Nutritional and Medical Implications of

Short Gut Syndrome with

Multiple Nutrient Deficiencies

A Case Study

Regina M. Gill University of Maryland, College Park

Dietetic Intern

June 15, 2011

©

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Table of Contents

Executive Summary…………………………………..……………………………….……………………………………………….3

Case Report……………………………………………..………………………………………………………………………………….4

General Information...……………..………..………………………………….…..……………………………………4

Medical/Surgical Data..……………………………………………………………….…..................................4

Nutritional History………………………..……………………………………..…….……………………………………4

Hospital Course of Patient.………………………………………………………………………………………………………….8

Case Discussion……………………………………………………………………………………………………………………………9

Medical Considerations.……………………………………….………………………………………………………….9

Nutritional Therapy.……………………………………………………………………………………………………….12

Implications of Findings to the Practice of Dietetics……………………………………………………….12

Appendices

Appendix A – Figure of a Normal Gastrointestinal Tract...………………………..…..…………………………..13

Appendix B – Table 1: Hospital Medications ……………………...………………………………………………….….15

Table 2: Pertinent Laboratory Values……………………………………….…………………………..18

Glossary of New Terms…..………………………………………………………………………………………………………….19

References.……………………………………………………...............................................................................21

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Executive Summary

The digestive system is composed of a series of organs that are joined together stretching from the

mouth to the anus, better known as the gastrointestinal (GI) tract, to help break down food and absorb

nutrients that the body needs (3). Most of the organs in the GI tract are hollow to allow food to pass through

during the breakdown process via peristalsis, involuntary smooth muscle contractions. Once food is swallowed

and reaches the stomach, contents are pushed into the small intestine, a complex tube that extends 600 cm

(20 feet), where the final stages of digestion occur as a result of the secretion of juices from the liver and

pancreas, and then nutrients are absorbed, in the duodenum, jejunum, and ileum.

Short Bowel Syndrome (SBS) can be defined as “the loss of nutrient-, fluid-, and electrolyte-absorptive

capacity associated with partial or near-complete loss of the small intestine (4).” The reduction in absorptive

capacity leads to frequent diarrhea, steatorrhea, electrolyte imbalances, dehydration, weight loss, and

macronutrient and micronutrient deficiencies (5). In adults, a diagnosis of SBS is made when the small

intestine is less than 200 cm in length (8). SBS can be congenital or acquired from one or more major

resections of the small intestine (8).

Deficiencies of fat-soluble vitamins (A, D, E, and K) and essential fatty acids (omega-3 and omega-6) are

commonly seen in patients with SBS due to frequent diarrhea and fat malabsorption, which can be

exacerbated by certain medicinal treatments for diarrhea. Depending on which part of the small intestine is

resected, deficiencies of vitamin B, particularly vitamin B12 when the terminal ileum is removed, are possible.

There is no one specific treatment for SBS. If treatment is initiated, the goals should be to prevent

further nutrition-related consequences, such as diarrhea and dehydration, and “correct any preexisting

nutrient deficiencies (1).” Treatment for SBS should include high doses of multiple vitamin and mineral

supplements, but could also include total parenteral nutrition.

The following case study presents a 54 year-old female with a history of short bowel syndrome and

chronic lung disease who was admitted with respiratory failure, hypoxemia, and malabsorption. This report

discusses the nutritional and medical interventions for a patient with short bowel syndrome with multiple

nutrient deficiencies.

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Case Report

Patient Information

DP, a 54 year old white female, was admitted to Anne Arundel Medical Center with shortness of

breath. DP’s diagnoses at the time of admission were respiratory failure, dyspnea, hypoxemia, and

hypokalemia, interstitial lung disease (ILD), bilateral pneumonia, pulmonary infiltrates, hypoxia,

thrombocytopenia, and colovaginal fistula. The patient was admitted on March 27, 2011 and discharged on

April 11, 2011.

