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Advanced MNT 2 > Short Bowel Syndrome > Flashcards

Short Bowel Syndrome Flashcards

1
Q

Short bowel syndrome is the metabolic & nutritional consequences which result from inadequate _______________

Unable to support the individual’s ______ and _____ requirements
Deficiency in bowel length due to extensive surgical resection

A

bowel mucosal absorptive surface area

nutritional & fluid

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2
Q

SBS is characterized by …

Severe, chronic _____________
__________ of macro- & micronutrients

_______
_________ Imbalances

Progressive ______ and ________

A

diarrhea & steatorrhea
Malabsorption

Dehydration
Electrolyte

weight loss & malnutrition

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3
Q

SBS diarrhea is due to ____, _____, and _____

A

malabsorption, altered motility, & increased secretions

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4
Q

SBS is Difficult to diagnose on _____ alone–need to consider symptoms

A loss of _______% of small bowel
<______ of remaining small bowel length

If >_____% of bowel removed/less than ______ remaining=> will have severe malabsorption and will likely need ____ for survival

A

length

70-75%
200 cm

75%
100 cm
PN

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5
Q

Etiology of SBS - Adults

A

Crohn’s disease (main)
Mesenteric infarct
Small bowel volvulus
Radiation enteritis
Cancer
Trauma
Small bowel fistulas

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6
Q

Etiology of SBS - Children

A

Necrotizing enterocolitis (NEC)
Small bowel volvulus
Intestinal atresia
Crohn’s disease

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7
Q

Factors that Influence the Severity of SBS

Remaining ___________
Health of remaining __________
__________ of resection
Presence of the ____________
Presence of the ________
Degree of __________ of the remaining bowel

A

Remaining bowel length
Health of remaining intestinal mucosa
Location of resection
Presence of the ileocecal valve
Presence of the colon
Degree of adaptation of the remaining bowel

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8
Q

Malabsorption increases with increased amount of small bowel removed or non-functional

Minimal small intestine length necessary for adequate absorption of oral/enteral is:
~______ of small bowel if no colon
~______ of small bowel with an intact colon

A

150 cm
60-90 cm

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9
Q

Location of Bowel Resection

Consider ________ and ________ of the segment removed

A

nutrients absorbed and functions

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10
Q

With Duodenal resection:
_____________ may occur

With Jejunal resection:
_________ can occur
Adequate absorption unless >_____% removed
______ can assume absorptive functions of the jejunum

A

Dumping syndrome

Lactose intolerance
75
Ileum

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11
Q

Ileal Resection

Only site for _____ and _____ absorption
Resections of > _____ results in a net loss of ______ causing _______ and ________

Large resections can result in severe malabsorption of _____, _______, ____, ____, _____, _____, and ____

Loss of the ileal _____
____________ =>dehydration & electrolyte deficiencies
Loss of the ICV can result in=> ___________

A

bile salt & vitamin B12

100 cm
bile salts
steatorrhea & cholerrheic diarrhea

fat, fat soluble vitamins, Ca, Mg, Zn, selenium, & B12

brake
End-jejunostomies
bacterial overgrowth

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12
Q

Partial or Total Resection

Increased risk of _______ and ______ losses
Intestinal transit time will be _______ with presence of a colon

____________=> slows gastric emptying
Intact colon=>metabolism of _____=> source of ____

A

dehydration and electrolyte
prolonged

Colonic brake
SCFA
kcal

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13
Q

_________ is when Remaining small bowel undergoes structural & functional changes to increase nutrient absorption

what can occur? (4)

Begins_________ after surgery and occurs over a _______ period

A

Intestinal Adaptation

Hyperplasia
elongation
increase height of the villi
increases in brush border enzymes

immediately
2-3 year

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14
Q

Factors which influence adaptation

A

Oral/enteral nutrition
Complex luminal nutrients vs. simple
Glutamine
Short-chain fatty acids (SCFA)
Hormones

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15
Q

hormones important in influencing intestinal adaptation

A

Intestinal hormones: enteroglucagon, glucagon-like peptide 1, peptide YY

Growth Hormone

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16
Q

Increased rate of gastric emptying Caused by loss of intestinal ________ & _________, loss of the ________

________=>rapid transit in remaining bowel

A

hormones
feedback control
pyloric sphincter

Ileal resection

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17
Q

Malabsorption of …

Fluid & electrolytes
Bile salts=>_________
Fat=>________
Fat soluble vitamins
Vitamin ____
Minerals: ____________
Lactose

