Presentation on theme: "INTESTINAL FAILURE Dr Mike Stroud FRCP"— Presentation transcript:
1 INTESTINAL FAILURE Dr Mike Stroud FRCP Senior Lecturer in Medicine & NutritionConsultant GastroenterologistChair British Intestinal Failure Alliance
2 Intestinal Failure: Definition The reduction of functioning gut mass to below the minimum necessary for the absorption of nutrientsand/or water & electrolytesNightingale, 2001Fleming & Remington, 19812
4 Types of Intestinal Failure Self-limiting intestinal failureType 2Significant & prolonged PN support(>28 days)Type 3Chronic IF(long term PN support)short termmedium termlong termLal et al. AP&T 2006:24;19-31
5 INTESTINAL FAILURE Type 1 Surgical ileus Critical illness GI problems VomitingDysphagiaPancreatitisGI obstructionDiarrheoaOncologyChemo/DXTGVHDType 2Post surgery awaiting reconstruction‘Disaster’CrohnsSMARadiationAdhesionsFistulaeType 3Short Bowel syndrome +/- other pathologyCrohns +/-SBSRadiation+/-SBSDysmotilityMalabsorptionSclerodermaCV ImmunodefInoperable obstructionCa
6 Short Bowel Syndrome Group Common Uncommon Small intestinal resections Crohn's diseasePost irradiation enteritisRepeated surgery for surgical compsMassive intestinal resectionInfarction (SMA/SMV thrombosis)SMA embolusMassive volvulusDesmoid tumourEC fistulaHigh outputBypass surgeryGastric bypass (obesity)
7 Types of short-bowelJejunostomyIleostomyJejuno- colicIleo- colic
8 Physiological changes with SBS Gastric emptying with jejunostomySB transit time with jejunostomyGastric secretionsgastric acid (hypergastrinaemia)GI hormonesgastrin, CCK, PYY, GLP-2
9 Problems in short-bowel patients NutritionalMacro-nutrient and energy deficiencies.Water and sodium lossesMagnesium/potassiumVitamin and trace element deficiencies.OtherBile salt diarrhoeaGall stonesoxalate absorption from colon and renal stones.D-lactic acidosis
13 Citrulline Permanent IF Transient IF 95% positive predictive value in distinguishing transient from permanent IFLong-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 severityGases, urea/creatinine, etc. Xylose not used.Crenn P et al. Gastroenterology 2000; 119:
14 Salt and water in SBSr = 0.96p <0.001Nightingale, 1990
15 Potassium & magnesium Potassium Magnesium Negative K balance when jejunum <50 cmHyperaldosteronism in chronic Na deficiencyDeficiency is common40% jejunum-colon pts70% jejunostomy ptsNo correlation between Mg balance & jejunal length
16 Treatment: High Output State Drink little hypotonic fluidMaximum 1L/dayDrink a glucose-saline solutionDrug therapyAntimotilityLoperamide (up to 32mg QDS)Codeine phosphate (up to 60mg QDS)AntisecretoryOmeprazole (40mg BD)?Octreotide (50µg BD)Magnesium supplementsMagnesium oxideVitamin DNutritionLow residue diet
17 Jejunum Hypotonic fluids Na Water, tea, coffee, fizzy drinks, soup Jejunal mucosaUnable to maintain a Na gradient >30-40mmol/L17
19 Sodium balance Patient with jejunostomy at 100 cm 50loperamidecodeineelectrolyte25Sodium balance (mmol/day)electrolyte-25-50codeineloperamide& codeine-75loperamide-100ranitidinecontrol-125Nightingale JMD et al. Clin Nutr 1992; 11: 101-5
20 Stir into 1L water & chill overnight: enjoy the next day! E-mix recipeIngredientAmountNoteGlucose20g6 teaspoonsSalt3.5g1 level 5ml teaspoonSodium bicarbonate2.5g1 heaped 2.5ml teaspoonStir 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 sufficientBags need to be tailored to requirementsRequirements alter daily until steady stateRandom urine Na: best measure of depletion
24 Maximising GI function Fistuloclysis & enteroclysis Infusion of feed into distal limb of ECF or loop stomaPromotes intestinal adaptation before reconstructive surgery?Can replace IVN in selected patients
25 Manchester to London canoe Lifelong HPNSome patients can manage a good quality of lifeFull time workHolidayChallengeManchester to London canoe
29 Glucagon-like Peptide 2 Naturally occurring 33 AA peptideProductionIntestinal L cells (ileum & colon)Releasestimulated by luminal nutritionReceptorsMainly in jejunum & proximal ileumActionStrong 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 / possibleMultidisciplinary approach essentialMedications, diet, fluid intakeStoma care crucialPsychological issues should not be overlookedOptimise medical treatmentsIncluding PN were neededSurgical approachesAssess if any bowel can be brought back into continuityLong term outcomeBalance life expectancy with quality of life for that patientKnow your patients well to give them the best advice
33 IF in SouthamptonSouthampton has had NST for >25 years started by Prof Alan JacksonLong record (>20 yrs) as a regional centre for Type 3 HPN patientsIncreasing number of specialist Type 2 referrals since appointment of Andy King April 09Specific 12 bedded IFU since Apr 2010First 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 201012 bed on Ward E8 within regional HPB surgical unitAdjacent to Surgical High CareIFU supported by extended multi-disciplinary healthcare teamMajority Type 2/3 IF on IFU but no side roomsSome patients looked after in specialized areas e.g BM Tx/ITUIFU Nurse: patient ratio 1.25 wte nurses per bed6 trained +2 assistants on an early shift6 trained +1 assistant on a late shift3 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 investigatedCases 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.
