Correspondence to:
Prof. Brian J Rowlands,
Section of Surgery,
Queen's Medical Centre.
University Hospital.
Nottingham NG7 2UH, UK
Pathophysiology of sepsis
197
Major Surgery
Acute pancreatitis
SEPSIS
Obstructive jaundice
SIRS
Intra-abdominal sepsis
CARS
Inflammatory bowel disease
Apoptosis
Organ dysfunction
Ischaemia-reperfusion
MODS
Homeostasis
DEATH
Burns
Rg. 1 Common
surgical conditions
that lead to well
recognised syndromes,
disruption of metabolic homeostasis and
death.
SIRS
Multisystem trauma
Non immunological
Local
Mechanical
Healthy enterocyte
Tight junction
Cell turnover
Normal motility
Systemic
Circulatory lymphocytes
Bacteriological
>
Aerobic micro-organisms
Anaerobic micro-organisms
199
(Zhemical
Gastric acidity
Salivary lysozyme
Lactoferrin
Mucous secretion
Bile salts
Luminal secretions
Fig. 2 Components of
the 'gut-liver axis' that
provide a barrier to
invasion of the
systemic circulation by
bacteria and toxins.
Gut associated
lymphoid
tissue
Luminal
bacteria
Mesenteric
blood flow
to pro-inflammatory factors. Increased gastric acid production, colonisation with Helicobacter pylori, ingestion of non-steroidal anti-inflammatory analgesics and the use of broad-spectrum antibiotics, predispose
the gastrointestinal mucosa to ulceration. Maintenance of mucosal blood
flow, oxidative fuel supply and a normal intestinal bacterial flora protect
against barrier dysfunction. Failure of the intestinal mucosal barrier results
in permeation of microbial and dietary antigens across the intestinal wall.
The transmural migration of enteric bacteria or their products
(endotoxins) to extra-intestinal sites has been termed translocation, and
may occur by the transcellular or paracellular routes. Enhanced uptake of
macromolecules and bacteria has been demonstrated where the intestinal
mucosa is damaged by inflammation, infection, neoplasia or trauma. In
addition, systemic endotoxaemia, bacterial translocation, and increased
intestinal permeability to macromolecules have been demonstrated in
patients with rheumatic diseases, haemorrhagic shock, burns, burn sepsis,
major trauma, following chemotherapy or radiotherapy, and in
experimental endotoxaemia in the absence of macroscopic intestinal
disease. However, translocations of endotoxin or bacteria have not been
found commonly in patients after major trauma or burns18.
Bowel
motility
The mucosa at the tip of the villi is particularly prone to ischaemia due to
the counter current exchange mechanism of the vessels and occurs when
there is shunting of blood during low flow states. More subtle mucosal
damage detectable only microscopically may occur following mild
ischaemia. In transient hypoperfusion or hypoxia, the mucosal injury is
more pronounced during reperfusion when the oxygen supply is reestablished. Blood loss and shock have detrimental effects on the immune
and hepatic cells, reducing their capacity to clear bacteria and endotoxin.
Blood transfusion can activate polymorphonuclear leucocytes which then
sequestrate in various sites and has been imphcated in the development of
transfusion-related renal and pulmonary pathology. Autologous blood
may have the same effect leading to leucocyte activation and cytokine
release. The activation and accumulation of neutrophils leads to sludging
of capillaries and reduction of mucosal blood flow.
Complete disruption of the bowel wall, which may occur with
perforation or frank infarction, can induce profound hypotension and
shock due to massive fluid losses into the bowel wall and peritoneal
cavity. This may result in the intraluminal contents entering the systemic
circulation either directly or indirectly. If there is minimal contamination
British Medical Bulletin 1999,55 (No. 1)
201
202
The causes of intestinal ischaemia are diverse and may represent part of a
generalised hypoperfusion insult or decreased blood flow confined to part
of the splanchnic circulation. In sepsis, intestinal ischaemia may develop
as a result of poor extraction and utilisation of nutrients by the intestine
despite normal oxygen content and delivery20. Selective splanchnic flowdependent tissue hypoxia may develop in sepsis whereby oxygen delivery
fails to meet demands and blood is shunted away from the mucosa. A
reduction in blood flow to a segment of intestine may occur due to
obstruction or strangulation of the bowel, or due to atherosclerosis and
thromboembolic disease of the splanchnic vessels.
