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PubMed1979

[Evaluation of the biliary excretion of penicillin G. (author's transl)].

Biliary excretion of penicillin G was studied experimentally by perfusion of isolated rabbit liver. Under these conditions, bile recovery accounted for 5% of the amount of penicillin G added to the perfusing blood (10 mg); peak biliary level averaged 135.3 micrograms/ml. In man after intravenous administration of a 599 mg dose of penicillin G (1 MU) to patients provided with T-tube drainage (n = 10), the maximum biliary concentration averaged 18.0 +/- 8.0 micrograms/ml at 2 hours; biliary recovery of penicillin G accounts for 0.12% of the administered dose. The excretion of penicillin G in the juice collected through duodenal tubing in normal subjects averaged 0.07% of the administered dose (599 mg IV). Per-operative assays showed that the concentration determined at 1 hour after intravenous administration of the drug (599 mg) in the gallbladder bile (45.7 +/- 16.7 micrograms/ml) and common duct bile (93.5 +/- 16.3 micrograms/ml) were definitely higher (4.5--9 times) than the serum levels measured simultaneously. The biliary excretion of penicillin G is compared with the biliary elimination of a certain number of beta-lactam derivatives studied under the same conditions (ampicillin, metampicillin, carbenicillin, cefalothin, cefaloridine, cefacetrile, cefalexin, cefazolin).

Animals↗

PubMed1997

An analysis of upper GI endoscopy done for patients in surgical intensive care: high incidence of, and morbidity from reflux oesophagitis.

OBJECTIVE: To investigate the role of upper gastrointestinal (GI) endoscopy in a surgical intensive care unit [ICU]. DESIGN: Retrospective analysis. SETTING: University hospital, The Netherlands. SUBJECTS: 87 Male and 42 female patients, mean age 62.0 years (range 14-86). INTERVENTIONS: 198 Upper GI endoscopies. MAIN OUTCOME MEASURES: Incidence of, indication for, and abnormalities noted at upper GI endoscopy. RESULTS: 52 (40%) and 18 (14%) patients underwent 82 and 27 upper GI endoscopies, respectively, for evaluation of upper GI haemorrhage and surgical anastomoses. 59 Patients (46%) underwent 89 endoscopies for placement of nasoduodenal feeding tubes (n = 86, 97%), biliary stents (n = 2, 2%) and gastrostomy cathether (n = 1, 1%). The causes of haemorrhage were: oesophagitis (n = 13, 25%), duodenal ulcer (n = 13, 25%), gastric ulcer (n = 7, 13%) and others (n = 14, 28%). In 6 cases (11%), no bleeding site was detected. As a coincidental finding, a third of all patients had oesophagitis. The incidence of haemorrhage in patients treated and not treated by mechanical ventilation was 43/1350 (3.2%) and 9/1470 (0.6%), respectively (p < 0.0001). CONCLUSIONS: Upper GI endoscopy is a common diagnostic and therapeutic procedure in a surgical ICU. Reflux oesphagitis is often found and is clinically important. Mechanical ventilation is a risk factor for upper GI haemorrhage.

Critical Care↗

PubMed1997

[The value of diagnostic peritoneal lavage in emergency situations].

PURPOSE: The literature on diagnostic peritoneal lavage in the assessment of blunt abdominal trauma reflects an ongoing controversy. Therefore we conducted a prospective evaluation of the diagnostic management of blunt abdominal trauma used at our clinic, in which this procedure plays a substantial role. During the years 1993 and 1994 a total of 75 patients could be included in the study. The study population consisted of all patients with a diagnosis of blunt abdominal trauma. In addition, all trauma patients who were unresponsive on admission to the emergency receiving unit underwent the same program of diagnostic work-up. This group included polytraumatized patients, patients with craniocerebral injuries and all those who had been intubated prior to admission. Patients with stable vital signs were evaluated first by sonography of the abdomen, whereas those showing signs of hypovolemic shock received a diagnostic peritoneal lavage as the first evaluation of abdominal trauma. In order to assess the relative value of the two diagnostic methods, all patients who had had ultrasound as their first examination subsequently also underwent peritoneal lavage. RESULTS: 37 patients (49%) had lavage evidence of intraperitoneal bleeding. Of these 22 (29% of the total) subsequently underwent emergency laparotomy with lesions requiring surgical treatment found in 21 (95%). Only in one patient (1.3% of the study population) laparotomy failed to reveal a lesion requiring surgical correction. The accuracy of peritoneal lavage findings as an indication for laparotomy was 99%, compared to 82% for ultrasonography used as a initial diagnostic procedure. Diagnostic peritoneal lavage is quick, safe and almost independent of the experience of the investigating physician. It can be performed during other diagnostic procedures and can be repeated at will. If beyond macroscopical evaluation the lavage fluid is assessed chemically, even duodenal and pancreatic lesions as well as injuries to other hollow viscera can be suspected. With a sensitivity of 100% and a specificity of 98%, diagnostic peritoneal lavage is an extremely reliable diagnostic tool. It should be used as the initial diagnostic procedure in all hypovolemic and/or unresponsive patients suspected of having suffered blunt abdominal trauma. In conscious patients with stable vital signs, ultrasonography can be used for initial diagnosis. It should, however, be complemented by subsequent peritoneal lavage whenever the clinical course gives rise to suspicion.

