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In is Issue 1 Nutrition Options in Short-Bowel Syndrome SPRING 2017
Division of Gastroenterology, Gastric Carcinoids with Duodenal Ulcers
Hepatology, and Nutrition Living Donor Liver Transplant LDLT
ancreasest onors and wards
7 ittsurgh Gut Clu
hat s This
Nutrition Options in Short-Bowel Syndrome
By David G. Binion, MD, and Zachary Zator, MD
ntestinal transplantation is an option for select patients with shortbowel syndrome
associated intestinal failure SS who fail or do not tolerate nutritional rehabilitation
here are a range of factors to consider in the nutritional management of patients
before and after intestinal transplantation
SS can be defined as the inability to maintain proper nutritional balance — including
of proteins, electrolytes, macronutrients, micronutrients, and fluids — while adhering
to a conventional diet in the face of an anatomically or functionally limited gut surface
he ideal management of patients with SS involves a multidisciplinary team of
gastro enterologists, nurses, dietitians, pharmacists, and surgeons Pharmacotherapeutic
agents aimed at minimiing fluid losses have been routinely employed to support these
patients or instance, antidiarrheal agents, such as loperamide or diphenoylate, are
used alongside proton pump inhibitors Somatostatin analogs, like octreotide, inhibit
gastrointestinal secretions from the stomach, pancreas, and intestines and have been
proven beneficial in the past owever, their role can be limited, as somatostatin can
st actually inhibit enteral protein synthesis n recent years, attention has turned beyond
mere supportive care to potentially therapeutic pharmacologic agents, such as teduglutide,
a human recombinant
P analog, which was approved in
lucagonlike peptide
P is secreted in response to luminal nutrients reaching
the distal ileum and colon, and promotes the growth of intestinal mucosa by increasing
mesenteric blood flow, decreasing gastric acid secretion, and enhancing crypt cell growth
Continued on Page 2
Areditation Stateent he University of Pittsburgh School of Medicine is accredited by
ge the Accreditation Council for Continuing Medical ducation ACCM to provide continuing
medical education for physicians
he University of Pittsburgh School of Medicine designates this enduring material for a maimum
i of AMA PA Category Credits™ ach physician should only claim credit commensurate
with the etent of their participation in the activity ther health care professionals are awarded
continuing education units CU, which are euivalent to contact hours
Dislosures r inion reports grants and research support from anssen iotech, Merck, and
UC Pharma, and he also serves as a consultant for anssen iotech, Abbie, UC Pharma,
and Synthetic iologics All other contributing authors and editors of this publication report
no relationships with proprietary entities producing health care goods and services
d Instrutions o take the CM evaluation and receive credit, please visit
UPMCPhysicianResources.com/GI and click on UPMC Digest Spring 2017.
Affiliated with the University of Pittsburgh School of Medicine, UPMC is
ranked among the nation’s best hospitals by U.S. News & World Report.
2 DIGEST — SPRING 2017
Nutrition Options in Short-Bowel Syndrome (Continued ro Page 1
while inhibiting apoptosis owever, the endogenous form of
P common deficiencies seen in one pediatric study after transition
is rapidly degraded in vivo As a recombinant analog of
P, to enteral nutrition were iron £ ¡, magnesium £ ,
teduglutide has a significantly longer halflife and acts by binding to inc , vitamin ¡, and vitamin A Another
P receptors and potentiating its effects n phase randomied, study found that almost all patients £ were deficient in the
placebocontrolled trials, the active form of vitamin within days of transplantation As a
volume of parenteral support result, proactive supplementation with both a multivitamin and
that patients reuired was micronutrientspecific formulations is considered necessary
significantly reduced in those in the posttransplant population
,
patients receiving teduglutide Proper nutritional management of patients before and after
he medication is fairly well intestinal transplantation involves a directed, multidisciplinary
tolerated, with abdominal pain approach aimed at defining, monitoring, and eliminating deficiencies
, minor inectionsite in individual patients ith the help of supportive care techniues
reactions , nausea , and novel pharmacologic agents like teduglutide, patients with short
and headaches being the most commonly reported adverse bowel syndromeassociated intestinal failure can be managed
effects
iven the nature of the drug, theoretic concerns eist related successfully f intestinal transplantation is reuired, careful attention
to tumor promotion, and colonoscopy is recommended si months must be paid to not only caloric reuirements, but also to hydration
before and one year after drug initiation status and micronutrient and macronutrient homeostasis
hen medical management of SS fails, intestinal transplan
tation is pursued in select patients he optimal strategy to manage Dr. inion is a proessor o ediine wit te Di ision o
nutritional needs in these comple postoperative patients is astroenterolog epatolog and Nutrition. e ser es as
not entirely known Moreover, reuirements vary depending on a odiretor and translational resear leader or te
D
the length of time since transplantation ight after transplant, Center and direts te Di ision’s Nutrition Support Progra.
