Refeeding syndrome in Southeastern Taiwan:Our experience with 11 cases

AIM:To present our experience with refeeding syndrome in southeastern Taiwan.METHODS:We conducted a retrospective study during a 2-year period at the Mackay Memorial Hospital,Taitung Branch.We enrolled patients with very little or no nutrition intake for more than 10 d,a high risk group of refeeding syndrome,including those suffering from alcohol abuse,cancerous cachexia,chronic malnutrition,and prolonged starvation.RESULTS:A total of 11 patients(7 males,4 females)with nasogastric feeding were included as having refeeding syndrome.Most of them had the symptoms of diarrhea,lethargy,and leg edema.The initial nutritional supplement was found to be relatively high in calories(1355.1±296.2 kcal/d),high in protein(47.3±10.4 gm/d),low in vitamin B1(2.0±0.5 mg/d),low in potassium(1260.4±297.7 mg/d),and low in phosphorus(660.1±151.8 mg/d).Furthermore,hypophosphatemia(2.4±0.9 mg/dL)was noted during follow-up.Based on the suggestions of a dietician and a gastroenterologist,the clinical disorders of diarrhea,malaise and leg edema were significantly improved.The level of phosphate was also increased(3.3±0.6mg/dL).CONCLUSION:Refeeding syndrome is an overlooked and risky disorder that has some potentially fatal complications.Nasogastric feeding in nursing homes is an important risk factor for patients and deserves greater attention based on the initial results of this study.

Imaging changes of the pancreas and the occasion of refeeding in patients with acute pancreatitis

Objective: To explore the objective basis of the time and characterstics of refeeding of patients with acute pancreatitis (AP). Methods: AP patients were randomly divided into routine group (n=105) and special group (n=99). The refeeding time and characteristics of the routine group were based on their levels of blood and urine amylase, function of the gastrointestinal tract, and symptoms and signs, and those of the special group on their imaging changes of ultrasonography and CT of the pancreas. Clinical data from the groups were analyzed prospectively and statistically. Results: At the beginning of refeeding, patients of the two groups showed a high recurrence rate of ab- dominal pain (routine group, 9.1%; special group, 10.5%), but no AP relapse. Three days to 2 weeks after refeeding, the patients of the routine group had a higher recurrence rate of abdominal pain (11.1%) and a relapse rate of AP (14.1%) as compared with those of the special group (P<0. 05). Two weeks later, both rates decreased apparently. However, 3 days to 4 weeks after refeeding, the patients of the special group had no recurrence of abdominal pain and relapse of AP. Imaging changes of the pancreas and peripancreatic tissue were not consistent with the symptoms and signs of AP patients. The higher the Balthazar CT grading and APACHE-Ⅱ score, the higher the recurrence rate of abdominal pain and the relapse rate of AP after refeeding (P<0. 05). Conclusions: Symptoms and signs were usually dis- cordant to the imaging changes of the pancreas in AP patients. Imaging changes of the pancreas might serve as a basis for the best occasion of refeeding light semi-fluid or light food in AP patients.

Oral refeeding in mild acute pancreatitis:An old challenge

Although the idea that pancreas rest has long been considered as a very relevant topic in acute pancreatitis (AP)therapy,the right time and type of diet to be offered to patients recovering from an acute attack are a great challenge to clinicians who treat this condition.Fortunately,the last decade was noted for several trials looking for the best answer to the question:"when and how to start oral refeeding in AP?"It is well known that 80%of patients present with mild disease characterized by usually uncomplicated clinical course are managed with pancreatic rest through nil per oral;while the use of specific nutritional intervention is an exception.Therefore,mild AP has been the most investigated form of AP and researchers have tried different kind of meals to offer calories and reduce costs by shortening hospitalization time.Usually in mild AP,the oral refeeding is introduced between the first 3 d and 7 d after hospitalization but,the type of diet and patients’tolerance have been scrutinized in detail with mixed results.Although 20%to 25%have pain recurrence requiring nutritional support and greater time of hospitalization,most patients seem to tolerate oral refeeding well.We propose analyzing the most recent investigations of this matter and their conclusions to develop a better understanding of the management of AP.

