seeking enteral autonomy: managing the patient with short ... · seeking enteral autonomy: managing...

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WOCN Richmond Oct 2016

CRParrish

Seeking Enteral Autonomy:Managing the Patient with Short Bowel Syndrome

Carol Rees Parrish MS, RD

Nutrition Support Specialist

Digestive Health Center

University of Virginia Health System

Charlottesville, VA

2016 Mid-Atlantic Region WOCN, Richmond VA

I have the following relevant relationship(s) to

disclose:

Shire Pharmaceuticals for book publishing.

Learning Objectives

� The participants will be able to:

1) Explain the factors that contribute to high stool

output in SBS

2) Appropriately select and dose medications to enhance

absorption and decrease stool volume.

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Case 70 y/o sharp, active, very compliant F presents to GI nutrition clinic

� SBS from Crohn’s: 128cm SB distal to L.O.T. with end jejunostomy

� 24 hour ostomy volume = 1500-2200mL; UOP - unknown

� BUN/creat = 47/1.3; 1 month ago after IV fluids � BUN/creat: 28/0.9

� Ht: 5’4” Wt: 102# UBW: 120#

� Nutrition/Hydration Regimen:

• Oral diet: short bowel, 5 meals & snacks, 1 liter ORS sipped over day

• Nocturnal PN added 3 days/wk 1 month ago when “renal function declined”

• Lactated ringers “prn”

• Enteral feeding: 1.5 cal/mL product @ 100mL/hr overnight until 4 cans infused

� 30 min before breakfast:

◦ 1 pepcid, 2 lomotil, opium tincture 0.6 ml

� With breakfast:

◦ 1 celexa, lactaid tablet, chewable vitamin, 2 cranberry extract, 1/2 lopressor

� 30 min before lunch:

◦ 1 claritin, 2 lomotil, ferrous sulfate liquid, opium tincture 0.6 ml

� With lunch:

◦ 1 calcium, lactaid, 2 cranberry extract, liquid vitamin D drops, chewable vitamin

� 30 minutes before dinner:

◦ 1 pepcid, 2 lomotil, lactaid, opium tincture 0.6 ml

� Bedtime:

◦ 1 claritin, 2 lomotil, opium tincture 0.6 ml, 1/2 lopressor, Lipitor (?), Keflex

Meds (= 33)

Etiology of SBS & High Output

Stomas in Adults

� Complications from abdominal surgery◦ > incidence of SBS with laparoscopic vs. open procedures

◦ Hernia repairs

◦ Bariatric surgery � Volvulus

� Malignancy - tumor resection

� Mesenteric ischemic events

� Crohn’s disease

� Trauma

� OtherJeppesen PB. JPEN J Parenter Enteral Nutr.

2014;38(1 Suppl):8S-13S.

McBride CL, et al. Am Surg. 2014;80(4):382-5.

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When Does it Present a Problem?

� Unable to maintain nutrition, hydration, & micronutrient status

while eating/drinking a normal diet & fluids

� Wide range in normal SB length: 300-800cm

� Problems arise when > 75% removed (< 200cm remaining)

• Medicare criteria is <150cm

� Note: remaining colon = 50-60cm SB

DiBaise J, et al. Pract Gastroenterol 2014;(8):30.

Contributors to Diarrhea & Malabsorption

� Loss of absorptive surface area

� Loss of feedback mechanisms leading to:� Dumping into upper gut

� Accelerated intestinal transit

� Poor mixing of pancreatico-biliary secretions with food

� Gastric hypersecretion� Sheer volume of gastric secretions

� Lower pH entering upper gut deactivates pancreato-biliary secretions

� Onging or new medical issues� Inability to control primary disease, C. diff., small bowel bacterial

overgrowth

DiBaise J, et al. Pract Gastroenterol. 2014;Aug:30.

Go VL, et al. Gastroenterology 1970;58(5):638-646.

Clinical Translation

� Diarrhea

� Steatorrhea/malabsorption

� Malnutrition

� Nutrient deficiencies

� Metabolic bone disease

� Dehydration

� Electrolyte disarray

� Metabolic acidosis

� Bacterial overgrowth

� Nephrolithiasis

� Cholelithiasis

� Cholerrheic (bile salt) diarrhea� Only in those with colon segment

� Medication malabsorption

Nightingale J, et al. Gut. 2006;55 Suppl 4:iv1-12.

