短肠综合征的营养康复治疗

短肠综合征的治疗主要为营养支持和小肠移植,但两种疗法都有其限制和不足之处。作者总结了３例短肠综合征患者联合应用重组人生长激素、谷氨酰胺、纤维素行营养康复治疗的经验,３例患者残存小肠的长度分别为６５、７５、３０ｃｍ,治疗后患者残存肠管的吸收功能和营养状况均有明显改善。作者认为营养康复疗法为短肠综合征提供了一个新的有效的治疗选择。     

小肠、阑尾

胃肠道间质瘸外科治疗疗效分析；改良肠外排列治疗复发性小肠梗阻S2例分析；双气囊电子小肠镜在小肠疾病诊断中的临床应用；短肠综合征患者血清瓜氨酸水平与小肠吸收面积和功能的相关性；小儿车祸伤空肠嵌入腰椎2-3裂隙致肠梗阻一例；急性阑尾炎并存结肠肿瘤的漏诊分析：附26例报告；     

短肠综合征康复治疗的实验研究和临床应用

目的观察应用重组人生长激素、谷氨酰胺和膳食纤维行康复治疗的实验动物及短肠综合征患者的治疗效果。方法 30只大鼠分为对照组、短肠组和生长激素 (growthhormone ,GH)组 ,短肠组和GH组切除 80 %小肠 ,GH组术后第 1天开始注射GH 1U·kg-1·d-1,共 2 8d ;9例患者残存小肠长度为 (4 4± 2 4)cm ,其中 3例无完整结肠。结果S期细胞比率系数、增殖指数和增殖细胞核抗原表达的增强表明外源性GH可明显促进残存小肠粘膜的增殖 ,GH的作用机理可能与原癌基因C jun表达的改变有关。康复治疗后 9例患者营养状况和残存肠管吸收功能均明显改善 ,8例患者进行了随访 ,75 %的患者完全脱离肠外营养 ,2 5 %的患者需间断肠外营养补充。结论康复治疗为短肠综合征提供了一个新的有效的治疗方法     

短肠综合征康复治疗的实验与临床研究

目的 研究生长激素对大部小肠切除后残存小肠粘膜增殖活性的影响;评价短肠康复治疗的临床疗效。方法 利用病理图象分析、流式细胞分析、免疫组化法和ＲＴ－ＰＣＲ法观察比较对照组（假手术组）、短肠组（８０％小肠切除）和生长激素组（８０％小肠切除加１Ｕ．ｋｇ＾－１．ｄ＾－１生长激素皮下注射２８ｄ）ＳＤ大鼠小肠粘膜的增殖状况。观察肠康复治疗（肌注生长激素８～１２Ｕ．ｄ＾－１加静脉滴注加谷氨酰胺０．６ｇ．ｋｇ＾－     

亲属活体小肠移植后急性排斥反应的监测与治疗一例

目的探讨亲属活体小肠移植后急性排斥反应的监测与治疗。方法对1例短肠综合征患者施行亲属活体小肠移植，手术分两期进行。供者为患者的母亲，供、受者HLA有4个抗原相符。移植肠段长120cm，一期手术时供、受者肠道不进行吻合，移植肠两端在腹壁造口，一期手术后188d，再行二期手术，分别将受者残存小肠的近端、远端与移植肠袢的近端、远端作端侧吻合。术后观察移植小肠引流液的性状，定期内镜观察，并行移植肠组织学检查。采用他克莫司、霉酚酸酯及甲泼尼龙预防排斥反应，并予两剂达利珠单抗诱导。结果受者两次手术均顺利。一期手术后37d出现急性排斥反应，给予皮质激素冲击治疗9d，未能逆转，后改为莫罗单抗-CD3治疗8d后逆转。术后121d，肠镜及组织学检查证实移植肠修复良好，小肠绒毛形态及结构基本正常，D-木糖吸收试验提示移植肠吸收功能改善。现患者已存活213d，体重增加4．5kg，进半流质饮食，生活自理。结论小肠移植后可采取肠镜和组织学检查，并结合临床表现来综合判断排斥反应。发生急性排斥反应时，及时予以激素冲击治疗，无效时可用莫罗单抗-CD3。     

