Abstract
While enteral nutrition is the preferred mode of nutritional delivery in the critically ill, adequate delivery of enteral feeds to critically ill patients is frequently hampered by a variety of factors, the most frequent of which is gastric dysmotility. Impaired gastric motor function in these patients not only involves all regions of the stomach but is also associated with an enhanced enterogastric inhibitory feedback. The etiology of impaired gastric motility during critical illness remains unclear. In addition to mechanical ventilation, medication, hyperglycemia, shock, circulating inflammatory cytokines, and the admission diagnosis, a number of recent findings suggest that disturbances to the gastrointestinal hormones which mediate enterogastric feedback inhibition may be important. The motor abnormalities that have been identified in both proximal and distal regions of the stomach in response to small intestinal nutrient stimulation are consistent with enhanced enterogastric inhibitory effects. Plasma levels of the two major gastrointestinal hormones, cholecystokinin (CCK) and peptide YY (PYY), that mediate this enterogastric feedback are significantly elevated in critically ill patients. More importantly, both fasting and nutrient-stimulated plasma concentrations of CCK and PYY are higher in patients with delayed gastric emptying, and there is an inverse relationship between the rate of gastric emptying and both the plasma levels as well as the integrated changes in the plasma levels of CCK and PYY. These findings strongly support the potential role of plasma CCK and PYY in the pathogenesis of gastric dysmotility in critically ill patients.
Access this chapter
Tax calculation will be finalised at checkout
Purchases are for personal use only
Similar content being viewed by others
Abbreviations
- ICU:
-
Intensive care unit
- CCK:
-
Cholecystokinin
- PYY:
-
Peptide YY
- GLP-1:
-
Glucagons-like peptide 1
- IPPW:
-
Isolated pyloric pressure wave
- MMC:
-
Migrating motor complex
- IL:
-
Interleukin
References
Adrian TE, Ferri GL, Bacarese-Hamilton AJ, Fuessl HS, Polak JM, Bloom SR. Human distribution and release of a putative new gut hormone, peptide YY. Gastroenterology. 1985;89:1070–7.
Alpers DH. Enteral feeding and gut atrophy. Cur Op Clin Nutr Metab Care. 2002;5:679–83.
Artinian V, Krayem H, DiGiovine B. Effects of early enteral feeding on the outcome of critically ill mechanically ventilated medical patients. Chest. 2006;129:960–7.
Berger MM, Chiolero RL, Pannatier A, Cayeux MC, Tappy L. A 10-year survey of nutritional support in a surgical ICU: 1986–1995. Nutrition. 1997;13:870–7.
Bosscha K, Nieuwenhuijs V, Vos A, Samsom M, Roelof J, Akkermans L. Gastrointestinal motility and gastric tube feeding in mechanically ventilated patients. Crit Care Med. 1998;26:1510–17.
Brener W, Hendrix TR, McHugh PR. Regulation of the gastric emptying of glucose. Gastroenterology. 1983;85:76–82.
Chapman M, Fraser R, Vozzo R, Bryant L, Tam W, Nguyen N, Zacharakis B, Butler R, Davidson G, Horowitz M. Antro-pyloro-duodenal motor responses to gastric and duodenal nutrient in critically ill patients. Gut. 2005;54:1384–90.
Chapman MJ, Fraser RJ, Bryant LK, Vozzo R, Nguyen NQ, Tam W, Zacharakis B, Davidson G, Butler R, Horowitz M. Gastric emptying and the organization of antro-duodenal pressures in the critically ill. Neurogastroenterol Motil. 2008;20:27–35.
Corazziari E, Ricci R, Biliotti D, Bontempo I, De Medici A, Pallotta N,Torsoli A. Oral administration of loxiglumide (CCK antagonist) inhibits postprandial gallbladder contraction without affecting gastric emptying. Dig Dis Sci. 1990;35:50–54.
Corvilain B, Abramonwicz M, Fery Y, Schoutens A, Verlinden M, Balase E, Horowitz M. Effect of short term starvation on gastric emptying in humans: relationship to oral glucose tolerance. Am J Physiol. 1995;269:G512–7.
Dive A, Moulart M, Jonard P, Jamart J, Mahieu P. Gastroduodenal motility in mechanically ventilated critically ill patients: a manometric study. Crit Care Med. 1994;22:441–7.
Dive A, Michel I, Galanti L, Jamart J, Vander Borght T, Installe E. Gastric acidity and duodenogastric reflux during nasojejunal tube feeding in mechanically ventilated patients. Intensive Care Med. 1999;25:574–80.
Doig AK, Simpson F. Evidence-based guidelines for nutritional support of the critically ill: results of a bi-national guideline development conference. www.EvidenceBased.net; 2005.
Doig AK, Simpson F, Delaney A. A review of the true methodological quality of nutritional support trials conducted in the critically ill: time for improvement. Anaesth Analg. 2005;100:527–33.
Dubois A, Henry DP, Kopin IJ. Plasma catecholamines and postoperative gastric emptying and small intestinal propulsion in the rat. Gastroenterology. 1975;68:466–9.
Fraser R, Fone D, Horowitz M, Dent J. Cholecystokinin octapeptide stimulates phasic and tonic pyloric motility in healthy humans. Gut. 1993;34:33–7.
Fried M, Erlacher U, Schwizer W, Lochner C, Koerfer J, Beglinger C, Jansen JB, Lamers CB, Harder F, Bischof-Delaloye A, et al. Role of cholecystokinin in the regulation of gastric emptying and pancreatic enzyme secretion in humans. Studies with the cholecystokinin-receptor antagonist loxiglumide. Gastroenterology. 1991;101:503–11.
Greeley GH, Jr., Jeng YJ, Gomez G, Hashimoto T, Hill FL, Kern K, Kurosky T, Chuo HF, Thompson JC. Evidence for regulation of peptide-YY release by the proximal gut. Endocrinology. 1989;124:1438–43.
Grossman MI. Candidate hormones of the gut. Gastroenterology. 1974;67:730–55.
Harrington L. Nutrition in critically ill adults: key processes and outcomes. Crit Care Nurs Clin N Am. 2004;16:459–65.
Hernandez G, Velasco N, Wainstein C, Castillo L, Bugedo G, Maiz A, Lopez F, Guzman S, Vargas C. Gut mucosal atrophy after a short enteral fasting period in critically ill patients. J Crit Care. 1999;14:73–7.
Heyland D. Nutritional support in the critically ill patients. A critical review of the evidence. Crit Care Clin. 1998;14:423–40.
Heyland D, Cook DJ, Winder B, Brylowski L, Van demark H, Guyatt G. Enteral nutrition in the critically ill patient: a prospective survey. Crit Care Med. 1995;23:1055–60.
Heyland D, Dhaliwal R, Drover JW, Gramlich L, Dodek P. Canadian Critical Care Clinical Practice Guidelines. Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients. JPEN J Parenter Enteral Nutr. 2003;27:355–73.
Heyland DK, Tougas G, King D, Cook DJ. Impaired gastric emptying in mechanically ventilated, critically ill patients. Intensive Care Med. 1996;22:1339–44.
Heyland DK, MacDonald S, Keefe L, Drover JW. Total parenteral nutrition in the critically ill patient: a meta-analysis. JAMA. 1998;280:2013–9.
Horowitz M, Dent J, Fraser R, Sun W, Hebbard G. Role and integration of mechanisms controlling gastric emptying. Dig Dis Sci. 1994;39:7S–13S.
Kao C, Changlai S, Chieng P, Yen T. Gastric emptying in head-injury patients. Am J Gastroenterol. 1998;93:1108–12.
Kelly KA. Gastric emptying of liquids and solids: roles of proximal and distal stomach. Am J Physiol. 1980;239:G71–6.
King PM, Heading RC, Pryde A. Coordinated motor activity of the human gastroduodenal region. Dig Dis Sci. 1985;30:219–24.
Kreiss C, Schwizer W, Borovicka J, Jansen JB, Bouloux C, Pignol R, Bischof Delaloye A, Fried M. Effect of lintitript, a new CCK-A receptor antagonist, on gastric emptying of a solid-liquid meal in humans. Regul Pept. 1998;74:143–9.
Kudsk K, Croce MA, Fabian TC. Enteral versus parenteral feeding: effects on septic morbidity after blunt and penetrating abdominal trauma. Ann Surg. 1992;215:503–11.
le Roux CW, Ghatei MA, Gibbs JS, Bloom SR. The putative satiety hormone PYY is raised in cardiac cachexia associated with primary pulmonary hypertension. Heart. 2005;91:241–2.
Ledeboer M, Masclee AA, Coenraad M, Vecht J, Biemond I, Lamers CB. Antroduodenal motility and small bowel transit during continuous intraduodenal or intragastric administration of enteral nutrition. Eur J Clin Invest. 1999;29:615–23.
Liddle RA, Gertz BJ, Kanayama S, Beccaria L, Coker LD, Turnbull TA, Morita ET. Effects of a novel cholecystokinin (CCK) receptor antagonist, MK-329, on gallbladder contraction and gastric emptying in humans. Implications for the physiology of CCK. J Clin Invest. 1989;84:1220–5.
