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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