Management of the lower gastrointestinal system in burn: A comprehensive review.

BACKGROUND: Burn produces complex gastrointestinal (GI) responses. Treatment, including large volume fluid resuscitation and opioid analgesia, may exacerbate GI dysfunction. Complications include constipation and opioid-induced bowel dysfunction (OBD), acute colonic pseudo-obstruction (ACPO), bacterial translocation and sepsis, and abdominal compartment syndrome (ACS). Contamination of perineal burns contributes to delayed healing, skin graft failure and sepsis and may impact upon morbidity and mortality. The authors carried out a literature review on management of the lower GI system in burn. This study aimed to explain: current prevention and treatment modalities; drawbacks and complications associated with available treatments, and to provide direction for development of best practice guidelines. ACS is associated with high mortality and should be treated with careful fluid resuscitation and diuresis, to minimise and remove oedema. METHODS: A comprehensive search of English language literature was performed on PubMed, Medline and Embase. Both MeSH and keywords searches were used. RESULTS: Evidence available on the management of lower gastrointestinal system in burn is summarised. Levels of evidence available are generally low (level III-IV). CONCLUSION: Structured, graded interventions are required for prevention and treatment of constipation and OBD. Correction of electrolyte imbalance, adequate enteral intake and mobilisation are pre-requisites. Laxatives should be used according to World Gastroenterology Organisation recommendations. Resistant constipation may respond to changes in medication, but ACPO should be suspected and treated when present. Other complications, such as bacterial translocation and ACS are common in major burns. There is evidence that selective digestive tract decontamination reduces mortality and infectious episodes in major burns. ACS is associated with high mortality and should be treated with careful fluid resuscitation and diuresis. Surgery is reserved for non-responsive and severe cases. Perineal burns present challenges in wound and bowel management. Faecal management systems and negative pressure wound therapy (NPWT) may improve wound control and hygiene, but diversion colostomy will still be beneficial in some cases. There is a clear need for rigorous studies to guide practice more effectively in these challenging conditions.

Cavitation of mesenteric lymph nodes: a rare complication of coeliac disease, associated with a poor outcome.

Five cases are presented, all of which showed peculiar cavitation of mesenteric lymph nodes. Clinically, three presented with abdominal symptoms, a mass or obstruction, warranting laparotomy. Two patients showed cavitating mesenteric lymph nodes at autopsy. Lymph nodes were enlarged with central, partly cystic degeneration; milky fluid exuded from the cut surface. In each case, investigation showed intestinal villous atrophy and splenic atrophy; coeliac disease was confirmed by response to gluten withdrawal. Three patients died, two from cachexia and the other from pneumonia; the other two are alive and well one year and six years after presentation. Review of the literature shows 12 previously reported cases, with a mortality of about 50%. The diagnosis is made by the histopathologist, alerting appropriate treatment. The pathogenesis is unknown.

Campylobacter pylori: clinical, histological, and serological studies.

The presence of Campylobacter pylori, histologically diagnosed gastritis, and antibodies to C pylori were determined in a series of 113 patients undergoing endoscopy. Paired biopsy specimens from the fundus, body, and antrum were collected from 59 patients and from the antrum of 54 patients. The presence of C pylori was confirmed by either culture or silver stain in 30 of 59, 31 of 59, and 54 of 103 biopsy specimens from the fundus, body, and antrum, respectively. Of the specimens which contained C pylori 20 of 30 (66%) from the fundus, 25 of 31 (80%) from the body, and 54 (100%) from the antrum showed gastritis. C pylori and gastritis were shown in seven of nine (78.1%) of patients with gastric ulcers and in nine of 11 (82%) of patients with duodenal ulcers. Using an enzyme linked immunosorbent assay (ELISA) technique to detect IgG antibody to C pylori, all patients with histologically diagnosed gastritis and organisms present had titres of greater than or equal to 640; eight of 39 (21%) of patients without gastritis and without organisms gave similar titres. Hence the presence of C pylori was associated with gastritis and with raised titres of IgG antibody.

Circulating immune complexes in idiopathic glomerular disease.

Circulating immune complexes (CIC) could be found in the majority of 271 sera from 131 patients with idiopathic minimal change, membranous and mesangial proliferative glomerulonephritis when a combination of CIC assays detecting different properties of CIC were used. In neither individual patients nor in any of the three groups as a whole did CIC levels reflect the state of the renal lesion. No correlation was found between the class of immunoglobulin in the CIC and that deposited in the kidney. With the exception of minimal change disease in which non-C1q binding IgG CIC predominated, a range of CIC was found in the patients examined. The pattern of CIC detected did not allow different forms of renal disease to be distinguished. IgA CIC could be found in mesangial proliferative glomerulonephritis both with and without IgA deposition and in some patients with membranous and minimal change disease, as well as in a high proportion of sera from 12 patients with the Henoch-Schönlein syndrome. CIC size was estimated in six patients, but only in one did a specific size of complex predominate. The CIC which may be found in the majority of sera from patients with idiopathic glomerulonepohritis provide little information of clinical value; no direct relationship can be demonstrated between the CIC found and the renal lesion.