Rosner M. Pract Gastroenterol 2009;(4):42.

Tappenden KA. JPEN. 2014;38(1 Suppl):23S-31S.

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Factors Enhancing Adaptation & Absorption

� Intact, luminal nutrients

� Length & quality of remaining bowel

� Which segments of SB remain

� Intact colonic segment

� Age of patient (?)

� Integrity of other organs

� Time elapsed since original insult

◦ Depending on interventions to date

� Patient adherence to therapies Tappenden KA. JPEN J Parenter

Enteral Nutr. 2014;38(1 Suppl):14S-22S.

� GI anatomy

� Op reports/ reliable drawing

� Small bowel follow through (SBFT)

� Idea of gross anatomy & transit time

� Abdominal CT

� Past medical/surgical history

Data

Collection

Parrish CR. Pract Gastroenterol 2005;(9):67.

� Urine output <1000mL/day

� Stool output >1500-2000mL/day

� Rapid weight loss

� Dark urine

� Chronic fatigue

� Hypotension

� Dehydration admits?

� Recurrent kidney stones

� Decline in kidney function

� Light-headedness on standing

� Thirst, dry mouth

� Thick saliva

Parrish CR, et al. Pract Gastroenterol. 2015;(2):10-18.

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Common Causes of Increased Stool Output

� C. difficile/other GI infection

� Initiation of a new medication

� Sudden discontinuation of important gut slowing med

◦ Pt runs out & forgets to inform health care team…

� Drinking too much fluid or poor fluid choices

� New hyperthyroidism

� Recurrent/active disease

� “Outflow” diarrhea from stricture/obstructive process

Data cont.

� Baseline 24 hour I & O:� Urineo Goal = 1200mL; stone formers > 1500mL

� Stool/ostomyo Goal = < 1500mL

� 24 hour fast� Differentiate osmotic vs. secretoryo NPO x 24 hours w/ strict measurement of stool output

� 48 - 72 hour quantitative fecal fat:� 100g fat/day diet or enteral feeding during collection period

Goals of Therapy

Slow motility� ↑ nutrient contact time

� ↑ absorption

� ↓ stool/ostomy output

� ↑ urine output

All else falls in line

Maintain nutritional

status

Maintain appropriate

weight

Maintain hydration

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Survey Results SBS Patients Entering

Bowel Rehab Program

Estívariz CF, et al. Nutrition. 2008;24:330-339.

� Had received little prior dietary instruction from healthcare providers

� Were making food and beverage choices that would:

� � stool output

� � parenteral nutrition requirements

Diet Guidelines1-3,6

General Tips • 6-8 small meals / snacks per day—start with 2-3 day diet record• Taylor diet to individual—tell them what they can eat!

• Chew foods well

• Written diet materials for SBS available @ www.ginutrition.virginia.edu

Fluids • Oral rehydration solutions

• Fluids may need to be limited in some pts & IV fluids given

Carbohydrates • Generous complex CHO intake (pasta, rice, potatoes, breads, etc.)

• Limit simple sugars & sugar alcohols in BOTH foods/fluids; limit lactose & lactaid

milk

• NO ENSURE/BOOST etc.

Fat • Limit fat to < 30% in those w/ a colon; may need to limit in those without

• Ensure oils w/ essential fatty acids included (sunflower, soybean, corn, walnut)

Protein • High quality protein at each meal & snack

Fiber • Encourage some fiber (in food) in those with a colon segment

Oxalate • Limit in those w/ a colon; ENSURE adequate urine output first

Salt • Usual intake in those with a colon; �� salt intake in those without

� In stable well-nourished pts that want to try them--ok...

◦ Can � viscosity of effluent & may improve quality of life in some.

� In pts w/ poor intake, don’t fill them up on this!

� May exacerbate water/electrolyte depletion depending on type

& amount of fiber used.

� Can � bile salt loss (by entrapment of whole micelles in gut ?)