Abdominal Injuries↗

PubMed1985

Intestinal phase of gastric acid secretion in humans with and without portacaval shunt.

To examine the effect of proximal small intestinal stimulants of gastric acid secretion in cirrhotic patients with portacaval shunt, unshunted cirrhotics, and normal subjects, a mixture of L-amino acids was administered intraduodenally, into the proximal jejunum, or intravenously to 8 cirrhotic patients with portacaval shunt and to 8 unshunted subjects (4 cirrhotic and 4 healthy volunteers). In addition, the effect of intrajejunally administered hyperosmolar mannitol (850 mosmol/kg) and intrajejunal balloon distention (40 mmHg) was determined. In the shunted and unshunted groups gastric acid secretion significantly increased equally in response to intravenous and intraduodenal amino acid infusion, whereas amino acids administered intrajejunally did not significantly alter acid secretion. Perfusion of the jejunum with hyperosmolar mannitol resulted in significant stimulation of acid secretion in the shunted subjects, whereas in the unshunted subjects it caused significant inhibition. In addition, jejunal balloon distention significantly stimulated secretion in the shunted subjects, but not in the unshunted group. Serum gastrin did not change significantly during any of the experiments and plasma amino acids were not different after jejunal compared with duodenal perfusion. These studies indicate the following: Enteral and parenteral amino acids increase gastric acid secretion similarly in subjects with and without portacaval shunt. The intestinal phase of gastric acid secretion is initiated by intraduodenal, but not intrajejunal, amino acids. As plasma amino acid concentrations were similar regardless of the route used, this suggests that the intestinal phase of acid secretion cannot be fully explained by the postabsorptive stimulation by amino acids. Intrajejunal distention with a balloon or infusion of hyperosmolar mannitol into the proximal jejunum stimulates acid secretion only in subjects with portacaval shunt.

Adult↗

PubMedDate not supplied

[Procedure for determining the initiation of tube feeding in children in an intensive care unit].

A procedure is proposed to determine the timing of tube feeding in children treated in an intensive care unit, which records the hypertonia of the pyloric sphincter and consists in the determination the time of gastric administration of distilled water before its evacuation into the duodenal lumen (water evacuation test) visualized in the real-time mode through abdominal ultrasonography. The proposed procedure was successfully applied to 42 children aged 3 months to 14 years who had severe brain injury, appendicular peritonitis, polytrauma, and polysegmental pneumonias. This determining procedure makes it possible to exclude radiation exposure in patients treated in intensive care units and to improve the outcomes of treatment, by prescribing the artificial feeding, that is adequate to the patients' status, in the periods optimal for each specific clinical case.

Adolescent↗

PubMedDate not supplied

Transnasal endoscopic placement of feeding tubes in the intensive care unit.

BACKGROUND: There is an increasing demand for enteral feeding in intensive care unit (ICU) patients. However, gastroparesis is common, and jejunal placement with gastric decompression leads to delays in feeding. In an attempt to minimize delays, we describe our technique and results with transnasal endoscopic placement of double-lumen gastric aspiration, jejunal feeding tubes (DLFT). METHODS: Fifty-one consecutive ICU patients referred for nutrition support were studied; 29% had respiratory failure, 28% acute head injury, and 33% acute pancreatitis. A 5.8-mm ultraslim video endoscope was used to place a guidewire through the nose terminating beyond the Ligament of Treitz. After withdrawal of the endoscope, a DLFT was passed over the wire. Final position of the tube was checked and adjusted under direct vision by reendoscopy though the opposite nasal passage. RESULTS: Initial placement of the guidewire and DLFT was successful in 46 of 51 patients. Massive gastric dilatation and acute pancreatitis complicated by duodenal compression impeded full duodenoscopy in 5 patients, necessitating fluoroscopy for correct guidewire deployment. In confirming correct tube placement, there was near perfect concordance between reendoscopy and x-ray (45/46). Previously unrecognized upper gastrointestinal tract pathology was detected in most patients, with acute gastritis in 47, superficial gastric ulceration in 24, and erosive esophagitis in 5. CONCLUSIONS: Transnasal endoscopic placement of feeding tubes in the ICU is quick, effective, and minimally disruptive of intensive therapy. In addition, it can reveal unrecognized pathology, which potentially could lead to improvements in overall medical care.

