appliances became unnecessary (Kock, 1970, 1971). The patients empty the reservoir two or three times

Transcription

1 Gut, 1971, 12, Absorption studies in patients with 'intraabdominal ileostomy reservoirs' and in patients with onventional ileostomies. JAGENBUG, G. DOTEVALL, J. KEWENTE, N. G. KOCK, AND B. PHLPON From urgial Department, the Department of Clinial Chemistry, and Medial Department, ahlgren's Hospital, University of Gothenburg, Gothenburg, weden UMMAY Twenty patients with ileostomy were studied onerning the absorption of D-xylose, fat, L-phenylalanine, and vitamin B12. Ten patients had a onventional ileostomy, whereas 1 others were provided with an intraabdominal intestinal ileostomy reservoir resulting in faeal ontinene. No remarkable differenes in the absorption of D-xylose, fat, or L-phenylalanine were found between the two groups of ileostomy patients. Most of the absorption values were within normal or borderline ranges. n the reservoir group the hilling test gave subnormal values in six out of 1 patients, whereas only one patient in the group with a onventional ileostomy had a subnormal value. The reason for this finding is briefly disussed. The progressive deline in mortality and morbidity assoiated with protooletomy, together with the good results after present-day surgial treatment of patients with olitis, has led to a wider use of protooletomy both in patients with muous ulerative olitis and transmural regional enteritis loalized to the olon. Consequently the number of patients provided with a permanent ileostomy ontinues to inrease. Although most of these patients are restored to normal health and ative and produtive lives the ileostomy reates in many of them soial and psyhologial problems. The flow of intestinal ontents through the ileostomy is more or less ontinuous and not voluntarily ontrolled exept to a small extent by the diet. leostomy applianes have to be arried ontinuously in order to ollet the intestinal disharge. The possibility of leakage is always present and odour from the intestinal disharge onstitutes a serious problem for some patients. Oasional or onstant skin irritation is a frequent late ompliation of ileostomy (Watts, de Dombal, and Goligher, 1966; Biermann, Toker, and Toker, 1966). n order to eliminate these drawbaks of the ileostomy an intraabdominal ileal reservoir was onstruted in patients with permanent ileostomy (Kok, 1969). n most of the patients faeal ontinene was obtained and external ileostomy eeived for publiation 29 Deember 197. applianes beame unneessary (Kok, 197, 1971). The patients empty the reservoir two or three times a day with the aid of a atheter. As the intestinal ontents are stored longer in the intestine of the patienits with an ileostomy reservoir than in patients with a onventional ileostomy it was theoretially possible that absorption ould be improved by the ileostomy reservoir. On the other hand hanges in the ileal mirobial flora of the reservoir (Brandberg, Kok, and Philipson, 1971) and possible strutural hanges in the muous membrane of the reservoir ould affet the absorptive apaity of this part of the intestine resulting in dereased absorption. The aim of the present investigation was to eluidate these problems by omparing some absorption parameters in patients with ileostomy reservoirs with those in patients with onventional ileostomies. Material and Methods Twenty patients who had previously undergone protooletomy were studied. n 1 patients an intraabdominal intestinal reservoir had been onneted to the ileostomy (Kok, 1969) whereas the other patients had onventional ileostomies. The indiations for the operations were muous ulerative olitis, transmural reginal enteritis, and familial polyposis (Table ). n none of the patients with 437 Gut: first published as /gut on 1 June Downloaded from on 24 Deember 218 by guest. Proteted by opyright.

