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Clinical 2 > Short bowel > Flashcards

Short bowel Flashcards

1
Q

“Which of the following characteristics of an initial enteral feeding regimen would be most appropriate for a patient with SBS?

  1. A fiber-free, energy-dense formula administered via bolus infusion
  2. A hydrolyzed, elemental formula that is high in medium-chain triglyceride (MCT) oil
  3. An isotonic, polymeric, fiber-containing formula administered via continuous gastric infusion
  4. A semi-elemental, peptide-based formula administered nocturnally”
A
  1. A semi-elemental, peptide-based formula administered nocturnally
    When initiating enteral feedings in a patient with SBS, it is important that the formula be isotonic. Polymeric formulas are generally well tolerated. Gastric feeding may result in less diarrhea than small bowel feeding. The inclusion of soluble fiber may also be beneficial because it can slow gastric emptying, enhance adaptation, and provide an energy source in those patients who have a colon. Slow initiation of feedings administered via continuous gastric infusion as opposed to bolus administration may be better tolerated.
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2
Q

which type of anastomosis has the worst predicted outcome?

A

“The end jejunostomy variant is the most difficult to manage and the most likely to require permanent PN

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3
Q

how long does it take for intestines to adapt? What are the benefits?

A

1 to 2 years and is associated with progressive improvement in nutrient and fluid absorption.”

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4
Q

“Bowel-Related Complications in Short Bowel Syndrome

A 
Malabsorptive diarrhea
Malnutrition
Fluid and electrolyte disturbances
Micronutrient deficiency
Essential fatty acid deficiency
Small bowel bacterial overgrowth
D-lactic acidosis
Oxalate nephropathy
Renal dysfunction
Metabolic bone disease
Acid peptic disease
Anastomotic ulceration/stricture
Bowel obstruction
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5
Q

when is b12 supplement required in SB?

A

Vitamin B12 is primarily absorbed in the terminal ileum and typically requires supplementation when at least 50 cm of terminal ileum has been resected. Loss of the ileum, gastric hypersecretion, and/or bacterial overgrowth can all contribute to vitamin B12 deficiency.”

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6
Q

Nephrolithiasis in SB patients

A

Normally, dietary oxalate binds to calcium and is excreted in the stool.
However, in the presence of fat malabsorption, fatty acid anions compete with oxalate anions to bind to available calcium. The excess and unbound oxalate are absorbed in the colon and filtered in the kidneys-> high concentration of serum oxalate + relative dehydration, metabolic acidosis, and hypomagnesemia in patients with SBS-> stone formation in the kidneys.
- patients who retain a colon are advised to consume a low-fat, low-oxalate diet; increase calcium intake; and remain well hydrated to minimize the risk of oxalate nephrolithiasis

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7
Q

Metabolic bone disease in SB

A
  • ## patients with SB are at high risk of osteopenia/osteoporosis due to Vit D and calcium malabsorption and hyperparathyroidism
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8
Q

What is SBS?

A

Combination of 2:

1) large loss of functional mass from surgical resection, congenital disease 2) decrease in absorption

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9
Q

What is the spectrum of SBS

A

Short bowel syndrome SBS- insufficiency Intestinal failure

it is a spectrum

  • can have absorption sufficiency
  • can have absorption insufficiency
  • can progress to intestinal failure-
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10
Q

what is intestinal failure?

A

inability to maintain fluid, electrolyte and nutritional status w/o PN- these patients are on PN for life; sometimes even with PN fluids and electrolytes are not normalized

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11
Q

What are the 3 types of SBS

A

• Type 1: end-jejunostomy: no large intestine and ileum. Parts of jejunum can also be removed
• Type 2: jejunocolic anastomosis: no ileum, someitmes even parts of jejunum are removed
• Type 3: jejunoileal/ jejuno-
ileocolonic anastomosis: sections of jejunum are removed

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12
Q

Which short bowel sub-type is most likely to have the best prognosis?