Reverse or inverted apical ballooning in a case of refeeding syndrome

Takotsubo cardiomyopathy is characterized by the development of transient left ventricular regional wall motion abnormalities,in the absence of significant coronary artery obstruction. This syndrome usually occurs in women and is frequently associated with an intense emotional or physical stress. It usually involves apical segments,but in the recent years atypical forms have been described. Inverted or reverse Takotsubo is a variant in which the basal and midventricular segments are hypokinetic,sparing contractile function of the apex. In this report we describe the case of a 54-year-old woman,with chronic malnutrition,initially admitted because of hypoglycemia and severe electrolyte disturbance due to a refeeding syndrome. Within the next hours she experienced acute cardiac symptoms and developed heart failure with low cardiac output. Electrocardiogram(ECG),elevation of troponin and echocardiographic findings were consistent with inverted Takotsubo cardiomyopathy. To the best of our knowledge,this is the first incidence reported of inverted Takotsubo triggered by refeeding syndrome.

YAP regulates the liver size during the fasting-refeeding transition in mice

Liver is the central hub regulating energy metabolism during feeding-fasting transition.Evidence suggests that fasting and refeeding induce dynamic changes in liver size,but the underlying mechanisms remain unclear.Yes-associated protein(YAP)is a key regulator of organ size.This study aims to explore the role of YAP in fasting-and refeeding-induced changes in liver size.Here,fasting significantly reduced liver size,which was recovered to the normal level after refeeding.Moreover,hepatocyte size was decreased and hepatocyte proliferation was inhibited after fasting.Conversely,refeeding promoted hepatocyte enlargement and proliferation compared to fasted state.Mechanistically,fasting or refeeding regulated the expression of YAP and its downstream targets,as well as the proliferation-related protein cyclin D1(CCND1).Furthermore,fasting significantly reduced the liver size in AAV-control mice,which was mitigated in AAV Yap(5SA)mice.Yap overexpression also prevented the effect of fasting on hepatocyte size and proliferation.Besides,the recovery of liver size after refeeding was delayed in AAV Yap shRNA mice.Yap knockdown attenuated refeeding-induced hepatocyte enlargement and proliferation.In summary,this study demonstrated that YAP plays an important role in dynamic changes of liver size during fasting-refeeding transition,which provides new evidence for YAP in regulating liver size under energy stress.

Enteral refeeding syndrome after long-term total parenteral nutrition

Background Early enteral feeding （EF） may result in fever, elevated white blood cell count, increased serum levels of liver enzymes, and diarrhea. We name the complications ＂enteral refeeding syndrome＂, as a subtype of refeeding syndrome, because they are likely to result from long-term lack of lumen nutrition. The aim of this study was to investigate the characteristics of enteral refeeding syndrome after long-term total parenteral nutrition （TPN）, and the solution for the disease. Methods We collected the clinical data of 100 patients with gastrointestinal fistula, who were cured from Apirl 2001 to July 2002. Their fasting time, daily stool frequency, body temperature, heart rate, respiratory rate, levels of transaminases, alkaline phosphatase （AKP）, and γ-glutamylcyclotransferase （γ-GT）, white blood cell count, and systemic inflammatory reaction syndrome （SIRS） score were recorded before and 1, 3, 5, 10, and 15 days after EF. Student＇s t test and analysis of variance were used to analyze the data. Results Of the 100 patients, 56 were cured after selective resection of intestinal fistula, 15 were cured by emergency operation, and 29 recovered spontaneously. The levels of AKP and y-GT increased significantly on the 3rd day after EF [On the 3rd day after EF, （243.0±121.6） U/L and （177.2±109.9） U/L vs. before EF （181.5±127.5） U/L and （118.4±94.2） U/L, P〈0.05], and decreased gradually afterwards. The SIRS scores on the 1st day （1.05±1.08） and 3rd day （0.96±1.11） after EF were significantly higher than that before EF （0.72＋0.84）, then decreased to 0.83±0.91, 0.49±0.73 and 0.32±0.60 on the 5th, 10th and 15th days after EE The number of patients with diarrhea at 1, 3, 5, 10 and 15 days post-EF were 31, 26, 12, 13, and 7, respectively. Conclusions The longer the TPN lasts, the more severe the enteral refeeding syndrome becomes. Continuous EF is effective for the syndrome. Early enteral nutrition is useful in preventing it.

