Early enteral nutrition versus delayed enteral nutrition in patients with gastrointestinal bleeding: A PRISMA-compliant meta-analysis.

BACKGROUND: Controversy persists about whether early enteral nutrition administration is related to worse prognosis than delayed enteral nutrition for patients with gastrointestinal bleeding. OBJECTIVES: To systematically evaluate the effect of early enteral nutrition on the patient with gastrointestinal bleeding through the meta-analysis. METHODS: Such electronic databases including PubMed, EMBASE, Cochrane Library, CNKI, and CBM were searched from 1985 to March 2018. Randomized controlled trials that compared early enteral nutrition versus delayed enteral nutrition in patients with gastrointestinal bleeding were considered eligible. Data extraction and the methodological quality assessment of the included trials were carried out according to the Cochrane Handbook. We calculated the pooled risk ratio, weighted mean difference, and the corresponding 95% confidential interval using RevMan5.3. RESULT: A total of 5 trials involving 313 patients were included. Compared with delayed enteral nutrition, there was a tendency for a decreased rebleeding rate in the early enteral nutrition group, but the trend was not statistically significant (risk ratio = 0.75, 95% confidential interval: 0.34-1.64, I = 0). As for mortality within 30 days, no significant difference was found between the 2 groups (risk ratio = 0.74, 95% confidential interval: 0.23-2.39, I = 0). In addition, the pooled analysis showed that early enteral nutrition was related to reduced hospitalized days (weighted mean difference = -1.69, 95% confidential interval: -2.15 to -1.23; I = 27%) CONCLUSION:: For patients with gastrointestinal bleeding, early enteral nutrition within 24 hours does not result in the significantly higher risk of rebleeding and mortality compared with delayed enteral nutrition, but decrease hospitalized days. Patients who are at low risk for rebleeding can be fed early and discharged early. However, larger, high-quality randomized controlled trials are needed to verify these findings, and when the gastrointestinal bleeding patient start enteral nutrition is worth studying.

Use of Enteral Nutrition for Gastrointestinal Bleeding Prophylaxis in the Critically Ill: Review of Current Literature.

PURPOSE OF REVIEW: This review provides a comprehensive overview of the etiology of stress-related mucosal disease, current acid suppression therapy recommendations, and the role enteral nutrition may play in disease prevention. RECENT FINDINGS: Recent literature indicates enteral nutrition may prevent complications of stress-related mucosal disease by increasing splanchnic blood flow, enhancing gastrointestinal motility, and promoting cellular immunity and integrity through local nutrient delivery. Stress-related mucosal disease is a common complication of hospitalization in the critically ill which may lead to overt gastrointestinal bleeding and enhanced mortality. High-risk patients have historically been prescribed acid suppression therapy, though enteral nutrition may also have a role in disease mitigation.

Hematochezia caused by eosinophilic proctocolitis in a newborn before oral feeding: a case report.

BACKGROUND: Hematochezia is a frequent symptom in early infancy. However, it occurs very rarely within the immediate neonatal period, and its occurrence before any oral intake is particularly rare. Because of the "congenital" presentation of hematochezia in our patient, we initially considered our case to be a non-classical, potentially severe type of food protein-induced allergic proctocolitis. This diagnosis needs to be confirmed by an abnormal oral challenge test once the hematochezia has disappeared. If such a challenge cannot demonstrate an allergic origin, then the etiology of the hematochezia could be a neonatal transient eosinophilic colitis. Only two similar cases have been described so far. CASE PRESENTATION: We report the case of a black baby boy of African origin born at 36 weeks 5 days of gestational age who presented with massive hematochezia immediately after birth. A rectosigmoidoscopy revealed a severe inflammation associated with diffuse eosinophilic infiltration on biopsy. His clinical outcome was favorable after introduction of an amino acid formula diet. We initially considered our case to be a non-classical, potentially severe type of food protein-induced allergic proctocolitis but reintroduction of standard formula milk at the age of 3 months was successful. So, our patient is the first newborn in Europe who fits the diagnosis of "neonatal transient eosinophilic colitis." CONCLUSIONS: We discuss the possible etiology of "congenital" eosinophilic inflammation of the distal colon and conclude that hematochezia in well-looking neonates, in the absence of negative challenge tests later on, is more likely to be a neonatal transient eosinophilic colitis than an allergic proctocolitis. This new entity could be more frequent than previously thought, changing our medical care strategies for this kind of neonatal symptom.

Diagnosis of Bleeding Meckel's Diverticulum in Adults.

