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Nutritional support teams increase percutaneous endoscopic gastrostomy uptake in motor neuron disease

World Journal of Gastroenterology 2012年第44期18卷 6461-6467页

作者： Lin Zhang Leanne Sanders robert jl fraser Nutrition and Dietetic Department Flinders Uni- versity of South Australia Bedford Park 5042 South Australia Australia Department of Nutrition and Dietetics Repa- triation General Hospital Daw Park 5041 South Australia Aus- tralia School of Medicine Flinders University of South Australia Bedford Park 5042 South Australia Australia

AIM:To examine factors influencing percutaneous endoscopic gastrostomy(PEG) uptake and outcomes in motor neuron disease(MND) in a tertiary care ***:Case notes from all patients with a confirmed diagnosis of MND who had attended the clinic at the Repatriation General Hospital between January 2007 and January 2011 and who had since died,were *** were extracted for demographics(age and gender),disease characteristics(date of onset,bulbar or peripheral predominance,complications),date and nature of discussion of gastrostomy insertion,nutritional status [weight measurements,body mass index(BMI)],date of gastrostomy insertion and subsequent progress(duration of survival) and quality of life(QoL) [Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised(ALSFRS-R)].In addition,the type of clinician initiating the discussion regarding gastrostomy was recorded as Nutritional Support Team(involved in providing nutrition input viz Gastroenterologist,Speech Pathologist,Dietitian) and other(involved in non-nutritional aspects of patient care).Factors affecting placement and outcomes including length of survival,change in weight and QoL were ***:Case records were available for all 86 patients(49 men,mean age at diagnosis 66.4 years).Thirty-eight patients had bulbar symptoms and 48 had peripheral disease as their presenting ***-six patients reported ***-one patients had undergone gastrostomy *** major indications for PEG placement were dysphagia and weight *** patients required immediate full feeding,whereas 17 patients initially used the gastrostomy to supplement oral intake,4 for medication administration and 1 for *** the PEG regime met 73% ± 31% of the estimated total energy requirements,increasing to 87% ± 32% prior to *** was stabilization of weight in patients undergoing gastrostomy [BMI at 3 mo(22.6 ± 2.2 kg/m 2) and 6 mo(22.5 ± 2.0 kg/m 2) after PEG placement compared to

关键词： Motor neuron disease Multidisciplinary ma-nagement Nutrition support team Percutaneous endo-scopic gastrostomy Survival

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Lower esophageal sphincter relaxation is impaired in older patients with dysphagia

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World Journal of Gastroenterology 2011年第10期17卷 1326-1331页

作者： Laura K Besanko Carly M Burgstad Reme Mountifi eld Jane M Andrews Richard Heddle Helen Checklin robert jl fraser Investigation and Procedures Unit Repatriation General Hospital Department of Gastroenterology and Hepatology Royal Adelaide Hospital Discipline of Medicine University of Adelaide Adelaide 5000 South Australia Australia Department of Medicine Flinders University of South Australia Bedford Park 5042 South Australia Australia

AIM: To characterize the effects of age on the mechanisms underlying the common condition of esophageal dysphagia in older patients, using detailed manometric analysis. METHODS: A retrospective case-control audit was performed on 19 patients aged ≥ 80 years (mean age 85 ± 0.7 year) who underwent a manometric study for dysphagia (2004-2009). Data were compared with 19 younger dysphagic patients (32 ± 1.7 years). Detailed manometric analysis performed prospectively included basal lower esophageal sphincter pressure (BLESP), pre-swallow and nadir LESP, esophageal body pressures and peristaltic duration, during water swallows (5 mL) in right lateral (RL) and upright (UR) postures and with solids. Data are mean ± SE; a P-value < 0.05 was considered significant. RESULTS: Elderly dysphagic patients had higher BLESP than younger patients (23.4 ± 3.8 vs 14.9 ± 1.2 mmHg; P < 0.05). Pre-swallow LESP was elevated in the elderly in both postures (RL: 1 and 4 s P = 0.019 and P = 0.05; UR: P < 0.05 and P = 0.05) and solids (P < 0.01). In older patients, LES nadir pressure was higher with liquids (RL: 2.3 ± 0.6 mmHg vs 0.7 ± 0.6 mmHg, P < 0.05; UR: 3.5 ± 0.9 mmHg vs 1.6 ± 0.5 mmHg, P = 0.01) with shorter relaxation after solids (7.9 ± 1.5 s vs 9.7 ± 0.4 s, P = 0.05). No age-related differences were seen in esophageal body pressures or peristalsis duration. CONCLUSION: Basal LES pressure is elevated and swallow-induced relaxation impaired in elderly dysphagic patients. Its contribution to dysphagia and the effects of healthy ageing require further investigation.