◦ May affect fat and fat soluble vitamin absorption.

� Does not improve hydration of pts.

Bulk Forming Agents & Jejunostomies / Ileostomies

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� Hypertonic fluids

� Fluids that pull water into the SB lumen to dilute the higher

osmotic fluid, increasing stool volume

� Examples: fruit juices & drinks; sodas, sweetened liquid nutritional

supplements, sweetened tea, ice cream, sherbet

� Hypotonic fluids

� Fluids that pull sodium into the SB lumen to increase the

osmolarity of the fluid, and along with it, water, increasing stool

volume

� Water, tea, coffee, alcohol, diet drinks

Parrish CR, et al. Pract Gastroenterol. 2015;Feb:10.

� Take small amounts of fluids with meals

� Sip more between meals

� Demonstrate to pt contribution of oral fluids to stool/ostomy output by:

� Severely decreasing oral fluid intake for 24 hours

� Need to keep UOP > 1200mL/day

� Add IV fluids

� Infuse ORT/ appropriate fluid via PEG tube at night

Newton CR, et al. J R Soc Med. 1985;78(1):27-34.


1) Passive absorption

2) Active absorption

• Sodium-potassium ATP pump

3) Glucose-coupled transport

• Coupling is obligatory

• Permits 1 Na+ molecule w/ each

glucose

• Coupled transport is uni-directional


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Oral Rehydration Solutions (ORS)

� Are not for everybody…

� Start with 500mL/day

� Sipping is better than gulping

� Try as ice cubes/popsicles

� Commercial and ORT-like recipes available

� “A Patient’s Guide to Managing a Short Bowel”

(see resource section)

Nauth J, et al. Nutr Rev. 2004;62(5):221-31.

Parrish CR, et al. Pract Gastroenterol 2015;Feb:10.

Vitamins & Minerals

� Little evidence for dosing� Consider:

• Osmotic drag from so many pills (& fluid to take them)

• Sheer cost

• Time to take them all

� Add therapeutic vitamin & mineral supplement• Chewable, crushed, or liquid form

• Daily, twice daily—½ to 1 tab

� B12/methylmalonic acid• High dose oral vs. SQ or IM monthly injections

Parrish CR, et al. Pract Gastroenterol 2014;Oct:40.

Vitamin D & Bone Health

� Baseline DEXA scan, then as needed

� Baseline 25-OH vitamin D

� Vitamin D – alter dosing if cannot normalize

◦ Higher daily dose, twice-daily, crushed tabs, liquid, etc.

� Avoid 50,000 units weekly

� Sunlight/ UV light

◦ Sunlight, Sperti lamp, tanning beds

� Calcium

◦ Diet contribution & supplements (< 500mg/dose divided BID-TID)

Parrish CR, et al. Pract Gastroenterol 2014;Oct:40.

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Pharmacotherapy (Consider ALL medications)

� Prescription, over-the-counter, supplements, etc.

� Scheduled; NOT “PRN”

� Timing in relation to meals

� Dosing/ form

• Tab, capsule, sustained or delayed-release?

• Elixirs/suspensions: sugar alcohols !

� Are you getting clinical efficacy?

� Is medication available @ local pharmacy?

� Are they still needed? -- reevaluate

� Periodically, do the � total pill count

Broadbent M. J Palliat Med. 2006;9(6):1481-1491.

Ward N. J Gastrointest Surg 2010;14(6):1045-1051.

Anti-Secretory Agents8

Anti-motility Agents

� Check for C. difficile first

� Take 30-60 minutes BEFORE meals

� Every 6 - 8 hours, NOT QID or “prn”

• Take advantage of pt getting up at night (they are!)

• Pill/s ready at bedside with sip of water

� Endpoint?

• Output �’s too much (i.e., constipated/ stool thick)

• Pt is nauseated, mental status changes, sleepy, etc.

Chan LN, et al. Pract Gastroenterol. 2015;March:28.

Williams RN, et al. J Clin pathol. 2009;62:951-953.

