Carol Rees Parrish, R.D., M.S., Series Editor Parenteral .
NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #55Carol Rees Parrish, R.D., M.S., Series EditorParenteral Nutrition in Pancreatitisis Passé: But Are We Readyfor Gastric Feeding?A Practical Guide to Jejunal Feeding:Revenge of the Cyst – Part IIJoe KrenitskyDiklar MakolaCarol Rees Parrish(See September 2007 for Part I on evidence supporting jejunal vs parenteral or gastric feeding)Nutrition support is required to prevent or reverse malnutrition in the 15%–20% ofpatients that develop severe or complicated pancreatitis who are unable to resume oralintake in seven-to-ten days. The best available data supports the use of jejunal feedingover parenteral nutrition in those patients. Jejunal enteral nutrition can be successfullyachieved by using nasojejunal access (in those patients requiring 30 days of nutritionsupport) and either percutaneous endoscopic gastrostomy with jejunal extension ordirect percutaneous jejunostomy access in patients requiring longer support. Symptoms such as diarrhea, nausea, vomiting, abdominal pain, and excessive gastric secretion may appear to be obstacles to successful enteral feeding, but our experiencedemonstrates that patients rarely remain intolerant to enteral feeding and require parenteral nutrition. The transient gastrointestinal symptoms associated with enteral feeding can be managed by the following recommendations outlined in this article. The useof long term enteral nutrition in patients with chronic pain, pseudocysts, malnutritionand other complications is increasing, but the efficacy of this practice still needs to beclearly demonstrated in randomized controlled trials.(continued on page 58)Joe Krenitsky, MS, RD, Nutrition Support Specialist; Diklar Makola, MD, MPH, PhD, Gastroenterology Fellow; Carol Rees Parrish MS, RD, Nutrition Support Specialist all at Digestive HealthCenter of Excellence, University of Virginia Health System, Charlottesville, VA.54PRACTICAL GASTROENTEROLOGY OCTOBER 2007
Parenteral Nutrition in Pancreatitis is PasséNUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #55(continued from page 54)INTRODUCTIONhe majority of patients with pancreatitis have amild form of the disease and recover fully after ashort period (3–5 days), while the remaining15%–20% of patients will progress to a more complicated course, ultimately requiring nutritional support(1). In the past, parenteral nutrition (PN) was the mainstay of treatment; however, the evidence that hasaccrued in recent years has demonstrated that jejunalenteral feedings are, by far, the safest means to achievethis end (2). Although the decision to enterally feedmay seem simple, the reality is that enteral feedingrequires tenacity and clinical acumen. This articlechronicles the evidence, as well as our experience,with jejunally feeding the patient with severe, complicated pancreatitis and the nutritional concerns that mayarise long term.TPRACTICAL ASPECTS OF ENTERAL NUTRITIONAlthough reviews and practice guidelines have concluded that jejunal enteral nutrition (EN) is the preferred route for providing nutrition support duringacute pancreatitis (3–7), our discussions with nutritionsupport professionals from across the nation suggestthat routine use of PN in patients with pancreatitisremains quite common. Lack of technical expertise,difficulty in placement and maintaining jejunal accessand perceptions of feeding intolerance that preventsuccessful EN continue to be barriers to successful ENduring pancreatitis at many facilities.ENTERAL ACCESSShort-term jejunal enteral access can be achievedthrough the placement of a nasojejunal feeding tube inmost patients. Fluoroscopy and endoscopy are frequently used to assist and ensure the placement offeeding tubes beyond the Ligament of Treitz (LOT). Inour institution, fluoroscopic placement is the morecost-effective method, therefore, we reserve endoscopic tube placement for those patients that alreadyrequire endoscopy, or in whom fluoroscopic placementhas been unsuccessful. Our early experiences ofattempting to drag or advance feeding tubes with anendoscope were not only time consuming, but fre58PRACTICAL GASTROENTEROLOGY OCTOBER 2007quently resulted in displacement of the tube when theendoscope was removed. More recently, when endoscopic placement is required, the use of a pediatricendoscope