A

jejunoileal anastomosis- has a colon and all components of small bowel, but its just shorter

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13
Q

Jejunoileal anastomosis
Probability of PN dependance
Possible symptoms manifestations
Prognosis

A

Probability of PN dependance: low, but increased risk with <35cm of jejunum remaining
Possible symptoms manifestations: gastric acids hypersecretion and impaired digestion
Prognosis: good

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14
Q

Jejunocolic anastomosis
Probability of PN dependance
Possible symptoms manifestations
Prognosis

A

Probability of PN dependance: variable, higer in patients with <60-65cm of jejunum remaining
Possible symptoms manifestations: increased diarrhea, vit b12 deficiency, impaired bile salt resorption, deficiency in fat-soluble vit, fat malabsorption
Prognosis: fair

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15
Q

Jejunostomy
Probability of PN dependance
Possible symptoms manifestations
Prognosis

A

Probability of PN dependance: high
Possible symptoms manifestations: increased stomal output and fluid malabsorption, magnesium deficiency, vit b12 deficiency, impaired bile salt absorption
Prognosis: poor

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16
Q

What are the length of sb that should remain for each type to have the best prognosis?

A

jejunoileal anastomosis- at least 30cm of small bowel + colon to realistically wean off PN
jejunocolic anastomosis - at least 60 cm of rof small bowel + colon for better prognosis
end jejunostomy - at least 100 cm of small bowel for better prognosis

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17
Q

Common causes of SBS

A
  • Mesenteric ischemia- lack of blood flow to the gut
  • Malignancy- which leads to gut removal
  • Radiation enteritis- high inflammation of the bowel-> non functional or has to be removed
  • Crohn’s + multiple resections • Trauma
  • Surgical complications
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18
Q

how large is each component of SB

A
  • Duodenum 25-40cm;

* Jejunum 60% of small bowel • Ileum 40% of small bowel

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19
Q

how much of SB is required to avoid major nutrient deficiencies?

A

~200cm of duodenum and jejunum required to avoid significant nutritional deficits

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20
Q

If less than __ of small intestine without colon, usually requires PN dependence

A

If less than 100cm of small intestine without colon, usually requires PN dependence

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21
Q

why end jejunosotmy almost always requires life-long PN

A

due to severe fluid and electrolyte losses

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22
Q

what are the complications and related deficiencies in End jejunostomy and jejunocolic anastomosis

A

loss of B12
• Fat malabsorption, fat-soluble vitamins deficiencies
- Bile salts are absorbed in the ileum-> no ileum = loss of bile salts-> diarrhea

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23
Q

What are common deficiencies in SB

A

Mg, Ca, vitamin B12, zinc

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24
Q

Complications of absence of ileocecal valve?

A

increased risk of SIBO (Small intestinal bacterial overgrowth) ; increased transit time

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25
Q

What are hypersecretions? Why is it bad?

A

specific for SB patients
stomach secretes way more acid than needed-> upper GI problems, change of pH of contents that empty into the SB
there is optimal pH for absorption and digestion -> hypersecretions will lead to even worse absorption and digestion
acidic hypersecretions also make it harder for SB to adapt over time

26
Q

what do we need to know to determine the treatment of SB

A 
• Underlying diagnosis
• Comorbid conditions
• Condition of the GI tract/health of
remaining intestine
• How much intestine is left? 
• Is colon preserved?
• Presence of ileocecal valve
• How long ago was resection
27
Q

What are the 3 phases of SB treatment

A

Acute (~3 weeks)
• Extensive loss of fluid and electrolytes within ++ diarrheal losses
• PN required immediately
• Trophic EN may be initiated (try, if diarrhea—> wait for stabilization), slow, continuous

Adaptation (~ 2 years!)
• Try to wean PN → EN/PO (PN is expensive, has complications and low QOL)
• Small PO intake as diarrhea slows
• Reduction in diarrhea (sign that motility and absorptive capacity improves)

Maintenance- not every patient will reach this
• Stabilized on medical therapy
• If patient does not stabilize = intestinal failure (IF)

28
Q

how can we determine how much of small bowel is left?

A

barium contrast small bowel series can be used to estimate the amount left and see if there are strictures, if there is colon left
if colon is left- as it reabsorbs fluid and electrolytes-> lower risk for watery diarrhea loss- having colon is helpful

29
Q

Medical treatment of SB

A

• PN and/or IV to maintain fluid and electrolyte balance
- When discharged home, need to teach patient to track I/O
• Motility controlled with meds
• Gastric hypersecretion Proton pump inhibitors, H2 antagonists
• Meds may not be absorbed
• Surgery: Lengthening or transplant

30
Q

what is considered as adequate hydration?