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Antidiarrheal Agents9

Other Therapies Sometimes Attempted

Use Selectively (if at all)

Bile acid binders

Only in pts with a colon

Pancreatic enzymes

Pancreatic insufficiency

Antibiotics

(small bowel bacterial

overgrowth)

Probiotics

Insufficient data to

support its use

Glutamine

Insufficient data to support its use

Chan LN, et al. Pract Gastroenterol. 2015;March:28.

DiBaise JK. Pract Gastroenterol. 2008;Dec:15.

Intestino-Trophic Agents

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Recombinant Growth Hormone (rhGH):

Meta-Analysis of 5 Small Studies

� Patients receiving rhGH ± Gln:

� ↑’d weight & lean body mass

� ↑’d energy, fat, nitrogen absorption

� ↓’d PN volume, calories, number of PN infusions/wk

� Only rhGH+Gln grps maintained PN reductions at 3-months

� + Effects of rhGH on weight & energy absorption are temporary

� ~ 5kg wt loss

� Evidence is inconclusive to recommend rhGH

Wales PW, et al. Cochrane Database Syst Rev. 2010;CD006321.

DiBaise J, et al. Pract Gastroenterol 2015;May:56.

Glucagon-like peptide-2 (GLP-2)

� Endogenous peptide released from the distal ileum/ proximal

colon in response to enteral nutrients

� Acts locally

� Physiological effects: � Inhibits gastric acid secretion and emptying

� Stimulates intestinal blood flow

� Increases intestinal barrier function

� Enhances nutrient and fluid absorption

� May also bone resorption

Jeppesen PB. Curr Opin Endocrinol

Diabetes Obes. 2015;22:14-20

Evidence for Teduglutide (TED) [GLP-2 Analog]

Pivotal Phase 3 Study

� Multicenter, Multinational, Double-blind, Placebo-controlled

� 86 PN-dependent SBS patients given SQ teduglutide

� % of pts with > 20% in PN /wk at wks 20-24:

� 63% vs. 30% in TED vs. placebo group respectively; p = 0.002)

� PN in liters/wk (TED vs. placebo):

� 4.4 vs. 2.3 L

� 54% vs. 23% ↓’d > 1 PN infusion day/wk

� All while maintaining weight & urine output > 1000mL/day

Jeppesen PB, et al. Gastroenterology. 2012;143:1473.

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Teduglutide Extension Studies

� 52 Weeks (n= 52)

� 0.05-mg/kg/d vs. 0.10-mg/kg/d dose:

� 68% vs. 52% had a >20% volume reduction in PN

� 68% and 37% reduction of > 1 days of PN dependency

� PN independence achieved in 4 pts

� Up to 2.5 years (n = 88)

� 13 pts achieved full enteral autonomy

� Long-term TED treatment resulted in sustained, continued PS

reductions

� Overall health/nutritional status was maintained with PS reductions

O’Keefe SJ et al. Clin Gastroenterol Hepatol. 2013;11:815-823.

Schwartz LK, et al. Clin Transl Gastroenterol. 2016 Feb 4;7:e142.

Considerations Before Using Trophic Agent

� Pt actually has SBS

� On PN/IV fluids >3 times/week for 1 year or more

� Pt has been educated & optimized on:

� Diet/hydration therapy

� Anti-secretory drugs

� Anti-diarrheal drugs

� Absence of contraindications (active GI malignancy,

strictures, active CD, etc.)

� Is adherent/reliable with therapies

DiBaise J, et al. Pract Gastroenterol 2015;May:56.

“Tools” for our Patients

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More Tools

Date/Time WeightStool/

Ostomy OutputUrine

Output

Silent Knight pill crusher

Hammer & Baggie

Mortar & Pestle

Resources

� UVAHS GI Nutrition Website www.ginutrition.virginia.edu with links to:

�Under “Nutrition Articles”

◦ Recent 6 part series on SBS in Practical Gastroenterology (see references at end)

�Under Patient Education

◦ Short Bowel Diet & Hydration Information

Resource available at no

cost to patients & clinicians

@ www.shortbowelsupport.com

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Available through CRC Press at:https://www.crcpress.com/Short-Bowel-

Syndrome-Practical-Approach-to-

Management/DiBaise-Parrish-

Thompson/p/book/9781498720786

June 2016

Patient Support Resources

� Oley Foundation

www.oley.org

(800/776-OLEY)

� Short Bowel Syndrome Foundation

www.shortbowelfoundation.org

(888-740-1666)

Nutrition Support SpecialistDigestive Health Center

University of Virginia Health SystemCharlottesville, VA

E-mail: [email protected]

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References

1) Barrett JS, et al. Dietary poorly absorbed, short-chain

carbohydrates increase delivery of water and fermentable

substrates to the proximal colon. Aliment Pharmacol Ther.