to place the guidewire then advancing thefeeding tube over the guidewire, has been a more practical and successful approach.Transnasal endoscopic placement of feeding tubeshas been described, eliminating the need for intravenous sedation, but this method requires the use of anultra thin endoscope (8). Wiggins has also described anendoscopically guided NJ placement push technique inwhich a 12 Fr Endotube stiffened by placement of twowires in its lumen is pushed into the small bowel underendoscopic visualization (9).Magnetic guidance of feeding tubes on/4/45/) anduse of modified feeding tubes that generate an electromagnetic signal recognized by an external receiverplaced on the abdomen have reported success withplacement of feeding tubes beyond the pylorus, butthere is limited data about their effectiveness for placement of feeding tubes beyond the LOT (10).Although there are no randomized studies supporting one type of nasojejunal access over another, ourexperience has been that the use of the largest size of the“small bore” feeding tubes (12 Fr as opposed to 8 or 10Fr), results in less clogging without any discernableincrease in patient discomfort. Double lumen gastrojejunal tubes that have 2 lumens are available (TycoKendall Healthcare e); the first lumen terminates in thestomach and the second in the jejunum. Double lumentubes, which allow feeding into the distal opening andsimultaneous gastric decompression/drainage throughthe proximal opening, may be useful to decrease nausearelated to retention of endogenous gastric secretionswithout the need for a second nasal tube for nasogastricdecompression. One potential disadvantage of doublelumen tubes is that in order to maintain an externaldiameter that is relatively comfortable for the patient(14-16 Fr); the jejunal portion of the tube is usually 6-8Fr and may be prone to frequent clogging. In addition,because dual-lumen tubes are also used for decompression, the external diameter of the tube is significantlylarger and stiffer than a small bore feeding tube and(continued on page 61)
Parenteral Nutrition in Pancreatitis is PasséNUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #55(continued from page 58)long-term patient comfort is an issue (personal experience of the authors).When EN is required for periods of 30 days or less,many clinicians prefer to maintain nasojejunal access,reserving placement of percutaneous jejunal access forpatients requiring long-term EN (11,12). Although it ispossible to maintain nasal access for longer than 30days, long-term nasojejunal tubes are not as desirableby most patients that are candidates for discharge tohome (personal experience of the authors).No randomized studies exist aimed at determiningthe optimal duration of EN support for patients withcomplicated pancreatitis. However, long-term EN withdelayed introduction of oral intake (mean of 4.4 months)may be beneficial in patients with acute severe necrotizing pancreatitis (13) and in those with chronic recurrentpancreatitis with pseudocysts (13–16). There is a needfor randomized studies to determine if there are outcomebenefits (infectious complications, reduced hospitalizations, decreased surgical necessity) with extended jejunalEN and delayed oral intake in the setting of pancreatitiscomplicated by pseudocyst or necrosis.Long-term jejunal access can be achieved by endoscopic placement of either percutaneous gastrostomywith jejunal extension (PEG-J) or by direct percutaneous jejunostomy (DPEJ). Although PEG-J has beencriticized as having a significantly greater attrition ratethan DPEJ in terms of tube patency (17), this limitationappears to primarily affect small-bore PEG-J devices.One case series that reported significantly more attritionfrom occlusion of the J-arm with PEG-J compared todirect percutaneous jejunostomy, utilized small bore (9Fr) jejunal extension through a 20 Fr PEG (17). Anothercase series documented similar problems with smallbore jejunal extensions, reporting 83% of all occlusionsin jejunal extensions occurring in the smaller tubes (8.5Fr) (18). Those case series that have reported low malfunction rates with PEG-J tubes have utilized a 24 FrPEG with a 12 Fr jejunal extension (13,16). Varioustechniques for PEG-J placement exist and have beendescribed in various publications (11,13,17,19). Ourpractice is to pay particular attention to