Amy Lofl eyClinical Update

CLINICAL CASE STUDY: SHORT BOWEL

SYNDROME

Overview of Short Bowel Syndrome TerminologyPhysiologyPathophysiologyTreatmentMedicationRecommendations

Multidisciplinary team

Case StudyMedical HxNutrition Assessment

Nutrition Intervention

Prognosis Conclusion

OBJECTIVES

Clinical Update

SHORT BOWEL SYNDROME

Short bowel syndrome (SBS): “inadequate functional bowel to support nutrient and fluid requirements for that individual, regardless of the length of the GI tract in the setting of normal fluid and nutrient intake”[1].

Ileocecal valve: valve at the end of the ileum that allows transit of small intestine contents into the large intestine.

Intestinal adaptation: “a growth process of the remaining small bowel through morphological and functional changes, leading to improved absorption”[2].

Dumping syndrome: rapid emptying of the stomach into the small bowel especially when simple carbohydrates are consumed

TERMINOLOGY [1,2]

NORMAL PHYSIOLOGY [4,5]

The small intestine is the site of nutrient absorption. Normal length of a small intestine varies between 300 to

800 cm in an adult and 250 cm in a term baby. On average it absorbs 150-300 g monosaccharides, 60-100

g fatty acids, 60-120 g amino acids and peptides and 50-100 g ions.

Most absorption occurs in the ileum. The first 100-150 cm of jejunum is where carbohydrates,

nitrogen and fat are absorbed.

The large intestine is the site at which water and salts are absorbed. It is approximately 1.5 m in length and absorbs 500 to 1000

ml a day.

Bowel Segment Main function

Duodenum

Absorption of CHO, FAT, PRO

Micronutrient absorption (iron, calcium, phosphorus, magnesium, copper, folic acid)

Jejunum

Primary site of CHO & PRO absorption

Water-soluble vitamin absorption

Ileum

Primary site of vitamin B12 and bile salt

absorption

Absorption of fat-soluble vitamins

ColonFluid absorption

Na, Cl, K, and fatty acid reabsorption

NORMAL PHYSIOLOGY [2]

Decreased ability for bowel to absorb normally.

Signs and symptoms Diarrhea Weight loss Dehydration Nutritional deficiencies Electrolyte imbalances

The health and amount of remaining small bowel will determine the type of nutrition support a patient will require both short term and long term.

PATHOPHYSIOLOGY [2,4]

Other portions of the small intestine will adapt absorption abilities for the removed portions.

The jejunum and ileum are the most important for absorption. The jejunum is more adaptive to absorption problems than the ileum.

The length of ileum that is left will determine the absorption of vitamin B12 and fat malabsorption.

If no ileum is left a patient may be dependent on TPN.

The presence or absence of the ileocecal valve will aff ect transit time, ostomy, how fluid is managed, and if small bowel bacteria will grow.

PATHOPHYSIOLOGY [3]

Bowel Segment Complications of Resection

Duodenum Decreased macronutrient digestion

Acidosis, anemia, osteopenia

Jejunum Macronutrient and water-soluble vitamin malabsorption

Fluid and electrolyte losses

Ileum Unable to absorb B12

Loss of fat-soluble vitamins

Decreased absorption of trace elements

Increased risk of renal oxalate stones

Colon Dehydration

Electrolyte abnormalities

Reduce ability to absorb bile salts

PATHOPHYSIOLOGY [2]

Recovery from bowel surgery can vary in length of time depending on: Age Comorbidities Preexisting malnutrition Primary diagnosis Loss of ileocecal valve Length of remaining bowel

Adaptation can begin within 48 hours and continue 12-24 months after surgery. Adaptation occurs by the bowel lengthening and becoming

thicker with a larger diameter.

