Joseph
M
experience Miller,
2MD.
and
An
elemental
tested
gastrointestinal
in
tract
undergoing
The
patients
Minimal
variations
as it was
used
in the
patients
the well
TheAmerican
Journal
composition patients.
residue diet clinically,
chemistry
Am.
J. Clin.
of Clinical
Nutrition
some indicated
Nutr.
chemical
absorption
form in
advantageous
usefulness
although
and
simple
especially
showed
studied.
and Complete
proved
also
coagulation
Synthetically formulated, chemically defined diets made from simple carbohydrates, amino acids, small amounts of an essential fat, minerals, and vitamins produce a minimal quantity of fecal residue and are finding increasing favor as aids in the management of certain medical problems. Difficulties encountered in manufacturing amino acids have largely been overcome, making possible the formulation of palatable liquid or pudding forms of elemental diets that supply all essential nutrients. The osmolality of these diets can be controlled by varying the amount of additional water ingested. The extremely low fecal residue of an elemental liquid diet is especially valuable to the surgeon, since low residue is a major advantage in the treatment of some intestinal conditions. On the whole, an elemental diet differs considerably from standard liquid diets and tube-feeding mixtures commonly used in hospital practice, mainly by meeting all nutritional needs with minimal demand on the patient’s digestive system. Presently available elemental diets have stemmed in large measure from the work of Rose (1), who reported on the effects of feeding amino acids to volunteers in 1949. His investigations were conducted with the intention of developing a means of administering amino acids intravenously. Another early investigator, Schultz (2), observed no abnormalities in reproduction or lactation when he fed rats protein-free rations containing amino acids. Studies by a group of investigators at the National Institutes of Health (NIH) more intensely investigated the formulation of ele46
defined surgical
fecal and
responded
in blood
of of
minimal
surgery,
diet1
3MD.
diet
a variety
and
abdominal
an elemental
C Taboada,
Juanito
ABSTRACT nutritionally
problems.
with
in
that
28: 46-50,
in
patients
of them
showed
the
diet
the
was upper
patients
with
feeding
taste
fatigue.
was safe,
at least
1975.
mental diets and later supplied the framework for human therapy (3,4). Extension of the work of the NIH group by Winitz and some of his colleagues (5) showed that human volunteers could be maintained in good health on an elemental diet for a period of 22 weeks, no significant changes in weight, blood chemistry, and urine being encountered. A similar study (6) showed that although diet and environment did alter the fecal bacterial content, the changes were within normal limits. Studies of intestinal absorption support the claim that elemental diets are absorbed in the upper reaches of the small intestine. Borgstr#{246}m and his associates (7) clearly demonstrated that absorption of fat, carbohydrate, and protein in man begins in the duodenum and is completed within the first 100 cm of the jejunum. Fats are absorbed nearer the begininning of the jejunum than carbohydrates, and carbohydrates are absorbed before protein. Little glucose is absorbed in the stomach and colon (8). Significant amounts of amino acids are absorbed within 15 mm after ingestion and maximal concentration of the amino acids in the bloodstream occurs between 15 and 50 mm after eating (9). Absorption is facilitated by an iso-osmolar environment. Normal plasma is 280 ± 10
milliosmolar mosmols/liter.
tension of A proper
‘JEJUNAL Brand Special Dietary Food, Johnson & Johnson, New Brunswick, New Jersey 08903, U.S.A. 2 Correspondence should be addressed to this author at 1915 Knollton Road, Timonium, Maryland 21093, U.S.A. Surgical Service, Provident Hospital, Incorporated, Baltimore, Maryland, USA.
28:
JANUARY
1975,
pp. 46-50. Printed
in
U.S.A.
Downloaded from https://academic.oup.com/ajcn/article-abstract/28/1/46/4716334 by East Carolina University Health Sciences Library user on 11 January 2019
Clinical
CLINICAL
EXPERIENCE
AN
ELEMENTAL
DIET
47
Methods The
dietary
recommended
TABLE 1 Composition dietary food
composition daily
is shown
intake
1. The
in Table
comprises
379
g
of JEJUNAL brand special fed to hospitalized patients Gram 3.69 4.79 4.56 2.69 2.36 2.73 0.64 3.46
L-Isoleucine L-Leucine L-Lysine HCI L-Phenylalanine L-Threonine DL-Methionine L-Tryptophan L-Valine L-Tyrosine ethyl ester HC1 L-Arginine HO L-Histidine HOH20 L-Alanine L-Aspartic acid L-Glutamine L-Proline S-Serine Safflower oil Sorbic acid Sodium phosphate (monobasic) Potassium chloride, anhydrous Calcium acetate H2O Calcium gluconate Magnesium gluconate Manganese gluconate 3H20 Cupric gluconate Zinc sulfate - H2O Potassium iodide Ferrous ammonium sulfate - 6H2 0 Vitamin A palmitate#{176} Vitamin D2#{176} Vitamin B, 2 Ascorbic acid Thiamin mononitrate Riboflavin Pyridoxine HCI DL-Alpha tocopherol acetate Para-amino benzoic acid, K-salt D-Biotin Folic acid Inositol Niacinamide D-Calcium pantothenate Menadionc sodium bisulfite (Vit. K3) Choline bitartrate Dextrose and malto dextrin Flavoring ingredients Total: a
Vitamin
AID2
IU. C624 IU. dTo ml tap water to obtain liquid diet.
