1. INTESTINAL FAILURE Dr Mike Stroud FRCP
Senior Lecturer in Medicine & Nutrition
Consultant Gastroenterologist
Chair British Intestinal Failure Alliance

2. Intestinal Failure: Definition
The reduction of functioning gut mass to below the minimum necessary for the absorption of nutrients
and/or water & electrolytes
Nightingale, 2001
Fleming & Remington, 1981 2

4. Types of Intestinal Failure
Self-limiting intestinal failure
Type 2
Significant & prolonged PN support
(>28 days)
Type 3
Chronic IF
(long term PN support)
short term
medium term
long term
Lal et al. AP&T 2006:24;19-31

5. INTESTINAL FAILURE Type 1 Surgical ileus Critical illness GI problems
Vomiting
Dysphagia
Pancreatitis
GI obstruction
Diarrheoa
Oncology
Chemo/DXT
GVHD
Type 2
Post surgery awaiting reconstruction
‘Disaster’
Crohns
SMA
Radiation
Adhesions
Fistulae
Type 3
Short Bowel syndrome +/- other pathology
Crohns +/-SBS
Radiation+/-SBS
Dysmotility
Malabsorption
Scleroderma
CV Immunodef
Inoperable obstruction Ca

6. Short Bowel Syndrome Group Common Uncommon Small intestinal resections
Crohn's disease
Post irradiation enteritis
Repeated surgery for surgical comps
Massive intestinal resection
Infarction (SMA/SMV thrombosis)
SMA embolus
Massive volvulus
Desmoid tumour
EC fistula
High output
Bypass surgery
Gastric bypass (obesity)

7. Types of short-bowel
Jejunostomy
Ileostomy
Jejuno- colic
Ileo- colic

8. Physiological changes with SBS
Gastric emptying
 with jejunostomy
SB transit time
 with jejunostomy
Gastric secretions
gastric acid (hypergastrinaemia)
GI hormones
gastrin, CCK, PYY, GLP-2

9. Problems in short-bowel patients
Nutritional
Macro-nutrient and energy deficiencies.
Water and sodium losses
Magnesium/potassium
Vitamin and trace element deficiencies.
Other
Bile salt diarrhoea
Gall stones
oxalate absorption from colon and renal stones.
D-lactic acidosis

11. Jejunal length (m)
r = 0.96
p <0.001
Nightingale, 1990

12. Variability of intestinal length
Technique
Author n
Small intestinal length (m)
Mean
Range
Autopsy
Bryant, 1924
Laparotomy
Cook, 1974 6
421
Backman, 1974 32
643
Slater, 1991 38
500

13. Citrulline Permanent IF Transient IF
95% positive predictive value in distinguishing transient from permanent IF
Long-term PN needed:
Fasting plasma citrulline of less than 20 μmol/L at 2 years.
For most types of failure we measure something to grade severity
Gases, urea/creatinine, etc. Xylose not used.
Crenn P et al. Gastroenterology 2000; 119:

14. Salt and water in SBS
r = 0.96
p <0.001
Nightingale, 1990

15. Potassium & magnesium Potassium Magnesium
Negative K balance when jejunum <50 cm
Hyperaldosteronism in chronic Na deficiency
Deficiency is common
40% jejunum-colon pts
70% jejunostomy pts
No correlation between Mg balance & jejunal length

16. Treatment: High Output State
Drink little hypotonic fluid
Maximum 1L/day
Drink a glucose-saline solution
Drug therapy
Antimotility
Loperamide (up to 32mg QDS)
Codeine phosphate (up to 60mg QDS)
Antisecretory
Omeprazole (40mg BD)
?Octreotide (50µg BD)
Magnesium supplements
Magnesium oxide
Vitamin D
Nutrition
Low residue diet

17. Jejunum Hypotonic fluids Na Water, tea, coffee, fizzy drinks, soup
Jejunal mucosa
Unable to maintain a Na gradient >30-40mmol/L 17

