Transmucosal passage of bacteria in critically ill patients may lead to a significant incidence of systemic sepsis. This has attracted much clinical interest, as it has been shown that malnutrition in itself, impairs various aspects of barrier function. Bacterial translocation is increased in animal models where nutrients are given by the parenteral route, while enteral feeding reverses this. Translocation is also considerably increased in response to a non-lethal endotoxin challenge, if there is pre-existing protein energy malnutrition. Similar results have been obtained where the insult is caused by the inflammatory agent, zymosan. Dietary fibre reduces the deleterious effects of either agent on translocation, although the type of fibre is important. Bulk forming but non-fermentable fibres are more effective than easily fermentable types (for example, pectin). Glutamine was not effective in preventing elemental diet induced bacterial translocation. Thus, although fermentable fibre and glutamine have positive effects on mucosal mass, they do not affect translocation. Enteral nutrition thus seems to be superior to parenteral nutrition in maintaining the functional barrier of the gut. A clearer understanding of the physiology of these effects may lead to use of specifically modified enteral diets in the critically ill patient.
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