mixture
2.55 4-43 1.13 0.58 1.96
5.03 0.99 1.24 1.60 0.27
5.45 3.12 0.02 13.30
3.24 0.026 0.014 0.00097 0.00018 0.068 O.025’ -
_C
0.00055 0.14 0.00 14 0.0018 0.0026 0.11 0.39 0.00021 0.00011 0.13 0.019 0.012 0.0044 0.4468 379.00 29.7769
used.
480.0 g dry powder 25% total solids (w/v)
b6,250
add 1,680 to obtain
of
Downloaded from https://academic.oup.com/ajcn/article-abstract/28/1/46/4716334 by East Carolina University Health Sciences Library user on 11 January 2019
dilution of an elemental chemical diet places its osmolality in the upper range of foodstuffs normally consumed. The elemental diet that was the subject of our study, for example, creates a tension of 1,170 mosmols/liter when given as a beverage. In normal digestion, the daily volume of intestinal secretion falls between 8,000 and 10,000 ml (10). Only bile and pancreatic juice approach isotonicity; the remainder of the secretions are hypoosmolar to varying degrees. Thus about 75% of the fluid input in the upper intestinal tract is hypotonic and serves to dilute the hyperosmolar diet. Interestingly enough, in the Borgstrom study a threeto fivefold dilution of the test meal occurred in the duodenum (7). An elemental diet modified to eliminate its fat content could be given parenterally, but physicians agree that the best route for satisfying nutritional requirements is the gastrointestinal tract. Geyer (11) has demonstrated that from the standpoint of cellular nutrition there is no difference between enteral and parenteral supply routes, but there are three advantages in supplying nutriment through the gastrointestinal tract: 1) the risk of sepis is greatly reduced because there is no need for long-term insertion of an intravenous catheter; 2) toxicity associated with intravenous administration of certain minerals is avoided; and 3) since enteral nutrients need not be sterilized, there are fewer problems in handling and storage. Advantages of an elemental diet in patient care have been described by Thompson and his associates (12), who used one to feed a patient who had only 4 cm of jejunum remaining between the duodenum and the transverse colon. As preparation for study in surgical patients, the elemental diet was studied in rats and healthy human volunteers and it was concluded that a general state of good health could be maintained with the formulation as the sole source of nutrition (13-15). It was observed that the blood urea nitrogen (BUN) was depressed. Hematocrit and hemoglobin showed a “trend toward depression” even though they remained within normal range. Therefore it was recommended that these modalities be monitored closely during the initial phases of clinical study.
WITH
MILLER
48 and dextrose nitrogen from
oligosaccharides, amino acids,
and
5.88 1.6
g g
of of
safflower oil. Electrolytes supplied included 64.8 mEq of sodium, 40.13 mEq of potassium, 60.0 mEq of calcium, and 109 mEq of chloride. Enough vitamins and accessory food nutrients were provided to meet body requirements. As given during the study, each patient was supplied with 1,750 kcal in 1,920 ml of diet (25% total solids w/v) during a 24-hour period. Additional water consumption was encouraged to depress osmolality during the initial feeding regimen for osmotic sensitive patients. It was deemed necessary to institute such a precaution in order to prevent diarrhea. The elemental diet was supplied to the patient in eight flavored servings, including five beverages, two hot broths, and one pudding. The feedings were provided every 2 hours from 8:00 AM to 10:00 PM. When the diet was intubated through a nasogastric tube, a beverage was substituted for the pudding. This was considered an optimal schedule, though there could be an advantage to intubating an elemental diet over 24 hours in certain patients. The beverage was made by mixing the diet with cold tap water and the broth and pudding were mixed with hot tap water according to the schedule shown in Table 2. All three diet forms dissolved readily. The elemental diet tested could be expected to more than meet the nutritional needs of most nonambulatory patients. Simple carbohydrates, amino acids, fat (safflower oil) containing linoleic acid, minerals, vitamins, and accessory food nutrients are supplied in measured amounts in each packet of diet. Each packet of the elemental diet (60 g) was added to 210 ml of water and mixed vigorously in a blender. It is easy, therefore, for the physician to determine the exact amount and nature of the nutrients his patient is ingesting. TABLE 2 Preparation for JEJUNAL Serving I 2 3 4 5 6 7 8
and
feeding brand Flavor
Orange Beef Cherry Banana Grapefruit Beef Orange Pineapple Fruit Punch
schedule
Form
Time
Beverage Broth Beverage Pudding Beverage Broth Beverage
8:00 AM 10:00AM 12:00 AM 2:00PM 4:00PM 6:00PM 8:00 PM
Beverage
10:00
PM
Beverage preparation -empty contents of package into container, add 210 ml of cold water (7 ounces), and mix vigorously until powder dissolves. A blender may be used if available. Broth preparation-empty contents of package into container, add 210 ml of hot water (7 ounces), and mix vigorously until powder dissolves. A blender may be used if available. Pudding preparation-empty contents of package into container, add 60 ml (2 ounces) of hot water, and mix vigorously. Do not boil.