18. Jejunum Decreasing fluid losses & increasing absorption
Electrolyte Mix
100mmol/l Na Na X
Na+ + H20 18

19. Sodium balance Patient with jejunostomy at 100 cm50
loperamide
codeine
electrolyte 25
Sodium balance (mmol/day)
electrolyte
-25
-50
codeine
loperamide
& codeine
-75
loperamide
-100
ranitidine
control
-125
Nightingale JMD et al. Clin Nutr 1992; 11: 101-5

20. Stir into 1L water & chill overnight: enjoy the next day!
E-mix recipe
Ingredient
Amount
Note
Glucose
20g
6 teaspoons
Salt
3.5g
1 level 5ml teaspoon
Sodium bicarbonate
2.5g
1 heaped 2.5ml teaspoon
Stir into 1L water & chill overnight: enjoy the next day!

21. Parenteral fluids  nutrition
Fluid & nutrition requirements are best considered separately
“Standard IVN” bags will not be sufficient
Bags need to be tailored to requirements
Requirements alter daily until steady state
Random urine Na: best measure of depletion

22. Recommended diet Jejunostomy patients Jejunocolic anastomosis
Nutrient group
Amount
Note
Energy
High
30-60 kcal/kg/day
Protein
g N2/kg/day (80-100g protein)
Fat
Fibre
Low
Jejunocolic anastomosis
Nutrient group
Amount
Note
Energy
High
30-60 kcal/kg/day
Protein
g N2/kg/day (80-100g protein)
Fat
Low/moderate
according to degree of steatorrhoea
Fibre
Moderate/high
Oxalate
Low

23. Maximise macronutrients & electrolytes
Enteral feeding
Avoid elemental diets
high osmolality (small molecules)
low macronutrient & Na+ content
high volume required to meet requirements
No benefit over polymeric & will increase output
Oral nutrition + supplements (? With added Na)
Sometimes enteral nutrition useful
Usually supplementary overnight enteral feed
Occasionally impaired swallow X
Aim
Maximise macronutrients & electrolytes
Minimise volume

24. Maximising GI function Fistuloclysis & enteroclysis
Infusion of feed into distal limb of ECF or loop stoma
Promotes intestinal adaptation before reconstructive surgery?
Can replace IVN in selected patients

25. Manchester to London canoe
Lifelong HPN
Some patients can manage a good quality of life
Full time work
Holiday
Challenge
Manchester to London canoe

26. Surgical approaches Restorative surgery Fistula repair
Restore intestinal continuity
Intestinal lengthening
Bianchi technique
STEP
Intestinal transplantation
Small bowel ± colon
Other abdominal organs
+/-Abdominal wall

27. Intestinal lengthening
STEP
Bianchi technique
Serial Transverse EnteroPlasty

28. Liver
No liver

29. Glucagon-like Peptide 2
Naturally occurring 33 AA peptide
Production
Intestinal L cells (ileum & colon)
Release
stimulated by luminal nutrition
Receptors
Mainly in jejunum & proximal ileum
Action
Strong intestinotrophic properties
 Bone density
 Intestinal perfusion
 Nutrient absorption
 Mucosal proliferation
 Cytoprotection

30. Teduglutide in HPN Patients
Jeppesen et al, Gut 2011:60(7):

31. Summary Understand the basic physiology
Makes the management easy / possible
Multidisciplinary approach essential
Medications, diet, fluid intake
Stoma care crucial
Psychological issues should not be overlooked
Optimise medical treatments
Including PN were needed
Surgical approaches
Assess if any bowel can be brought back into continuity
Long term outcome
Balance life expectancy with quality of life for that patient
Know your patients well to give them the best advice

32. Regional HPN &
IF Networks

33. IF in Southampton
Southampton has had NST for >25 years started by Prof Alan Jackson
Long record (>20 yrs) as a regional centre for Type 3 HPN patients
Increasing number of specialist Type 2 referrals since appointment of Andy King April 09
Specific 12 bedded IFU since Apr 2010
First Independent AHP PN prescribers in the UK (2007 with published audit confirming excellent outcomes which won National GSK Advanced Practice Award

34. The UHS Intestinal Failure Unit
Opened April 2010
12 bed on Ward E8 within regional HPB surgical unit
Adjacent to Surgical High Care
IFU supported by extended multi-disciplinary healthcare team
Majority Type 2/3 IF on IFU but no side rooms
Some patients looked after in specialized areas e.g BM Tx/ITU
IFU Nurse: patient ratio 1.25 wte nurses per bed
6 trained +2 assistants on an early shift
6 trained +1 assistant on a late shift
3 trained +2 assistants on a night.