Acute Disease↗

PubMed2002

Central melanocortin receptor agonist reduces spontaneous and scheduled meal size but does not augment duodenal preload-induced feeding inhibition.

Central melanocortin (MC) receptor agonists inhibit food intake and may be downstream mediators of the effects of central leptin, which (1) reduces food intake by selectively decreasing meal size and (2) augments the feeding-inhibitory effects of gastrointestinal food stimuli. Central administration of the MC-3/4 receptor (MC-3/4R) agonist, MTII, inhibits feeding in rats, but its effects on meal pattern and potential interactions with gastrointestinal controls of food intake remain unclear. We examined meal patterns and intake in male Sprague-Dawley rats following central intracerebroventricular administration of MTII (0.01-1.0 nmol) in two situations: (1) during daytime 60-min scheduled access to liquid glucose (12.5%) in combination with a duodenal preload of 12.5% glucose or physiological saline (4.4 ml/10 min), and (2) during subsequent overnight access to 45 mg of solid chow pellets. Both duodenal glucose preloads and MTII reduced subsequent glucose intake. However, no dose of MTII augmented the reductions in food intake produced by duodenal glucose alone. During overnight access to pelleted chow, the 0.1- and 1.0-nmol doses of MTII reduced food intake, meal size, meal duration, and body weight, and increased the satiety ratio (duration of intermeal interval/preceding meal size) but did not change meal frequency. The present data (1) demonstrate that MTII, like leptin, reduces food intake by a selective reduction in meal size and not meal frequency, and (2) suggest that MTII increases the feeding-inhibitory potency of negative feedback signals critical to the control of meal size during spontaneous chow access, but not scheduled access to palatable liquid nutrient solutions.

Animals↗

PubMed1986

Successful treatment of Diphyllobothrium latum and Taenia saginata infection by intraduodenal 'Gastrografin' injection.

Tapeworm infections are very difficult to cure completely. Thirteen patients with tapeworm infection, seven with Diphyllobothrium latum and six with Taenia saginata, were treated by the introduction of a radio-opaque contrast medium, 'Gastrografin', into the duodenum through a duodenal tube. The whole tapeworm with the scolex was expelled unfragmented within 1 h in eleven cases. One patient expelled a tapeworm 3 days after treatment; the peristalsis of his intestine had been severely disturbed after an attack of cerebral apoplexy. The tapeworm could not be expelled by the remaining patient, probably because she had severe intestinal adhesion. The injection of gastrografin allowed clear visualisation of the tapeworm, the diagnosis of the infection could be confirmed, and the descent of the tapeworm could be observed serially. This treatment had no serious adverse effects in any of out patients.

Adult↗

PubMed1993

Continuous duodenal infusions of levodopa.

Infusion of carbidopa/levodopa or levodopa through a duodenal tube can facilitate increased mobility and functional ability in individuals with Parkinson's disease when conventional drug therapy is unsuccessful in achieving desired outcomes. Therapy requires appropriate patient selection, ongoing assessment of the patient's physical and emotional needs and collaboration between the patient, nurses and physicians. Determining the amount of medication required to achieve the desired outcomes takes time. Implantable pumps may be a future strategy. Future research should focus on patient and family coping throughout hospitalization and at home so the emotional needs of this specific population can be met.

Activities of Daily Living↗

PubMed1978

Site of emetic action of oral copper sulfate in dogs. (I) Thresholds of various portions of gastrointestinal tract to locally applied copper sulfate.

Emetic thresholds to copper sulfate administered into the Pavlov pouch, Forrest pouch, Thiry fistulas of the jejunum and ileum, and duodenal, jejunal and ileal catheters were measured in dogs to conjecture the site of emetic action of copper sulfate. The oral emetic threshold had been measured preoperatively. In the stomach, the pyloric antrum had a high sensitivity, while the corpus had a low sensitivity to the topically applied copper sulfate. In the intestine, the sensitivity was high in the duodenum, whereas a low sensitivity was noted in the jejunum. Almost no sensitivity was observed in the ileum. Thus it would appear that the site of the emetic action of copper sulfate was the pyloric antrum and/or duodenum.