关键词： Dysphagia Elderly Esophageal Motility Lower Esophageal Sphincter Aging

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Modulation of individual components of gastric motor response to duodenal glucose

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World Journal of Gastroenterology 2013年第35期19卷 5863-5869页

作者： Adam M Deane Laura K Besanko Carly M Burgstad Marianne J Chapman Michael Horowitz robert jl fraser Discipline of Acute Care Medicine University of Adelaide Intensive Care Unit Royal Adelaide Hospital National Health and Medical Research Council of Australia Centre for Clinical Research Excellence in Nutritional Physiology and Outcomes Investigation and Procedures Unit Repatriation General Hospital Department of Gastroenterology and Hepatology Royal Adelaide Hospital Discipline of Medicine University of Adelaide Royal Adelaide Hospital

AIM:To evaluate individual components of the antro-pyloro-duodenal(APD)motor response to graded small intestinal glucose infusions in healthy ***:APD manometry was performed in 15healthy subjects(12 male;40±5 years,body mass index 26.5±1.6 kg/m2)during four 20-min intraduodenal infusions of glucose at 0,0.5,1.0 and 1.5 kcal/min,in a randomised double-blinded *** solutions were infused at a rate of 1 mL/min and separated by 40-min"wash-out"*** are mean±*** analyses are repeated measure analysis of variance with Bonferroni post-hoc ***:At 0 kcal/min frequency of pressure waves were:antrum(7.5±1.8 waves/20 min)and isolated pyloric pressure waves(IPPWs)(8.0±2.3 waves/20min)with pyloric tone(0.0±0.9 mmHg).Intraduodenal glucose infusion acutely increased IPPW frequency(P<0.001)and pyloric tone(P=0.015),and decreased antral wave frequency(P=0.007)in a dosedependent fashion.A threshold for stimulation was observed at 1.0 kcal/min for pyloric phasic pressure waves(P=0.002)and 1.5 kcal/min for pyloric tone and antral ***:There is hierarchy for the activation of gastrointestinal motor responses to duodenal glucose *** increase in IPPWs is the first response observed.

关键词： Glucose Gastrointestinal motility Pyloric Antral Duodenum Manometry Motor activity Blood glucose

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World Journal of Gastroenterology 2017年第15期23卷 2785-2794页

作者： Charles Cock Laura K Besanko Carly M Burgstad Alison Thompson Stamatiki Kritas Richard Heddle robert jl fraser Taher I Omari Investigation and Procedures Unit Repatriation General Hospital Department of Gastroenterology and Hepatology Flinders University of South Australia Gastroenterology Unit Women's and Children's Health Network Human Physiology School of MedicineFlinders University of South Australia

AIM To investigate the functional effects of abnormal esophagogastric(EGJ) measurements in asymptomatic healthy volunteers over eighty years of age. METHODS Data from 30 young controls(11 M, mean age 37 ± 11 years) and 15 aged subjects(9 M, 85 ± 4 years) were compared for novel metrics of EGJ-function: EGJcontractile integral(EGJ-CI), "total" EGJ-CI and bolus flow time(BFT). Data were acquired using a 3.2 mm, 25 pressure(1 cm spacing) and 12 impedance segment(2 cm) solid-state catheter(Unisensor and MMS SolarGI system) across the EGJ. Five swallows each of 5 m L liquid(L) and viscous(V) bolus were analyzed. Mean values were compared using Student's t test for normally distributed data or Mann Whitney U-test when non-normally distributed. A P value < 0.05 was considered *** EGJ-CI at rest was similar for older subjects compared to controls. "Total" EGJ-CI, measured during liquid swallowing, was increased in older individuals when compared to young controls(O 39 ± 7 mm *** vs C 18 ± 3 mm ***; P = 0.006). For both liquid and viscous bolus consistencies, IRP4 was increased(L: 11.9 ± 2.3 mm Hg vs 5.9 ± 1.0 mm Hg, P = 0.019 and V: 14.3 ± 2.4 mm Hg vs 7.3 ± 0.8 mm Hg; P = 0.02) and BFT was reduced(L: 1.7 ± 0.3 s vs 3.8 ± 0.2 s and V: 1.9 ± 0.3 s vs 3.8 ± 0.2 s; P < 0.001 for both) in older subjects, when compared to young. A matrix of bolus flow and presence above the EGJ indicated reductions in bolus flow at the EGJ occurred due to both impaired bolus transport through the esophageal body(i.e., the bolus never reached the EGJ) and increased flow resistance at the EGJ(i.e., the bolus retained just above the EGJ).CONCLUSION Bolus flow through the EGJ is reduced in asymptomatic older individuals. Both ineffective esophageal bolus transport and increased EGJ resistance contribute to impaired bolus flow.

