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Metabolic Handling of 13C Labelled Tripalmitin in Healthy Controls And 44 Arch Dis Child 1998;79:44–47 Metabolic handling of 13C labelled tripalmitin in Arch Dis Child: first published as 10.1136/adc.79.1.44 on 1 July 1998. Downloaded from healthy controls and patients with cystic fibrosis J L Murphy, K M Laiho, A E Jones, S A Wootton Abstract uring total excretion of the 13C label in stools.3 Aim—To examine the gastrointestinal Despite raised total stool lipid losses, more of handling and metabolic disposal of emul- the 13C labelled palmitic acid was absorbed in sified [1-13C]palmitic acid esterified into a this group of patients with cystic fibrosis com- triglyceride in nine healthy children and pared with healthy children (94% v 76%, seven patients with cystic fibrosis on respectively), suggesting that there is not a spe- enzyme replacement treatment. cific malabsorptive defect of labelled palmitic Methods—After an overnight fast, each acid in cystic fibrosis when ingested as the free child was given 10 mg/kg body weight acid. We also showed that palmitic acid was the [1,1,1-13C]tripalmitin with a standardised major stool fatty acid in those stools with the test meal of low natural 13C abundance. highest 13C enrichment and that, primarily, the The total enrichment of 13C was measured 13C label was restricted to the species con- using isotope ratio mass spectrometry in sumed by the subjects (that is, palmitic acid). stool collected for a period of up to five Using diVerent 13C labelled triglycerides and days and in breath samples collected over fatty acids, maldigestion and malabsorption a 24 hour period. have been assessed by measuring the excretion 4–6 Results—The mean proportion of admin- of label on the breath alone. Such studies istered 13C label excreted in stool was 6% have not directly determined the excretion of (range, 1–12.7%) in healthy children and label in the stool, assuming that diVerences in 24.6% (range, 0–64%) in patients with the excretion of label on the breath are cystic fibrosis. Healthy children excreted determined wholly by diVerences in digestion 31.3% of the administered label on their within the gastrointestinal tract. A further breath (range, 14.2–42.9%). Correcting theoretical limitation of using breath tests is the the excretion of administered 13C label on implicit assumption that alterations in lipid the breath for diVerences in digestion and maldigestion and/or malabsorption do not 7 absorption in patients with cystic fibrosis aVect fatty acid oxidation. We are not aware of increased the diVerence between indi- any studies in cystic fibrosis that have meas- http://adc.bmj.com/ viduals from 0–31.3% of administered ured directly the extent of digestion and dose (mean, 17.9%) to 0–49.1% of ab- absorption in combination with “breath tests” 13 sorbed dose (mean, 23.2%) and was poorly using C labelled lipids. To address this issue, related to the amount of 13C label in stool. we have examined both the gastrointestinal handling and the subsequent metabolism of Conclusion—Measurements of breath 13 13 emulsified [1- C]palmitic acid esterified into a CO2 do not consistently reflect the gas- trointestinal handling of emulsified 13C triglyceride in healthy children and patients with cystic fibrosis by measuring excretion of labelled tripalmitin because of diVerences on September 29, 2021 by guest. Protected copyright. the label in stools and on the breath as 13CO . in digestion and absorption in cystic 2 fibrosis. Further studies need to examine whether “breath tests” alone can predict Subjects and methods with confidence the gastrointestinal han- 13 Seven patients with cystic fibrosis (three boys dling of other C labelled triglycerides and four girls) aged 4–11 years (mean, 8.0 and fatty acids. years) from the cystic fibrosis clinic at South- (Arch Dis Child 1998;79:44–47) ampton University Hospitals NHS Trust were Keywords: fatty acids; absorption; metabolism; stable studied while on their normal habitual pancre- Institute of Human atic enzyme replacement treatment. Patients Nutrition, University isotopes; cystic fibrosis of Southampton, with small bowel resection or other known fac- Southampton SO16 tors that might limit absorption (for example 6YD, UK Measurements of total stool lipid made during Crohn’s disease) were excluded from the study. J L Murphy gross balance studies provide a gross measure The cystic fibrosis patients were taking be- K M Laiho of the availability of dietary lipid in cystic tween 13 462 and 34 000 IU lipase/kg body A E Jones 1 S A Wootton fibrosis. Modern developments in mass spec- weight/day (mean, 18 877); an enzyme dosage trometry in combination with stable isotopes achieved by self-titration against gastrointesti- Correspondence to: provide the opportunity to examine the func- nal symptoms and bowel habit. No attempt