Administration, Oral↗

PubMed1998

Food intake responses to upper gastrointestinal lipid infusions in humans.

Previous studies in humans and animals have shown that the presence of lipid in the small intestine can reduce food intake. Studies that have combined intraduodenal lipid infusions with gastric distension produced a greater reduction in food intake than when these two stimuli were separated. In this study, subjects received duodenal lipid (Intralipid 20%) infusions for varying periods before and during the consumption of a liquid test meal. The aim of this procedure was to maximise the interaction between intestinal nutrient stimulation and gastric distension. A dose-dependent decrease in food intake was observed that corresponded to the duration of infusion; 90- (180 kcal) and 45-min (90 kcal) infusions but not 15-min (30 kcal) infusions significantly reduced intake compared to saline. These results show that concomitant intestinal nutrient stimulation and gastric distension is an effective test for the measurement of suppression of food intake by intestinal nutrients.

Adult↗

PubMed2003

Enteral glutamine stimulates protein synthesis and decreases ubiquitin mRNA level in human gut mucosa.

Effects of glutamine on whole body and intestinal protein synthesis and on intestinal proteolysis were assessed in humans. Two groups of healthy volunteers received in a random order enteral glutamine (0.8 mmol.kg body wt(-1)x h(-1)) compared either to saline or isonitrogenous amino acids. Intravenous [2H5]phenylalanine and [13C]leucine were simultaneously infused. After gas chromatography-mass spectrometry analysis, whole body protein turnover was estimated from traced plasma amino acid fluxes and the fractional synthesis rate (FSR) of gut mucosal protein was calculated from protein and intracellular phenylalanine and leucine enrichments in duodenal biopsies. mRNA levels for ubiquitin, cathepsin D, and m-calpain were analyzed in biopsies by RT-PCR. Glutamine significantly increased mucosal protein FSR compared with saline. Glutamine and amino acids had similar effects on FSR. The mRNA level for ubiquitin was significantly decreased after glutamine infusion compared with saline and amino acids, whereas cathepsin D and m-calpain mRNA levels were not affected. Enteral glutamine stimulates mucosal protein synthesis and may attenuate ubiquitin-dependent proteolysis and thus improve protein balance in human gut.

Adult↗

PubMedDate not supplied

Esophagogastric decompression and enteral feeding following cholecystectomy: a controlled, randomized prospective trial.

One hundred fourteen patients scheduled to undergo elective cholecystectomy were prospectively randomized into one of four treatment groups to study the potential benefits of esophagogastric decompression with and without immediate postoperative enteral nutrition. Group I was the control, and patients received only iv fluids and were allowed to eat as tolerated. Group II patients received iv fluids and esophagogastric decompression. Group III patients received esophagogastric decompression and enteral sterile water through the duodenal feeding lumen. Group IV patients received esophagogastric decompression and infusion of an elemental diet through the feeding lumen. The surgical techniques were standardized for all patients. The results of the study indicated no statistically or clinically significant differences among any of the treatment groups regarding; (1) need for parenteral analgesics or antiemetics, (2) tolerance of regular diet, (3) postoperative day of discharge, and (4) postoperative day that other discharge criteria were met. It is concluded that there is no objective benefit to the routine use of esophagogastric decompression with or without enteral nutrition in elective cholecystectomy patients.

Cholecystectomy↗

PubMed1976

[Insufficiency of secretion from the exocrine pancreas in infants (excluding mucoviscidosis) Diagnosis and consequences].

The diagnosis of insufficiency of exocrine pancreatic secretion was made in two infants after demonstration of a marked decrease in the flow rate of enzyme secretions during the duodenal infusion of milk and after the IV injection of C.C.K.-P.Z. The two infants had a normal sweat test. One had pancreatic lipomatosis with neuropaenia, whilst the other had pancreatic deficiency which did not fall into the context of Shwachman's syndrome. This study suggests that the absence of exocrine pancreatic secretion is accompanied by multiple abnormalitites : decreased absorption of fats and vitamin B12 and, it would appear, variations in certain activities of the jejunal mucosa and decreased insulin stimulation from the intestine. Such a situation reflects the complexity of the relations established between the organs participating in the processes of absorption and digestion.

Child↗

PubMedDate not supplied

Percutaneous endoscopic gastrojejunostomy: a dual center safety and efficacy trial.