内脏脂肪素与糖尿病肾脏病hsCRP及UAER的关系

目的探讨血清内脏脂肪素（visfatin）与糖尿病肾脏病患者高敏C反应蛋白（hsCRP）及尿白蛋白排泄率（UAER）的关系。方法将90例2型糖尿病（T2DM）患者分为单纯T2DM组（A组）46例,糖尿病肾脏病（DKD）组（B组）44例;另设50例健康体检者为正常对照组（C组）。测定身高、体重、腰围（WC）、血压（BP）,计算体重指数（BMI）。检测3组血清visfatin、hsCRP及血糖、血脂、肾功能等各项生化指标。血清visfatin与hsCRP、UAER行相关性分析。结果A、B组血清visfatin水平和hsCRP均明显高于C组（P〈0．01）。B组中血清visfatin水平和hsCRP均明显高于A组（P〈0．05,P〈0．01）。相关性分析中,B组血清visfatin水平与UAER呈正相关（r=0．479,P〈0．01）,与hsCRP亦呈正相关（r=0.376,P〈0．05）。结论血清visfatin与DKD的炎症状态以及尿白蛋白排泄有关,可能在其发病机制中发挥一定作用。     

短肠综合征治疗方法的选择

短肠综合征（SBS）是肠衰竭的主要病因,有着较高的并发症发生率和病死率.近年来,随着重症医学和全肠外营养（TPN）技术的进步,大大提高了丧失大部肠道病人的长期存活率.SBS治疗措施的制定应该基于病人的年龄、残存胃肠道的长度和功能、基础营养状况、总的健康状况和可能发生的并发症,要求内科学、营养学、外科学和心理学的综合治疗.肠道吸收面积减少引起吸收障碍,导致多种营养相关问题是其临床治疗的主要难点.     

连续横向肠成形术（STEP）——外科治疗短肠综合征的新方法

短肠综合征（shortbowel syndrome，sss）是指小肠吸收面积减少后而出现的水电解质代谢紊乱和营养吸收不良综合征。外科手术是治疗短肠综合征的重要手段之一．手术方式分为非移植手术和移植手术两类。国际上较为公认的非移植手术主要有两种：Bianchi术和连续横向肠成形术（serial transverse enteroplasty procedure，STEP），其目的都是为延长食物在肠道内滞留的时间，增加吸收时间和吸收量．从而使患者脱离全肠外营养（TPN）。近年来，STEP术式因其简单、安全的手术方式，日益受到大家的重视。     

2型糖尿病患者尿蛋白水平与血清白细胞介素1β和晚期蛋白氧化产物的关系

目的观察不同尿白蛋白排泄率（UAER）的2型糖尿病患者血清白细胞介素18（IL-1β）和晚期蛋白氧化产物（AOPP）水平,探讨其在糖尿病蛋白尿发生和发展中的作用。方法选择2008年11月至2010年2月在我院住院的2型糖尿病患者62例,按照UAER水平分组：间断白蛋白尿组（n=20）,UAER〈20μg／min;微量白蛋白尿组（n=22）,UAER20-200μg／min;临床白蛋白尿组（n=20）,UAER〉200μg／min。选择同期健康体检者20例作为对照组。比较各组血清IL-1μ和AOPP水平。结果3组糖尿病患者血清IL-1β和AOPP水平均高于对照组（P〈0．05）,微量白蛋白尿组IL-1β和AOPP水平均高于正常白蛋白尿组（P〈0．05）,显性白蛋白尿组IL-1β和AOPP水平均高于微量白蛋白尿组和正常白蛋白尿组（P〈0．01）。血清IL-1β与AOPP呈正相关（r=0．760,P〈0．01）,血清IL-1β和AOPP与UAER呈正相关（r分别为0．809和0．813,P〈0．01）。结论IL-1β和AOPP可作为糖尿病肾脏微血管病变的早期预测因子,对预防糖尿病肾脏微血管病变有重要意义。     

肠缺血再灌注对小肠功能的影响

目的从不同角度探讨大鼠肠缺血再灌注对小肠屏障、吸收、通透和传输等功能的影响,为更深入地研究肠道损伤及其保护提供防治依据.方法以Wistar大鼠肠缺血再灌注(I/R)作模型,将动物随机分为健康对照(C)、肠系膜上动脉夹闭1h(I)、夹闭后再灌1h(R 1h)、2h(R 2h)和4h(R 4h)共5个组.分别测血或小肠组织的二胺氧化酶(DAO)、D-乳酸、D-木糖、肠传输、脂质过氧化物(MDA)和髓过氧化物酶(MPO),并作小肠普通光镜检查.结果R 1h和R 4h组的血浆DAO显著升高(P<0.05),小肠DAO各组有不同程度的降低,R 2h组降低显著,血浆和小肠DAO的变化呈负相关(r=-0.648,P<0.05).缺血和再灌注后各时相点血D-乳酸浓度升高,其中R 1h和R 2h升高显著(P<0.05).缺血再灌后肠道D-木糖的吸收增加,小肠的传输显著加快.结论肠缺血和再灌注后小肠的屏障、吸收、通透和传输功能均显示不同程度的改变.     