35. NSIFT - Standards of in Hospital Practice
2010: <20% good practice

36. UHS PN practice 2012/13 NSIFT involved in 99.6% of 427 patients
PN use in 66% and oral enteral in 33%

37. Catheter Related Sepsis
Following opening of IFU protocols developed for Ix and Rx of CRS in conjunction with microbiology.
All cases of pyrexia in patients on PN are investigated
Cases of infection in IF patients managed in conjunction with Microbiology which provides daily consultant-led clinical ward rounds (lead IF micro consultant Dr Adriana Basarab)
24 hour consultant microbiology on-call service with on-site specialist laboratory service.
All cases audited within monthly ‘Root-Cause’ process.

38. UHS Catheter Related Sepsis
Historical (cases/1000 PN days)
IFU
(cases/1000 PN days)
Non-IFU
10.01
3.64
5.52
2011 – 12
1.28
8.06
0.98
6.35

39. HPN patients Reading - 2 Bath - 1 Bristol - 1 Basingstoke - 6
Southampton - 34
Winchester - 3
Poole - 6
Worthing - 2
Chichester - 3
Dorchester - 2
Bournemouth - 8
IOW - 4
Portsmouth - 2

40. HPN Patients outcomes UKDDF 2012
Excellent quality outcomes
CRS 1.42 per 1000 patient days
catheter occlusion 0.31 per 1000 patient days.

41. IF outpatient clinics
Weekly MDT clinic for Type 2 and 3 IF patients >10 years with joint med/surg review since 2009
Ad-hoc day-case review for urgent cases (although lack clinical examination/procedure room)
Paediatric IBD/IF Transition clinic with Mark Beattie (President of BSPGHAN) every 6 months
Joint small bowel transplant assessment clinics with Oxford (Prof Peter Friend + Mr Anil Vaidja) every 6 months (2 x transplants)
Monthly OP clinic at Royal Bournemouth Hospital for Dorset IF patients
Planning outreach clinic to serve Sussex patients if designated
IF Regional out-patient experience published in 2010
‘The value of multidisciplinary nutritional gastroenterology clinics for intestinal failure and other gastrointestinal patients’ Frontline Gastroenterology 2010; 1:

42. Surgery for Intestinal Failure
44 patients over the 3 years
65% of patients were from the surrounding region
Complex referrals:
30 enterocutaneous fistulae
Of which 19 had laparostomies
In 22 cases other organs were involved
5 urology
5 pancreatico-biliary
4 gastro-oesophageal
8 colorectal

43. Surgical Complexity
12 patients required interventional radiology placement of large bore drains in the acute phase of their illness to drain sepsis
5 patients had radiation enteritis
19 patients had had 3 laparotomies or more in the 3 months prior to transfer

44. Surgery - Outcomes No in-hospital or 1-year mortality
1 patient (2.2%) unexpected return to ICU
0f 30 patients who were TPN dependant 29 of patients are free of TPN (97%).
1 patient (3.3%) re-fistulated - this resolved spontaneously

45. SHIFNET The Southern Home Intestinal Failure Network
Better Patient Care
Shared protocols
Clinical Governance
Standardised audit
Education
Communication
Website
Northampton
Milton Keynes
Oxford
Bucks Trust
Stoke Newington
London
Reading
Slough
Bath
Swindon
Basingstoke
Salisbury
Winchester
Southampton
Dorchester
Portsmouth
Chichester
Worthing
Poole
St Mary’s
Bournemouth

46. Type 3 Intestinal Failure Case Presentation
Dr Trevor Smith
Nutrition Support & IF Team
University Hospital Southampton

47. Case Presentation 2004 22 year old male
Presented with life threatening acute abdomen
SMA infarct
Emergency laparotomy at local hospital

