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PubMed1985

Effect of increased amounts of pectin on a solid-liquid meal digestion in healthy man.

The effect of three concentrations of high-methoxy apple pectin (5, 10, and 15 g), on solid-liquid meal digestion was studied in 12 healthy men by the gastrointestinal intubation technique. The gastric emptying of water and carbohydrates is significantly reduced only after 10 and 15 g pectin. The changes in gastric pH are similar for pectin-free and pectin-containing meals. Cumulative lipase and trypsin outputs are not significantly different with and without pectin. When gastric uronic acid concentration is above 6 g/l, the duodenal absorption of carbohydrates is significantly reduced (p less than 0.001). The mean blood glucose levels with 10 and 15 g pectin are significantly higher than the control values at 180 min (p less than 0.05). Pectin does not modify serum concentrations of secretin, cholecystokinin (CCK), vasoactive intestinal polypeptide (VIP), gastric inhibitory polypeptide (GIP), and somatostatin but serum motilin and gastrin levels are below the control values after high fiber meal.

Adult↗
PubMed1984

Endoscopic visualization of an intraluminal dacron graft: definitive diagnosis of aortoduodenal fistula.

The literature contains more than 250 cases of graft enteric fistula. The classic symptom complex involves antecedent bleeding followed by exsanguinating hemorrhage within hours to days. In patients with gastrointestinal hemorrhage and a history of aortic graft implantation, the role of endoscopy is crucial, first to delineate any coexistent disease and secondarily to view the fistula itself. Although only 20 cases have been so diagnosed, aggressive intubation of the distal duodenum in a patient fully prepared for surgical intervention may yield a definitive diagnosis of aortoduodenal fistula, thus facilitating appropriate aggressive surgical management.

Aged↗
PubMed1998

The effect of the mode of administration on the hypolipidaemic activity of niacin: continuous gastrointestinal administration of low-dose niacin improves lipid-lowering efficacy in experimentally-induced hyperlipidaemic rats.

The effect of different routes and modes of administration of niacin (nicotinic acid) on its hypolipidaemic activity has been evaluated. Our working hypothesis was that the major sites of niacin action are located presystemically (i.e. in the gut wall or the liver, or both) which would make niacin a gastrointestinal drug. For such drugs continuous administration to the gastrointestinal tract is expected to augment their efficacy compared with bolus oral administration or parenteral administration. The hypothesis was examined in two rat models of experimentally induced hyperlipidaemia-Model A, based on a cholesterol-enriched diet, and Model B, in which acute hyperlipidaemia is induced by intraperitoneal administration of triton (225 mg kg(-1)). Continuous administration of niacin into the duodenum at 1.66 mg h(-1) (total dose 40 mg kg(-1) day(-1)) for up to 7 days (Model A) or at 2.22 mg h(-1) over 18 h (Model B) had significantly greater lipid-reducing effects both on total cholesterol and on triglyceride levels (15-25%) and elevation of high-density lipoprotein (HDL) cholesterol levels than did bolus oral administration of the same dose. Continuous duodenal infusion of niacin also had an even greater lipid-reducing effect than continuous intravenous infusion of the drug at the same rate and dose. The results indicate that the site(s) of action are located presystemically and that continuous duodenal administration of a low dose of niacin (40 mg kg(-1)) has a greater lipid-lowering effect than a higher dose (200 mg kg(-1)) administered by peroral bolus administration. These conclusions were validated by administration of a specially designed niacin sustained-release matrix tablet formulation that was non-invasively administered to hyperlipidaemic rats. The hypolipidaemic activity of the sustained-release tablet was of similar magnitude to that resulting from continuous duodenal administration, thus providing a pharmacodynamic rationale for this mode of administration.

Animals↗
PubMedDate not supplied

Bedside transpyloric tube placement in the pediatric intensive care unit.