TABOADA
Results All patients tolerated the diet well except one who was dropped from the study on the second day because of nausea, vomiting, and increased frequency of bowel movements. Some of the patients showed taste fatigue, but did consume the diet. Neither electrolytes and enzymes nor prothrombin and partial thromboplastin time were affected to a degree that was considered significant. The patients apparently consumed enough of the diet to keep themselves in reasonable electrolyte balance. Some slight variations in body weight were seen in patients who could be weighed. Most patients experienced either a marked decrease or a complete cessation of stool passage. In a patient with a decompressive cecostomy, the amount of fluid passing through the opening was greatly reduced. The following case reports are representative of results obtamed and serve as examples of how the elemental diet can be useful: Case no. 1: A 39-year-old Negro man was placed on the diet for 2 days to prepare him for closure of his sigmoid colostomy. On the final day of the diet, the day before surgery, the proximal and distal loops of the intestine were irrigated. After this preparation, the colostomy was closed without fecal soiling and normal wound healing followed. Conventional measures require 48 to 72 hours in the hospital to prepare the bowel, whereas with the elemental diet the lack of residue permits the patient to remain at home during more of the preoperative period, with consequent saving of time and money. Case no. 2: It was necessary to empty the intestinal tract of a 59-year-old Caucasian woman who was scheduled for surgery. This was accomplished by maintaining her for 3 days on the elemental diet, during which time she also was given enemas. After this preparation she underwent a panhysterectomy, a resection of the sigmoid colon, and excision of the terminal ileum to remove a metastasized carcinoma of the left ovary. Case no. 3: When a 28-year-old Negro man with a splenic flexure fecal fistula was placed on the diet, his fistula stopped draining and he had only one rectal bowel movement in 5 days. The fistula shrank during the 5 days the patient took the diet, but because it “tasted like
Downloaded from https://academic.oup.com/ajcn/article-abstract/28/1/46/4716334 by East Carolina University Health Sciences Library user on 11 January 2019
dextrose dietary
AND
CLINICAL
EXPERIENCE
WITH
Discussion Variations in serum electrolytes and enzymes were not considered significant, but it is noteworthy that 6 of the 30 patients studied developed hyperchloremia associated with low carbon dioxide levels. For example, a patient with prediet chloride readings of 95 and 97 mEq/liter had a rise to readings of 112 and 108 mEq/liter associated with a CO2 level of 23 mm mEq/liter. Another patient had chloride readings of 123, 115, Il l,and 113 mEq/liter while on the diet and these readings were associated with a CO2 level of 20 mm mEq/liter. The clinical significance of these findings is not clear, but elevated chloride levels associated
ELEMENTAL
DIET
49
with relatively low carbon dioxide does suggest the need for biochemical monitoring of patients on elemental diets. The elemental diet was found to be safe in our applications, none of which involved long-term use, and it shows promise in a number of indications. Its usefulness is obvious as a means of preparing the patient for operations on the small intestine, colon, and anus, and the formation of an ileal conduit for urinary bladder replacement. Patients requiring extensive hemorrhoidectomy, excision of pilonidal cyst, and closure of decubitus ulcers over the sacrum, gluteal tuberosity, and femoral trochanters are subjects for elemental diet therapy. Other candidates are patients with fistulas originating in the small intestine, colon, biliary tract, and pancreas, and patients with active enteritis and various types of colitis. Elemental diet feeding should also be helpful in patients who will not eat, particularly the elderly, and must be fed by nasogastric tube. Patients receiving abdominal irradiation or 5-fluorouracil treatment, and patients with head and neck malignancies in various stages of treatment are also subjects for elemental diet feeding. Experience suggests that certain patients, such as the one described in case history no. 6, might benefit more from elemental diet by intubation over 24 hours instead of a series of intragastric injections over more limited time spans (eight times in 14 hours in case no. 6). The liquid form of the elemental diet is easily intubated by an adjustable gravity feed or by a small pump attached to the delivery system. Periods of hyperglycemia might