165
Patients with hypophosphatemia after acetaminophen-induced liver damage
have a better prognosis. Severe hypophosphatemia, however, results in respiratory
insufficiency and dysfunction of the nervous system and erythrocytes166 and, thus,
serum phosphate levels should be monitored and corrected in order to support liver
regeneration.
17.6 Disease-Specific Nutrition Therapy

17.6.1 Acute Liver Disease
17.6.1.1 Acute Hepatitis
Acute viral hepatitis often is associated with a varying degree of anorexia and the
sensation of abdominal fullness leading to reduced food intake and weight loss.
Depending on the magnitude of cholestasis, there may be an impairment of fat mal-
absorption. Nutrition therapy is warranted in malnourished subjects and when inad-
equate food intake persists. Since no data from formal trials are available, nutritional
management should adopt the strategies outlined for alcoholic steatohepatitis.

Without treatment, ALF results in death within days.167 In the treatment of ALF,
measures to stabilize the metabolism and vital functions and the treatment of brain
edema are of utmost importance. Hypoglycemia is a clinically relevant and common
problem in ALF102 resulting from a loss of hepatic gluconeogenetic capacity, lack of
glycogen, and hyperinsulinism.103 As a standard procedure, hypoglycemia is treated
by infusing glucose at a rate of 1.5 to 2 g · kgBW–1 · d–1.104,105 In ALF, nutritional
therapy has two objectives:
1. Ensuring the adequate provision of energy, especially assuring euglycemia

by giving glucose, lipid, vitamins, and trace elements.
2. Ensuring optimal rates of protein synthesis by providing an adequate intake
of protein or amino acids, respectively.
In the absence of data from clinical trials, it is difficult to give recommendations.

In recognition of this deficit, a survey was carried out in European hepatology cen-
ters on issues of parenteral nutrition in patients with ALF.120 One important result
was that centers with a high caseload favor nasoduodenal tube feeding, which could
be carried out successfully in the majority of cases. Therefore, it is recommended
that patients with ALF should receive enteral nutrition via nasoduodenal tube. No
recommendations concerning a disease-specific composition of enteral formulae can
currently be given. The recommended amount of enteral formula is based on the
dosage in critical illness.
Also, when using parenteral nutrition, sufficient glucose provision (2 to 3 g · kg BW–1
· d ) is mandatory for the prophylaxis and treatment of hypoglycemia. Xylitol or sorbi-
–1
tol in exchange for glucose are of no proven benefit in acute ALF; moreover, both have
to be metabolized by the liver before they can be utilized. Ensuring euglycemia has
been shown to confer a survival and morbidity benefit to critically ill patients regard-
less of etiology.168,169 Great care, however, must be taken to avoid hypoglycemia.170
There are no systematic data on the role of lipid as a nutrient in this context.
Exogenously applied, lipid seems to be well tolerated by most patients.118,119 According
to the European survey, two-thirds of participating hepatology centers give parenteral
lipid to patients with acute liver failure, the majority opting for an LCT/MCT emul-
sion.120 In clinical practice, glucose and lipid (0.8 to 1.2 g · kgBW–1 · d–1) can be given
simultaneously; the use of lipid may be especially advantageous in the presence of

insulin resistance.
Amino acid administration is not mandatory in hyperacute liver failure. In acute
or subacute liver failure, however, amino acids (0.8 to 1.2 g · kgBW–1 · d–1 in paren-
teral nutrition) or protein (0.8 to 1.2 g · kgBW–1 · d–1 in enteral nutrition) should be
used in order to support protein synthesis. The use of amino acid infusions has often
been omitted for fear of aggravating existing hyperammonemia and hyperamino-
acidemia and causing cerebral edema and HE. In the survey, however, the majority
reported giving i.v. amino acids.120 Some clinicians reported use of standard amino
acid solutions while the majority prescribed BCAA-enriched solutions aiming for a
correction of the deranged plasma amino acid pattern.171–173 Because elevated arterial
ammonia levels have been recognized as an independent predictor of poor outcome
in ALF patients,133–135 it seems prudent to adjust the provision of amino acids accord-
ing to the ammonia levels monitored. While pathophysiological considerations pro-
vide a rationale for the use of liver-adapted solutions rich in BCAA, no clinical trial
in acute ALF has shown an outcome benefit in comparison to standard solutions.
Adequate metabolic monitoring is necessary in order to adapt nutrient provision to
substrate utilization in order to prevent substrate overload due to inadequate intake.
Strict control of the plasma levels of glucose (target: 5 to 8 mmol/l), lactate (target:
<5.0 mmol/l), triglycerides (target: <3.0 mmol/l), and ammonia (target: <100 µmol/l)
is necessary for this purpose.120,136
17.6.2 Chronic Liver Disease

17.6.2.1 Alcoholic Steatohepatitis (ASH)
Supplementary enteral nutrition is indicated when ASH patients cannot meet their
caloric requirements through normal food and when there are no contraindications
like ileus. Clinical trials14–17,174,175 in ASH patients show that supplementary enteral
nutrition either by oral nutritional supplement or by tube feeding ensures adequate
energy and protein intake without the risk of complications, such as HE. Enteral
nutrition appears preferable to parenteral nutrition, but there has been no large ran-
domized trial comparing the feeding regimens in ASH patients.
Enteral nutrition was as effective as steroids in patients with severe alcoholic hep-
atitis. Survivors of the 28-day treatment period who had been treated with enteral
nutrition showed a lower mortality rate in the following year.175 Severely malnour-
ished ASH patients who achieve an adequate intake of oral nutrition supplements
have an improved survival rate, regardless of whether or not additional anabolic ste-
roids are used.15 Malnourished ASH patients are at great risk of developing refeeding
syndrome and additional phosphate, potassium, and magnesium will be required,
together with water soluble vitamins.
In general, oral nutrition supplements are recommended, but if patients are not
able to maintain adequate oral intake, tube feeding should be used. There is no evi-
dence that the use of fine bore nasogastric tubes poses an undue risk in patients
with esophageal varices.18,19,176 Placement of a percutaneous endoscopic gastrostomy
(PEG) is associated with a higher risk of complications (due to ascites or varices) and
is not recommended.177
As a standard approach, standard whole protein formulae should be used aiming
for an energy intake of 35 kcal · kgBW–1 · d–1 and a protein intake of 1.2 to 1.5 g · kg
BW–1 · d–1.14–17,175 Formulae with high energy density (1.5 to 2.4 kcal · ml–1) are pref-
erable in patients with ascites to avoid positive fluid balance. When patients develop
HE during enteral nutrition, BCAA-enriched formulae should be used.177 A direct
comparison between standard formula and BCAA-enriched formula has not yet been
made in ASH patients. It should be kept in mind that in ASH patients as in cirrhotics,
a low protein intake can worsen HE.19,178
Parenteral nutrition should be commenced immediately in ASH patients with
moderate or severe malnutrition who cannot be fed sufficiently either orally or enter-
ally. Parenteral nutrition supplemental to oral nutrition ad libitum did not improve
survival, but did not negatively affect the mental state.47–49,174,179–182 It has been shown
that a late evening carbohydrate snack is associated with improved protein metabo-
lism in cirrhotic patients.140–142 Therefore, it is recommended that patients with ASH
and/or cirrhosis who need to be managed nil by mouth (nothing through the mouth)
for more than 12 hours (including nocturnal fasting) should be given i.v. glucose at
2 to 3 g · kgBW–1 · d–1. When this fasting period lasts longer than 72 hours, total
parenteral nutrition should be implemented.
Parenteral nutrition should be formulated and administered as in liver cirrhosis
patients (176.2.3). All water soluble vitamins, in particular thiamine (vitamin B1),
pyridoxine (vitamin B6), nicotinamide (vitamin PP), and folic acid, and fat soluble
vitamins should be administered daily in a standard total parenteral nutrition (TPN)
dosage. Due to the high risk of Wernicke’s encephalopathy, vitamin B1 must be
administered prior to starting i.v. glucose in alcoholic patients. Recently, high doses
for both prophylaxis (250 mg i.m. daily for three to five days) and treatment (500 mg
i.v. t.i.d. for two to three days) of Wernicke’s encephalopathy have been advocated.183
In jaundiced patients, vitamin K deficiency due to cholestasis-induced fat malab-
sorption may require i.v. vitamin K for correction.
17.6.2.2 Nonalcoholic Steatohepatitis (NASH)

In overweight individuals with NASH, weight reduction is the key to the successful
treatment of this condition. The histopathologic changes of NASH can be amelio-
rated or even fully regress by weight reduction regardless of whether it is achieved by
dietary counseling,59 bariatric surgery,60–62 or inhibition of intestinal fat absorption by
orlistat.63 Likewise, insulin resistance59,63 and lipid metabolism59,62 can be improved.
Targeting insulin resistance by use of insulin-sensitizing drugs like pioglitazone
or rosiglitazone, the beneficial effects on liver histology184,185 seem to be offset by a
considerable gain in body weight and body fat mass.184,186
Taken together, overweight NASH patients benefit from effective long-term
weight reduction regardless of the therapeutic strategy implemented.
17.6.2.3 Liver Cirrhosis
In patients with cirrhosis, the primary goal is to ensure a quantitatively adequate
nutrient intake.16–19,187–189 Increasing protein intake by nutrition therapy can decrease
mortality,20 and adequate nutrition after successful treatment of portal hypertension

by transjugular intrahepatic portosystemic stent-shunt (TIPS) has the potential to
improve body composition.67,68
Regarding the method of nutritional intervention, nutritional counseling alone187
or in combination with oral nutrition supplements16,17,189 will often prove success-
ful. Supplemental enteral nutrition should be given when patients with liver cirrho-
sis cannot meet their nutritional requirements from normal food despite adequate
individualized nutritional counseling. Very often, the spontaneous food intake of
these patients is overestimated and the therapeutic gain18,19,69,70 by timely use of tube
feeding is missed. Due to somnolence and psychomotor dysfunction, oral nutrition
is often insufficient even in mild HE (I°-II°).69,70 Therefore, tube feeding may be
required to ensure adequate nutrient provision. The risk of aspiration in uncoopera-
tive patients and those with advanced HE should be considered when deciding on
whether to feed by the enteral or the parenteral route. As already discussed for ASH
patients, tube feeding is not contraindicated in the presence of esophageal varices,
but the use of PEGs in cirrhotics is discouraged. Ascites, impairment of the coagula-
tion system, and portosystemic collateral circulation due to portal hypertension have
been reported as contraindications to PEG placement.190
Cirrhotic patients should achieve an energy intake of 35 kcal · kgBW–1 · d–1 and
a protein intake of 1.2 to 1.5 g · kgBW–1 · d–1 24 using a standard whole protein for-
mula. The appropriateness of this recommendations has been tested recently. Diets
containing 1.2 g · kgBW–1 · d–1 protein could safely be administered to patients with
cirrhosis suffering from episodic HE. Even transient protein restriction did not con-
fer any benefit to patients during an episode of encephalopathy.191 In stable cirrhot-
ics, formulae enriched in BCAA are not necessary. Such formulae are helpful in
the very select subgroup of protein intolerant patients with HE.192 In stable patients
with cirrhosis, long-term (12 and 24 months) nutritional supplementation with oral
BCAA granulate as oral nutrition supplement has the potential to slow the progres-
sion of hepatic failure and prolong event-free survival,193–195 but this treatment is not
reimbursed in many countries. When patients develop HE during enteral nutrition,
BCAA-enriched formulae should be used.177
Regarding trace elements and vitamins, in a pragmatic approach, liberal supple-
mentation is recommended in the first two weeks of nutritional support because the
laboratory diagnosis of a specific deficiency may be more costly and would delay
provision. Oral zinc supplementation as a treatment of HE has been disappointing in
controlled trials,196–208 despite encouraging case reports.160,161 Urea production capac-
ity increased after oral zinc application when previously subnormal plasma levels
were normalized.199 Supplementing zinc and vitamin A may indirectly improve food
intake and nutritional state by improving dysgeusia.200,201 Supplementation with cal-
cium and vitamin D is recommended for patients with osteopenia, although this did
not result in any improvement in bone density in patients with primary biliary cirrho-
sis; estrogen substitution proved to be much more effective in female patients.164,165,202
Vitamin B1 must be provided to all patients with alcoholic liver disease before pro-
viding glucose as outlined in Section 17.6.2.1.
Parenteral nutrition is a valuable second line option and must be implemented
immediately when moderately or severely malnourished cirrhotics cannot be
nourished sufficiently by either the oral or enteral route. Parenteral nutrition should
be considered in patients with unprotected airways and advanced HE when swallow
and cough reflexes are compromised.
Patients with liver cirrhosis suffer from a depletion of hepatic glycogen stores
and thus are less prepared to adequately master periods of even short-term food
deprivation. A late evening carbohydrate snack can improve protein metabolism in
cirrhotics140–142 and, thus, every patient with cirrhosis who needs to be managed nil
by mouth for more than 12 hours (including nocturnal fasting) should be given i.v.
glucose at 2 to 3 g · kgBW–1 · d–1 as the minimum metabolic intervention. When
this fasting period lasts longer than 72 hours, TPN should be implemented and, as
an intermediary measure, hypocaloric peripheral parenteral nutrition may be used
when fasting periods are expected to last for less than 72 hours.
If parenteral nutrition is used as the exclusive form of nutrition, then the i.v. provi-
sion of all macro- and micronutrients must be ensured from the beginning of TPN.
Carbohydrates should be given as glucose to cover 50 to 60% of nonprotein energy
requirements. Ensuring euglycemia has been shown to confer a survival and morbid-
ity benefit to critically ill patients regardless of etiology.168,169 Great care, however,
must be taken to avoid hypoglycemia.170 In case of hyperglycemia, glucose infusion
should be reduced to 2 to 3 g · kgBW–1 · d–1 and i.v. insulin infusion should be used.
The simultaneous infusion of lipid and glucose provides a better metabolic profile
than glucose alone.203 Plasma clearance and oxidation of infused lipids are normal in
cirrhosis patients.123,124 Regarding the optimal composition of i.v. oxidative fuels fat
and carbohydrate, only limited information is available.204,205 European guidelines
recommend fat provision to cover 40 to 50% of nonprotein energy requirements using
emulsions with a content of n-6 unsaturated fatty acids lower than in traditional pure
soy bean oil emulsions.177 Compared to the traditional soy bean-based long-chain
triglycerides (LCT) emulsions (n-6:n-3 = 8:1), new fat emulsions have a lower content
of n-6 unsaturated fatty acids due to the admixture of medium-chain triglycerides
(MCT) and/or olive oil and/or fish oil rendering them less suppressive to leukocyte
and immune function and less stimulant of proinflammatory modulators.206–210
The infusion of amino acids should provide an amount of 1.2 g · kgBW–1 · d–1
in compensated cirrhosis without malnutrition and 1.5 g · kgBW–1 · d–1 in decom-
pensated cirrhosis with severe malnutrition. In clinical trials, studying patients with
liver cirrhosis and severe HE, the provision of protein or amino acids ranged from
0.6 to 1.2 g · kgBW–1 · d–1.211 In patients with alcoholic hepatitis or alcoholic cirrho-
sis with or without low-grade HE, the provision ranged from 0.5 to 1.6 g · kgBW–1
· d–1.17–19,48,49,179–182,212 For parenteral nutrition in compensated cirrhosis amino acid
solutions with a special “hepatic formula,” composition are not required.
For parenteral nutrition of cirrhotics with overt HE amino acid solutions with
a special “hepatic formula” high in BCAA (35% to 45%) but low in tryptophan,
aromatic and sulfur-containing amino acids were developed.171,213,214 Such solutions
help to correct the amino acid imbalance in liver cirrhosis. The efficacy of BCAAs in
the treatment of hepatic encephalopathy has been studied215–219 and a meta-analysis
showed an improvement in mental state by the BCAA-enriched solutions, but no
definite benefit in survival.211 Hepatic encephalopathy of cirrhotic patients, however,
is precipitated by serious and life-threatening complications, such as infection or
hemorrhage, which are more potent determinants of survival than HE. Therefore, it
is not surprising that BCAA-based parenteral nutrition failed to improve short-term
survival. Likewise, in a Cochrane analysis of seven randomized controlled trials
studying 397 patients with acute HE, the parenteral BCAA administration had a sig-
nificant, positive effect on the course of HE, but not on survival.220 A liver-adapted
complete amino acid solution should be given in more severe HE (III°–IV°). Blood
from gastrointestinal hemorrhage is a protein source of low biologic value leading
to BCAA antagonism.151 This antagonism leads to hyperammonemia, but HE could
be overcome by the infusion of just isoleucine.152 Isoleucine solutions for i.v. infu-
sions, however, are not commercially available. Special hepatic formula amino acid
solutions (c.f. above) contain high amounts of isoleucine and of the other BCAAs,
leucine, and valine.
For parenteral nutrition, water, electrolytes, water- and fat-soluble vitamins, and
trace elements should be given daily in order to cover daily requirements. Trace
elements should be administered daily in a standard TPN dose. In a pragmatic
approach, routine administration of twice the normal daily requirement of zinc (=
2 × 5 mg · d–1) is recommended. Malnourished cirrhotic patients are in danger of
developing refeeding syndrome and additional phosphate, potassium, and magne-
sium may be required.136
17.7 Perioperative Nutrition