BACKGROUND: The purpose of this study was to demonstrate the feasibility of placing transpyloric feeding tubes at the bedside without fluoroscopy in critically ill pediatric patients. METHODS: The patient population consisted of 90 patients (ages 1 week to 15 years, median age 9 months) admitted to a 26-bed pediatric intensive care unit in a university-affiliated pediatric hospital. Patient weights ranged from 2.4 to 100 kg with a median weight of 7.5 kg. Seventy-six patients were endotracheally intubated and mechanically ventilated; one patient had a tracheotomy. A total of 24 patients were pharmacologically paralyzed; 38 patients were receiving catecholamine infusions, and 17 patients had intracranial monitoring devices in place. All had concurrent nasogastric suctioning. Nonweighted Silicone Rubber 6F or 8F nasoenteric tubes were inserted at the bedside using metoclopramide, air insufflation and positioning to achieve transpyloric passage. Blue-dyed water was instilled in 58 patients to test for reflux and confirm transpyloric position. RESULTS: Successful nonfluoroscopic bedside transpyloric (duodenal or jejunal) tube placement was verified radiographically in 84 (93%) patients; seven of these patients were less than 4 weeks of age. One patient had blue dye in the nasogastric fluids, consistent with duodenogastric reflux or failure of transpyloric passage. The abdominal radiographs confirmed the results of the blue dye test in all 58 patients. There were six (6.7%) unsuccessful attempts at transpyloric bedside tube placement: four were a result of hemodynamic instability, one was a result of oropharyngeal trauma, and one was due to intestinal malrotation. The average time for placement was 15 minutes with a range of 5 to 45 minutes. No complications from tube placement were observed. CONCLUSIONS: Bedside placement of transpyloric feeding tubes is a safe and effective method to institute enteral feedings in critically ill pediatric patients.

Adolescent↗
PubMed1983

Colonic inhibition of pancreatic and biliary secretion.

The purpose of this study was to determine whether or not nutrients in the colon influence pancreatic and biliary secretion in humans. In six healthy subjects, similar caloric loads (117 cals) of oleic acid, essential amino acids, and glucose in isomolar (280 mosmol/L), similar pH (7.4) solutions were infused into the right colon at 10 ml/min through a colonic tube passed by mouth. A background of submaximal pancreatic and biliary secretion was maintained by continuous intravenous infusion of the octapeptide of cholecystokinin. Biliary and pancreatic secretions were quantitated using the gastroduodenal intubation perfusion technique. Among the three nutrients tested, only oleic acid in the colon decreased pancreatic enzymes and bicarbonate outputs. The mean trypsin output decreased from 26.3 +/- 2.6 kU/h to 12.3 +/- 1.9 kU/h (46% +/- 6% of control), while the lipase output decreased from 62 +/- 6.6 kU/h to 36 +/- 5.6 kU/h (58% +/- 6% of control). Similarly, the output of bicarbonate in the duodenal aspirate decreased from 31 +/- 7.2 mEq/h to 16.3 +/- 3.1 mEq/h (61% +/- 5% of control). Intracolonic perfusion of essential amino acids or glucose had no effect on pancreatic enzymes and bicarbonate secretion. In contrast, all three nutrients in the colon inhibited biliary secretion. The mean output of bilirubin decreased from 56 +/- 6 mg/h to 19 +/- 2 mg/h (35% +/- 5% of control) during intracolonic perfusion of oleic acid. Essential amino acids lowered the output of bilirubin from 54 +/- 12 mg/h to 31 +/- 8.6 mg/h (65% +/- 6% of control), whereas glucose lowered it from 53 +/- 12 mg/h to 22 +/- 4 mg/h (45% +/- 5% of control). This differing response of pancreatic and biliary output to intracolonic perfusion of nutrients suggests differential sensitivity of the pancreas and gallbladder to these inhibitory influences. In malabsorption states, unabsorbed nutrients in the colon may inhibit pancreatic and biliary secretion, further contributing to the loss of nutrients from the gastrointestinal tract.

Adolescent↗
PubMed1990

Effects of cimetropium bromide on gallbladder contraction in response to oral and intraduodenal olive oil.