placement of thePEG (into the distal portion of the stomach, to the rightof the spinal column, facing the pylorus) because wehave found that this position decreases the distance thej-arm must traverse across the stomach and allows thejejunal extension to reach well beyond the LOT andappears to result in less displacement of the jejunal tube(13). One advantage of PEG-J tubes is that they allowdecompression of gastric secretions while feeding intothe jejunum. Although persistent gastric outlet obstruction occurred in only 14% of patients with complicatedpancreatitis, in our experience, a much larger percentageof patients utilized the gastric port of the PEG-J torelieve symptoms of nausea during the initial period ofjejunal feeding (13).DPEJ tubes have also been successfully used toprovide long-term EN (11,13,17,19). The major limitation with DPEJ’s is their inability to facilitate gastricdecompression in patients with functional gastric outlet obstruction. Patients that receive a DPEJ and havepersistent gastric outlet obstruction may require a second percutaneous gastric tube for decompression andbe exposed to the inherent risks that this may involve.POSITION OF THE TIP OF THE TUBEPositioning the tip of a feeding tube into the duodenumfrequently allows successful EN in the setting of gastric dysmotility due to critical illness or gastroparesis.However, there is evidence that feeding into the duodenum is a strong stimulus to pancreatic secretions(20–22). Several studies have reported that infusingeither elemental or polymeric feeding into the duodenum resulted in increased secretion of amylase, lipase,trypsin, bile acid, CCK and gastrin when compared tocontrols and those receiving PN (21,22). In contrast,when elemental or polymeric formulas were infused40–60 cm beyond the Ligament of Treitz, there wasactually an inhibition of pancreatic secretions compared to PN (21). Bedside techniques for blind placement of post-pyloric feeding tubes are rarelysuccessful in placing feeding ports beyond the LOT.Most facilities use either endoscopic or fluoroscopicplacement to ensure that feeding tubes are adequatelydistal to the LOT. A word of caution; it is essential thatthe clinician recognizes the location of the feedingports in relation to the tip of the feeding tube. Feedingtubes that have several feeding ports proximal to thetip (frequently seen with weighted tubes) may appearto be beyond the LOT, while in reality the feedingports remain in the duodenum and result in pancreaticPRACTICAL GASTROENTEROLOGY OCTOBER 200761
Parenteral Nutrition in Pancreatitis is PasséNUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #55stimulation and worsening of pancreatitis/symptoms,leading clinicians to think that jejunal EN does notwork. Feeding ports should be distal to the LOT tominimize pancreatic stimulation or reflux of formulawhen feeding patients with severe acute pancreatitis.The standard small bore feeding tube at our facility(polyurethane 43 inch, 12 Fr Entriflex e), placed throughthe jejunal port of a PEG tube, has allowed adequatejejunal access in the majority of our patients, howeversome patients have required a longer tube (55 inch, 12Fr Entriflex ) e), to reliably feed distal to the LOT.FORMULA SELECTIONThe initial studies of jejunal EN in acute pancreatitisused elemental or semi-elemental formulas, but several studies since have described successful jejunal ENusing polymeric formulas with positive results(13,23–28). The conventional wisdom that elementalor semi-elemental formulas are better tolerated inpatients with pancreatitis is based on two assumptions:1. Standard EN formulas containing fat will stimulatethe pancreas exacerbating the pancreatitis, and2. Maldigestion from pancreatic insufficiency alwaysaccompanies pancreatitis and therefore, an elemental or semi-elemental formula is needed.One early case report suggested that jejunaladministration of a polymeric EN formula resulted in afive-fold increase in pancreatic lipase output comparedto elemental EN (29). However, more recent researchsuggests that “pancreatic rest” can be achieved byadministering a polymeric formula, as long as it isinfused sufficiently distal to the LOT (21).A study in healthy volunteers demonstrated that apolymeric liquid diet administered through a tubelocated just proximal to the LOT, resulted in a significant increase in