Nutrition therapy prior to elective surgery should be managed according to the
recommendations given for the underlying disease, which most likely is liver cir-
rhosis in the majority of cases. Cirrhotic patients have a reduced rate of complica-
tions and an improved nitrogen economy after abdominal surgery if they receive
nutritional support instead of just fluid and electrolytes.221–223 It may safely be
assumed that enteral nutrition in the early postoperative period yields even better
results; however, no studies have compared the two regimens in liver cirrhosis. A
beneficial effect on gut permeability of sequential parenteral/enteral nutrition (via
jejunostomy) as compared to parenteral nutrition alone and no postoperative nutri-
tion has been reported.223
Cirrhotic patients should receive early postoperative (additional) parenteral nutri-
tion after surgery if they cannot be nourished sufficiently by the oral/enteral route.
In cirrhotic patients undergoing liver resection, esophageal transection and splenec-
tomy or splenorenal shunt, the rate of HE was not increased when a conventional
rather than a BCAA-enriched amino acid solution was used.222
17.8 Liver Transplantation
Although the prognostic relevance of undernutrition in transplant candidates is well
recognized, it has not yet been shown that preoperative nutritional intervention
improves clinically relevant outcomes. However, nutritional therapy in undernour-
ished cirrhotic patients is clearly indicated as outlined above. In the only randomized
trial addressing this question, there was no advantage of oral nutrition supple-
ments over nutritional counseling and normal food in adults.187 Since normal food
and nutritional counseling lead to the same adequate intake as when oral nutrition
supplements are added, both regimens are considered similarly effective. Pediatric
transplant patients with predominantly cholestatic liver disease show a better increase
in body cell mass if they receive BCAA-enriched formula.224
After liver transplantation, normal food and/or enteral nutrition should be initiated
within 12 to 24 hours postoperatively in order to achieve lower rates of morbidity and
complications and cost than during parenteral nutrition.154,225 Whole protein formu-
lae with226 or without pre- and probiotics225,227 or peptide-based formulae via catheter
jejunostomy228,229 have been used for early enteral nutrition of adult liver transplant
recipients. Nasogastric or nasoduodenal tubes after endoscopic placement227 or via
catheter jejunostomy223,228,229 placed during laparotomy are used.
In hepatic transplant patients, the principles of parenteral nutrition are no dif-
ferent from those in abdominal surgery. In the early postoperative phase, hyper-
glycemia (due to disturbed glucose metabolism and insulin resistance) should be
managed by reducing glucose intake because higher insulin doses are unable to
increase glucose oxidation.106 The diabetogenic potential of the immunosuppres-
sant tacrolimus can be lowered by reducing its dose, aiming for trough levels of
3 to 8 ng · ml–1 without undue risk of rejection.230 Regarding lipid emulsions, an
improved functioning of the reticuloendothelial system was observed when using
MCT/LCT emulsions with a lower content of n-6 unsaturated fatty acids compared
to pure soy bean oil emulsions.127
After transplantation, there is a considerable nitrogen loss and patients remain
in negative nitrogen balance for up to 28 days74,99,153 necessitating an increase in the
provision of protein or amino acids. Protein or amino acid intakes of 1.0 to 1.5 g · kg
BW–1 · d–1 have been reported.8,154 There is no need to use a BCAA-enriched amino
acid solution after liver transplantation.154
In transplanted patients, the often preexisting chronic dilutional hyponatremia
should be corrected carefully in order to avoid pontine myelinolysis.231 Magnesium
levels need to be monitored in order to detect and treat ciclosporin- or tacrolimus-
induced hypomagnesemia.232 Postoperative hypophosphatemia and its possible rela-
tion to parenteral nutrition following right hemihepatectomy in living donors has
been reported by some, but not all study groups.233–235
At present, no specific recommendations can be made with regard to optimal
organ donor conditioning. Fatty liver is known to be a risk factor for primary graft
malfunction. No data are available addressing the role of nutritional management
of the organ donor. Animal data indicate that the balanced nutrition of a brain dead
liver donor, using moderate amounts of carbohydrate, lipid (long-chain fatty acids
and possibly fish oil), and amino acids, is associated with improved function of
the transplanted organ.236 The value of donor or organ conditioning, which aims to
reduce ischemia/reperfusion damage in man by provision of high doses of arginine
or glutamine, is unclear.
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18 Nonalcoholic
Liver Disease
Fatty
Kevin M. Korenblat
Contents
18.1 Introduction................................................................................................... 301
18.2 Clinical Manifestations................................................................................. 303
18.3 Pathology.......................................................................................................304
18.4 Natural History..............................................................................................304
18.5 Mechanisms of Disease Development........................................................... 305
18.5.1 Organ-Level Metabolic Changes....................................................... 305
18.6 Molecular Mechanisms in the Development of NAFLD..............................306
18.6.1 Transcription Factors.........................................................................306
18.6.2 Cytokines and Adipokines................................................................307
18.6.3 Lipotoxicity........................................................................................307
18.7 Treatment.......................................................................................................307
18.7.1 Lifestyle Modification/Weight Reduction.........................................308
18.7.2 Bariatric Surgery...............................................................................309
18.7.3 Insulin Sensitizing Agents.................................................................309
18.7.3.1 Metformin...........................................................................309
18.7.3.2 Thiazolidinediones.............................................................309
18.8 Pediatric NAFLD.......................................................................................... 310
18.9 Conclusion..................................................................................................... 310
References............................................................................................................... 311
18.1 Introduction
The modern history of nonalcoholic fatty liver disease (NAFLD) as a distinct clini-
cal entity has its origins with three independent publications 30 years ago describ-
ing liver disease with histologic features similar to those seen with alcohol-related
injury, but in patients reliably lacking excessive alcohol consumption.1–3 Many of
these patients were obese, glucose intolerant, or had hypertriglyceridemia. In the
years that followed, NAFLD has emerged as a substantial cause of liver disease and
progress made into understanding the natural history, mechanisms, and treatments
of this condition.
Hepatic steatosis with varying degrees of inflammation is a recognized histo-
logic pattern in liver diseases that include Wilson’s Disease, kwashiorkor, and some
medication-related liver injuries.4,5 These unrelated diseases are often referred to
301
as secondary causes of NAFLD and distinguished from the bulk of patients with
primary NAFLD:
Wilson’s disease
Abetalipoproteinemia
Total parenteral nutrition (TPN)
Kwashiorkor
Celiac disease
Jejunal-ileal bypass
Medications
Tamoxifen
Antiretroviral protease inhibitors
Amiodarone
Methotrexate
Precise data on the prevalence of NAFLD remains elusive. There are currently
over 50 population-based studies of the prevalence of NAFLD from 15 countries.6 In
these studies, the rates of NAFLD in the general population vary from 2.8 to 46%.
Among high-risk populations, those with diabetes or obesity, the prevalence is 7
to 99%. These ranges illustrate the difficulties of studying a process that reflects a
spectrum of disease and lacks a dispositive screening test applicable at the popula-
tion level.
Despite these limitations, common themes have emerged. In the third U.S.
National Health and Nutritional Examination Survey (1988–1994) (NHANES III),
7.9% of the study population had aminotransferase elevations.7 The percentage nar-
rows to 5.5% if individuals with daily alcohol consumption or serologic evidence of
hepatitis B, hepatitis C, and iron overload are excluded. In this subset of both men
and women, abnormal aminotransferases were strongly associated with markers of
the metabolic syndrome.
The reliance on aminotransferase elevations as a metric for NAFLD is problematic
because the prevalence rates will be dependent on the threshold used to define the refer-
ence range and current reference ranges may fail to capture all patients with NAFLD.8,9
An alternate approach utilizes hepatic imaging and many population-based stud-
ies have used ultrasonographic imaging of the liver to gauge steatosis. In the largest
population-based application of ultrasound performed in Japan, the prevalence of
hepatic steatosis was estimated at 14%.10 As a screening tool, however, ultrasound
has limitations. Ultrasound is unable to discern features of necroinflammation or
fibrosis and a threshold of steatosis—estimated as >30%—is cited for the detection
of steatosis.11
A promising noninvasive imaging technique is magnetic resonance spectroscopy
(MRS) to quantify intrahepatic fat content. In a large, ethically diverse group of
subjects from Dallas County (Texas), MRS was applied in 2,287 participants of the
Dallas Heart Study. The range of intrahepatic triglyceride (IHTG) content went from
0 to 47.5% and followed a nonnormalized distribution. The median IHTG was 4.69%
in the entire cohort. Within a subset of lean, nondiabetics with low levels of alcohol
consumption and normal aminotransferases, the median IHTG was 1.9% and 5.6%
Nonalcoholic Fatty Liver Disease 303
defined the 95th percentile. When this upper limit of normal is applied to the entire
cohort, 30.7% had hepatic steatosis.12
The population-based estimates have been further refined in groups at high-risk
for NAFLD. Among subjects eligible for bariatric surgery, approximate rates of ste-
atosis are 76% of which 5.8% have cirrhosis. NAFLD is also overrepresented in type
2 diabetics with rates of NAFLD estimated between 40 to 70%.13
18.2 Clinical Manifestations
NAFLD is most commonly described as a spectrum of disease ranging from hepatic
steatosis alone to steatohepatitis.14 The latter is also known as nonalcoholic steato-
hepatitis (NASH) and is the form of NAFLD that is associated with progressive liver
disease and risk of cirrhosis. The major component of intrahepatic fat is triglycer-
ide, which can exist within the hepatocyte cytoplasm as macrovascular droplets that
enlarge displacing the nucleus to the cell membrane or microvesicular fat, numerous
small droplets of fat that separate the cytoplasm from the nucleus. The former is
more typical of NAFLD, while the latter is seen in metabolic disorders that affect
mitochondrial oxidative phosphorylation (e.g., Reye’s syndrome).
Patients with steatosis are frequently identified only by abdominal imaging
undertaken for reasons other than a directed study of the liver. In individuals with
NASH, abnormal aminotransferases uncovered as part of a yearly medical evalu-
ation or a preinsurance evaluation may be the first clue of disease. NAFLD can
present in all ages and can be found in all ethnic groups; however, NAFLD tends
to be less frequent in African Americans despite similar or greater levels of obesity
than in Hispanic and non-Hispanic Caucasians. In a study of patients enrolled in a
large health maintenance organization in Alameda County in California, African
Americans comprised 9% of HMO enrollees though only 3% met a case defini-
tion for probable NAFLD with an average body mass index (BMI) of 36.6 kg/m2.
Hispanics, in comparison, comprised 10% of enrollees, but 28% of those who met
the case definition of NAFLD and the BMI of suspected cases was 34 kg/m2.15
As in the original description of the disease, individuals with NAFLD tend
to be centrally obese though excessive body weight is not a requirement.16 Most
patients will present without symptoms of liver disease unless more advanced fibro-
sis sufficient to result in either hepatic dysfunction or portal hypertension is present.
Constitutional symptoms, such as fatigue or a vague right upper quadrant discom-
fort, may be elicited though it may not be obvious that these symptoms are from
liver disease. Elevated aminotransferases are the most common clinical finding in
NAFLD. Alanine aminotransferase (ALT) elevations are typically less than 5 times
the upper limits of the reference range and typically greater in magnitude than eleva-
tions in aspartate aminotransferase (AST) unless cirrhosis is present, in which case
the ratio of AST to ALT may be greater than 1. Isolated alkaline phosphatase eleva-
tions may be present in 10% of subjects with NAFLD.17
The strictly biochemical approach to NAFLD has its limitations. Amino
transferases elevations may be intermittent and there are ample reports of NAFLD
occurring despite normal aminotransferases. In a group of 80 patients with the met-
abolic syndrome but normal aminotransferases referred for abdominal surgery, 58
had nonalcoholic steatohepatitis and 8 had cirrhosis.9 The recognized limitations in

aminotransferase elevations have given voice to those who have encouraged lower-
ing of the reference range for the aminotransferases.
Auto-antibodies, particularly antinuclear antibodies and antismooth muscle actin
antibodies, may be present in one-third of subjects with NAFLD and serum ferritin
elevations are common. Elevated serum ferritin, however, does not necessarily imply
parenchymal iron overload and there is no clear association between disease causing
alleles in the HFE gene responsible for hemochromatosis with either hepatic fibrosis
or hyperferritinemia.18
18.3 Pathology
Liver biopsy remains an essential diagnostic tool in the evaluation of NAFLD. Liver
biopsy permits exclusion of other pathologic conditions and can assess the severity
of steatosis, necroinflammation, and fibrosis. The degree of steatosis is variable and
may be discordant with the inflammatory changes. Typical inflammatory features
of NAFLD include a mixed lobular infiltrate with polymorphonuclear leukocytes,
acidophil bodies, and hepatocyte ballooning.19 Acidophil bodies are hepatocytes
that have either undergone or are in the process of undergoing apoptotic cell death.
Hepatocyte ballooning describes swollen-appearing hepatocytes from microtubular
disruption. Neither ballooning nor acidophil bodies are unique to NAFLD; however,
the presence of ballooning in the appropriate context is sufficient for the diagnosis
of steatohepatitis.20
The histologic features of steatosis, lobular inflammation and hepatocyte balloon-
ing, comprise the essential feature that determine the NAFLD activity score (NAS),
a validated histology scoring system for NAFLD that is used to distinguish steatosis
from steatohepatitis.21 Fibrosis in NAFLD, as in other forms of liver disease, reflects
collagen deposition by activated hepatic stellate cells within the space of Disse. Early
fibrosis in NAFLD is frequently perisinusoidal within acinar zone 3. This is often
described as a “chicken wire” fibrosis for its delicate lace-like pattern. Progression
of disease gives way to periportal fibrosis that can eventually bridge and cirrhosis
is established. Though biopsy is a critical component to the evaluation of NAFLD,
a shortcoming that requires acknowledgment is sampling variability that may influ-
ence the precision of grading and staging hepatic histology.22
18.4 Natural History
Emerging data from a combination of longitudinal and cross-sectional studies have
helped to delineate the natural history of NAFLD. The longest longitudinal study to
date is of 129 Swedish subjects followed for 13 years.23 Individuals with steatosis alone
progressed at a variable rate to NASH though symptomatic liver disease was rare.
However, among patients with NASH at baseline, 41% developed progressive fibrosis.
In both the Swedish and a cross-sectional study from Olmstead County,
Minnesota, mortality rates within the NAFLD cohort were higher than in refer-
ence populations. Death from cardiovascular disease in the NAFLD cohort ranged
from 5 to 25% and occurred at a higher rate than liver disease-associated mortality
(2 to 13%) with NAFLD groups when compared to their respective reference

populations.24
Symptomatic liver disease developed in 5% of patient in the Swedish study, though
this may underestimate the true risk of progressive liver disease. Cryptogenic cirrho-
sis is the fourth most common indication for liver transplantation and studies in sub-
group have identified features of obesity and diabetes in 73% leading to speculation
that a sizeable number of subjects with cryptogenic cirrhosis may reflect progression
of liver disease resulting from NAFLD.25,26
18.5 Mechanisms of Disease Development

The cause of NAFLD is the subject of intensive investigation at many levels. Two
early paradigm were first to emerge. The first was a separation of the steatosis for-
mation from necroinflammation leading to the “two-hit” hypothesis.27 This theory
posits accumulation of hepatic fat as an initial inciting step. The second step is the
injury elicited by the fat, also known as lipotoxicity from a combination of cytokine
induced injury, lipid peroxidation, and reactive oxygen species.
The second organizing principle is that of NAFLD as the hepatic manifestation
of the metabolic syndrome.28,29 The metabolic syndrome is a disorder characterized
by decreased insulin sensitivity and often coexisting with proinflammatory states.
Accepted criteria used in its diagnosis involve the finding of three or more of the
following: central obesity, hypertriglyceridemia, low HDL cholesterol, hypertension,
and increased fasting plasma glucose.30 The full metabolic syndrome can be identi-
fied in as many as 88% of those with biopsy-proven NAFLD and this observation led
to many studies of the organ-level metabolic changes associated with NAFLD.
18.5.1 Organ-Level Metabolic Changes

Euglycemic-hyperinsulinemic glucose clamps are the gold standard for assessment
of insulin sensitivity. Application of this technique in clinical studies has established
insulin resistance in obese nondiabetics with NASH and steatosis, nonobese non-
diabetics with steatosis, and nonobese diabetics with steatosis.31–34 Insulin signaling
is impaired in the muscle, adipose tissue, and liver, and the degree of impairment
increases in a monotonic fashion with the degree of hepatic steatosis.35 Though both
intrahepatic triglyceride content and visceral adipose tissue volume correlated with
each other and tissue insulin sensitivity, in multivariate analysis, intrahepatic triglyc-
eride content is a superior predictor of insulin resistance than visceral adipose tissue
volume. Whether hepatic fat is the cause or result of insulin resistance is not known.
Hepatic steatosis is common in type 2 diabetes, but not universal. Thus, hepatic ste-
atosis is not universal in all cases where insulin resistance is dominant.
One of insulin’s actions in adipose tissue is the suppression of release of free
fatty acids that are eventually taken up by the liver and reesterified to triglycerides
and increased free fatty acid delivery to the liver could account for one mechanism
to promote an increase in hepatic steatosis. Hepatic triglycerides not consumed
in the process of mitochondrial, peroxisomal, or microsomal fatty acid oxidation
are secreted as apoB-100 containing very low density lipoproteins (VLDL). An
imbalance between the intrahepatic accumulation of triglycerides and its removal

would provide another potential mechanism for hepatic steatosis. ApoB-100 pro-
duction is the rate-limiting step in VLDL synthesis and decreased apolipoprotein
synthesis in subjects with NASH compared to lean and body mass index matched
controls with NASH has been reported.36
A more comprehensive study of obese subjects found similar rates of VLDL-
apoB-100 secretion rates, but increased VLDL-triglyceride secretion rates linearly
related to increases IHTG content. Nonsystemic fatty acids, presumably derived from
intraabdominal fat, intrahepatic fat, and de novo hepatic lipogenesis were the prin-
ciple source for the increase in VLDL-triglyceride secretion that plateaus at hepatic
triglyceride contents above >10%. These findings provide experimental support to
the hypothesis of an imbalance in free fatty acid delivery relative to its hepatic secre-
tion as a mechanism for hepatic triglyceride accumulation.37
18.6 Molecular Mechanisms in the

Development of NAFLD
Hepatic lipid uptake, metabolism, and its de novo synthesis are regulated by a myr-
iad molecules of which transcription factors, cytokines, and adipokines appear most
relevant to NAFLD.
18.6.1 Transcription Factors
The mammalian sterol response, element-binding proteins 1c (SREBP-1c) is one
of three isoforms of a class of transcription factors that upon its nuclear translo-
cation activates hepatic lipogenesis. Overexpression of SREBP-1c in mouse mod-
els leads to the development of hepatic steatosis.38 Conversely, ob/ob mice that
harbor mutations in the leptin receptor and are both obese and insulin-resistance
experience a 50% reduction in hepatic triglyceride when SREBP-1c is inacti-
vate.39 SREBP-1c is able to achieve this effect by activation of genes involve in
lipogenesis, such as fatty acid synthase, and acyl-coA carboylase 1.40 Whether
upregulation of lipogenesis through SREBP-1c is a mechanism in human cases of
NAFLD is unclear, though there is preliminary data that supports the relevance
of this pathway.41
SREBP-1c can also transcriptionally activate the perioxisome proliferator-acti-
vated receptor gamma (PPAR γ). PPAR γ consists of three isoforms (γ1, γ2, and
γ3) created by alternate splicing. Activation of this transcription factor expressed
largely, but not exclusively, in adipose tissue, increases the expression of genes
associated with fatty acid uptake and the storage of triglycerides. PPAR γ2 is
exclusively expressed in adipocytes, exhibits a correlation with body mass index42
and rare heterozygous mutations of PPAR γ result in a syndrome of severe insulin
resistance and hepatic steatosis.43,44 Perhaps the strongest evidence for a role for
PPAR γ in NAFLD comes from emerging data on treatment of NAFLD with thi-
azolidinediones, agonists of the PPARs.
18.6.2 Cytokines and Adipokines