The ischaemic injury sustained and changes observed are dependent on
the duration and severity of the ischaemia and whether these changes are
reversible. Three patterns of intestinal ischaemia are apparent. These are
complete vascular occlusion, compensated partial ischaemia and partial
ischaemia followed by reperfusion. In complete vascular occlusion rapid
progression to transmural infarction ensues. In compensated partial
ischaemia, the injury may be so mild that no morphological or physiological change can be detected or there is a slight alteration in vascular
permeability. An increase in intestinal capillary permeability is usually
found with 1 h partial regional ischaemia but may occur after only 20
min. If significant partial ischaemia is reversed, the injury sustained by the
bowel may be exacerbated by reperfusion21. A decrease of intestinal
arterial pressure to 25-35 mmHg for 3 h may lead to a loss of villous
height and a reduction in mucosal thickness. This mucosal damage is
enhanced if the ischaemic episode is followed by 1 h of reperfusion. This
reperfusion injury is more severe than that produced by 4 h of ischaemia
alone.
When ischaemia is relieved by reperfusion or resuscitation, oxygenderived free radicals (ODFR) are generated by the xanthine oxidase
pathway and cause direct injury to the lipid membranes of cells and
hyaluronic acid of their basement membrane22. Xanthine dehydrogenase
occurs naturally and is found in abundance in the intestine. The
dehydrogenase form catalyses the conversion of xanthine and water to
uric acid with the reduction of the nicotinamide adenine dinucleotide
203
Malnutrition
The nutritional status of the patient has been shown to be important in
determining the outcome of patients following trauma and surgical
disease. Patients may present with pre-existing malnutrition due to the
inability to swallow, malabsorption, poverty, self-neglect and prolonged
starvation following surgery and in the intensive care unit. In patients
recovering from abdominal surgery enteral feeding improves muscle
function and reduces morbidity and mortality. Malnutrition and total
parenteral nutrition have been shown to cause atrophy of the
enterocytes and colonocytes. Although total parenteral nutrition (TPN)
may improve outcome in those with intestinal failure and in the severely
malnourished it may lead to atrophy of the intestinal mucosa and a
reduction in IgA antibody production. This is because the enterocytes
and colonocytes are better supported by enteral intraluminal infusion of
nutrients. Patients who develop sepsis, SIRS and MODS very rapidly
develop severe nutritional depletion due to an increase in their rate of
metabolism and consumption of their endogenous stores of protein and
energy, especially if no attempt is made to support their nutritional
status using parenteral or enteral feeding protocols.
Hepatic dysfunction
205
Tissue oxygenation
207
Nutritional support
Newer therapies
survival are causally linked. The substrates may exert their beneficial
effects by improving nitrogen balance and metabolism or by enhancing
immune function and clearance of translocated bacteria. The strongest
candidates as selective gut nutrients are glutamine for the enterocyte and
short chain fatty acids for the colonocyte. Recent evidence shows that
glutamine supplemented parenteral nutrition improves outcome in
critically ill intensive care unit patients and surgical patients38'39. The
results from studies of enteral supplementation of glutamine are
disappointing40, but a recent study shows encouraging results in severely
injured patients with a low frequency of pneumonia, sepsis and
bacteraemia41. Modest intakes of standard oral diet (0.6 g nitrogen/kg
daily) are sufficient to maintain gut integrity and immune function.
Short chain fatty acids and n-3 polyunsaturated have modest beneficial
effect in patients with intestinal inflammation42. Arginine has proven
immunological benefits43. Despite this, oral supplementation with
arginine has been shown to be detrimental in experimental colitis
causing increased colonic inflammation44 but beneficial to mucosal
barrier function and survival after experimental ischaemia/reperfusion
injury45. There is growing evidence that the L-arginine-nitric oxide
pathway is important in the development of colonic inflammation and
that this may lead to new therapeutic strategies in inflammatory bowel
diseases46-47. Arginine supplements for critically ill patients should be
used cautiously at present. There is insufficient evidence from clinical
studies to support the use of orthinine, branched chain amino acid or
nucleotide supplementation by themselves. Supplementation of enteral
diets with combinations of novel substrates is beneficial to patients in a
number of different clinical situations where gut barrier function is
compromised by malnutrition and hypermetabolism48'49. The use of diets
(containing fibre, fermented oats and lactobacillus) that support
probiotic bacteria (microbial interference treatment) has been advocated
as an important new development in the support of these patients50'51.
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