Medical and Surgical Data

DP’s past medical history is significant for short bowel syndrome (SBS), chronic malabsorption, chronic

diarrhea, colovaginal fistula, deep vein thrombosis (DVT), pernicious anemia, Lupus anticoagulant disorder

(hypercoagulable state), osteopenia, rheumatoid arthritis, mycobacterium avium-intracellulare complex

(MAC), and lung infection. Pertinent past surgical history includes three colon surgeries with a large amount of

the small and large intestines removed, hysterectomy, and cosmetic surgery for non-healing wound.

Nutritional History

Food and Nutrient history:

DP’s diet history includes hot chocolate with marshmallows for breakfast and her only meal of the day, dinner,

is usually a frozen meal. She stated that her appetite is good, but she only eats at dinnertime because food

runs straight through her causing diarrhea and she does not want to worry about running to the bathroom

when she is out of the house. She does like to eat out at restaurants close to home, such as Applebee’s and

Famous Dave’s. DP has no known drug or food allergies. DP usually takes a multivitamin/mineral supplement

in addition to supplements of vitamin A, D, and E, as well as Tums. DP revealed that although she should be

taking the supplements, she has not been able to afford them recently. She does not consume commercial

nutrition beverages such as Ensure, nor has she ever had nutrition support. DP has been seen previously by a

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Registered Dietitian that recommended small, frequent meals to help with the diarrhea. She followed the

recommendation for a while, but is no longer following because she claims that it does not work for her.

Anthropometric Measurements:

DP has had fluctuations in her weight for many years. Prior to her colon surgeries, DP weighed 202 lbs.

After the first surgery in 1992, she lost 100 lbs. in a year and her weight dropped to 102 lbs. She recovered

well and regained her weight and went back to work for five years until she had second bowel surgery (1998),

after which she lost nearly 100 lbs. again. DP stated that her usual body weight over the last few years has

been 134 lbs and she would like to stay at that weight.

1992 1993 1998 1999 2009 2011 (admit)

202 lbs. 102 lbs. 202 lbs. 105 lbs. 134 lbs. 117 lbs.

(Weight history self-reported with the exception of weight on day of admission.)

Biochemical Data and Medical Tests:

See Appendix A for laboratory results and medications, dosages, and dates of administration. A number of

diagnostic tests were performed on DP.

• Strep Pneumoniae antigen, urine – 3/27/2011: Negative for S. Pneumoniae antigen.

• Legionella antigen, urine – 3/27/2011: Negative for L. Pneumophila serogroup 1.

• Chest CT Angiography Thoracic – 3/28/2011: Results show bilateral alveolar interstitial infiltrates

suggesting inflammatory process such as pneumonia. There is no evidence of pulmonary embolism

and the thoracic aorta shows no evidence of an aneurysm.

• Chest CT with IV contrast – 04/02/11: The findings show no pulmonary emboli but much more

extensive ground glass infiltrates. Considering the circumstances, this may indicate a progression of

pneumonia.

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• Stool culture of intestinal feces – 4/1/2011: Results showed no growth of enteric pathogens after a

48-hour incubation period.

• Chest X-ray – 4/1/2011: Results showed no evidence of a specific pneumonic infiltrate.

• 4/5/2011: Improved appearance from 4/1/2011 with partial clearing of the lungs.

• Pneumocystis Carinii Stain for the detection of Pneumocystis carinii pneumonia – 4/1/2011: Results

were negative.

• Chest X-ray computed tomography (CT) scan without contrast – 4/11/2011: The findings showed

improvement in the ground-glass infiltrates but also showed fluid at the left lung base and prominent

interstitial disease.

Nutrition-Focused Physical Findings:

During the admitting physical exam, DP showed signs of generalized malaise and severe dyspnea. Her

blood pressure was 146/94 millimeters of mercury (mmHg), heart rate was 103 beats per minute, respiratory

rate was 20 breaths per minute, and temperature was 96.7°F. DP appeared thin and ill. Her hair was thin and

falling out, she had decreased night vision, and had red bumps on her skin, which appeared to be due to

hyperkeratosis, an excessive development of keratin in hair follicles. She was experiencing bilateral scattered

wheezes and bilateral crackles with decreased air entry into her lungs. She had no complaints of nausea,

vomiting, or diarrhea, although she has chronic diarrhea that she manages with medication. After admission, a

bronchoscopy was performed on DP to confirm the presence of mycobacterium avium complex. The results

were found to be positive for M. avium complex rRNA.