A

• Adequate hydration is considered to be present when urine output is > 1 L/day and urinary sodium concentration is > 20 mEq/L (mmol/L).

31
Q

when should motility drugs be taken?

A

30-60 minutes before meals and at bedtime

32
Q

what can be a potential cause of diarrhea when patient goes back gome?

A

if patient goes home and suddenly has diarrhea problems—> ask them how they take their motility meds
some of them forget to take them
do not focus on fixing diet first

33
Q

what are the potential Nutr Diagnoses in SBS pt

A

in the beginning: “altered GI function” “impaired nutrient utilization”
later: inadequate energy protein intake” “inadequate vitamin/mineral intake”
“malnutrition”

34
Q

What can diet improve in SBS patients

A

Diet can improve stool output and both nutritional and hydration status

35
Q

Nutrition intervention for end jejunostomy

A

• PN→EN trophic/EN→Oral rehydration solutions → PO food = Low residue diet and lactose as tolerate
- with EN or PO initiation: if diarrhea gets worse-stop, wait for stabilization and try again
• Add one new food at a time, monitor GI
• Chew well
• Small portions
• Avoid simple sugars and sugar alcohols (they draw water into GI—> diarrhea gets worse)
• Chew well
• Typically: Home PN/EN with limited oral diet
• Long-term PN, consider iron infusion
• Cycle PN for improved QOL
• Iron supplementation: iron doesn’t mix well with lipids-> it is not added to mineral doses-> as it is not in the standard addition, we need to consider iron infusion if there are on long-term PN

36
Q

Nutrition treatment for Anastomosis sub-types with colon

A
  • PN→EN trophic/EN→Oral rehydration solutions → Low fat, low oxalate, high calcium diet
  • Add one new food at a time, monitor GI
  • Chew well
  • Low caffeine and alcohol (initially)
  • Avoid alcohol sugars and simple sugars
  • Insoluble fibre usually not tolerated
  • Soluble fibre encouraged
  • If achieve nutritional autonomy, may need to increase dietary intake by 50% above estimated needs.
  • Small, frequent meals best.
37
Q

What is the problem with oxolate

A

only needs to be avoided in patients that still have their colon

• Oxalate generally binds to Ca within the bowel, excreted.
• In patients with fat malabsorption, Ca binds to fat instead of oxalate.
• Oxalate now freely absorbed in colon.
• Delivered to kidneys and excreted.
• Prevent oxalate stones:
- Adequate hydration
- Avoidance of high oxalate foods such as beets, spinach, rhubarb, strawberries, nuts, chocolate, tea, wheat bran, and all fresh, canned, or cooked dry beans (excluding Lima and green beans) is recommended.

38
Q

Energy, protein, carbs, fat, fiber, fluid, oxalate, lactose, sodium, recommendations for patients with Colin and end jejunostomy

A

Energy (both): 35-45kcal/d
Protein (both): 1.5-2.0g/kg; 20-30% of energy goal

Carb:
With colon: 50-60% of energy goal (limit simple sugars)
End jejunostomy: 20-40% of energy goal (limit simple sugars)

Fat
With colon: 20-30% of energy goal
End jejunostomy: 40-60% of energy goal

Fibre
With colon: 10-15g/d (as tolerated); Soluble encouraged
End jejunostomy: 10-15g/d (as tolerated). soluble fiber is not recommended as it will bind all the water and w/o colon this water won’t be absorbed

Fluid
With colon: Isotonic/hypotonic
(may need ORS;
End jejunostomy: May need IV and limited PO)
Isotonic, high sodium ORS (ORS preferred; restrict water, coffee, tea; May need IV and limited PO). water will flow straight through, thus will require sodium + glucose ORS to be actively transported
have water restriction- drink ONS all day long if allowed PO
if allowed PO- can drink a bit of water, but mostly ORS

Oxalate
With colon: Low oxalate diet + adequate fluids
End jejunostomy: No restriction as it cannot be absorbed in colon as it is not present

Lactose (both): Do not restrict if tolerated

Sodium (both): encourage liberal salt

39
Q

Clinical factors that predict weaning from PN

A
  • Retained segments of small bowel
  • Length of residual small bowel
  • Integrity of residual small bowel
  • Presence of colon
  • Presence of ileum/ileocecal valve
  • Absence of residual disease in bowel
  • Intestinal adaptation
  • Duration of time on PN: long PN will make it harder to wean off
  • Nutrition status prior to weaning
  • Fasting citrulline levels: >15-20mcmol/L
40
Q

Factors to consider before weaning PN:

A 
• Patient can meet daily fluid goal w/o excessive stool or ostomy output
• Urine output >1L/d
• I/O + balance of >500ml/d
• Meet 80% of energy goal
• Stable body weight (no more than
1.5kg loss of weight when PN reduced)
• Serum electrolytes stable (with or
without supplementation)
41
Q

how would u approach discontinuing PN?

A

before completely stopping PN, you would be decreasing PN, 10% every 1-2 weeks if pt is tolerating it well
before weaning, pt has to be able to meet their fluid intake with ORS

42
Q

EN considerations in SBS

A

• Slow and continuous
• Overnight cycle
• Gastric feeding
• Start with NG not PEG, may not tolerate EN and if a long-term EN was installed-> no good!
• Isotonic, polymeric formula
- may try semi, but NOT elemental as it is hypertonic and will draw fluid-> diarrhea
• Fibre formulas may be beneficial (if colon)
• Both MCT and LCT mixture of fats: may be beneficial as pt have fat malabsorption. MCT are better absorbed

43
Q

Acute phase: nutrtion guidelines

A

• CPN, bowel not adapted and need nutrients
• Can start EN using polymeric or semi-
elemental into stomach
– not enough to meet needs
– combine with PN: in acute phase you cannot use just EN- it has to be combined with PN
• Check electrolytes daily until stable

44
Q

Nutrition guidelines for chronic management

A
  • CPN/EN cycle overnight (some need forever)
  • Complete transition to EN for some
  • PO intake small, frequent, chew well
  • PO diet depends on SBS sub-type
  • Can use MCT oil to help fat malabsorption
  • Vitamin B12 injections if ileum resected/gone- this is forever, compared to IBD patients with inflamed illeum
  • Monitor tolerance, weight loss, hydration, diarrhoea→ back to CPN until stable
45
Q

PN and QOL link

A

weaning pts off PN significantly improves QOL

46
Q

A 33-year-old man was admitted to your hospital because of generalized weakness, emaciation, anorexia, and vomiting related to volvulus. An end-to-side anastomosis was performed between his proximal jejunum and his ascending colon, with only 40 cm of his small bowel remaining.

On admission, patient’s body weight was 36 kg, body mass index (BMI) 12.2 kg/m2

What SBS sub-type is this case?
A. End-jejunostomy
B. Jejunocolic anastomosis
C. jejunoileal anastomosis

A

B. Jejunocolic anastomosis

47
Q

A 33-year-old man was admitted to your hospital because of generalized weakness, emaciation, anorexia, and vomiting related to volvulus. An end-to-side anastomosis was performed between his proximal jejunum and his ascending colon, with only 40 cm of his small bowel remaining.

On admission, patient’s body weight was 36 kg, body mass index (BMI) 12.2 kg/m2

What will be your first nutrition intervention?
A. EN
B. PO
C. PPN
D. TPN/CPN
A

D. TPN/CPN

serious malnourishment-> CPN to deliver sufficient nutrients

48
Q

• On admission, patient’s body weight was 36 kg, body mass index (BMI) 12.2 kg/m2
• Your pharmacy has unlimited compounding and carries 20% ILE • A PICC has been inserted and is functioning
Calculate a 3in1 CPN prescription
Estimated energy and protein needs are:
A. 1620kcal/d & 72g/d
B. 2100kcal/d & 54g/d
C. 1200 kcal/d & 20g/d

A

A. 1620kcal/d & 72g/d

start with higher range as the pt is very undernourished
36kg *45 kcal

49
Q

• On admission, patient’s body weight was 36 kg, body mass index (BMI) 12.2 kg/m2
• Your pharmacy has unlimited compounding and carries 20% ILE • A PICC has been inserted and is functioning
Calculate a 3in1 CPN prescription
Estimated energy and protein needs are:
Estimated fluid needs are 1620ml/d
A. True B. False