Liddle RA, Morita ET, Conrad CK, Williams JA. Regulation of gastric emptying in humans by cholecystokinin. J Clin Invest. 1986;77:992–6.
Lin HC, Doty JE, Reedy TJ, Meyer JH. Inhibition of gastric emptying by glucose depends on length of intestine exposed to nutrient. Am J Physiol. 1989;256:G404–11.
Lin HC, Chey WY, Zhao X. Release of distal gut peptide YY (PYY) by fat in proximal gut depends on CCK. Peptides. 2000;21:1561–3.
Lundberg JM, Tatemoto K, Terenius L, Hellstrom PM, Mutt V, Hokfelt T, Hamberger B. Localization of peptide YY (PYY) in gastrointestinal endocrine cells and effects on intestinal blood flow and motility. Proc Nat Acad Scie USA. 1982;79:4471–5.
MacIntosh CG, Andrews JM, Jones KL, Wishart JM, Morris HA, Jansen JB, Morley JE, Horowitz M, Chapman IM. Effects of age on concentrations of plasma cholecystokinin, glucagon-like peptide 1, and peptide YY and their relation to appetite and pyloric motility. Am J Clin Nutr. 1999;69:999–1006.
McClave SA, Sexton LK, Spain DA, Adams JL, Owens NA, Sullins MB, Blandford BS, Snider HL. Enteral tube feeding in the intensive care unit: factors impeding adequate delivery. Crit Care Med. 1999;27:1252–6.
McDermott JR, Leslie FC, D’Amato M, Thompson DG, Grencis RK, McLaughlin JT. Immune control of food intake: enteroendocrine cells are regulated by CD4+ T lymphocytes during small intestinal inflammation. Gut. 2006;55:492–7.
McWhirter JP, Pennington CR. Incidence and recognition of malnutrition in hospital. BMJ. 1994;308:945–8.
Mentec H, Dupont H, Bocchetti M, Cani P, Ponche F, Bleichner G. Upper digestive intolerance during enteral nutrition in critically ill patients: frequency, risk factors, and complications. Crit Care Med. 2001;29:1955–61.
Mesquita MA, Thompson DG, Troncon LE, D’Amato M, Rovati LC, Barlow J. Effect of cholecystokinin-A receptor blockade on lipid-induced gastric relaxation in humans. Am J Physiol. 1997;273:G118–23.
Minard G, Kudsk KA, Melton S, Patton JH, Tolley EA. Early versus delayed feeding with an immune-enhancing diet in patients with severe head injuries. JPEN J Parenter Enteral Nutr. 2000;24:145–9.
Montejo JC. Enteral nutrition-related gastrointestinal complications in critically ill patients: a multicenter study. The Nutritional and Metabolic Working Group of the Spanish Society of Intensive Care Medicine and Coronary Units. Crit Care Med. 1999;27:1447–53.
Moran TH, McHugh PR. Cholecystokinin suppresses food intake by inhibiting gastric emptying. Am J Physiol. 1982;242:R491–7.
Murray CD, Martin NM, Patterson M, Taylor SA, Ghatei MA, Kamm MA, Johnston C, Bloom SR, Emmanuel AV. Ghrelin enhances gastric emptying in diabetic gastroparesis: a double blind, placebo controlled, crossover study. Gut. 2005;54:1693–8.
Mutlu GM, Mutlu EA, Factor P. GI complications in patients receiving mechanical ventilation. Chest. 2001;119:1222–41.
Naslund E, Gryback P, Backman L, Jacobsson H, Holst JJ, Theodorsson JJ, Hellstrom PM. Distal small bowel hormones: correlation with fasting antroduodenal motility and gastric emptying. Dig Dis Sci. 1998;43:945–52.
Nematy M, O’Flynn J, Wandrag L, Brynes A, Brett S, Patterson M, Ghateir M, Bloom S, Frost G. Changes in appetite related gut hormones in intensive care unit patients: a pilot cohort study. Crit Care. 2005;10:R1–10.
Nguyen NQ, Fraser RJ, Chapman M, Bryant LK, Holloway RH, Vozzo R, Feinle-Bisset C. Proximal gastric response to small intestinal nutrients is abnormal in mechanically ventilated critically ill patients. World J Gastroenterol. 2006a;12:4383–8.
Nguyen NQ, Fraser RJ, Chapman M, Bryant LK, Wishart J, Holloway RH, Horowitz M. Fasting and nutrient-stimulated plasma peptide-YY levels are elevated in critical illness and associated with feed intolerance: an observational, controlled study. Crit Care. 2006b;10:R175.
