Short Bowel Syndrome Secondary to Ischemic

Bowel Resulting in a Duodenal Stump

A Case Study PresentationBy: Erin Huckle

The Patient

60 y/o white male with short bowel syndrome secondary to bowel ischemia, hospitalized for evaluation and treatment of

ischemic bowel

The patient was admitted with:

Septic shock

GI bleed

Past Medical History

The patient presented with a complex medical history significant for…

• Short bowel syndrome • Ischemia, bowel• Bacteremia• Septic embolism• Atrial fibrillation• CAD s/p stent placement x 3• Ischemic cardiomyopathy

• Anemia, unspecified • Hypertension• Acute kidney injury• Severe malnutrition

History of Illness July 2011: patient developed bowel ischemia, underwent a

colectomy and partial small bowel resection with jejunostomy

Central line was placed, TPN started

Line became infected, patient developed septic emboli

Lengthy hospital stay, patient discharged to SNF

History of Illness At SNF, patient c/o abdominal pain, sent to local emergency

department

Patient hospitalized, bloody output from jejunostomy

A CT demonstrated pneumotosis throughout the small bowel from ligament of Treitz to jejunostomy

Patient transferred for further evaluation and treatment

SurgeryOnce transferred, the patient underwent numerous procedures including:

Exploratory laparotomy, lysis of adhesions, and ileocolostomy takedown

Resection of ischemic small bowel (the entirety of his remaining small bowel – duodenal stump)

Wound vac placement

Surgeries

Before surgeries (normal bowel) After colectomy &

partial bowel resection

After last surgery – remainder of bowel

removed to ligament of Treitz

Issues to be Addressed

Life-long Issues

Nutritional Assessment

Medical Diagnosis

Nutrition Diagnosis

Nutritional Interventions

Short & Long Term Goals

Long-term risks of TPN

Outcomes

Life-Long Issues

1. The patient will require life-long TPN. No solid foods. Only limited clears.

2. The patient will have a life-long gastrostomy tube to drain the contents of the stomach

3. The patient will have a life-long gastroduodenostomy tube to drain the contents of the duodenal stump

Food/Nutrition-Related History

Diet: NPO for most of hospital stay, advanced to limited clears, no jello, no concentrated sweets

Total energy intake: 1750 kcal/day and 126 gm protein/day from TPN

Emotions:

• Unhappy with inability to eat

• Asked anyone who entered his room for food/beverages

• Frustrated with further diet modifications – avoidance of concentrated sweets, jello, etc.

Hospital MedicationsThe patient can take NO MEDICATIONS BY MOUTH – They WILL

NOT be absorbed

Nexium – decrease stomach acid production

Glucagen, prn – control CBGs

Humulin R, prn – control CBGs

Vancomycin – antibiotic

Zosyn – antibiotic

Anthropometric MeasurementsHeight: 68 inches

Weight: 100.3 kg (admission), 105.2 kg (discharge)

- 10.7# weight gain

BMI: 33.5

Ideal Body Weight/Dosing Weight: 70 kg

%IBW: 143%

Biochemical AssessmentLab Values Reference Range 5-Feb 6-Feb 7-Feb 8-Feb 9-Feb 13-Feb

Na 134 - 143 137 141 147 145 150 145

K 3.4 - 5.0 4.8 4.3 3.6 2.9 3.8 3.4

Cl 97 - 108 107 115 114 113 119 115

BUN 6 20 55 46 34 33 30 32

Cr 0.7 - 1.3 4.85 3.75 2.87 2.21 1.79 1.24

Gluc 60 - 99 153 111 158 163 116 113

Corrected Ca 8.6 - 10.2 8.7 9 8.9 9 9.2 9.2

Mg 1.8 - 2.5 - 1.2 1.6 1.9 1.5 1.6

Phos 2.4 - 4.7 - 7.4 5.9 3.3 2.8 3

CBGs 60 - 99 - 111-153 89-185 129-256 117-166 88-121

Nutrition-Focused Physical Findings

Mouth: Lips dry, tongue slightly red, teeth in poor condition

Hair: appeared brittle and dry, balding

Nails: dry, white, chalky appearance

Skin: soft and warm, skin on lower extremities appeared tight and shiny, no pitting