Adipose tissue was historically considered to be site of fat deposition only; however, it
is now accepted that it is a metabolically active tissue that can influence insulin sensitiv-
ity and lipid metabolism in adipose and other tissues. Two adipokines that have been
well studied in NAFLD are TNF-alpha and adiponectin. TNF-alpha is secreted by both
adipocytes and hepatocytes and promotes insulin resistance though there was no dif-
ference in circulating levels of TNF-alpha in subjects with NASH relative to weight
matched controls.45 Adiponectin, by comparison, promotes insulin sensitivity.46 In the
same study that evaluated TNF-alpha, the expression of adiponectin was dramatically
higher in controls than NASH subjects and the low serum adiponectin levels correlated
with the severity of hepatic histology in NASH. In response to an oral fat load, adiponec-
tin increased in control subjects, but showed a slight decrease in NASH subjects.45
18.6.3 Lipotoxicity
Necroinflammation resulting from hepatic steatosis comprises the second of the “two
hits” resulting in liver damage from NAFLD. How precisely steatosis contributes to
cellular damage is unknown. The generation of reactive oxygen species in response to
the oxidation of free fatty acids (FFAs) is one hypothesized mechanism. FFAs undergo
oxidation in mitochondria, peroxisomes, and microsomes. Cytochrome P4502E1 is a
member of the P450 mixed function oxidase system and is involved in the metabolism
of xenobiotics. The activity of CYP2E1 is greater in patients with NASH and has been
associated with disordered insulin signaling and hepatic lipid peroxidation.47
An additional source of inflammation and injury is suggested to occur with mac-
rophage infiltration of white adipose tissue. Central adiposity, of which omental fat
is a major contributor, exhibits a strong correlation with hepatic fat content. In obese
humans, omental fat becomes infiltrated with CD68-positive macrophages to a much
greater extent than subcutaneous adipose tissue and the degree of infiltration correlates
with scores of necroinflammation. The presence of these macrophages is postulated to
contribute to the necroinflammatory injury, possibly through the elaboration of soluble
factors that gain access to the liver by direct secretion into the portal circulation.48,49
18.7 Treatment
To date, all treatment strategies proffered for NAFLD appear to address either the
issue of insulin resistance or oxidative stress. Therapies that have been tried include
lifestyle modification, bariatric surgery, antioxidant therapy, insulin sensitizing
agents, and lipid-lowering medications. Therapies used in clinical trials include:
Diet
Exercise
Weight loss medications
Orlistat
Sibutramine
Endocannabinoid antagonists
Bariatric Surgery
Antioxidants
Vitamin E
N-acetylcysteine
Cytoprotective agents
Ursodeoxycholic acid
Anticytokine agents
Pentoxifylline
Insulin sensitizing agents
Metformin
Thiazolidinediones
Lipid lowering medications
Atorvastatin
Fenofibrate
Despite the increasing volume of literature in this area, no single therapy has yet
to emerge that would satisfy the requirement of rigorous evidence-based processes.
The reasons for this are many and include small study populations and the use of
endpoints, such as aminotransferases, that are unreliable predictors of hepatic his-
tology. Though some studies have used pre- and postintervention liver biopsy to
address this latter concern, even histologic changes are at best surrogates for what
ultimately are the most informative of endpoints of liver disease-related morbidity,
need for liver transplantation, and mortality. To date, the most promising therapies
focus on weight loss or improvements in insulin sensitivity.
18.7.1 Lifestyle Modification/Weight Reduction

Nutritional assessment of subjects with NAFLD reveal greater than average con-
sumption of meat (both lean and nonlean meats), increased carbohydrate consump-
tion from sweetened liquids, and low-nutrient and high sodium foodstuffs.50,51 Weight
reduction by a combination of increased energy expenditure (exercise) and decreased
caloric intake makes intuitive sense for a disease so closely linked to insulin resis-
tance. Support for this approach can be drawn from the Diabetes Prevention Program
in which over 3,000 prediabetics were randomized to receive either metformin with
written recommendations for healthier diets and exercise or an intensive lifestyle
modification program that included 150 minutes of moderate activity weekly and a
goal to lose 7% of body weight. Intensive lifestyle modification proved to be far more
effective in reducing the incidence of diabetes than metformin-treated subjects.52
The outcome of the study is even more sobering in light of the fact that an arm of
the study that used troglitazone as a treatment was discontinued after some study
subjects developed life-threatening medication-induced liver injury.
This success notwithstanding, most weight loss studies through lifestyle modifi-
cations in NAFLD have substantial methodologic issues. Intensive nutritional coun-
seling has been shown to decrease steatosis and inflammation in one small study and
a widely accepted recommendation is for those with obesity and NAFLD to target a
10% reduction in body weight.53
18.7.2 Bariatric Surgery

Bariatric surgery is indicated in the treatment of obesity when the body mass index
is at least 40 kg/m2 or in those at least 35 kg/m2 and coexisting weight-related mor-
bidities (e.g., type 2 diabetes, arterial hypertension, and obstructive sleep apnea).
Contemporary surgical procedures include the Roux-en-Y gastric bypass, biliopan-
creatic diversion with and without duodenal switch, laparoscopic adjustable gastric
banding, and vertically banded gastroplasty. These surgical procedures are very
effective at achieving and maintaining weight loss. On average, a 61.2% reduction
in weight can be achieved with bariatric surgery with concomitant improvements of
associated weight-related comorbidities.54
The efficacy of weight loss surgery with respect to NAFLD has been evaluated
in retrospective and prospective observational studies. The majority of studies that
have included pre- and postoperative liver biopsies have demonstrated improvements
in steatosis and inflammation and either no significant change or an improvement in
fibrosis over a period of follow up ranging from 1 to 3.5 years.55
These promising data notwithstanding, concern persists about the potential risks
of bariatric surgery. Historically, these concerns were engendered from experience
with jejunal–ileal bypass, which resulted in the development of cirrhosis in 5 to
40% of patients56 and acute liver failure. In comparison, neither Roux-en-Y gastric
bypass nor laparoscopic adjustable gastric banding have been reported to cause
either acute or chronic liver disease. Transient elevations in aminotransferases and
portal vein thrombosis have been observed with these surgeries, though are believed
to arise from complications of the operative procedure.57–60 Transient elevations in
aminotransferases with and without hyperbilirubinemia have been observed fol-
lowing biliopancreatic diversion and, in rare cases, death from liver failure has
been reported.61
18.7.3 Insulin Sensitizing Agents

18.7.3.1 Metformin
Metformin is a commonly prescribed oral antidiabetic medication of the biguanide
class. Its mechanism of action involves the activation of the kinase LKB1 to phos-
phorylate adenosine monophosphate activated protein kinase (AMPK), which is a
key regulator of glucose and fatty acid metabolism.62 Treatment of NAFLD with
metformin has been evaluated in at least seven clinical trials of which only four
report follow-up histology.63–69 In a pilot study of 26 patients who completed 48
weeks of treatment, 30% showed improvement in liver histology and ALT levels. All
of the histologic responders also were those who lost more than 5 kg of body weight
during the trial.65
18.7.3.2 Thiazolidinediones
The thiazolidinediones (TZDs) are agonist of the peroxisome proliferator-activated
receptor gamma and result in improved insulin sensitivity in adipose tissue, skel-
etal muscle, and liver. Troglitazone was the first TZD approved for the treatment of
diabetes; however, this medication was withdrawn after numerous reports surfaced
of severe drug-induced liver injury. Clinical trials of TZDs in NAFLD have used
rosiglitazone and pioglitazone, two other agent in the class for which medication-
induced liver injury is rare. All of the six clinical trials with these agents have
documented improvements in aminotransferases, hepatic fat content, and necroin-
flammatory activity.70–75 In a placebo-controlled trial of pioglitazone in subjects with
NASH, six months of treatment resulted in a 54% reduction of hepatic fat content
with concomitant improvements in hepatocyte ballooning and inflammation, but not
fibrosis.74 These successes notwithstanding, these agents have important side effects
that include weight gain and risk of increased mortality from cardiovascular dis-
ease.76 TZDs are also contraindicated in patients with heart failure. Most impor-
tantly, response to TZDs is incomplete and, in a one-year trial with rosiglitazone,
only 47% had an improvement in steatosis.75 These issues notwithstanding, TZDs
are emerging as the leading agent in the treatment of NAFLD. Though not currently
a standard of care in the management of NAFLD, compelling arguments could be
made for their use in type 2 diabetics with concomitant NAFLD.
18.8 Pediatric NAFLD

Though historically considered a disease of adults, there is a growing awareness and
concern for the NAFLD in pediatric populations reflecting the epidemic of child-
hood obesity. A study from Japan using ultrasound imaging reported an incidence
of fatty liver in 2.6% of school age children.77 The more recent Study of Child and
Adolescent Epidemiology (SCALE) reported a prevalence of 9.6% in San Diego,
California, based on autopsy performed on children from age 2 to 19 years over a
10-year period.78 Fatty liver is present in 38% of obese children and shows a striking
heritability. Parents and siblings of children with NAFLD have greater rates of exces-
sive intrahepatic triglyceride content than overweight children without NAFLD.79
And similar to findings regarding race and ethnicity in adults, Hispanic children
have been observed to have five times the odds of having fatty liver than African
American children after controlling for the severity of obesity.
Akin to adult NAFLD, the disease is strongly associated with insulin resistance.80
Where a difference with the adults disease does exist is in the association with hypo-
thalamic or pituitary disease81 and histologic findings. Children with NAFLD have
two distinct histologic patterns. The adult pattern (steatosis, hepatocyte ballooning,
and perisinusoidal fibrosis) is present, but a minority of the time. More commonly,
liver biopsies in children have steatosis with a prominence of portal inflammation
and varying degrees of fibrosis.82 The mechanisms that determine which pattern
will occur are not known nor are the clinical import of having one or the other of
the pattern.
18.9 Conclusion
Over the past three decades, NAFLD has emerged as a substantial cause of liver
disease-related morbidity and mortality in both children and adults. A growing body
of literature suggests that the disease should be considered as the hepatic manifesta-
tion of insulin resistance and the metabolic syndrome. No definitive treatment for
NAFLD has been established; yet, strategies that improve obesity (lifestyle modi-
fication, bariatric surgery) or improve insulin resistance appear to hold the most
promise for effective treatment of this disorder.
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19 Weight Management
Strategies
Shelby Sullivan
Contents
19.1 Introduction................................................................................................... 315
19.2 Assessing Body Mass.................................................................................... 316
19.3 Energy Balance.............................................................................................. 316
19.3.1 Therapeutic Lifestyle Changes.......................................................... 318
19.3.2 Diet.................................................................................................... 318
19.3.3 Exercise.............................................................................................. 319
19.3.4 Behavior Modification....................................................................... 320
19.4 Pharmacotherapy........................................................................................... 321
19.4.1 Sibutramine........................................................................................ 321
19.4.2 Orlistat............................................................................................... 322
19.5 Bariatric Surgery........................................................................................... 322
19.5.1 Roux-en-Y Gastric Bypass (RYGB)................................................... 323
19.5.2 Laparoscopic Adjustable Gastric Banding (LAGB).......................... 323
19.6 Conclusions.................................................................................................... 323
References............................................................................................................... 324
19.1 Introduction
We are currently experiencing an epidemic of overweight and obesity both in
the United States and abroad. The most current National Health and Nutrition
Examination Survey (NHANES) data as of the writing of this chapter was from
2005–2006, which showed that more than one third of U.S. adults (33.3% of men and
35.3% of women) were obese as defined by a body mass index (BMI) of >30 kg/m 2.1
Obesity is associated with increased risks for diabetes, hypertension, cardiovascular
disease, and certain cancers as well as an increase in relative risk of mortality. A
study of over one million healthy, nonsmoking U.S. adults found that obese white
men and white women had a 2.58 and 2.00 relative risk of death, respectively, com-
pared to lean men and women.2
The health risks of obesity and the need for weight loss are well known and even
small reductions in weight are associated with significant health benefits.3 However,
successful weight loss continues to be a challenge for patients and clinicians. This
chapter will review the fundamentals of energy balance and detail weight manage-
ment strategies.
315
19.2 Assessing Body Mass

The body is divided into lean body mass and fat mass. Lean body mass includes
bone, muscle, and organs. Lean body mass can be further divided into intracellular
and extracellular mass; however, for the purposes of this section we are focusing on
the differentiation between lean mass (or fat free mass) and fat mass. Body com-
position can be measured using densitometry, bioelectrical impedance, underwa-
ter weighing, and with total body water techniques using deuterium oxide (heavy
water). While these measures are commonly used in research, they are not practical
in the hospital setting.
We typically use BMI as an easily calculated surrogate marker for body com-
position. It is calculated from height and weight, and it relates to risks of morbid-
ity and mortality as well energy requirements. It is not a perfect substitution; some
populations (e.g., football players, bodybuilders) may have a high BMI primarily
due to their increased muscle mass. However, it is adequate to detect and quantify
overweight/obesity in the majority of Americans because most Americans who have
BMIs in the overweight and obese ranges have an excess of body fat.
BMI = wt (in kg)/height (in m2)
Classification of underweight, normal weight, overweight, and obesity in adults is

based on BMI-related mortality data (Table 19.1).2,4,5
19.3 Energy Balance
Energy is stored in the body as triglyceride or glycogen in a number of tissues includ-
ing adipose tissue, skeletal muscle, and liver. Triglyceride is a more efficient means
of energy storage because each gram liberated 9.3 kcal when oxidized in comparison
to glycogen, which liberates 4.1 kcal when oxidized. Additionally, glycogen is stored
as a gel requiring roughly three times its weight in water. In a 70 kg (154 lb) man,
approximately 2,500 kcal of glycogen is stored in skeletal muscle and 400 kcal are
stored in the liver. The energy stored in triglyceride far exceeds this with 3,000 kcal
stored in skeletal muscle, 450 kcal in the liver, and 120,000 kcal in adipose tissue.
Table 19.1
BMI and Weight Classification
BMI Classification
<18.5 kg/m2 Underweight
18.5–24.9 kg/m2 Normal weight
25–29.9 kg/m2 Overweight
30–34.9 kg/m2 Class I obesity
35–39.9 kg/m2 Class II obesity
>40 kg/m2 Class III obesity
Weight Management Strategies 317
The total energy expenditure or energy required by an individual can be deter-

mined by the equation below:
Total Energy Expenditure (TEE) = B

asal Metabolic Rate (BMR) + Activity +
Thermic Effect of Food
BMR is the amount of energy consumed at rest. The amount of energy needed
to maintain 1 kg of lean body mass is remarkably constant for individuals with a
similar height. BMR is also known as resting metabolic rate (RMR), basal energy
expenditure (BEE), or basal energy requirement (BER). The differences in BMR
between individuals reflect differing body composition. The total energy expendi-
ture, however, can vary widely from person to person based on activity level. This
includes all activity (exercising, fidgeting, housework, etc.). BMR can be determined
experimentally with a calorimeter, but, for practical purposes, calculations can be
used to estimate BMR. Many methods are available for calculating BMR. One of the
classic calculations that approximates BMR is the Harris–Benedict equation:6
Men: BMR (in kcal/day) = 66.5 + (13.8 × wt in kg) + (5 × ht in cm)

– (6.76 × age in years)
Women: BMR (in k/cal/day) = 655 + (9.56 × wt in kg) + (1.85 × ht in cm)
– (4.68 × age in years)
Once BMR is determined, one can then determine the amount of calories expended
in activity or physical activity level (PAL). PAL is the ratio of TEE to BMR. This
varies far more from person to person than BMR and depends on BMI, age, and sex.
The data for PALs has been derived from a doubly labeled water database for basal
energy expenditure and metabolic equivalents (METS) for a number of activities.7,8
PAL can be divided by average daily activity levels of individuals (Table 19.2). The
BMR is then multiplied by the PAL to determine BMR + Activity.
The thermic effect of food is the heat that is produced by the metabolism and stor-
age of nutrients. It is essentially the energy costs of digestion, transport, and storage
of nutrients. The heat produced varies between macronutrients, but is 6 to 10% of
TEE on average.
An adjusted body weight rather than actual body weight should be used in obese
patients to avoid overfeeding.
Table 19.2
Physical Activity Levels (PAL)
Activity Level PAL
Sedentary 1.0–1.4 (ex. no recreational exercise, minimal exertion during the day)
Low active 1.4–1.6 (ex. small amount of recreational exercise, job requiring some walking during
the work day)
Active 1.6–1.9 (ex. fairly active during the day, plus some moderate to intense exercise)
Very active 1.9–2.5 (ex. endurance athletes)
Adjusted body weight = ideal body weight + ([actual body weight – ideal body
weight] × [0.25])
When calories are consumed in excess of total energy expenditure, they are stored
with the majority of energy, which is stored as triglyceride in adipose tissue. When
more calories are expended than consumed, triglycerides are released from adipose
tissue to be oxidized for energy and weight is lost. It is important to note, however,
the calculations presented above are only estimations and can be affected by a vari-
ety of factors.
19.3.1 Therapeutic Lifestyle Changes

The medical treatment of obesity involves not only identifying patients that need to
lose weight, but also providing a structured, goal-oriented approach that can be mod-
ified depending on the clinical response. The components of this approach include
diet, physical activity, and behavior modification. In discussing weight loss, it must
be stressed to patients that changes they make are lifestyle changes and will be life-
long. If patients return to prior habits, they will regain their weight. It is important
for the physician to provide long-term surveillance to ensure continued success of
the patient, and, if needed, recruit additional support, such as dieticians, physical
therapists, family members, or referral for behavior therapy.
19.3.2 Diet
Decreasing calorie intake should be considered the basis of any weight loss pro-
gram. The National Institute of Health (NIH) currently recommends 300 to 500
kcal decrease in calories per day in persons with a BMI of 27 to 35 for a goal of 10%
weight loss over six months (1/2 to 1 pound weight loss per week). For the same per-
cent weight loss in persons with BMI >35, the NIH recommends decreasing calories
by 500 to 1000 kcal/day (1 to 2 pound weight loss per week). While these recommen-
dations are evidence based, practically speaking, determining a patient’s total energy
expenditure can be cumbersome as seen above and may be inaccurate primarily due
to variations in energy expenditure. Therefore, a simple calorie guideline based on
weight has been proposed as an easy way for clinicians to identify calorie goals for
patients initiating therapeutic lifestyle changes (Table 19.3).9 Very low calorie diets
(VLCD), which vary in calories but are typically 800 kcal or less, have been used for
weight loss. However, a meta-analysis has recently shown that although VLCDs are
associated with significantly more weight loss in the short term, at one year there is
no difference between low calorie diets and VLCD.10 In addition, VLCDs need to be
medically monitored due to their increased association with weight loss complica-
tions, thus, they are rarely recommended.
There are many “diets” currently in fashion. These vary the macronutrient content
of the diet. Diets that restrict dietary fat have been extensively studied and do cause
weight loss.11 However, in a randomized control trial comparing a low-fat ad libitum
diet and a low-calorie diet providing 1,200 to 1,500 kcal/day, the low-calorie diet
was associated with almost double the weight loss of the low‑fat diet. Additionally, a
Table 19.3
Suggested Energy Composition of Initial Reduced-Calorie Diet
Weight in Pounds Suggested Energy Intake kcal/day
150–199 1000
200–249 1200
250–299 1500
300–349 1800
>300 2000
Source: Klein, S. AGA technical review on obesity. Gastroenterology 2002;123(3):882–

