Nutritional Management in Short bowel syndrome

Shraddha BhattDietetic Intern

ARAMARK Healthcare Distance Learning Dietetic Internship

Virginia Hospital CenterDecember 21, 2014

Outline

• Disease description

• Evidence-Based Nutrition Recommendations

• Case Presentation

• Nutrition Care Process

• Conclusion

Short bowel Syndrome

Malabsorptive syndrome due to functional and/or anatomic loss of extensive small bowel

SBS: small bowel length of <200cm without a colon or 50cm of SB with a colon

26% of 40,000 home TPN patients had SBS in 1992, according to Oley Foundation home Parenteral nutrition (PN) registry for US

ETIOLOGY OF SBS

Adults

• Mesenteric vascular accidents

• Crohn’s disease• Radiation enteritis• Trauma • Recurrent intestinal

obstruction• Volvulus

Children

• Necrotizing enterocolitis• Intestinal atresia• Volvulus• Extensive agangliosis• Gastroschisis• Congenital short bowel• Meconium peritonitis

SBS: Clinical features

Symptoms

- Diarrhea- Dehydration- Electrolyte abnormalities- Malnutrition- Weight loss, vitamin deficiencies, mineral deficiencies

Complications

- Peptic ulcer disease

- Kidney stones- Gallstones- Small bowel bacterial overgrowth- Metabolic bone disease- Treatment related: Line infections, hepatic dysfunction

SBS TREATMENT OPTIONS

Intestinal Rehab

Surgical Augmentatio

n

Long term TPN

Intestinal Transplant

Evidence-Based Nutrition Recommendations (ASPEN)

Small frequent meals (If colon present: 50-60% kcal from complex CHO, 20-30%kcal from fats, 30-30% proteins. If colon absent:40-50%kcal from complex CHO, 30-40% kcal from fats,

20-30% kcal from protein)

Anti- diarrheals

Oral rehydration solution Enteral nutrition

Anti-secretory agents

Parenteral nutrition

Evidence-Based Nutrition Recommendations

Prospective analysis of serum carotenoids, vitamin A and tocopherols in adults with short bowel syndrome undergoing

intestinal rehabilitation

• Method: 21 PN dependent adult SBS patients similar in age, gender, BMI, diseases leading to SBS, length of residual small bowel, presence of colon and PN regimen were enrolled in a 12-week intestinal rehabilitation program which included individualized dietary modification, multivitamin supplementation and randomization to receive either s.c. placebo or human growth hormone (GH).

• Result: Serum α- tocopherol concentration was negatively correlated with PN lipid dose (r=-0.34, p<0.008). Also significant % of subjects were depleted in diet-derived carotenoids despite oral and intravenous multivitamin supplementation and dietary adjustment during intestinal rehabilitation and PN weaning.

Ref: Luo M, Estivariz CF, Schleicher RL et al. Prospective analysis of serum carotenoids, vitamin A and tocopherols in adults with short bowel syndrome undergoing intestinal rehabilitation. J. Nutrition. 2009; 25(4): 400–407

Growth Hormone for Intestinal Adaptation in Patients With Short Bowel Syndrome: Systematic Review and Meta-Analysis

of Randomized Controlled Trials

• Method: Searched publications regarding randomized controlled trials (RCT) on the use of growth hormone (GH) with or without glutamine for the treatment of patients with SBS and its effect on body weight, lean body mass and intestinal absorption function.

• Result: A meta-analysis of 4 trials involving 70 patients showed that GH had a positive but short term effect in terms of increased weight (p <0.0001), energy absorption (p=0.04), lean body mass (p<0.001), nitrogen absorption (p=0.04) and fat absorption (p=0.04)

Evidence-Based Nutrition Recommendations

Ref: Guo MX, You-sheng Li, Lei FM et al. Growth Hormone for Intestinal Adaptation in Patients With Short Bowel Syndrome: Systematic Review and Meta-Analysis of Randomized

Controlled Trials. Elsevier HS Journals. 2011; 72: 109-119.

CASE PRESENTATION

• A 67 year old African American female was brought to the hospital

from her workplace where she was found supine, in a mute condition.

The patient underwent a stroke code at the hospital.

• Past medical history: type 2 diabetes mellitus, recent treatment for

pneumonia approximately 3weeks ago, uncontrolled hypertension

with baseline pressures usually between 150s to 160s systolic, CHF,

diastolic dysfunction hypothyroidism, DM2 retinopathy under

treatment at NIH.