2 438 leostomy Ulerative olitis 6 8 Crohn's disease 3 2 Familial polyposis 1. Jagenburg, G. Dotevall, J. Kewenter, N. G. Kok, and B. Philipson eservoir Table ndiations for protooletomy in 1 patients with onventional ileostomy and in 1 patients with ileostomy reservoir Age Group (years) Conventional leostomy leostomy eservoir Table The age distribution of the patients in the two groups studied Crohn's disease was the small intestine involved. The age distribution of the patients in the two groups is given in Table. The patients with onventional ileostomy had undergone the operation one to 1 years before the investigation, whereas the patients with ileostomy reservoir had been operated on less than two years before the study. The patients were all in good general health and well rehabilitated. They were admitted to hospital during the study. Before the absorption tests were arried out blood samples were taken for determination of haemoglobin, serum iron, total iron-binding apaity (TBC), serum folate, serum vitamin B12, eletrolytes, and serum reatinine. D-XYLOE EXCETON TET D-xylose, 25 g, in 5 ml water was administered to the fasting patients and urine was olleted for five hours. Urinary D-xylose was determined aording to a modifiation (Kerstell, 1961) of the method of oe and ie (1948). Urinary exretion > 5 g/5 hours is onsidered as normal. FAT BALANCE The patients were kept on a standard diet ontaining 1 g fat daily for six days. The ontents from the ileostomy reservoir and the output from the onventional ileostomy were olleted in one-day periods. Carmine as a marker for the olletion was given before, 'in the middle, and at the end of the study. The olletions were weighed and the fat ontent of eah olletion was determined aording to the method of van de Kamer, ten Bokkel Huinik, and Weyers (1949). A mean faeal exretion of less than 6 g/day is onsidered as normal. PHENYLALANNE ABOPTON TET The patients were given 1 mg L-phenylalanine per kg body weight dissolved in 3 ml of offee. The loading was performed in the morning with the patient in the fasting state. Venous blood was taken before and 3, 45, 6, 9, 12, and 18 min after the loading. Plasma phenylalanine was measured fluorimetrially (Wong, O'Flynn, and nouye, 1964). CHLLNG TET t was arried out as desribed by Grasbek, Nyberg, and iurala (1956). Urinary exretion exeeding 1% was onsidered as normal. The test was done without administration of intrinsi fator. None of the patients had anaidity as revealed from a normal gastri seretion test (Diagnex-blue). VTAMN B 12 Vitimin B12 in serum was determined by a mirobiologial method (Hutner, Bah, and oss, 1956) using Euglena grailis (Z-strain). Vitamin B12 > 15 ng/l is regarded as normal. FOLATE Folate in serum was assayed with Latobaillus asei aording to the tehnique desribed by Hansen (1964). Values of serum folate. 3. ng/ml are regarded as normal. esults The levels of haemoglobin, serum iron, TBC, and serum folate were normal in all ases and there were no signifiant differenes between the two groups. erum reatinine and eletrolytes were also normal in all instanes. The urinary D-xylOse exretion was less than 5 g/five hours in four out of 1 patients with onventional ileostomy and in five out of 1 patients with reservoir (Fig. 1). The subnormal values were not orrelated to the time lapse after operation nor to the primary disease for whih the operation was performed. The fat exretion exeeded 6 g/24 hours in four out of 1 patients in the ileostomy group and in eight out of 1 in the reservoir group but the mean exretion in the two groups was similar (7.6 and 8.3 g respetively). The highest fat exretion observed was 14 g/24 hours. The mean weight of the intestinal disharge was 558 g/24 hours for patients with ileostomy and 642 g/24 hours for patients with reservoir (Fig. 2). The phenylalanine absorption as shown by the plasma phenylalanine urve after oral loading was similar in the two groups (Fig. 3) and did not differ from that obtained in normal subjets (Jagenburg and odjer, 1971). The mean body weight was Gut: first published as /gut on 1 June Downloaded from on 24 Deember 218 by guest. Proteted by opyright.

3 Absorption studies in patients with 'intraabdominal ileostomy reservoirs' and onventional ileostomies exr. g 5hrs 4j D -XYLOETET Fig. 1 1 patients with onventional ileostomy () and in 1 patients with ileostomy reservoir (). g/'24 hrs -@ _ * D-xylose exretion (normal > 5 glfive hours) in FAECAL FAT _ kq/24 hrs E J W C, C Q E U) C n Time ( hours) Fig. 3 Plasma phenylalanine urve after oral L-phenylalanine loading (5 mg/kg body weight) in 1 patients with onventional ileostomy ( ) and 1 patients with ileostomy reservoir (o-----o). The means and E are given. FAECAL WEGHT 439 Fig. 2 Faealfat ontent (normal < 6 g/24 hours) and faeal weight in 1 patients with onventional ileostomy () and in 1 patients with ileostomy reservoir (). The mean values of six one-day periods are given. Gut: first published as /gut on 1 June Downloaded from on 24 Deember 218 by guest. Proteted by opyright.

