Improving quality of Life with Intestinal Rehabilitation

Intestinal rehabilitation is the process of slowly restoring the intestine’s ability to digest food and absorb nutrients. This is usually done through medicines, Diet and Surgery other than organ (intestine) transplant.

Who should try intestinal rehabilitation?

Intestinal rehabilitation is required if:

• They are on total parenteral nutrition (TPN) because of intestinal failure.
• They were able to stop TPN, but they still have trouble digesting and absorbing nutrients because of intestinal failure.

TPN is a complete form of nutrition given into the blood through a vein (intravenously) by a central line placed in the child’s chest, neck or groin.

A child may be on TPN if they have an intricate digestive condition that does not allow them to get all their nutrition by mouth or feeding tube. This includes children with short bowel syndrome, motility disorders, absorptive disorders or other conditions that can cause intestinal failure.

Some children on TPN get part of their nutrition by mouth or feeding tube; some take TPN only.

Why is intestinal rehabilitation used?

TPN is a lifesaver for patients who cannot absorb enough nutrition through their small intestine. But if TPN is used long-term, it can result in liver failure and life-threatening infections.

Our goals with intestinal rehabilitation are to:

•  End or reduce the need for TPN.
•  Children should start eating by mouth.
•  Prevent the need for intestine transplant if possible.

If intestinal rehabilitation does not work or is not an option for the children, intestine transplant may be the next step.

What does the Intestinal Rehabilitation Program do?

The specialists first look at:

• Children’s intestinal and liver health.
• Whether the children may be able to switch from TPN to eating by mouth or feeding tube. This can depend on factors like why the children have intestinal failure and how much of their intestine remains if part was removed by surgery.
• If we find that the children will benefit from intestinal rehabilitation, the children will take part in an intensive program over several month.

If  we find that the children will benefit from intestinal rehabilitation, the children will take part in an intensive program over several months. The intestinal rehabilitation team will:

• Evaluate the children’s intestinal function in detail.
• Take steps to reduce the risk of central-line infections while the children are on TPN.
• Create an individualized nutrition plan to find the diet that works best for the children body.
• Manage overgrowth of bacteria in the intestines.
• Perform nontransplant surgery, such as intestine lengthening or tapering where needed.
• Teach the children and family about how to care for the central line, how to manage day-to-day nutrition and what to expect.
• Depending on the children needs, the children may stay in the hospital for the first phase of intestinal rehabilitation. This will be followed by regular clinic visits. 

What happens after intestinal rehabilitation?

Once the child is able to eat by mouth and is off TPN, the specialists will keep seeing them in the Intestinal Rehabilitation Clinic for follow-up visits. Our focus at these clinic visits is to monitor the child’s growth; go over nutrition and feeding plans; and watch for anaemia, bacteria growth or other problems that can sometimes happen. On-going care from intestinal rehabilitation experts is important to keeping the children healthy.

Liver diseases in pregnancy

For healthcare providers liver diseases during pregnancy have a challenge. The liver diseases unique to pregnancy include hyperemesis gravidarum(HG), acute fatty liver of pregnancy (AFLP), intrahepatic cholestasis of pregnancy (ICP), and hemolysis and elevated liver enzymes and low platelets (HELLP) syndrome.

The diseases unique to pregnancy, pregnant women are also ingenuous to viral infections such as acute hepatitis A, hepatitis B, hepatitis C, hepatitis E. Out of these four viruses, only hepatitis B and C can lead to chronic disease, and therefore could be pre-existing. Hepatitis A and hepatitis E does not lead to chronic hepatitis. There are safe and effective vaccines against hepatitis A and B only but are not usually administered during pregnancy. Pregnant women have to be aware not to become infected during pregnancy. Both hepatitis A and E are transmitted through contaminated food and water (via the fecal-oral route).

