G196(P) Residual Small Bowel Length Predicts Raised D-Lactate When Screening For Bacterial Overgrowth in Children with Intestinal Failure

Abstract

Aims Small bowel bacterial overgrowth (SBBO) may cause non specific symptoms in children with intestinal failure (parenteral nutrition (PN) >28days). Rapid detection of raised serum D-lactate (DL) may be a clinically useful non invasive marker of SBBO. We present the first large cohort of DL in a tertiary referral centre, in patients with current or recent intestinal failure (IF) with new symptoms suggestive of SBBO. Methods Retrospective review over a 3 year period (01/01/2009 to 31/12/2011) of Patients with IF (0-18 years) and suspected SBBO was done. Demographics, aetiology of IF, symptoms, recent radiology and treatment were recorded. In those with short bowel syndrome, length of remaining small bowel was expressed as percentage of expected small bowel length appropriate for age (SBL) using a published formula. Raised DL was identified as >20mumol/L and recurrence as DL >20mumol/L at least 4 weeks apart and with standard treatment (rehydration, withholding or alteration of feeds, bicarbonate and/or antibiotics). Results Out of total cohort of 209, 49 patients (28 males; age range 0.16-13.07 and mean 4.76 years) were screened for DL. Aetiology for IF was bowel resection due to congenital malformation (17), necrotising enterocolitis (15), dysmotility (6) and enteropathy (11). 25/49 had raised DL and 24/49 did not have raised DL. There was no statistically significant difference in risk factors for raised DL comparing age, bowel resection, absence of ileo-caecal valve, abnormalities on barium study and use of proton pump inhibitors. SBL was significantly shorter (p = 0.001) in raised DL group (median 29.6%; range 11.4-100) than in group without (median 100%; range 19.10- 100). Patients with <35% SBL, had 77% sensitivity for developing raised DL. Relationship to feed could not be analysed due to lack of accurate information on patients' carbohydrate intake. Response to treatment was available in 12/25 and all had improvement in symptoms with fall in DL. Recurrence occurred in 48%. Conclusion Children with IF due to <35% expected SBL, when screened, have a 77% likelihood of having SBBO shown by raised DL. Screening in at risk patients allows prompt detection and treatment of SBBO. Recurrence is common necessitating prolonged antibiotic regimens.