To evaluate the influence of the stomach and the cholinergic system on gallbladder contraction induced by physiological stimuli, the reduction in gallbladder volume in 7 healthy volunteers has been studied by real-time ultrasonography after the oral and intraduodenal administration of olive oil, preceded by pretreatment with cimetropium bromide or placebo. After an overnight fast, each subject swallowed 50 ml olive oil or it was administered through a naso-duodenal tube in the proximal duodenum. Cimetropium bromide 5 mg or placebo was given intravenously under double-blind control. After the placebo pretreatment, gallbladder contraction was greater and faster after intraduodenal oil than after oral oil. Cimetropium bromide decreased the extent, velocity and duration of gallbladder contraction induced by intraduodenal olive oil but it only reduced the velocity of the contraction induced by oil given orally. It is concluded that in normal human subjects the stomach modulates the extent and velocity of postprandial gallbladder contraction and that anticholinergic agents antagonize the gastric and duodenal phases of the response of the gallbladder to a meal.

Administration, Oral↗
PubMed1993

Intraduodenal infusion of a water-based levodopa dispersion for optimisation of the therapeutic effect in severe Parkinson's disease.

Motor performance of five patients with advanced Parkinson's disease was investigated during their optimum oral therapy (conventional tablets and/or depot capsules) and during a continuous duodenal infusion of levodopa. Due to the low water solubility of the drug, conventional tablets of levodopa+carbidopa (Sinemet) were milled and dispersed in a 1.8% aqueous methylcellulose solution. The dispersion was delivered nasoduodenally by a portable pump. The effect of levodopa in the two dosing regimens was estimated optico-electronically every 15 min and was also evaluated from videorecordings every 30 min and plasma levels of levodopa was regularly measured. Each dosage regimen the was studied twice, at a 2-4 day interval. Duodenal infusion improved motor function in all five patients and the fluctuations were reduced when compared to the oral therapy. Variation in plasma levodopa concentrations was 3-10 fold during oral therapy, while during the infusion a stable concentration was obtained. The therapeutic concentration varied from 0.3-3 ml-1 between patients. The relative bioavailability of levodopa in the solid preparation compared to the dispersion was in all patients 100%. Our results encourage further development of a duodenal infusion system with a levodopa dispersion for clinical use in parkinsonian patients who show severe fluctuation.

Administration, Oral↗
PubMed2001

Nutrient-induced spatial patterning of human duodenal motor function.

The spatiotemporal patterning of duodenal motor function has been evaluated comprehensively for the first time in humans, with a novel 21-lumen manometric assembly. In nine young, healthy volunteers (6 male, 3 female), duodenal motility was recorded during fasting and three 45-min intraduodenal (ID) nutrient infusion periods (Intralipid at 0.25, 0.5, and 1.5 kcal/min). Pressures were recorded along the length of the duodenum with an array of 18 sideholes at 1.5-cm intervals. Pressure patterns were compared for the final 20 min of each of the four periods. Compared with fasting, ID lipid was associated with regional variation in pressure wave (PW) sequences, with fewer proximally and more distally; this was not observed during fasting (P < 0.001). During fasting and all rates of lipid infusion, most (87-90%) PW sequences were short (1.5-4.5 cm), with a small number (2-4%) of 10.5 cm or longer. At all times, antegrade PW sequences occurred more frequently than retrograde sequences over all distances examined (3, 4.5, and >6 cm), and the proportion of antegrade sequences increased with greater PW sequence length (P = 0.0001). Increasing ID lipid rates appeared to produce dose-related suppression of PW sequences (P < 0.001). The frequency and spatial patterning of human duodenal motor function show substantial variability in response to different nutrient delivery rates. These complex patterns are likely to be involved in duodenal modulation of flow and gastric emptying rate.

Adult↗
PubMed1975

Flow through the bile duct after cholecystectomy.

