MNT for Short Bowel Syndrome Flashcards
____ ____ ____ is explained as the metabolic and nutritional consequences which result from inadequate bowel mucosal absorptive surface area
Short bowel syndrome
Having inadequate bowel mucosal absorptive surface area means that someone is unable to support their ____ and ____ requirements
Nutritional and fluid
Short Bowel Syndrome is caused by a deficiency in bowel length due to extensive ____ resection
Surgical
Short bowel syndrome is characterized by…
-Severe, chronic diarrhea and steatorrhea
-Malabsorption of macro- and micro-nutrients
-Dehydration
-Electrolyte imbalances
-Progressive weight loss and malnutrition
Diarrhea with small bowel syndrome is due to…
-Malabsorption
-Altered motility
-Increased secretion
It is difficult to diagnose small bowel syndrome on ____ alone; we need to consider symptoms as well
Length
Diagnosing short bowel syndrome on length has what requirements?
-Loss of 70-75% of small bowel
-<200 cm of remaining small bowel length
If someone has >75% of bowel removed or less than 100 cm remaining, they will have severe malabsorption and will likely need ___ ____ for survival
Parenteral nutrition
Etiology of small bowel syndrome in adults:
-Crohn’s disease
-Mesenteric infarct
-Small bowel volvulus
-Radiation enteritis
-Cancer
Etiology of small bowel syndrome in children:
-Necrotizing enterocolitis
-Small bowel volvulus
-Intestinal atresia
-Crohn’s disease
What factors influence the severity of small bowel syndrome?
-Remaining bowel length and condition of the remaining bowel
-Location of resection
-Presence of the ileocecal valve
-Presence of the colon
-Degree of adaptation of the remaining bowel
____ increases with increased amount of small bowel removed or non-functional
Malabsorption
The minimal small intestine length necessary for adequate absorption of oral/enteral nutrition is…
-100 cm of small bowel if no colon
-60 cm of small bowel with an intact colon
We need to consider nutrients absorbed and the functions of the segments of intestine _____
Removed
If someone has a duodenal resection, ___ ___ may occur
Dumping syndrome
If someone has a jejunal resection, they may experience ___ intolerance
Lactose
Someone may have adequate absorption unless >___% of their jejunum has been removed
75
The ____ can assume the absorptive functions of the jejunum
Ileum
The ileum is the only site for absorption of what two things?
-Bile salt
-Vitamin B12
A resection of > 100 cm of the ileum results in a net loss of bile salts, leading to ____ and ____ ____
-Steatorrhea
-Cholerrheic diarrhea
Large resections of the ileum can result in severe malabsorption of…
-Fat
-Fat-soluble vitamins
-Calcium
-Magnesium
-Zinc
-Selenium
-B12
Ileal resections can result in loss of the ___ ___
Ileal break
End-jejunostomies can result in…
-Dehydration
-Electrolyte deficiencies
Loss of the ileocecal valve can result in ____ ____
Bacterial overgrowth
With a partial or total colon resection, there is an increased risk of ____ and ___ ___
-Dehydration
-Electrolyte losses
Intestinal transit time will be ____ with the presence of a colon
Prolonged
The ___ ___ slows gastric emptying
Colonic break
Having an intact colon means that you can metabolize ____ ___ ___ ___, which provides a source of calories
Short-chain fatty acids
Whatever small bowel is remaining undergoes structural and functional changes to increase ____ ____
Nutrient absorption
What types of changes occur in the remaining small bowel?
-Hyperplasia
-Elongation
-Increase height of the villi
-Increases in brush border enzymes
Intestinal adaptation occurs over ___-__ years after surgery
1-2
What factors influence adaptation?
-Oral/enteral nutrition
-Complex luminal nutrients vs simple
-Glutamine
-Short-chain fatty acids
-Hormones (enteroglucagon, glucagon-like peptide 1, peptide YY, growth hormone)
Those with small bowel syndrome have an increased rate of gastric emptying due to…
-Loss of intestinal hormones and feedback control
-Loss of the pyloric sphincter
If someone has an ileal resection, they would have ____ transit in remaining bowel
Rapid
Someone with short bowel syndrome would have impaired absorption of…
-Fluid and electrolytes
-Bile salts->cholerrheic diarrhea
-Fat->steatorrhea
-Fat-soluble vitamins
-Vitamin B12
-Minerals: Zinc, calcium, magnesium, manganese, copper, selenium, and chromium
-Lactose
Gastric _____ can occur after significant small bowel resections
Hypersecretion
A decrease in ____ and ____ secretion leads to increased serum gastrin levels and increased gastric acid secretion
Cholecystokinin and secretin
What are the clinical manifestations of having increased gastric acid secretion?