be made less intense or even prevented in diabetic patients by 24-hour administration, which would minimize loss of kilogram-calories and fluid from excretion by the kidneys. The liver, where the processes of deamination and glyconeogenesis take place, controls the utilization of amino acids. If sufficient glucose is available for kilogram-caloric needs, the amino acids are saved from catabolism and can contribute to protein manufacture. Insulin, in addition to its role in glucose metabolism, is also necessary for entry of amino acids into the cells and for their incorporation into ribosomal protein. Loss of glucose via the urine leads to impaired use of the amino acids. Spreading the diet over a period of 24 hours should result in more
Downloaded from https://academic.oup.com/ajcn/article-abstract/28/1/46/4716334 by East Carolina University Health Sciences Library user on 11 January 2019
medicine” he refused to continue any longer. He was discharged from the hospital and follow-up after 2 months revealed that the fistula had closed spontaneously. The patient might have recovered more quickly if he had remained on the diet for a longer period of time. Case no. 4: A 44-year-old Negro man was admitted to the hospital for treatment of a sacral decubitus ulcer. After 9 days of therapy with the elemental diet (during which the patient had only one bowel movement that included 5 ml of mucus) the ulcer had practically disappeared. Case no. 5: The stress of a hysterectomy exacerbated a chronic ulcerative colitis in a 65-year-old Negro woman. Her stools, 24 a day, contained blood and pus with the feces. She responded remarkably well to a 7-day program of treatment with the elemental diet and steroid enemas. The number of evacuations was reduced to 4 a day and consisted of mucus without fecal material and blood. Proctoscopy revealed improvement in the rectal and colonic mucosa. Case no. 6: A 50-year-old Negro woman with hypertension and diabetes mellitus had a severe neurologic deficit resulting from a cerebrovascular accident. Eating was a problem for her. The problem was solved by insertion of a nasogastric tube and administration of the diet through the tube for 17 days. Fecal soiling of the buttocks was stopped, since she had but one soft stool during this period. A sacral decubitus ulcer was noted during the early treatment period, but it healed before the 17-day treatment was completed.
AN
50
MILLER
efficient
use of glucose and use of amino acids.
thus
in
more
U
References 1. ROSE,
W. C. Amino acid requirements of man. Federation Proc. 8: 546, 1949. 2. SCHULTZE, M. 0. Reproduction of rats fed protein-free diets. J. Nutr. 60: 35, 1956. 3. GREENSTEIN, J. P., AND M. WINITZ. Chemistry of the amino acids. New York: Wiley, 1961. 4. WINITZ, M., J. GRAFF, N. GALLAGHER, A. NARKIN AND D. A. SEEDMAN. Evaluation of chemical diets as nutrition for man-in-space. Nature 205: 741, 1965. 5. WINITZ, M., D. A. SEEDMAN AND J. GRAFF. Studies in metabolic nutrition employing chemically defined diets. I. Extended feeding of normal human adult males. Am. J. Clin. Nutr. 23: 525, 1970. 6. WINITZ, M., R. F. ADAMS, D. A. SEEDMAN, P. N. DAVIS,
L. G. JAYKO
AND
J. A. HAMILTON.
Studies in metabolic nutrition employing chemically defined diets. II. Effects on gut microflora populations. Am. J. Clin. Nutr. 23: 546, 1970. 7. BORGSTROM, B., A. DAHLQVIST, G. LUNDH AND J. SJOVALL. Studies of intestinal digestion and absorption in the human. J. Clin. Invest. 36: 1521, 1957.
TABOADA 8.
WILSON, T. H. Intestinal Absorption. Philadelphia: Saunders, 1962, p. 263. 9. WHITE, A., P. HANDLER AND E. L. SMITH Principles of Biochemistry (4th ed.). New York: Blakiston Division, McGraw-Hill, 1969, p. 1187. 10. RANDALL, H. T. Fluid and electrolyte therapy in surgery. In: Principles of Surgery, edited by S. I. Schwartz. New York: Blakiston Division, McGraw-Hill, 1969, p. 46. 11. GEYER, R. P. Parenteral nutrition. Physiol. Rev. 40: 150, 1960. 12. THOMPSON, W. R., R. V. STEPHENS, H. T. RANDALL AND J. R. BOWEN. Use of the “Space Diet” in the management of a patient with extreme short bowel syndrome. Am. J. Surg. 117:
449, 1969. 13. MOHAMMED,
K., A. H. CAMPBELL,
J. WILL-
SON AND G. H. LORD. The effect of feeding an elemental chemical diet on mature rats (nutrition). Nutr. Rept. Intern. 6: 281, 1972. 14. CAMPBELL, A. H., W. R. SEWELL, M. CHUD-
KOWSKI, J. E. WILLSON, G. H. LORD MOHAMMED. The effects of feeding
AND
K.
and eleToxicologic Pharmacol.
mental chemical diets to mature rats: and Pathologic Studies. Toxicol. AppI. 26: 63, 1973. 15. GOPELAN, H., P. LACHANCE AND K. MOHAMMED. Short-term effects of feeding an elemental diet in healthy men. Nutr. Rept. Intern. 8: 49, 1973.
