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Dietetic Management of Short Bowel Syndrome

Dietetic Management of Short Bowel Syndrome. Ali Singer Gastroenterology Specialist Dietitian Frenchay Hospital. Content. Definition Physiology Management Case Study. Definition.

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Dietetic Management of Short Bowel Syndrome

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  1. Dietetic Management of Short Bowel Syndrome Ali Singer Gastroenterology Specialist Dietitian Frenchay Hospital

  2. Content • Definition • Physiology • Management • Case Study

  3. Definition • The reduction of functioning gut mass to below the minimum necessary for the absorption of nutrients and/or water and electrolytesFleming & Remington, 1981

  4. Variability in Intestinal Lengths • Small intestinal length at autopsy: • 3-8.5m Bryant, 1924 • Shorter in women • SBS more common in women (67%) • Small intestinal length at laparotomy: n mean (cm) range (cm) Cook, 1974 6 421 320-521 Backman, 1974 32 643 400-846 Slater, 1991 38 500 302-782

  5. 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

  6. Commonest causes: • Crohns • Superior mesenteric • artery thrombosis • Irradiation Causes of SBS

  7. 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

  8. Types of Short Bowel

  9. Jejunum Na+/H2O secretion 1st 100cm Leaky Na+ absorption Small conc. gradient only Dependent on H2O movement Coupled to gluc/AA absorption Maximal Na+ absorption when [Na+] 120mmol/l Ileum Active Na+/H2O absorption Less leaky Na+ absorption Large conc. gradient Not dependent on H2O movement Not coupled to gluc/AA absorption Increased by Aldosterone Normal GI Physiology

  10. Normal GI Physiology

  11. Jejunal-colon: NORMAL Jejunostomy: FAST Gastrointestinal Motility 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

  12. 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

  13. Critical Lengths

  14. Nutritional Support and Bowel Length

  15. <200cm: restrict oral hypotonic fluids, sip glucose - saline supplement (100mmol/L Na, like jejunostomy fluid) • <100cm: parenteral saline • <50cm: parenteral nutrition and saline

  16. 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

  17. 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

  18. Hypomagnesaemia

  19. Clinical Picture

  20. 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

  21. 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

  22. 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

  23. The Fat Dilemma 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.

  24. Common: B12 deficiency; replace Selenium deficiency; replace Magnesium deficiency; replace if occurs Vitamins D, E, A, K and essential fatty acids; replace Rare: Potassium deficiency Zinc deficiency; rare unless large stool volumes Water and sodium; rare as absorbed well in colon, if occurs sips of glucose saline drink Deficiencies

  25. 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)

  26. 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

  27. Ca Oxalate Renal Stones

  28. 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

  29. 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

  30. 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

  31. Other Causes • 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

  32. Stage 1: Establish Stability • Severe dehydration & Na+ depletion • Keep patient NBM • IV normal saline (2-6L/day)

  33. Treat the Cause • Intraabdominal sepsis / abscess • Partial / intermittent bowel obstruction • Strictures; placement / muscle tunnel / adhesions / crohns / ischaemic fibrosis / radiotherapy • 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

  34. 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

  35. Na+ and H2O Hypotonic Fluids 0 mmol Na+ High Output 100 mmol/L Na • Leaky • Small conc. gradient only • Dependent on H2O movement Na 140 mmol/L jejunum Unable to maintain Na gradient Electrolyte Mix 90 mmol Na+/L Smaller volume 100mmol/L Na+ Na+ 140 mmol/L

  36. Oral Rehydration Therapy

  37. 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

  38. Antisecretory: Omeprazole; decreases gastric acid secretion Ranitidine/cimetidine Octreotide; decreases intestinal secretions Antimotility: Loperamide upto 64mg PO o.d asdecreased enterohepatic circulation Codeine Lomotil Drug Therapy • Vit/min supplements: • B12, selenium, Mg2+, vit A, D, E, K

  39. Parenteral Therapy • 0.5–1L saline sc +/- 4mmol MgSO4 1-3/week • 1L saline IV +/- 4-12 mmol MgSO4 > 3/ week • IVN

  40. Outcome Aims • Clinical: • No thirst or signs of dehydration • Acceptable strength, energy and appearance • Measures: • 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

  41. Stage 3: Rehabilitation • Transfer to IF unit • Wound healing • Stoma care • HPN training • 1st patient 1978 • Longest 27 years • Mean age 50.2 years (19.9 – 76.9) • ~27 new patients per year per unit • Social issues

  42. Stage 4: Long-Term Care • 3 monthly multidisciplinary clinics • IF unit • Shared care with local hospital

  43. Outcome 1 year after starting HPN (467 patients) BANS 1996-2000

  44. Mr J: background information • 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!)

  45. High output ileostomy output (estimated up to 2.5L per day) Issues Dehydration ( UO,  urine Na) Renal impairment & stone formation

  46. Assessment: Concerns • Renal impairment: * stage 4 CKD • Poor seal on stoma bags • Not leaving house when stoma active

  47. Intervention

  48. Outcomes • Outcome measures • Biochemistry:

  49. 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

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