Client History:

DP has not worked since 1998 as a Geriatric Nurse Practitioner due to her medical complications.

Currently, DP lives in low income housing, receives Medicare, Medicaid, and SNAP (food stamp) benefits ($124

per month), and buys foods that she can afford. Her family is very supportive and visited her often while in the

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hospital. DP smoked two packs of cigarettes per day for 25 years, but quit in early 2008. DP has no specific

cultural attitudes that influence her dietary intake. DP’s physical activity level is sedentary, mainly due to

symptoms of hypoxemia with exertion.

Nutrition Diagnosis: Nutrition Care Process

Initial Nutrition Diagnosis with NCP code:

Patient assessed with predicted suboptimal nutrient intake (NI-5.11.1) related to a physiological condition

associated with increased need for a nutrient due to altered metabolism as evidenced by presence of a

condition for which research shows an increased prevalence of insufficient nutrient intake in a similar

population.

Initial Intervention with NCP code:

Vitamin and Mineral Supplements: Vitamin (ND-3.2.3) A (1), D (3), E (4)—Increasing intake of vitamins to

prevent and resolve nutrient deficiency related to malabsorption.

Nutrition Monitoring with NCP Code:

Fat and cholesterol intake: Essential fatty acids (FH-1.5.1.8)—Increase intake of EFA to prevent and resolve

nutrient deficiency. Recommendation was made for patient to eat a slice of toast with margarine, a

convenient source of linoleic acid, an essential fatty acid, every morning.

Nutrition Prescription:

Source Calorie requirements Protein requirements Fluid requirements

Facility standards 1500 kcals/day* 46 g/day 1500 ml/day

ADA Evidence Analysis

Library

N/A N/A N/A

Online nutrition care

manual (1)

1500 kcals/day 46 g/day 1500 ml/day

*Mifflin-St. Jeor Equation (MSJE) with a stress factor of 1.3

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Hospital Course of Patient

Medical Treatment:

DP had a number of medical treatments during the course of her stay in the hospital. She received

nebulization respiratory therapy treatments with Levalbuterol (Xopenex) and Ipratropium (Atrovent) nearly

every four hours daily for respiratory failure. A Peripherally Inserted Central Catheter (PICC) line was placed on

3/31/11.

Nutritional Treatment:

DP received an oral general diet order during the entire length of time that she was admitted to

AAMC. Her dietary intake was 25-50% on the day of the initial nutrition assessment. At the two subsequent

follow-up visits on 4/5/11 and 4/8/11, her dietary intake was 50-75%. DP’s dietary intake increased over the

course of her stay, and on some days she ate nearly all of her meal. Although DP had a good appetite and her

body mass index was normal for her height (22.5 kg/m2), her hemoglobin and hematocrit were both below

normal levels all but two days during her admission, and her physical signs and symptoms indicated a poor

nutritional status due to several nutrient deficiencies, particularly fat-soluble vitamins and essential fatty acids.

Due to the SBS causing chronic diarrhea, DP was taking Cholestyramine (Questran), a medication that

comes as a powder and then is mixed with liquid that is typically used for lowering cholesterol levels in the

blood, but also used to manage diarrhea, such as in DP’s case (2). Cholestyramine decreases absorption of

essential fatty acids and fat-soluble vitamins as well as other medications and supplements causing a drug-

nutrient interaction. Taking the cholestyramine with SBS may exacerbate malabsorption. For this reason, high

dosage vitamin and mineral supplements were recommended to reduce nutrient deficits of vitamins A, D, E,

and essential fatty acids, particularly omega-3 fatty acid. On 4/5/11, DP was started on the appropriate

supplements (please refer to appendix B).

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Nutritional goals for DP include high dosage vitamin and mineral supplementation to reduce nutrient

deficits of vitamins A, D, and E along with a multivitamin/mineral and small frequent meals that are low in fat

except for essential fatty acids, and no fruit juices (which may exacerbate the diarrhea).

Case Discussion

Medical Considerations

The digestive system is composed of a series of organs that are joined together stretching from the

mouth to the anus, better known as the gastrointestinal (GI) tract, to help break down food and absorb

nutrients that the body needs (3). See figure 1 for an illustration of the digestive system and all of its organs.

Most of the organs in the GI tract are hollow to allow food to pass through during the breakdown process via

peristalsis, involuntary smooth muscle contractions. The pancreas and liver assist with digestion and

absorption by producing and secreting necessary digestive juices and enzymes (3).

Food digestion begins when food is chewed, mixed with salivary amylase, an enzyme found in saliva, to

begin breaking down starch from carbohydrate foods, and then swallowed. The food then travels down the

esophagus by peristalsis to the stomach. In the stomach, the food and liquid are mixed with digestive juices

(hydrochloric acid, pepsin for protein breakdown, and gastric lipase for fat breakdown), to continue the

digestive process (4). From there, the contents of the stomach are pushed into the small intestine, a complex

tube that extends 600 cm (20 feet), where the final stages of digestion occur as a result of the secretion of

juices from the liver and pancreas, and then nutrients are absorbed, in the duodenum, jejunum, and ileum.

The pancreas plays an integral role in digestion and absorption because it secretes proteolytic enzymes to

break down protein, amylase to break down starch, and lipolytic enzymes to break down fats (4). Once the

nutrients are absorbed, the undigested portion of food, such as fiber, is pushed into the colon to be excreted.

SBS can be defined as “the loss of nutrient-, fluid-, and electrolyte-absorptive capacity associated with

partial or near-complete loss of the small intestine (4).” The reduction in absorptive capacity leads to frequent

diarrhea, steatorrhea, electrolyte imbalances, dehydration, weight loss, and macronutrient and micronutrient

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deficiencies (5). Once a significant portion of the small intestine is lost, the residual function is determined by

the mucosal surface area; this area “determines absorptive capacity and is functionally related to the number

and height of villi and microvilli (4).”

Deficiencies of fat-soluble vitamins (A, D, E, and K) and essential fatty acids (omega-3 and omega-6) are

commonly seen in patients with SBS due to frequent diarrhea and fat malabsorption, which can be

exacerbated by certain medicinal treatments for diarrhea. Depending on which part of the small intestine is

resected, deficiencies of vitamin B, particularly vitamin B12 when the terminal ileum is removed, are possible.

When dietary fat is eaten but not emulsified to an absorbable state by bile salts as it travels the length

of the small bowel, fat will be malabsorbed causing fatty, foul-smelling stools, steatorrhea. Not only will the

fat be unabsorbed, but also the fat-soluble vitamins. This can cause the body to become depleted of essential

fatty acid stores as well as the fat-soluble vitamins (6). “Essential fatty acids are fats required by the body that

cannot be synthesized by other nutrients, and must be either absorbed in sufficient quantities through the

gastrointestinal tract or given intravenously (6).” The physical signs and symptoms of essential fatty acid

deficiency are “flaky, dry skin, patchy red areas on the skin, alopecia, brittle nails, easy bruising, bleeding

tendencies, diarrhea, delayed wound healing, and increased incidence of infections and illnesses (6).” It is

recommended that a tablespoon of safflower or soybean oil (both contain linoleic acid) be used at every meal

or snack to prevent essential fatty acid deficiency (6). Studies show that there is an inverse relationship

between linoleic acid status and inflammation (7). It is important for patients with fat malabsorption to take

fat-soluble vitamin supplements, preferably in chewable form.

Vitamin A deficiency can cause detrimental effects on the body, such as xerophthalmia (dryness of the

eye), night blindness (impaired adaptation to darkness), follicular hyperkeratosis (thickening of the hair

follicles), and keratinization of the skin as well as the mucous membranes in the respiratory and GI tracts (4).