Downloaded from https://academic.oup.com/ajcn/article-abstract/28/1/46/4716334 by East Carolina University Health Sciences Library user on 11 January 2019
efficient
AND
M
experience Miller,
2MD.
and
An
elemental
tested
gastrointestinal
in
tract
undergoing
The
patients
Minimal
variations
as it was
used
in the
patients
the well
TheAmerican
Journal
composition patients.
residue diet clinically,
chemistry
Am.
J. Clin.
of Clinical
Nutrition
some indicated
Nutr.
chemical
absorption
form in
advantageous
usefulness
although
and
simple
especially
showed
studied.
and Complete
proved
also
coagulation
Synthetically formulated, chemically defined diets made from simple carbohydrates, amino acids, small amounts of an essential fat, minerals, and vitamins produce a minimal quantity of fecal residue and are finding increasing favor as aids in the management of certain medical problems. Difficulties encountered in manufacturing amino acids have largely been overcome, making possible the formulation of palatable liquid or pudding forms of elemental diets that supply all essential nutrients. The osmolality of these diets can be controlled by varying the amount of additional water ingested. The extremely low fecal residue of an elemental liquid diet is especially valuable to the surgeon, since low residue is a major advantage in the treatment of some intestinal conditions. On the whole, an elemental diet differs considerably from standard liquid diets and tube-feeding mixtures commonly used in hospital practice, mainly by meeting all nutritional needs with minimal demand on the patient’s digestive system. Presently available elemental diets have stemmed in large measure from the work of Rose (1), who reported on the effects of feeding amino acids to volunteers in 1949. His investigations were conducted with the intention of developing a means of administering amino acids intravenously. Another early investigator, Schultz (2), observed no abnormalities in reproduction or lactation when he fed rats protein-free rations containing amino acids. Studies by a group of investigators at the National Institutes of Health (NIH) more intensely investigated the formulation of ele46
defined surgical
fecal and
responded
in blood
of of
minimal
surgery,
diet1
3MD.
diet
a variety
and
abdominal
an elemental
C Taboada,
Juanito
ABSTRACT nutritionally
problems.
with
in
that
28: 46-50,
in
patients
of them
showed
the
diet
the
was upper
patients
with
feeding
taste
fatigue.
was safe,
at least
1975.
mental diets and later supplied the framework for human therapy (3,4). Extension of the work of the NIH group by Winitz and some of his colleagues (5) showed that human volunteers could be maintained in good health on an elemental diet for a period of 22 weeks, no significant changes in weight, blood chemistry, and urine being encountered. A similar study (6) showed that although diet and environment did alter the fecal bacterial content, the changes were within normal limits. Studies of intestinal absorption support the claim that elemental diets are absorbed in the upper reaches of the small intestine. Borgstr#{246}m and his associates (7) clearly demonstrated that absorption of fat, carbohydrate, and protein in man begins in the duodenum and is completed within the first 100 cm of the jejunum. Fats are absorbed nearer the begininning of the jejunum than carbohydrates, and carbohydrates are absorbed before protein. Little glucose is absorbed in the stomach and colon (8). Significant amounts of amino acids are absorbed within 15 mm after ingestion and maximal concentration of the amino acids in the bloodstream occurs between 15 and 50 mm after eating (9). Absorption is facilitated by an iso-osmolar environment. Normal plasma is 280 ± 10
milliosmolar mosmols/liter.
tension of A proper
‘JEJUNAL Brand Special Dietary Food, Johnson & Johnson, New Brunswick, New Jersey 08903, U.S.A. 2 Correspondence should be addressed to this author at 1915 Knollton Road, Timonium, Maryland 21093, U.S.A. Surgical Service, Provident Hospital, Incorporated, Baltimore, Maryland, USA.
28:
JANUARY
1975,
pp. 46-50. Printed
in
U.S.A.