932. With permission.
recent meta-analysis of 13 studies has shown that over six months, low carbohydrate
diets may produce more weight loss than conventional low-fat diets.12 This difference
is lost by 12 months in most studies. The long-term effects of a low carbohydrate
diet have not been extensively studied. Although in studies up to one year, there is
a favorable outcome on cardiovascular risk factors; it is unclear if this effect is long
lasting. Furthermore, a recent study of participants in the National Weight Control
Registry, which is a registry of people who have lost at least 30 pounds and have
maintained their weight loss for at least one year, found that although more par-
ticipants were on a low carbohydrate diet as of 2003 compared with 1995 (17.1%
and 5.9%, respectively), success in maintaining weight loss was still associated with
consumption of a low-calorie moderate fat diet.13 Currently, the NIH recommends
30% or less total calories from fat (8 to 10% saturated fat), 15% of total calories from
protein, and 55% or more calories from carbohydrates. Again, any dietary change
that causes a calorie deficit will cause weight loss and regardless of the method of
weight loss, patients need a long-term commitment to the dietary change in order to
be successful at losing and maintaining their weight loss.
Other than macronutrient composition, the diet plan should stress other com-
ponents of healthy eating. Physicians should emphasize the importance of regular
meals, as skipping meals can lead to overeating later in the day. Patients should also
focus on portion control. Lastly, physicians should encourage food choices that are
low calorie, but nutrient dense.
19.3.3 Exercise
Exercise is not a critical component of weight loss. Exercise performed by itself and
not in conjunction with calorie reduction typically does not produce clinically sig-
nificant weight loss;14 however, exercise has many other beneficial metabolic effects.
Exercise performed in conjunction with reducing weight has been shown to decrease
loss of lean tissue seen during weight loss in both adults and elderly adults.14–17
Exercise can also decrease baseline serum free fatty acids18,19 and improve skeletal
muscle insulin sensitivity to glucose metabolism.20,21
Although exercise is not crucial for weight loss, it is likely a key component of
weight maintenance. The exercise required for weight maintenance is substantial,
though, as one study found that 80 minutes/day of moderate activity (e.g., brisk
walk) or 35 minutes of vigorous activity (e.g., running) was needed.22 Another study
found that an energy expenditure of 2,500 kcal/week (approximately 25 miles of
walking) was associated with better weight maintenance than lower levels of energy
expenditure.23 Furthermore, 94% of the participants in the National Weight Control
Registry regularly exercise, with an average of 2,700kcal/week in energy expendi-
ture (approximately 27 miles walking).13 In this population, decreases in physical
activity have been associated with weight regain.
The current recommendations by the U.S. Department of Agriculture (USDA) for
exercise are based on an individual’s goals. To reduce the risk of chronic diseases in
adulthood, the USDA recommends 30 minutes of moderate intensity (e.g., brisk walking)
per day on most days of the week. To manage weight into adulthood, the USDA recom-
mends 60 minutes of moderate to vigorous intensity exercise per day on most days of the
week. To prevent weight regain in persons who have lost weight, the USDA recommends
60 to 90 minutes of moderate intensity exercise per day on most days of the week.
19.3.4 Behavior Modification

Behavior modification in the treatment of obesity is the process of identifying and
then modifying lifestyle habits that contribute to a person’s obesity. Behavior modi-
fication has three general principles: (1) it is goal oriented, (2) it is process oriented,
and (3) it advocates small rather than large changes. Goals should be well defined
and easy to quantify, e.g., performing moderate intensity exercise for 30 minutes 5
days a week. Process oriented means that the goals that are set are reasonable for
patients to achieve, and it stresses prior planning to ensure that these goals are met.
Small changes are recommended over large changes because making small stepwise
changes are typically easier to maintain than large changes.
The components of behavior modification that support the general principles
include: self-monitoring (recording food intake, physical activities, and behaviors
daily), stimulus control (identifying triggers for eating and avoiding them), social
support (recruiting friends and family to help achieve weight loss goals), cognitive
restructuring (thinking positively about self and weight loss), problem solving (iden-
tifying barriers to success and finding ways to deal with them), and relapse preven-
tion (managing episodes of overeating or weight regain).24 Self-monitoring is one of
the key components of behavior modification and should be stressed to patients.25,26
A variety of tools are available to aid patients in self-monitoring. For example, the
USDA’s Web site (www.mypyramid.gov) contains a Web-based dietary plan as well
as a dietary and physical activity tracker.
Although behavior modification has been shown to have an average of 9% weight
loss,25 group behavior modification therapy may be difficult to find, and, moreover,
in many cases is too expensive for patients. Commercial weight loss centers also can
be an option, but these may be too expensive as well for many patients. However,
there are some simple steps that a physician can do in the office to promote behavior
modification. First, identify a small change that the patient can make (e.g., switching
from regular soda to diet soda). Second, make a plan for how that change will be
carried out. Next, have the patient keep a record of that behavior change. At the next
office visit, review the patient’s record. Congratulate successes, but avoid criticism.
Instead, if patients do not meet their goals, identify barriers to meeting their goals
and discuss ways to deal with those barriers.
19.4 Pharmacotherapy
Weight loss medications can enhance weight loss; however, they should only be used
in conjunction with therapeutic lifestyle changes. It should be stressed to the patient
that these medications are not a replacement for therapeutic lifestyle changes. In
addition, weight loss medications should be considered a long-term medication, if
not life-long. Patients will regain weight if the medications are stopped and should
be counseled about this prior to starting the medications. Conversely, if the medica-
tion has not caused weight loss within one to two months, it will likely not cause
further weight loss and should be stopped. Indications for use of weight loss medica-
tions include:
• BMI >30 kg/m2 or BMI >27 kg/m2 with concomitant obesity-related risk
factors or diseases
• Unable to achieve weight loss goal despite therapeutic lifestyle changes
• No contraindications to use
There are multiple weight loss medications that are currently approved for use in
the United States; however, only sibutramine and orlistat are approved for long-term
use. Because these medications need to be used long-term, only the drugs that are
approved for long-term use will be discussed further.
19.4.1 Sibutramine
Sibutramine is a central reuptake inhibitor of norepinephrine and serotonin thought
to act by suppressing appetite. Meta-analyses of long-term randomized control trials
have shown that subjects taking sibutramine lose ~4.5% more weight than control
subjects.27,28 Furthermore, sibutramine has been shown to be effective in diabetic
subjects29 and intermittent use of the medication is as efficacious as continuous use
at one year.30 Again, all of these studies included therapeutic lifestyle changes in
both the control and drug arms of the study. Sibutramine has been shown to be less
effective without these lifestyle changes.31
Sibutramine can increase heart rate and blood pressure, and carries a risk of
serotonin syndrome when combined with MAOIs (monoamine oxidase inhibitors),
triptans, and opioids. Contraindications to its use include poorly controlled hyperten-
sion, coronary artery disease, angina, arrhythmias, congestive heart failure, stroke,
transient ischemic attacks, seizure disorder, severe liver or kidney disease, and con-
comitant use of MAOIs. The most common side effects are dry mouth, headache,
constipation, and insomnia. Most insurance carriers do not cover sibutramine, and
the cost for a month’s supply varies from $100 to $140.
19.4.2 Orlistat
Orlistat binds to intestinal lipases and prevents the digestion and absorption of fat in
the intestine. Patients taking orlistat are instructed to consume 30% or less of their
daily calories as fat. Under this condition, prescription strength orlistat will block
roughly 30% of ingested fat from being digested and absorbed, although the actual
percentage may vary from person to person.32 Meta-analyses of long-term orlistat
use demonstrate approximately 3% more weight loss at one year than with thera-
peutic lifestyle changes alone,33,34 and twice as many subjects lost >5% and >10% of
their total body weight on orlistat compared with placebo.
The most common side effects of orlistat include: abdominal pain, fatty/oily stool,
increased defecation, liquid stools, fecal urgency, flatulence, flatus with discharge, fecal
incontinence, and oily evacuation. Most side effects do improve over time while still on
the medication.35 Approximately 5% of patients taking orlistat will develop deficiencies
in fat soluble vitamins; therefore, a multivitamin should be prescribed with orlistat and
taken separately.35 Orlistat also may interfere with the absorption of lipophilic medica-
tions. Orlistat should not be given simultaneously with these medications and serum drug
levels of the lipophilic drug should be monitored frequently. Prescription orlistat costs
$250 to $300 for a one-month supply. A nonprescription form is also available, which is
essentially half of the prescription dose. The nonprescription form costs approximately
$60 for a one-month supply, but is not as effective as the prescription dose.
19.5 Bariatric Surgery
Bariatric surgery can be an effective method of weight loss for some obese patients.
These surgeries do come with risk; however, the weight loss achieved with bariat-
ric surgery improves diseases that are associated with obesity and, in some cases,
completely reverses them.36 Moreover, data from long-term studies have shown that,
although some weight regain does occur, significant weight loss is maintained and
obesity-related disease mortality is decreased after bariatric surgery.37,38
Bariatric surgery also should be performed only as an adjunct to therapeutic life-
style changes. Indications for surgery include:
• BMI > 40 kg/m2 or BMI 35 to 40 kg/m2 with life-threatening cardiopulmo-

nary disease, severe diabetes, or lifestyle impairment.
• Failure to achieve weight loss with other treatment modalities.
Contraindications to bariatric surgery include a history of medical noncompli-

ance, psychiatric illness, and high risk of death during the procedure. Success of the
surgery requires involvement of a team of medical, surgical, psychiatric, and nutri-
tion experts. The most common current techniques include laparoscopic adjustable
gastric banding and roux-en-y gastric bypass and will be discussed further below;
less common techniques include biliopancreatic diversion and biliopancreatic diver-
sion with duodenal switch. Patients should be aware of multiple complications, risks
associated with the procedure, and that complication rates are lower at centers with
more experience.39
19.5.1 Roux-en-Y Gastric Bypass (RYGB)

RYGB was first reported in 1967 by Mason and Ito. It is the most commonly performed
bariatric surgery.40 The procedure is both restrictive and malabsorptive, and it may
have effects on the neuroendocrine system regulating appetite and satiety.41 First, a
small (10 to 30 ml) pouch is made out of the stomach either by stapling across or com-
plete transection. Then, the small intestine is divided 30 to 60 cm distal to the ligament
of Treitz. The segment of bowel proximal to the division is the biliopancreatic limb,
and the portion distal to the division is the roux limb. The roux limb is anastomosed to
the gastric pouch. The biliopancreatic limb is anastomosed 75 cm from the gastroje-
junostomy in a standard RYGB procedure. For the super obese patient, the distance
between the gastrojejunostomy and the jejunostomy may be as much as 150 cm.
The procedure can be done open or laparoscopically. Patients undergoing RYGB,
regardless of open or laparoscopic technique, typically loose ~60% of their excess
body weight.36,42 The complications of open RYGB include: hemorrhage, wound
infection, arrhythmias, pulmonary emboli, hernias, staple line disruption, dumping
syndrome, anastomotic strictures, and anastomotic leaks. These can occur in 5 to
10% of patients.43 The laparoscopic approach does have several advantages includ-
ing less wound complications, less blood loss, faster recovery, but also may be asso-
ciated with increased risk of anastomotic strictures. Patients will need nutritional
counseling before and after the procedure with nutrient supplementation starting at
the time of surgery with regular follow-up as nutritional deficiencies are common in
RYGB patients.
19.5.2 Laparoscopic Adjustable Gastric Banding (LAGB)

The LAGB procedure involves the surgical placement of a silicone band around the
upper stomach, just distal to the gastroesophageal junction. The band is connected
to a port that is implanted subcutaneously. The port can be accessed to infuse or
withdraw saline to adjust the circumference of the band.
Weight loss for LAGB is ~50% of excess weight at two years on average.36,42 With
additional adjustments of the band after the initial weight loss, additional weight loss
may be achieved and in some cases may reach levels similar to RYGB. However,
the efficacies of these two treatments have never been studied in a randomized trial.
The risks of the procedure are less than those of RYGB and include: local infection,
erosion of the band into the mucosa, band prolapse, and esophageal dilatation. The
30-day mortality rate is 0.1% in the hands of experienced surgeons.36,42
19.6 Conclusions
Obesity treatment is important for the health of our obese patients. Weight loss and
weight maintenance are challenging, but even a 5% reduction in weight is associated
with significant health improvements. It is important for the clinician to empha-
size therapeutic lifestyle changes when discussing weight loss. Moreover, clinicians
should be open to using adjunctive treatments, such as pharmacotherapy or bariatric
surgery to enhance weight loss and weight maintenance in their patients.
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20 Bariatric Surgery
Alessandrina Freitas and John F. Sweeney
Contents
20.1 Introduction................................................................................................... 328
20.2 History of Bariatric Surgery.......................................................................... 328
20.3 Indications for Surgery.................................................................................. 328
20.4 Surgical Procedures....................................................................................... 329
20.4.1 Restrictive Procedures....................................................................... 329
20.4.1.1 Vertical Banded Gastroplasty (VBG)................................. 330
20.4.1.2 Adjustable Gastric Banding................................................ 330
20.4.1.4 Vertical (Sleeve) Gastrectomy............................................. 332
20.4.2 Malabsorptive Procedures................................................................. 333
20.4.2.1 Biliopancreatic Diversion +/– Duodenal Switch................ 333
20.4.3 Restrictive/Malabsorptive Combinations.......................................... 333
20.4.3.1 Roux-en-Y Gastric Bypass.................................................. 333
20.5 Complications: Identification and Management............................................ 334
20.5.1 Complications Common to All Bariatric Procedures....................... 334
20.5.1.1 Deep Venous Thrombosis/Pulmonary Embolism.............. 334
20.5.1.2 Bleeding.............................................................................. 334
20.5.1.3 Anastomotic Leak............................................................... 335
20.5.1.4 Wound Infection................................................................. 335
20.5.1.5 Failure to Lose Weight or Regaining of Weight................. 336
20.5.2 Complications of Restrictive Procedures.......................................... 336
20.5.2.1 Gastric Prolapse.................................................................. 336
20.5.2.2 Pouch Dilation.................................................................... 336
20.5.2.3 Band Erosion....................................................................... 336
20.5.2.4 Port/Tube Dysfunction........................................................ 337
20.5.2.5 Need for Band Removal...................................................... 337
20.5.3 Complications of Malabsorptive Procedures..................................... 337
20.5.3.1 Small Bowel Obstruction.................................................... 337
20.5.3.2 Marginal Ulceration............................................................ 337
20.5.3.3 Malnutrition........................................................................ 338
20.5.2.4 Micronutrient Deficiencies.................................................. 338
20.5.2.5 Protein Malnutrition........................................................... 338
20.5.2.6 Excessive Weight Loss........................................................ 339
20.6 Outcomes....................................................................................................... 339
20.6.1 Diabetes............................................................................................. 339
20.6.2 Hypertension......................................................................................340
20.6.3 Obstructive Sleep Apnea...................................................................340
327
20.6.4 Hyperlipidemia..................................................................................340
20.6.5 Osteoarthritis.....................................................................................340
20.7 Summary.......................................................................................................340
References............................................................................................................... 341
20.1 Introduction
Over the past 30 years, there has been a virtual explosion in the epidemic of obe-
sity here in the United States. There are several causes for this dramatic increase
of obesity: labor-saving devices, the decrease in physical activity, the increase in
sedentary occupations and lifestyles, and the ready availability of high caloric
food. This is problematic because obesity is associated with an increase in chronic
debilitative diseases like diabetes, hypertension, hyperlipidemia, amongst others.
The increase in these diseases is driving up healthcare costs dramatically. This
chapter will review the history of bariatric surgery, indications for bariatric sur-
gery, surgical procedures currently available, identification and management of
postoperative complications, and the short- and long-term outcomes for the various
operations discussed.
20.2 History of Bariatric Surgery

The birth of bariatric surgery can be traced to the 1950s at the University of
Minnesota. Researchers there were evaluating the nutritional importance of the
proximal and distal small intestine in a series of animal experiments. They discov-
ered that bypassing most of the intestines while keeping the stomach intact induced
a state of malabsorption that was associated with significant weight loss in a canine
model. This so-called jejunoileal (JI) bypass was applied shortly thereafter and was
initially deemed a huge success; patients could eat whatever they wanted and still
lose weight. Unfortunately, too many patients developed complications, such as diar-
rhea, night blindness (from vitamin A deficiency), osteoporosis (from vitamin D
deficiency), protein-calorie malnutrition, and kidney stones. The more worrisome
complications included progressive hepatic fibrosis, cirrhosis, and eventual liver fail-
ure in a significant number of patients. These latter complications were felt to be
secondary to toxic overgrowth of bacteria in the bypassed intestine. Because of these
problems, the JI bypass is no longer a recommended surgical procedure for weight
loss. An important lesson learned from this experience was that long-term follow-up
by an experienced bariatric surgeon is required for all patients who undergo a bariat-
ric procedure for weight loss.
20.3 Indications for Surgery

