Evisceration of Small Bowel Through Rectum: A Case Report.

Evisceration of small bowel through the rectum is extremely uncommon, chronic long standing prolapse and/or increased intra-abdominal pressure being the most frequent association. Management is in line of any acute abdomen with resuscitation beginning as soon as patient arrives with covering the bowel with moist hot packs. The management of such patients depends on the general state of each individual patient. In extremely frail patients, palliative care should be instituted. Laparotomy and Hartmann's procedure is the safest option. Here we report a case of an elderly female with full-thickness chronic rectal prolapse who presented acutely at the Emergency Department with small bowel eviscerating through the anus following it herniating through the rectum.

Is sarcopenia a useful predictor of outcome in patients after emergency laparotomy? A study using the NELA database.

Introduction Studies have reported on the use of frailty as a prognostic indicator in patients undergoing elective surgery. Similar data do not exist for patients undergoing emergency surgery. The aim of this study was to evaluate the effect of preoperative sarcopenia measured by computed tomography (CT) on outcome following emergency laparotomy. Materials and methods Data from the National Emergency Laparotomy Audit database were retrieved for patients who had undergone an emergency laparotomy over 12 months at York NHS Foundation Trust. Sarcopenia was assessed by psoas density and area on preoperative CT. Mortality rates at 30 days and 1 year were recorded. Secondary outcomes included discharge rates to non-independent living. Results A total of 259 patients were included. Overall cohort 30-day and 1-year mortality was 13.9% (36/259) and 28.2% (73/259), respectively. Sarcopenia measured by psoas density was associated with increased mortality compared with patients who did not develop sarcopenia at 30 days (29.7%, 19/64, vs. 8.7%, 17/195; P < 0.001; odds ratio, OR, 4.42; 95% confidence interval, CI 2.13-9.26) and at 1 year (57.8%, 37/64, vs. 18.5%, (36/195; P < 0.001; OR 6.05; 95%CI 3.28-11.18). An increase in mortality was seen in patients with sarcopenia measured by psoas area at 30 days (21.3%, 13/61, vs. 9.1%, 17/187; OR 2.71; 95%CI 1.23-5.96, P = 0.013) and at 1 year (42.6%, 26/61, vs. 20.9%, 39/187; OR 2.82; 95% CI 1.52-5.23, P < 0.001). Conclusions Sarcopenia assessed by measurement of psoas density and area on CT is associated with increased mortality following emergency laparotomy. The use of sarcopenia as a predictive tool merits further attention and may be useful in patients undergoing emergency surgery.

The role of thoracic epidural anesthesia in severe acute pancreatitis.

In animal studies of severe acute pancreatitis, thoracic epidural anesthesia appears to enhance the splanchnic circulation, improve end-organ perfusion, and favorably influence mortality. The application of thoracic epidurals in the critically ill human patient is less clear. Methodological difficulties in reliably assessing mesenteric flow have hampered progress, and clinical concerns surrounding this potentially attractive therapeutic modality remain unanswered. Future research needs to focus on the impact of epidural anesthesia on basic human physiological parameters to help direct further randomized studies in human disease.

A single-blinded randomised clinical trial of permissive underfeeding in patients requiring parenteral nutrition.

BACKGROUND & AIMS: The importance of adequate nutritional support is well established, but characterising what 'adequate nutrition' represents remains contentious. In recent years there has been increasing interest in the concept of 'permissive underfeeding' where patients are intentionally prescribed less nutrition than their calculated requirements. The aim of this study was to evaluate the effect of permissive underfeeding on septic and nutrition related morbidity in patients requiring short term parenteral nutrition (PN). METHODS: This was a single-blinded randomised clinical trial of 50 consecutive patients requiring parenteral nutritional support. Patients were randomized to receive either normocaloric or hypocaloric feeding (respectively 100% vs. 60% of estimated requirements). The primary end point was septic complications. Secondary end points included the metabolic, physiological and clinical outcomes to the two feeding protocols. RESULTS: Permissive underfeeding was associated with fewer septic complications (3 vs. 12 patients; p = 0.003), and a lower incidence of the systemic inflammatory response syndrome (9 vs. 16 patients; p = 0.017). Permissively underfed patients had fewer feed related complications (2 vs. 9 patients; p = 0.016). CONCLUSION: Permissive underfeeding in patients requiring short term PN appears to be safe and may results in reduced septic and feed-related complications. TRIAL REGISTRATION: NCT01154179 TRIAL REGISTRY: http://clinicaltrials.gov/ct2/show/NCT01154179.

Colonoscopy in the octogenarian population: diagnostic and survival outcomes from a large series of patients.