A

cholerrheic diarrhea
steatorrhea
B12
Ca, Zn, Mg, Mn, Cu, selenium & chromium

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18
Q

____________ Can occur after significant SB resections

A

gastric hypersecretion

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19
Q

gastric hypersecretion results in…

Decreased ____ and _____ secretion=> increased serum _____levels=> increased ______ secretion

_____ volume of secretions entering the SB and promotes ____
______ damage to intestinal mucosa
Denatures __________

Precipitates _______ – disrupts _______ formation
Stimulates _______

A

CCK & secretin
gastrin
gastric acid

Increases
diarrhea
Acid
pancreatic enzymes

bile salts
micelle
peristalsis

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20
Q

what causes small bowel bacteria overgrowth

A

Removal of the ICV
Blind loops
Antimotility meds
Acid-suppression meds

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21
Q

small bowel bacterial overgrowth results in ?

A

Deconjugated bile salts

Inflammatory mucosal damage

Gas, abdominal bloating & pain, steatorrhea, fat-soluble vitamin & vitamin B12 deficiency

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22
Q

what is hyperoxaluria ?
when does it occur?

A

when steatorrhea, calcium bound to unabsorbed FA instead of oxalate, which increases absorption on free oxalate resulting in nephrolithiasis

occurs only if colon present

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23
Q

what anemias can occur with SBS

A

vit B12 or folate deficiencies

these are macrocytic

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24
Q

metabolic bone disease can occur with SBS due to malabsorption of _______ and _______. Also from ________ and _______.

A

vit D and calcium
metabolic acidosis
chronic inflammation

25
Q

metabolic acidosis is caused by ?

A

bicarb loss from diarrhea and
…excess lactic acid production from SIBO

26
Q

chronic inflammation occurs when patient has ____

A

IBD

27
Q

Diet history: analysis of home diet/nutrition support, supplement use, foods that trigger ____________ or bowel movements

A

increased ostomy output

28
Q

Nutrition assessment includes …

Detailed _______ records

Lab assessment: _______, ________, AND ________

A

I & O

electrolytes
malabsorption work-up
vitamin & mineral levels

29
Q

ENERGY SBS

Individualize
______ kcal/kg; may need up to ____ kcal/kg
For those on PN: ___ kcal/kg

A

35-45
60
32

30
Q

SBS PROTEIN

_____ g/kg
If on PN: _______ g/kg

Increased needs for …
Malnutrition
Recent ______
Presence of other diseases or conditions
Malabsorption

A

1.5-2.0
1.0-1.5

surgery

31
Q

SBS FLUID

Increased fluid needs due to ______ or ______

A

diarrhea or ostomy output

32
Q

For those with an ostomy, oral consumption of fluid should be _______ than ostomy output

Monitor closely and replace losses
Can be given ______________ to be Sipped slowly over the day
If >____/day ostomy output=> ________

A

greater

Oral Rehydration Solution (ORS)
2L
IVF with electrolytes

33
Q

there are ____ post op phases of SBS

A

3

34
Q

PHASE 1
Duration: ________

Severe _________
__________ of ________
Massive _____________

Rigorous ________ of fluid & electrolyte losses
Nutrition Support: __________

A

Initial 1-3 weeks

malabsorption
Hypersecretion of gastric secretions
diarrhea/ostomy output

IV repletion
NPO with TPN

35
Q

PHASE 2
Duration: ________

______ malabsorption occurs with deficiencies in __________
Period of greatest ___________

Nutrition Support: ______________

A

1-3 months

Fat
fat-soluble vitamins, Ca, Mg, Zn
intestinal adaptation

TPN and initiation of enteral nutrition when/if diarrhea/ostomy output decreases to <2 L/d

36
Q

PHASE 3
Duration: _____________
Goal is _____________

__________ controlled
Nutrition Therapy: ____________

Not all patients attain this phase=> _______

A

3-12 months or longer
adaptation and transition to oral diet

Diarrhea
discontinue TPN & increase to full enteral or oral feedings

home TPN

37
Q

ENTERAL NUTRITION types ?