Hyperemesis Gravidarum(HG)

Despite several hypotheses, the pathogenesis of liver disease in HG is not well understood. Over expression of cytokine-producing cells was implicated as a potential cause for pregnancy-related liver diseases such as preeclampsia and HG. Other hypotheses predicted damage to the liver resulting from impaired maternal or fetal mitochondrial fatty acid oxidation, implicating deficiency in long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) as a reason for accumulation of fatty acids in the placenta and eventually causing liver damage. Other report linked fetal deficiency of hepatic carnitine palmitoyltransferase I, the enzyme responsible for transporting long chain fatty acids from the cytoplasm of cells across the outer mitochondrial membrane, to HG.

Patients with HG usually require hospitalization for intravenous fluid replacement, anti-emetics, bowel rest, and possible parenteral nutrition.

Hyperemesis gravidarum is usually a reversible condition with no permanent damage to the liver and almost never fatal.

Intrahepatic Cholestasis of Pregnancy (ICP)

Intrahepatic cholestasis of pregnancy (ICP) is a reversible condition of cholestasis that happens usually in the third trimester. Findings such as pruritus, high serum bile acids levels, and abnormal liver function tests usually resolve after delivery.

Although ICP is a gentle condition for the mother, poor fetal outcomes can occur. In some studies ICP resulted in premature births up to 60%. Other complications such as fetal distress and intrauterine fetal death were reported at 61% and 1.6% respectively.

Recent advances in the pediatric Gastroenterology

Pediatric gastroenterology is described as a sub-specialty of gastroenterology and Pediatrics. It is agitated with treating the gastrointestinal tract, liver and pancreas of children from infancy till age eighteen. The main diseases concerned with it are, persistent vomiting, acute diarrhea, gastritis and problems with the development of the gastric tract.

The treatments by pediatric gastroenterologists are chronic or incurable, and impact not just during the child's initial years but throughout their adult life as well. Management strategies for these conditions need to encompass broad multidisciplinary approaches, with an emphasis upon optimal care in the short-term and enhanced outcomes in the long-term. Whilst providing consistent high-quality, child and family-focused care is important, the introduction of new treatments and the promise of future cure provide on-going challenges. The inflammatory bowel diseases are examples of such conditions.

The inflammatory bowel diseases comprise Crohn disease (CD) and ulcerative colitis (UC), Increasing rates of IBD have been seen in many areas of the world. In recent years it has been increased up to 10-fold in rates of CD and UC. High rates have been seen in individuals migrating from the Indian subcontinent to industrialized countries, such as Canada.

Pathogenesis of coeliac disease, it has become clear that there are a number of potential strategies by which these pathways could be interrupted. One very promising example is the development of vaccine-based treatment currently undergoing clinical trials in several countries. This novel immune-based strategy promises to lead to a new approach to the treatment of coeliac disease. Namely, the introduction of a vaccine will mean that individuals diagnosed with coeliac disease who are then treated with the vaccine, will subsequently be able to tolerate a gluten-containing diet, without need for gluten-free diet. This promise of a cure for coeliac disease could transform the limitations of coeliac disease, and make huge differences in the lives of many children and families. However, this approach is still the “ambulance at the bottom of the cliff.” The development of effective and safe preventative strategies may be even more important and have greater impact. One example of such an approach is the timing of introduction of gluten-containing foods in infancy.

Higher rates of childhood obesity have led to increased rates of non-alcoholic fatty liver disease. These changes have significant implications during childhood and also for future adult years. This condition has become an increasingly common indication for liver transplant, which consequently leads to a further set of long-term health issues.

The development and assessment of new diagnostic tools and markers would ensure optimization of initial assessment and on-going management, Furthermore; other endeavors should focus on advancing our understanding of the pathogenesis of specific conditions, providing impetus to finding cures.

Gastrointestinal physiology and digestive disorders in sleep

Digestive system and sleep is an excellent example of brain-body interaction. New advances in measuring techniques provide an opportunity to evaluate physiology that is dependent upon the sleep/wake state or circadian rhythm and potentially differentiate between normal and pathological conditions.

It has been demonstrated that sleep and circadian factors influence appetite, nutrient absorption, and metabolism. Disruption of sleep and circadian rhythms may increase vulnerability to digestive disorders, including reflux, ulcers, inflammatory bowel issues, irritable bowel disease, and gastrointestinal cancer.

Sleep deprivation and impaired sleep quality have been associated with poor health outcomes. Many patients experience sleep disturbances, which can increase the risk of medical conditions such as hypertension, obesity, stroke, and heart disease as well as increase overall mortality.

Proinflammatory cytokines, such as tumor necrosis factor, interleukin-1, and interleukin-6, have been associated with sleep dysfunction. Alterations in these cytokines have been seen in certain gastrointestinal diseases, such as gastroesophageal reflux disease, inflammatory bowel disease, liver disorders, and colorectal cancer. Sleep disorders have been linked to neurocognitive effects such as slower response time, impaired attention, and increased likelihood of falling asleep at work. Most studies suggest that the daily sleep requirement for adults is 7 to 9 hours per night.

The connection between the brain and the gastrointestinal system is imperative to the regulation of the digestive tract and maintenance of the gut immune system.

The gut-brain axis works through mechanisms that involve immune activation, intestinal permeability, and enteroendocrine signaling. This bidirectional network involves the central nervous system (CNS), autonomic nervous system, and enteric nervous system (ENS). The network incorporates sympathetic and parasympathetic activity, which drive afferent signals through enteric and vagal pathways to the CNS and efferent signals from the CNS to the intestine. There are neural and hormonal influences that allow the brain to modulate the activity of intestinal cells such as interstitial cells of Cajal, enterochromaffin cells, and smooth muscle cells. This dynamic relationship between the brain and the gastrointestinal system involves feedback loops, which also influence the circadian rhythm and sleep regulation pathways. This suggests that there is a relationship between sleep disturbances and physiologic changes of the gastrointestinal tract.

Obesity plays a significant role in multiple gastrointestinal disease processes, such as GERD, hepatic steatosis, and potentially colon cancer. Obesity is a major risk factor for sleep apnea, resulting in poor sleep, which can, in turn, lead to gastrointestinal disease. A strong focus on weight reduction can improve existing symptoms in patients with underlying gastrointestinal conditions. Furthermore, weight reduction can potentially reduce the risk of a patient developing certain disease states.

Pediatric inflammatory bowel disease (IBD): A concern for the Future

The etiology of IBD is unclear. There are several theories but most agree that IBD is multifactorial. It is believed that a complex interaction of environmental, genetic, and immune factors lead to the development of IBD. Approximately 20% of all inflammatory bowel disease (IBD) first presents in childhood or adolescence, and approximately 10% of the estimated children with IBD are under age 17.

As with adults, the clinical presentation of IBD depends on the site and extent of mucosal inflammation. IBD is an important cause of gastrointestinal pathology in children and adolescents. The incidence of pediatric inflammatory bowel disease is increasing; therefore, it is important for the clinician to be aware of the presentation of this disease in the pediatric population.

The detection is cumbersome for the pediatric IBD at presentation due to atypical symptoms or extraintestinal manifestations (e.g., chronic anaemia, short stature, unexplained fever, arthritis, mouth ulcers).Laboratory tests, radiology studies, and endoscopic procedures are helpful in diagnosing IBD and differentiating between Crohn’s disease and ulcerative colitis.

Serologic testing in pediatric patients includes traditional IBD serologic markers such as anti–Saccharomyces cerevisiae antibodies and perinuclear antineutrophil cytoplasmic antibody, as well as newer antimicrobial antibodies, including antibodies to outer membrane.

Once diagnosed, the goal of medical management is to induce remission of disease while minimizing the side effects of the medication. Specific attention needs to be paid to achieving normal growth in this susceptible population. Surgical management is usually indicated for failure of medical management, complication, or malignancy.

In the last coming years more treatment, medicines and drugs option have become available including antibiotics, 5-aminosalicylate, corticosteroids, immunomodulators and biological agents. When anti-tumor necrosis factor (TNF)-α became available to patients with IBD, the risk for surgery is less in comparison to earlier, with the use of anti-TNF-α treatment the risk of surgery has decreased significantly.

It should be appreciated that in children as well as in adults Crohn’s diseases encompasses a varied range of disease phenotypes and severities and therefore optimal patient selection, timing and therapy helps in proper clinical judgment.