Serum citrulline is a simple quantitative marker for small intestinal enterocytes mass and absorption function in short bowel patients

BACKGROUND: To investigate the clinical significance of serum citrulline in evaluating the remnant small bowel enterocytes mass and absorptive function in short bowel (SB) patients. MATERIALS AND METHODS: Serum citrulline concentrations were determined using high-performance liquid chromatography (HPLC) in 22 SBS patients and 33 healthy controls. Five-hour urine D-xylose excretion and digestive protein absorption were measured using HPLC and micro-Kjeldahl method, respectively. Small bowel length and surface area were assessed on X-ray radiograph. Correlations between serum citrulline levels and small bowel length, small bowel surface, and nutritional substrate digestive absorption percentage were analyzed. For six patients receiving bowel rehabilitation therapy, serum citrulline, D-xylose excretion, and intestinal protein absorption were measured pre- and immediately postmanagement, and their correlations were analyzed. RESULTS: Serum citrulline levels were significantly lower in SB patients compared with healthy controls. In SB patients, they correlated well with remnant small bowel length (r = 0.82, P < 0.001), surface area (r = 0.86, P < 0.001), 5-h urine D-xylose excretion (r = 0.56, P = 0.007), and digestive protein absorption (r = 0.48, P = 0.046). The increased percentage of serum citrulline level in six patients receiving rehabilitation therapy followed a trend of correlating with that of intestinal protein absorption (r = 0.79, P = 0.063) and urine D-xylose excretion (r = 0.81, P = 0.053). CONCLUSIONS: In patients with short bowel syndrome, serum citrulline is a simple and accurate biomarker for the severity of intestinal failure and may be a candidate marker for the gut-trophic effects of bowel rehabilitation therapies.     

Serial transverse enteroplasty enhances intestinal function in a model of short bowel syndrome

OBJECTIVE/SUMMARY BACKGROUND DATA: Serial transverse enteroplasty (STEP) is a new intestinal lengthening procedure that has been shown to clinically increase bowel length. This study examined the impact of the STEP procedure upon intestinal function in a model of short bowel syndrome. METHODS: Young pigs (n=10) had a reversed segment of bowel interposed to induce bowel dilatation. Five pigs underwent a 90% bowel resection with a STEP procedure on the remaining dilated bowel while 5 served as controls and had a 90% bowel resection without a STEP procedure. Determinations of nutritional status, absorptive capacity, and bacterial overgrowth were conducted 6 weeks after resection. Statistical comparisons were made by 2-sample t test (significance at P<0.05). RESULTS: The STEP procedure lengthened the bowel from 105.2+/-7.7 cm to 152.2+/-8.3 cm (P<0.01). The STEP animals showed improved weight retention compared with controls (mean, -0.5%+/-1.8% body weight versus -17.6%+/-1.5%, P<0.001). Intestinal carbohydrate absorption, as measured by d-Xylose absorption and fat absorptive capacity as measured by serum vitamin D and triglyceride levels, were increased in the STEP group versus controls. Serum citrulline, a marker of intestinal mucosal mass, was significantly elevated in the STEP pigs compared with controls. None of the STEP animals but 4 of 5 control animals were noted to have gram-negative bacterial overgrowth in the proximal bowel. CONCLUSIONS: STEP improves weight retention, nutritional status, intestinal absorptive capacity, and serum citrulline levels in a porcine short bowel model. A salutary effect upon bacterial overgrowth was also noted. These data support the use of this operation in short bowel syndrome.     

Serum citrulline and rejection in small bowel transplantation: a preliminary report

BACKGROUND: There is no known serum marker for intestinal rejection. Serum concentrations of the amino acid citrulline arise almost exclusively from the intestinal mucosa. We examined the impact of acute cellular rejection (ACR) of intestinal allografts on serum citrulline levels. METHODS: Citrulline concentrations were assayed in serum samples of healthy volunteers (n=6) and seven patients who underwent small bowel transplants (SBTx). Trends in mean citrulline concentrations versus degree of ACR were assessed by matching posttransplantation citrulline concentrations with patients' grade of ACR at time of serum collection. Rejection was confirmed by biopsy and graded by following standardized criteria. An additional patient had citrulline concentrations determined for 31 sequential specimens 3-60 days posttransplant. RESULTS: Mean citrulline concentrations in controls were significantly higher than posttransplantation samples at any rejection grade. Mean concentrations declined significantly as rejection severity increased. The overall downward trend was statistically significant (P<0.05). In sequential measurements, citrulline levels increased significantly over time with declining severity of rejection. The increase in mean citrulline concentration between posttransplant days 3-16 and 52-60 was significant (P<0.01). CONCLUSIONS: Serum citrulline levels decline with increasing grade of ACR and may be a useful serum marker for intestinal rejection.     

