Sone of Pedic Gastroenterology and Natron
BG ST Spine Kae hc dln
Effect of Glutamine-Supplemented Elemental Diet on
Mucosal Adaptation following Bowel Resection in Rats
Sonia Michail, Hamid Mohammadpour, Jung H. Y. Park, and Jon A. Vanderhoof
Department of Pediatvies, University of NebraskaiCreighton University, Omaha, Nebraska, U.S.A
‘Summary: Glutamine is the major fuel for enterocytes
and prevents mucosal atrophy in certain animal models,
Previous studies in our laboratory have failed (0 show a
trophic effect of glutamine on the small-bowel mucosa
following massive resection when added to a chow dict
However, the complexity of the chow diet might poten-
fially interfere with the adequate evaluation ofthe trophic
elfect of u single agent such as hutamine. This study was,
therefore designed to determine whether the addition of
glutamine to an elemental dict would augment mucosal
adaptation following massive small intestinal resection in
‘rat model. Male Sprazue-Duvsley rats were divided into
two dietary groups, one receiving an amino acid-based
pediatric elemental diet supplemented with 22% glutamine,
and the other receiving the diet supplemented with 22
Following massive small-bowel resection, the
small intestine functionally acapts to inereused nu
tvient needs through increasing its slbsorptive sur-
face area and subsequently its functional capacity
(1). Several factors regulate this intestinal epithelial
proliferation, Enteral nutrition plays an important
role in stimutating adaptation following resection
and regeneration of the damaged mucosa following
injury (2.3)
Glutamine is @ nonessential amino acid that acts
as an important respiratory fuel for enterocytes
(4,5). ts addition to parenteral nutrition it has been
shown to protect against atrophy of the intestinal
mucosa (6) After small bowel resection, there isan
increase in gut ghitamine utilization (7). It would
‘Aaddress correspondence and reprint requests to Dr. Jon A.
Vanderhoot, Toint Section of Pediatric Grstracnteroogy si
Nuteition, 8800 Dodge Street, Suite 330, Oma, NE SRILA,
USA
‘Manuscript received November 16, 19%; revision received
Jury TR, 1998; accepted January 18, 1995,
394
tlucose. One half of the animals in ench dietary group
received 80% jejunoileal resection, and the remainder
were sham operated. Fifteen days postsurgery, mucosal
weight, DNA, protein, and sucrase activities were deter-
‘mined in both the proxival and the distal small intestine.
While both groups of resected snimals developed marked
increases in all parameters of adaptation, the elutaming
supplemented group did not differ from the control diet
sroup in any parameter. The addition of glutamine to an
‘elemental diet had no enhancing effect on intestinal ad-
aptation after bowel resection. These results are similar
1o those previously observed in our laboratory when ght
‘amine was added to chow diet. The addition of glutamine
{0 an elemental dict cannot be justified on the basis of its,
trophic effect in animals
therefore seem reasonable to hypothesize that glu-
tamine would have an enhancing trophic effect on
sinall intestinal adaptation, However, previous
studies in our laboratory have failed to demonstrate
a trophic effect of pharmacological doses of dietary
glutamine in a rat animal model when added to
chow diet. It is possible that the complexity of the
rat chow diet might have potentially interfered with
the adequate evaluation of the trophic effect of a
single agent such as glutamine (8). This study was
therefore designed to determine whether the uddi-
tion of glutamine to an elemental diet would aug-
ment mucosal adaptation after massive small-bowel
resection in a rat model.
MATERIALS AND METHODS
The animals used in this study were cared for
according to the guidelines of the Animal Review
Committee at the University of Nebraska Medical
Center, Forty 8-week-old male Sprague-DawleyGLUTAMINE AND INTESTINAL ADAPTATION 395
rats weighing ~250 g (Sasco, Omaha, NE, U.S.A.)
were acclimatized to the laboratory conditions for 3
‘days in hanging stainless steel cages. The rats were
randomly divided into two groups. One group re-
ceived an 80% jejunoileal resection, and the other
group were sham operated.
All rats were anesthetized with an intraperitoneal
injection of sodium pentobarbital (5 me/kg); their
abdomens were shaved, and the skin was prepped
with betadine. A midline abdominal incision was
made, the small intestine was located, and the in-
tervening vessels were ligated with 5-0 silk. ‘The
resection was then performed by removing all
bowel between the points 4 cm distal to the ligament
of Treitz and 12 em proximal to the ileocecal valve.
‘The remaining jejunum was anastomosed to the
midileum using interrupted sutures of 6-0 Dexon
(Davis and Geek, Manati, Puerto Rico). The small
bowels of sham-operated animals were transected
12 cm proximal to the ileocecal valve and reanasto-
mosed. All rats were given access to drinking water
containing 5% glucose and 0.0225% tetracycline for
24h
Each group of rals was then further divided into
two dietary groups, one supplemented with t-glu-
tamine (Sigma, St. Louis, MO, U.S.A.), and the
other supplemented with glucose. These substances
Were mixed in # non-glutamine-containin
acid-based pediatric elemental diet (Neocate
One +; SHS Inc., Gaithersburg, MD, U.S.A.)