No observable physical findings of muscle wasting or depletion of fat stores

Client HistoryOccupation: Previously managed an RV park, lost job in 2006

Social history: Never married, no children

Living/housing situation: Desires to go home and live in double-wide mobile home with his brother and elderly mother

Tobacco use: 1 pack/day for 48 years – Quit in July 2011

Alcohol use: 2-3 drinks per day

Drug use: Current THC use, history of cocaine and meth use

Estimated Needs

Total Estimated Energy Needs: 1540-1750 kcal/day

(22-25 kcal/kg IBW – patient with a BMI > 30)

Total Protein Estimated Needs: 105-140 gm protein/day

(1.5-2.0 gm protein/kg IBW – patient with a BMI > 30-40)

Total Fluid Estimated Needs: 1750 ml/day

(1 ml/kcal/day)

Diagnosis – Bowel IschemiaDefinition: Damage to or death of part of the intestine due to a decrease inblood supply

Symptoms include:• Abdominal pain

- most common - pt’s chief complaint• Diarrhea• Vomiting• Fever

Diagnosis – Bowel Ischemia

Common causes include:

• Hernia

• Bowel adhesions

• Embolus

• Arterial thrombosis

• Venous thrombosis

• Low blood pressure

Usual medical treatment:

Surgery is usually necessary. The sections of dead bowel are removed and healthy ends of the bowel are reconnected.

Diagnosis – Short Bowel Syndrome (SBS)

Definition:

Inadequate absorptive capacity due to decreased length and/or decreased functional bowel. Typically occurs with 70-75% loss of small bowel.

Symptoms can include:• Diarrhea• Steatorrhea• Edema (especially of the legs)• Very foul-smelling stools• Weight loss

Diagnosis – Short Bowel Syndrome (SBS)

Goals of Treatment for SBS:

Provide the patient with adequate nutrients, water, and electrolytes to maintain health.

Facilitate the use of total parenteral nutrition (TPN) when necessary

Maximize the potential of the remaining bowel in order to reduce or eliminate the use of TPN

Short Bowel SyndromeNutrition concerns related to SBS:

• Nutrient deficiencies

• Hydrations status

• Avoidance of concentrated sweets and caffeine

Absorption

Nutrition Diagnosis

Impaired nutrient utilization related to malabsorption as evidenced by need for parenteral nutrition

Intervention/MNTParenteral Nutrition Interventions:

Placed TPN orders, modified on a daily basis if needed.

Example of TPN order placed for this patient:

Cyclic TPN x 18 hrs: 60 ml x 1 hr; increase to 105 ml/hr x 16 hrs; decrease to 60 ml x 1 hr to provide 25 kcal/kg, 1.8 gm

protein/kg, with 20% lipids (39 g lipid/day) in a volume of 1800 ml/day

Interventions/MNTParenteral Nutrition Interventions (continued):

• Make changes to rate and volume of TPN as needed

• Monitor CBGs and recommend adjustments in insulin drip accordingly

• Monitor lab values and make adjustments to TPN substrates accordingly

ShortagesDue to national shortages the patient’s TPN did not contain

magnesium sulfate or additional selenium.

If needed, the patient would have to receive Mg SO4 or additional selenium via IV or PO medication.

Intervention/MNTNutrition Education

Provided pt with written and verbal SBS education

Emphasis placed on avoidance of concentrated, sweetened beverages & caffeine-containing beverages.

Pt expressed frustration to further diet restrictions, but verbalized understanding.

Intervention/MNTOral Nutrition Supplements

Provided nurses and pt with oral rehydration therapy (ORT) formulas for SBS

ORT can help the pt to meet fluid needs by increasing fluid absorption

Goal: Sip 1 L ORT over the course of the day

ORT RecipeGatorade Formula

1 cup Gatorade

1 cup water

¼ teaspoon salt

Mix together & drink.