Définition et épidémiologie du grêle court et de l’insuffisance intestinale

Short bowel syndrome (SBS) is defined by a remaining post-duodenal small bowel in continuity of less than 200 cm, leading to a malabsorption of macronutrients and/or water, electrolytes and micronutrients. Depending on the anatomy of the remnant bowel, three categories of SBS are identified: end-jejunostomy (anatomical type I), jejunocolic anastomosis (anatomical type II) and jejunoileal anastomosis with côlon in continuity (anatomical type III). Types II and III have better prognosis thanks to better absorption. Despite the lack of precise epidemiological data, prevalence of SBS is estimated to be 5 to 10 cases per million, and its incidence about 2 cases per million per year.SBS differs from intestinal failure (IF), defined as the reduction of gut function below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, such that intravenous supplementation (IVS) is required to maintain health and/or growth. There are three types of IF, differentiated according to a functional classification. Type I is an acute, short-term IF, due to a usually self-limiting condition. Type II is a prolonged acute condition, requiring IVS over periods of weeks or months. Type III results from a chronic condition, in metabolically stable patients, and requires IVS over months or years. Prevalence of functional type II IF is estimated to be about 9 cases per million, and 5 to 20 per million for type III when due to a curable disease. The reduction of gut absorptive function that doesn’t require IVS is defined as “intestinal deficiency”.     

Factors predicting a successful outcome after pharmacologic bowel compensation.

OBJECTIVES: The authors determined those factors that predict a successful outcome in patients who receive pharmacologic agents to promote bowel absorption after massive intestinal resection. SUMMARY BACKGROUND DATA: Patients with the short bowel syndrome are maintained on long-term total parenteral nutrition (TPN) or more frequently considered for intestinal transplantation as part of their treatment program. The authors have administered a combination of trophic agents and a specialized diet to further enhance intestinal compensation and optimize nutrient absorption in patients with intestinal failure. METHODS: Forty-five TPN-dependent adults with a jejunal-ileal remnant < or = 50 cm and a portion of colon in continuity were treated with growth hormone, glutamine, and a modified diet for 4 weeks and observed for an average of 1.8 years. RESULTS: The average age of the patients was 43 years, the average jejunal-ileal length was 23 cm, and the average length of time the patient received TPN was 4.3 years. After 4 weeks of therapy, 26 (58%) were free of TPN support. Predictors of a favorable response included greater bowel length, lower body weight, and greater bowel length-body weight ratio. At follow-up, the percentage of patients who were not receiving TPN had fallen to 40%. CONCLUSIONS: Approximately half of a group of patients, thought to have absorptive surface area inadequate to be independent of TPN support, can maintain themselves on enteral feedings after this intestinal rehabilitation program. Because of the risk, costs, and alterations in lifestyle associated with long-term TPN or intestinal transplantation or both, it seems prudent to consider a program of bowel rehabilitation with an individual patient before embarking on another therapeutic plan.     

Systemic GLP-2 levels do not limit adaptation after distal intestinal resection

BACKGROUND/PURPOSE: Glucagonlike peptide 2 (GLP-2) is trophic for the small bowel; it is produced by L cells in the distal intestine in response to luminal nutrients. This study tests the hypothesis that distal small bowel and cecal resection would decrease GLP-2 levels and reduce adaptation. METHODS: Male Sprague-Dawley rats (200 to 300 g) underwent either ileal transection (controls) or resection of the ileum and cecum, leaving 10 or 20 cm jejunal remnant anastomosed to the ascending colon. Animals were followed up for up to 21 days. Endpoints were daily weights, intestinal histology, in vivo absorption of 3-0 methylglucose (a measurement of active nutrient absorptive capacity), and serum GLP-2 levels. RESULTS: The control group had a maximum 6% weight loss around day 2, and then recovered with a steady weight gain. The 10-cm jejunal remnant group lost weight continuously and never recovered postsurgery. The 20-cm jejunal remnant group of animals had a maximum of 12% weight loss by day 4 and then slowly gained weight. The average villus height increased significantly (P <.01) in the 10-cm and 20-cm jejunal remnant groups compared with controls. Absorption of 3-0 methylglucose was significantly decreased (P <.01) in both resected groups. Serum GLP-2 levels were increased significantly (P <.05) when compared with controls in both resection groups. CONCLUSIONS: Increased serum GLP-2 levels were found in the ileocecal resection rat model, and these levels correlated with morphologic adaptation. However, this morphologic adaptation was not sufficient to restore nutrient absorption as shown by weight changes and 3-0 methylglucose absorption. Thus, the original hypothesis of this study is incorrect: systemic GLP-2 levels do not limit adaptation following distal ileocecal resection.     