BACKGROUND AND AIMS: Various modalities have been used to diagnose Meckel's diverticulum (MD) in practice, but with their diagnostic accuracy deemed to be unsatisfactory for clinical practice. Moreover, the usefulness of these modalities has not been evaluated for the diagnosis of bleeding MD in adults, due to the relative rarity of this condition. Therefore, the aim of our multicenter study was to determine the most accurate modality for the preoperative diagnosis of bleeding MD in adults. METHODS: We conducted a retrospective analysis of the diagnostic accuracy for small bowel bleeding associated with MD of different modalities in patients ≥18 years old who underwent assessment for MD, with confirmation at the time of explorative surgery. Diagnostic accuracy of the different modalities was evaluated against the diagnosis obtained using technetium-99m pertechnetate scintigraphy (also known as Meckel's scan), considered to be the gold standard for the diagnosis of bleeding MD in pediatrics. RESULTS: Thirty-five adults were identified with bleeding in MD over the study period, between 2005 and 2012. Among these patients, only 24 (68.6%) were diagnosed with MD preoperatively. The mean (95% confidence interval) diagnostic accuracy of selected modalities was as follows: Meckel's scan, 21.4% (5.7%-51.2%); capsule endoscopy, 35.7% (14.0%-64.4%); balloon-assisted enteroscopy (BAE), 85.0% (61.1%-96.0%); angiography, 0.0% (0.0%-80.2%); computed tomography, 31.8% (14.7%-54.9%); and small-bowel follow-through, 62.5% (25.9%-90.0%). The diagnostic accuracy was significantly higher for BAE than for Meckel's scan (P = 0.001). CONCLUSIONS: Among available diagnostic modalities, BAE provides the highest accuracy for the diagnosis of bleeding MD in adults and, therefore, should be considered as the preferred modality for preoperative diagnosis.

[Effects of mono-, poly- and composite probiotics on the ulceration caused by restraint stress].

It was studied the effect of probiotic strains of Bifidobacterium animalis VKL, Bifidobacterium animalis VKB and Lactobacillus casei IMVB-7280, and their mixtures on erosive and ulcerative lesions of the gastric mucosa (GM) of rats. GM was induced by water-immersion restraint stress. It was found that investigated probiotics did not have gastroprotective properties under a single and seven-day prophylactic administration. However, multiprobiotics (polyprobiotic Bifidobacterium animalis VKL and Bifidobacterium animalis VKB and composite probiotic Bifidobacterium animalis VKL, Bifidobacterium animalis VKB and Lactobacillus casei IMVB-7280) reduced the erosive and ulcerative lesions and the intensity of bleeding in rat GM when given within 14 days. It was shown that one of the mechanisms of antiulcer preventive effect of the multistrain probiotics is the restoration of pro/antioxidant balance in the GM under the stress action. The obtained results show the effectiveness of poly- and composite probiotics in the gastric ulcer prevention.

Alergia ao leite de vaca: achados do ultrassom com Doppler colorido em neonatos com hematoquezia / Cow's milk allergy: color Doppler ultrasound findings in infants with hematochezia

OBJETIVO: o ultrassom (US) tem sido uma importante ferramenta de diagnóstico para identificar várias causas de hemorragia gastrointestinal. Neonatos com alergia ao leite de vaca (ALV) podem apresentar hematoquezia, e a confirmação do diagnóstico pode ser difícil. O objetivo deste estudo é descrever achados com ultrassom em escala de cinza e com Doppler colorido em pacientes com ALV. MÉTODOS: estudamos, retrospectivamente, 13 neonatos com ALV. Todos eles apresentaram hematoquezia severa e dor abdominal e foram submetidos a um estudo com US, com o diagnóstico de colite alérgica. O diagnóstico teve como base os achados clínicos, a recuperação após a dieta de exclusão do neonato ou da mãe, no caso de amamentação exclusiva, e o teste de provocação oral positivo. RESULTADOS: a idade média variou de um a seis meses (média = 3,53). Sete dos 13 neonatos (53,8%) passaram novamente por ultrassonografia em escala de cinza e com Doppler colorido após a dieta de exclusão. Dentre eles, 12 dos 13 (92,3%) mostraram anormalidades no US e no ultrassom com Doppler colorido (USDC) no início. Os achados positivos que sugeriram colite foram paredes intestinais espessas e aumento na vascularização, principalmente no cólon descendente e sigmoide. Os resultados da colonoscopia e histopatológicos foram compatíveis com colite alérgica. Após uma mudança na dieta, os 13 neonatos se recuperaram e seus testes de provocação oral foram positivos. CONCLUSÃO: o US com Doppler pode ser muito útil para diagnosticar a colite secundária, como a ALV, e para excluir várias outras doenças abdominais que podem imitar essa doença.