Although jejunal tube placement through a percutaneous endoscopic gastrostomy (PEG) has not been proven to be preferable to PEG feeding, it would be theoretically advantageous for those patients prone to gastrointestinal aspiration. However, reliable placement of a small bowel feeding tube through a PEG has been technically difficult. We have previously reported successful placement of a percutaneous endoscopic gastrojejunostomy (PEG/J) with minimal complications. These results are in contrast to other series that report technical difficulty, frequent tube dysfunction and gastric aspiration. We describe an over-the-wire PEG/J technique performed by multiple operators at two medical centers. Gastrostomy tube placement was successful in 94% of patients. Initial placement of the jejunal tube was successful in 88% of patients. Second attempts were 100% successful. The average procedure time was 36 minutes. The distal duodenal and jejunal placement of the jejunal tube resulted in no episodes of gastroduodenal reflux. Complications included jejunal tube migration (6%), clogging (18%), and unintentional removal (11%). The majority of patients were ultimately converted to either oral or intragastric feedings. We conclude that the PEG/J system is a reliable, reproducible method of small bowel feeding and is associated with no episodes of tube feeding reflux when the jejunal tube is positioned in the distal duodenum or beyond. Furthermore, it provides a temporary nutritional bridge for those patients who are later transitioned to either PEG or oral feeding.

Adult↗

PubMed1995

Octreotide versus pyloric exclusion in reducing gastrointestinal secretions entering the duodenum in a canine model.

Pyloric exclusion is advocated in the treatment of duodenal injury. The beneficial effect is thought to be due to diversion of gastric secretions and resultant reduction of biliary and pancreatic secretions. The long-acting somatostatin analog, Octreotide, makes the inhibitory actions of somatostatin on gastric, biliary, and pancreatic secretions a potential alternative to pyloric exclusion. We compared the effect of pyloric exclusion to the effect of Octreotide on the volume of gastrointestinal secretions entering the duodenum by creating a duodenal fistula using a canine model. Five animals had modified Thomas cannulas placed in the duodenum. Two animals had staple closure of the pylorus with a gastrojejunostomy in addition to the cannula. Gastrointestinal secretions were measured in 2- or 3-hour collection periods performed every third or fourth day. Animals were administered saline or Octreotide (100 micrograms/hour) intravenously during each collection. Up to 9 hours of collections under both saline and Octreotide (18 hours total) were done on each dog. Octreotide alone reduces gastrointestinal secretions entering the duodenum more than pyloric exclusion alone. Pyloric exclusion and Octreotide together offered no additional reduction in gastrointestinal secretions entering the duodenum over Octreotide alone.

Animals↗

PubMed1988

Sucralfate is protective against indomethacin-induced intestinal ulceration in the rat.

The therapeutic effects of sucralfate on ulcerated gastric and duodenal mucosa is well known. There is, however, very little information about its effect on the mucosa of the small intestine. We studied the possible protective effect of sucralfate against indomethacin-induced intestinal ulceration in the rat. Sucralfate was found to possess a marked protective effect on the intestinal mucosa (ulcer index 23.16 +/- 6.58 vs. 225 +/- 36.37; p less than 0.001). Sucralfate elevated basal mucosal prostaglandin E2 generation (p less than 0.001), and partially overcame the inhibition of prostaglandin E2 synthesis caused by indomethacin (p less than 0.03), but had no effect on mucosal cAMP level. The effect of sucralfate on prostaglandin E2 content might partially explain its protective effect on the intestinal mucosa.

Animals↗

PubMed1997

Malrotation: the postoperative period.

BACKGROUND/PURPOSE: There have been many reports of patients who have persistent gastrointestinal symptoms after undergoing Ladd's procedure. Postoperative return of bowel function in many of these patients seems to be delayed. METHODS: Postoperative return of bowel function after performance of a Ladd's procedure was studied retrospectively in a series of 57 children treated between 1981 and 1994. Excluded were those patients who had a malrotation in combination with an abdominal wall defect, a congenital diaphragmatic hernia, or duodenal atresia. Patients were divided in two groups; one group consisted of patients less than 1 year of age and one group of those 1 year of age and older. RESULTS: Nasogastric tube decompression was necessary for an average of 6.7 days in the first group and 4.3 days in the older children (P = .03). A midgut volvulus delays resumption of bowel function postoperatively. Gastric tube decompression was necessary for 8.6 days (n = 15) compared with only 5.1 days (n = 45) for the group without a volvulus (P = .003, analysis by t test). CONCLUSION: The authors recommend that a central venous line be inserted for feeding purposes when a volvulus is present at operation.

Adolescent↗