Intestinal failure

Question 1

What is intestinal failure?

Answer 1

The inability to maintain adequate nutrition or fluid status via the intestines resulting in a need for IV supplementation through PE nutrition

Question 2

What are the characteristics of intestinal failure?

Answer 2

Micronutrient , fluid, electrolyte imbalance,malabsorptions and lack of energy

Question 3

You can get acute and chronic intestinal failure. What types come under which heading?

Answer 3

Acute = type 1 and 2 
Chronic = type 3

Question 4

What is type 1 IF?

Answer 4

Self limiting short term postoperative or paralytic ileus. Cared for on the ward

Question 5

What is type 2 IF?

Answer 5

Prolonged, associated with sepsis and metabolic complication or abdominal surgery with complications. Cared for on HDU or ITC

Question 6

What is type 3 Intestinal failure?

Answer 6

Long term but stable. Home parentral nutrition often indicated

Question 7

What causes Type 1 IF?

Answer 7

Sepsis, GI problems with vomiting, dysphagia, pancreatistsi, obstruction, oncology (following chemo or radio therapy

Question 8

How is type 1 IF treated?

Answer 8

Normally occurs in previously healthy individuals.
Replace fluid lost and correct electrolytes. PN if unable to tolerate food/fluids after 7 days
PPI, Octreotide, Alpha hydroxycholecalciferol

Question 9

What is PPI used for in IF?

Answer 9

To reduce gastric secretions

Question 10

What is Octreotide used for in IF?

Answer 10

Suppress pancreatic secretions

Question 11

What is Alpha hydroxycholeciferol used for in IF?

Answer 11

Preserve Magnisium

Question 12

What types of venous access can be used to give PN?

Answer 12

Blue PVC
PICC line (peripherally inserted central catherter) up to 14 days
Hickmann line (tunneled catheter)
Vascuport (good for home PN)
Often inserted with ultrasound guidance

Question 13

What are the complications with establishing vascular access for PN?

Answer 13

Pneumothorax Arterial puncture or misplacement

Question 14

WHy would you never give PN through veins below the waist?

Answer 14

Much greater risk of infection- you are essentially giving lots of glucose

Question 15

Which vein is often used for PN?

Answer 15

Subclavian veins

Question 16

What are the complications of PN?

Answer 16

Sepsis
SVC thrombosis
Line fracture/leakage/migration
Metabolic bone disease
Nutrient toxicity/insufficiency
Liver disease (monitor liver function)
Metabolic disturbance
PSYCHOSOCIAL
Inappropriate usage

Question 17

What are the causes of type 2 intestinal failure?

Answer 17

Surgical complications (most common)
Sepsis
Abdominal fistula (crohn's),
 trauma or vascular event, 
SMA (superior mesenteric artery syndrome),
Malignancy

Question 18

What is superior mesenteric syndrome?

Answer 18

third and final portion of the duodenum is compressed between the abdominal aorta (AA) and the overlying superior mesenteric artery.

Question 19

What is the treatment for Type 2 IF?

Answer 19

PN +/- some entral feeding and trying to wean them off it slowly.

Question 20

What foods should people begin with when coming off PN?

Answer 20

Clear soups and fluids, jellys and high calorie supplementation drinks

Question 21

What are the causes of type 3 IF?

Answer 21

Short Bowel syndrome (most common)

Crohns, malabsorption, dysmotility, inoperable Ca, Radiation (prostate/ovarian cancer)

Question 22

What is the treatment for type 3 IF?

Answer 22

Home PN
Intestinal transplantation- very specific cases as the long term survival is a bit lower then long term PN
GLP2 treatment for short bowel treatment (new and only licensed in neonates- promising)
Bowel lengthening (normally in children) Either STEP (transverse) or Bianchi (longitudinal).

Question 23

How is home PN initiated?

Answer 23

Conversation with patient and relatives. Inpatient training with specialist nurse in aseptic technique for weeks- months.
GO home and have nurse check on them

Question 24

What are the most common implications for home PN?

Answer 24

Non malignant GI problems
Cancer
CNS and mental health conditions

Question 25

What is short bowel syndrome?

Answer 25

A small intestine <200cm long. Insufficient length of small bowel to meet nutritional needs.
Males often have a longer bowel than females

Question 26

How long is the small bowel normally?

Answer 26

250-850cm

Question 27

What length of bowel will definitely need home PN?

Answer 27

<50cm

Question 28

What length of bowel will boarderline need home PN?

Answer 28

50cm + all of colon

100cm of small bowel

Question 29

What is adaption of the bowel?

Answer 29

The body may slowly adapt to a smaller length of bowel

Question 30

What salt solution is used in type 1 IF?

Answer 30

OGS- oral glucose saline. Its like dyoralyte

Question 31

What is really important in nutrition and PN?

Answer 31

Documentation of discussions and decisions

Question 32

Nutrition is a MD service. Who is part of the team

Answer 32

Doctor (gastroenterologist)
Specialist nurse
Dietitian
Pharmacist
Biochemist 
Ward round of inpatients and MDT every week

Question 33

When is a small bowel transplantation considered?

Answer 33

Last resort. Usually combined with a liver transplant. DUe to liver disease or loss of venous access
50-60% 5 year survival and you may have a stoma but you are eating

Question 34

What is a stoma?

Answer 34

an artificial opening made into a hollow organ, especially one on the surface of the body leading to the gut or trachea.