OBJECTIVE: Our aim was to audit the diagnostic and survival outcomes of colonoscopy in octogenarians and to determine if it confers any survival benefit. METHODS: A review of a prospectively maintained database over a two year period between October 2005 and September 2007 was undertaken. Data on numerous outcome variables and survival were collected and analysed. Categorical variables were compared using the Chi-square test. Kaplan-Meier survival curves were constructed and log rank test were used to compare survival curves. RESULTS: There were 1905 patients, of which 289 (15%) were over the age of 80 years. Caecal intubation was significantly lower in octogenarians when compared with young patients (239/289, (82%) vs. 1411/1616 (88%), p = 0.025). The most common reason for failure to intubate the caecum was presence of stenosing pathology in distal bowel (octogenarians 46% (23 out of 50 failed intubations) vs. young 23% (49 out of 205 failed intubations), p = 0.002). A greater proportion of octogenarians had poor bowel preparation when compared with the young (20% vs. 13%, p = 0.001). Significantly more pathology was detected in octogenarians (72% vs. 59%, p = 0.001). Forty-four (15.2%) octogenarians were found to have malignancy. Of these, only 23 (52%) underwent subsequent surgery. Median survival of octogenarians who had surgery was not statistically better (31 (IQR 12-38) months vs. 16 (IQR 5-31) months, p = 0.10) than those who did not. CONCLUSION: Colonoscopy is safe in octogenarians and provides a high yield. Our results suggest that it does not appear to result in any survival benefit. However, to establish this, further research with larger cohorts and longer follow-up periods would be required.

A prospective randomised trial of probiotics in critically ill patients.

BACKGROUND AND AIMS: Probiotics exert a beneficial effect on the host through modulation of gastrointestinal microflora. The aim of this study was to investigate the effect of the probiotic Lactobacillus plantarum 299v on gut barrier function and the systemic inflammatory response in critically ill patients. SUBJECTS AND METHODS: One hundred and three critically ill patients were randomised to receive an oral preparation containing L. plantarum 299v (ProViva) in addition to conventional therapy (treatment group, n = 52) or conventional therapy alone (control group, n = 51). Serial outcome measures included gastric colonisation, intestinal permeability (lactulose/rhamnose dual-sugar probe technique), endotoxin exposure (IgM EndoCAb), C-reactive protein and Interleukin 6 levels. RESULTS: L. plantarum had no identifiable effect on gastric colonisation, intestinal permeability, endotoxin exposure or serum CRP levels. There were no differences between the groups in terms of septic morbidity or mortality. On day 15 serum IL-6 levels were significantly lower in the treatment group compared to controls. CONCLUSIONS: The enteral administration of L. plantarum 299v to critically ill patients was associated with a late attenuation of the systemic inflammatory response. This was not accompanied by any significant changes in the intestinal microflora, intestinal permeability, endotoxin exposure, septic morbidity or mortality.

Influence of synbiotic containing Lactobacillus acidophilus La5, Bifidobacterium lactis Bb 12, Streptococcus thermophilus, Lactobacillus bulgaricus and oligofructose on gut barrier function and sepsis in critically ill patients: a randomised controlled trial.

BACKGROUND & AIMS: Infective complications are a common cause of mortality and morbidity in critically ill patients. Many factors affect sepsis, one of which is gut barrier function. The aim of this study was to determine whether the oral administration of a synbiotic preparation could alter gut barrier function in critically ill patients and thus reduce sepsis. METHODS: A total of 90 patients admitted to an intensive care unit (ICU) were randomised to receive either synbiotic or placebo preparations (45 into each group). The synbiotic preparation consisted of Lactobacillus acidophilus La5, Bifidobacterium lactis Bb 12, Streptococcus thermophilus and Lactobacillus bulgaricus (probiotics) with oligofructose (prebiotic). Gut barrier function was assessed by measurement of intestinal permeability (lactulose/rhamnose test) and culture of nasogastric aspirate on days 1 and 8. All septic complications and mortality were recorded. RESULTS: There were no differences between the groups in terms of age, sex, APACHE II or POSSUM scores. After 1 week of therapy, patients in the synbiotic group had a significantly lower incidence of potentially pathogenic bacteria (43% versus 75%, P = 0.05) and multiple organisms (39% versus 75%, P = 0.01) in their nasogastric aspirates than controls. There were no significant differences between the groups in terms of intestinal permeability, septic complications or mortality. CONCLUSIONS: The administration of synbiotic in critically ill patients favourably altered the microbial composition of the upper gastrointestinal tract but had no effect on intestinal permeability and was not associated with measurable clinical benefit.