Downloaded from https://academic.oup.com/ajcn/article-abstract/28/1/46/4716334 by East Carolina University Health Sciences Library user on 11 January 2019
Clinical
CLINICAL
EXPERIENCE
AN
ELEMENTAL
DIET
47
Methods The
dietary
recommended
TABLE 1 Composition dietary food
composition daily
is shown
intake
1. The
in Table
comprises
379
g
of JEJUNAL brand special fed to hospitalized patients Gram 3.69 4.79 4.56 2.69 2.36 2.73 0.64 3.46
L-Isoleucine L-Leucine L-Lysine HCI L-Phenylalanine L-Threonine DL-Methionine L-Tryptophan L-Valine L-Tyrosine ethyl ester HC1 L-Arginine HO L-Histidine HOH20 L-Alanine L-Aspartic acid L-Glutamine L-Proline S-Serine Safflower oil Sorbic acid Sodium phosphate (monobasic) Potassium chloride, anhydrous Calcium acetate H2O Calcium gluconate Magnesium gluconate Manganese gluconate 3H20 Cupric gluconate Zinc sulfate - H2O Potassium iodide Ferrous ammonium sulfate - 6H2 0 Vitamin A palmitate#{176} Vitamin D2#{176} Vitamin B, 2 Ascorbic acid Thiamin mononitrate Riboflavin Pyridoxine HCI DL-Alpha tocopherol acetate Para-amino benzoic acid, K-salt D-Biotin Folic acid Inositol Niacinamide D-Calcium pantothenate Menadionc sodium bisulfite (Vit. K3) Choline bitartrate Dextrose and malto dextrin Flavoring ingredients Total: a
Vitamin
AID2
IU. C624 IU. dTo ml tap water to obtain liquid diet.
mixture
2.55 4-43 1.13 0.58 1.96
5.03 0.99 1.24 1.60 0.27
5.45 3.12 0.02 13.30
3.24 0.026 0.014 0.00097 0.00018 0.068 O.025’ -
_C
0.00055 0.14 0.00 14 0.0018 0.0026 0.11 0.39 0.00021 0.00011 0.13 0.019 0.012 0.0044 0.4468 379.00 29.7769
used.
480.0 g dry powder 25% total solids (w/v)
b6,250
add 1,680 to obtain
of
Downloaded from https://academic.oup.com/ajcn/article-abstract/28/1/46/4716334 by East Carolina University Health Sciences Library user on 11 January 2019
dilution of an elemental chemical diet places its osmolality in the upper range of foodstuffs normally consumed. The elemental diet that was the subject of our study, for example, creates a tension of 1,170 mosmols/liter when given as a beverage. In normal digestion, the daily volume of intestinal secretion falls between 8,000 and 10,000 ml (10). Only bile and pancreatic juice approach isotonicity; the remainder of the secretions are hypoosmolar to varying degrees. Thus about 75% of the fluid input in the upper intestinal tract is hypotonic and serves to dilute the hyperosmolar diet. Interestingly enough, in the Borgstrom study a threeto fivefold dilution of the test meal occurred in the duodenum (7). An elemental diet modified to eliminate its fat content could be given parenterally, but physicians agree that the best route for satisfying nutritional requirements is the gastrointestinal tract. Geyer (11) has demonstrated that from the standpoint of cellular nutrition there is no difference between enteral and parenteral supply routes, but there are three advantages in supplying nutriment through the gastrointestinal tract: 1) the risk of sepis is greatly reduced because there is no need for long-term insertion of an intravenous catheter; 2) toxicity associated with intravenous administration of certain minerals is avoided; and 3) since enteral nutrients need not be sterilized, there are fewer problems in handling and storage. Advantages of an elemental diet in patient care have been described by Thompson and his associates (12), who used one to feed a patient who had only 4 cm of jejunum remaining between the duodenum and the transverse colon. As preparation for study in surgical patients, the elemental diet was studied in rats and healthy human volunteers and it was concluded that a general state of good health could be maintained with the formulation as the sole source of nutrition (13-15). It was observed that the blood urea nitrogen (BUN) was depressed. Hematocrit and hemoglobin showed a “trend toward depression” even though they remained within normal range. Therefore it was recommended that these modalities be monitored closely during the initial phases of clinical study.
WITH
MILLER
48 and dextrose nitrogen from
oligosaccharides, amino acids,
and
5.88 1.6
g g
of of
safflower oil. Electrolytes supplied included 64.8 mEq of sodium, 40.13 mEq of potassium, 60.0 mEq of calcium, and 109 mEq of chloride. Enough vitamins and accessory food nutrients were provided to meet body requirements. As given during the study, each patient was supplied with 1,750 kcal in 1,920 ml of diet (25% total solids w/v) during a 24-hour period. Additional water consumption was encouraged to depress osmolality during the initial feeding regimen for osmotic sensitive patients. It was deemed necessary to institute such a precaution in order to prevent diarrhea. The elemental diet was supplied to the patient in eight flavored servings, including five beverages, two hot broths, and one pudding. The feedings were provided every 2 hours from 8:00 AM to 10:00 PM. When the diet was intubated through a nasogastric tube, a beverage was substituted for the pudding. This was considered an optimal schedule, though there could be an advantage to intubating an elemental diet over 24 hours in certain patients. The beverage was made by mixing the diet with cold tap water and the broth and pudding were mixed with hot tap water according to the schedule shown in Table 2. All three diet forms dissolved readily. The elemental diet tested could be expected to more than meet the nutritional needs of most nonambulatory patients. Simple carbohydrates, amino acids, fat (safflower oil) containing linoleic acid, minerals, vitamins, and accessory food nutrients are supplied in measured amounts in each packet of diet. Each packet of the elemental diet (60 g) was added to 210 ml of water and mixed vigorously in a blender. It is easy, therefore, for the physician to determine the exact amount and nature of the nutrients his patient is ingesting. TABLE 2 Preparation for JEJUNAL Serving I 2 3 4 5 6 7 8
and
feeding brand Flavor
Orange Beef Cherry Banana Grapefruit Beef Orange Pineapple Fruit Punch
schedule
Form
Time
Beverage Broth Beverage Pudding Beverage Broth Beverage
8:00 AM 10:00AM 12:00 AM 2:00PM 4:00PM 6:00PM 8:00 PM
Beverage
10:00
PM
Beverage preparation -empty contents of package into container, add 210 ml of cold water (7 ounces), and mix vigorously until powder dissolves. A blender may be used if available. Broth preparation-empty contents of package into container, add 210 ml of hot water (7 ounces), and mix vigorously until powder dissolves. A blender may be used if available. Pudding preparation-empty contents of package into container, add 60 ml (2 ounces) of hot water, and mix vigorously. Do not boil.
