/pdf/second-european-evidence-based-consensus-on-the-diagnosis-hg0loy9hft.pdf

Second European evidence-based consensus on the diagnosis and management of ulcerative colitis Part 2: Current management

BACKGROUND Liver cholestasis can be a life-threatening complication during home parenteral nutrition and may lead to combined liver-intestinal transplantation. OBJECTIVE To assess the prevalence of home parenteral nutrition-related liver disease and its contributing factors in patients with permanent intestinal failure. DESIGN Prospective cohort study. SETTING Two approved home parenteral nutrition centers. PATIENTS 90 patients with permanent intestinal failure who were receiving home parenteral nutrition were enrolled from 1985 to 1996. INTERVENTION Clinical, biological, endoscopic, and ultrasonographic follow-up. Histologic examination of the liver was done in 57 patients (112 liver biopsies). MEASUREMENTS The Kaplan-Meier method was used to determine the actuarial occurrence of chronic cholestasis and complicated home parenteral nutrition-related liver disease (bilirubin level > or =60 micromol/L [3.5 mg/dL], factor V level < or =50%, portal hypertension, encephalopathy, ascites, gastrointestinal bleeding, or histologically proven extensive fibrosis or cirrhosis). Contributing factors were assessed by using univariate and multivariate (Cox model) analysis. RESULTS 58 patients (65%) developed chronic cholestasis after a median of 6 months (range, 3 to 132 months), and 37 (41.5%) developed complicated home parenteral nutrition-related liver disease after a median of 17 months (range, 2 to 155 months). Of these patients, 17 showed extensive fibrosis after 26 months (range, 2 to 148 months) and 5 had cirrhosis after 37 months (range, 26 to 77 months). The prevalence of complicated home parenteral nutrition-related liver disease was 26%+/-9% at 2 years and 50%+/-13% at 6 years. Six patients died of liver disease (22% of all deaths). In multivariate analysis, chronic cholestasis was significantly associated with a parenteral nutrition-independent risk for liver disease, a bowel remnant shorter than 50 cm in length, and a parenteral lipid intake of 1 g/kg of body weight per day or more (omega-6-rich long-chain triglycerides), whereas complicated home parenteral nutrition-related liver disease was significantly associated with chronic cholestasis and lipid parenteral intake of 1 g/kg per day or more. CONCLUSION The prevalence of complicated home parenteral nutrition-related liver disease increased with longer duration of parenteral nutrition. This condition was one of the main causes of death in patients with permanent intestinal failure. Parenteral intake of omega-6-rich long-chain triglycerides lipid emulsion consisting of less than 1 g/kg per day is recommended in these patients.

Prevalence of Liver Disease and Contributing Factors in Patients Receiving Home Parenteral Nutrition for Permanent Intestinal Failure

BACKGROUND AND AIMS
No gold standard exists for nutritional screening/assessment. This cross-sectional study aimed to collect/use a comprehensive set of clinical, anthropometric, functional data, explore interrelations, and derive a feasible/sensitive/specific method to assess nutritional risk and status in hospital practice.


PATIENTS AND METHODS
100 surgical patients were evaluated, 49M:51F, 55 +/- 18.9 (18-88) years. Nutritional risk assessment: Kondrup's Nutritional Risk Assessment, BAPEN's Malnutrition Screening Tool, Nutrition Screening Initiative, Admission Nutritional Screening Tool. Nutritional status: anthropometry categorised by Body Mass Index and McWhirter & Pennington criteria, recent weight loss > 10%, dynamometry, Subjective Global Assessment.


RESULTS
There was a strong agreement between all nutritional risk (k = 0.69-0.89, p < 0.05) and between all nutritional assessment methods (k = 0.51-0.88, p < or = 0.05) except for dynamometry. Weight loss > 10% was the only method that agreed with all tools (k = 0.86-0.94, p < or = 0.05), and was thereafter used as the standard. Kondrup's Nutritional Risk Assessment and Admission Nutritional Screening Tool were unspecific but highly sensitive (> or = 95%). Subjective Global Assessment was highly sensitive (100%) and specific (69%), and was the only method with a significant Youden value (0.7).


CONCLUSIONS
Kondrup's Nutritional Risk Assessment and Admission Nutritional Screening Tool emerged as sensitive screening methods; the former is simpler to use, Kondrup's Nutritional Risk Assessment has been devised to direct nutritional intervention. Recent unintentional weight loss > 10% is a simple method whereas Subjective Global Assessment identified high-risk/undernourished patients.

Nutritional risk and status assessment in surgical patients: a challenge amidst plenty.

https://www.spg.pt/wp-content/uploads/2015/11/2012_UC_Consensus_1_Definitions_and_diagnosis.pdf

European evidence-based Consensus on the diagnosis and management of ulcerative colitis: Definitions and diagnosis

### 5.1 General

The general principles for treating active ulcerative colitis are to consider the activity, distribution (proctitis, left-sided, extensive,1 and pattern of disease (relapse frequency, course of disease, response to previous medications, side-effect profile of medication, extra-intestinal manifestation), before treatment decisions are made in conjunction with the patient.