Both glucose and glutamine were mixed to obtain
final concentration of 2%
Analysis
Resected and sham animals were killed 15 days
postsurgery. As Hanson et al. have noted, adapta
tion is nearly complete by that time in the rat (9).
‘The small intestine from the pylorus to the ileocecal
valve was carefully removed, stripped of its mesen:
tery, and divided at the anastomosis. The bowel
was rinsed with cold isotonic saline, and the ends
were trimmed to remove any damaged tissues.
Bowel segment lengths were determined by laying
the segments straight on a wet glass plate and mea-
suring with a ruler. The mucosa was scraped,
weighed, and subsequently homogenized in deion-
ized Water. Mucosal protein was measured by the
method of Lowry et al. (10). Deoxyribonucleic acid
(DNA) was extracted and measured according to
Burton, a modified by Giles (11,12), Disaechar
dase activity was measured by the method of Dahl-
vist (13)
Al results are expressed as the mean * standard
error of mean for exch group of animals. Significant
differences among means were analyzed using anal-
ysis of variance and Duncan's multiple range test
(14), Differences were considered statistically siz-
nificant at p < 0.08.
RESULTS
Mean body weights from the start of test dict 10
the 15th postoperative day increased by 44 g in the
resected group receiving glutamine supplement
tion and 51 g for the resecied group receiving glu
cose (p > 0.05). For the sham-operated rats, body
‘weight increments were 80.75 and 80.5 g for the
glutamine- and the glucose-supplemented groups,
respectively (p > 0.05) (Fig. 1). The difference in
incremental weight gain between the glucose- and
glutamine-supplemented animals did not reach sta
tistical significance on any of the postoperative
days. Mucosal weight, protein, DNA content, and
sucruse activities showed no significant differences,
between the two dietary groups (Tables t and 2). As
expected, the resected group showed significantly
higher mucosal weight, protein, DNA content, and
suerase activities in both duodenum and ileum.
DISCUSSION
Short bowel syndrome is a condition that results
from resection of a large portion of the small bowel
(15). In humans, nutrition is maintained parenteral
ly during the carly postoperative period. However,
long-term parenteral nutrition may eventually be
unnecessary for survival because of a process
known as intestinal adaptation (16), This process
highly dependent upon enteral nutrition (17-21)
Several investigators have been interested in iden-
Uilying the different nutrients that are most capable
of enhancing intestinal adaptation (22-27)
Recently there has been an increasing interest in
the use of glutamine for several gastrointestinal dis-
orders. Glutamine is a neutral amino acid used ex-
tensively by the gut, preferentially over glucose.
Although it is « nonessential amino acid, it acts asa
principal fuel and an important respiratory sub-
strate for rapidly dividing cells, especially entero-
cytes (5), The skeletal muscles are the major tissues,
J Pein Gateautvsl Nar Vol 21, Na 4 BS396
‘woight in me
o 1 2 5 7 8 1 48
days after surgory
involved in glutamine production (28). During per
‘ods of operative stress, the release of
from the muscle is accelerated. This acceleration,
however, is ussociated with a decrease in circulat-
ing concentration of glutamine, suggesting an in-
creased cellular uptake. Studies have shown that
after surgery, even a standard laparotomy, glu-
tamine consumption by the intestinal tract is in-
creased by 75% (29).
In 1987, Hwang et al. demonstrated that glu-
tamine supplementation of total parenteral nutrition
solutions prevented mucosal atrophy after partial
small-bowel resection in rats (30). Grant also
showed that glutamine supplementation of total
parenteral nutrition solution promotes intestinal
TABLE 1, The effect af glutamine on mucosal weight
protein, DNA, and sucrase activity after 806
Jejunoileal resection
5. MICHAIL
4
AL
oe reste
ete
FIG. 1. This figuee represents
the increase in body weight fol
lowing surgery in relation to
dict
mucosal height and gut nitrogen content (31). Klim-
berg et al, examined glutamine metabolism in the
shortened bowel and showed an increase in gut glu-
‘amine utilization associated with an increase in gut
cellularity and glutaminase content (7). Glutamine
hhas several beneficial effects in experimentally in-
duced enterocolitis. These effects include signiti-
cantly improved nutritional status, decreased intes-
tinal injury, decreased bacterial translocation, re~
duced endotoxemia, and improved survival in this
lethal model of enterocolitis (32),
‘The importance of glutamine as a metabolic sub-
strate for the small intestine makes it a potential
candidate as a facilitator for intestinal adaptation
following massive small-bowel resection, Previous
TABLE 2, The effects of glutamine on mucosal weight,
protein, DNA, and sucrase activity in
shani-operated rats
Vorabies ‘Guanine ———