lecture 11 Flashcards
Indications for surgical interventions
IBD that is refractory to other medical treatment • Abscess not responsive to therapy (antibiotics, bowel rest) • GI obstructions – Masses, bezoars etc. • Malignant masses requiring resection • Acute emergencies – Ulcers – GI bleed – GI perforation – Peritonitis – Necrotic bowe
Lower GI Resections & Nutrition Implications
When removal of portion of GIT occurs:
– Function of portion removed is lost
– Changes in motility, absorption, waste handling
– All can impact nutritional status
• Larger resections –> (usually) larger nutritional implications
Nutritional Care for the Patient Post GI Surgery
• Post-GI surgery nutrition regimen will be dependent on the type of surgery, portion of the GI tract resected • Why? the more is removed the less things will be absorbed
Major Determinants of Fluid Absorption
motility,
luminal osmolarity,
surface area
mucodsal integrity
Colectomies
• Colectomy: procedure to remove all or part of the large intestine
• Types of colectomies
ØTotal colectomy: entire colon
ØPartial / Subtotal colectomy:part
ØHemicolectomy:removal of the right of left portion
ØProctocolectomy: removal of colon and rectum
Nutritional Considerations Post Colon Surgery
No Ostomy
• Patients may or may not experience GI symptoms
– Disruption of gut microbiota, fluid resorption have not normalized/adapted.
• Most common:
–diarhea
–dehydration
• Nutrition therapy: treat the symptom
- maintain hydration, electrolye repletion if large volumes of stool output
consumme easily digested foods w
otherwise normal diet
Ostomies
Ostomy: surgically created opening from the intestine to skin
• Stoma: actual end of the bowel that cen be seen prtruding throught the abdominal wall
• Classified based on location:
– Colostomy
– Jejunostomy
– Ileostomy
Characteristics of Different Types of Ostomies
descending or sigmoid colostomy: normal poo
transverse colostomyL semi-solid poo
Ascending colostomy: liqui
Nutritional Considerations: Colostomies
Usually start functioning 2-5 days post- surgery • No evidence for specialized diet – Smaller portions, 4-6 meals/d – Cook foods well; chew thoroughly • Odor and gas production may be problematic (bacterial fermentation) – List based on anecdotal reports • Ascending colostomy – Hydration could be an issue • Increase fluid consumption
• Ileocecal valve
– Controls rate of movement from small intestine to large intestine (colon)
– Loss (if resected) may result in hastened motility
Liquid or paste-like
Continuous drainage
Contains digestive enzymes
Nutritional Considerations: Ileostomies
Normally start function ~24h post-surgery
• Specialized diets generally not necessary
– ↑ fluid losses à ↑ consumption of fluid
– ↑ Na loss in ileostomy output à liberalize salt consumption
– If output >1L/d, consider oral electrolyte replacement solution (ORS)
• Gas and odours less a concern (vs colostomy)
– Why?
– If gas an issue, avoid activities that increase amount of air swallowed
• Such as:SMOKING, CHEWING GUM, DRINKING THROUGH A STRAW, CARBONATED BEV.
Loose stool/effluent
– Rx foods that can thicken stool
– Gut-slowing medications (i.e. Imodium)
Foods to Thicken Stool and Control Diarrhea Bananas Cheese White bread/toast Cream of rice Cream of w
Ileostomies & Blockages
• Blockage at ileostomy site
– Increased risk first 6-8 weeks post-op
• May be caused by high fibre, difficulty to digest, stringy foods
– i.e. Nuts, popcorn, dried fruits, raw cabbage, corn, celery, carrots, cucumber skin,
coconut, apples with peels, grapes, tough fibrous meats
• Tips to reduce the risk of a blockage
– Chew food well
– Introduce fibrous foods in small amounts, one at a time, gradually increasing
intake
– Consume fluids with meals
GI Fistulas
• An abnormal opening or passage between two internal organs
of from an internal organ to the surface of the body
• Types of fistula, classified by:
1. lOCALIZATION + ANATOMICAL LOCATION
2.Physiology
3Etiology
Internal:
Consists of an abnormal
communication between adjacent
hollow viscera
Enterocutaneous: Consists of an abnormal communication/passage between the GI tract and the surface of the body/skin
GI Fistula Classification Upon Physiology
High output fistulas: >500ml/d
• Moderate output fistulas: 200-500ml/d
• Low output fistulas: <200ml/day
Etiology / types
Spontaneous: (10-25%) : Crohn’s disease
Cancer
Diverticulitis
Radiation enteritis
Surgical (75-90%): Iatrogenic lesion (sutures) Anastomotic failure Abdominal wall dehiscence Mesh rupture Drain puncture
Traumatic: <5% (Diagnostic intervention (puncture) (Traffic) accident Gun shot wound Knife injury
Potential Complications from a Fistula
Sepsis • Fluid/electrolyte imbalances • Malnutrition • Hemorrhage • Pain • Anxiety/poor body image • Expense • Death – Prior to use of artificial nutrition, mortality rate was 100% in patients with a high output fistula
Cornerstones of Enterocutaneous Fistula Management
S =Sepsis control • O = optimization nutritional status • W = wound care • A = assessment of fistula anatomy • T = timing of surgeries • S = Surgical strategies
Nutrition Therapies in ECF
Parenteral Nutrition: • Fistulas originating from pancreas • High output fistulas originating in the jejunum or ileum • Proximal fistulas where distal EN access is not feasible • A fistula where output cannot be collected in a manner that protects the skin
Enteral Nutrition / PO Diet: Low output fistulas • Esophageal, gastric, duodenal fistulas – Feed distal • Proximal jejunal fistula with distal enteral access • Distal ileal or colonic fistulas
Short Bowel Syndrome (SBS)
Malabsorptive condition resulting from extensive resection of the small bowel
3 common anatomical variants of SBS based on remaining bowel segments
- jejunal resection
ileal resection
extensive resection
SBS Criteria
General criteria (patient likely to be dependent on PN): ØEnd Jejunostomy: >100cm small bowel left ØJejunocolonic anastomosis:>60cm small bowel (jejenum) with colon intact
Underlying Conditions That May Lead to SBS in Adults
• Relatively rare à true prevalence unknown
• Underlying conditions that may precipitate SBS
Ø Resected Crohn’s disease (most common)
Ø Prolonged mesenteric vascular occlusion
Ø Complications from other abdominal procedures
Ø Major abdominal trauma (i.e. GSW, MVC)
Ø Strangulated bowel / volvulus
Ø Malignancy
Ø Radiation enteritis
Ø Multiple bowel fistulas
Clinical & Metabolic Status of a Patient with SBS
Depends on Several Factors
- Extent and site of resection]2. presence or absence of the ileucecal valve
- function and health of remaining digestive tract and assocaited organs
- activity and course of the underlying disease leading to intestional failure
- patients age
- prescence or absence of the colon in continuity w the small bowel
Clinical Manifestations of SBS
1. malabsorption of macronutrients , vits, fluid, electrolye, trace elements diarhea steatorhea wt loss dehydration
all lead to malnutrition, hypovolemia, hypoalbumineria
Mecahnism of malabsortion
acid hypersecreation rapid intestinal transit impairde residual bowel bacterial overgrowth loss of surface area bile acid wasting
