Introduction To Intestinal Failure

Question 1

ESPEN definitions of intestinal failure and insufficiency

Answer 1

• intestinal failure: the reduction of gut function below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, such that intravenous supplementation is required to maintain health and/or grow
• intestinal insufficiency: the reduction of gut absorptive function that doesnt require intravenous supplementation to maintain health and/or growth (less severe)

Question 2

Types of intestinal failure (types I, II, III)

Answer 2

• type I (duration: days): most common. Can be mechanical (tumor) or non-mechanical (fails to contract normally after being handled in surgery)
• type II (duration: weeks-months): post-surgery awaiting reconstructions, crohn’s disease, fistulae
• type III (duration: months-years): short bowel syndrome, intestinal dysmotility

Question 3

Causes of intestinal failure

Answer 3

• dysmotility
• short bowel syndrome
• extensive mucosal disease i.e Crohn’s
• mechanical obstruction
• fistulae

Question 4

Intestinal failure: short bowel syndrome (types, causes, consequences)

Answer 4

• types: jejunostomy (becomes issue if jejunum is <1 metre), ileostomy (this is where jejunum or ileum brought out to surface in stoma). May be possible to recover gut function by reverting and connecting back to the colon (this can recover ~950 kcal/day due to bacterial fermentation capacity)
• causes: intestinal resection (as a result of thrombosis/embolism), resection due to disease (i.e Crohn’s), gastric bypass, fistulae
• nutritional consequences: reduced absorptive function (increasing risk of deficiencies), restricted oral/enteral nutrition, accelerated GI transit time, small bowel bacterial overgrowth

Question 5

Intestinal failure: Mesenteric ischaemia

Answer 5

• condition where the gut has a compromised blood supply which may cause distal bowel infarction
• either treated with surgical resection (small bowel resection and hemi-colectomy) or can have angio-procedure where clot is dissolved or removed if bowel not completely infarcted

Question 6

Intestinal failure: Crohn’s disease (causes, complications, treatment)

Answer 6

• chronic inflammatory bowel disease causing inflammation which affects full thickness of bowel, with propensity to affect the ileum and ascending colon
• there is a genetic predisposition (NOD2, IL23) and smoking is a risk factor
• results in blunting of villi and reduced absorptive surface
• most important cause of small bowel syndrome
• best treated now with immunosuppressants, surgical resection becoming more rare
• a complication includes ‘sticturing’ where inflammation causes scarring, fibrotic structures which narrow the gut lumen. Can be treated with endoscope and balloon to widen lumen
• can also cause fistulae (abnormal gut connections) ie enterocutaneous fistulae (gut to skin)

Question 7

Intestinal failure: Chronic intestinal pseudo-obstruction (CIPO)

Answer 7

• this is where cannot contract gut properly (dysmotile bowel) causes vomiting, sickness and abdominal pain
• causes small bowel bacterial overgrowth
• use PN as form of nutrition, however, important psychologically that they do eat, so use venting peg to remove food directly after eating

Question 8

Intestinal failure: Fistulae causing small bowel syndrome

Answer 8

• common is crohn’s disease and post-operative complication

- high fistulae results in small bowel syndrome

Question 9

Management of intestinal failure

Answer 9

• mild can be treated with ONS, oral glucose, NaCl, dietary adjustments
• moderate can be treated using enteral nutrition
• severe can be treated with parental nutrition
• oral rehydration solutions: st marks, diarolyte
• anti- secretory drugs: proton pump inhibitors, octreotide
• electrolytes (magnesium)
• anti-motility drugs: codeine phosphate
• encouraging intestinal adaptation using teduglutide (promotes proliferation and blood supply), which can reduce reliance on artificial nutrition in the long-term
• liraglutide (GLP-1 agonist) which inhibits gastric emptying and improves absorption of fluid and energy
• management priority list: fluid balance, protein energy balance, electrolytes, micronutrients