4 44 ng/ 4+. Jagenburg, G. Dotevall, J. Kewenter, N. G. Kok, and B. Philipson VT. B12 EUM CHLLNG-TET somewhat higher in the ileostomy group (68-2 kg) than in the reservoir group (57.9 kg). This explains the slightly higher plasma phenylalanine onentrations in the ileostomy group (Jagenburg and odjer, 1971), as the test dose of phenylalanine was given in relation to body weight. Vitamin B,2 in serum was within the normal range in all patients. The hilling test was below 1% only in one of the patients with a onventional ileostomy but in six out of 1 patients with a reservoir (Fig. 4). Disussion * exr. t is remarkable that the omplete removal of the olon and retum in man does not produe serious absorptive and metaboli disturbanes. Although protooletomy and ileostomy have been more widely used only during the last two deades it is well doumented that the majority of these patients are restored to exellent health and good rehabilitation (oy, auer, Beahrs, and Farrow, 197). Exept for a loss of biarbonate and water in the alkaline ileostomy effluent, resulting in slight dehydration and inreased urine aidity in some ileostomy patients (Clarke and MKenzie, 1969), the absorption seems to be unaffeted by the protooletomy as judged from long-term observations of these patients Fig. 4 Vitamin B12 level in serum (normal > 15 ng/l) and the results from hilling test (normal > 1O /) in 1 patients with onventional ileostomy () and 1 patients with ileostomy reservoir (). n the present series of 1 patients with onventional ileostomy four had slightly redued D-xylose absorption (4-5 g xylose exreted in the urine per five hours), four had a somewhat redued fat absorption (85-9 %), and one had a low hilling test (exretion 4 %). The subnormal values were not orrelated to the time lapse sine the operation nor to the disease ausing the operation. From the present investigation it appears that a slightly impaired absorption of D-xylose, fat, and vitamin B12 may our in patients with ileostomy. Beause of the exellent health of the patients with subnormal values the linial signifiane of the slightly impaired absorption an, however, be questioned. The introdution of the ileostomy reservoir as part of the armamentarium for the management of patients with a permanent ileostomy raises questions on the influene of this proedure on the absorption of the small intestine. Beause of the storage of the intestinal ontents in the reservoir improved absorption ould be expeted. The hanged mirobial flora in the ileostomy reservoir (Brandberg et al, 1971), on the other hand, ould negatively influene the absorption as there might be a baterial onsumption of, for example, arbohydrates. As seen from the present study there was no signifiant differene in the absorption of D-xylose, L-phenylalanine, and fat between the patients with onventional ileostomies and those with reservoirs. Gut: first published as /gut on 1 June Downloaded from on 24 Deember 218 by guest. Proteted by opyright.