A

Fosters intestinal adaptation

Continuous infusion

38
Q

ENTERAL NUTRITION FOSTERS INTESTINAL ADAPTATION

usually can be implemented within _______ after surgery

make sure it is infused into __________ in order to maximize the absorptive surface area

A

1 month
most proximal area

39
Q

ENTERAL NUTRITION CONTINUOUS INFUSION

may need this for __________ if unable to meet needs with oral diet

A

home tube feeding

40
Q

Research supports using ___________ formulas due to increased ____________ and decreased _________

If colon is intact, use a ____________ formula=> _____

If unsuccessful=> try a ______________

________ formulas=> no longer recommended

A

isotonic, polymeric
stimulation of intestinal adaptation
osmotic load

soluble fiber-containing
SCFA

semi-elemental/peptide-based formula with MCT

Elemental

41
Q

Must consider anatomy for macronutrient distribution
Colon in continuity=>

______ CHO, ______ fat
______% of kcal from CHO
______% from fat
_____% from protein

_______ CHO; _______ fiber=>______

Absence of colon=> Moderate in CHO & fat
40-50% of kcal from CHO, 30-40% kcal from fat, 20% from protein
Complex CHO; soluble fiber

A

Higher
lower
50-60
20-30
20

Complex
soluble
SCFA

42
Q

Macronutrients…
Absence of colon=>

_______ in CHO and ______ fat
______% of kcal from CHO
______% kcal from fat
______% from protein

_______ CHO; ______ fiber

A

Moderate
Moderate

40-50
30-40
20

complex
soluble

43
Q

FOR ORAL NUTRITION…
Consume ___ _______ meals
Mimimize intake of __________
Emphasize ________ CHO

Chew food thoroughly
when do u drink fluid ??????
Drink _______ beverages - ____

Liberal use of salt (if _____)
Avoid caffeine & alcohol

A

5-6 small
concentrated sweets
complex

not during meals
isotonic
ORS

no colon

44
Q

Individualize restrictions

If colon intact=>Restrict _________

________—if needed
Provide diet education with sample menus

A

oxalate intake

Low lactose

45
Q

Sources of oxalate ?

A

berries
nuts
chocolate
green beans
celery
spinach
beets
beer
sweet potatoes
soy

46
Q

Micronutrients (for those on oral &/or enteral nutrition)

___________ for all patients
Assess individually for additional supplementation

If steatorrhea=>_______________

In the absence of the ileum/large resection =>___________

A

MVI with minerals

fat-soluble vitamin supplement in water-soluble form

1000 mcg vit B12 IM injection monthly

47
Q

other possible micronutrients you might give

A

calcium citrate
Mg
Zinc
K+, Na, Cl, bicarbonate

48
Q

Calcium citrate supplementation=>________

Magnesium is _________ or ___________

A

500-600 mg tablet, 1-2 tablets TID

Mg lactate: 84 mg tablet 1-2 tablets TID
Mg gluconate: 1000 mg tablet or liquid, 1-3 tablets TID

49
Q

Zinc=>lose _____ mg zinc/L of output
Rx _____ of _______ tablet, _____ tablets daily

K+, Na, Cl, Bicarbonate=> ____

A

12

220 mg zinc sulfate
1-3

ORS

50
Q

Pharmacologic Management of SBS

A

Antimotility/antidiarrheals
Proton pump inhibitors & H2-receptor antagonists
Bile acid sequestrants
somatostatin analogue

51
Q

Antimotility/antidiarrheals example

A

loperamide

52
Q

Bile acid sequestrants example

A

cholestyramine

53
Q

Food-drug interaction with bile acid sequestrants

A

Decreased absorption of fat-soluble vitamins, Ca, Fe, Zn, Mg, & folate

54
Q

somatostatin analogue ?

A

octreotide

55
Q

octedtride effects ?

FDI?

A

Antisecretory action
Antimotility
Reduces ostomy output and diarrhea

Food-drug interactions: N/V

56
Q

FDA-Approved Proadaptive Therapy for Management of SBS ?

example ?

what does it do?

A

Glucagon-like peptide 2 (GLP-2) analogues

e.g., teduglutide (GATTEX)

Found to increase improve structural integrity of intestinal mucosa, increase intestinal absorption, and reduce PN requirements

57
Q

Surgical Management of SBS

A

Longitudinal intestinal lengthening & tapering (LILT)

Serial transverse enteroplasty procedure (STEP)

Small bowel transplantation

*look these up to see what they are

58
Q
A

Advanced MNT 2 (17 decks)

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