Respiratory infections and impaired immunity can occur as a result of keratinization.

The prevalence of SBS in the United States in unclear. In 1992, it was estimated that 40,000 people

had intestinal failure and received home total parenteral nutrition (TPN) (4,8). This data showed that 26% of

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those patients had SBS. However, this data did not consider patients who did not require TPN or those

successfully weaned from TPN (8). In adults, a diagnosis of SBS is made when the small intestine is less than

200 cm in length (8). SBS can be congenital or acquired from one or more major resections of the small

intestine (8). This is usually related to trauma to the abdominal region, inflammatory bowel disease, primarily

Crohn’s disease, radiation therapy for genitourinary or gynecologic malignancies, volvulus, and complications

of surgery (6).

There is no one specific treatment for SBS. If treatment is initiated, the goals should be to prevent

further nutrition-related consequences, such as diarrhea and dehydration, and “correct any preexisting

nutrient deficiencies (1).” Studies suggest that administering exogenous growth hormone, supplemental

glutamine, and a modified fiber-containing diet could enhance nutrient absorption (9). Byrne et al. (9) has

reported that this combination demonstrated statistically significant increases in absorption of calories,

protein, carbohydrate, and water and sodium, which resulted in significantly decreased stool output. Fat

absorption, however, did not change. Treatment for SBS should include high doses of multiple vitamin and

mineral supplements. Refer to Appendix B to view the supplements taken by DP. The prognosis for patients

with SBS varies. The nutrient absorptive capacity can improve over time with proper nutritional and medical

interventions.

DP has typical characteristics of SBS and compares quite closely with usual findings in the literature in

regard to having chronic diarrhea, physical signs and symptoms of deficiencies of essential fatty acids, fat-

soluble vitamins, and vitamin B12, and the need for vitamin and mineral supplementation. The keratinization

that DP has, as a result of vitamin A deficiency, could ultimately be contributing to the worsening condition of

her lung disease. One difference in DP’s case is that she is not on TPN nor has she ever been. Most articles

that address SBS dietary management focus on TPN dependence or supplemental TPN to maintain good

nutrition status. However, long-term TPN has several complications and may inhibit bowel adaptation (10).

Improvements in DP’s nutritional status will also help to decrease complications of her lung disease; and an

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oral diet high in essential fatty acids with ample vitamin and mineral supplementation, along with tincture of

opium to control diarrhea, would be a good start.

Nutritional Therapy

An oral diet is recommended to promote bowel adaptation; a process which includes villus

hyperplasia, increases in the number of transporters per cell, diameter, and villus height, in order to optimize

bowel absorptive capacity (10,6, 8). Small, frequent meals are generally recommended. Certain foods should

be avoided in patients with SBS, such as concentrated sweets like fruit juices, soft drinks, and desserts, caffeine

and alcohol, and dairy products. These foods and beverages can increase fluid loss and exacerbate diarrhea

(6). Most patients who have undergone major bowel resections will receive TPN initially, first 7-10 days (5, 8).

Enteral nutrition is also used to promote bowel adaptation. “The role of enteral feedings is to provide a

trophic stimulus to the GI tract; parenteral nutrition is used to restore and maintain nutrient status (5).” TPN is

recommended and necessary for patients with less than 100 cm of bowel and a non-functioning colon (8).

Medium-chain triglycerides (MCTs) are commonly used in patients with SBS to improve fat absorption and

decrease steatorrhea; however, they do not supply essential fatty acids and absorption only occurs in patients

with a preserved colon (10).

The nutritional therapy recommended for DP was very similar to that recommended in the literature.

DP has had SBS since 1998. Unlike many patients with SBS, DP never received enteral or parenteral nutrition

support after the bowel resection. DP has maintained an oral diet. During her hospital stay, she received a

regular diet, but was encouraged to decrease intake of fruit juices and lactose, and increase her intake of foods

containing essential fatty acids, like margarine and salad oils.