5 Absorption studies in patients with 'intraabdominal ileostomy reservoirs' and onventional ileostomies 441 The relatively high faeal fat exretion values in the present investigation require some omment. Aording to the reports of some authors (Wollaeger, Comfort, and Osterberg, 1947; kala, Krondl, Vulterinova', Horakova', and gastna', 1967), an inrease in dietary fat intake leads to an inrease in faeal fat loss both in healthy subjets and in patients with malabsorption. Previous studies of faeal fat exretion in patients with ileostomy seems to have been performed with the patients on their usual diet (Kramer, Kearney, and ngelfinger, 1962) whereas the subjets in our study were kept on a standard diet ontaining 1 g fat daily. The relatively high dietary fat ontent in our study an probably explain the high faeal fat values found in both groups in our study. The faeal weight an be regarded as a rude measure of water absorption. Although the weight varied onsiderably between individuals the distribution of the weight values was, however, equal in both groups, indiating no signifiant differene in water absorption. Vitamin B12 in serum was within the normal range in all patients. The patients in the reservoir group had, however, been operated on less than two years before the investigation and no onlusions an therefore be drawn from these values onerning absorption. ix out of 1 patients with a reservoir had subnormal hilling test values. One explanation for this remarkable finding ould be that, aording to Hulten, Kewenter, Persson, and Ahren (197), the hilling test values are often low when determined within one year after the reation of an ileostomy. Most of the patients having had an ileostomy for more than one year had a normal hilling test. Another possibility ould be that the absorptive apaity of the terminal ileum, used for onstrution of the reservoir, is diminished either beause of the baterial flora or beause of strutural hanges in the muous membrane. tudies are in progress to eluidate these questions. This work was supported by the wedish Medial esearh Counil (projet no. B71-1 7x-577-7A, B71-1 3x-652-6A). eferenes Biermann, H. J., Toker, A. M., and Toker, L.. (1966). tatistial survey of problems in patients with olostomy or ileostomy. Amer. J. urg., 112, Brandberg, A., Kok, N. G., and Philipson, B. (1971). The mirobial flora of intestinal effluent in patients with onventional ileostomy and in patients with intraabdominal ileostomy reservoir. (To be published.) Clarke, A. M., and MKenzie,. G. (1969). leostomy and the risk of urinary uri aid stones. Lanet, 2, Grasbek,., Nyberg, W., and iurala, M. (1956). Urinary exretion of radionitamin B,, (hilling test). (wedish.) Nord. Med., 56, Hansen, H. A. (1964). On the diagnosis of foli aid defiieny. Aademi thesis, Goteborg. Hulten, L., Kewenter, J., Persson, E., and Ahr6n, C. (197). Vitamin B,,-absorption in ileostomy patients after operation for ulerative olitis. and. J. Gastroent., 5, Hutner,. H., Bah, M. K., and oss, C.. M., (1956). A sugarontaining basal medium for vitamin B12-assay with Euglena; appliation to body fluids. J. Protozool., 3, Jagenburg,., and odjer,. (1971). To be published. van de Kamer, J. H., ten Bokkel Huinink, H., and Weyers, H. A. (1949). apid method for the determination of fat in fees. J. biol. Chem., 177, Kerstell, J. (1961). A simplified method for the determination of xylose in urine. and. J. lin. lab. nvest., 13, Kok, N. G. (1969). ntra-abdominal 'reservoir' in patients with permanent ileostomy. Arh. urg., 99, Kok, N. G. (197). Continent ileostomy with the aid of an intraabdominal ileal pouh. 4th World Congress ofgastroenterology, Copenhagen, Denmark, 12th-18th July, 197. Advane abstrats. Ko_k, N. G. (1971). leostomy without external applianes. A survey of 25 patients provided with intraabdominal intestinal reservoir. Ann. urg., in press. Kramer, P., Kearney, M. M., and ngelfinger, F. J. (1962). The effet of speifi foods and water loading on the ileal exreta of ileostomized human subjets. Gastroenterology, 42, oe, J. H., and ie, E. W. (1948). A photometri method for the determination of free pentoses in animal tissues. J. biol. Chem., 173, oy, P. H., auer, W. G., Beahrs,. H., and Farrow, G. M. (197). Experiene with ileostomies. Evaluation of long term rehabilitation in 497 patients. Amer. J. urg., 119, kaila,., Krondl, A., Vulterinova, M., Horakova, J., and tastni,. (1967). Effet of inreased dietary fat intake in patients after resetion of the small intestine and malabsorption of different aetiology on faeal fat exretion. Gastroenterologia (Basel), 18, Watts, J. MK., de Dombal, F. T., and Goligher, J. C. (1966). Longterm ompliations and prognosis following major surgery for ulerative olitis. Brit. J. urg., 53, Wollaeger, E. E., Comfort, M. W., and Osterberg, A. E. (1947). Total solids, fat and nitrogen in the fees:. A study of normal persons taking a test diet ontaining a moderate amount of fat; omparison with results obtained with normal persons taking a test diet ontaining a large amount of fat. Gastroenterology, 9, Wong, P. W. K., O'Flynn, M. E., and nouye, T. (1964). Miromethods for measuring phenylalanine and tyrosine in serum. Clin. Chenm., 1, Gut: first published as /gut on 1 June Downloaded from on 24 Deember 218 by guest. Proteted by opyright.