48. “Cut and Shut ?” Extensive intestinal ischaemia
Extensive SB and colonic resection
End Jejunostomy 20cm from DJ flexure
Mucous fistulae to ‘50cm’ colon
• Discharged home after long admission, including
ITU with multi-organ failure

49. Medical Issues: 2004-2008 High stomal losses (5-6 l/day)
Limited oral intake
Antisecretory and antimotility agents
Dietary manipulation
6 litre iv fluid requirement
4 litres PN & 2 litres 0.9% saline
555 mmol sodium per day
Weight stable at 67kg
BMI 20
Unable to gain weight; physically very weak

50. Medical Issues: 2004-2006 Behavioural problems
Depressed/socially isolated
Psychiatry review in UHS and community
?related to cerebral damage during critical illness
Recurrent line infections
Multiple interruptions to nutrition
IFALD
ALT 72; ALP414; Bili 10
Osteoporosis

51. Therapeutic options considered
Intestinal lengthening procedure
Only 20cm of jejunum therefore not possible
Intestinal transplantation assessment
Assessed in Cambridge
Turned down because of mental health issues

52. Therapeutic interventions in Southampton
Taurolidine line locks
Significant reduction in admissions for line sepsis

53. J Saunders, M Naghibi, T Smith, A King, Z Leach and M Stroud
Taurolidine significantly reduces the incidence of catheter related blood stream infections in patients on home parenteral nutrition.
J Saunders, M Naghibi, T Smith, A King, Z Leach and M Stroud
Southampton NIHR Biomedical Research Centre, Southampton General Hospital, Southampton, UK.

54. Southampton indications for taurolidine

55. Results
*per 1000 patient days HPN

56. Therapeutic interventions in Southampton
Taurolidine line locks
Significant reduction in admissions for line sepsis
Reconstructive surgery
Re-anastamosis of jejunum to remaining colon
20cm + 50cm colon
High risk of intractable diarrhoea
Distal colostomy considered

57. Surgery in 2008 4 years after initial event
Anastamosed 20 cm of jejunum to 30cm of colon
End sigmoid colostomy
Uneventful recovery
12 days in hospital
HPN dependent
IF team not very optimistic that surgery would radically change prognosis:
nutritional balance, line complications, liver

58. Life after surgery: 2009 Stoma losses ↓ >50%
IV fluids requirements ↓ to 4.1L per day
LFTs normalised
Weight gain
no change to PN protein/energy
Functional improvement
Huge improvement in QOL

59. Results Date June 2006 May 07 Nov 08 Surgery Jan 2009 July 2009
Weight (kg)
67.5
67.7
66.9
70.5 75
BMI
20.8
20.6
21.8
23.1
Fluid input (litres)
6.1
4.1
Stoma output (litres)
5-6
3.5
2.5 2
ALT iu/l 72 67 14 16 23
ALP iu/l
414
152 94 96
104
Bil mmol/l 10 8 11
Urine Na mmol/l
10-78
10-57 - 85

61. Mechanisms underlying the benefits of jejuno-colic anastamosis
Improved sodium & water resorption
Decreases in hyperaldersteronism
↓ urinary potassium losses
↑ potassium availability to form lean body mass
Adaptive small bowel changes
GLP2 peptide from colon
↑ absorptive capacity
Reduced small bowel transit times
Peptide YY acting as a ‘colonic brake’
Nitrogen & energy recovery by the rejoined colonic segment

62. Progress in 2009 Clinically and subjectively much improved
Transplant assessment
Reviewed in joint clinic in Southampton
Admitted for assessment in Oxford
Deemed unnecessary
But, why did he have a mesenteric infarct?

63. Patent Foramen Ovale

64. Current health 2010-2014 HPN dependent, but rarely uses saline
Eating, with manageable stomal losses
Maintains healthy weight
Decreased line infections
fewer connections and taurolidine
Last admission for CRS May 2012 after fighting......
Better quality of life
Time off IV infusions
Expert in poisonous snakes and spiders!!
Has avoided transplantation

65. Current health 2010-2014 LFTs – normal Micronutrient screen – normal
Bone health
Osteoporosis treated with IV Zolendronic acid
T score now -1.8
T score -2.7 in 2006
Mental health
Stable, with easy access to CMH team