A

Adequate hydration is considered to be present when urine output is > 1 L per day and urinary sodium concentration is >20 mEq/L

so we dont know, but you should start with 1ml/kcal

50
Q

GOAL TPN will provide:
A. 115g dextrose, 54g protein, 20g lipids
B. 320g dextrose, 80g protein, 55g lipids
C. 260g dextrose, 72g protein, 45g lipid

A

C. 260g dextrose, 72g protein, 45g lipid

with this subtype, we want higher carb, lower fat ratio
Guidelines from ASPEN:
CHO: 50-60% of TEE
PRO: 20-30% of TEE
Lipid: 20-30% of TEE

calculate dextrose:
36kg* 5mg/kg/min (max GIR)1440min/d ÷ 1000mg/d= 259.2g
260g3.4kcal/g = 884 kcal
884kcal dextrose / total daily 1620 kcal= ~55% of TEE

calculate protein
72g/d *4kcal = 288kcal
288 kcal from total 1620kcal -> ~18% of TEE (cannot consider protein flush, as this is PN))

calculate lipids
1620kcal-288-884= 448kcal lipid
448kcal÷10kcal/g= 45g
450kcal from lipid out of 1620 total kcal-> 28% of total TEE (safety check- less than 30% of TEE)
45g/36kg-> 1.25g/kg (1-2g/kg is tolerated by most, but has to be monitored, normally we aim for 1g/kg
by using a better source of lipids, higher amounts are of a lesser concern )

51
Q

What is the concentration of AA in this prescription? 260g dextrose, 72g protein, 45g lipid, 1620ml

A

4.4

52
Q

How many ml of lipids qill be added to the soluti9on

260g dextrose, 72g protein, 45g lipid, 1620ml

A

225

53
Q

How will you initiate your PN?

Start at 1/3 of goal rate
Start at 1/2 goal rate
Initiate at goal rate

A

Start at 1/3 of goal rate
this patient has a BMI of 12 which puts him at a high risk for feeding syndrome when we have a high risk of refeeding syndrome we start PN at 1/3 of the goal rate and progress slowly
We start only after correcting electrolyte abnormalities and supplemented thiamine

54
Q

How will you initiate your PN?
This patient will require IV at least until goal
PN is reached.
A. True B. False

A

True

pt is loosing electrolytes and fluids
IV might even be required after reaching PN goals

55
Q

With 40cm of small bowel + colon, do you expect this patient to wean easily from PN?

a. true
b. false

A

b. false

the pt needs at least 60cm of SB to wean from PN relatively easily

56
Q

Your next nutrition intervention will be:

A. Reduce PN
B. Initiate 10ml/hr EN C. ONS
D. Low residue diet

A

B. Initiate 10ml/hr EN

tropic phase helps wean from PN
should not reduce PN until adaptation phase

57
Q

When will you attempt PO

a. When diarrhea reduced
b. When meeting 100% of needs by PN
c. After 3 weeks

A

a. When diarrhea reduced

58
Q 
What will be first PO intake?
A. Banana
B. Oral rehydration solution 
C. Water
D. Soup
A

B. Oral rehydration solution

59
Q

Long-term PO diet for this patient will be:
Does this patient need a B12 injection?

a. Low residue, low lactose
b. Low residue
c. Low fat, low oxalate, high calcium diet

A

c. Low fat, low oxalate, high calcium diet

low residue is for patients with jejunostomy

60
Q

Does this patient need a B12 injection?

A. YES B. NO

A

Yes as he has no ileum

61
Q

what are the common electrolyte abnormalities? caus

A

Common electrolyte abnormalities include hypokalemia, hypomagnesemia, and hypocalcemia.

62
Q

why is there hypomagnesemia?

A

hypomagnesemia can occur because of (1) loss of magnesium-absorbing gut, (2) the binding of magnesium by unabsorbed fatty acids, and (3) sodium/water depletion that leads to secondary hyperaldosteronism with subsequent urinary magnesium losses

Clinical 2 (14 decks)

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