Appropriate patient selection is essential for successful outcomes of bariatric sur-
gery. Prior to consideration for a weight reduction procedure, the patient should have
documented attempts at weight loss by nonoperative means. The National Institute
of Health (NIH) guidelines for consideration for bariatric surgery are a body mass
index (BMI) >40 or >35 with significant medical comorbidities attributed to obesity.
Bariatric Surgery 329
These comorbidites include, but are not limited to, hypertension, diabetes, hyperlipi-
demia, osteoarthritis, obstructive sleep apnea, and gastroesophageal reflux disease.
Once these rather straightforward guidelines have been met, a more detailed evalu-
ation of the patient is undertaken to ensure that the patient will be able to comply
with the resultant lifestyle alterations. Psychiatric stability and the cognitive ability
to generally understand the procedure and it’s expected outcomes is paramount. The
patient must be motivated and willing to participate in long-term follow-up. Finally,
existing medical comorbidities must be evaluated to ensure that the patient can phys-
ically withstand the proposed operation and could be reasonably expected to benefit
from long-term weight reduction.
Specific contraindications to bariatric surgery are few as long as the previous
discussed criteria are met. Patients who cannot provide informed consent due to
debilitating psychiatric disease or cognitive impairment and those who have an unac-
ceptably high perioperative mortality risk should be excluded. Endocrine disorders
that are associated with weight gain (e.g., hypothyroidism, Cushing’s Syndrome)
must be under control before surgery is considered.
Bariatric surgery is usually considered for patients in the 18- to 60-year-old range.
Weight reduction surgery can be performed in patients older than 60 years of age as
long as the patients have a satisfactory performance status. Weight reduction surgery
in the adolescent population is becoming more common, despite some residual con-
troversy as to its appropriate application and still limited, long-term outcome data.
It is clear that adolescents who have undergone bariatric procedures achieve weight
loss and resolution of comorbidities at a rate equal to, and perhaps superior than,
adult populations. The earlier intervention in comorbid conditions before they have
time to develop irreversible sequelae has been cited on numerous occasions as ratio-
nale for adolescent weight reduction surgery. Currently, procedures that have been
applied to the adolescent population are the adjustable gastric band, Roux-en-Y gas-
tric bypass, and sleeve gastrectomy. Until further information regarding outcomes
is available, bariatric surgery in adolescents should only be performed as part of an
institutional review board (IRB)-approved protocol.
20.4 Surgical Procedures
Surgery is the only proven method to achieve long-term weight reduction in the mor-
bidly obese. The evolving field of bariatric surgery is now comprised of operations
that are based on restriction, malabsorption, or a combination of these two methods.
Although all of these procedures are commonly performed through a laparoscopic
approach, there are some patients that, due to extreme obesity, multiple previous
abdominal surgeries, or comorbid physiology that makes CO2 insufflation danger-
ous, in whom open surgery may be a more suitable option. Only the laparoscopic
approach to these operations will be discussed here.
20.4.1 Restrictive Procedures
The concept of restrictive weight loss surgery is simple: reduce the amount of oral
intake by limiting the gastric volume. Retention of food in the limited upper gastric
pouch (vertical banded gastroplasty, adjustable gastric banding) and limited total res-
ervoir size and increased intraluminal pressure (sleeve gastrectomy) produce early
satiety. Purely restrictive procedures have the advantage of leaving the alimentary
tract in continuity minimizing the risks of metabolic complications.
20.4.1.1 Vertical Banded Gastroplasty (VBG)

Thirty years ago, VBG was the most commonly performed weight loss surgery.
Historically, patients undergoing a VBG had excellent early weight loss, but demon-
strated a tendency to regain weight over the long term. Over the years, it has fallen
out of favor due to the increased effectiveness of gastric bypass and the increased
ease of adjustable gastric banding.
VBG can be done as an open, laparoscopic, or hand assisted procedure. An area
5 to 9 cm below the gastroesophageal junction is identified and the circular stapler
is used to create a circular defect through the anterior and posterior gastric walls.
The second stapler application is a linear staple line directed toward the angle of His
(angle of entry of the esophagus into the stomach) from the superior aspect of the
newly created circle. The restricting pouch is completed by the placement of a band
to create a controlled outflow stoma.
20.4.1.2 Adjustable Gastric Banding

Currently there are two U.S. Food and Drug Administration (FDA)-approved adjust-
able gastric banding devices in the United States. It is the safest bariatric procedure
performed today, with a 0.05% mortality.1 The primary advantage of the adjustable
gastric banding is the availability to modify stoma size over time in order to provide
early satiety with minimal symptoms, such as vomiting or dysphagia. The addition
or removal of saline is generally titrated to a weight loss of 1 or 2 lbs per week.
Disadvantages include the ability to circumvent weight loss by ingestion of high
calorie liquids and the need for frequent follow-up in the first two years for band
adjustments. Conversion rate to an open procedure is roughly 1%.1
There are three basic steps for placement of an adjustable gastric band. These
include dissection of the proximal stomach with creation of a retrogastric tunnel,
band placement and fixation, and subcutaneous access port placement. Dissection
of the proximal stomach is now commonly done via the pars flaccida technique to
create a retrogastric tunnel. This results in a lower rate of gastric prolapse and gastric
pouch dilation when compared to the older perigastric technique.2,3
Port placement varies based on surgeon preference, but generally follows a simi-
lar configuration. A 5 mm optical access trocar is placed at the left anterioaxillary
line just off the costal margin.
Following CO2 insufflation, a 15-mm port is placed in the left midclavicular line
15 cm inferior to the xiphoid process. A 12-mm port is placed in the right midclavic-
ular line 15 cm below the xiphoid. A final 5-mm port is placed in the right anterior
axillary line at the costal margin. The liver is elevated, allowing better visualiza-
tion of the gastroesophageal junction. The band is inserted into the abdomen via
the 15-mm port, where it is ready for later use. The gastric fundus is then caudally
retracted and attachments between the fundus and diaphragm are divided (Figure
20.1). This allows for visualization of the angle of His, essential for the later passing
Figure 20.1 (See color insert following page 112) Dissection of angle of His. (From
Jones DB. Atlas of Minimally Invasive Surgery. Cine-Med Inc, 2006. With permission.)
of the band. Excision of perigastric fat pads, especially those around the gastroe-
sophageal junction, is performed. The pars flaccida technique to create a retrogastric
tunnel is carried out and the grasper is visualized at the previously dissected angle
of His (Figure 20.2). The band is brought through this tunnel to encircle the upper
stomach and is locked in place (Figure 20.3). A 5-mm instrument should be able
to be passed between the stomach and band. The band is secured in placed with a
tension-free anterior fundoplication, using permanent suture (Figure 20.4). The final
portion of the procedure is placement of the access port that allows band adjustment
over time. The tubing is delivered out through the 15-mm trocar site and is attached
to the access port, leaving any excess tubing to lie freely within the peritoneal cavity.
All intraperitoneal instruments can be removed and insufflation ceased.
Figure 20.2 (See color insert following page 112) Pars flaccida approach for creation
of retrogastric tunnel. (From Jones DB. Atlas of Minimally Invasive Surgery. Cine-Med Inc,
2006. With permission.)
Figure 20.3 (See color insert following page 112) Lap band placement. (From Jones
DB. Atlas of Minimally Invasive Surgery. Cine-Med Inc, 2006. With permission.)
Figure 20.4 (See color insert following page 112) Completed anterior fundoplication
to prevent gastric prolapse. (From Jones DB. Atlas of Minimally Invasive Surgery. Cine-Med
Inc, 2006. With permission.)
The access port is secured at four corners with permanent suture to the anterior
rectus sheath. The band is left empty initially and all incisions are closed in the
usual fashion.
An over-penetrated abdominal x-ray should be obtained in the recovery room
to document band orientation. Contrast esophagraphy should be performed post-
operatively if there is any question about pouch anatomy, or if there is concern for
obstruction or perforation. Band adjustments are made in the office every six to
eight weeks.
20.4.1.4 Vertical (Sleeve) Gastrectomy

Sleeve gastrectomy (Figure 20.5) initially was proposed as the first step of a two-stage
surgery for the super obese patient. Following sleeve gastrectomy and weight loss,
the patient would then undergo a bypass procedure. However, the sleeve gastrectomy
is now being used as a stand alone operation for weight reduction. This restrictive
procedure resects approximately 80 to 90% of the stomach, leaving behind only a
narrow tube to function as an alimentary conduit. There is some concern over the
lack of long-term postoperative data and some ambiguity on the most efficacious
surgical technique. However, studies have demonstrated good results without any
serious complications.4
There are several key steps to performing the sleeve gastrectomy, whether
approached open or laparoscopically. Starting 3 to 6 cm from the pylorus and pro-
ceeding to the angle of His, a linear stapler is used to transect the vascular supply
of the greater curvature. A Harmonic scalpel is applied to divide the gastroepip-
loic vessels and the short gastric vessels are individually ligated. A 32 to 48 French
bougie is placed via the esophagus along the lesser gastric curvature. This allows a
continuous, consistent guide for the sleeve caliber. As would be expected, use of a
Figure 20.5 (See color insert following page 112) Completed appearance of a sleeve
gastrectomy. (Tucker ON. Indications for sleeve gastrectomy. J Gastrointest. Surg. Springer.
4:664, 2008. With permission.)
larger caliber bougie results in a lower incidence of stricture.5 Several firings of a lin-
ear stapler cutter are applied to transect the antrum, corpus, and fundus. The entire
staple line is then inverted with a continuous seroserosal suture. The bougie is then
removed and the gastric sleeve is examined endoscopically for any areas of stricture
or leak. A gastrograffin swallow is performed on the first postoperative day to rule
out any leaks or strictures and, if negative, the patient is begun on a clear liquid diet
per protocol.
20.4.2 Malabsorptive Procedures
Modern malabsorptive procedures share a common design of an enteric limb in con-
tinuity with the stomach and a chemical limb carrying bile and pancreatic secretions.
These limbs join together to form the common channel in which nutrients can be
absorbed. The major improvement over early malabsorptive surgeries is the avoid-
ance of bacterial proliferation in a portion of bowel without flow.
The degree of malabsorption is proportional to the length of bypass. All of these
procedures bypass at least a portion of the stomach, duodenum, and early jejunum.
20.4.2.1 Biliopancreatic Diversion +/– Duodenal Switch

Biliopancreatic diversion is the most technically challenging bariatric procedure
performed today. It results in a high percentage of weight loss, but also carries the
most significant morbidity and mortality of any of the weight loss surgeries. Thirty
day mortality following biliopancreatic diversion or duodenal switch is 1.1%.6
20.4.3 Restrictive/Malabsorptive Combinations
20.4.3.1 Roux-en-Y Gastric Bypass
The RYGB accounts for up to 80% of bariatric procedures performed in the United
States today. Thirty day operative mortality is 0.5%.6,7 The restrictive portion of the
procedure is the creation of a 15 to 30 ml gastric pouch. Malabsorption is employed
via a variable-length Roux limb that is anastomosed to the gastric pouch.
The operation begins by identifying the ligament of Treitz. The proximal jejunum
is divided approximately 40 cm distal to the ligament of Treitz with a linear stapling
device. A Roux limb is created by measuring approximately 75 to 150 cm from the
tip of the divided distal small bowel. There is no evidence supporting a specific Roux
limb length as long as it is greater than 75 cm in length. A side-to-side jejunojejunos-
tomy is established at this point between the proximal biliopancreatic limb and the
Roux limb to reestablish gastrointestinal (GI) continuity. With this accomplished, a
15 to 30 ml gastric pouch is created by dividing the stomach with an endoscopic sta-
pling device. A gastrojejunostomy is then fashioned between the gastric pouch and
the tip of the Roux limb. This can be accomplished using a circular stapler, a linear
stapler, or by hand sewing the anastomosis. Intraoperative endoscopy is undertaken
to evaluate the anastomosis, check for bleeding, and perform an intraoperative leak
test (Figure 20.6).
Figure 20.6 (See color insert following page 112) Completed appearance of a Roux-
en-Y gastric bypass. (From Jones DB. Atlas of Minimally Invasive Surgery. Cine-Med Inc,
2006. With permission.)
20.5 Complications: Identification and Management

Regardless of the weight reduction surgery performed, the obese patient is at an increased
risk for multiple perioperative complications. Some complications are universal in the
bariatric population while others are specific to the type of procedure performed.
20.5.1 Complications Common to All Bariatric Procedures

20.5.1.1 Deep Venous Thrombosis/Pulmonary Embolism
Prevention of deep venous thrombosis (DVT) begins prior to anesthesia induction,
with the application of sequential compression devices. Pharmacologic prophylaxis
with heparin or low molecular weight heparin should be employed in all bariatric
surgery patients. There is little evidence supporting the preferential use of one of these
drugs or the duration of prophylaxis in the bariatric population. In the case of a known
hypercoagulable disorder or history of previous DVT or thrombophlebitis, a preop-
eratively placed inferior vena cava filter should be considered. Some have also advo-
cated preoperative evaluation of mean pulmonary artery pressure in those patients at
very high risk and IVC filter placement if the pressure is found to be ≥40.8
The incidence of DVT following bariatric surgery is 2%. Body habitus prevent-
ing early ambulation, prevalence of venous stasis disease, and relative polycythemia
from chronic hypoventilation all contribute to this number. The diagnosis of DVT in
the obese patient can be challenging. The classic sign of unilateral swollen limb may
be difficult to recognize. Therefore, a high clinical suspicion must be kept and the
use of duplex venous ultrasound applied if there is any suspicion.
Pulmonary embolism (PE) can be suddenly fatal. Cardinal symptoms of tachy-
cardia, pleuritic chest pain, respiratory distress, and desaturation not appropriately
responsive to oxygen therapy should immediately raise suspicion for PE. Diagnosis
can be made by computerized tomography (CT) scan or lung/ventilation (V/Q) scan.
20.5.1.2 Bleeding
Hemorrhage can present early in the postoperative course or be delayed (after 48
hours). An early postoperative bleed presents with hematemesis, bloody bowel move-
ments, and, if severe, hypotension, tachycardia, and a precipitous fall in hematocrit.
Bleeding more than 48 hours postoperative present with dark blood in the stool and
may represent clot evacuation from the operative sites. Bleeding usually occurs from
staple lines and may be intraluminal or intraabdominal. Estimates of hemorrhage

following laparoscopic RYGB are 1.1 to 4%.9
Techniques to decrease the risk of postoperative hemorrhage are well known. These
include the usual careful attention to hemostasis intraoperatively, over sewing of staple
lines, and the use of staple line reinforcing products. Additionally, use of shorter staple
height may result in better hemostasis by an increased compression of tissues.9
Like all surgically significant bleeding, the first priority of management is IV fluid
resuscitation and transfusion of blood products as needed. Reoperation to localize
and contain the source of bleeding may be necessary if the patient becomes unstable
or the bleeding is brisk and ongoing. GI bleeding that presents late is less likely to
require operative management.
20.5.1.3 Anastomotic Leak
Due to the greater number of involved staple lines, anastomotic leak is more com-
mon after malabsorptive surgery. However, this complication can be seen following
restrictive procedures involving resection of gastric segments. Anastomotic leaks
occur in 2 to 4% of surgeries involving a staple line or anastomosis.10 Leak rates
after RYGB are 1 to 5%5 and most often involve the gastrojejunostomy or gastric
transection site. Older age, male gender, diabetes, and sleep apnea have been cited as
independent risk factors for anastomotic leak. Conversion from a previous restrictive
procedure to a RYGB holds a greater risk for leak than primary RYGB.7
Anastomotic leaks can occur early or late in the postoperative course. Leaks
within the first 48 hours are more likely to be related to technical problems at the
anastomosis site and are more likely to warrant emergent reexploration. Leaks
occurring 5 to 10 days postoperatively result from poor healing of the anastomosis
or ischemia. These late leaks have a more indolent presentation.
Tachycardia is the first sign of an anastomotic leak. Other signs and symptoms
include fever, tachypnea, hypoxia, hiccups, and anxiety.8,10 By the time a patient com-
plains of increased abdominal or back pain, he or she may be systemically ill. If a leak
goes unrecognized, progression to overt peritonitis, sepsis, and death may be rapid.
A gastrograffin upper GI study should be routinely performed prior to initiating clear
liquids and repeated if there is concern for a leak and the patient’s condition allows.
Reoperation may be necessary to repair a failed anastomotic site, especially if the
leak is large and/or the patient’s condition deteriorates. If the leak is small and the patient
is clinically stable, percutaneously placed drains, restriction of PO intake with paren-
teral nutritional support as needed, and antibiotics may be sufficient intervention.
20.5.1.4 Wound Infection
Wound infections are one of the most common postoperative complications seen in
the bariatric population. Prophylactic antibiotics strictly administered prior to inci-
sion is the best preventive measure. One of the major benefits of the laparoscopic
approach to these procedures is the much lower rates of wound infection using the
laparoscopic approached as opposed to open surgery.
Several factors contribute to the relatively high rate of wound infections follow-
ing bariatric surgery. Morbidly obese body habitus and the often coexisting diabetes,
complicate normal wound healing. Additionally, the diminished immune defense

capacity associated with morbid obesity is well documented.11–13
Cellulitis without underlying infection may require only antibiotics. However,
the thick layer of poorly vascularized subcutaneous fat disrupted during the surgery
provides the ideal environment for liquefaction and subsequent infected fluid col-
lections. Treatment of these infections is antibiotics, reopening and drainage of the
wound, and allowing the open wound to heal by secondary intention.
20.5.1.5 Failure to Lose Weight or Regaining of Weight

Regardless of procedure performed, 15% of patients do not achieve the goal of
50% of excess body weight lost after bariatric surgery.14 Reasons include diet non-
compliance, such as the intake of high calorie liquids or forced overeating after
restrictive procedures and intestinal adaptation following malabsorptive surgery.
Physical disruption of the staple line in a nontransected RYGB results in an unre-
stricted gastric volume and decreased weight loss. Nutritional counseling, before
and after surgery, is helpful in reducing the patient choice factors that contribute
to weight loss failure.
20.5.2 Complications of Restrictive Procedures

20.5.2.1 Gastric Prolapse
Gastric prolapse (“band slipping”) is herniation of the stomach cephalad through
the band, which enlarges the pouch and causes band malposition. The incidence
of herniation after adjustable gastric banding is now 1 to 2%,1,3 a great reduc-
tion since adoption of the pars flaccida technique. In comparison with the older
perigastric technique, the pars flaccida technique provides better posterior fixa-
tion of the band. Anterior fundoplication secures the anterior aspect of the band.
Leaving the band empty initially decreases postoperative vomiting and also
decreases herniation.
20.5.2.2 Pouch Dilation

