Mini Case Study Presesntation

1. Mini Case Study Presesntation Hilary Smith November 18, 2014

2. Patient BC • 76 y/o female, lives with husband • Admitted 11/11/14 • CC: lethargy, falling at home, decreased appetite, anorexia, and drainage from her abdomen • Has enterocutaneous fistula

3. SBO Chronic diarrhea Pancreatitis Hepatitis C Endometriosis Arthritis HTN Recent history of: CDiff Bowel Resection Cholecystectomy Liver biopsy Partial small bowel resection x 2 Prior Medical History

4. Past NWH Consults • Admitted 1/2/12 • SBO, D/C with high fiber diet and follow-up outpatient colonoscopy, 1/6/12 • Admitted 12/13/13 • SBO, D/C with regular diet 12/16/13 • Admitted 7/30/14 • Recurrent SBO. Had surgery 8/1 – small bowel resection • CT scan of her abdomen and pelvis revealed small bowel enterocutaneous fistula, 8 days post-op • MD ordered NPO and TPN

5. Past NWH Consults Continued • MD wanted to attempt conservative management to close the fistula since she was so close to her actual operative date • Plan: placement in rehabilitation. Rehabilitation accepted and D/C NWH 8/19/14. • 8/16/14 NWH Surgical consult – Plan: Continue on TPN until fistula closes • 9/11/14: Rehabilitation facility thought a new hole was in her incision • NWH Surgeon: Tracking of fluid up through subcutaneous tissue, did not believe there was a second fistula

6. Past NWH Consults Continued • 9/25/14 NWH Surgeon thought the fistula may have closed. No ostomy bag discharge. • Surgeon wanted her on clear liquids x 1 week. If she tolerated and no drainage from fistula site, wanted to try and wean her off TPN and get her out of the rehab facility. • 10/2/14 developed PICC line infection at rehab • NWH Surgeon wanted clear liquids x 1 more week and Ensure TID, still wants rehab to wean pt off TPN • 10/23/14 tolerating diet at rehab. Surgeon recommended increase po intake and protein supplements, if tolerating, wean off TPN and D/C rehab. • Admitted 11/11/14 to NWH

7. Anthropometrics • Height: 154 cm • Weight: 55kg (11/12) • BMI: 23.2 Normal • %IBW: 104% • IBW: 52.5 kg • UBW: 55kg (per pt)

8. Labs • Mg 1.6 low • Phos 1.2 low • Glucose 134 high • Albumin 2.9 low • Vitamin D 18.9 low • TSH3 0.240 low • C difficile: +antigen, -toxin, +amplified • 11/12/14

9. Pertinent Medications • D5NS + KCl @120 ml/hr • Vancomycin • Flagyl • Magnesium sulfate • Zofran PRN

10. Nutrition/Fluid Needs • Calorie needs – Mifflin St. Jeor • Weight used: 55kg (admit wt) • Activity factor: 1.4 to 1.5 • 1368-1466 kcal/day • Protein Needs • 1.3-1.5 g/kg • 72-83g/day • Fluid Needs • 30 ml/kg • 1650 ml/day

11. Can She Meet Her Needs? • Clear liquid diet • Vital AF 1.2 TID • 850 kcal, 53g protein • Ensure Clear BID • 400 kcal, 14g protein • Total: 1250 kcal, 67g protein • 89% of calorie needs, 86% protein needs offered from supplements

12. RD/Intern Visit • 11/13/14, Consult for nutrition assessment • Pt says poor appetite since last surgery in August • Was D/C from rehab 10 days PTA • Pt says she may have gained weight on TPN • On clears diet and PO Vital AF 1.2 TID, pt making good attempt at intake

13. PES Statement Altered GI function as related to abdominal wall fistula as evidenced by limitation to clear liquid diet and supplements

14. Assessment and Plan • Status: Severe Level 4 • Monitor supplement and diet tolerance • Add Ensure clear apple BID to increase calorie and protein intake • Pt may need TPN if fistula output is high

15. Current Status • PPN ordered 11/15/14 • Started TPN 11/17/14 @ 2100 via PICC • Clinimix E 5/15 @ 53 ml/hr • 63g protein, 188g CHO • Lipid frequency: 5x/weekly; serum triglycerides mildly elevated @ 177. • Care manager: cycle TPN for D/C, fistula is draining less.

16. Literature Support – Enterocutaneous Fistulas • Treatment should concentrate initially on correction of fluid and electrolyte imbalances, drainage of collections, treatment of sepsis and control of fistula output • No evidence that bowel rest results in increased rates of fistula closure • Enteral should be used if possible, but high-output small bowel fistulas usually require PN due to feeding intolerance, lack of access to the GI tract, or increased fistula output • BC has High output: drains more than 500 ml/day • Operative repair should be performed when spontaneous closure does not occur • Should be delayed for at least 3 months

17. Literature Support – How to Diagnose C. diff • Stool culture in symptomatic patient • Use a 2-step strategy • Use enzyme immunoassay to detect glutamate dehydrogenase (GDH) as initial screening • Use the cell cytotoxicity assay or toxigenic culture as the confirmatory test for GDH-positive stool specimens only • Alternative: use polymerase chain reaction test

18. BC’s Results • Positive: C Diff Antigen • Indicates presence of C Diff • Negative: C Diff Toxin • C diff toxin absent, or specimen is below the detection limit of the test • Positive: C Diff Amplified • Indicates presence of C Diff toxin B gene • Uses polymerase chain reaction to detect • Sensitivity: 98.79%; specificity: 90.82%

19. Questions?????

20. References • Overview of Enteric Fistulas, UpToDate • Nutrition and Management of Enterocutaneous Fistula, British Journal of Surgery • Clinical Practice Guidelines for Clostridium difficile infection in Adults: 2010 Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA)