Transcript Case Study: Short Bowel

Dietetic Management of
Short Bowel Syndrome
Ali Singer
Gastroenterology Specialist Dietitian
Frenchay Hospital
Content
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Definition
Physiology
Management
Case Study
Definition
• The reduction of functioning gut mass to
below the minimum necessary for the
absorption of nutrients and/or water and
electrolytes
Fleming &
Remington, 1981
Variability in Intestinal Lengths
• Small intestinal length at autopsy:
• 3-8.5m
• Shorter in women
• SBS more common in women (67%)
Bryant, 1924
• Small intestinal length at laparotomy:
Cook, 1974
Backman, 1974
Slater, 1991
n
6
32
38
mean (cm)
421
643
500
range (cm)
320-521
400-846
302-782
Record of Intestinal Length
• Length removed often recorded
• Length remaining is more important:
• Laparotomy
• SB contrast studies (less accurate)
• Nutritional/fluid supplements needed if
< 200cm SB
Commonest causes:
• Crohns
• Superior mesenteric
artery thrombosis
• Irradiation
Causes of SBS
Intestinal Failure
Acute
Chronic
Fistula / obstruction Small bowel dysfunction
Ileus
Enteritis
Chemotherapy
Short bowel
Jejunum-colon Jejunostomy
Infection
Gut bypass
Small bowel dysfunction
Enteritis
Irradiation
Dysmotility
Crohns
SBS: Anatomy
• Mid-SB resection:
• Uncommon
• Rarely problems
• Jejunocolic anastomosis:
• Usually fluid balance maintained
• Nutritional issues when SB <100cm
• Jejunostomy/high output enterocutaneous fistula:
• Large stoma/fistula water and sodium losses
• Dehydration
• +/- nutritional problems
Types of Short Bowel
Pt Groups
Jejunum
Ileum
Colon
Nutritional needs
Jejunum - ileum Resected
Intact
Intact
Rarely need nutrition
Jejunum -colon
Resected
Intact
Gradual undernutrition
Adaption occurs
<50cm may need TPN
Resected
/ Absent
Absent
Fluid & electrolyte losses
No adaption
<100cm IV saline
<75cm IV nutrition also
Jejunostomy
Intact
Normal GI Physiology
Jejunum
Ileum
• Na+/H2O secretion 1st
Active Na+/H2O absorption
• Less leaky
• Na+ absorption
100cm
• Leaky
• Na+ absorption
• Small conc. gradient only
• Dependent on H2O movement
• Coupled to gluc/AA
absorption
• Maximal Na+ absorption
when [Na+] 120mmol/l
• Large conc. gradient
• Not dependent on H2O
movement
• Not coupled to gluc/AA
absorption
• Increased by Aldosterone
Normal GI Physiology
Liquid
Vol secreted (L)
External
Food & drink
Salivary
glands
Saliva
Stomach
Gastric juice
Pancreas
Pancreatic juice
0.5-0.8
Liver
Bile
0.5-0.9
Jejunum
Passive proximal secretion
& distal absorption
Ileum
Active absorption
2
0.5-1
2-3
1-2
Total
1-2
2-5, vit B12, bile
salts
Colon
External
Vol absorbed(L)
Large capacity
Faeces
400
6.5-9.7
3-9
Gastrointestinal Motility
Jejunal-colon:
NORMAL
Jejunostomy:
FAST
Peptide YY and GLP-2 (glucagon-like peptide 2) are
released when food passes the terminal ileum and
caecum that act as ileal and colonic braking
mechanisms; this is lost in jejunostomy
Physiological Consequences
• Increased gastric emptying
• Increased SB transit
• Increased gastric secretions (first 2 wks)
• Resection of ileal & colonic braking mechanism
• Changes in GI hormones
• Reduced peptide YY, glucagon like peptide 2
• Increased gastrin
Critical Lengths
Critical SB length
Note
Jejunostomy
100cm
More needed if
diseased bowel
Jejunocolic
anastomosis
~50cm
Depends on amount of
residual colon
Nutritional Support and Bowel