In patients who have had restrictive procedures, forced eating of a greater volume
than can be accommodated by the gastric reservoir can result in discomfort, vomit-
ing, and nutritional deficiency.
Over time, the ingestion of a larger volume than can be comfortably accommo-
dated may lead to pouch dilation and resultant decreased weight loss. Gastric pouch
dilation also may result from outflow obstruction by the band. Patients complain of
dysphagia and gastroesophageal reflux. Simply removing some of the fluid via the
port can resolve this complication.1,14
20.5.2.3 Band Erosion
This is a rare complication (0 to 7%).1,14 When it does occur, it is usually a slow
process and may be asymptomatic. A loss of restrictive function and recurrent port
site infections should prompt investigation of band erosion. Faults in surgical tech-
nique, such as gastric microperforation or fundoplication over the buckling device
contribute to its occurrence.9 Band erosion can be evaluated by esophagogastroduo-

denoscopy (EGD).
20.5.2.4 Port/Tube Dysfunction

Mechanical disruptions of the port and tubing system of adjustable gastric bands,
such as tube kinking/disconnection or port malfunction, render the band ineffective
and prevent it from being adjusted. Therefore, these problems necessitate operative
correction in order to maintain weight loss.
Tube kinking can be avoided by leaving the tubing long and freely floating within
the peritoneal cavity and by port placement a distance away from the fascial defect
to allow for a gradual curve in the tubing.
Port site infections are very rare and should immediately raise concern for
band erosion.
20.5.2.5 Need for Band Removal

Factors, such as failure to lose weight, band erosion, and patient intolerance of symp-
toms, may all necessitate removal of the band. Removal, which occurs in 0.6 to 6%,1,2
can usually be accomplished laparoscopically. Depending on the patient wishes and
need for additional weight loss, these patients may be converted to a malabsorptive
procedure.
20.5.3 Complications of Malabsorptive Procedures

20.5.3.1 Small Bowel Obstruction
Bowel kinking or mechanical stricture at an anastomotic site can result in periopera-
tive bowel obstruction. Identification may be made by upper gastrointestinal studies
with small bowel follow through showing an isolated narrowing or acute angle. If
suspicion remains after a nondiagnostic obstructive series, a CT scan should be per-
formed. Reoperation may be necessary in the early postoperative period to relieve
the obstruction. Small bowel obstruction may also present much later in the postop-
erative course. In these late obstructions, the culprit is either adhesive bands or the
development of an internal hernia. Even if the mesenteric spaces were meticulously
closed intraoperatively, the sutures may become loosened and the spaces reemerge
after significant weight loss.
A bowel obstruction in a patient following an RYGB should always prompt imme-
diate surgical evaluation and intervention to prevent bowel strangulation.
20.5.3.2 Marginal Ulceration
Ulcer formation at the anastomotic site occurs in up to 15% of patients following
RYGB.12 Factors that contribute to ulceration are large gastric pouch with many pro-
ductive parietal cells, use of nonabsorbable sutures, decreased perfusion of anasto-
motic sites, and nonsteroidal antiinflammatory drug (NSAID) use. Peak incidence
of marginal ulceration is in the second postoperative year.14 Symptoms include ret-
rosternal burning, nausea and vomiting, and dyspepsia. Medical management with
acid suppressive medications (proton pump inhibitors), and sulcrafate is usually
successful. If resolution of symptoms is not achieved after a six-week course, upper

endoscopy is done for definitive diagnosis. Biopsies for Heliobacter pylori should
be taken during endoscopy. An upper GI contrast study is also performed to rule
out gastro-gastric fistula. For severe refractory symptoms, operative revision may
be necessary.
If ulceration at the gastrojejunal stoma of RYGB is not controlled, stomal stenosis
resulting in intractable vomiting and severe malnutrition occurs. Stenosis at stoma
sites can be treated by endoscopy and successive balloon dilatation.
20.5.3.3 Malnutrition
Many obese patients suffer from some degree of preoperative malnutrition that can
be exacerbated by the operation performed. There are also several well-documented
nutrition complications common in the postoperative bariatric population.
20.5.2.4 Micronutrient Deficiencies
Micronutrient deficiencies are the most common complication following malabsorp-
tive bariatric procedures. These deficiencies are often asymptomatic and routine
yearly lifetime screening is prudent.
Iron deficiency eventually occurs in up to 75% of patients who have undergone
a malabsorptive procedure.10 This results from the duodenum being bypassed and,
thus, losing the site of predominant iron absorption. Women of childbearing age are
especially prone to iron deficiency anemia given the increased losses of menstruation.
Daily supplements of 650 mg ferrous sulfate orally is prescribed for all patients.
Likewise, the loss of vitamin D-dependent calcium absorption in the bypassed
duodenum often leads to calcium deficiency. The resultant bone mineral loss and
propensity toward osteoporosis rarely is severe enough to cause pathologic fracture.
At this time, routine bone density examinations are not recommended. Daily cal-
cium supplementation of 1,200 mg is recommended.
An intrinsic factor is produced by the gastric parietal cells and is essential for
absorption of vitamin B12 in the terminal ileum. Therefore, B12 deficiency can
be problematic for RYGB and biliopancreatic diversion patients. Symptomatic
peripheral neuropathy or overt megaloblastic anemia is rare, seen in less than 5%
of patients.10
Fat soluble vitamin (A, D, E, K) deficiencies can all result from the decreased
ileal absorptive time. However, this is rarely symptomatic. Other rare micronutrient
deficiencies include zinc, thiamine, folate, and selenium. Unexplained fatigue, neu-
rologic symptoms, or persistent vomiting should prompt a thorough evaluation for
micronutrient deficiency.
20.5.2.5 Protein Malnutrition

Although less commonly encountered, protein malnutrition is a debilitating compli-
cation of malabsorptive surgery. This is seen most profoundly following biliopan-
creatic diversion, occurring in up to 11.9% of patients.8 Protein malnutrition is also
a problem following RYGB with a very short common channel. The average time
to diagnosis of protein malnutrition is 18 months postoperatively.14 Protein mal-
nutrition presents with fatigue, edema, recurrent vomiting, high bowel frequency
and steatorrhea, hypercoagulability, immune suppression, and hypoalbuminemia.

Diagnoses is confirmed by low serum albumin and depressed total iron binding
capacity. Mortality associated with severe protein malnutrition has been reported
up to 1%.14 All patients should receive nutritional counseling to intake 40 to 60 g of
protein per day. In patients exhibiting signs of protein malnutrition, a high nitrogen
diet should immediately be started and other routes of enteral or parental feeding
explored as necessary. In patients with refractory protein malnutrition, operative
revision or reversal may become necessary. However, repeat surgery in a patient
with an extremely depressed capacity for wound healing must be carefully consid-
ered before reoperation.
20.5.2.6 Excessive Weight Loss

Excessive weight loss to a BMI less than 20 is a very rare complication of bariatric
surgery. All of these patients should undergo contrast radiography and upper endos-
copy to rule out mechanical causes, such as stricture or bowel obstruction. Psychiatric
evaluation also should be performed and any underlying illness aggressively treated.
High protein oral supplements and even parental nutrition may be necessary in some
patients. In extreme cases, revision or reversal of the surgery is unavoidable.
20.6 Outcomes
Weight loss following bariatric surgery is commonly reported as the mean percent-
age of excess weight loss by the formula: (weight loss/excess weight) × 100. Excess
weight is the discrepancy between preoperative weight and ideal weight. A large
meta-analysis of 134 studies found the mean weight loss across all types of bariat-
ric surgery to be 61.2%. This percentage varies by the type of surgery performed,
with gastric banding procedures resulting in 47.5%, gastric bypass resulting in
61.6%, and biliopancreatic diversion resulting in 70.1% of excess weight lost.6
Although the observed weight loss is numerically impressive, it should be noted
that most patients following bariatric surgery are still obese. Resolution of pre-
operative comorbidities is perhaps a more meaningful way to measure outcomes
following bariatric surgery.
20.6.1 Diabetes
All types of bariatric surgery have been observed to improve type 2 diabetes. Many
patients are eventually able to discontinue use of hypoglycemic agents and maintain
normal blood glucose and HbA1C levels. Complete resolution of diabetes has been
quoted in a meta-analysis as 76.8% across all bariatric procedures.6 Diabetes resolu-
tion is more likely following malabsorptive or combined malabsorptive/restrictive
procedures. Interestingly, improvement and even resolution of diabetes often occurs
within days of surgery, long before any significant weight loss has occurred. There
are numerous theories attempting to explain this observation. Current research into
the effect of bariatric procedures on gastrointestinal hormones including leptin,
ghrelin, resistin, enteroglucagon, and cholecystokinin are likely to provide the rea-
soning to this well-documented phenomenon.
20.6.2 Hypertension
Blood pressure shows a predictable decrease following weight loss, with a reduction
of 1% of body weight correlating with a 1 mm Hg decrease in systolic pressure and
a 2 mm Hg decrease in diastolic pressure.6 A greater than 40% reduction in the rate
of systolic and diastolic hypertension has been observed in male bariatric surgery
patients.18 Improvement in blood pressure after bariatric surgery is independent of
the type of surgery performed.
20.6.3 Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is an extremely common comorbidity of obesity.
Obese patients are prone to airway collapse during nocturnal respiration due to
fat deposition in the parapharyngeal region. OSA leads to complaints of chronic
fatigue, daytime sleepiness, and excessive snoring or gasping for breath while
asleep. OSA as an independent risk factor for hypertension, cardiac arrhythmias,
myocardial infarction, pulmonary hypertension, and cor pulmonale. The incidence
of sleep apnea in patients who present for bariatric surgery is 45% to greater than
70%.15–17 This number increases to more than 94% for those with a BMI >60.15 The
association is so high that some practitioners advocate routine screening for OSA
and referral for preoperative polysomnography as part of a routine preoperative
evaluation. Multiple studies have shown significant improvement or resolution of
OSA following bariatric surgery.16,17
20.6.4 Hyperlipidemia
Cholesterol is improved by weight loss after bariatric surgery. Improvements in low
density lipoproteins (LDLs), high density lipoproteins (HDLs), and triglycerides
have all been observed postoperatively.18
20.6.5 Osteoarthritis
Obese patients who present for bariatric surgery almost uniformly have some degree
of musculoskeletal complaints. Excellent pain improvement has been observed after
bariatric surgery, including one study that reported an 89% complete resolution of
osteoarthritis pain in at least one joint.19 The greatest decrease in musculoskeletal
complaints is in the cervical and lumbar spine and in the feet.20
20.7 Summary
Obesity is a major health problem in the United States and throughout much of
the industrialized world. Nonsurgical treatments for obesity thus far have been
unsuccessful in providing long-term weight loss. Bariatric surgery is the only
effective, well-established weight loss treatment for the severely obese. However,
bariatric surgery is invasive and obese patients are high risk surgical candidates.
Bariatric surgery is an option for well-screened patients who are committed to
long-term lifestyle changes and physician follow-up. Resolution or improvement

in comorbidities, such as diabetes, hypertension, hyperlipidemia, obstructive
sleep apnea, and osteoarthritis following bariatric surgery is well documented in
the literature. Additionally, multiple studies have shown improved survival for
severely obese patients who underwent bariatric surgery compared to patients
who did not have operative intervention. The type of surgery most appropri-
ate for a specific patient, the preoperative evaluation needed, and the long-term
postoperative care depends on a multidisciplinary team led by an experienced
bariatric surgeon.
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tors for wound infections in open bariatric surgery. Obes Surg. 14:16–22, 2004.
14. McNatt SS, Longhi JJ, Goldman CD, McFadden DW. Surgery for obesity: a review
of the current state of the art and future directions. J Gastrointest Surg. 11:382–402,
2007.
15. Lopez PP, Stefan B, Schulman CL, Byers PM. Prevalence of sleep apnea in morbidly
obese patients who presented for weight loss surgery evaluation: more evidence for rou-
tine screening for obstructive sleep apnea before weight loss surgery. Am Surg. 74:834–
838, Sept 2008.
16. Haines KL, et al. Objective evidence that bariatric surgery improves obesity-related
obstructive sleep apnea. Surgery. 141(3):354–358, Mar 2007.
17. Rasheid S, Banasiak M, Gallagher SF, et al. Gastric bypass is an effective treatment for
obstructive sleep apnea in patients with clinically significant obesity. Obes Surg.13:58–
61, 2003.
18. Vogel JA, Franklin BA, Zalesin KC, et al. Reduction in predicted coronary heart disease
risk after substantial weight reduction after bariatric surgery. Am J Cardiol. 99(2):222–
226, Jan 2007.
19. Lementowski PW, Zelicof SB. Obesity and osteoarthritis. Am J Orthoped. 37(3):148–
51, Mar 2008.
20. Hooper MM, Stellato TA, Hallowell PT, et al. Musculoskeletal findings in obese sub-
jects before and after weight loss following bariatric surgery. Int J Obes. 31:114–120,
2007.
21 Obesity and
Gastrointestinal Cancers
Yume Nguyen and Bhaskar Banerjee
Contents
21.1 Introduction................................................................................................... 343
21.2 Potential Mechanisms....................................................................................344
21.3 Inflammation and Cancer.............................................................................. 345
21.4 Calorie Restriction......................................................................................... 345
21.5 Physical Activity............................................................................................346
21.6 Colon Cancer.................................................................................................346
21.6.1 Gender Difference............................................................................. 347
21.6.2 Physical Activity................................................................................ 347
21.6.3 Diet....................................................................................................348
21.6.4 Underlying Molecular Basis.............................................................. 348
21.7 Esophageal and Gastric Cardia Adenocarcinoma......................................... 348
21.8 Pancreatic Cancer.......................................................................................... 349
21.9 Hepatocellular Carcinoma............................................................................. 350
References............................................................................................................... 350
21.1 Introduction
Obesity is linked to many chronic health conditions including stroke, coronary heart
disease, diabetes mellitus, gallbladder disease, dyslipidemia, respiratory dysfunc-
tion, and certain forms of cancer. Obesity has become a growing epidemic in many
regions of the world and in the United States over one-third of adults are overweight
or obese. Overweight or obesity results from a chronic state of positive energy bal-
ance due to an excess of nutritional intake relative to energy expenditure. Excess
weight has been associated with increased mortality from all cancers combined and
for cancers of several specific sites. The exact figures are uncertain, but some studies
estimate overweight and obesity account for 20% of all deaths from cancer in women
and 14% in males.1 Obesity is associated with a number of malignancies including
leukemia, non-Hodgkin lymphoma, multiple myeloma, breast, cervical, colorectal,
esophageal, gallbladder, kidney, liver, ovarian, pancreatic, prostate, stomach, and
uterine cancers. In addition to increasing the risk of developing cancer, some studies
show that obese or overweight patients have a poorer outcome once diagnosed with
cancer. In addition to having more advanced disease at the time of diagnosis, obese
343
patients have a higher rate of recurrence of prostate/breast cancer, have a worse

response rate to chemotherapy, and have more complications perioperatively.
Compounding the problem, obese persons are less likely to undergo cancer screen-
ing exams, such as colonoscopy or mammography. This may be due to the patient
factors, such as embarrassment or a perception that the exam would be too difficult
to undergo. Physician or other healthcare provider factors also may contribute to this
relatively low rate of screening. Referral for routine screening may not be offered
to obese patients due to other health problems that may overshadow routine health
maintenance or a perception that these procedures may be technically difficult. For
some morbidly obese patients, many tests are simply not available to them due to the
inability to support the excess weight or large size.2,3
This chapter will focus on obesity as a risk factor in the development of gas-
trointestinal cancers; however, it is worth mentioning that some cancer treatments
often cause weight gain. The Childhood Cancer Survivor Study showed that acute
lymphoblastic leukemia (ALL) survivors who received cranial radiation therapy at a
young age are at higher risk for obesity compared to a sibling control group.4 It has
been speculated that this finding may be associated with a leptin receptor polymor-
phism in patients with ALL.5 Other cancer treatments, such as steroid medications
or hormones, may promote weight gain as well.
21.2 Potential Mechanisms

Much interest and intense research has focused on the underlying mechanism respon-
sible for the link between obesity and cancer. It is now known that adipose tissue is
an actively secreting endocrine organ. There are several biologically active adipocy-
tokines, or adipokines, associated with obesity, such as adiponectin, leptin, vascular
endothelial growth factor (VEGF), TNF-alpha, insulin, insulin-like growth factor-1
(IGF-1), as well as several factors associated with inflammation and oxidative stress.
Much attention has been paid to these adipokines to search for a causal or associated
link between obesity and cancer. These adipokines regulate several physiologic pro-
cesses, such as appetite, insulin sensitivity and regulation, immunity, inflammation,
and angiogenesis.
Leptin is a hormone secreted by adipocytes and is involved in appetite regulation
and energy homeostasis via its influence at the hypothalamus level. Leptin levels,
which correlate with the amount of fat stores, affect the inflammatory and immune
response and enhance cellular proliferation and antiapoptotic activity in colonic tis-
sue.6 The inappropriate response and altered immune response may contribute to
the dysregulated growth of tumorigenesis. Adiponectin is produced exclusively by
adipocytes and, unlike other adipokines, its levels are decreased in obesity states. It
has been shown in vitro to inhibit angiogenesis and tumor proliferation. It is postu-
lated that adiponectin affects the obesity–cancer association by acting as a negative
regulator of endothelial cell proliferation.7 The role of insulin in regulating glucose
homeostasis and supplying energy to cells and tissues for cellular growth and differ-
entiation may be a key link in the promotion of uncontrolled cell growth associated
with tumor formation. Insulin exerts its effect via transmembrane receptor activation
and downstream intracellular signaling. Ultimately, transcription of certain genes
Obesity and Gastrointestinal Cancers 345
and translation of proteins may impact cellular proliferation and growth, which can
have an influence on tumor development. Insulin also has affects on the synthesis and
biological availability of the male and female sex steroids, including androgens, pro-
gesterone, and estrogens. Insulin is likely linked to carcinogenesis by acting directly
on cells or indirectly via its interaction with insulin-like growth factor-1 (IGF-1) or
other endocrine hormones, such as estrogens. Insulin increases levels of IGF-1 that
has been implicated in several types of cancers and its receptor is overexpressed in
many different tumors. Its effect on tumorigenesis may be through its indirect action
on various oncogenes, such as p53 tumor suppressor gene.8 Both insulin and IGF-1
in vitro inhibits apoptosis and promotes cellular proliferation.9
21.3 Inflammation and Cancer