lipase, amylase and trypsin output,while administration through a tube located 60 cm distal to the LOT did not result in a similar increase inoutput (30). Another study found that when polymericformulas were infused 40–60 cm distal to LOT therewas actually an inhibition of pancreatic secretionscompared to PN (21).62PRACTICAL GASTROENTEROLOGY OCTOBER 2007In a randomized trial, Windsor, et al reported thatpolymeric EN resulted in significant reductions in Creactive protein and APACHE II score compared topatients receiving PN (31). Pupelis, et al randomizedpatients to receive either jejunal EN with a polymericformula, or standard therapy (npo receiving IV fluids)(32). Patients receiving polymeric formula via nasojejunal EN had significantly decreased mortality (p 0.05) compared to standard therapy. Modena, et al in astudy utilizing historical controls, reported that thegroup receiving polymeric jejunal EN had significantreductions in mortality (p 0.001), less pancreaticnecrosis (p 0.001), organ failure or need for surgery(p 0.001) than those patients receiving PN (33).A retrospective study of patients with complicatedpancreatitis receiving long-term (average 4.4 months)polymeric jejunal EN reported median CT severityindex significantly improved (p 0.001) while receiving polymeric jejunal EN. In addition, those patientswith a BMI 18.5 at entry experienced a significantweight increase (13).Although polymeric formulas appear to be well tolerated by the average patient with pancreatitis, there isa concern that those patients with pancreatic exocrineinsufficiency may experience malabsorption or diarrhea. Several investigators have described the incidence of pancreatic exocrine insufficiency in patientswith pancreatitis (34,35), but there is limited dataregarding the incidence of malabsorption in patientsreceiving enteral feeding. A retrospective review of127 patients with complicated pancreatitis whoreceived jejunal EN reported that 19 of the 63 patients(30%) tested for fecal fat had evidence of steatorrhea(13). However, only two of 126 patients in this cohortreceived a semi-elemental EN; all other patients withsteatorrhea were reported to tolerate and clinicallyprogress well on polymeric EN after pancreatic enzymepowder was added to the feeding formula.There is only one randomized study that hasdirectly compared the use of semi-elemental to polymeric EN in acute pancreatitis (36). The pilot studyenrolled 30 subjects and found that both formulas werewell tolerated without a significant difference in stoolfat or protein loss between the two groups. Furthermore,no significant differences in pain scores, amylase or Creactive protein were noted, implying lack of increased
Parenteral Nutrition in Pancreatitis is PasséNUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #55inflammation in the polymeric group. The semi-elemental EN group had a significantly shorter hospitalstay (23 2 versus 27 1, p 0.006) and less weightloss. However, the difference in weight, although statistically different (2.4 lbs), could be attributed solely totransient changes in fluid status known to occur in thispatient population. Considering the small number ofpatients, and the apparent lack of pain exacerbation,increase in inflammatory markers, or any sign ofincreased feeding intolerance or malabsorption of polymeric feeding, a much larger, double-blind study wouldbe required to know if there is a meaningful advantageto elemental formulas that would justify the significantly increased cost of these formulas (Tables 1 and 2).MANAGEMENT OF “FEEDING INTOLERANCE”DiarrheaPancreatic InsufficiencyDiarrhea is not an uncommon finding in patients withpancreatitis that receive EN, but diarrhea does notequal feeding intolerance, nor does it necessarilyequate to malabsorption (37). Pancreatic insufficiencymay be associated with the occurrence of steatorrheathat may present as diarrhea. Pancreatic exocrine insufficiency occurs in 35%–86% of patients with severeacute pancreatitis (35,38,39) and pancreatic endocrineimpairment (hyperglycemia) was documented in 25%of patients in one study (40). A greater frequency ofboth exocrine and endocrine pancreatic insufficiencyhas been reported in patients with alcohol-inducedacute pancreatitis compared to gallstone-associatedpancreatitis (35,39). Migliori, et al (35) found that 84%of patients with acute alcoholic