-Increases volume of secretions entering the small bowel and promotes diarrhea
-Acid damage to the intestinal mucosa
-Denatures pancreatic enzymes
-Precipitates bile salts - disrupts micelle formation
-Stimulates peristalsis
Small bowel bacterial overgrowth is caused by…
-Removal of the ileocecal valve
-Blind loops
-Antimotility medications
-Acid-suppression medications
Small bowel bacterial overgrowth results in…
-Deconjugated bile salts
-Inflammatory mucosal damage
-Gas
-Abdominal bloating and pain
-Steatorrhea
-Fat-soluble vitamin and B12 deficiencies
With steatorrhea, ____ is preferentially bound to unabsorbed fatty acids instead of _____
Calcium; oxalate
Increased absorption of free oxalate leads to ____
Nephrolithiasis
Hyperoxaluria and nephrolithiasis occur only if the _____ is present
Colon
The risk of hyperoxaluria is increased with ____ ____
Volume depletion
Vitamin B12 or folate deficiency can lead to _____ _____
Macrocytic anemia
People with short bowel syndrome may develop metabolic bone disease due to…
-Malabsorption of vitamin D and calcium
-Metabolic acidosis
What should be included in a nutrition assessment for someone with short bowel syndrome?
-Thorough knowledge of current medical status
-Current GI symptoms/complications
-Remaining small bowel anatomy
-Weight history
-Diet history: analysis of home diet/nutrition support, supplement use
-NFPE
-Input/output records
-Lab assessment: electrolytes, malabsorption workup, vitamin and mineral levels
-Food-medication interactions
Energy requirements for someone with short bowel syndrome should be ____
Individualized
On overage, people with short bowel syndrome should get ___-____ kcal/kg, but some people may need up to ___ kcal/kg
35-45; 60
For people with short bowel syndrome on parenteral nutrition, they should receive ____ kcal/kg
32
Someone with short bowel syndrome who eats orally or is on enteral nutrition should get ___-___ g/kg of protein per day
1.5-2
For someone with short bowel syndrome on parenteral nutrition, they should receive ___-___ g/kg of protein
1.0-1.5
What things might increase protein needs for someone with short bowel syndrome?
-Malnutrition
-Recent surgery
-Presence of other diseases or conditions
-Malabsorption
Those with short bowel syndrome have ____ fluid needs due to diarrhea/ostomy output
Increased
For ostomy patients, oral consumption of fluid should be ____ than ostomy output
Greater
We should monitor fluid intake/output closely and ____ losses
Replace
___ ___ ____ should be sipped slowly throughout the day
Oral rehydration solution
If someone has over ___ ____ of ostomy output per day, they should receive IV fluids with electrolytes
2 liters
Phase I of post-operative short bowel syndrome lasts the initial ___-___ weeks post surgery
1-3
What may happen during phase 1 of post-operative short bowel syndrome?
-Severe malabsorption
-Hypersecretion of gastric secretions
-Massive diarrhea/ostomy output
-Rigorous IV repletion of fluid and electrolyte losses
Someone in phase I post-op short bowel syndrome should be ____ and receive ____ for nutrition support
NPO, TPN
Phase II post-op short bowel syndrome lasts ___-___ months
1-3
During phase II, ____ malabsorption occurs with deficiencies in fat-soluble vitamins, calcium, magnesium, and zinc
Fat
Phase II is the period of greatest intestinal _____
Adaptation
Someone in phase II post of short bowel syndrome should be on _____, with the initiation of enteral nutrition when/if diarrhea or ostomy output decreases to less than 2 liters per day
TPN
Phase III post op short bowel syndrome lasts ___-___ months or longer
3-12
The goal during phase III is adaptation and transition to ____ diet
Oral
In phase III post-op, ____ should be well-controlled
Diarrhea
In phase III of the post-op diet, patients should discontinue TPN and increase to full ____/____ feedings
Enteral/oral
Not all patients attain phase III of the post-op short bowel syndrome diet; some may be on home ____
TPN
Enteral nutrition fosters intestinal ____
Adaptation
Usually, enteral nutrition can be implemented within ____ ____ after surgery
1 month
Enteral nutrition should be infused into the most ____ area (i.e., stomach) to maximize the absorptive surface area
Proximal
Those with short bowel syndrome who are getting enteral nutrition should get ____ infusion
Continuous
Patients may need home tube feedings if unable to meet needs with ____ diet alone
Oral
Research supports using ____, ____ tube feeding formulas due to increased stimulation of intestinal adaptation and decreased osmotic load
Isotonic, polymeric
If the colon is intact, we should use a ____ ____ containing formula (short-chain fatty acids)
Soluble fiber
If tube feeding is unsuccessful, try a ____-____/____-____ formula with MCT
Semi-elemental/peptide-based
_____ formulas are no longer recommended for those with short bowel syndrome
Elemental
When determining macronutrient distribution, we need to consider ____
Anatomy
If the colon is in continuity, we should recommend a higher ___, lower ____ diet
Carbohydrate, fat
What is the macronutrient distribution we should recommend to a patient with small bowel syndrome who has their colon in continuity?
