What is the risk of nocturnal supine enteral nutrition?

UNLABELLED: One complication of enteral nutrition (EN) is gastro-esophageal reflux disease. Semi-recumbent position is advised because posture influence reflux in critically ill patients. No data is available in stable patients. AIM: To study influence of position on reflux during nocturnal nutrition by percutaneous endoscopic gastrostomy in stable patients. METHODS: Prospective cross-over study. Reflux was measured by 48 h-pH-metry, in supine and semi-recumbent position. The end point was % time spent under pH 4. For analysis, 2 subgroups were identified (refluxers and non-refluxers). A total of 16 patients (65 year+/-13) were included, most had neurological diseases. RESULTS: There was no increase of reflux probability in any position in all patients (% time spent under pH 4: supine vs. semi-recumbent: 4.4+/-7.7 vs. 3.5+/-7.0 NS). In non-refluxers, supine position did not increase % time under pH 4 (0.1+/-0.12 vs. 0.3+/-0.6, NS), and did not modify other parameters (number of reflux 0 +/-0.9 vs. 7 +/-19 NS, duration of the longest reflux (min) 1.1+/-1.7 vs. 1+/-1.7 NS). In refluxers, supine position did not worsen pre-existent reflux (% time under pH 4: 11.7+/-8.7 vs. 8.9+/-9.7 NS, number of reflux 119+/-88 vs. 91+/-89 NS, duration of the longest reflux (min) 19+/-19 vs. 24+/-21 NS). CONCLUSION: Our data suggest that position does not influence reflux in stable patients with EN.

Hepatocyte nuclear factor-1 alpha gene inactivation: cosegregation between liver adenomatosis and diabetes phenotypes in two maturity-onset diabetes of the young (MODY)3 families.

Heterozygous germline mutations of the hepatocyte nuclear factor (HNF)-1 alpha are associated with maturity-onset diabetes of the young (MODY)3. Recently, the biallelic inactivation of the HNF-1 alpha gene was reported in liver adenomas. We show the occurrence of liver adenomatosis in six MODY3-affected patients from two unrelated and large families. Liver adenomatosis was characterized by the presence of numerous adenomas within a normal hepatic parenchyma. The HNF-1 alpha hot-spot germline mutation P291fs was identified in the two probands and in 16 relatives from the two families. The six patients affected by liver adenomatosis and diabetes exhibited the mutation. The analysis of liver-cell tumors from two affected patients evidenced the biallelic inactivation of HNF-1 alpha. The familial screening confirmed the clinical heterogeneity of the liver phenotype, from silent liver adenomatosis to fatal hemorrhage. These observations warrant the systematic screening for liver adenomatosis in MODY3 families to prevent its potentially deadly complications. Moreover, such screening may help to determine if a particular mutational spectrum of HNF-1 alpha is associated with liver adenomatosis and to establish its prevalence in this frequent form of diabetes in the young adult.

Increased oro-cecal transit time in grade I or II hepatic encephalopathy.

UNLABELLED: The pathogenic mechanisms of hepatic encephalopathy remain to be elucidated. It has been suggested that a digestive motor disorder could promote the absorption of toxins produced within the lumen and thus enhance hepatic encephalopathy. AIM: To evaluate oro-cecal transit time in cirrhotic patients with and without hepatic encephalopathy. METHODS: Hospitalized patients with alcoholic cirrhosis without encephalopathy and with spontaneous grade I and II encephalopathy were included. Severity of hepatic encephalopathy was assessed clinically and the Child-Pugh score was used to describe cirrhosis severity. Nine healthy volunteers constituted a control group. Oro-cecal transit time was measured with the sulfasalazine test. RESULTS: Twenty-eight patients (mean age 62.5 +/- 8.5 years) were included. Ten had hepatic encephalopathy of unknown cause and 18 were free of hepatic encephalopathy. Oro-cecal transit time was significantly longer in patients with hepatic encephalopathy (641 +/- 350 min) compared to patients without hepatic encephalopathy (298 +/- 96; P<0.05) and to controls (354 +/- 90; P<0.05). Oro-cecal transit time was comparable for each Child-Pugh score and was not different between the two grades of hepatic encephalopathy. CONCLUSION: Oro-cecal transit time is longer in alcoholic cirrhosis patients with hepatic encephalopathy. This digestive motor disorder provides a partial explanation of hepatic encephalopathy of unknown etiology.

[Disseminated strongyloidiasis associated with pulmonary fibrosis and gastrointestinal bleeding]. / Anguillulose maligne associée à une fibrose pulmonaire et une hémorragie digestive.

Strongyloidiasis is a parasitic disease that can be lethal in immunosuppressed patients especially if lung fibrosis is associated, which has been rarely reported. We report the case of a patient treated with corticosteroids for pulmonary fibrosis who developed disseminated strongyloidiasis revealed by massive gastrointestinal bleeding. Diagnosis was based on histological analysis of gastrointestinal biopsies and broncho-alveolar lavage. Treatment improved digestive features as well as respiratory function.

[Aorto-digestive fistula and aortic prosthesis. Report of four cases]. / Fistule aorto-digestive après pose de prothèse vasculaire aortique. A propos de quatre cas.

The diagnosis of gastrointestinal bleeding secondary to aortoduodenal fistula and the decision to proceed to an early diagnostic and/or therapeutic laparotomy are often difficult in practice. We report 4 cases of patients with aortic prostheses who were hospitalized for gastrointestinal bleeding secondary to aortoduodenal fistula. All of them presented initially with lightheadedness before evidence of GI bleeding. Emergency esophagogastroduodenoscopy performed for 3 patients was normal for 2 of them and showed an ulcer with a stitch at its center in the third duodenum for the other. Abdominal CT scan performed for all the patients confirmed the diagnosis for only one case. Of the 3 patients with a normal CT scan, 2 underwent angiography which provided the diagnosis of aortoenteric fistula successfully treated by embolization. The other angiogram was normal. Surgery was required to establish the diagnosis in one patient and diagnosis was post mortem for the last one.