TABOADA
Results All patients tolerated the diet well except one who was dropped from the study on the second day because of nausea, vomiting, and increased frequency of bowel movements. Some of the patients showed taste fatigue, but did consume the diet. Neither electrolytes and enzymes nor prothrombin and partial thromboplastin time were affected to a degree that was considered significant. The patients apparently consumed enough of the diet to keep themselves in reasonable electrolyte balance. Some slight variations in body weight were seen in patients who could be weighed. Most patients experienced either a marked decrease or a complete cessation of stool passage. In a patient with a decompressive cecostomy, the amount of fluid passing through the opening was greatly reduced. The following case reports are representative of results obtamed and serve as examples of how the elemental diet can be useful: Case no. 1: A 39-year-old Negro man was placed on the diet for 2 days to prepare him for closure of his sigmoid colostomy. On the final day of the diet, the day before surgery, the proximal and distal loops of the intestine were irrigated. After this preparation, the colostomy was closed without fecal soiling and normal wound healing followed. Conventional measures require 48 to 72 hours in the hospital to prepare the bowel, whereas with the elemental diet the lack of residue permits the patient to remain at home during more of the preoperative period, with consequent saving of time and money. Case no. 2: It was necessary to empty the intestinal tract of a 59-year-old Caucasian woman who was scheduled for surgery. This was accomplished by maintaining her for 3 days on the elemental diet, during which time she also was given enemas. After this preparation she underwent a panhysterectomy, a resection of the sigmoid colon, and excision of the terminal ileum to remove a metastasized carcinoma of the left ovary. Case no. 3: When a 28-year-old Negro man with a splenic flexure fecal fistula was placed on the diet, his fistula stopped draining and he had only one rectal bowel movement in 5 days. The fistula shrank during the 5 days the patient took the diet, but because it “tasted like
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Discussion Variations in serum electrolytes and enzymes were not considered significant, but it is noteworthy that 6 of the 30 patients studied developed hyperchloremia associated with low carbon dioxide levels. For example, a patient with prediet chloride readings of 95 and 97 mEq/liter had a rise to readings of 112 and 108 mEq/liter associated with a CO2 level of 23 mm mEq/liter. Another patient had chloride readings of 123, 115, Il l,and 113 mEq/liter while on the diet and these readings were associated with a CO2 level of 20 mm mEq/liter. The clinical significance of these findings is not clear, but elevated chloride levels associated
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with relatively low carbon dioxide does suggest the need for biochemical monitoring of patients on elemental diets. The elemental diet was found to be safe in our applications, none of which involved long-term use, and it shows promise in a number of indications. Its usefulness is obvious as a means of preparing the patient for operations on the small intestine, colon, and anus, and the formation of an ileal conduit for urinary bladder replacement. Patients requiring extensive hemorrhoidectomy, excision of pilonidal cyst, and closure of decubitus ulcers over the sacrum, gluteal tuberosity, and femoral trochanters are subjects for elemental diet therapy. Other candidates are patients with fistulas originating in the small intestine, colon, biliary tract, and pancreas, and patients with active enteritis and various types of colitis. Elemental diet feeding should also be helpful in patients who will not eat, particularly the elderly, and must be fed by nasogastric tube. Patients receiving abdominal irradiation or 5-fluorouracil treatment, and patients with head and neck malignancies in various stages of treatment are also subjects for elemental diet feeding. Experience suggests that certain patients, such as the one described in case history no. 6, might benefit more from elemental diet by intubation over 24 hours instead of a series of intragastric injections over more limited time spans (eight times in 14 hours in case no. 6). The liquid form of the elemental diet is easily intubated by an adjustable gravity feed or by a small pump attached to the delivery system. Periods of hyperglycemia might be made less intense or even prevented in diabetic patients by 24-hour administration, which would minimize loss of kilogram-calories and fluid from excretion by the kidneys. The liver, where the processes of deamination and glyconeogenesis take place, controls the utilization of amino acids. If sufficient glucose is available for kilogram-caloric needs, the amino acids are saved from catabolism and can contribute to protein manufacture. Insulin, in addition to its role in glucose metabolism, is also necessary for entry of amino acids into the cells and for their incorporation into ribosomal protein. Loss of glucose via the urine leads to impaired use of the amino acids. Spreading the diet over a period of 24 hours should result in more