OBJECTIVE: ultrasound (US) has been an important diagnostic tool to identify several causes of gastrointestinal bleeding. Infants with cow's milk allergy (CMA) may present hematochezia and the confirmation of the diagnosis can be difficult. The aim of this study is to describe grayscale and color Doppler ultrasound findings in patients with CMA. METHODS: we retrospectively studied 13 infants with CMA. All infants presented severe hematochezia and abdominal pain. All underwent an US study with the diagnosis of allergic colitis. This diagnosis was based on clinical findings, recovery after infant or mother exclusion diets in the case of exclusive breastfeeding and positive oral challenge test. RESULTS: the mean age ranged from 1 to 6 months (mean = 3.53). Seven out of 13 infants (53.8%) had grayscale and color Doppler sonographic repeated after exclusion diet. Twelve out of 13 (92,3%) showed abnormalities at US and CDUS at beginning. The positive findings suggesting colitis were thickened bowel walls and increased vascularity, especially in the descending and sigmoid colon. Colonoscopy and histopathological findings were compatible with allergic colitis. After a diet change the 13 infants recovered and their oral challenge tests were positive. CONCLUSION: Doppler US may be very useful in diagnosing secondary colitis, such as CMA, and to exclude several other abdominal diseases that can emulate this disease.

Cow's milk allergy: color Doppler ultrasound findings in infants with hematochezia.

OBJECTIVE: ultrasound (US) has been an important diagnostic tool to identify several causes of gastrointestinal bleeding. Infants with cow's milk allergy (CMA) may present hematochezia and the confirmation of the diagnosis can be difficult. The aim of this study is to describe grayscale and color Doppler ultrasound findings in patients with CMA. METHODS: we retrospectively studied 13 infants with CMA. All infants presented severe hematochezia and abdominal pain. All underwent an US study with the diagnosis of allergic colitis. This diagnosis was based on clinical findings, recovery after infant or mother exclusion diets in the case of exclusive breastfeeding and positive oral challenge test. RESULTS: the mean age ranged from 1 to 6 months (mean=3.53). Seven out of 13 infants (53.8%) had grayscale and color Doppler sonographic repeated after exclusion diet. Twelve out of 13 (92,3%) showed abnormalities at US and CDUS at beginning. The positive findings suggesting colitis were thickened bowel walls and increased vascularity, especially in the descending and sigmoid colon. Colonoscopy and histopathological findings were compatible with allergic colitis. After a diet change the 13 infants recovered and their oral challenge tests were positive. CONCLUSION: Doppler US may be very useful in diagnosing secondary colitis, such as CMA, and to exclude several other abdominal diseases that can emulate this disease.

Dietary nitrate and reductive polyphenols may potentiate the vascular benefit and alleviate the ulcerative risk of low-dose aspirin.

The recent revelation that daily low-dose aspirin not only lowers risk for vascular events, but also can notably decrease risk for a range of adenocarcinomas, decreasing total cancer mortality by about 20%, makes it highly desirable to implement this protective strategy on a population-wide basis. Nonetheless, the fact that low-dose aspirin approximately doubles risk for serious gastrointestinal bleeding may impede health authorities from recommending its use by people judged to be at low cardiovascular risk. Nitric oxide (NO) exerts gastroprotective effects by boosting blood flow and mucus production in the gastric mucosa - effects which demonstrably oppose the pro-ulcerative impact of aspirin and other NSAIDs. A nitrate-rich diet, as well as ingestion of reductive catechol-bearing polyphenols, can collaborate in promoting NO generation in gastric juice, and they are protective in rodent models of gastric ulceration. Moreover, a high-nitrate diet, as well as certain reductive polyphenols such as epicatechin and quercetin, can exert platelet-stabilizing effects complementary to those of aspirin, and act in other ways to preserve vascular health. Hence, diets rich in nitrate and reductive polyphenols have the potential to amplify the vascular-protective benefits of low-dose aspirin, while diminishing its pro-ulcerative risk. Low-dose aspirin may be more unequivocally recommendable within the context of such a dietary strategy.