The human bile duct has no intrinsic motility, but following cholecystectomy, flow through the bile duct is governed by the intraductal pressure generated by the liver, by the resistance to flow through the duct and sphincter at the terminal end of bile duct and by intraduodenal pressure. Pressure-flow experiments were performed upon 50 patients with biliary T-tube drainage following cholecystectomy and choledochostomy; nine patients had also undergone transduodenal sphincterotomy. Saline solution was introduced into the bile duct at controlled pressures, ranging from zero to 30 centimeters of water, while recordings were made of the flow rate of saline solution, intraduodenal pressure and respiratory movements. Although the flow rate of saline solution increased as its perfusion pressure was increased, three types of variation in flow were also recorded: rhythmic arrests of flow, occurring four to eight times per minute, believed to be due sphincteric contractions; nonrhythmic arrests of flow, lasting up to one minute, believed to be due to sphincteric contraction, and variations in flow associated with changes in intraduodenal pressure. The resistance to the flow of saline solution and the variations in flow rate were also similar in the patients who had undergone sphincterotomy. This study supports the view that sphincteric activity is present followingcholecystectomy, that the choledochal sphincter has rhythmic activity which differs from that of duodenal motility and that sphincter probably opens and closes continuously in a rhythmic manner during fasting periods in patients who have undergone cholecystectomy.

Bile Ducts↗
PubMed1996

Motility agents for the placement of weighted and unweighted feeding tubes in critically ill patients.

OBJECTIVE: To determine if successful attempts at feeding tube placement into the small bowel could be increased with the use of a weighted end or by pre-treatment with a drug to increase gastric motility. DESIGN: A prospective randomized control study, double blinded for a drug study drug, in a population of critically ill patients. SETTING: A 635-bed acute care hospital in Philadelphia, Pennsylvania. PATIENTS: Eighty-three patients in the critical care setting randomized into four groups receiving either parenteral normal saline (NS) 100 cc, erythromycin (EMY) 200 mg, or metoclopramide (MET), 10 mg, 30 min prior to attempted tube placement with either a weighted (WEI) (57 patients) or unweighted tube (UNW) (26 patients). RESULTS: When analyzed for number of attempts prior to successful tube placement into the stomach there was a significant difference between the unweighted and weighted groups: 2.08 +/- 1.03 attempts vs 1.51 +/- 0.94, P < or = 0.015. Duodenal migration at 24 h was demonstrated in three patients in the NS/UNW group and in two patients in the NS/WEI group as compared to no patients in either the EMY/WEI or the MET/WEI groups (p < or = 0.025, Fisher's exact test). CONCLUSIONS: These data demonstrate that the use of weighted feeding tubes decreases the number of attempts required to achieve gastric intubation, but that motility agents given prior to tube insertion do not augment advancement of the feeding tube beyond the stomach and may in fact hinder placement into the duodenum.

Critical Care↗
PubMed2001

Effects of nutrients and serotonin 5-HT3 antagonism on symptoms evoked by distal gastric distension in humans.

Distal gastric distension may contribute to meal-related dyspeptic symptoms. This study's aims were to determine the effects of distinct nutrient classes on symptoms induced by distal gastric distension and their dependence on 5-hydroxytryptamine(3) (5-HT3) receptors. Nine healthy subjects rated pain, nausea, and bloating induced by isobaric distal gastric distensions (6-24 mmHg) during duodenal lipid, carbohydrate, protein, or saline perfusion after treatment with placebo or the 5-HT3 receptor antagonist granisetron (10 microg/kg iv). Distensions produced greater pain, nausea, and bloating with lipid at 1.5 kcal/min compared with saline (P < or = 0.02), primarily because of greater distal gastric volumes at each distending pressure. In contrast, carbohydrate and protein had no significant effect. At 3 kcal/min, lipid increased symptoms through a volume-independent as well as a volume-dependent effect. Granisetron did not affect symptom perception or gastric pressure-volume relationships. In conclusion, isobaric distal gastric distension produces more intense symptoms during duodenal lipid compared with saline perfusion. Symptom perception during distal gastric distension is unaffected by 5-HT3 receptor antagonism.

Adult↗
PubMedDate not supplied

Efficacy of erythromycin for postpyloric placement of feeding tubes in critically ill children: a randomized, double-blind, placebo controlled study.