patients generally need higher caloric intake to maintain a healthy
nutritional state et at three months after transplantation, the
enteral graft generally absorbs carbohydrates and other forms of
energy uite well n one pediatric study, a ratio of energy intake to Dr. ator is a ear
gastroenterolog ellow wit te
resting energy ependiture of ± was needed for patients Di ision o astroenterolog epatolog and Nutrition
on full parenteral nutrition P, compared with a ratio of ± were e also ser es as te ie
ellow.
¡ for full enteral intake ongterm data from a different study
suggests that these escalated enteral reuirements may decrease
over time nsuring that patients meet these needs while tran
sitioning from parenteral to enteral nutrition is critical to nutritional
homeostasis rom a practical perspective, it is important to References
recognie that the enteral energy needed to maintain adeuate
eppesen P,
ilroy , Pertkiewic M, Allard P, Messing , ’¤eefe S
nutrition is highest early after transplant, but likely returns closer andomised Placebocontrolled rial of eduglutide in educing Parenteral
to the population norms over time hese early nutritional utrition and¢or ntravenous luid euirements in Patients ith Short owel
demands can be met through increased caloric intake Syndrome ut. ¥ ¡¦ £
utside of caloric reuirements in the posttransplant population, ’¤eefe S, eppesen P,
ilroy , Pertkiewic M, Allard P, Messing Safety
attention must be paid to maintaining adeuate hydration early all and fficacy of eduglutide After eeks of reatment in Patients ith
Short owel ntestinal ailure Clin astroenterol epatol. ¥ ¡¦
patients who undergo intestinal transplantation are managed with an
ileostomy for at least the initial period after transplant he ileostomy rdone , arbotrystram , acaille , Chardot C,
anousse S, Petit M,
Colombung , alodier , Salomon , albotec C, Campanoi A, uemmele ,
facilitates endoscopic biopsies to monitor for reection but also évillon , Sauvat , ¤apel ,
oulet ntestinal Absorption ate in Children
bypasses the absorptive surface of the colon n general, ostomy After Small ntestinal ransplantation Clin Nutr. ¥ £¡¦ ¡£
output greater than m¢kg¢d is considered increased n this
Ubesie AC, Cole C, athan , iao
M, Alonso M, Meoff A
, enderson
scenario, underlying infection viral, bacterial should be investigated, C, ¤ocoshis SA Micronutrient eficiencies in Pediatric and oung Adult
accompanied by supportive care with fluid supplementation ntestinal ransplant Patients Pediatr ransplant. ¥ ¡¡¦
ollowing intestinal transplantation, patients are at risk for Matarese , vorchik , Costa
, ond
, ¤oritsky A, erraris P, ouger
specific micronutrient deficiencies, and careful monitoring and ecker , ’SullivanMaillet ¤, Abulmagd ¤M Pyridoal’Phosphate
eficiency After ntestinal and Multivisceral ransplantation Clin Nutr.
treatment are essential to avoid complications he most £¥ £¦ £
Affiliated with the University of Pittsburgh School of Medicine, UPMC is ranked among the nation’s best hospitals by U.S. News & World Report.