ORT RecipeGrape or Cranberry Juice Formula

1/8 cup grape/cranberry juice

7/8 cup water

1/8 teaspoon salt

Mix together & drink.

Short-Term GoalsProvide the patient with adequate nutrients, water, and

electrolytes to maintain health

Goal CBGs of ~110-150 mg/dl, d/t improved pt outcomes associated with better glycemic control

Avoid any food intake

Avoid concentrated sweetened beverages, caffeine

Trial oral rehydration therapy

Long-Term GoalsProvide patient’s medical team with discharge TPN orders

Maintain health as best as possible by obtaining adequate nutrients and electrolytes from TPN until no longer a desirable option

Long-Term Complications of TPN

Common complications of long-term TPN use include:

Hepatic dysfunction

Cholelithiasis

Metabolic acidosis

Outcome11 day hospital stay

Discharged on home TPN, home health nurse will follow

“Not if, but when…”

Quality of Life

Option for Hospice care

Discharge MedicationsClonidine patch – control high BP

TPN

Fat Emulsion – 20%

All other IV meds were stopped

Discussion & Summary

Patient will face life-long issues

What if the patient takes food by mouth?

Living environment at home

Patient & family will need to make decisions about the future

ReferencesAcademy of Nutrition and Dietetics. Nutrition Care Manual. Available at: http://nutritioncaremanual.org. Accessed March 27, 2012.

Biomedical Central Nursing. “Gastroenterology Grand Rounds: Persistent metabolic acidosis in a patient with short bowel syndrome on long term TPN.” Accessed 25 March 2012 from http://www.bcm.edu/gastro/VGICC/GI-M0054/09-DISC.HTM

Children’s Hospital of Pittsburgh. “Total Parenteral Nutrition (TPN)” Children’s Hospital of Pittsburgh. Accessed 25 March 2012 from http://www.chp.edu/CHP/tpn+intestine

Jensen GL, Mirtallo J, Compher C, Dhaliwal R, Forbes A, Grijalba RF, Hardy G, Kondrup J, Labadarios D, Nyulasi I, Castillo-Pineda JC, Waitzberg D. Adult Starvation and Disease-Related Malnutrition: A Proposal for Etiology-Based Diagnosis in the Clinical Practice Setting From the International Consensus Guideline Committee. Journal of Parenteral and Enteral Nutrition March 2010; 34 (2): 156-9.

McClave SA, Martindale RG, Vanek VW, McCarthy M, Roberts P, Taylor B, Ochoa JB, Naolitano L, Cresci G, A.S.P.E.N. Board of Directors, American College of Critical Care Medicine. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient. Journal of Parenteral and Enteral Nutrition May/June 2009; 33 (3): 277-316.

Oregon Health & Science University. Suggested Guidelines for Nutrition Care: Adult TPN Guidelines. Revised Oct 2011. Available at: https://ozone.ohsu.edu/foodandnutritionservices/suggestedguidlines/adulttpn.pdf

Oregon Healthy & Science University. Suggested Guidelines for Nutrition Care: Adult Short Bowel Syndrome Guidelines. Revised Dec 2011. Available at https://ozone.ohsu.edu/foodandnutritionservices/suggestedguidlines/adultshortbowelsyndrome.pdf:

Parrish CR. The Clinician’s Guide to Short Bowel Syndrome. Practical Gastroenterology: Nutrition. Issues in Gastroenterology, Series #31. September 2005.

Parrish, CR. The Hitchhiker’s Guide to Parenteral Nutrition Management for Adult Patients. Practical Gastroenterology: Nutrition. Issues in Gastroenterology, Series #40. July 2006.

U.S. National Library of Medicine: PubMed Health. “Intestinal Ischemia and Infarction” PubMed Health, Accessed 25 March 2012 from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002136/

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