PATHOPHYSIOLOGY [2,5]

TYPES OF RESECTIONS

http://transplants.ucla.edu/body.cfm?id=69

Children Necrotizing enterocolitis

(NEC) Intestinal atresia

(volvulus, hernia, intussusception)

Congenital short bowel syndrome

Trauma Gastroschisis Apple peal anomaly Crohn’s disease Abdominal tumors Radiation enteritis Hirschsprung’s disease

Adults Massive surgical resection Crohn’s Malignancy Radiation enteritis Trauma Vascular catastrophies

(embolism/thrombus) Volvulus Stangulated hernias SB fistulas Surgical bypass Surgical error or obesity

treatment Chronic intestinal pseudo-

obstruction

ETIOLOGY OF SBS [1,]

Two treatment therapies: Pharmocotherapy and Medical Nutrition Therapy Pharmocotherapy includes antimotility agents, antisecretory

agents, H2 Blockers, and IVs MNT includes TPN, EN, and oral feeds, as well as educating

patient on how to eat and care for nutrition support. SNAPP is an acronym to help remember how SBS is treated

S=sepsis – treated with antibiotics and CT scan N=nutrition – hydration is the fist concern, enteral nutrition is

the preferred feeding. First line of feeding is TPN and then weaned to tube feeding and then oral feedings if feasible

A=anatomy – knowing the anatomy helps to determine treatment and side effects

P=protect the skin – if a stoma is created wound care needs to be taught

P=planned surgery – additional surgeries for further resection, stoma care, and fistulas.

MEDICAL TREATMENT [7,4]

MEDICATION USES

TPN is needed immediately after surgery to maintain fl uid and electrolytes until bowel function returns. Should begin within the first 24 hours and is usually required

for the first 7-10 days. TPN energy requirements: 25-35 kcal/kg/day with 1-1.5 g/kg/

day protein EN feedings are started within 2-3 days after surgery or

fl uid and electrolyte losses are reduced and patient is stable. Start with trickle feeds and advanced as tolerated about every 3-7 days. Lactose free formulas are usually suggested to decrease

lactose malabsorption and symptoms.“Management includes meticulous nutritional support,

with emphasis on early advancement of enteral feeds, weaning from parenteral nutrition, monitoring for complications, and addressing possible associated liver dysfunction”

MEDICAL TREATMENT [8]

The ability to return to a normal diet is determined by the amount of remaining bowel, presence of a colon, and an intact ileocecal valve.

Oral rehydration solutions may be required if less than 100 cm of jejunum remains to help absorb sodium.

PRACTICE RECOMMENDATIONS [1,4]

PRACTICE RECOMMENDATIONS [7]

Nutrient Small Bowel Ostomy Colonic continuity

Carbohydrates 50% of total energy complex carbohydrates including soluble fiber, limit simple sugars

50-60% of total energy complex carbohydrates, including soluble fiber

Proteins 20-30% of total energy 20-30% of total energy

Fats <40% of total energy 20-30% of total energy

Fluids ORS important; minimize fluids with meals, sipping of fluids between meals

Minimize fluids with meals, sipping of fluids between meals

Vitamins Daily multivitamin with minerals; monthly B-12; possibly vitamins A, D, and E supplements

Daily multivitamins with minerals; possibly B-12; possibly vitamins A, D, and E supplements

Minerals Generous use of sodium chloride on food; calcium 1,000-1,500 mg daily, possibly iron, magnesium and zinc supplements

400-600 mg calcium with meals; possibly iron, magnesium, and zinc supplements; reduced oxalate

Meals 4-6 small meals 3 small meals plus 2-3 snacks

EVIDENCE-BASED PRACTICE

“The goal of therapy is to maximize small bowel absorption of fl uids and nutrients to prevent defi ciencies and dehydration”(7).

The optimal diet for individuals with jejunostomies includes: 50% CHO 20-30% protein ≤40% fat. Including foods high in fiber to help slow gastric emptying, transit

time, and thicken ostomy effl uent. The optimal diet for individuals with intact colon includes:

A diet high in complex CHO, and lower in fat with a distribution 50-60% CHO 20-30% protein 20-30% fat.

It is best to avoid foods and drinks that are high in simple sugars to prevent dumping syndrome

PRACTICE RECOMMENDATIONS [7,1]

Proper eating techniques Eating slowly Resting after eating Minimal fluid with meals Proper preparation of ORS if required Avoid sweets Liberal use of salt – encourage salty foods and the salt shaker Fiber is needed for patients with a colon Lactose should be no more than 20 g/day

Oral diets Patients may need 200-400% more than their needs to take into

account malabsorption A higher carbohydrate diet is recommended for those with a

colon whereas a higher fat, low carbohydrate diet is needed in patients with jejunostomies.