Gluconeogenesis during starvation and refeeding phase is affected by previous dietary carbohydrates levels and a glucose stimuli during early life in Siberian sturgeon(Acipenser baerii)

Gluconeogenesis responses was assessed during a short starvation period and subsequent refeeding in Siberian sturgeon(Acipenser baerii) previously fed different dietary carbohydrates levels and experienced to a glucose stimuli during early life. The sturgeon larvae were previously fed either a high glucose diet(G) or a low glucose diet(F) from the first feeding to yolk absorption(8 to 12 d post-hatching [dph]). Each group of fish was sub-divided into 2 treatments at 13 dph and was fed either a high-carbohydrate diet(H) or a low carbohydrate diet(L) until 20 wk. In the current study, the fish in 4 groups(GL, FL, GH and FH) were experienced to starvation for 21 d following by re-feeding of their corresponding diets for 21 d.Fish were sampled at postprandial 6 and 24 h before starvation(P6 h and P24 h), starvation 7,14 and 21 d(S7, S14 and S21) and 1, 7,14 and 21 d during refeeding(R1, R7, R14 and R21). Plasma samples during refeeding were taken at P6 h at each time point. Glycaemia levels, liver and muscle glycogen contents,activities and mRNA levels of hepatic gluconeogenic enzymes were examined. We found that both dietary carbohydrate levels and early glucose stimuli significantly affected the metabolic responses to starvation and refeeding in Siberian sturgeon(P < 0.05). During prolonged starvation, Siberian sturgeon firstly mobilized the liver glycogen and then improved gluconeogenesis when the dietary carbohydrates were abundant, whereas preserved the liver glycogen stores at a stable level and more effectively promoted gluconeogenesis when the dietary carbohydrates are absent to maintain glucose homoeostasis.During refeeding, as most teleostean, Siberian sturgeon failed controlling the activities and mRNA levels of phosphoenolpyruvate carboxykinase cytosolic forms(PEPCK-C), fructose-1,6-bisphosphatase(FBPase),but particularly controlled phosphoenolpyruvate carboxykinase mitochondrial forms(PEPCK-M) activities and mRNA expression of glucose-6-phosphatase(G6 Pase, except in GL group). Siberian sturgeon has a full compensatory ability on growth, but this ability would be obstructed by early glucose stimuli when refeeding the low carbohydrate diet after S21.

A Calcified Artery of Drummond, Could It Be a Sentinel Sign of Further Complications?

Objective: To understand the role of the artery of Drummond in the elderly population. The artery plays a crucial role in the anastamosis between the inferior mesenteric artery and superior mesenteric artery. Its maintenance is particularly important for the survivability of the bowel in events of stenosis of either one of the native arteries;SMA or IMA. Method: A 94 year old lady presents with post-prandial abdominal pain and significant emaciation. The patient undergoes clinical and radiological investigations to find out the cause of her ailments. Results: Abdominal X-ray revealed a serpentine structure that was later defined as the artery of Drummond, CT scan revealed a calcified and enlarged artery of Drummond in addition to an occluded origin of SMA and celiac artery as well as a severe stenosis origin of IMA. Conclusion: The artery of Drummond was immensely hypertrophied and was supplying the entire bowel through the native IMA;subsequent occlusion of the IMA was the main cause that caused the demise of the patient.