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Biomedical subjects

J M Nightingale

Publications and source records attributed to J M Nightingale.

At least 19 recordsLinked to original sources
PubMed1996

Gastrointestinal hormones in short bowel syndrome. Peptide YY may be the 'colonic brake' to gastric emptying.

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

Adult↗
PubMed1996

Three simple methods of detecting malnutrition on medical wards.

Malnutrition in hospital is often unrecognized. A nutrition team aims to teach simple methods of detecting malnutrition. On a single day all medical in-patients underwent a nutritional assessment. Eighty-four patients (43 men), median age 71 years (range 28-97), were assessed. The most common diagnoses were cardiac disease (26), stroke/dementia (12), non-malignant lung disease (9) and malignancy (6). A weight loss of more than 10% (%WL) was found in 17/65 (26%) and a body mass index (BMI) of less than 19 kg/m2 in 13/69 (19%). A mid-arm muscle circumference (MAMC) less than the fifth percentile occurred in 16/83 (19%) patients. Percentage weight loss alone detected seven patients of whom four were overweight (BMI > 25 kg/m2), BMI alone detected three patients, and MAMC alone eight patients of whom three could not be weighed and three had fluid retention. There was fluid retention in 35/84 (42%) patients of whom nine were malnourished (six detected by BMI and/or %WL, and three by MAMC alone). All three measurements were made in 64 patients, six (9%) of whom were detected as malnourished by all three methods. Combining the three measurements 29/84 (35%) of patients were malnourished and only 28% of these patients had been assessed by a dietitian. BMI and %WL detect most patients but fluid retention may limit their accuracy. MAMC is useful in those who cannot be weighed or who have fluid retention.

Adult↗
PubMed1995

Adult patients with a short bowel due to Crohn's disease often start with a short normal bowel.

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

Adult↗
PubMed1995

The short-bowel syndrome.

Patients with a short bowel have usually had a bowel resection for Crohn's disease. Two types of short-bowel patient can be distinguished: those with a jejunostomy and those with their jejunum anastomosed to a functioning colon. Both types of patient have problems with macronutrient absorption, although those with a colon experience fewer problems because some energy from unabsorbed carbohydrate is salvaged in the colon. Patients with a jejunostomy have problems with large stomal losses of water, sodium and magnesium, whereas those with a jejuno-colic anastomosis rarely have problems with water and electrolyte absorption. Patients with a jejunostomy 100-200 cm from the duodeno-jejunal flexure ('absorbers') usually absorb more from the diet than they pass through the stoma and therefore require oral electrolyte or nutrient supplements. Those with a residual jejunal length of less than 100 cm usually secrete more from the stoma than they take in orally ('secretors') and therefore require long-term parenteral fluid or nutrient supplements. A high output resulting from a jejunostomy is treated by reducing the oral intake of hypotonic fluid, administering a sipped glucose-saline solution and, often, by giving drugs that reduce intestinal motility (most effective in absorbers) or gastrointestinal secretions (most effective in secretors). Gallstones are common both in short-bowel patients with and in those without a colon (45%), and calcium oxalate renal stones occur in the former (25%). However, it is now possible to provide adequate nutrition and fluid supplements for most patients with a short bowel, and the prospects for the rehabilitation of such patients are good.

Anastomosis, Surgical↗
PubMed1995

Fungal feeding-line infections: beware the eyes and teeth.

Twenty-four fungal feeding-line infections occurred in 17 patients during 1984-1992. Thirteen were receiving long-term home parenteral feeding and, in them, the first infection occurred after a median of 30 months (range 1-120) continuous feeding with a line that had been in situ for a median of 20 months (range 1-37). Four were receiving short-term feeding through a line that had been inserted 1-2 months previously. At the time of the first infection all patients were febrile and most were anaemic (15/16), however a leucocytosis was rare (three of 16). The fungi isolated were Candida albicans(6), Candida parapsilosis(5), Candida glabrata(2), Candida guillermondii(2) and other species (2). In 16 patients, the feeding-line was removed at the time of the first infection and no other treatment was given, and no other complications occurred in eight (50%) of these. In 11, the line was reinserted a median of 7 days after removal (range 1-11). Four patients (24%) developed a Candida infection of the eye 1-8 weeks after the diagnosis, uveitis (2) and endophthalmitis (2) which, in one patient, led to complete blindness in one eye. Two patients had recurrent infections which began within a month of dental therapy. In one, the infections stopped after dental extractions and, in the other, after a dental clearance. An ophthalmoscopic examination should be performed in all patients with a fungal feeding-line infection. Recurrent candidal infections may have a dental origin.