-50-60% kcal from carbohydrates
-20-30% kcal from fat
-20% kcal from protein
If someone does not have a colon, we should recommend a diet that is ____ is carbohydrates and fat
Moderate
What is the macronutrient distribution we should recommend to a patient with small bowel syndrome who does not have a colon?
-40-50% of kcal from carbohydrates
-30-40% kcal from fat
-20% kcal from protein
For anyone with small bowel syndrome, we should promote ____ carbohydrates and ____ fiber (SCFA)
Complex; soluble
What are some recommendations for those with short bowel syndrome on oral nutrition?
-Avoid concentrated sweets
-5-6 small meals
-Chew food thoroughly
-Emphasize complex carbohydrates
-Limit fluids with meals (sip fluids between meals)
-Drink isotonic beverages (oral rehydration supplements(
-Liberal use of salt (if no colon)
-Avoid caffeine and alcohol
We should ____ restrictions for those on oral nutrition
Limit
If someone has an intact colon, we should restrict ____ intake
Oxalate
What are sources of oxalates?
-Berries
-Nuts
-Chocolate
-Green beans
-Celery
-Spinach
-Beets
-Beer
-Sweet potatoes
-Soy
We can recommend a low ____ diet if needed
Lactose
We should also provide diet education with sample ____
Menus
Those on oral or enteral nutrition should receive a ____ with minerals
Multivitamin
We should assess those on oral or enteral nutrition individually for additional _____ of vitamins and minerals
Supplementation
If those on oral or enteral nutrition are having steatorrhea, we should provide them with fat-soluble vitamin supplements in a ____-____ form
Water-soluble
In the absence of the ileum/large resection, someone on oral or enteral nutrition should receive _____ mcg of vitamin B12 IM injection monthly
1000
For someone on oral or enteral nutrition, they should receive a calcium citrate supplementation of ____-____ mg, 1-2 tablets three times per day
500-600
For someone on oral or enteral nutrition, they should receive magnesium lactate in ____ mg 1-2 tablets three times per day OR magnesium gluconate ____ mg tablet or liquid, 1-3 tablets three times per day
84; 1000
People lose ____ mg of zinc per liter of output
12
We should provide ____ mg of zinc sulfate, 1-3 tablets daily
220
What would be replenished by oral rehydration supplements?
-Potassium
-Sodium
-Chloride
-Bicarbonate
What are examples of pharmacologic management of short bowel syndrome?
-Antimotility/antidiarrheals (ex: loperamide)
-Proton pump inhibits and H2-receptor antagonists
-Bile acid binders (cholestyramine)
-Octreotide (somatostatin analogue)
What are food-drug interactions with bile acid binders like cholestyramine?
-Decreased absorption of fat-soluble vitamins, calcium, iron, zinc, magnesium, and folate
What can Octerotide (somatostatin analogue) help with?
-Antisecretory action
-Antimotility
-Reduces stomal output and diarrhea
What are food-drug interactions with Octerotide (somatostatin analogue)?
-N/V
-Hyperglycemia
The FDA has approved trophic factors for management of short bowel syndrome because they enhance intestinal ___ and ____
Adaptation and absorption
What are two examples of trophic factors that may be prescribed for the management of short bowel syndrome?
-Growth hormone (Ex: somatotropin)
-Glucagon-like peptide 2 analogue (Ex: teduglutide)
What are three examples of surgical management of short bowel syndrome?
-Longitudinal intestinal lengthening and tapering
-Serial transverse enteroplasy
-Small bowel transplantation