was Dr J L Murphy, Clinical tional capacity of the gastrointestinal tract to made to alter or intervene with the manage- Nutrition and Metabolism Unit, Mailpoint 113, Level C handle specific triglycerides found in the diet. ment of the pancreatic enzyme replacement West Wing, Southampton Because palmitic acid is the predominant satu- treatment. Nine healthy children (six boys and General Hospital, Tremona rated fatty acid in the UK diet,2 previously we three girls) aged 5–8 years (mean, 7.2 years) Road, Southampton SO16 examined the absorptive capacity of the gut from local schools also participated in the 6YD, UK. using 13C labelled palmitic acid in healthy chil- study. Informed consent was obtained from all Accepted 5 February 1998 dren and patients with cystic fibrosis by meas- of the subjects and the study protocol was Metabolic handling of 13C labelled tripalmitin in cystic fibrosis 45 approved by the Ethical Committee of South- before and during the stool collection period. ampton and South West Hampshire Health None of the animal source protein foods eaten Arch Dis Child: first published as 10.1136/adc.79.1.44 on 1 July 1998. Downloaded from Commission. (such as eggs and meat) were naturally After an overnight fast, the [1,1,1- enriched with 13C. 13C]tripalmitin was administered orally to the subjects at a dose of 10 mg/kg body weight (99 BREATH AND STOOL ANALYSES atom % excess; Masstrace, Woburn, USA) as The methodology for processing stools has part of a controlled standard test meal consist- been described previously.8 Enrichment of 13C 13 ing of 120 g white bread, 100 g orange juice, in the stool and as CO2 on the breath was and 10 g butter of low 13C abundance analysed by continuous flow isotope ratio mass (−25.5‰).8 The patients with cystic fibrosis spectrometry (ANCA-NT GSL; Europa Sci- took the same amount of enzymes with the test entific Ltd). Total stool lipid was extracted meal that they would usually take with a snack from stools by a modification of the method of meal and this ranged from 1458 to 6849 IU Folch and colleagues.11 The 13C enrichment of 13 lipase/kg body weight/day (mean, 3750). The samples of breath CO2 and stool was 13C labelled tripalmitin was given as a glucose- expressed as the “per ml relative diVerence sucrose-casein emulsion, using a modification from the reference standard Pee Dee Belemnite 9 13 12 of Emken et al, because emulsification before (PDB)” as defined by Craig ( CPDB,‰). The administration overcomes the problems associ- proportion of administered 13C label in the ated with the physicochemical properties of the stools was calculated according to the formula crystalline form of this label, which might oth- presented by Schoeller and colleagues.13 The erwise result in poor digestion and absorption apparent absorption of the 13C label was deter- if given in a free, unemulsified form.10 mined from the diVerence between the amount Breath samples were collected using breath of label administered and that excreted in the collection bags (Quintron) before consuming stool. the test meal to provide a measure of baseline The proportion of 13C label excreted on the 13 13 C excretion on the breath, and were then col- breath as CO2 was expressed as a percentage lected at hourly intervals for a period of at least of absorbed 13C label each hour and as the six hours and then after eight hours, 10 hours, cumulative percentage dose excreted over 24 and 24 hours. Specimen breath samples were hours, according to the formula presented by transferred into evacuated gas sample contain- Watkins et al.4 ers (Exetainers; Isochem, Finchampstead, UK) for analysis in duplicate. All subjects were STATISTICS rested for the duration of the tests and were The results are reported as mean (SD). Statis- given constant supervision at the Clinical tical comparisons between the data were Nutrition and Metabolism Unit at Southamp- performed using the unpaired Student’s t test. ton General Hospital. No additional food or DiVerences between means were considered drink was permitted during the initial six hour significant when p < 0.05. Associations be- http://adc.bmj.com/ period except for bottled mineral water. After tween variables were tested by the Pearson six hours, the subjects ate a meal without any product moment correlation coeYcient (R). foods naturally enriched for 13C. Whole body CO2 excretion was measured by indirect calor- Results imetry (GEM; Europa Scientific Ltd, Crewe, In healthy children, 6.0% (3.7%) of the UK) for a period of 15 minutes at the same administered 13C label was excreted in the stool time points as breath sampling over the first six (range, 1–12.7%) (table 1). In contrast, hours to calculate the amount of label excreted patients with cystic fibrosis excreted more 13C on September 29, 2021 by guest. Protected copyright. each hour.
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