Circulating immune complexes following food: delayed clearance in idiopathic glomerulonephritis.

Following a meal containing a variety of animal and vegetable proteins circulating immune complexes (CIC) have been found in sera from eight normal subjects. Levels of CIC rose to significantly higher levels in ten patients with idiopathic immune complex glomerulonephritis and return to fasting levels was significantly delayed. The type of CIC detected bore no relation to those in renal biopsy material. The CIC which accumulated in GN were small (MW similar to or approximately 350,000), and plasma exchange did not influence the extent or duration of CIC rise following the meal. An immunological defect manifested by impaired clearance of frequently encountered antigens may exist in subjects who develop GN. The CIC detected in the serum of these patients may be markers of this state and cannot be assumed to be the pathogenic agents in the disease.

Reduction of post-transplant proteinuria due to recurrent mesangial proliferative (IgM) glomerulonephritis following plasma exchange.

A patient developed recurrent IgM proliferative glomerulonephritis and a nephrotic syndrome following HLA-identical living donor renal transplantation. Two intensive five-day courses of plasma exchange were followed by sustained reduction of proteinuria. Renal function has remained normal at all times. Immune complex sizing revealed a high titer of middle range complexes (mol. wt. 1 x 10(6) daltons app.); immune complex clearance following an antigen load was not improved by plasma exchange suggesting no alteration of reticulo-endothelial function. Possible mechanisms of benefit are discussed.

The value of three immune complex assays in the management of systemic lupus erythematosus: an assessment of immune complex levels, size and immunochemical properties in relation to disease activity and manifestations.

Sixteen patients with systemic lupus erythematosus, fourteen with renal involvement have been studied over a 30-month period. Circulating immune complex levels have been assayed by three techniques. The results of tests on 141 sequential sera suggest that the three assays detected overlapping populations of the range of complexes present. Immune complex levels are shown to be good markers of disease activity and certain immunochemical properties of the complexes emerged as better markers than others. Immune complex size is a more important determinant of disease manifestation than are overall immune complex levels. High doses of intravenous methyl prednisolone, which did not reduce overall complex levels, reduced levels of those complexes (molecular weight 600,000-900,000 Daltons) associated with renal involvement.

The delayed appearance of an antinuclear factor and the diagnosis of systemic lupus erythematosus in glomerulonephritis.

In 11 patients who presented with apparently idiopathic glomerular disease the antinuclear factor (ANF) was absent initially but was eventually detected during observation extending over 6 years. In 4 patients a diagnosis of systemic lupus erythematosus (SLE) has now been made and the disease treated. Of the remaining 7, 2 had conditions known to be associated with a positive ANF, and in 4, drug therapy induced the ANF. Clinical features, complement studies and measurement of anti-DNA antibody were of value in distinguishing those patients with SLE from the others.

The treatment of lupus nephritis by methyl prednisolone pulse therapy.

Four patients with proliferative glomerulonephritis due to systemic lupus erythematosus were treated with intravenous methyl prednisolone 'pulse' therapy. In all, eight courses of therapy were given, three for acute oliguric renal failure; and on each occasion there was a good response to the treatment. Clinical, histological and immunological details of the patients are presented. The diagnosis, treatment, and monitoring of disease activity in lupus nephritis are discussed in the light of this experience.

Early arterial lesions in maturity onset diabetes mellitus detected by an ultrasonic technique.

Using an ultrasonic technique preclinical atheroma was studied in maturity onset diabetics. The elasticity of the leg arteries was measured as the elastic modulus in 32 patients and a normal range was established in 13 controls. The elastic modulus was higher (i.e. the arteries were stiffer) in diabetics than controls and this was associated with a higher mean blood pressure in the diabetics. Nine phenformin and 10 chlorpropamide treated diabetics had evidence of more severe arterial disease than 13 diet treated patients. This could not be accounted for by other factors known to influence arterial disease.

A comparison of phenformin and metformin in the treatment of maturity onset diabetes.

A comparison of the effects of two dose levels of phenformin (50 mg once and twice daily) and metformin (850 mg twice daily and 1,700 mg twice daily) has been undertaken in 24 maturity onset diabetics whose diabetes had remained inadequately controlled with dietary measures alone. Both biguanides effectively reduced the fasting blood sugar and body weight of the patients, metformin apparently having a greater effect on blood sugar than phenformin. Serum triglycerides were lower on the larger dose of metformin than on either dose of phenformin. Both drugs in the larger doses reduced the serum cholesterol. Side effects were more common with metformin, particularly in the higher dosage and overall control of the diabetes was achieved in the same proportion of patients (33%).