关键词： Aging Esophagus Impedance Manometry Pressure Esophagogastric junction

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Subtypes of functional dyspepsia

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World Journal of Gastroenterology 2006年第17期12卷 2667-2671页

作者： Georgina Baker robert J fraser Graeme Young Department of Gastroenterology Repatriation General Hospital and Flinders Medical Centre Australia

Functional dyspepsia is a common clinical condition characterised by chronic or recurrent upper abdominal pain or discomfort commonly associated with a variety of associated gastrointestinal symptoms and a normal endoscopy. To standardise research-based approaches, an initial categorisation of into sub groups was agreed to, based on clusters of symptoms. However the early expectation that these subgroups would be associated with distinct pathophysiologies amenable to specific therapy has not been realised. A classification based on the most troublesome symptom has been suggested but the utility of this is also unclear. More recent data suggest that some of the pathophysiologic dysfunctions may be associated with specific symptoms and so provide a better tool for grouping patients. But this approach remains incomplete as current insights into the pathogenesis are still too limited for this to be satisfactory. In conclusion, no classification provides for an adequate treatment-based approach to the syndrome of functional dyspepsia. As a consequence treatment remains largely empiric.

关键词： Functional dyspepsia Classification Subtypes Symptoms Pathophysiology Management

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Proximal gastric motility in critically ill patients with type 2 diabetes mellitus

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World Journal of Gastroenterology 2007年第2期13卷 270-275页

作者： Nam Q Nguyen robert J fraser Laura K Bryant Marianne Chapman Richard H Holloway Department of Gastroenterology Hepatology and General Medicine Royal Adelaide Hospital South Australia Investigation and Procedures Unit Repatriation General Hospital South Australia Anaesthesia and Intensive Care Royal Adelaide Hospital South Australia

AIM： To investigate the proximal gastric motor response to duodenal nutrients in critically ill patients with longstanding type 2 diabetes ***： Proximal gastric motility was assessed （using a barostat） in 10 critically ill patients with type 2 diabetes mellitus （59±3 years） during two 60-min duodenal infusions of Ensure （1 and 2 kcal/min）, in random order, separated by 2h fasting. Data were compared with 15 non-diabetic critically ill patients （48 ± 5 years） and 10 healthy volunteers （28 ±3 years）. RESULTS： Baseline proximal gastric volumes were similar between the three groups. In diabetic patients, proximal gastric relaxation during I kcal/min nutrient infusion was similar to non-diabetic patients and healthy controls. In contrast, relaxation during 2 kcal/ min infusion was initially reduced in diabetic patients （P 〈 0.05） but increased to a level similar to healthy humans, unlike non-diabetic patients where relaxation was impaired throughout the infusion. Duodenal nutrient stimulation reduced the fundic wave frequency in a dose-dependent fashion in both the critically ill diabetic patients and healthy subjects, but not in critically ill patients without diabetes. Fundic wave frequency in diabetic patients and healthy subjects was greater than in non-diabetic ***： In patients with diabetes mellitus, proximal gastric motility is less disturbed than nondiabetic patients during critical illness, suggesting that these patients may not be at greater risk of delayed gastric emptying.