Nguyen NQ, Fraser RJ, Bryant LK, Chapman M, Holloway RH. Proximal gastric motility in critically ill patients with type 2 diabetes mellitus. World J Gastroenterol. 2007a;13:270–5.
Nguyen NQ, Fraser RJ, Bryant LK, Chapman MJ, Wishart J, Holloway RH, Butler R, Horowitz M. The relationship between gastric emptying, plasma cholecystokinin, and peptide YY in critically ill patients. Crit Care. 2007b;11:R132.
Nguyen NQ, Fraser RJ, Chapman MJ, Bryant LK, Holloway RH, Vozzo R, Wishart J, Feinle-Bisset C, Horowitz M. Feed intolerance in critical illness is associated with increased basal and nutrient-stimulated plasma cholecystokinin concentrations. Crit Care Med. 2007c;35:82–8.
Nguyen NQ, Ng MP, Chapman M, Fraser RJ, Holloway RH. The impact of admission diagnosis on gastric emptying in critically ill patients. Crit Care. 2007d;11:R16.
Nguyen NQ, Chapman MJ, Fraser RJ, Bryant LK, Burgstad C, Ching K, Bellon M, Holloway RH. The effects of sedation on gastric emptying and intra-gastric meal distribution in critical illness. Intensive Care Med. 2008a;34:454–60.
Nguyen NQ, Fraser RJ, Bryant LK, Burgstad C, Chapman MJ, Bellon M, Wishart J, Holloway RH, Horowitz M. The impact of delaying enteral feeding on gastric emptying, plasma cholecystokinin, and peptide YY concentrations in critically ill patients. Crit Care Med. 2008b;36:1469–74.
Nguyen NQ, Fraser RJ, Bryant LK, Chapman M, Holloway RH. Diminished functional association between proximal and distal gastric motility in critically ill patients. Intensive Care Med. 2008c;34:1246–55.
Pironi L, Stanghellini V, Miglioli M, Corinaldesi R, De Giorgio R, Ruggeri E, Tosetti C, Poggioli G, Morselli Labate AM, Monetti N, et al. Fat-induced ileal brake in humans: a dose-dependent phenomenon correlated to the plasma levels of peptide YY. Gastroenterology. 1993;105:733–9.
Quirk J. Malnutrition in critically ill patients in intensive care units. Br J Nursing. 2000;9:537–41.
Ritz MA, Fraser R, Edwards N, Di Matteo AC, Chapman M, Butler R, Cmielewski P, Tournadre JP, Davidson G, Dent J. Delayed gastric emptying in ventilated critically ill patients: measurement by 13 C-octanoic acid breath test. Crit Care Med. 2001;29:1744–9.
Souba WW. Cytokine control of nutrition and metabolism in critical illness. Curr Prob Surg. 1994;31:577–643.
Straathof JW, Mearadji B, Lamers CB, Masclee AA. Effect of CCK on proximal gastric motor function in humans. Am J Physiol. 1998;274:G939–44.
Tarling MM, Toner CC, Withington PS, Baxter MK, Whelpton R, Goldhill DR. A model of gastric emptying using paracetamol absorption in intensive care patients. Intensive Care Med. 1997;23:256–60.
Thomas L., Robert D. Nutritional status and body composition in critically ill patients. Relationship between results and mortality. Am J Clin Nutr. 1979;32:510–11.
White CM, Poxon V, Alexander-Williams J. A study of motility of normal human gastroduodenal region. Dig Dis Sci. 1981;26:609–17.
Yuan C, Foss J, O’Connor M, Roizen M, Moss J. Effects of low-dose morphine on gastric emptying in healthy volunteers. J Clin Pharmacol. 1998;38:1017–20.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2011 Springer Science+Business Media, LLC
About this chapter
Cite this chapter
Nguyen, N.Q., Holloway, R.H. (2011). Gut Peptides and Enteral Feeding in Critically Ill Patients: Implications for Gastric Dysmotility and Appetite. In: Preedy, V., Watson, R., Martin, C. (eds) Handbook of Behavior, Food and Nutrition. Springer, New York, NY. https://doi.org/10.1007/978-0-387-92271-3_83
Download citation
DOI: https://doi.org/10.1007/978-0-387-92271-3_83
Published:
Publisher Name: Springer, New York, NY
Print ISBN: 978-0-387-92270-6
Online ISBN: 978-0-387-92271-3
eBook Packages: MedicineMedicine (R0)