DIETARY ADVICE [1]

Physician Hospitalist Infectious Disease Surgeon

Registered Dietitian Metabolic Nurse NursesPharmacist

MULTIDISCIPLINARY TEAM

CASE STUDY

Age: 66 YOFPresents to hospital with nausea and

vomiting

Medical DiagnosisColitis

MRS. E

Past Medical HistoryCOPDPerforated diverticulitis w/colostomy (now reversed)

HTNGERDBreast Cancer

Past Surgical HistoryExploratory lap and resection

HysterectomyMastectomy

Social HistorySmoke one pack/dayOccasional alcohol use

PAST MEDICAL/SURGICAL/SOCIAL HISTORY

INITIAL NUTRITION ASSESSMENT (9/2/13)

Assessment • Abdominal pain• Constipation• Vomiting• Diet order: NPO• Colitis that may need surgery• Patient is intubated• fragile skin

Anthropometrics • Height: 66 inches • Height: 93.89 kg• BMI = 33.4 • IBW = 59 kg • %IBW = 159%

Labs• Albumin 2.4 L• Phosphorus 8.6 H• Ammonia 149 H• Glucose 220 H

Energy and protein needs (based on facility guidelines)• Calorie needs: 1035-1317

kcals (11-14 kcals/ kg)• Protein needs: 118 g (2

g/kg IBW)• Carbohydrate needs: 147 g

(50%)• Fluid Needs: 1500 mL

Inadequate protein-energy intake RT GI/oral complaints, alteration in GI tract structure and/or function, sedated on ventilator, distention, no bowel sounds, constipation AEB 0% meal, NPO diet restriction, inadequate protein possible d/t surgery pending.

NUTRITION DIAGNOSIS

Intervention TF – continuous; Osmolite with start rate of 10 mL/hour

(goal rate 10 mL/hour). Provides 254.4 kcals, 8 g protein

Goal: Tube feeding will meet 50% of estimated needs within 2-3 days

Monitor/Evaluate Monitor rate for start GI function/tolerance Labs (sodium, glucose, phosphorus, potassium, magnesium,

intake, output) Status weight

NUTRITION INTERVENTION/MONITOR/EVALUATE

Medication Use Nutrition Interaction

Propofol Sedative Provides 1.1 kcals/ml

Levophed Used for hypotension or removing blood flow to the GI tract

Don’t feed while one this medication

Cipro Antibiotic

Vancomycin Antibiotic

Zosyn Antibiotic

MEDICATIONS

Diet order: NPONutrition Dx: Inadequate protein energy intake Meds: propofol @ 12.3 mL/hour = 325 kcal

Levophed @ 0.037 mcg/kg/min Cipro, vancomycin, flagyl, zosyn

Wt: 216 lbs. 9# weight gain in 1 dayLabs

Potassium 3.2; Ammonium 43; Fasting Glucose 173; intake 8729; output 1485 (og=300, stool-50)

Total colectomy, ileostomy, w/jejunostomy (gangrene bowel)

Goal: Tube feeding will meet 50% of estimated needs within 2-3 days

Monitor: GI function/tolerance, labs, weight Follow up daily

9/3/13 NUTRITION FOLLOW UP

Diet order: NPONutrition Dx: Inadequate protein-energy intake Meds: propofol @ 14 mL/hour = 370 kcalsLabs

Potassium 3; phosphorus 1.7; Ammonium 38; Fasting Glucose 196; intake 7209; output 3450 (og =800; ileo=150)

Patient remains intubated, s/p colectomy secondary to ischemia, viable ileostomy (95 cmsm bowel from ligament of treitz)

Goal: trickle feeding vs. PN start over next 2 daysCoordination of care: surgery notes may start PN in

next 24 hours.