Implications of Findings to the Practice of Dietetics

Short bowel syndrome is a devastating disorder of the gastrointestinal tract. Patients with SBS have a

number of nutritional complications and deficiencies. Treating a condition such as this requires critical

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thinking and knowledge of medical nutrition therapy to make nutritional recommendations in the patient’s

best interest considering all factors. This case report shows how critical medical nutrition therapy was in

treating DP’s condition. Without the knowledge of dietitians, DP’s nutrient deficiencies might have gone

undiagnosed. DP was admitted to the hospital for complications due to her lung disease; however, the

nutrition team discovered that she had nutrient deficiencies as a result of SBS that were ultimately impacting,

and possibly worsening, her lung disease. It is crucial to balance medical and nutritional therapy to provide the

patient with the best, individualized care.

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Appendix A

Source: http://www.search.com/reference/Gastrointestinal_tract

Figure 1.

Gastrointestinal tract

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Appendix B

Table 1. Hospital Medications

Medication

Dosage Dates of

Administration

Medical Function Nutrition Side Effects

Acetaminophen

(Tylenol)

650 mg 3/27-4/11

Every 6 hours

PRN

Analgesic Caffeine increase rate

of absorption & effect

Albuterol 5% 2.5 mg 3/28

Every 4 hours

Bronchodilator Sore/dry throat,

anorexia

Alprazolam (Xanax) 0.25 mg 3/28-4/11

Every 4 hours

Antianxiety Increased weight and

appetite

Azithromycin

(Zithromax) IVPB

500 mg

250 mL 3/27-3/28

Daily

Antibiotic Stomatitis w/ IV, N/V,

diarrhea, abd pain

Caspofungin

(Cancidas)

70 mg

50 mg

3/29 Daily

3/30-4/3

Antifungal N/V, dyspepsia or

Diarrhea

Cefepime

(Maxipime)

1 g 3/28-4/3

Every 8 hours

Antibiotic Anorexia, oral

candidiasis, sore

mouth

Cholestyramine

(Questran)

1 packet 3/27-4/8

2 times daily

Antihyperlipidemic,

Antidiarrheal

May decrease

absorption of fat, fat-

soluble vitamins, Ca,

Fe, Zn, Mg, Fol

Cyanocobalamin

(Vitamin B12)

1000

mcg/mL

Every 30 days B complex vitamin Caution with Fol

supplement

Enoxaparin

(Lovenox)

60 mg 3/28-4/9

Every 12 hours

Anticoagulant N/A

Ethambutol

(Myambutol)

400 mg 3/27-4/4

2 times daily

Tuberculosis

treatment

Anorexia, abd pain,

N/V

Famotidine (Pepcid) 20 mg 3/28-4/5

2 times daily

Antigerd Decreased gastric acid

secretions, increased

gastric pH, N/V

Fentanyl

(Sublimaze)

50 mcg 4/1

Every 1 hour

Analgesic Anorexia

Fluconazole

(Diflucan)

100 mg 3/27-3/29

2 times daily

Antifungal Dry mouth, N/V,

diarrhea, dyspepsia

Folic acid tablet 1 mg 3/27-4/11

3 times daily

B Complex Vitamin,

antianemic

N/A

Furosemide (Lasix) 40 mg 4/5 Loop Diuretic Anorexia, increased

thirst

Hydrocortisone 3/27-4/11 Anti-inflammatory Increased appetite

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rectal cream 2.5% 2 times daily and weight

Hydroxychloroquine

(Plaquenil)

200 mg 3/27-4/11

Daily

Antiarthritic

(rheumatoid)

Anorexia, decreased

weight

Ipratropium

(Atrovent) 0.02%

0.5 mg 3/28-4/11

Every 4 hours

Bronchodilator Dry mouth,

metallic/bitter taste

Levalbuterol

(Xopenex) nebulizer

solution

1.25 mg 3/28-4/11

Every 4 hours

Bronchodilator Increased appetite,

sore/dry throat

Methylprednisolone

sodium succinate

(solu-medrol)

125 mg 4/2-4/8

Every 6 hours

Anti-inflammatory Increased appetite

and weight

Metronidazole

(Flagyl)