UPMC Division of Gastroenterology, Hepatology, and Nutrition 3
Gastric Carcinoids with Duodenal Ulcers int or Diagnosis
o ultiple ndocrine Neoplasia Type N
By Cynthia Cherfane, MD
CASE PRESENTATION
A yearold man with a history of coronary artery
disease was admitted to the hospital for nonS
segment elevation myocardial infarction SM
e underwent percutaneous coronary intervention
and was started on aspirin and clopidogrel is course
was complicated by an intracranial hemorrhage and
coffee ground emesis
is past medical history included hyperparathyroidism and islet igure 1 arge ulcers in the second portion of the duodenum in the setting of
cell tumor cosecreting gastrinoma¢glucagonoma status post M and ©ollingerllison syndrome
distal pancreatectomy in ££ amily history was significant for
heart failure in his father and prolactinoma in his mother e does
not smoke or drink alcohol
Upper endoscopic eamination revealed A grade esophagitis
and multiple small polyps to mm in the gastric fundus and
body Multiple superficial ulcers in the second portion of the
duodenum were also evident
astric polyp biopsies were positive
for welldifferentiated, lowgrade carcinoid involving the oyntic
and muscularis mucosa
astrin and chromogranin levels were
measured after stopping proton pump inhibitors PP and were
shown to be elevated
ased on the history of pancreatic neuroendocrine tumor,
hyperparathyroidism, and family history of pituitary adenoma,
this patient most likely had multiple endocrine neoplasia type
M syndrome M is an autosomal dominant disorder igure 2
astric polyps with biopsies positive for carcinoid tumor
characteried by three primary tumor sites¦ the pituitary,
parathyroid, and pancreas ther tumors, such as gastric
carcinoid tumors type , adrenal adenomas, and lipomas, hese tumors are usually small ª cm and multifocal hey are
have been described in these patients well differentiated with low risk of metastasis ª and have a
good prognosis A low gastric p differentiates type from type
here are four types of gastric carcinoids
astric carcinoid type and is thought to result from the concomitant presence of a
constitutes to of gastric carcinoids, and is the type gastrinoma M patients have a to fold higher risk of
associated with M and ©ollingerllison syndrome ©S developing a gastric carcinoid tumor compared to patients with
sporadic ©S Patients who are not known to have M
Continued on Page 7
P
PysiianResouresoGI or consults and reerrals please call UC’s -hour physician OnDemand service at 1 7
4 DIGEST — SPRING 2017
Living-Donor Liver Transplant LDLT Time to Shit the aradigm
By Abhinav Humar, MD, and Swaytha Ganesh, MD
iver transplantation has been well established as a therapeutic Ma is heralded for its obectivity and its success in reducing
option for patients with various endstage liver diseases S waitlist mortality, but some aspects concerning medical urgency
he first successful liver trans plant was performed by homas for liver transplants are not accurately represented by the M
Starl, M, in £¡, back when deceased donors were the primary Survival cannot be predicted precisely in to of cases,
source of the liver for transplantation ue to significant shortages and mortality risk among the of patients with ascites is
of deceased donor organs and the long wait for liver transplan ta underestimated
tion, attempts have been made to epand the donor pool, including More than , people are currently on a wait list for a liver
the use of livers from marginal donors, split livers from deceased transplant, with only an estimated , deceased donor transplants
donors, and transplants from living donors and living donor transplants done per year i e , less than
of patients on the wait list are transplanted per year ne out of
THE PROBLEM every five patients either dies or is removed from the list, and the
ivingdonor liver transplant provides a lifesaving option overall waitlist mortality in the United States is approimately
for patients with endstage liver disease A portion of a healthy ¡, with a range of to he number of deceased donor
liver from a family member, friend, or altruistic donor is trans transplants has not increased incrementally from ££ to , but
planted into the recipient ue to the liver’s uniue ability to the wait list continues to grow each year offers a solution to
regenerate, offers a viable option for both the recipient and organ shortages while also serving as a lifesaving option for patients
the donor he United etwork for rgan Sharing US has ue to patients’ long waitlist periods up to two years and changes
allocated deceased donor livers based on the Model for nd in the liver allocation policies, as well as regional disparities,
Stage iver isease M score since ebruary he is a crucial, lifesaving option he mean M score is now much
M allocation is now based on Ma as of anuary higher « to obtain a transplant, especially in the greater
he donor organs are offered to patients with the highest risk of Pittsburgh region, where UPMC now transplants patients with
death, based on the M Prior to the M era, liver allocation very high M scores About of waitlist patients die while
was based on the ChildurcottePugh score on the list without an opportunity to receive a transplant
PRGRA
S
• ivingDonor iver ransplant D iver Referrals y State, 1201–12201
1 1
— total Ds perfored at P
adult 1 PA
and pediatri sine 2010, aing up WV
• 2 of Region 2 volues OH
MD
• of state volues NY
• 7 of national volues VA
Other
— P
is te only enter perforing D
in estern Pennsylvania
* Source: Organ Procurement and Transplantation Network, Accessed 12/22/14
Affiliated with the University of Pittsburgh School of Medicine, UPMC is ranked among the nation’s best hospitals by U.S. News & World Report.
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