Length
Jejunal length
Jejunum-colon
Jejunostomy
0 - 50 cm
Parenteral nutrition
Parenteral nutrition and
saline +/- Mg
51 - 100cm
Oral / Enteral nutrition
Parenteral nutrition and
saline +/- Mg
85 - 100cm
Parenteral saline
101 - 150cm
None
Oral / enteral nutrition
and glucose / saline
solution
151 - 200cm
None
Oral / enteral glucose
/ saline solution
• <200cm: restrict oral hypotonic fluids, sip
glucose - saline supplement (100mmol/L Na,
like jejunostomy fluid)
• <100cm: parenteral saline
• <50cm: parenteral nutrition and saline
GI Secretions
Jejunum – colon
• Reabsorb unabsorbed fluid in colon
Jejunostomy
• Salt and water loss from stoma
• <100cm jejunum: losses > oral intake
• Rapid sodium fluxes occur in jejunum
• If water/solutions of <90mmol/L sodium are drunk a
net efflux of sodium into the bowel lumen occurs until
100mmol/L is reached
Absorptive Functions
B12 and fat malabsorption occur if >60-100cm
terminal ileum resected
• Increased hepatic synthesis of bile salts cannot
compensate; unabsorbed bile salts contribute to
colonic secretion
Magnesium deficiency
• Chelation of unabsorbed fatty acids reduces
absorption
• Increased renal excretion; secondary
hypoaldosteronism
Hypomagnesaemia
Magnesium chelation with
unabsorbed fatty acids
Reduced absorption
Reduced secretion
and function PTH
Reduced manufacture
of 1,25 hydroxy-vitamin D
Hypoaldersteronism due
to hyponatremia
Decreased jejunal
magnesium absorption
Direct increase in renal
magnesium losses
Clinical Picture
Water
Na
• Thirst
• Low BP/ postural hypotension
• Urea/ Creatinine/ Potassium
• Daily body weight
• Fluid balance/ stoma output
• Low urine volume
• Urine Na 1-2/7, then weekly, as
OP 2-3 monthly
• Depletion if urine Na <10mmol
Mg
Serum
magnesium
High stoma
output
Sx in Mg <
0.6mmol/L
Nutrition
BMI
<18.5kg/m2
Mid-arm muscle
circumference
<19cm:
<22cm men
Adaptive Processes
• Hyperphagia; increased food intake
• Structural adaption:
• increasing absorptive area
• Functional adaption;
• slowing gastrointestinal transit (gastric emptying and
small bowel transit)
• Occurs in jejunum-colon patients due to high peptide YY
and GLP-2, leads to increased jejunal absorption of
macronutrients (glucose, water, Na, Ca) and overtime
may no longer need TPN
Jejunum-Colon Pts
Post resection:
• Parenteral fluids and nutrition (helps surgical repair, ileus
recovery and avoids deficiencies)
• 6/12 PPI
• Multivitamin
Long term:
• Undernutrition
• Diarrhoea due to malabsorption
• Vitamin/mineral deficiency
Undernutrition
• >50% of energy from diet malabsorbed
• High energy foods, sip feeds +/- NG/PEG feed;
if fails TPN. Improves over time.
• Long term TPN:
• Absorption of <33% oral energy intake
• Absorption 30-60%, high energy requirements
• Large volume stomal output / diarrhoea
• High carbohydrate, normal fat, low oxalate diet
• Topical sunflower oil for essential fatty acids
The Fat Dilemma
High fat diet
Unabsorbed long chain fatty acids in colon
Reduce
transit times
Reduce water and
sodium absorption
Reduce bacterial
carbohydrate fermentation
Bind calcium
and magnesium
Increase oxalate
absorption
Increased stool losses
Renal stones
Increased
D lactic acidosis
But high carbohydrate without fat is unpalatable and fat yields twice
as much energy as carbohydrate; also a low fat diet risks essential
fatty acid deficiency.