• Findings: The patient was found to have dilated small bowel likely due

to small bowel obstruction (SBO) per the CT of abdomen. GI and

nutrition consultations were requested by the admitting physician.

Nutrition Care Process: Assessment

• Client History: 67 year old working female, non-smoker, had no family history for early strokes or heat attack. She was prescribed aspirin, labetalol, lantus, Pepcid, nicardipine, fentanyl and vancomycin.

• Food/Nutrition-Related History: Prior to admission patient used to take following medications: Simvastatin, clonidine, Lasix, Lisinopril, Coreg, Levothyroxine, Aspirin and Glipizide. Unable to obtain any information regarding food/nutrition related history since patient was intubated.

• Nutrition-Focused Physical Findings: Right sided hemiplegia, drowsiness, BP:189/127 and altered mental status. These physical findings are consistent with classic symptoms of Cerebrovascular accident (CVA), hypertension and AFib.

Nutrition Care Process: AssessmentAnthropometrics Height Weight DBW BMI

157 81.6 165% 33.10

Macronutrient Needs (based on ABW:57.7kg)

Calories Protein

18-23kcal/kg due to intubation= 1039-1327kcal 1-1.2g/ kg =58-69kg 

Measurement Value Normal Rationale

Chloride  

114 96-106 mEq / L Metabolic acidosis, impaired renal function

Blood Urea Nitrogen  

45 (H) 6-20 mg / dl Impaired kidney function

Creatinine  

2.4 (H) 0.9-1.3 mg / dl Impaired kidney function

CO2 16 (L) 23-29MEQ/L Metabolic acidosis

Blood glucose 182(H) <70- 110mg/dl Diabetes

Nutrition related laboratory parameters

• ARAMARK Nutrition Status Classification: Utilizing ARAMARK’s Nutrition Status Classification Worksheet, the patient was classified as severely compromised (status 4), with 12 total nutrition care priority points. -- 2 points for nutrition history (fair appetite),

- 4 points for feeding modality (NPO) - 0 points for stable weight - 2 points for serum albumin (3.2 g/dl) - 2 points for diagnosis (CVA).

Based on the patient’s status, the plan for follow-up and re-assessment occurred every 1-4 days.

Nutrition Care Process: Assessment

• Nutrition Care Process: Nutrition DiagnosesPES: (Clinical): Altered GI function related to likely SBO as evidence by NG output of 1.2L overnight and 875ml since 7AM.

• Nutrition Care Process: Intervention(s)I: Enteral nutrition: Rate Goal: EN vs PN depending on bowel improvement • Nutrition Care Process: Monitoring and Evaluation

The initial plans for monitoring and evaluation included:- Plan to continue to keep patient NPO , NG to LCWS for monitoring NG output- Initiate tube feeding: With NG output improved and less abdominal distention, trickle feeds to be started: Osmolite 1.5- Repeat abdomen CT to evaluate SBO vs Ischemia- Initiate parenteral nutrition if patient with true SBO and no improvement by day 4 after this assessment.

Due to the patient’s status, follow-up assessments were scheduled every 1 to 4 days.

Findings in follow-up assessmentEx-lap and resection of small bowel was done due to necrosis of majority of small bowel, 65cm total small bowel was left in place

End to end anastomosis done with duodenum intact, 30cm from Ligament of Treitz and 30cm from ileo-ceacal valve was anastomosed and colon intact. Patient was intubated/vent, NG to LCWS, renal status was worsening. TPN started and trickle TF Osmolite 1 at 10ml

Repair of anastomotic leak of SB anastomosis. TF were stopped due to vomiting after suction, TPN was infusing at 50ml.

JP drain placed draining purulent fluid and two dehisced wounds at abdominal surgical inscision, was on HD, put on cyclic TPN

Discharge Details

• Discharged on TPN• JP drains removed• Referral for GI nutrition consultancy

CONCLUSION

Patients undergoing massive small-bowel resections often

experience fluid shifts and difficulties with volume and electrolyte

homeostasis in the early postoperative period and malabsorption of

vitamins and minerals.

Immediate treatment: resuscitation, stabilization, diagnosis and

treatment of complications. Nutrition intervention with TPN is often

required on a prolonged or permanent basis in the management of

SBS patients.

In addition to nutrition intervention, pharmacological treatment with

the use of antimotility agents such as Imodium is also essential to

slow the intestinal transit time and to allow increased absorption of

nutrients and fluid.

THANK YOU