Lecture 14: SBS Flashcards
what are potential complications from fistula?
sepsis, fluid/electrolyte imbalances, malnutrition, hemorrhage, pain, anxiety, death
most low-output ECFs will close within 4 wks of presentation, this is called _______
spontaneous closure
what are cornerstones of ECF (enterocutaneous fistula) management?
SOWATS: sepsis control, optimization of nutr status, wound care, assessment of fistula anatomy, timing of surgery, surgical strategy
when fistula first diagnosed, go-to nutrition therapy:
PN
PN is indicated for fistula when:
originating from pancreas, high output from jejunum/ileum, proximal fistula where distal EN access not feasible, output can’t be collected in way that protects skin
when is EN / PO indicated?
low output fistula, esophageal/gastric/duodensl fistula, proximal jejunal fistula with distal enteral access, distal ileal or colonic fistulas
temporary loss of GI motility is called:
ileus
most common complication of abdominal surgery:
post operative ileus
post op ileus usually resolve after __ h
24-72
other causes of ileus?
inflammation/SIRS, infection, certain drugs
symptoms of ileus:
nausea, vomiting, ab distention, delayed passage of flatus and stool
treatments for ileus:
NG suction, IV fluids/electrolytes, minimal sedative use
For ileus, PO diets and early EN can be intiated within ____ h after surgery; if EN not possible for longer period (__ days), then PN warranted
6; 7
what is SBS?
condition resulting from surgical resection, congenital defect, or disease associated loss of absorption, characterized by inability to maintain protein-energy, fluid, electrolyte balances when on normal diet
how big is bowel?
half a badminton court
what is intestinal failure?
reduction of gut function below minimum necessary for absorption of macros and/or water and electrolytes, such that IV supplementation is needed
prognosis for SBS depend on:
how much of bowel length reduced, types of bowel segments involved in SBS
__ jejunum is primary site of ____absorption
proximal; water sol vit, CHO, pro
intercellular junctions of jejunal epithelia are ____ while ileum has ____ intercellular junctions
porous; tighter
ileum is primary site of ____ absorption and _____ recirculation
b12; enterohepatic (bile)
PN dependence in SBS likely when:
end jejunostomy (<100cm small bowel left), jejunocolonic anastomosis (<60cm small bowel with colon intact)
common cause SBS in kids:
congenital malformation, severe infection, small bowel resection
common cause SBS in adults?
2ndary to serial/massive small bowel resections, condition related (crohn’s, mesenteric vascular insufficiency), post surgery complications, malignancy, trauma
what is gastroschisis?
part of bowel is outside of body
what is intussusception?
tube going inside a tube
necrotizing entercolitis found in:
premature babies
clinical manifestations of SBS include malabsorption of ______ which leads to malnutrition characterized by _____
macronutrients, vitamins, fluid, electrolytes, trace elements; hypovolemia, hypoalbuminemia, metabolic acidosis, diarrhea, steatorrhea, wt loss, dehydration
factors that affect clinical/metabolic status of pt with SBS
extent and site of resection, presence/absence of ileocecal valve, function and health of remaining GI tract, active and course of underlying disease, patient age, presence or absence of colon in continuity with small bowel
mechanisms of malabsorption:
acid hypersecretion, loss of SA, rapid intestinal transit, impaired residual bowel, bacterial overgrowth, bile acid wasting
why gastric acid hypersecretion?
loss of small bowel segments–>decreased gut hormones–>continued acid secretion/accelerated gastric emptying (dumping)
what does gastric acid hypersecretion cause?
damage to mucosa, interfere with pancreas enzyme activity
if ____ cm terminal ileum resected, bile synthesis is upregulated to compensate losses and bile entering colon interferes with fluid absorption so _____ occurs
<100; water diarrhea
if ____ cm terminal ileum resected, amt unrecycled bile lost > max rate hepatic synth, causing ______
> 100; bile insufficiency, fat malabsorption, steatorrhea
what is SIBO?
presence of excess bacteria in small intestine (>10^5-10^6 organisms/mL)
what is normal concentration of bacteria in gut?
<10^3 organisms/mL
gram ____ coliforms produce mucosa damaging toxins impacting absorption
negative
microorgs that prefer metabolize _______ produce bloating
CHO to SCFAs and gas
processes predisposing to SIBO:
diminished gastric acid secretion, small intestine dysmotility, disturbances in gut immune function, anatomical abnormalities of GIT
resection of ____ may promote retrograde transit of clonic bacteria into small bowel , causing SIBO
ileocecal valve
SIBO can result in:
microscopic mucosal injury, alteration in bile salt absorption, intestinal malabsorption
symptoms associated with SIBO:
ab pain/discomfort, bloating, distension, diarrhea, gas, weakness (non specific)
clinical manifestations of SIBO:
wt loss, steatorrhea, vit/mineral deficiency, excess folate, hypoproteinemia, decreased xylose absorption
goals in SBS:
maintain adequate nutrition
what you need to know to determine nutr therapy for SBS:
site of resection, how much left, health of bowel, presence of colon/ileocecal valve/ostomy/bowel complications/strictures/chronic obstruction/fistula
PN indicated for SBS if:
end jejunostomy w/ <100cm jejunum left; functional colon intact w/ <60cm of jejunum left
patients with < __% of colon may benefit from ___
50; ORS (iso-osmolar) like milk, diluted juice, some EN formulas, commercial or homemade ORS
hyperosmolar should be ____ and hypoosmolar should be restricted to ____oz/d
avoided; 4-6
structural changes that occur in intestinal adaptation
hyperplasia, angiogenesis, bowel dilation, bowel elongation
functional changes that occur in intestinal adaptation (1-2 yrs):
^ transporters/cell, accelerated crypt cell diferentiation, slower transit time, ^ nutr/fluid absorption
hydration factors to consider before weaning from PN:
reduce only if pt achieve daily fluid intake goal consistently, U/O exceeds 1L/d and at least 0.5 mL/kg/h on nights w/o PN
if U/O can’t be measured, look at _____
surrogate lab markers of hydration (BUN, creatinine, urine sodium and osmolarity)
meeting at least ___% of energy goal without symptoms that limit oral intake before weaning from PN?
80
no more than ___ kg loss of BW between PN reductions
1.5 (remember edema)
what is enteral balance?
oral fluid intake minus stool and u/o
before weaning from PN, what should enteral balance be?
positive (>500mL/d)
factors to consider before weaning off PN ?
hydration, energy goal, body weight, lab values, enteral balance
meds commonly used in SBS?
acid suppression agents (H2 receptor antagonists, PPIs), antimotility/antidiarrheal agents (loperamide), antisecretory agents (octreotide)
examples of bowel related complications?
malabsorptive diarrhea, malnutrition, fluid/electroyte disturbances, micronutrient deficiency, EFA deficiency, SIBO, D lactic acidosis, oxalate nephropathy, renal dysfunction, metabolic bone disease, acid peptic disease, anastomotic ulceration/stricture, bowel obstruction
what is prioritization matrix?
prioritize pt for screening/assessment by RD (ensure right pt receive right care at right time and serve better manage allocation of time and resources, support safe provision of pt care and clinical cross-coverage, facilitate transfer of accountability
what are the goals in SBS?
maintain adequate nutrition, maintain adequate hydration, maintain electrolyte balance, support bodily functioning