Deficiencies
Common:
Rare:
• B12 deficiency; replace
• Selenium deficiency;
• Potassium deficiency
• Zinc deficiency; rare unless
replace
• Magnesium deficiency;
replace if occurs
• Vitamins D, E, A, K and
essential fatty acids;
replace
large stool volumes
• Water and sodium; rare
as absorbed well in colon,
if occurs sips of glucose
saline drink
Other complications
Diarrhoea
• Limit food intake
• Consider loperamide 2-8mg 30mins pre meals, codeine
30-60mg 30mins pre meals
• If >100cm terminal ileum resected cholestyramine for bile
salt malabsorption and reduced oxalate absorption
Confusion
• Hypomagnesaemia, thiamine deficiency, lactic acidosis
(restrict mono / oligo saccharides) and hyperammonaemia
(inadequate citrulline manufacture, Tx is arginine)
Drug absorption
• warfarin, digoxin, thyroxine, loperamide and if <50cm jejunum
omeprazole may not be absorbed
Gallstones (calcium bilirubinate stones)
• Bilary stasis. Therefore occurs in 45%, especially men
• Tx IV amino acids, enteral feed, cholecystokinin injections, NSAIDS,
ursodeoxycholicacid, metronidazole, cholecystectomy
Renal stones (calcium oxalate stones/nephrocalcinosis/CRF)
• Occurs in 25% largely due to increased colonic absorption of oxalate
Social
Ca Oxalate Renal Stones
Symptomatic renal stones
Calcium oxalate
precipitation in renal tract
Increased colonic
absorption of oxalate
Fat
malabsorption
Bile salt induced
increased colonic
permeability to oxalate
Low oxalate diet
Avoid dehydration
Increase dietary Ca
Low fat diet
Replace fat with medium
chain triglycerides
Oral cholestyramine
Nephrocalcinosis
+/- renal failure
Reduced bacterial
degradation of oxalate
Pyridoxine or
thiamine deficiency
Replacement
Hypocitraturia
Jejunostomy Patient Issues
• Salt and water depletion
• May be large volume of stomal output
• Greater volume lost after food or fluids
• GI secretion  4L/day, majority absorbed in jejunum
therefore more fluid losses via stoma if short jejunum
• Jejunostomy fluid contains 100mmol/L Na, 15mmol/L K
• If given hypotonic fluids  100mmol/L the mucosa
allows leaking of fluid and electrolytes into the lumen
• Low sodium levels are NOT SIADH but sodium depletion,
this is resolved when urine Na  30mmol
Jejunostomy Patient Issues
• Hypokalemia
• Rare, occurs when <50cm jejunum
• Usually due to secondary hypoaldersteronism from Na depletion
• Can be due to hypomagnesaemia causing potassium
channel dysfunction and increased renal potassium
secretion which responds to Mg not K supplements
• Hypomagnesaemia
• B12 deficiency, confusion, drug absorption, and
gall stones
• Nutritional
High Output Jejunostomy
• Exclude other causes of a high output
• Stage1:
Establish stability
• Stage 2:
Establish oral intake
• Introduce enteral food/fluid/feed
• Stage 3:
Rehabilitation
• Stoma care, HPN training, social issues
• Stage 4:
Long term care
Other Causes
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Intra-abdominal sepsis
Partial/intermittent bowel obstruction
Enteritis (clostridium, salmonella)
Recurrent disease in remaining bowel (Crohn’s,
irradiation)
Bacterial overgrowth
Suddenly stopping drugs (steroids, opiates)
Giving prokinetics (metoclopramide)
Coeliac
Hyperthyroidism
Stage 1: Establish Stability
• Severe dehydration & Na+ depletion
• Keep patient NBM
• IV normal saline (2-6L/day)
Treat the Cause
• Intraabdominal sepsis / abscess
• Partial / intermittent bowel obstruction
• Strictures; placement / muscle tunnel / adhesions / crohns /
ischaemic fibrosis / radiotherapy
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Enteritis; clostridium / salmonella / rota virus
Recurrent disease; Crohns / irradiation
Sudden stopping of drugs; steroids / opiates
Drugs; prokinetics / metoclopramide / metformin / PPI / statin