2010;31:874-882.

2) Byrne TA, et al. Beyond the prescription: optimizing the diet

of patients with short bowel syndrome. Nutr Clin Pract.

2000;15:306-311.

3) Wolever TMS, et al. Sugar alcohols and diabetes: a review.

Can J Diabet. 2002;26(4):356-362.

References – Fiber and Ostomies

1) Aman P, et al. Excretion and degradation of dietary fiber constituents in ileostomy subjects consuming a low fiber diet with and without brewers spent grain. J Nutr 1994;124:359-363.

2) Crocetti D, et al. Psyllium fiber food supplement in the management of stoma patients: results of a comparative prospective study. Tech Coloproctol. 2014;18(6):595-6.

3) Dalhamn T, et al. The effect of sterculia bulk on the viscosity of stomaloutput from twelve patients with ileostomy. Scand J Gastroenterol. 1978;13(4):485-8.

4) Ellegård L, et al. Oat bran rapidly increases bile acid excretion and bile acid synthesis: an ileostomy study. Eur J Clin Nutr. 2007;61(8):938-45.

5) Gelissen IC, et al. Effect of Plantago ovata (psyllium) husk and seeds on sterol metabolism: studies in normal and ileostomy subjects. Am J ClinNutr. 1994;59(2):395-400.

References – Fiber and Ostomies

6) Higham SE, et al. The effect of ingestion of guar gum on ileostomy

effluent. Br J Nutr. 1992;67(1):115-22.

7) Isaksson H, et al. High-fiber rye diet increases ileal excretion of

energy and macronutrients compared with low-fiber wheat diet

independent of meal frequency in ileostomy subjects. Food Nutr

Res. 2013 Dec 12;57.

8) Newton CR. Effect of codeine phosphate, Lomotil, and Isogel on

ileostomy function. Gut. 1978;19(5):377-83.

9) Steinhart AH, et al. Effect of dietary fiber on total carbohydrate

losses in ileostomy effluent. Am J Gastroenterol. 1992;87(1):48-54.

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References Below Available @ www.ginutrition.virginia.edu

1) DiBaise J, et al. Part 1: Physiological Alterations and Clinical

Consequences. Pract Gastroenterol. 2014;Aug:30.

2) Parrish CR, et al. Part II: Nutrition Therapy for Short Bowel

Syndrome in the Adult Patient. Pract Gastroenterol. 2014;Oct:40.

3) Parrish CR, et al. Part III: Hydrating the Adult Patient with Short

Bowel Syndrome. Pract Gastroenterol. 2015;Feb:10.

4) Chan LN, et al. Part IV-A: A Guide to Front Line Drugs Used in the

Treatment of Short Bowel Syndrome. Pract Gastroenterol.

2015;March:28.

5) Chan LN, et al. Part IV-B: A Guide to Front Line Drugs Used in the

Treatment of Short Bowel Syndrome. Pract Gastroenterol.

2015;April:24.

References Below Available @ www.ginutrition.virginia.edu

6) DiBaise J, et al. Part V: Trophic Agents in the Treatment of Short Bowel Syndrome. Pract Gastroenterol. 2015;May:56.

7) DiBaise JK. Small Intestinal Bacterial Overgrowth: Nutritional Consequences and Patients at Risk. PractGastroenterol. 2008;Dec:15.

8) Parrish CR. The Clinician's Guide to Short Bowel Syndrome. Pract Gastroenterol. 2005;Sept:67.

9) Rosner M. Metabolic Acidosis in Patients with Gastrointestinal Disorders: Metabolic and Clinical Consequences. Pract Gastroenterol. 2009;April:42.

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