#### 5.1.1 Disease activity

The principal scoring systems used for clinical trials are covered in Section 5.1.2 and have been comprehensively reviewed.2 Some additional points are clinically relevant. In clinical practice it matters most to distinguish severe ulcerative colitis necessitating hospital admission from those with mild or moderate disease who can generally be treated as outpatients. The simplest, best validated and most widely used index for identifying acute severe UC remains that of Truelove & Wi_tts 3: any patient who has a bloody stool frequency ≥ 6/day and a tachycardia (> 90 bpm), or temperature > 37.8 °C, or anaemia (haemoglobin 30 mm/h) has severe ulcerative colitis (Table 1.3). This index has been used in 20/32 studies of intensive intravenous treatment for severe UC.4 Only one additional criterion in addition to the bloody stool frequency ≥ 6/day is needed to define a severe attack.5 While these criteria have the major limitation of being unresponsive and cannot track the course of disease, they do distinguish the severe from the moderate or mild and have value in everyday practice because they are easy to use, which no other index achieves. It should be standard practice to confirm active colitis by sigmoidoscopy or proctoscopy before starting treatment. Rectal mucosal biopsy helps exclude unexpected causes of symptoms similar to active disease (such as cytomegalovirus, amoebic, or other infection, rectal mucosal prolapse, Crohn's disease, or even irritable bowel syndrome and haemorrhoidal bleeding).

#### 5.1.2 Approach

Patients should be encouraged to participate actively in …

/pdf/european-evidence-based-consensus-on-the-management-of-3oopv702qw.pdf

European evidence-based Consensus on the management of ulcerative colitis: Current management.

Background. Small bowel transplantation is an evolving procedure. We reviewed the world experience since 1985 to determine the current status of this procedure. Methods. All of the known intestinal transplant programs were invited to contribute to an international registry using a standardized report form. Results. Thirty-three intestinal transplant programs provided data on 273 transplants in 260 patients who were transplanted on or before February 28, 1997. The number of procedures per year has increased at a linear rate since 1990, with 58 transplants performed in 1996. Two-thirds of the recipients were children or teenagers. The short gut syndrome was the most common indication for transplantation. The types of transplants included the small bowel with or without the colon (41%); the intestine and liver (48%); and multivisceral grafts (11%). The 1-year graft/patient survival for transplants performed after February 1995 was 55%/69% for intestinal grafts; 63%/66% for small bowel and liver grafts; and 63%/63% for multivisceral grafts. Transplants since 1991 and programs that had performed at least 10 transplants had significantly higher graft survival rates. Seventy-seven percent of the current survivors had stopped total parenteral nutrition (TPN) and resumed oral nutrition. Conclusions. Transplantation has become a lifesaving procedure for (1) patients with intestinal failure who cannot be maintained on total parenteral nutrution and (2) patients who require abdominal evisceration to completely remove locally aggressive tumors. The 5-year survival rate of intestinal transplantation with large series is comparable to lung transplantation.

Intestinal transplantation: 1997 report of the international registry. Intestinal Transplant Registry.

Combined small bowel and liver transplantation in the rat: possible role of the liver in preventing intestinal allograft rejection.

The initial clinical experience with simultaneous small bowel/liver transplantation (SBL) suggests that liver grafting may protect the small bowel from rejection. A pilot study of SBL in DA (RT1a) rats with Lewis (RT1l) allografts in our laboratory provided experimental support for this concept. However, the clinical applicability of the data was questioned because the transplants were performed in a low-immune-responder rat strain combination. This study examined the outcome of SBL in several rat strain combinations. Isolated small bowel transplants (SB) and SBL were performed in three groups: DA-->PVG (low immune responder), BN-->LEW (intermediate immune responder) and ACI-->LEW (high immune responder). Lewis-->Lewis isografts were used as controls. All of the rats with SB rejected their allografts, whereas all of the rats with simultaneous liver grafts had minimal or no signs of intestinal rejection. The outcome of SBL was profoundly affected by the donor-recipient strain combination. The low immune responders developed severe graft-versus-host disease. The intermediate immune responders developed mild-to-moderate GVHD and moderate liver rejection. The high immune responders developed severe liver rejection. In this study, the outcome of small bowel transplantation depended upon the strain combination used and whether or not a simultaneous liver graft was transplanted. The immune interactions that occur after multi-visceral transplantation are complex and cannot be easily predicted.

The effect of donor-recipient strain combination on rejection and graft-versus-host disease after small bowel/liver transplantation in the rat.

It has been more difficult to prevent intestinal allograft rejection than rejection of other solid organ transplants. Epithelial cells in the small intestine have the potential to actively participate in graft rejection because they constitutively express MHC class II antigens. The present study examined the ability of intestinal epithelial cells (IEC) to stimulate allogeneic T cells in vitro using one-way MLC. IEC from jejunum and ileum of ACI rats (RT1 a ) were used as the stimulator cells ; purified T lymphocytes from Lewis rats (RT1 1 ) were used as the responder cells. Freshly isolated IEC were poor stimulators of naive allogeneic T lymphocytes. However, IEC induced a strong proliferation of primed allogeneic T lymphocytes, and this response could be blocked by anti-MHC class II mAb (OX-4). IEC stimulated a vigorous proliferation of naive T cells when co-cultured with (1) macrophages syngeneic with responder T lymphocytes, (2) supernatants of LPS-stimulated macrophages, or (3) a combination of IL-1 and IL-6. We conclude that MHC class II positive IEC require soluble costimulatory factors to fully activate naive allogeneic T cells. Immune stimulation by enterocytes may be one of the reasons why it is so difficult to prevent intestinal allograft rejection. Strategies that block interactions among IEC, macrophages, and lymphocytes may reduce the immunogenicity of small bowel transplants.

Allogeneic lymphocyte proliferation stimulated by small intestine-derived epithelial cells.

The role of gut-associated lymphoid tissue in intestinal rejection. Allogeneic response to rat intestinal lymphocytes.

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