Candidiasis↗
PubMed1993

Disturbed gastric and small bowel transit in severe idiopathic constipation.

Many patients with severe idiopathic constipation complain of upper gastrointestinal symptoms, and these often persist after subtotal colectomy. To determine if there is a disturbance of upper gastrointestinal motility in this condition, we have studied gastric emptying for solids (111In-containing pancake) and liquids (99mTc-containing orange juice) for a longer period after a meal (6 hr) than in previously reported gastric emptying studies. Small bowel transit for solids was also measured. All patients had emptied their colon the day before the study. Twelve women (mean age 36 years) with a bowel frequency of less than once per week, proven slow intestinal transit, and a normal diameter colon were studied. Twelve healthy controls (eight female and four male, mean age 33) were also studied. As a group the constipated patients demonstrated no statistically significant delay in emptying during the first 3 hr, although the emptying rate for three of 12 individuals fell outside the normal range. However, at 6 hr after ingestion of the meal, six of 10 patients had residual gastric contents greater than normal--up to 48% solid residue (median: 11% for patients and 0% for controls, P < 0.01) and 40% of liquid (median 9% vs 0%, P < 0.01). Three of four patients with upper gastrointestinal symptoms 6 hr after the meal had gastric retention of solids markedly outside the normal range (48%, 32%, and 16%; normal < 4%). Small bowel transit time was assessed as the time for the solid phase to pass from the duodenum to the cecum; the constipated patients demonstrated delayed transit (median: 75 vs 55 min, P < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1993

Radioisotope determination of regional colonic transit in severe constipation: comparison with radio opaque markers.

Radio-opaque markers have a well established role in distinguishing between patients with normal and those with slow intestinal transit, but in the latter group their accuracy in defining the region of delay has not been established. To study regional colonic transit accurately the transit of a radioisotope labelled meal was determined and findings were compared with those of simultaneously ingested radio-opaque markers. Twelve healthy controls (mean age 33 years) and 12 severely constipated women (mean age 36 years, bowel frequency < once per week) were studied On day 1, a meal containing 10 MBq 111In bound to 0.7 mm resin microspheres was ingested. Subjects also ingested a set of radiologically distinguishable markers on three successive days. Abdominal scans were obtained three times daily for 7 days. Abdominal radiographs were obtained after 72 or 96 hours and again at 144 or 168 hours. Eight 'regions of interest' were created--one for the small bowel, six for the colon, and one for excreted stool. The constipated patients all showed colonic transit outside the normal range, with a variable site of delay demonstrated by time activity curves for each region. To provide a different measure of the effectiveness of colonic transport, the movement of the 'centre of mass' for the radioisotope and for the markers was then determined. The radioisotope and radiopaque marker methods gave similar results. At all times between 24 and 144 hours there was no significant difference for the position of the centre of mass between the radio-opaque and marker methods. At all times, however, the mean difference between the markers and the radioisotopes was positive, indicating that the center of mass of the markers was always head of that of the radioisotope. The mean difference between the methods was never greater than one region of interest, and ranged from 12 to 72% of one region of interest in the colon. The difference between these two methods could reach up to two colonic segments in certain patients at one time. Radioisotope ingestion provides accurate information about the transit through individual colonic regions because of the possibility of frequent observations and the clear delineation of the entire colon. Although these features were not obtained with radio-opaque markers, they are suitable as a screening test for the presence and pattern of colonic delay.

