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Case Scenario 1

Case Scenario 1. M/70 BW 60 Kg DM on insulin NKDA ADLI Admitted for bleeding and perforated gastric ulcer with emergency Billroth II gastrectomy done. Noted leakage from duodenal stump on postoperative day 5 Reoperation, peritoneal lavage and controlled duodenostomy tube inserted

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Case Scenario 1

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  1. Case Scenario 1 • M/70 • BW 60 Kg • DM on insulin • NKDA • ADLI • Admitted for bleeding and perforated gastric ulcer with emergency Billroth II gastrectomy done

  2. Noted leakage from duodenal stump on postoperative day 5 • Reoperation, peritoneal lavage and controlled duodenostomy tube inserted • At time of 2nd operation, lab result: WBC 8, Hb 10, Plt 150, Na 130, K 2.5, urea and creatinine normal, Alb 20, INR 1.4 • Is nutrition therapy indicated ? What route and in what form?

  3. Feeding jejunostomy was fashioned during 2nd laparotomy • When to start enteral feeding? • What type of formula should be used? • Any particular precaution in this patient’s nutrition therapy? • What needed to lookout for with patient on controlled duodenostomy?

  4. There is leakage around feeding jejunostomy tube so much so that the tube needed to be removed on day 7 after 2nd laparotomy • How can you deliver nutrition therapy to patient at this stage?

  5. A central line was inserted for TPN • What is your regime for TPN in this patient in terms of volume, amount of energy, nitrogen, proportion of glucose and lipid?

  6. Subsequently duodenostomy tube removed after contrast study revealed no more leakage from duodenal stump • How can you restart feeding and how to wean off TPN?

  7. Case Scenario 2 • F/45 • BW 70 Kg • HT, AF on digoxin • ADLI • NKDA • Admitted for massive bowel ischaemia due to embolism, extensive resection of small bowel and ascending colon done, primary anastomosis was performed, residual small bowel length 90cm

  8. What is short bowel syndrome (SBS)? • What are the manifestations of SBS? • Is permanent TPN necessary in all cases? • What factors affect the outcome of SBS?

  9. Central line was inserted during operation and she was started on TPN after operation • Patient had severe diarrhoea postoperatively, what would you look out for and what drugs can you prescribe?

  10. Diarrhoea was under control with your appropriate treatment, and patient is improving with TPN • When can we start enteral feeding and in what form?

  11. Patient was started on some elemental formula and TPN was tailed off accordingly • With diet adjustment, oral intake was gradually increased and patient was finally free from TPN

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