Inflammatory disease and outcome of short bowel syndrome

BACKGROUND: The outcome of the short bowel syndrome (SBS) is influenced by several factors including intestinal disease, remnant length and location, the other digestive organs, and intestinal adaptation. Because underlying inflammatory disease might influence several of these, the aim of this study was to evaluate the outcome of SBS in inflammatory conditions. METHODS: A total of 106 adult patients with SBS evaluated over a 20-year period were studied. Thirty (28%) patients had either Crohn's disease (n = 10) or radiation enteritis (n = 20). RESULTS: Multiple resections were more common in the inflammatory group (57% versus 12%, P <0.05.) These patients had longer intestinal remnants but the type of colonic remnant and the presence of an ileal remnant, the ileocecal junction and a stoma was similar in both groups. A similar proportion of patients in both groups required parenteral nutrition (PN) in the first year (73% versus 68%). Patients with inflammatory conditions were less likely to require PN after the first year (33% versus 63%; P<0.05). CONCLUSION: Patients with SBS resulting from inflammatory disease appear to have a better nutritional prognosis after the first year. While they are more likely to have had multiple resections and develop SBS with longer remnant length, inflammatory disease itself is an important prognostic factor. This may be related to resolution of inflammatory disease or a greater adaptive response.     

Medical management of motility disorders in patients with intestinal failure: a focus on necrotizing enterocolitis, gastroschisis, and intestinal atresia

Background

Intestinal failure (IF) is the dependence upon parenteral nutrition to maintain minimal energy requirements for growth and development. It may occur secondary to a loss of bowel length, disorders of motility, or both. Short bowel syndrome (SBS) is a malabsorptive state resulting from surgical resection, congenital defect, or diseases associated with loss of absorptive surface area. A particularly vexing problem is associated with whole bowel and/or segmental intestinal dysmotility. Motility disorders within the context of SBS and IF may relate to rapid intestinal transit secondary to loss of intestinal length, dysmotility associated with loss or poor antegrade peristalsis, or gastroparesis. Therapy may be classified into medical (prokinetic and antidiarrheal agents) and surgical to deal with the overdistended poorly motile bowel.

Methods

We performed a systematic review of the literature pertaining to IF, SBS, and dysmotility in the pediatric population with gastroschisis, necrotizing enterocolitis, and intestinal atresia. In addition to the available treatment options, we have provided a review of the literature and a summary of the available evidence.

Conclusion

Despite relatively poor level of evidence regarding the application of promotility and antidiarrheal medications in patients with SBS and IF, these agents continue to be used. Herein, we provide a review of the physiology and pathophysiology of intestinal motility/dysmotility and available strategies for the use of promotility and antidiarrheal agents in patients with IF/SBS.     

生长激素治疗短肠综合征患者随机对照试验荟萃分析

目的系统评价生长激素治疗短肠综合征的疗效和安全性。方法采用计算机检索、手工检索方法收集生长激素治疗短肠综合征的随机对照试验文献,按Cochrane协作网系统评价方法进行评价。结果共4个试验,70例患者被纳入本研究。Meta分析结果显示,生长激素能显著增加短肠综合征患者体重[MD＝1．66,95％CI（0．69,2．63）,P〈0．01],去脂体重[MD=1．93,95％CI（0．97,2．90）,P〈O．01],促进残余肠道对能量[MD=4．42,95％CI（0．26,8．58）,P〈0．05],氮[MD=4．85,95％CI（0．20,9．49）,P〈0．05],脂肪[MD=5．02,95％CI（0．21,9．82）,P〈0．05]的吸收。结论生长激素治疗短肠综合征短期疗效是安全、有效的,远期疗效还有待大样本、多中心的随机对照研究进一步验证。