9/4/13 NUTRITION FOLLOW UP

Diet order: NPO Nutrition Dx: Inadequate protein-energy intake Meds: propofol @ 16.8 mL/hour 443 kcals Labs

Phosphorus 1.9; Magnesium 1.5; Fasting Glucose 180; intake 6087; output 4590

Energy: 1035-1317 kcals, 118 g protein Goal: tolerate at least 50% of needs as PN over next 2 days Initiate PN: plan PN goal of 119 g protein (33.5%), 160 g

CHO (39%), 39 g fat (27.5%) to provide ~ 1400 kcal Tkcals provided plus meds=1255 kcals, 0 g lipids, 118 g

protein, 100 g CHO Coordination of care: noted surgery plans to start PN,

discussion of low rate EN but not yet ordered Monitor progression of diet vs. alternative nutrition Follow up daily

9/5/13 NUTRITION FOLLOW UP

Diet Order: NPONutrition Dx: Inadequate protein-energy intake Meds: propofol @ 16.8 mL/hour 443 kcalsEnteral kcals = 443 from propofolPN not startedWt. 110.6 kg Labs

Potassium 2.6; Magnesium 1.7; Fasting glucose 102; intake 2605; output 3751; lactic acid 1.5 (ileo 605, g 250)

PN not started secondary to only a femoral line and plans for PICC placement

Energy 1035-1317 kcals 118 g protein

9/6/13 NUTRITION FOLLOW UP

Goal: tolerate at least 50% PN/EN over 2 days Initiate EN osmolite at 10 mL/hour; 0 mL flushPatient with short gut syndrome start trickle feed via

g-tube and monitor Initiate PN at goal except CHO at reduced rate, hold

lipids secondary to med rate Provides 118 g protein, 120 CHO, 1400 kcals

Coordination of care: discussed start of trickle feeding with intensivist; plan to start PN after PICC

Monitor progression of diet vs. alternative nutritionFollow up 3-4 times/week

9/6/13 NUTRITION FOLLOW UP

Diet order: NPO New PES: Altered GI tract RT alteration in GI tract structure

and function AEB short gut syndrome, malabsorption Goal: Moving forward with PN to provide at least 75% of needs

w/meds over the next 1-2 days. Meds: propofol @ 19 ml/hr = 501 kcals PN: 120 g CHO (75%), 118 g pro (100%), 0 g l ipids, 1440 volume Wt.: 108 kg, wt decreased 2 kg over 1 day (lasix is noted in meds) Labs: alb 2.8, phos 3, mag 2.4, FSBS 171, intake 1439, output 2835,

i leo out 1100 Increase EN to 20 ml/hr @ 2000 today with no fl ush

Total kcals with meds is 508, total protein 18 g PN: decrease CHO to 50%, increase in TF and elevated BG, wil l also

decrease pro d/t increase in TF Total kcals with meds is 1173, 0 g lipids, 100 g protein, 80 g CHO

Collaborated with physician: discussed TF advancement, per MD wil l increase TF to 20 ml/hr at 2000 (24 hr after initial start)

Monitor GI function/tolerance and labs daily Total: 1424 kcals (100%), 118 g pro (100%), meets 72 of CHO needs

9/7/13 NUTRITION FOLLOW UP

EN: osmolite @ 20 ml/hr w/o flush Total kcals with meds: 508 and 18 g protein

PN: propofol 19ml/hr = 501 kcals total kcals= 1173 80 g CHO (50%), 100 g pro (85%), 0 g lipids

Wt.: 106.5 kg, Labs: alb 2.7, pot 3.9, FSBS 178, phos 5.2, alk phos wdlTolerating nutrition regimen ileo out 815, residue 100

mlGoal: PN + TF to provide 75-100% estimated needs of

1317 kcal, 118 g proteinCollaborate with other disciplines: discussed poc with

MD, once osmolite bag empty change to “a more calorie dense formula” per MD request

Monitor GI function/tolerance and labs daily

9/8/13 NUTRITION FOLLOW UP

Meds: pepcid, lasix, prednisone, zosynWt. 228# weight loss of 6# in 1 dayLabs: prealb 17.7, BUN 42, Na 146, FSBS 208, intake