250 mg 4/1-4/6

Every 8 hours

Antibiotic Dry mouth, N/V,

candidiasis, diarrhea

Midazolam (Versed) 1 mg/mL 4/1-4/4 Antianxiety Decreased weight and

appetite

Morphine 4 mg/mL 2-4 mg 3/30-4/11

Every 4 hours

PRN

Analgesic, narcotic N/V, constipation,

diarrhea, decreased

gastric motility

Naloxone (Narcan) 0.4 mg 4/1-4/9

Continuous

Opioid Antagonist N/V

Nitrofurantoin

(Macrobid)

100 mg 3/28 Antibiotic N/V, abd pain,

dyspepsia, diarrhea

Omega-3 acid ethyl

esters (Lovaza)

1 gm 4/11 –

4/5/2012

(Continue after

discharge)

2 times daily

Fish oil,

antihyperlipidemic

Taste changes/after

taste, dyspepsia,

belching

Ondansetron

(Zofran) injection

5 mg 3/27-4/11

Every 6 hours

PRN

Antiemetic,

Antinauseant

Abd pain,

constipation,

diarrhea, dry mouth

Opium tincture

10 mg/mL (1%)

2.7 mL 3/27-4/10 Antidiarrheal N/V, dizziness,

drowsiness,

constipation

Pancrelipase (Lip-

Pro-Amyl) (Creon

12000)

2 caps 3/27-4/11

Before meals

& at bedtime

Pancreatic enzyme

replacement

N/V, constipation,

diarrhea, abd cramps

Pantoprazole

(Protonix)

40 mg 4/6-4/11

Every morning

before

breakfast

Antigerd Diarrhea, nausea, abd

pain, decreases

gastric acid secretion

Potassium chloride

SA (K-DUR) tablet

40 mEq 3/27-3/28

Every 6 hours

Electrolyte

Replacement

GI irritation,

Nausea/Vomiting

(N/V), abdominal

(abd) pain, diarrhea

Thera vitamin 4/11 – Multivitamins Constipation,

17

(Multivitamins) 4/5/2012

(Continue after

discharge)

Daily

diarrhea, upset

stomach

Vitamin A 10,000

units

4/11 –

4/5/2012

(Continue after

discharge)

Daily

Fat soluble vitamin Adequate fat, vitamin

E and protein needed

for absorption

Vitamin D

(Ergocalciferol-D2)

50,000

units

3/27-4/11

Daily

Vitamin Anorexia, decreased

weight, increased

thirst, increases Ca

absorption.

Vitamin E 400

units

4/11 –

4/5/2012

(Continue after

discharge)

Daily

Fat soluble vitamin High PUFA intake

increases

requirements

Warfarin

(Coumadin)

5 mg

2.5 mg

1 mg

4/5 Nightly

4/6

4/7-4/11

Anticoagulant N/V, cramps, taste

changes. Intake of vit

K is essential

Zolpidem (Ambien) 5 mg 3/27-4/11

Nightly PRN

Sleep aid Dry mouth, N/V,

cramps, diarrhea

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Table 2. Pertinent Lab Values

Mar Apr

27 28 29 30 31 1 2 3 4 5 6 7 8 9 10 11 Normal

Range

NA 143 138 142 144 146 135-146

mmol/L

K 3.0 4.4 3.5 2.7 3.9 3.2-5.0

mmol/L

CL 111 111 115 109 107 101-111

mEq/L

CO2 23 23 17 27 29 21-31

mEq/L

BUN 6 5 21 11 11 5-20

mg/dL

CREAT 0.7 0.6 0.7 0.5 0.5 0.6-12

mg/dL

WBC 6.9 10.4 8.4 12.6 11.1 8.7 8.3 11.4 9.4 13.0 9.8 10.6 10.8 12.9 13.4 5-10 mm3

HGB 11.4 14.0 11.4 11.3 11.3 11.2 11.6 11.1 10.8 12.7 11.7 10.8 11.0 11.4 10.6 12-15 g/dL