BACKGROUND: Erythromycin enhances gastric emptying and has been suggested to facilitate nasoenteric feeding tube placement in adults. Our primary objective was to evaluate the effect of erythromycin on the transpyloric passage of feeding tubes in critically ill children, and second, to evaluate the effect of erythromycin on the distal migration of duodenal feeding tubes. METHODS: Seventy-four children were randomly assigned to receive erythromycin lactobionate (10 mg/kg) IV or equal volume of saline placebo 60 minutes before passage of a flexible weighted tip feeding tube. Abdominal radiographs were obtained 4 hours later to assess tube placement. If the tube was proximal to the third part of the duodenum, two additional doses of erythromycin/placebo were administered 6 hours apart. Those receiving additional doses had repeat radiographs 14 to 18 hours after tube placement. RESULTS: The number of postpyloric feeding tubes was similar in the erythromycin and placebo treated groups 4 hours after tube insertion (23/37 vs 27/37, p = .5). Of those with prepyloric tubes at 4 hours, none in the erythromycin group and 3 in the placebo group had the tube migrate to the postpyloric position by 14 to 18 hours (p < .05). Of those with postpyloric tubes proximal to the third part of the duodenum at 4 hours, additional doses of erythromycin did not cause more tubes to advance further into the intestine than did placebo (p = .6). CONCLUSIONS: Erythromycin does not facilitate transpyloric passage of feeding tubes in critically ill children. The distal migration of duodenal tubes further into the small bowel is also not enhanced by erythromycin.

Adolescent↗
PubMed1979

Jejunal secretion in response to a duodenal mixed nutrient perfusion.

A multilumen balloon tube constructed to separate duodenal and jejunal perfusion segments was placed in the proximal small bowel of 6 healthy volunteers. The effect of nutrient mixture in the duodenum on net jejunal water and electrolyte flux was then determined. The duodenum was perfused with a balanced electrolyte solution before and after the nutrient perfusion. Net water flux in the perfused jejunum changed from absorption 27.0 +/- 6.0 microliter/min/cm, (mean +/- SEM) to secretion 7.7 +/- 7.3 microliter/min/cm (P less than 0.025) during nutrient perfusion. There was also net chloride secretion and decreased net absorption of Na, K, and HCO3 (P less than 0.05). The jejunal absorption of water and electrolytes before and after the duodenal nutrient perfusion was the same. Results indicate that intestinal secretion may occur under physiologic conditions at sites remote to the application of food in humans.

Adult↗
PubMed1986

Trypsin suppression of pancreatic enzyme secretion. Differential effect on cholecystokinin release and the enteropancreatic reflex.

We have recently demonstrated that intraduodenal perfusion of trypsin inhibits phenylalanine-stimulated pancreatic enzyme secretion by suppression of release of cholecystokinin (CCK). It is not known whether trypsin in the duodenum inhibits pancreatic secretion stimulated by a cholinergic mechanism. To investigate this question gastrointestinal intubation and perfusion were performed in 12 healthy subjects. Volume and osmoreceptors in the duodenum, which are known to elicit pancreatic secretion through cholinergic pathways, were stimulated by infusing increasing volumes (1.0, 2.5, and 5.0 ml/min) of normal saline or increasing osmolality (300, 400, 500 mosmol) of NaCl solution. Increasing the rates of intraduodenal perfusion of normal saline or increasing the osmolality of the duodenal perfusates caused a dose-related increase in pancreatic trypsin and chymotrypsin outputs without affecting basal plasma CCK levels (0.9 +/- 0.1 pM). The volume- or osmolality-stimulated pancreatic secretions were abolished by atropine, but not by intraduodenal perfusion of trypsin. In contrast, intraduodenal perfusion of phenylalanine (10 mM) produced a significant increase in plasma CCK levels (6.7 +/- 0.8 pM) and a three- to fourfold increase in pancreatic enzyme outputs. Perfusion of the duodenum with bovine trypsin (1 g/L) reduced the plasma CCK levels to basal values and significantly attenuated the phenylalanine-stimulated enzyme secretion to 63% +/- 4% of control. Simultaneous administration of atropine and intraduodenal perfusion of trypsin completely abolished the pancreatic enzyme response to phenylalanine stimulation. These studies indicate that the intestinal phase of human pancreatic enzyme secretion is under both hormonal and neural control. Intraduodenal trypsin inhibits only pancreatic secretion mediated by CCK release, and not that mediated by cholinergic mechanisms. These observations suggest that feedback regulation of pancreatic enzyme secretion is stimulus specific.