pancreatitis and 22%with acute biliary pancreatitis demonstrated evidenceof exocrine pancreatic insufficiency using duodenalintubation and the amino acid consumption test. However Bozkurt, et al further found that while biochemicalpancreatic insufficiency occurred in 80%–85% ofcases, clinical signs of exocrine insufficiency occurredonly in 5%–10% (34). A retrospective review ofpatients with pancreatitis who received jejunal feedingsuggests that only a small percentage of those patientsare diagnosed with exocrine insufficiency (41).Depending on the extent of pancreatic damage,pancreatic enzyme insufficiency may display early on,or may occur much later as fibrosis and pancreatic cal-Table 1Nutrition Information of Various Elemental and Semi-Elemental FormulasProductSourceCaloriesper mLCHO g/LPro g/LFat g/LMCT:LCT1Price/1000 kcal*F.A.A.OptimentalPeptamenPeptamen 1.5Peptinex DTPerativeTolerexVital HNVivonex 1.5112.825:7545:5570:3070:3050:5040:60No MCT45:55No MCT 29.92 25.43 24.90 24.20 25.00 12.41 16.67 21.18 18.33*Phone numbers used to obtain pricing information on June 1, 2007:Ross: (800) 544-7495Nestle: (800) 776-5446Novartis: (800) 828-91941Medium chain triglyceride (MCT): Long chain triglyceride (LCT)Used with permission from the University of Virginia Health System Nutrition Support Traineeship SyllabusPRACTICAL GASTROENTEROLOGY OCTOBER 200763
Parenteral Nutrition in Pancreatitis is PasséNUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #55Table 2Cost Comparison of Elemental Formulas versusStandard Formulas with Pancreatic Enzymes AddedFormulaPrice/1000 kcal*ElementalF.A.A.Peptamen 1.5, unflavoredVital HNVivonex TEN 29.92 24.90 20.28 18.33Standard formula with and without 1 2 teaspoonViokase powder added per can**Jevity 1.5 14.02 / 11.02Two Cal HN 6.38 / 3.78Promote with Fiber 10.73 / 7.73Probalance 11.76 / 8.76*Cost information obtained from company using toll freenumber (2007 prices)**Cost based on « teaspoon of Viokase powder (8 oz.—Wal-Mart)added per can formula (1/2 teaspoon 0.75 cents)Note: 1 2 teaspoon contains 1.4 g Viokase powderUsed with permission from the University of Virginia Health SystemNutrition Support Traineeship Syllabuscification occur
Revenge of the Cyst –Part II NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #55 Joe Krenitsky, MS, RD, Nutrition Support Specialist; Diklar Makola, MD, MPH, PhD, Gastroen-terology Fellow; Carol Rees Parrish MS, RD, Nutrition Support Specialist all at Digestive Health Center of Excellence, University of Virginia Health System, Charlottesville, VA.
Parrish Village News. page 2 Parrish Village News Official publication of the Parrish Civic Association, a non profit coporation. P. O. Box 257 Parrish, FL 34219
WEST COAST HOTEL CO. v. PARRISH. 379 Syllabus. WEST COAST ttOTEL CO. v. PARRISH ET AL. APPEAL FROM THE SUPREME COURT OF WASHINGTON. No. 293. Argued December 16, 17, 1936.-Decided March 29, 1937. 1. Deprivatio
WEST COAST HOTEL CO. v. PARRISH. 379 Syllabus. WEST COAST ttOTEL CO. v. PARRISH ET AL. APPEAL FROM THE SUPREME COURT OF WASHINGTON. No. 293. Argued December 16, 17, 1936.-Decided March 29, 1937. 1. Deprivation of liberty to contract is forbidden by the Constitution if without due process of law; but restraint or regulation of this .
REEs and Electronics REEs have been used in electronics and advanced machinery for nearly three-quarters of a century. Demand for REEs in electronics began in earnest in the 1960s with the introduction of the first color television sets, which initially used europium to produce the color images on the screen.15 Since then,
Carol’s mother, Emilia, dies when Carol is just 8 years old. Young Carol takes the Blessed Virgin Mary as his mother. Carol enters a secret seminary in 1942, and is ordained a priest in 1946. Carol Wojtyla is elected Pope in 1978, and takes the name John Paul II. Pope John Paul II travels to more countries and canonizes more saints than
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of general rough paths. However, in this paper, we will focus on the case where the driving signal is of bounded variation. Following [6] we interpret the whole collection of iterated integrals as a single algebraic object, known as the signature, living in the algebra of formal tensor series. This representation exposes the natural algebraic structure on the signatures of paths induced by the .