Biomarkers for the diagnosis of the gastrointestinal (GI) cancers

Lower GI cancers are among the top three most frequent cancers in the United States and many western countries while upper GI cancers rank as the most prevalent type in many Asian countries, especially in central and eastern Asia. GI cancers are usually diagnosed in more advanced stages and in the absence of effective early diagnostic tools and therapeutic modalities, the survival rates are generally disappointingly low. Then the era of biomarkers came to solve the issue of the GI Cancer diagnosis.

Biomarker refers to a measurable indicator of some biological state or condition. This is also referring to a substance whose detection indicates the existence of a living organism. This is also used to evaluate or to examine normal biological processes, pathogenic processes, or pharmacologic responses to a therapeutic intervention.

Currently, serum biomarkers, which are sufficiently sensitive and specific for early detection and risk classification of gastric cancers. In future Three-dimensional combined biomarkers assay could improve diagnostic accuracy for gastric cancer. For cancer research MicroRNAs (miRNAs) have become the center of focus. However, there have been inconsistencies in the literature regarding the suitability of circulating miRNAs for early detection of gastrointestinal cancers.

Last few years major advances have been made to understand the role of epigenetic alterations in carcinogenesis, particularly for DNA methylation, histone modifications and non-coding RNAs. Aberrant hypermethylation of DNA at CpG islands is a well-established phenomenon that mediates transcriptional silencing of tumor suppressor genes, and it is an early event integral to gastrointestinal cancer development.

As such, detection of aberrant DNA methylation is being developed as biomarkers for prognostic and diagnostic purposes in gastrointestinal cancers. Diverse tissue types are suitable for the analyses of methylated DNA, such as tumor tissues, blood, plasma, and stool, and some of these markers are already utilized in the clinical setting.

Recent advances in the genome-wide epigenomic approaches are enabling the comprehensive mapping of the cancer methylome, thus providing new avenues for mining novel biomarkers for disease prognosis and diagnosis.

The biomarkers in GI cancers are useful not only for screening, diagnosis, and prognosis but also for prediction of the response to mechanism-based interventions, such as chemoprevention. On-going assessment of these diagnostic and predictive factors will probably lead to a change in the current staging of many GI cancers.

Telemedicine and Mobile Health Technology: Effective Management of Digestive Diseases

Telemedicine can be defined as the use of telecommunication and information technology to provide health care from an extent. It has been used to overcome distance barriers and to improve access to medical services that would often not be consistently available in distant rural communities. It has been used to save lives in critical and emergency situations.

Telemedicine is use to effectively manage disease activity, help monitor symptoms, improve compliance to the treatment protocol, increase patient satisfaction, and enhance the patient-to-provider communication.

EBSCO, PubMed, and Web of Science databases are used in Medical Subject Headings and other keywords to identify studies that utilized telemedicine in patients with digestive disease. 

Distance management intervention is defined as any remote management method in which there is a patient self-management component whereby the patient interacts remotely via a self-guided management program, electronic interface, or self-directs open access to clinic follow up.

Now a day’s inflammatory bowel disease (IBD) is biggest issue of the treatment as it is a group of chronic intestinal diseases that adversely affects quality of life and societal interaction and functioning. They are associated with significant morbidity and mortality, so telemedicine has helped in a great way.

Clinicians have focused on techniques to improve the out-patient management of IBD patients. Strategies to improve patient education alone increase IBD-related knowledge, but do not consistently improve clinical outcomes or decrease health care resource use. Focusing on improving self-management behaviour, however, may be effective. A previous systematic review on patient education and self-management reported that self-management strategies demonstrated improved outcomes of symptoms, psychological well-being, and health-care resource use.

Distance management of gastrointestinal diseases can be an important part of the management of patients, but may require tailoring of these approaches to select patient populations. A combined web-based and patient directed open access clinic distance management program, whereby patients interact with an electronic web-based management program and are able to initiate self-treatment strategies and self-referral to clinic assessments, may be a solution.

Telemedicine and mobile health technology may be effective in managing disease activity and improving quality of life in digestive diseases. Future studies should explore both gastrointestinal and gastroesophageal diseases using these types of interventions.