Adult↗
PubMed1996

[Cardiac tamponade after central venous catheterization in a newborn infant].

BACKGROUND: Cardiac tamponade due to an intrapericardial infusion is a serious complication of central venous catheterization. CASE REPORT: An infant born at 35 weeks of gestation age, weighing 2300 g, was operated on at H10 for a duodenal stenosis. On day 2, a polyurethane central venous catheter was inserted for parenteral nutrition via his right internal jugular vein. A frank blood return was obtained and a chest X-ray taken 2 hours later showed that the tip into the catheter was in the right ventricle. Four hours after insertion, a sudden deterioration of the infant's status led to tracheal intubation and artificial ventilation on 100% oxygen; no improvement was noted. The heart rate was 135 bpm, but the differential blood pressure was decreased at 68/56 mmHg and there was no blood return on the catheter. Cardiac tamponade was then suspected and immediately confirmed by pericardial tap that yielded 10.5 mL of the infused solution. The catheter tip was then repositioned and a good blood return was obtained. The infant's breathing and hemodynamic status improved dramatically. CONCLUSION: The use of very thin and flexible central venous catheters does not eliminate the risk of perforation of the cardiac chambers. A cardiac tamponade must always be considered in children with a central venous catheter when a sudden deterioration of hemodynamic status is noted.

Cardiac Tamponade↗
PubMed1986

Human duodenal mucosal bicarbonate secretion. Evidence for basal secretion and stimulation by hydrochloric acid and a synthetic prostaglandin E1 analogue.

The factors responsible for prevention of duodenal mucosal injury are not known. This series of experiments was performed to determine whether the human duodenum secretes bicarbonate that could prevent mucosal damage. To isolate a 4-cm segment of proximal (i.e., the duodenal bulb) or distal duodenum free of contamination from either gastric or pancreaticobiliary secretion, or both, methods were developed using occlusive balloons. The test segment was perfused with NaCl (2 ml/min, 37 degrees C) containing [14C]PEG as a nonabsorbable marker, and bicarbonate output was quantitated. Mean (+/- SE) basal proximal duodenal bicarbonate output was 143 +/- 17 mumol/cm X h. A 5-min infusion of 25, 50, and 100 mM HCl directly into the isolated proximal duodenal test segment increased bicarbonate output to 167 +/- 29, 199 +/- 19, and 278 +/- 49 mumol/cm X h, respectively, during the hour after acidification. Distal duodenal acidification (25, 50, and 100 mM) also increased bicarbonate output from the isolated proximal duodenal test segment. A synthetic prostaglandin E1 analogue, misoprostol (1.67-13.3 micrograms/min), infused directly into proximal or distal test segments significantly stimulated bicarbonate outbreak; peak responses were 644 +/- 35 mumol/cm X h and 171 +/- 20 mumol/cm X h (p less than 0.001), respectively. Thus, in humans, the proximal and distal duodenal mucosa secretes bicarbonate at rest; direct acidification of the proximal duodenum stimulates bicarbonate output; acidification of the distal duodenum beyond the isolated test segment also increased proximal duodenal bicarbonate output; and a synthetic prostaglandin E1 analogue stimulated both proximal and distal bicarbonate output; however, distal duodenal bicarbonate output was significantly less, indicating a proximal-to-distal gradient in bicarbonate secretion.

Adult↗
PubMed1976

Manometric studies on the human pyloric sphincter. Effect of cigarette smoking, metoclopramide, and atropine.

Pyloric sphincter pressure was assessed with water-perfused polyvinyl tubes. Smoking one cigarette significantly decreased the basal pyloric pressure, whereas 10 mg of metoclopramide as an intravenous bolus increased the pyloric pressure in normal subjects and in patients with gastric ulcer with low basal pressure. Duodenal acidification with 0.1 N HCl significantly increased pyloric pressure. Atropine 15 mug per kg, subcutaneously prevented the rise of pyloric pressure in response to acid infusion into the duodenum.

Adult↗