1 / 42

Clinical Case Study: Short Bowel Syndrome

Clinical Case Study: Short Bowel Syndrome. Amy Lofley Clinical Update. Objectives. Case Study Medical Hx Nutrition Assessment Nutrition Intervention Prognosis Conclusion. Overview of Short Bowel Syndrome Terminology Physiology Pathophysiology Treatment Medication Recommendations

pierce
Download Presentation

Clinical Case Study: Short Bowel Syndrome

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Clinical Case Study: Short Bowel Syndrome Amy Lofley Clinical Update

  2. Objectives • Case Study • Medical Hx • Nutrition Assessment • Nutrition Intervention • Prognosis • Conclusion • Overview of Short Bowel Syndrome • Terminology • Physiology • Pathophysiology • Treatment • Medication • Recommendations • Multidisciplinary team

  3. Short Bowel Syndrome Clinical Update

  4. Terminology[1,2] • 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

  5. 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.

  6. Normal Physiology [2]

  7. Pathophysiology [2,4] • 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.

  8. Pathophysiology [3] • 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 affect transit time, ostomy, how fluid is managed, and if small bowel bacteria will grow.

  9. Pathophysiology [2]

  10. Pathophysiology [2,5] • 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.

  11. Types of resections http://transplants.ucla.edu/body.cfm?id=69

  12. Etiology of SBS [1,] • 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 • 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

  13. Medical Treatment [7,4] • 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.

  14. Medication uses

  15. Medical Treatment [8] • TPN is needed immediately after surgery to maintain fluid 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 fluid 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”

  16. Practice Recommendations [1,4] • 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.

  17. Practice Recommendations[7]

  18. Evidence-Based Practice

  19. Practice Recommendations [7,1] • “The goal of therapy is to maximize small bowel absorption of fluids and nutrients to prevent deficiencies and dehydration”(7). • The optimal diet for individuals with jejunostomiesincludes: • 50% CHO • 20-30% protein • ≤40% fat. • Including foods high in fiber to help slow gastric emptying, transit time, and thicken ostomy effluent. • 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

  20. Dietary advice [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.

  21. Multidisciplinary team • Physician • Hospitalist • Infectious Disease • Surgeon • Registered Dietitian • Metabolic Nurse • Nurses • Pharmacist

  22. Case Study

  23. Mrs. E • Age: 66 YOF • Presents to hospital with nausea and vomiting • Medical Diagnosis • Colitis

  24. Past Medical/Surgical/social History • Past Surgical History • Exploratory lap and resection • Hysterectomy • Mastectomy • Social History • Smoke one pack/day • Occasional alcohol use • Past Medical History • COPD • Perforated diverticulitis w/colostomy (now reversed) • HTN • GERD • Breast Cancer

  25. Initial Nutrition Assessment (9/2/13) • 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 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%

  26. Nutrition diagnosis 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.

  27. Nutrition Intervention/monitor/evaluate • 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

  28. medications

  29. 9/3/13 Nutrition follow up • Diet order: NPO • Nutrition 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 day • Labs • 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

  30. 9/4/13 Nutrition follow up • Diet order: NPO • Nutrition Dx: Inadequate protein-energy intake • Meds: propofol @ 14 mL/hour = 370 kcals • Labs • 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 days • Coordination of care: surgery notes may start PN in next 24 hours.

  31. 9/5/13 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

  32. 9/6/13 Nutrition follow up • Diet Order: NPO • Nutrition Dx: Inadequate protein-energy intake • Meds: propofol @ 16.8 mL/hour 443 kcals • Enteral kcals = 443 from propofol • PN not started • Wt. 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

  33. 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 flush • Patient 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 nutrition • Follow up 3-4 times/week

  34. 9/7/13 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 lipids, 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, ileo out 1100 • Increase EN to 20 ml/hr @ 2000 today with no flush • Total kcals with meds is 508, total protein 18 g • PN: decrease CHO to 50%, increase in TF and elevated BG, will 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 will 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

  35. 9/8/13 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, phos5.2, alkphoswdl • Tolerating nutrition regimen ileo out 815, residue 100 ml • Goal: PN + TF to provide 75-100% estimated needs of 1317 kcal, 118 g protein • Collaborate 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

  36. 9/9/13 Nutrition follow up • Meds: pepcid, lasix, prednisone, zosyn • Wt. 228# weight loss of 6# in 1 day • Labs: prealb 17.7, BUN 42, Na 146, FSBS 208, intake 2580, output 5131 (stool=435, g-tube=100), CVP 14 • Tolerating GI • Goal: PN+TF to provide 90-100% estimated needs and protein within 24 hrs • EN: change formula to perative @ 30 ml/hr w/o flush • 936 kcals, 48 g prot, MD was more calorie dense formula • PN: change tkcals 871, 70 g protein • Total for TF+PN +meds = 1807 kcals, 118 g pro, 59 g lipids, 130 g CHO • Monitor GI, labs, skin and weight daily

  37. 9/10/13 Nutrition follow up • Labs: intake 3454, output 5380 (stool=590) • Tolerating GI, no change to needs • Goal: 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 CHO • PN: 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

  38. 9/11/13 Nutrition follow up • Diet order: Clear liquids • 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, ileo=900 • Tolerating GI • Energy needs reassessed: 1669-1855 (18-20), 118 g pro (2g/kg IBW), 220 g CHO (50%), fluid 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 prostat1548 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 liquids • PN: continue PN w/protein reduced to 50% from yesterday: 35 g protein=140kcals and 21 g CHO=71 kcals • Coordination of care: pt will get 1759 kcals (100%) and 144 g protein (122%) • Monitor GI, labs, PO, skin and weight daily

  39. 9/12/13 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 pro • EN: 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 • Ptdischarged prior to F/U

  40. Expected Outcomes • Prognosis is good with a full recovery. • Pt left with TF and oral diet

  41. Lessons Learned • SBS management is very complicated and needs careful management by a team including: physician, dietitian, surgeon. • The amount of bowel resected affects 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 differently • 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.

  42. References • Parrish CR. The clinician’s guide to short bowel syndrome. Nutrition Issues in Gastroeneterology2005;(31): 67-100. • Nutrition Care Manual. Short Bowel Syndrome. • Nutrition Care Manual. Bowel Resection. • Peck J, Soo L, Boland L, Windsor A, Engledow A. Short bowel syndrome: the pathophysiology and treatment. Gastrointestinal Nursing. 2012;10(2):32-38. • Krause • Rahhal RM. Short Bowel Syndrome. Chapter 20. 295-305. www.pnjhuaq.mhprofessional.com/downloads/products/0071633790/bishop_ch20_295_305.pdf. • 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. • Donohoe CL, Reynolds JV. Short Bowel Syndrome. The Surgeon. 2010: 270-276. • Seetharam P, Rodrigues G. Short bowel syndrome: a review of management options. Saudi J Gastroenterol. 2011;17:229-35.

More Related