HCT 34.4 41.3 34.1 33.9 34.2 34.8 35.2 33.4 32.6 37.0 34.2 31.9 32.6 33.8 31.7 35%-47%

GLUC 99 170 151 148 70-115

mg/gL

INR 5.0 1.5 1.2 1.2 1.2 1.6 2.0 2.1 2.3 1.9

*Values in red are not within normal limits

19

Glossary of New Terms*

Colovaginal fistula –an abnormal tube-like connection between the colon and the vagina

Deep vein thrombosis (DVT) – a blood clot that forms in a vein deep in the body

Duodenum – the first part of the small intestine, between the pylorus and the jejunum; it is 8 to 11

inches in length

Enteral nutrition – when a liquid food mixture (formula) containing protein, carbohydrates, fats,

vitamins and minerals, is given through a tube into the stomach or small intestine; also known as tube

feeding

Enterectomy – Excision of a portion of the intestines

Follicular hyperkeratosis – a skin condition that results from excessive development of keratin in the

hair follicles

Gastric lipase – an enzyme found in the stomach that breaks down fat

Gastrointestinal (GI) tract – a tube that extends from the mouth to the anus in which food moves

through to be digested and absorbed

Hydrochloric acid – a fluid formed in the stomach to aid in digestion

Hyperkeratosis – an overgrowth of the horny layer of the epidermis

Hypoxemia – Decreased oxygen tension (oxygen concentration) of arterial blood

Ileum – the lower three fifths of the small intestine from the jejunum to the ileocecal valve

Interstitial Lung Disease (ILD) – a disease of the lower respiratory tract characterized by

inflammation and disruption of the walls of the alveoli

Jejunum – the second portion of the small intestine extending from the duodenum to the ileum

Keratinization – the process of keratin formation that takes place within the keratinocytes as they

progress upward through the layers of the epidermis of skin to the surface stratum corneum

Lipotytic enzymes – enzymes that break down triglycerides into glycerol and free fatty acids

Lupus anticoagulant disorder (hypercoagulable state) – a blood disorder in which antibodies attack

plasma proteins thus leading to a high risk of clotting

20

Medium-Chain Triglycerides (MCT) – triglycerides with 8 to 10 carbon atoms; they are digested and

absorbed differently than the usual dietary fats and, for that reason, are used in treating

malabsorption

Mycobacterium avium-intracellulare complex (MAC) – an atypical mycobacterium that causes

systemic bacterial infection in patients with advanced immunosuppression

Night blindness – decreased ability to see at night or in darkness

Osteopenia – a significant decrease in the amount of bone mineral density normally found in a

population or group

Pepsin – the chief enzyme of gastric juice, which converts proteins into proteases and peptones

Pernicious anemia – a decrease in red blood cells as a result of inadequate vitamin B12 absorption

Proteolytic enzymes – enzymes (trypsin, chymotrypsin, and carboxypeptidase) that break down

proteins into peptides, proteases, peptones, and amino acids

Rheumatoid arthritis – a chronic systemic disease marked by inflammation of multiple synovial joints

Steatorrhea – fatty stools

Total parenteral nutrition (TPN) - when a liquid food mixture (formula) containing protein,

carbohydrates, fats, vitamins and minerals, is given through a tube into the vein

Villi – Plural of villus

Villus – A small fold or projection that covers the mucous membrane surface of the small intestine

Volvulus – a twisting of the bowel on itself, causing obstruction

Xerophthalmia – conjunctival dryness with keratinization of the epithelium following chronic

conjunctivitis and in disease caused by vitamin A deficiency

*(11)

21

References

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Disease > Diseases and Conditions of the Lower GI Tract > Bowel Surgery > Bowel Resection.

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http://nutritioncaremanual.org/topic.cfm?ncm_heading=Nutrition%20Care&ncm_toc_id=144

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9. Byrne, TA, Morrissey, TB, Nattakom, TV, Ziegler, TR, Wilmore, DW. Growth hormone,

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bowel syndrome. Journal of Parenteral and Enteral Nutrition. 1995;19:296-302.

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adult patients. J Clin Gastroenterol.2006;40:S85–S93.

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