Diet; lactose intolerant / coeliac
Stage 2: Establish Oral Intake
• Restrict oral fluids to <500ml/day
• Hypotonic (water, tea, coffee, squash, alcohol)
• Hypertonic (fruit juices, coca cola, sip feeds)
• Drink a glucose-saline solution <500ml/day
Hypotonic Fluids
High Output
0 mmol Na+
100 mmol/L Na
•Leaky
Na 140 mmol/L
•Small conc. gradient only
•Dependent on H2O movement
Unable to
maintain Na
gradient
jejunum
Electrolyte Mix
Smaller volume
90 mmol Na+/L
100mmol/L Na+
Na+ 140 mmol/L
Na+ and H2O
Oral Rehydration Therapy
Na
(mmol/L)
K
(mmol/L)
Glucose
(mmol/L)
Volume
(ml)
WHO
90
20
111
1000
Electrolyte
mix
90
0
111
1000
Dioralyte
60
20
90
200
Recipe: ORS
• 20g (6 teaspoons) glucose
• 3.5g (1 level 5ml teaspoon) salt
• 2.5g (1 heaped 2.5ml spoon) sodium
bicarbonate
• 1L water
• Add cordial, chill and drink through a straw
Drug Therapy
Antimotility:
Antisecretory:
• Loperamide upto
• Omeprazole; decreases
64mg PO o.d as decreased
enterohepatic circulation
• Codeine
• Lomotil
gastric acid secretion
• Ranitidine/cimetidine
• Octreotide; decreases
intestinal secretions
Vit/min supplements:
• B12, selenium, Mg2+, vit A, D, E, K
Parenteral Therapy
• 0.5–1L saline sc +/- 4mmol MgSO4
1-3/week
• 1L saline IV +/- 4-12 mmol MgSO4
> 3/ week
• IVN
Outcome Aims
• Clinical:
• No thirst or signs of dehydration
• Acceptable strength, energy and appearance
• Measures:
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Gut loss
<2L/day
Urine volume >800ml/day
Urinary Na+
>20 mmol/L
Normal serum Na+, Mg2+ and K+
Body weight within 10% of normal
Stage 3: Rehabilitation
• Transfer to IF unit
• Wound healing
• Stoma care
• HPN training
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1st patient 1978
Longest 27 years
Mean age 50.2 years (19.9 – 76.9)
~27 new patients per year per unit
• Social issues
Stage 4: Long-Term Care
• 3 monthly multidisciplinary clinics
• IF unit
• Shared care with local hospital
Outcome 1 year after starting
HPN (467 patients)
R efus ed
0.6
Withdrawn
1.1
In hos pital
0.9
100% mortality
P ancreatic malignancy (1)
C O AD (1)
MND (1)
8.1
Died
15.1
R eturned to oral
3.7% mortality
C rohn’s (188)
74.2
C ontinuing on HP N
0
20
40
% patients
60
80
BANS 1996-2000
Mr J: background information
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72 male  UC (1961)
Pan-protocolectomy (1962)
Refashioned/Re-sited Ileostomy (1993)
s/b Dr Kaskey, Renal Physician 2º renal
impairment and kidney stones
• Referred from renal dietetic clinic (pt
initially attempted to resist a referral!)
Issues
High output ileostomy
output (estimated up to
2.5L per day)
Dehydration ( UO,  urine Na)
Renal impairment
& stone formation
Assessment: Concerns
• Renal impairment:
* stage 4 CKD
• Poor seal on stoma
bags
• Not leaving house
when stoma active
Biochem
Result
Na
134
K
3.5
Ur
20.0 
Creat
233 
eGFR*
25 
Uric Acid
0.64
Intervention
Intervention
1. Add salt to meals
2. Low fibre diet
3. Restrict hypotonic fluids
to 1L/d
4. St Marks Fluid 1L/d
Rationale
Increase Na intake (&
serum Na)
 Insoluble fibre & residue
through bowel
Avoid drawing H20 (& Na)
into the bowel
Promote H20/ Na
absorption
5. Loperamide 4m.g qds
6. Forceval o.d
7. Check Mg and if
deplete, convert Mgglycerophosphate to Mgoxide
8. Refer to MXL
Anti-motility agent
On Mg supplements but
levels not checked
Mg oxide has less
diarrhoeal effect
Specialist f/u
Outcomes
• Outcome measures
• Biochemistry:
Biochem
Na
K
Ur
Creat
eGFR
Uric Acid
09.08.07
134
3.5
20.0
233
25
0.64
03.04.08
142
4.7
12.9
202
29
0.41
Outcomes
• Reduction in stoma output
•  from ~ 2.5 L to < 1L /d
• Thickened output (watery  porridge-like consistency)
• Pt satisfaction
• Practicalities in day-to-day management of stoma
• Follow-up
• Sole Dietetic f/u
• Renal physician’s happy with progress
Thank-you
Any Questions?