Encefalopatía de Wernicke tras duodenopancreatectomía cefálica / Wernicke's encephalopathy after cephalic pancreaticoduodenectomy

La encefalopatía de Wernicke (EW) es un trastorno neurológico agudo resultado del déficit de tiamina. Presentamos la aparición de dicho cuadro en un enfermo joven que es sometido a una duodenopancreatectomía cefálica ante una úlcera duodenal sangrante refractaria a tratamiento endoscópico y quirúrgico previo, precisando de una nutrición parenteral total, sin suplementos de tiamina(AU)

Wernicke’s encephalopathy is an acute neurological disorder resulting from thiamine deficiency. We report a case in a young patient who underwent a cephalic duodenopancreatectomy with a bleeding duodenal ulcer refractory to endoscopic and surgical treatment, requiring total parenteral nutrition, without thiamine supplementation(AU)

Gastric feedings effectively prophylax against upper gastrointestinal hemorrhage in burn patients.

The purpose of this study was to examine the effectiveness of gastric feeding in prevention of upper gastrointestinal (GI) hemorrhage. A retrospective chart review of 50 consecutive burn intensive care unit patients with admission dates from January 1, 2005, to December 31, 2007, was conducted. Five of 50 patients (10%) developed GI hemorrhage. Three men of 36 developed a GI hemorrhage (8%) compared with 2 of 14 women (14%). Patients who developed hemorrhage had a higher abbreviated burn severity index score of 11 compared with the control group of 9 and having a higher mortality rate of 80% compared with controls of 27%. Those patients who developed abdominal compartment syndrome were more likely to develop GI hemorrhage (40% rate compared with 4% in patients who did not develop abdominal compartment syndrome). Of 13 patients who were not tolerating their tube feed at some point during treatment, 4 developed hemorrhage (31%), whereas only 1 patient who was tolerating his or her tube feed developed hemorrhage (3%). Three of 19 (16%) patients on proton pump inhibitor prophylaxis developed a GI hemorrhage compared with 2 of 31 (6%) of patients who were not undergoing prophylaxis. Because of the potential side effects of proton pump inhibitor prophylaxis, the authors believe that when tolerated, gastric feedings should be the standard prophylaxis to prevent upper gastrointestinal hemorrhage. Acid suppression therapy may only be necessary for patients who are not tolerating their tube feeds, have other abdominal pathologies, or with a previous history of peptic ulcer disease.

Prevalence and outcome of allergic colitis in healthy infants with rectal bleeding: a prospective cohort study.

OBJECTIVES: Allergic colitis is often diagnosed clinically in healthy infants with rectal bleeding and often treated with costly hypoallergenic formula. The true prevalence of allergic colitis is unknown. We tested the hypothesis that allergic colitis is overdiagnosed in healthy infants with rectal bleeding. The authors also determined whether rectal bleeding in infants without allergic colitis would resolve without diet change. METHODS: For the purposes of this study, allergic colitis was defined histologically as colonic mucosa with >or= 6 eosinophils per high power field and/or eosinophils in colonic crypts or muscularis mucosae. We surveyed all 56 Ohio NASPGHAN members to determine standard practice regarding the evaluation of rectal bleeding in infants. In addition, infants

Proctocolitis in breast fed infants: a contribution to differential diagnosis of haematochezia in early childhood.

Dietary protein induced proctocolitis in exclusively breast fed infants is rarely taken into consideration as a cause of rectal bleeding or blood streaked stool in the neonatal period and early infancy. Eleven babies are presented in whom it is believed that bleeding through the rectum was due to proctocolitis as a result of allergy triggered by cows' milk protein transferred to the infants via the breast milk. Colonoscopy was performed in five infants, revealing benign eosinophilic proctocolitis. Standard treatment was the exclusion of the allergen from the mother's diet. Resolution of visible rectal bleeding took place within 72 to 96 hours after elimination of the offending protein from the mother's diet.

Management of disseminated intra-abdominal lymphangiomatosis with protein-losing enteropathy and intestinal bleeding.

We encountered an unusually severe case of intra-abdominal lymphangiomatosis associated with protein-losing enteropathy and intestinal bleeding. A low-fat diet effectively raised the patient's serum levels of hemoglobin and the total serum protein, perhaps by inducing a reduction in intestinal lymph flow and pressure.

Bleeding from duodenal lymphangiectasia.

An 8 year old girl with recurrent upper gastrointestinal bleeding was found to have localised duodenal lymphangiectasia by fibreoptic endoscopy. She did not show physical signs or laboratory evidence of significant enteric protein loss. A low fat diet seemed to prevent further bleeding. Duodenal lymphangiectasia may be associated with gastrointestinal bleeding in children.