关键词： Proximal gastric function Diabetes mellitus type 2 Critical illness Enteral nutrition

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Impact of bolus volume on small intestinal intra-luminal impedance in healthy subjects

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World Journal of Gastroenterology 2010年第17期16卷 2151-2157页

作者： Nam Q Nguyen Laura K Bryant Carly M Burgstad robert J fraser Daniel Sifrim Richard H Holloway Department of Gastroenterology & Hepatology Royal Adelaide HospitalAdelaide 5000Australia Investigation and Procedures Unit Repatriation General HospitalDaw Park 5041Australia Department of Medicine Centre for Gastroen-terological ResearchK.U.LeuvenLeuven 3000Belgium

AIM: To assess the impact of bolus volume on the characteristics of small intestinal (SI) impedance ***: Concurrent SI manometry-impedance measurements were performed on 12 healthy volunteers to assess the pattern of proximal jejunal fluid bolus movement over a 14 *** subject was given 34 boluses of normal saline (volume from 1 to 30 mL) via the feeding tube placed immediately above the proximal margin of the studied segment.A bolus-induced impedance event occurred if there was > 12% impedance drop from baseline,over ≥ 3 consecutive segments within 10 s of bolus injection.A minor or major imped-ance event was defined as a duration of impedance drop < 60 s or ≥ 60 s,***: The minimum volume required for a detectable SI impedance event was 2 mL.A direct linear relationship between the SI bolus volume and the occurrence of impedance events was noted until SI bolus volume reached 10 mL,a volume which always produced an impedance flow *** was a moderate correlation between the bolus volume and the duration of impedance drop (r = 0.63,P < 0.0001) and the number of propagated channels (r = 0.50,P < 0.0001).High volume boluses were associated with more major impedance events (≥ 10 mL boluses = 63%,3 mL boluses = 17%,and < 3 mL boluses = 0%,P = 0.02).CONCLUSION: Bolus volume had an impact on the type and length of propagation of SI impedance events and a threshold of 2 mL is required to produce an event.

关键词： Bolus volume Health Impedance Luminal flow Small intestine

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Mechanisms underlying feed intolerance in the critically ill: Implications for treatment

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World Journal of Gastroenterology 2007年第29期13卷 3909-3917页

作者： Adam Deane Marianne J Chapman robert J fraser Laura K Bryant Carly Burgstad Nam Q Nguyen Intensive Care Unit Royal Adelaide Hospital Adelaide South Australia Discipline of Medicine University of Adelaide and Investigation and Procedures Unit Repatriation General Hospital Adelaide South Australia Investigation and Procedures Unit Repatriation General Hospital Adelaide South Australia Department of Gastroenterology and Hepatology Royal Adelaide Hospital Adelaide South Australia

Malnutrition is associated with poor outcomes in critically ill patients. Although nutritional support is yet to be proven to improve mortality in non-malnourished critically ill patients, early enteral feeding is considered best practice. However, enteral feeding is often limited by delayed gastric emptying. The best method to clinically identify delayed gastric emptying and feed intolerance is unclear. Gastric residual volume （GRV） measured at the bedside is widely used as a surrogate marker for gastric emptying, but the value of GRV measurement has recently been disputed. While the mechanisms underlying delayed gastric emptying require further investigation, recent research has given a better appreciation of the pathophysiology. A number of pharmacological strategies are available to improve the success of feeding. Recent data suggest a combination of intravenous metoclopramide and en/thromycin to be the most successful treatment, but novel drug therapies should be explored. Simpler methods to access the duodenum and more distal small bowel for feed delivery are also under investigation. This review summarises current understanding of the factors responsible for, and mechanisms underlying feed intolerance in critical illness, together with the evidence for current practices. Areas requiring further research are also highlighted.

关键词： Critical illness Enteral nutrition Gastric emptying Gastric motility Gastrointestinal hormones Metoclopramide Erythromycin Prokinetic therapy

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Distal small bowel motility and lipid absorption in patients following abdominal aortic aneurysm repair surgery

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World Journal of Gastroenterology 2006年第4期12卷 582-587页

作者： robert J fraser Marc Ritz Addolorata C Di Matteo Rosalie Vozzo Monika Kwiatek robert Foreman Brendan Stanley Jack Walsh Jim Burnett Paul Jury John Dent Department of Medicine University of AdelaideSouth Australia Department of Gastroenterology Royal Adelaide HospitalAdelaide South Australia Vascular Unit Royal Adelaide Hospital AdelaideSouth Australia Gastrointestinal Investigation Unit Repatriation General Hospital Daw Park South Australia Vascular Unit Repatriation General Hospital Daw Park SouthAustralia