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medicine” he refused to continue any longer. He was discharged from the hospital and follow-up after 2 months revealed that the fistula had closed spontaneously. The patient might have recovered more quickly if he had remained on the diet for a longer period of time. Case no. 4: A 44-year-old Negro man was admitted to the hospital for treatment of a sacral decubitus ulcer. After 9 days of therapy with the elemental diet (during which the patient had only one bowel movement that included 5 ml of mucus) the ulcer had practically disappeared. Case no. 5: The stress of a hysterectomy exacerbated a chronic ulcerative colitis in a 65-year-old Negro woman. Her stools, 24 a day, contained blood and pus with the feces. She responded remarkably well to a 7-day program of treatment with the elemental diet and steroid enemas. The number of evacuations was reduced to 4 a day and consisted of mucus without fecal material and blood. Proctoscopy revealed improvement in the rectal and colonic mucosa. Case no. 6: A 50-year-old Negro woman with hypertension and diabetes mellitus had a severe neurologic deficit resulting from a cerebrovascular accident. Eating was a problem for her. The problem was solved by insertion of a nasogastric tube and administration of the diet through the tube for 17 days. Fecal soiling of the buttocks was stopped, since she had but one soft stool during this period. A sacral decubitus ulcer was noted during the early treatment period, but it healed before the 17-day treatment was completed.
AN
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References 1. ROSE,
W. C. Amino acid requirements of man. Federation Proc. 8: 546, 1949. 2. SCHULTZE, M. 0. Reproduction of rats fed protein-free diets. J. Nutr. 60: 35, 1956. 3. GREENSTEIN, J. P., AND M. WINITZ. Chemistry of the amino acids. New York: Wiley, 1961. 4. WINITZ, M., J. GRAFF, N. GALLAGHER, A. NARKIN AND D. A. SEEDMAN. Evaluation of chemical diets as nutrition for man-in-space. Nature 205: 741, 1965. 5. WINITZ, M., D. A. SEEDMAN AND J. GRAFF. Studies in metabolic nutrition employing chemically defined diets. I. Extended feeding of normal human adult males. Am. J. Clin. Nutr. 23: 525, 1970. 6. WINITZ, M., R. F. ADAMS, D. A. SEEDMAN, P. N. DAVIS,
L. G. JAYKO
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J. A. HAMILTON.
Studies in metabolic nutrition employing chemically defined diets. II. Effects on gut microflora populations. Am. J. Clin. Nutr. 23: 546, 1970. 7. BORGSTROM, B., A. DAHLQVIST, G. LUNDH AND J. SJOVALL. Studies of intestinal digestion and absorption in the human. J. Clin. Invest. 36: 1521, 1957.
TABOADA 8.
WILSON, T. H. Intestinal Absorption. Philadelphia: Saunders, 1962, p. 263. 9. WHITE, A., P. HANDLER AND E. L. SMITH Principles of Biochemistry (4th ed.). New York: Blakiston Division, McGraw-Hill, 1969, p. 1187. 10. RANDALL, H. T. Fluid and electrolyte therapy in surgery. In: Principles of Surgery, edited by S. I. Schwartz. New York: Blakiston Division, McGraw-Hill, 1969, p. 46. 11. GEYER, R. P. Parenteral nutrition. Physiol. Rev. 40: 150, 1960. 12. THOMPSON, W. R., R. V. STEPHENS, H. T. RANDALL AND J. R. BOWEN. Use of the “Space Diet” in the management of a patient with extreme short bowel syndrome. Am. J. Surg. 117:
449, 1969. 13. MOHAMMED,
K., A. H. CAMPBELL,
J. WILL-
SON AND G. H. LORD. The effect of feeding an elemental chemical diet on mature rats (nutrition). Nutr. Rept. Intern. 6: 281, 1972. 14. CAMPBELL, A. H., W. R. SEWELL, M. CHUD-
KOWSKI, J. E. WILLSON, G. H. LORD MOHAMMED. The effects of feeding
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K.
and eleToxicologic Pharmacol.
mental chemical diets to mature rats: and Pathologic Studies. Toxicol. AppI. 26: 63, 1973. 15. GOPELAN, H., P. LACHANCE AND K. MOHAMMED. Short-term effects of feeding an elemental diet in healthy men. Nutr. Rept. Intern. 8: 49, 1973.
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efficient
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