It is widely accepted that chronic inflammation is associated with an increased risk
of developing cancer, and a state of chronic low-grade systemic inflammation accom-
panies obesity. Several studies have been conducted that show that exercise and/or
calorie restriction can reduce certain inflammatory markers.10,11 Physical activity
and calorie consumption are both modifiable factors and are targets for directed
intervention in the carcinogenesis process. As such, substances that mediate the
effects of calorie restriction or physical activity are being sought out as they possess
substantial chemotherapeutic potential. However, the mechanism that underlies the
antitumor effect of calorie restriction and physical activity is poorly understood.
21.4 Calorie Restriction
Calorie restriction (CR) has long been known to decrease inflammation and improve
longevity through unclear mechanisms. Restriction of calories by 10 to 60% in
animal studies has been shown to decrease cell proliferation, increasing apoptosis
through antiangiogenic processes. The potent anticancer effect of caloric restric-
tion is clear, but caloric restriction alone is not generally considered to be a feasible
strategy for cancer prevention in humans. Identification and development of preven-
tive strategies that “mimic” the anticancer effects of low energy intake are currently
underway because it is not feasible to calorie restrict to such an extreme degree in
humans. The independent effect of energy intake on cancer risk has been difficult
to estimate because body size and physical activity are strong determinants of total
energy expenditure.
The exact mechanism responsible for the CR-mediated antitumor effects is
unknown. The benefits derived from calorie restriction may be mediated by IGF-
1, which stimulates the cell cycle, leptin, and insulin production. During times of
calorie restriction, IGF-1 levels are reduced and IGF-1 receptors are increased,
which creates a net negative circulating level of IGF-1. Others have focused on the
NF-E2–related factor 2 (Nrf2) pathway, which activates antioxidant enzymes when
triggered by caloric restriction. Some investigators have focused on the mitochondria
for answers relating to the question of CR and antitumor effects. It appears that mito-
chondria, the site of free-radical production, in the calorie-restricted mice have fewer
free radicals and may be regulated by PGC1-α.12 Resveratrol, a naturally occurring
antioxidant chemical found in red wine, acts on the gene SIRT1, which produces
enzymes that stimulate mitochondrial growth. This appears to suppress tumor for-
mation and growth in animal studies of cancer.13,14
21.5 Physical Activity

The mechanisms that account for the inhibitory effects of physical activity on the
carcinogenic process are reduction in fat stores, activity-related changes in sex hor-
mone levels, altered immune function, effects in insulin and insulin-like growth fac-
tors, reduced free radical generation, and direct effect on the tumor. Epidemiologic
evidence posits that the cascade of actions linking overweight and obesity to carcino-
genesis are triggered by the endocrine and metabolic systems. Perturbations to these
systems result in the alterations in the levels of bioavailable growth factors, steroid
hormones, and inflammatory markers.
21.6 Colon Cancer
Cancer of the colon and rectum is the second most common malignancy in the
United States and the third deadliest cancer. It is well known that obesity increases
the risk of developing colon cancer in men, but data on colon cancer risk in women
has been conflicting. Some estimates suggest an overall increased 30 to 60% risk
of developing colon cancer, but a recent meta-analysis suggests the risk is less than
previously reported at 20% or a relative risk (RR) of 1.21.15 The majority of studies
have focused on body mass index (BMI) or weight as an indicator of obesity, but
later studies have also highlighted the importance of central adiposity by utilizing
anthropometric measurements, such as waist circumference or waist-to-hip ratios.
Individuals within the highest percentile of waist circumference have a greater than
50% increased risk of colorectal cancer (CRC) compared to the lowest waist circum-
ference. This risk increases incrementally by 4% with every 2-in increase in waist
circumference15 These studies highlight that colon cancer is possibly related more
to the metabolic syndrome with emphasis on abdominal or visceral adiposity rather
than simply increased size or weight.
Not only do the obese have a higher risk for developing colon cancer, they are
more likely to have a poor or inadequate prep for colonoscopy. A BMI of ≥ 25 is an
independent risk factor for an inadequate bowel prep for colonoscopy and the likeli-
hood of a poor prep increases further with higher BMI values.16 Retained stool in a
poorly prepped colon increases the chance of neoplastic polyps being missed at the
colonoscopy exam. A more aggressive prep, e.g., over two days may be needed for
obese patients.
Although many studies group cancers of the colon and rectum together, as they
do share some environmental risks, rectal cancer has been shown to differ in their
etiology and behavior. Unfortunately, few studies have been done focusing on rectal
cancer alone and the link between obesity and rectal cancer has been weak. Whether
an association exists remains a source of controversy.
21.6.1 Gender Difference

The association of colon cancer and obesity is stronger in men than women with a
RR of 1.44 (95% CI, 1.32 to 1.58) and 1.09 (95% CI, 1.01 to 1.17), respectively. The
reason for this gender disparity is unclear, but may be related to the difference in
fat distribution between men and women and estrogen status. Some recent studies
maintain that CRC risk and obesity are maintained in subgroups of women, namely
premenopausal females <50 years of age. The period following menopause is a state
of low endogenous estrogen. Adipose tissue becomes the primary site of estrogen
production, which is not highly regulated by the hypothalamic-pituitary-ovarian
axis. HRT (hormone replacement therapy) has been shown to decrease the risk of
colon cancer in postmenopausal women in observational as well as intervention
studies.17,18 It has been theorized that estrogen modifies colon cancer development
and may be beneficial, whether from endogenous or exogenous sources, in post-
menopausal females by counteracting the tumor promoting effects of insulin. This
benefit is not seen in premenopausal females because the availability of estrogen is
tightly regulated.
The European Prospective Investigation into Cancer and Nutrition (EPIC) trial,
which included >350,000 European subjects with >6 years of follow-up, found that
elevated body weight and BMI were associated with increased risk of colon cancer
in men, but not women. However, when utilizing waist circumference, WHR, and
height as measures of obesity, there was an increased risk in both sexes. After strati-
fying for postmenopausal women on HRT, there was no association found utiliz-
ing anthropometric measurements in this population. Furthermore, postmenopausal
women not on HRT had a statistically significant association between waist circum-
ference and colon cancer.19 Slattery and colleagues presented conflicting data to that
of the EPIC trial. They note a positive association in premenopausal women and
those on HRT, but no association in the postmenopausal population regardless of
HRT status.20 Furthermore, in the NIH–AARP U.S. cohort, they found that colon
cancer risk was associated with obesity in younger and older females and HRT had
no effect on this finding.21
Other studies also have evaluated the relationship between obesity and colon
adenomas, a precursor to colon cancer. These studies have been largely consistent
with previous data, which reveal that the risk of colorectal adenoma is increased
with obesity in premenopausal females, but decreased in postmenopausal females,
especially those on HRT.22
21.6.2 Physical Activity

Migration and epidemiologic studies reveal a higher prevalence of colorectal can-
cer in Western industrialized countries. Several environmental and lifestyle fac-
tors have been implicated as causing this trend including diets high in fat, low
in fiber, sedentary lifestyle, and alcohol consumption. Several investigators have
looked into these individual confounders of obesity as independent risk factors
for CRC development. Many studies have consistently shown an inverse relation-
ship between physical activity and colon cancer. About a 40 to 50% reduction
in incidence was noted in these studies amongst individuals at the highest level
of activity.23 These findings have been seen in studies specifically for women in
the Nurses’ Health Study Research Group.24 In the EPIC trial, they found similar
risk reduction with physical activity with evidence of a dose-response effect, spe-
cifically in the right colon.25 These findings have not been seen in rectal cancer.
Interestingly, Meyerhardt and colleagues found that increased physical activity
after the diagnosis of stage I to III CRC is associated with improved cancer-spe-
cific and overall mortality.26
21.6.3 Diet
Dietary factors that potentially increase the risk of CRC include low fruit, vegetable,
or fiber intake, high red meat or saturated fat consumption, and exposure to caffeine
or alcohol. The significance of low fruit, vegetable, and fiber intake has been called
into question because of contradictory results from large observational studies and
negative results from randomized trials.
21.6.4 Underlying Molecular Basis

The underlying mechanism responsible for the association of excess weight and
CRC is an area of intense research. Factors that are associated with colon cancer,
such as a sedentary lifestyle, high fat/low fiber diet, and obesity are also associ-
ated with diabetes and insulin resistance. As such, the link between colon can-
cer and hyperinsulinemia has been studied extensively. Obesity, and specifically
visceral adiposity, is associated with elevated levels of insulin and IGF-1. Some
investigators have proposed that the elevated level of insulin promotes colonic
tumor growth. In the Cardiovascular Health Study Cohort, an observational study
of 5,849 participants over 65 years of age, found that individuals in the highest
quartile of fasting glucose were at 80% higher risk of developing incident col-
orectal cancer compared with those in the lowest quartile (RR 1.8; 95% CI 1.0
to 3.1).27
21.7 Esophageal and Gastric Cardia Adenocarcinoma

Barrett’s esophagus (BE) is the precursor lesion of most adenocarcinomas of the
esophagus and gastric cardia. The true prevalence of BE is unknown as most are
asymptomatic. Predicting those patients with BE who are at high risk of progressing
to esophageal adenocarcinoma (EAC) is also difficult. With the increasing incidence
of EAC and the poor prognosis associated with this diagnosis, there is great interest
in furthering our interest in this disease. One- and five-year survival remains dismal
at 44% and 13%, respectively. Several risk factors for development of Barrett’s have
been identified including gastro-esophageal reflux disease (GERD), central obesity,
and male gender.
The rise in EAC correlates with the increasing obesity epidemic in Western coun-
tries. Obesity, especially central adiposity, has long been associated with the develop-
ment of BE. However, recent meta-analysis finds obesity to be an indirect risk factor
due to its underlying association with GERD, and, once GERD occurs, increasing
BMI has no effect on progression to BE.28 It is postulated that obesity promotes
GERD possibly via increased intraabdominal pressure, relaxed lower esophageal
sphincter (LES), and higher rates of hiatal hernias.
A few studies have focused specifically on BMI and EAC controlling for GERD
symptoms and found that BMI is an independent risk factor suggesting that the risk
is not mediated by GERD alone.29,30 Abdominal obesity, which is more common
in males, is associated with EAC and may account for the gender difference seen
in EAC and gastric cardia adenocarcinomas.31 The reasons underlying why obesity
is not directly related to BE but is directly associated with EAC and gastric cardia
adenocarcinomas are still unknown. It does appear that increasing BMI is associated
with increasing risk of these cancers even within normal weight subjects.32 Of note,
esophageal squamous cell carcinoma and gastric noncardia adenocarcinoma are not
associated with BMI.
21.8 Pancreatic Cancer

Pancreatic cancer (PC) is the fourth leading cause of cancer mortality in Western
countries. The five-year overall survival rate remains dismal at less than 5% and
mortality rates are nearly equal to incidence rates. Despite advances in treatment, the
mortality from pancreatic cancer has not improved over the past few decades. The
best chance of survival is when the disease is localized at diagnosis; however, less
than 10% of cases are found at an early stage. Prevention by identifying risk factors
for pancreatic cancer may be the key to improving mortality from this deadly cancer.
Approximately 80% of pancreatic cancers are adenocarcinomas, and the peak inci-
dence occurs in the sixth to seventh decade of life. Cigarette smoking is the strongest
known risk factor. Others factors having a weaker link to pancreatic cancer include
diabetes, chronic pancreatitis, certain hereditary and familial cancer syndromes, and
obesity, especially in men.
Although obesity as a risk factor was found less consistently in women, the
Women’s Health Initiative examined central obesity specifically in postmenopausal
women, as determined by waist-to-hip ratio as opposed to general obesity as deter-
mined by elevated BMI, in relation to pancreatic cancer and found women in the
highest waist-to-hip quintile had 70% [95% CI 10 to 160%] excess risk compared to
the lowest quintile.33 In the largest prospective cohort study, The American Cancer
Society Cohort, mortality from pancreatic cancer was increased in these subjects
with a BMI >30 kg/m2 with relative risks between 1.26 to 2.76 for categories of
increasing BMI.1
The link between obesity and pancreatic cancer may arise as a result of sev-
eral mechanisms and is likely to be multifactorial. Observational studies have found
associations between insulin resistance or diabetes and pancreatic cancer, but it is
unclear if it is involved in the etiology or is a result of the malignant process. A case-
control study revealed higher levels of adiponectin, but lower levels of leptin in tissue
specimens of confirmed pancreatic cancer adjusting for risk factors of PC.34 The rela-
tionship to these adipokines in the pathogenesis of PC is unclear. In addition, a few
studies suggest that high consumption of fruits, vegetables, and increased physical
activity may reduce pancreatic cancer risk.35,36
21.9 Hepatocellular Carcinoma
Hepatocellular carcinoma (HCC) is the most common primary malignancy of the
liver. Incidence of HCC is increasing worldwide, but rates remain highest in Asian
countries and sub-Saharan Africa. The major risk factor for HCC is cirrhosis of the
liver due to viruses (Hepatitis B and C virus), toxins (including alcohol), metabolic
(diabetes, nonalcoholic fatty liver disease or NAFLD, hemochromotosis), and auto-
immune (primary biliary cirrhosis, autoimmune hepatitis).
Nonalcoholic fatty liver disease (NAFLD) or nonalcoholic steatohepatitis (NASH)
likely mediates the association between obesity and HCC. Obesity, particularly
abdominal obesity, is one element of the metabolic syndrome that is a risk factor for
developing NASH or NAFLD. A small percentage of NAFLD subjects progresses
to cirrhosis and a proportion of these may develop HCC. Amongst liver transplant
recipients with so-called cryptogenic cirrhosis, obesity was an independent risk fac-
tor for developing HCC (Odds ratio 11.1, p = 0.02).37 It is hypothesized that burned
out NASH represented a large proportion of these previously termed cryptogenic cir-
rhosis cases. Also, in patients with chronic hepatitis C, overweight and obesity were
shown to be independent risk factors of HCC, with a hazard ratio of 1.86 (95% confi-
dence interval, 1.09 to 3.16; P = .022) and 3.10 (95% confidence interval, 1.41 to 6.81;
P = .005), respectively, as compared with the underweight patients.38 Obesity and
insulin resistance often occur concomitantly and population studies have demon-
strated that diabetes is also an independent risk factor for HCC even in the absence of
known chronic liver disease.39 It is unclear whether treatment for NAFLD or NASH
will prevent progression to cirrhosis or alter the risk of HCC.
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22 Nutrition and Colon
Cancer Prevention
Petr Protiva
Contents
22.1 Introduction.................................................................................................. 353
22.2 Calories and Obesity.................................................................................... 354
22.3 Animal Proteins and Fats............................................................................. 354
22.4 Fruits, Vegetables, and Fiber........................................................................ 355
22.5 Calcium and Vitamin D................................................................................ 356
22.6 Folate, Vitamin B6, and Vitamin B12............................................................ 358
22.7 Selenium and Antioxidants.......................................................................... 359
References............................................................................................................... 359
22.1 Introduction
Colorectal cancer is a common malignancy in the United States. There are approxi-
mately 149,000 new cases diagnosed annually, and about 50,000 people die of
this disease each year. Colorectal cancer accounts for about 9% of cancer-related
deaths, making it the second most common cancer-related death in the United
States. Several factors contribute to an increased risk of developing colorectal
cancer, including genetic and environmental factors. Although genetic factors will
result in a significant risk increase, most cases of colorectal cancer are sporadic
with no family history of the disease. Numerous other factors have also been asso-
ciated with an increased risk of developing colorectal cancer including inflam-
matory bowel disease, diabetes mellitus or insulin resistance, cholecystectomy,
excessive alcohol intake, a history of smoking, a history of pelvic radiation, ure-
terocolic anastomosis, acromegaly, and prior treatment for Hodgkin’s lymphoma.
Additionally, there are positive associations between colorectal cancer and human
immunodeficiency virus as well as coronary artery disease; less clear associations
exist between colorectal cancer and Barrett’s esophagus or breast cancer 1 gene
(BRCA1) status.
Nutrition and nutritional status also are important modulators of colorectal can-
cer development. Studies suggest that obesity, defined as a body mass index (BMI)
greater than 30, may contribute a 1.5- to 2-fold increased relative risk of colorectal
cancer and also raises the risk of dying of this disease. Numerous epidemiological
studies have demonstrated that nutrition is an important risk factor for colorectal
cancer; nevertheless, its effect is difficult to quantify and is modest at best. Best
353
estimates suggest that a balanced, prudent diet rich in fruits and vegetables and low
in animal protein and saturated fats is associated with only about a 25 to 50% rela-
tive risk reduction compared to a Western-style diet. However, colorectal cancer is a
prevalent disease and even a modest risk reduction without side effects may translate
into major personal and societal benefits. Therefore, significant research efforts have
been devoted to studying the impact of individual dietary components on colorectal
cancer risk. Yet, considerable controversy exists, as nutritional habits are chronically
difficult to quantify even in a controlled interventional trial, let alone in population-
based studies. This chapter will discuss the evidence of dietary intervention and
habits on colorectal cancer risk.
22.2 Calories and Obesity

High caloric food intake that is not balanced by increased energy expenditure leads
to obesity. The extent to which food with high caloric content contributes to cancer,
independent of obesity or BMI, is not known, but increased BMI and obesity are
associated with an increased risk of colon cancer and adenomas. Two large prospec-
tive cohort studies have demonstrated an increased risk for colorectal carcinoma
associated with high BMI. Additionally, it was shown that patients who are obese
also appear to have a higher risk of dying from colorectal cancer. It appears that this
holds true especially for abdominal adiposity, and patients with increased abdominal
fat tend to have more insulin resistance and higher circulating insulin levels. Both
insulin resistance and high insulin-like growth factor 1 (IGF-1) levels are known to
be associated with a colorectal neoplasm risk in humans and in animal models.1,2
A recent systematic review and meta-analysis of prospective observational studies
involving analyses of 221 datasets and 141 articles, including 282,137 incident cases
from the past four decades, concluded that a 5 kg/m2 increase in BMI was associated
with a relative risk (RR) of 1.24 (1.20 to 1.28, 95% CI, P <0.001) for colon cancer in
men and a RR of 1.09 (1.05 to 1.13, 95% CI, P <0.001) in women. There was also a
significantly increased risk (RR of 1.09: 1.06 to 1.12, 95% CI, P <0.001) observed for
rectal cancer in men, but not in women.3
22.3 Animal Proteins and Fats