AIM： To investigate distal small bowel motility and lipid absorption in patients following elective abdominal aortic aneurysm （AAA） repair surgery, METHODS： Nine patients （aged 35-78 years; body mass index （BMI） range： 23-36 kg/m2） post-surgery for AAA repair, and seven healthy control subjects （20-50 years; BMI range： 21-29 kg/m^2） were studied, Continuous distal small bowel manometry was performed for up to 72 h, during periods of fasting and enteral feeding （Nutrison）. Recordings were analyzed for the frequency, odgin, length of migration, and direction of small intestinal burst activity. Lipid absorption was assessed on the first day and the third day post surgery in a subset of patients using the ^13C-triolein-breath test, and compared with healthy controls. Subjects received a 20-min intraduodenal infusion of 50 mL liquid feed mixed with 200μL ^13C-triolein. End-expiratory breath samples were collected for 6 h and analyzed for ^13CO2 concentration. RESULTS： The frequency of burst activity in the proximal and distal small intestine was higher in patients than in healthy subjects, under both fasting and fed conditions （P〈 0.005）. In patients there was a higher proportion of abnormally propagated bursts （71% abnormal）, which began to normalize by d 3 （25% abnormal） *** absorption data was available for seven patients on d 1 and four patients on d 3 post surgery. In patients, absorption on d 1 post-surgery was half that of healthy control subjects （AUC ^13CO2 1323±244 vs 2646±365; P〈0.05, respectively）, and was reduced to the one-fitch that of healthy controls by d 3 （AUC ^13CO2 470±832 vs 2646±365; P〈 0.05, respectively）. CONCLUSION： Both proximal and distal small intestinal motor activity are transiently disrupted in critically ill patients immediately after major surgery, with abnormal motility patterns extending as far as the ileum. These motor disturbances may contribute to impaired absorption of enteral nutrition, especially when intralumi

关键词： Critical illness Small intestine Motility Lipid absorption

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Proximal gastric response to small intestinal nutrients is abnormal in mechanically ventilated critically ill patients

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World Journal of Gastroenterology 2006年第27期12卷 4383-4388页

作者： Nam Q Nguyen robert J fraser Marianne Chapman Laura K Bryant Richard H Holloway Rosalie Vozzo Christine Feinle-Bisset Department of Gastroenterology Hepatology and General MedicineRoyal Adelaide HospitalSouth Australia University Department of Medicine University of AdelaideSouth Australia Department of Intensive Care Royal Adelaide HospitalSouth Australia Department of Gastroenterology Hepatology and General MedicineRoyal Adelaide HospitalSouth Australia Department of GastroenterologyUniversity of AdelaideSouth Australia

AIM： To determine the response of the proxima stomach to small intestinal nutrients in critically ill patients. METHODS： Proximal gastric motility was measured in 13 critically ill patients （49.3 ± 4.7 years） and 12 healthy volunteers （27.7 ± 2.9 years） using a barostat technique. Recordings were performed at baseline, during a 60-rain intra-duodenal infusion of Ensure^R （2 kcal/min）, and for 2 h following the infusion. Minimum distending pressure （MDP）, intra-bag volume and fundic wave activity were determined. RESULTS： The MDP was higher in patients （11.7 ± 1.1 vs 7.8 ± 0.7 mmHg; P 〈 0.01）. Baseline intrabag volumes were similar in the 2 groups. In healthy subjects, a ‘bimodal＇ proximal gastric volume response was observed. In patients, the initial increase in proximal gastric volume was small and delayed, but eventually reached a maximal volume similar to that of healthy subjects. In healthy subjects, the proximal gastric volume rapidly returned to baseline level after nutrient infusion （median 18 min）. In contrast, the recovery of volume to baseline was delayed in critically ill patients （median 106 min）. In 6 patients, the volume had not returned to baseline level 2 hours after nutrient infusion. In patients, fundic volume waves were less frequent （P 〈 0.05） and had lower amplitude （P 〈 0.001）, compared to healthy subjects. CONCLUSION： In critical illness, proximal gastric motor responses to small intestinal nutrient stimulation are abnormal.

关键词： Proximal gastric response Small intestinal nutrient Critical illness

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