2580, output 5131 (stool=435, g-tube=100), CVP 14Tolerating GIGoal: PN+TF to provide 90-100% estimated needs and

protein within 24 hrsEN: change formula to perative @ 30 ml/hr w/o flush

936 kcals, 48 g prot, MD was more calorie dense formulaPN: change tkcals 871, 70 g proteinTotal for TF+PN +meds = 1807 kcals, 118 g pro, 59 g

lipids, 130 g CHOMonitor GI, labs, skin and weight daily

9/9/13 NUTRITION FOLLOW UP

Labs: intake 3454, output 5380 (stool=590)Tolerating GI, no change to needsGoal: meet 90-100% estimated kcal and protein needs

via tube feeds next 24-48 hrs.EN: change to 40 ml/hr (increased by MD) no flush

1248 kcals, 64 g prot, 173 g CHOPN: change secondary to change in TF rate, meds:

287 kcals 54 g prot, 21 g CHO (per discussion w/Rph- needs small amount for compounder)

Monitor GI, labs, skin and weight daily

9/10/13 NUTRITION FOLLOW UP

Diet order: Clear l iquids Pt took 100% jello and juice this a.m. Meds: lasix, prednisone, zosyn Wt. 204#, 24# weight loss in 2 days (diuresing) Labs: FSBS 144, intake 2949, output 6125, i leo=900 Tolerating GI Energy needs reassessed: 1669-1855 (18-20), 118 g pro (2g/kg

IBW), 220 g CHO (50%), fl uid 1ml/kcal New goal: Meet 100% estimated calories and protein needs via TF

+po diet within next 24-48 hrs. EN: perative @ 40 ml/hr with 3 prostat 1548 kcals (93%), 109 g prot

(92%) Collaborated with MD, MD wants to add prostat to tube feeds today,

but continue TPN for 2 days and begin clear l iquids PN: continue PN w/protein reduced to 50% from yesterday: 35 g

protein=140kcals and 21 g CHO=71 kcals Coordination of care: pt wil l get 1759 kcals (100%) and 144 g

protein (122%) Monitor GI, labs, PO, skin and weight daily

9/11/13 NUTRITION FOLLOW UP

Diet order: Regular Labs: Na 139, K 4.3, FSBS 141, output 3150, ileo 1700 Tolerating GI Goal: TF + po to meet at least 100% needs: not met

(however 100% kcal pro needs met with TPN+TF) TPN to discontinue today, diet advanced to regular today,

anticipate goal met in next 1-2 days. Supplement: Ensure BID = provides 700 kcal, 27 g proEN: continue at current rate: perative @ 40 ml/hr with 3

prostat : 1548 kcals (93%), 108 g prot (92%) PN: Stop Monitor GI function/tolerance, PO adequacy dily Anticipate oral intake to slowly increase over the next 1-2

days, for now will keep TF at current goal Pt discharged prior to F/U

9/12/13 NUTRITION FOLLOW UP

Prognosis is good with a full recovery.

Pt left with TF and oral diet

EXPECTED OUTCOMES

SBS management is very complicated and needs careful management by a team including: physician, dietitian, surgeon.

The amount of bowel resected aff ects when and how a patient can be fed

It is very important to know the exact amount of bowel left and what sections they are.

Things I would have done diff erently When doing this assessment I would probably explain

more the amount of bowel left.Educate the patient on how they are supposed to eat. Recommend using a standard formula such as Isosource

that has a higher calorie instead of perative.

LESSONS LEARNED

1. Parrish CR. The clinician’s guide to short bowel syndrome. Nutrition Issues in Gastroeneterology 2005;(31): 67-100.

2. Nutrition Care Manual. Short Bowel Syndrome. 3. Nutrition Care Manual. Bowel Resection. 4. Peck J, Soo L, Boland L, Windsor A, Engledow A. Short bowel

syndrome: the pathophysiology and treatment. Gastrointestinal Nursing. 2012;10(2):32-38.

5. Krause6. Rahhal RM. Short Bowel Syndrome. Chapter 20. 295-305.

www.pnjhuaq.mhprofessional.com/downloads/products/0071633790/bishop_ch20_295_305.pdf.

7. Wall EA. An overview of short bowel syndrome management: adherence, adaptation, and practical recommendations. Journal of the Academy of Nutrition and Dietetics. 2013. 1200-1208.

8. Donohoe CL, Reynolds JV. Short Bowel Syndrome. The Surgeon. 2010: 270-276.

9. Seetharam P, Rodrigues G. Short bowel syndrome: a review of management options. Saudi J Gastroenterol . 2011;17:229-35.

REFERENCES