Diets high in red animal meat appear to promote colon carcinogenesis. There is prob-
ably not a single mechanism by which red meat consumption promotes colon car-
cinogenesis, but current theories suggest that (1) cooking meat at a high temperature
forms carcinogenic heterocyclic amines and polycyclic aromatic hydrocarbons, (2)
carcinogenic N-nitroso compounds are formed in meat endogenously, and (3) heme
iron in red meat can promote carcinogenesis because it increases cell proliferation in
the mucosa through lipoperoxidation and/or cytotoxicity of fecal water. Nitrosation
may also increase the toxicity of heme in cured products.4 Additionally, high protein/
high calorie diets may increase IGF-1 signaling, which is also associated with an
increased risk of colorectal neoplasm.2 Indeed, several large epidemiological studies
showed an increased risk for individuals with the highest intake of red or processed
meat consumed over long periods. A study involving more than 148,000 individuals
Nutrition and Colon Cancer Prevention 355
concluded that consumption of a high ratio of red meat to poultry and fish also rep-
resents a risk.5 A recent meta-analysis of 23 publications that reported results from
prospective studies on red meat and/or processed meat consumption in relation to
the risk of colon or colorectal cancer, was conducted. This meta-analysis reported a
RR for colorectal cancer of 1.2 (1.11 to 1.31, 95% CI) for processed meats and 1.28
(1.15 to 1.42, 95% CI) for red meats, comparing the highest with the lowest category
of intake.6 The excess risk seems to affect only the distal colon, and a high intake of
red meats is also associated with an increased risk of rectal cancers.
The data on fat intake and colon cancer is controversial, but it seems that total
fat does not appear to modulate colon cancer risk. However, it is possible that excess
intake of particular types of fat may affect the risk differently. There is a theory that
high fat diets promote carcinogenesis in the colon via promotion of IGF signaling
and insulin resistance or via fecal bile acids. Another interesting theory suggests that
diets high in cholesterol and/or n-6 polyunsaturated fats may promote carcinogenesis
by inducing an inflammatory reaction in the stromal compartment.7 Nevertheless, it
is difficult to disentangle the effects of high calorie diets from the effects of fats, as
most diets rich in fats are also high in energy content. Even in a controlled clinical
trial setting, it is difficult for subjects to maintain low fat diets over long periods of
time (years). It appears that excess calories from any source lead to weight gain and
an increase in the risk of multiple cancers, including colon cancer.8
22.4 Fruits, Vegetables, and Fiber

A high intake of fresh fruits and vegetables is encouraged because of their general
health benefits that extend beyond cancer prevention. Several factors are thought to
be responsible for this preventive effect. Fruits and vegetables provide nondigest-
ible fiber bulk, may prevent constipation, and reduce the exposure to intraluminal
carcinogens. They also contain small bioactive molecules and vitamins that may
prevent cancer by targeting various molecular pathways known to promote carcino-
genesis. Colonic bacteria ferment fibrous residues in plants’ nondigestible material
that leads to high intraluminal levels of short-chain fatty acids, such as butyrate, that
may affect differentiation, apoptosis, and epigenetic regulation of gene expression in
the colorectum.
In general, prospective studies provide weaker evidence than case-control stud-
ies on the association of fruit and vegetable consumption with reduced cancer risk.9
The discrepancies may be related to recall and selection biases in case-control stud-
ies. In contrast, the association may have been underestimated in prospective stud-
ies because of the combined effects of imprecise dietary measurements and limited
variability of dietary intakes within each cohort. A pooled analysis of 14 cohort
studies concluded that fruit and vegetable intakes were not strongly associated with
colon cancer risk overall, but may be associated with a lower risk of distal colon can-
cer.10 Diets rich in fruit and deep-yellow vegetables, dark-green vegetables, onions,
and garlic are also modestly associated with a reduced risk of colorectal adenoma,
a precursor of colorectal cancer.11 The evidence comes from the Prostate, Lung,
Colorectal, and Ovarian Cancer Screening Trial (PLCO) (1993–2001), where 3,057
cases with at least one prevalent histologically verified adenoma of the distal large
bowel were compared with 29,413 control subjects. Ongoing debate exists on whether
certain fruits and vegetables or organically farmed crops are more likely to reduce
the risk, especially when compared to industrially produced crops that are gener-
ally perceived to contain less bioactive phytochemicals. Indeed, some plants rich in
polyphenolic compounds exhibit strong anticancer or chemopreventive activity in
preclinical models,12,13 and human studies are under way. However, in general, those
studies are performed with plant extracts or pure isolated compounds and, thus, can-
not serve as an argument for preventive activity of the original edible plant.
Some epidemiology studies suggested that the preventive effect of plant food on
colon cancer also may be mediated by its fiber content. A large European study (n
= 519,978) showed that dietary fiber was inversely related to colon cancer incidence
(adjusted RR of 0.58, 95% CI 0.41 to 0.85), comparing the highest to lowest quin-
tiles of fiber intake.14 However, the data were not controlled for folate intake. The
large U.S. cohort study did not show an association between cancer risk and fiber
intake, including fiber in cereals.15,16 Randomized, controlled polyp prevention tri-
als found that fiber supplementation did not have a significant impact on recurrence
of colorectal adenomas.17,18 A meta-analysis of five studies also concluded that fiber
did not affect the incidence or recurrence of adenomatous polyps.19 Similarly, when
other dietary risk factors were taken into account, a pooled analysis of 13 prospective
cohort studies (725,628 men and women followed up to 20 years) showed no associa-
tion of fiber with the risk of colorectal cancer.20 Overall there is compelling evidence
that inadequate folate intake enhances the risk of colorectal cancer; however, artifi-
cial folate oversupplementation may lead to accelerated carcinogenesis most likely
in individuals with existing cancerous or precancerous lesion.
22.5 Calcium and Vitamin D

Numerous epidemiologic studies have suggested that calcium or dairy products may
lower the risk of colorectal neoplasia. Data from a prospective epidemiologic study
in over 45,000 Swedish men, age 45 to 79 years, with a mean follow-up of between 6
and 7 years, showed a reduction in colorectal cancer incidence when analyzed for the
highest versus the lowest quartile for calcium intake (mean odds ratio of 0.68: 95%
CI: 0.51, 0.91; P for trend =0.01). Using multivariate analysis, the data from this study
suggested that there might be a threshold effect at about 1,200 to 1,400 mg of cal-
cium per day.21 Because high calcium intake is also linked to prostate cancer, there
may be a minimum safe level of calcium intake, around 700 mg/day, that confers
protection against colorectal cancer without significantly increasing prostate cancer
risk. Two other epidemiologic studies, with 8- and 19-year follow-ups, showed an
inverse relationship between calcium intake and incidence of colorectal cancer.22,23
In the Health Professionals Follow-up Study and the Nurse’s Health Study, the risk of
distal colon cancer was reduced in subjects who took up to 1,250 mg/day elemental
calcium versus <500 mg/day (RR 0.58, 95% CI 0.32 to 1.05).24
Calcium supplementation appears to prevent the recurrence of colorectal ade-
nomas and is recommended as the primary or secondary prevention by the American
College of Gastroenterology.25 In a randomized, controlled, double-blind, multicenter
trial of 930 subjects with a history of colorectal adenoma, calcium supplementation
was associated with a significant, though moderate, reduction in the risk of recurrent
colorectal adenomas, with an adjusted risk ratio of 0.81 (95% CI, 0.67 to 0.99; P =
0.04, placebo vs. 1,200 mg elemental calcium supplementation).26 An analysis of three
trials including 1,485 subjects with previously removed adenomas who were random-
ized to calcium versus placebo supplementation also showed that the recurrence of
adenomas was significantly lower in subjects randomized to calcium supplementation
(RR: 0.80, CI: 0.68, 0.93; P-value = 0.004).27 However, the Women’s Health Initiative
(n = 36,282) did not find a significant decrease in incidence or stage of colorectal can-
cer in the group, which had been randomly assigned to receive 500 mg calcium and
vitamin D 200 IU twice daily, compared to the placebo.28 The average age of women
at the start of randomization was 62 years, and follow-up was 7 years. This interval
may have been too short to find an effect on cancer incidence. Long-term follow-up
for subjects from the women’s health initiative (WHI) trial is under way.
It is not clear how calcium protects from the development of colon cancer. It may
offer protection by reducing epithelial cell proliferation in the colon, either directly
by acting via the calcium sensing receptor,29 through the cardiac L-type calcium
channel present in the colon30 or indirectly by binding secondary bile acids and ion-
ized fatty acids.31–34 Moreover, there is a functional interaction between calcium and
vitamin D with an implication for colon cancer prevention.29
Vitamin D is a fat-soluble molecule that acts principally through interaction
with a high-affinity binding protein vitamin D receptor (VDR), which is a mem-
ber of the steroid receptor, super family ligand-dependent, transcription factor.
Binding of calcitriol to VDR induces a configurational change and the recep-
tor then heterodimerizes with the retinoid X receptor and the complex binds
to vitamin D responsive elements in the nucleus. This interaction induces gene
transcription, which results primarily in cell cycle arrest, differentiation, and
apoptosis. Furthermore, there are nonreceptor-dependent actions of vitamin D
upon the cell, which include activation of calcium channels, at least in the small
intestine and colon.35 There are several known polymorphisms in the VDR that
are functionally associated with differences in bone density and in serum calcit-
riol levels, but the effect on the action of vitamin D on the colon is unclear.36 In
fact, one study showed that VDR polymorphism genotypes and haplotypes did
not directly alter colorectal adenoma recurrence risk, but the reduction in risk
associated with a high intake of dairy products was confined to individuals with
ApaI aA/AA genotype.37
Epidemiologic data show that exposure to sunlight results in a reduction in the
incidence of many cancers, but most clearly of colorectal cancer. There is a distinct
north to south latitude difference in colorectal cancer development.38 Six of seven
studies on colorectal cancer showed a significant reduction of cancer and one was
borderline significant.39 A prospective study of serum levels of vitamin D revealed a
55% reduction in cancer development in the highest compared to the lowest quartile.40
Perhaps one of the most important observations is that of interplay between vitamin
D levels, calcium intake, and colon cancer risk, originating from subsequent analy-
ses of a polyp prevention trial.26 The data showed that most of the effect of calcium
in lowering the incidence of recurrent adenomas occurred in individuals who had
baseline levels of serum 25 hydroxyvitamin D above the median (about 29 ng per
ml) with little effect in individuals with lower levels.41 Therefore, it is the combina-
tion of calcium and vitamin D that is important in altering adenoma recurrence. An
additional 10-year follow-up study on subjects from the calcium and polyp preven-
tion trial26 showed that, in calcium-supplemented subjects, the beneficial effect upon
adenoma recurrence extended for another five years after subjects stopped taking
supplemental calcium (40% less adenoma recurrence when compared to placebo
control subjects).42 Interestingly, colon cancer chemopreventive activity of hormonal
replacement therapy may be, at least partially, mediated through vitamin D action
in the colorectum.43
22.6 Folate, Vitamin B6 , and Vitamin B12

The area of nutritional supplements and vitamins involved in one carbon metabo-
lism is a focus of intense research, as methylation of DNA and proteins is involved
in nucleic acid synthesis, epigenetic regulation of gene expression, and modula-
tion of intracellular signaling pathways. Folic acid, vitamins B6 and B12 as well as
dietary choline, methionine, and betaine participate in single carbon metabolism
and increase the complexity of data analysis in human chemoprevention studies.
Translational studies examining the effect of both folate supplementation and deple-
tion–repletion regimens on the colon and circulating biomarkers were conducted,
and the gene expression and DNA methylation data is being carefully analyzed in
hopes of shedding more light on this complex topic.44
Folate is present in green, leafy vegetables, fruits, cereals, grains, nuts, avocados,
lentils, beans, and meats. Folic acid, the form of the vitamin included in food supple-
ments, has the same biologic effects as folate, but is more bioavailable. The role of
folate in cancer prevention is uncertain. Alcohol consumption and the presence of
genetic polymorphisms in the folate metabolizing pathway makes interpreting the
data from studies difficult. Folate intake has been associated with a decreased risk
for colon and other cancers, especially in individuals who consume alcohol, in obser-
vational studies. Subjects with the methylenetetrahydrofolate reductase (MTHFR)
genotype, which leads to lower enzymatic activity, have a reduced risk of colon can-
cer45 as well as cancers of the esophagus, stomach, and pancreas.46 Combined results
from the Nurses Health Study and the Health Professionals Follow-Up Study showed
an inverse relationship between folate intake and the risk of developing adenomatous
polyps.47 The Nurses Health Study demonstrated a decreased risk of colon cancer in
women who took multivitamins containing folic acid for at least 15 years (RR 0.25,
CI 0.13 to 0.51).48 However, the results from the Women’s Health Initiative showed
that, although an increased intake of dietary folate and vitamin B6 lowered colorectal
cancer risk, supplementation with folic acid and vitamin B6 did not.49 A recent nested
case-control study within the Alpha-Tocopherol, Beta-Carotene Cancer Prevention
Study showed that serum vitamin B6 was inversely associated with colon cancer
(odds ratio: 0.30 (95% CI, 0.11 to 0.82)) in the highest versus lowest quintile, but
folate and other one-carbon-related biomarkers were not associated with colon or
rectal cancer.50 Alcohol consumption interferes with folate availability and raises the
risk of colon cancer. One study showed that the increased risk of colon cancer associ-
ated with alcohol is not seen in men with the highest folate intake.51
In contrast to biologic and observational evidence supporting a role in cancer

prevention, results from randomized trials are controversial. The largest controlled
trial to evaluate folic acid supplementation in patients with colorectal adenomas,
the Aspirin/Folate Polyp Trial found no decrease in new adenomas at three- and
six-year follow-ups. In this trial, 1021 subjects with prior adenomas were random-
ized in 4 arms and 2/4 arms received 1 mg folic acid for three to six years. The
incidence of at least one advanced lesion was 11.6% for folic acid and 6.9% for
placebo (RR = 1.67; 95% CI 1.00 to 2.80; p =. 05). The RR of having >3 polyps =
2.3 (CI = 1.2 to 4.3, p = 0.02). Prostate cancer developed in 7.3% of those receiving
folic acid versus 2.8% among placebo group (p <0.01).52 In HOPE-2 trial involv-
ing 5m522 subjects, active arm received 2.5 mg folic acid, 1 mg B12, 50 mg B6 ×
5 years. The RR of colon cancer was 1.4 (95% CI, 0.9 to 2.8). Only one trial that
used a high dose (5 mg) of daily folate supplementation concluded that, at a high
dose, folic acid supplementation is associated with a significant reduction in the
recurrence of colonic adenomas, but only 49 in the folic acid group and 45 in the
placebo group completed this study.53
22.7 Selenium and Antioxidants

Preclinical animal studies suggest that selenium intake reduces the risk of a vari-
ety of tumors. An inverse association between selenium and cancer also was
shown in several epidemiological studies.54,55 However, while selenium levels up
to 130 ng/ml correlate with low cancer mortality, this data from 14,000 patients
also suggests that levels above 130 ng/ml correlate with an increase in mortal-
ity.56 Data from a randomized trial examining the link between selenium and
skin cancer also reported a significant reduction of mortality for cancers of the
lung, colon (nearly 50% decreased risk), and prostate; nevertheless, one should
note that the primary outcome in this study was skin cancer and selenium treat-
ment did not protect against development of basal or squamous cell carcinomas
of the skin.57 Extended follow-up analyses of the data revealed that selenium
supplementation was also associated with a decreased risk for developing ade-
nomatous polyps.58
Findings from randomized trials on the association between antioxidant use and
cancer risk have been mostly negative. The Women’s Antioxidant Cardiovascular
Study (n = 7,627), a double-blind, placebo-controlled 2 × 2 × 2 factorial trial of vita-
min C, natural-source vitamin E, and beta carotene concluded that these supplemen-
tations offer no overall benefits in the primary prevention of total cancer incidence
or cancer mortality.59
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Nutritional

Boca Raton London New York

CRC Press is an imprint of the

© 2011 by Taylor and Francis Group, LLC

No claim to original U.S. Government works

Printed in the United States of America on acid-free paper

International Standard Book Number: 978-1-4200-8654-6 (Hardback)

Library of Congress Cataloging‑in‑Publication Data

Nutritional management of digestive disorders / editor, Bhaskar Banerjee.

Visit the Taylor & Francis Web site at

and the CRC Press Web site at

Chapter 1 The History of Medical Nutrition Therapy in the Treatment

Chapter 2 Assessment of Nutritional Status........................................................ 17

Chapter 3 Management of Disorders of Deglutition............................................ 37

Chapter 4 Eosinophilic Esophagitis..................................................................... 59

Chapter 5 Management of Chronic Nausea and Vomiting.................................. 73

Chapter 6 Celiac Disease..................................................................................... 91

Chapter 7 Probiotics in Irritable Bowel Syndrome............................................ 113

Chapter 8 The Role of Nutrition in Inflammatory Bowel Disease:

Chapter 9 Probiotics for Antibiotic-Associated Diarrhea and Clostridium

Chapter 10 Endoscopic Enteral Access and Enteral Nutrition............................ 159

Chapter 11 Self-Expanding Metallic Stents in the Management of

Chapter 12 Management of Chronic Malabsorption........................................... 191

Chapter 13 Total Parenteral Nutrition: Theory and Application

Chapter 14 Home Nutrition Support.................................................................... 221

Chapter 15 Intestinal Failure and Liver Disease Related to Parenteral

Chapter 16 Nutrition in Acute Pancreatitis.......................................................... 253

Chapter 17 Nutrition in Liver Disease................................................................. 271

Chapter 18 Nonalcoholic Fatty Liver Disease..................................................... 301

Chapter 19 Weight Management Strategies......................................................... 315

Chapter 20 Bariatric Surgery............................................................................... 327

Chapter 21 Obesity and Gastrointestinal Cancers............................................... 343

Chapter 22 Nutrition and Colon Cancer Prevention............................................ 353

Francis W. Chan, MD Priya A. Jamidar, MD

Rémy F. Meier, MD Waqar A. Qureshi, MD

Ryan F. Porter, MD Alain M. Schoepfer, MD

Petr Protiva, MD Tatjana Schütz

Fergus Shanahan, MD, BSc, FRCP John F. Sweeny, MD, FACS

1.2 Dietary Treatment of Gastrointestinal Diseases

1.2.2 Gastrointestinal Disorders and Diet Therapy

1.3 Postsurgical Diets

1.4.2 Nasal and Gastric Feedings

1.4.3 Small Bowel Feeding

1.4.4 Development of Enteral Formulas

1.4.5 Modern Enteral Nutrition Therapy

1.5 Parenteral Nutrition

1.5.1 Glucose in Parenteral Nutrition

Carbohydrates were recognized as a principal component of metabolism, an

1.5.4 First Successful Total Parenteral Nutrition

1.5.5 Modern Parenteral Nutrition

Nutrient Disequilibrium and

Physiologic and Physiologic and

Figure 2.1 Development of clinical nutritional disease.

of gastrointestinal disease, nutrient intake may be adequate, but malabsorption and

deliberating the decision to provide these therapies. Nutrition intervention should

2.2 Nutritional Assessment Methods

2.2.1 Patient History

patient, family, or caregiver. Understanding the pathophysiology of various disease

GI dysfunction. Review of operative reports and directed questions to the surgeon

2.3 Prediction of Complications and

4.1 Introduction, Definition, and Diagnostic Criteria

4.8 Monitoring of Patients with