40 HPN Patients outcomes UKDDF 2012 Excellent quality outcomesCRS 1.42 per 1000 patient dayscatheter occlusion 0.31 per 1000 patient days.
41 IF outpatient clinicsWeekly MDT clinic for Type 2 and 3 IF patients >10 years with joint med/surg review since 2009Ad-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 monthsJoint 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 patientsPlanning outreach clinic to serve Sussex patients if designatedIF 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 years65% of patients were from the surrounding regionComplex referrals:30 enterocutaneous fistulaeOf which 19 had laparostomiesIn 22 cases other organs were involved5 urology5 pancreatico-biliary4 gastro-oesophageal8 colorectal
43 Surgical Complexity12 patients required interventional radiology placement of large bore drains in the acute phase of their illness to drain sepsis5 patients had radiation enteritis19 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 ICU0f 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 CareShared protocolsClinical GovernanceStandardised auditEducationCommunicationWebsiteNorthamptonMilton KeynesOxfordBucks TrustStoke NewingtonLondonReadingSloughBathSwindonBasingstokeSalisburyWinchesterSouthamptonDorchesterPortsmouthChichesterWorthingPooleSt Mary’sBournemouth
46 Type 3 Intestinal Failure Case Presentation Dr Trevor SmithNutrition Support & IF TeamUniversity Hospital Southampton
47 Case Presentation 2004 22 year old male Presented with life threatening acute abdomenSMA infarctEmergency laparotomy at local hospital
48 “Cut and Shut ?” Extensive intestinal ischaemia Extensive SB and colonic resectionEnd Jejunostomy 20cm from DJ flexureMucous fistulae to ‘50cm’ colon• Discharged home after long admission, includingITU with multi-organ failure
49 Medical Issues: 2004-2008 High stomal losses (5-6 l/day) Limited oral intakeAntisecretory and antimotility agentsDietary manipulation6 litre iv fluid requirement4 litres PN & 2 litres 0.9% saline555 mmol sodium per dayWeight stable at 67kgBMI 20Unable to gain weight; physically very weak
50 Medical Issues: 2004-2006 Behavioural problems Depressed/socially isolatedPsychiatry review in UHS and community?related to cerebral damage during critical illnessRecurrent line infectionsMultiple interruptions to nutritionIFALDALT 72; ALP414; Bili 10Osteoporosis
51 Therapeutic options considered Intestinal lengthening procedureOnly 20cm of jejunum therefore not possibleIntestinal transplantation assessmentAssessed in CambridgeTurned down because of mental health issues
52 Therapeutic interventions in Southampton Taurolidine line locksSignificant 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 StroudSouthampton NIHR Biomedical Research Centre, Southampton General Hospital, Southampton, UK.
56 Therapeutic interventions in Southampton Taurolidine line locksSignificant reduction in admissions for line sepsisReconstructive surgeryRe-anastamosis of jejunum to remaining colon20cm + 50cm colonHigh risk of intractable diarrhoeaDistal colostomy considered
57 Surgery in 2008 4 years after initial event Anastamosed 20 cm of jejunum to 30cm of colonEnd sigmoid colostomyUneventful recovery12 days in hospitalHPN dependentIF 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 dayLFTs normalisedWeight gainno change to PN protein/energyFunctional improvementHuge improvement in QOL
59 Results Date June 2006 May 07 Nov 08 Surgery Jan 2009 July 2009 Weight (kg)67.567.766.970.575BMI20.820.621.823.1Fluid input (litres)6.14.1Stoma output (litres)5-63.52.52ALT iu/l7267141623ALP iu/l4141529496104Bil mmol/l10811Urine Na mmol/l10-7810-57-85
61 Mechanisms underlying the benefits of jejuno-colic anastamosis Improved sodium & water resorptionDecreases in hyperaldersteronism↓ urinary potassium losses↑ potassium availability to form lean body massAdaptive small bowel changesGLP2 peptide from colon↑ absorptive capacityReduced small bowel transit timesPeptide YY acting as a ‘colonic brake’Nitrogen & energy recovery by the rejoined colonic segment
62 Progress in 2009 Clinically and subjectively much improved Transplant assessmentReviewed in joint clinic in SouthamptonAdmitted for assessment in OxfordDeemed unnecessaryBut, why did he have a mesenteric infarct?
64 Current health 2010-2014 HPN dependent, but rarely uses saline Eating, with manageable stomal lossesMaintains healthy weightDecreased line infectionsfewer connections and taurolidineLast admission for CRS May 2012 after fighting......Better quality of lifeTime off IV infusionsExpert in poisonous snakes and spiders!!Has avoided transplantation
65 Current health 2010-2014 LFTs – normal Micronutrient screen – normal Bone healthOsteoporosis treated with IV Zolendronic acidT score now -1.8T score -2.7 in 2006Mental healthStable, with easy access to CMH team