Short Bowel Syndrome Secondary to Ischemic Bowel Resulting in a Duodenal Stump

1. Short Bowel Syndrome Secondary to Ischemic Bowel Resulting in a Duodenal Stump A Case Study Presentation By: Erin Huckle

2. 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

3. 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

4. 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

5. 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

6. Surgery Once 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

7. Surgeries After last surgery – remainder of bowel removed to ligament of Treitz Before surgeries (normal bowel) After colectomy & partial bowel resection

8. 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

9. Life-Long Issues • The patient will require life-long TPN. No solid foods. Only limited clears. • The patient will have a life-long gastrostomy tube to drain the contents of the stomach • The patient will have a life-long gastroduodenostomy tube to drain the contents of the duodenal stump

10. 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.

11. Hospital Medications The 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

12. Anthropometric Measurements Height: 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%

13. Biochemical Assessment

14. 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

15. Client History Occupation: 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

16. 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)

17. Diagnosis – Bowel Ischemia Definition: Damage to or death of part of the intestine due to a decrease in blood supply Symptoms include: • Abdominal pain - most common - pt’s chief complaint • Diarrhea • Vomiting • Fever

18. 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.

19. 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

20. 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

21. Short Bowel Syndrome Nutrition concerns related to SBS: • Nutrient deficiencies • Hydrations status • Avoidance of concentrated sweets and caffeine

22. Absorption

23. Nutrition Diagnosis Impaired nutrient utilization related to malabsorption as evidenced by need for parenteral nutrition

24. Intervention/MNT Parenteral 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

25. Interventions/MNT Parenteral 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

26. Shortages Due 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.

27. Intervention/MNT Nutrition 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.

28. Intervention/MNT Oral 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

29. ORT Recipe Gatorade Formula 1 cup Gatorade 1 cup water ¼ teaspoon salt Mix together & drink.

30. ORT Recipe Grape or Cranberry Juice Formula 1/8 cup grape/cranberry juice 7/8 cup water 1/8 teaspoon salt Mix together & drink.

31. Short-Term Goals • Provide 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

32. Long-Term Goals • Provide 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

33. Long-Term Complications of TPN Common complications of long-term TPN use include: • Hepatic dysfunction • Cholelithiasis • Metabolic acidosis

34. Outcome • 11 day hospital stay • Discharged on home TPN, home health nurse will follow • “Not if, but when…” • Quality of Life • Option for Hospice care

35. Discharge Medications • Clonidine patch – control high BP • TPN • Fat Emulsion – 20% All other IV meds were stopped

36. 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

37. References Academy 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/ Pictures from Google Images