Intestinal Failure

Question 1

what does intestinal failure result from?

Answer 1

= an inability to maintain adequate nutrition or fluid status via the intestines

Question 2

how can intestinal failure occur?

Answer 2

• obstruction
• dys-motility
• surgical resection
• congenital defect
• disease associated loss of absorption

Question 3

what is intestinal failure characterised by?

Answer 3

= inability to maintain protein energy fluid, electrolyte or micro-nutrient balance

Question 4

what does the reduction in function of intestine mean?

Answer 4

= the reduction in function is below the minimum necessary for the absorption of macronutrients and/or water and electrolytes such that IV supplementation is required to maintain health and growth

Question 5

what happens to the gut in intestinal failure?

Answer 5

= gut is no longer able to supply the hydration and nutritional needs of the body

Question 6

describe the difference between acute short term and chronic long term intestine failure?

Answer 6

Acute short term
= 2 weeks
e.g. mucositis post chemo

Chronic long term
e.g. short gut syndrome

Question 7

describe the 3 types of intestinal failure?

Answer 7

Type I
= short term
- self limiting intestinal failure

Type II
= medium term
- significant and prolonged PN support (>28days)

Type III
= long term
- chronic IF (long term PN support)

Question 8

describe type I intestinal failure.

Answer 8

• surgical ileus
• critical illness
  GI problems;
• vomiting
• dysphagia
• pancreatitis
• GI obstruction
• diarrhoea
• oncology = chemo/DXT, GVHD

Question 9

describe type II intestinal failure.

Answer 9

- post surgery awaiting reconstruction;
= disaster
= crohns   
= SMA
= radiation
= adhesions 
= fistulae

Question 10

describe the type III intestinal failure.

Answer 10

= short bowel syndrome +/- other pathology 
= Crohn's +/- SBS
= radiation +/- SBS 
= dys-motility 
= malabsorption 
- scleroderma 
- CV immunodef
= inoperable obstruction, Ca

Question 11

describe the duration of type I intestinal failure?

Answer 11

= short term (days/week)

Question 12

how would you treat Type I intestinal failure?

Answer 12

= in normal/moderately malnourished

• Replace fluid, correct electrolytes
• Parenteral Nutrition if unable to tolerate oral food/fluids > 7days post op
• Acid Suppression: proton pump inhibitors
• Octreotide
• Alpha hydroxycholecalciferol to preserve Mg
• Intensive multi-disciplinary input
• Allow some diet / enteral feeding

Question 13

give 3 features of type II intestinal failure?

and describe how would you treat it?

Answer 13

• Septic patients
• Abdominal fistulae
• Perioperative who may develop a complication of feeding
• Weeks/months of care (ICU/HDU)
• Parenteral +/- some enteral feeding

Question 14

describe type III intestinal failure malnourished state.

Answer 14

= home parenteral nutrition

Normal/mildly malnourished, stable

• Short gut syndrome
• Crohn’s disease
• Neoplasia
• Vascular
• Mechanical
• Radiation enteritis
• Dys-motility

Question 15

what is the normal length the small bowel and what is it in short bowel syndrome?

Answer 15

normal = 250-1050cm
(males longer than females)

short bowel = < 200cm

Question 16

why does a short bowel cause problems?

Answer 16

= length is too small to meet nutritional needs without artificial nutritional support

Question 17

what is short bowel syndrome a common indication for?

Answer 17

= home parenteral nutrition

Question 18

when does home parenteral nutrition occur?

Answer 18

when small bowel is <50cm

Question 19

see slIde 14

Answer 19

see slide 14

Question 20

what are the 4 types of short bowel?

Answer 20

1) jejunostomy
2) ileostomy
3) jejune-colic anastomosis
4) oleo-colic anastomosis

Question 21

describe the length of the jejunum and the nutrition it requires?

Answer 21

0-50cm = parenteral, saline
51-100 = parenteral, saline
101-150 = oral/enteral, OGS
151-200 = non, OGS

Question 22

what is the type of PN therapy dependent on?

Answer 22

= type venous access

Question 23

what are the 2 types of venous access used in parenteral nutrition?

Answer 23

1) peripheral
- blue 22G PVC

2) Central
- PICC (peripherally inserted central catheter) 14days
- tunnelled catheter (Hickman line)
- vascuport
- ultrasound guided
- complications: pneumothorax/arterial puncture/misplacement

Question 24

what are 11 complications of parenteral nutrition?

Answer 24

• Sepsis
• SVC thrombosis
• Line fracture
• Line leakage
• Line migration
• Metabolic bone disease
• Nutrient toxicity/insufficiency e.g. Manganese
• Liver disturbance
• Metabolic disturbance
• Psycho-social
• Inappropriate usage

Question 25

what does type III intestinal failure require?

Answer 25

= home parenteral nutrition
= intestinal transplantation
- specific indications, long term survival lower than HPN
= glucagon like peptide 2 treatment for SBS
= bowel lengthening