Adult↗
PubMed1993

Disturbed gastric emptying in the short bowel syndrome. Evidence for a 'colonic brake'.

Gastric emptying of liquid (orange juice containing technetium-99m (99mTc) labelled antimony sulphide colloid) and solid (570 kcal pancake containing 0.5 mm resin microspheres labelled with Indium-111 (111-In)) was measured in seven patients with jejunum and no colon (jejunal lengths 30-160 cm), six patients with jejunum in continuity with the colon (jejunal length 25-75 cm), and in 12 normal subjects. In patients with no colon early emptying of liquid was rapid (median 25% emptying: 7 v 25 min, no colon v normal, p < 0.05); early gastric emptying of solid was rapid in two (each with less than 100 cm jejunum) and normal in the other five. Gastric emptying of liquid and solid for patients with jejunum in continuity with the colon was normal for the first three hours. There was increased liquid and solid retained in the stomach at six hours in both groups of patients (p < 0.01). Small bowel transit time was faster than in normal subjects for liquid in both groups of patients (p < 0.05) and for solid in those with no colon (p < 0.05). Rapid gastric emptying of liquid may contribute to the large stomal output in patients with a high jejunostomy. Preservation of the colon after a major small intestinal resection exerts a braking effect on the rate of early gastric emptying of liquid.

Adult↗
PubMed1993

The short bowel syndrome: what's new and old?

Conditions which resulted in colonic preservation such as strangulated hernia, intestinal volvulus, and mesenteric infarction were once the main reasons for a major intestinal resection leading to the short bowel syndrome. Now Crohn's disease is the most common underlying diagnosis; such patients often have a jejunostomy. A measurement of the residual jejunal length from the duodenojejunal flexure makes possible predictions of patient outcome. Patients with a jejunostomy and less than 100 cm jejunum usually need long-term parenteral support, whereas 50 cm or more of jejunum usually suffices for adequate oral nutrition if the colon is preserved. While patients with and without a colon have problems with nutrient absorption, those with a jejunostomy also have problems of water, sodium and magnesium losses. Stomal losses may exceed oral intake and all such patients ('secretors') need parenteral supplements. Fluid and sodium losses can be reduced by octreotide, omeprazole or H2 blockers but not sufficiently to avoid the need for intravenous supplements. Colonic preservation increases the incidence of calcium oxalate renal stones (20%). Patients with and without a colon have a high prevalence of gallstones (40%). Clinically important intestinal adaptation occurs in those with a colon but not in those with a jejunostomy. Many surgical techniques, including small bowel transplantation, have been suggested to improve absorption, but as the quality of life of most patients with a short bowel is good with current treatments, they are not at present recommended.

Adaptation, Physiological↗
PubMed1992

Controlled trial of endoscopic injection treatment for bleeding from peptic ulcers with visible vessels.

Controlled trials have shown that bleeding peptic ulcers can be successfully treated by endoscopy and injection of adrenaline, with or without sclerosant. However, these trials have been done in major research centres, and endoscopic treatment of upper gastrointestinal bleeding has not yet become routine in general hospitals. We have done a prospective, randomised, controlled trial of injection treatment for bleeding peptic ulcers in a district general hospital. Between April, 1989, and June, 1991, all patients with acute upper gastrointestinal bleeding (n = 555) underwent endoscopy by an experienced endoscopist within 24 h of admission. 98 patients were found to have an ulcer with a visible vessel, of whom 93 were randomised to injection (n = 48) or standard treatment alone (n = 45). Injection treatment consisted of 1-2 ml of 1 in 10,000 adrenaline injected at four to six sites around the ulcer. Adrenaline and 5% ethanolamine oleate (1-2 ml) were then injected directly into the vessel. The medical team managing the patient was unaware of the endoscopic treatment given. The two groups were similar for age, initial haemoglobin concentration, shock, and ulcer site. Rebleeding (injected 8 [16.7%] vs control 21 [46.7%], p = 0.011) was significantly reduced in treated patients. The treated group also had lower mortality (4 [8.3%] vs 9 [20%]), requirement for surgery (4 [8.3%] vs 8 [17.8%]), and mean blood-transfusion requirement (5 vs 7.5 units). Endoscopic injection treatment in our patients significantly reduced rebleeding rate and may have other benefits. This cheap and widely applicable treatment can be used routinely in the management of patients with bleeding peptic ulcers who are at high risk of rebleeding.

Adolescent↗
PubMed1992

Colonic preservation reduces need for parenteral therapy, increases incidence of renal stones, but does not change high prevalence of gall stones in patients with a short bowel.

Forty six patients with less than 200 cm of normal jejunum and no functioning colon were compared with 38 patients with similar jejunal lengths in continuity with a functioning colon. Women predominated (67%), and the most common diagnosis in each group was Crohn's disease (33 of 46 no colon, 16 of 38 with colon). All patients without a colon and less than 85 cm of jejunum and all those with a colon and less than 45 cm jejunum needed long term parenteral nutrition. Six months after the last resection 12 of 17 patients with less than 100 cm jejunum and no colon needed intravenous supplements compared with 7 of 21 with a colon. Between 6 months and 2 years, little change occurred in the nutritional/fluid requirements in either group, though there was weight gain. Of 71 patients assessed clinically at a median of 5 years, none with more than 50 cm of jejunum and a colon needed parenteral supplements. Most (25 of 27) of those without a colon who did not need parenteral supplements required oral electrolyte replacement compared with few (4 of 27) with a colon. None of the patients without a colon developed symptomatic renal stones compared with 9 of 38 (24%) with a colon (p < 0.001). Stone analysis in three patients showed calcium oxalate. Gall stone prevalence was high but equal in the two groups--43% of those without and 44% of those with a colon.

Calcium Oxalate↗
PubMed1992

Oral salt supplements to compensate for jejunostomy losses: comparison of sodium chloride capsules, glucose electrolyte solution, and glucose polymer electrolyte solution.

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

Adult↗
PubMed1991

Length of residual small bowel after partial resection: correlation between radiographic and surgical measurements.

The capacity for absorption after a small bowel resection depends upon the remaining length of intestine. This is important in planning nutritional therapy and affects surgical policy should further resection appear necessary. In 18 patients, the remaining small bowel length from the duodenojejunal flexure had been measured at operation and found to be less than 200 cm; this was compared with a measurement obtained by one observer using an opisometer on a subsequent barium follow-through (BaFT) examination. A significant correlation (p less than 0.001) of 0.72 was found. Radiographic measurement was easiest when the bowel was short (less than 150 cm) and all seen on one film with no overlapping loops. A residual small intestinal length of less than 200 cm measured from a BaFT radiograph is sufficiently accurate to formulate management decisions.

Barium Sulfate↗
PubMed1991

Effect of omeprazole on intestinal output in the short bowel syndrome.

Ten patients with an end jejunostomy and one with a jejuno-rectal anastomosis (jejunal length 30-140 cm) ate a constant chosen diet for 2 control days, and 2 test days when 40 mg omeprazole orally was taken each morning. In the 7 patients with a net secretory output of fluid, there was a mean reduction in wet weight of 0.66 kg/24 h (range -0.16 to 1.45 kg/24 h; P less than 0.05) and sodium 46 mmol/24 h (-51 to 135 mmol/24 h; N.S.); the four patients with net absorption of fluid showed no reduction in intestinal output. One patient with 30 cm jejunum responded little to oral but did so to intravenous 40 mg omeprazole twice a day with a reduction in wet weight of 3.00 kg/24 h and sodium 157 mmol/24 h. In one patient oral 40 mg omeprazole daily gave equivalent results to oral 300 mg ranitidine twice daily; in 2 others it was equivalent to intravenous 50 micrograms octreotide twice daily. Omeprazole reduces the intestinal output in patients with the short bowel syndrome and a net secretory output, but not enough to prevent the need for parenteral fluid and electrolyte replacement.

Anastomosis, Surgical↗
PubMed1990

Jejunal efflux in short bowel syndrome.

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

Administration, Oral↗