Download presentation
Presentation is loading. Please wait.
Published byShannon McGee Modified over 9 years ago
1
Sodexo Dietetic Internship Case Study Yaniv Yarkoni, MS June 6, 2013
2
SBS DEFINITION Inadequate absorptive capacity due to decreased length and/or decreased functional bowel 70% loss of small bowel OR bowel length of <100 cm of small bowel without a colon or <50cm w/ colon “SBS results from surgical resection, congenital defect or disease-associated loss of absorption and is characterized by the inability to maintain protein- energy, fluid, electrolyte or micronutrient balances when on a conventionally accepted, normal diet” 1 Etiology= massive resection, IBD, malignancy, radiation, trauma, vascular issues, hernias, fistulas, surgeries & intestinal obstruction Hofstetter S, Stern L, Willet J. Key issues in addressing the clinical and humanistic burden of short bowel syndrome in the US. Curr Med Res Opin. 2003;1-32.
3
SBS Prevalence Schalamon et al: SBS–related mortality ranges from 15% to 47% Survival related negatively to: Enterostomy Small bowel length <50 cm Arterial infarction as a cause of SBS NOT to parenteral support dependence A 20-year review of 210 postoperative cases of SBS: 25% of these patients post-op complications 67% required long-term parenteral support 13% deaths
4
SBS INTRODUCTION Complications= PRO-E imbalances, fluid - electrolyte imbalances and TPN Tx w/ med problems, weight loss & malnutrition Hallmark symptoms= diarrhea & steatorrhea Other S&S= abdominal pain, electrolyte disturbances, dehydration, and malnutrition Temporary malabsorption Ileocecal valve function
5
Adaptation Time it takes for intestines to correct damage by inc. absorption by remaining lumen Begins following resection lasting up to 2 yrs. Intestine hypertrophies, resulting in changes: microvilli height, crypt depth, enterocyte proliferation, enzymes Increase in absorptive surface Positive patient adaptation: young age, long remaining bowel, adequate blood flow, ileocecal valve
6
Total Parenteral Nutrition 10,000-15,000 SBS patients that require TPN Limitations: Costly Life-threatening complications Poor catheter technique Incorrect insertion site Infections Central venous thrombosis Intestinal failure, liver and renal D., organ failure 50% at risk of further surgical interventions
7
SBS Management Primary goals= 1) Maximize working gut while ensuring that pts are receiving adequate nutrients, water & electrolytes to maintain health 2) Reduce symptoms; intestinal rehabilitation to promote absorption of fluid & nutrients Highly individualized & comprehensive Nutrition=Oral, enteral, parenteral or comb
8
SBS Management Glucagon-like peptide 2 (GLP-2) plays a key role in stimulating intestinal absorption 1 Other mediators: GH, GLP-1, enteroglucagon, cholecystokinin, gastrin, insulin, and neurotensin Drug Teduglutide (Revestive) in Europe Heyland et al: Glutamine (0.5g/kg/d) to reduce complications, ICU length of stay & mortality 2 1 Buchman AL, Scolapio J, Fryer J. AGA technical review on short bowel syndrome and intestinal transplantation. Gastroenterology.2003;124:1111-34 2 Parrish CR. The clinician’s guide to short bowel syndrome. Practical Gastroenterology. September 2005;1-106.
9
TPN Considerations Symptoms, complications & inconveniences significantly influence quality of life (QOL) Reddy and Malone study (J of Parenteral & Enteral Nutrition, 1998) National reimbursement (2002) for home TPN = $2.3 billion Total average annual patient reimbursement for hospitalization & supplies= $100K each Annual out of pocket cost/family= $4,716 Hofstetter S, Stern L, Willet J. Key issues in addressing the clinical and humanistic burden of short bowel syndrome in the US. Curr Med Res Opin. 2003;1-32.
10
Medical Nutrition Therapy Parenteral, enteral & oral nutrition support in comb. Normal Diet Low residue, fat, oxalate, lactose-free Diet Insoluble fiber not tolerated initially; soluble fiber OK Sugar-Free, Clear Liquid Diet No caffeine & alcohol initially Central PN (5d/wk, 2-6 wks) 200ml 50% dex, 600ml 10 % aa, 300 ml 10% lipids, TV 1392 ml @58 ml/hr IV fluids and electrolytes Vit & minIron def. anemia common Rees Parrish: “No diet is a good diet if not eaten”
11
General Guidelines for SBS MNT Jejunostomies / Ileostomies: High fat diet 25% CHO, 25% PRO, 50-60% FAT Intact Colon: High CHO diet 55% CHO, 25% PRO, 20% FAT Breads, rolls, plain waffles / pancakes / muffins, tortillas, rice, pasta Avoid concentrated sweets Avoid donuts, sweet rolls, pastries, pop-tartsEat small frequent mealsLimit fluids with meals, drink isotonic bev Solids, then liquidsLactose restriction if necessary LactaidAvoid high oxalate foods in kidney stones pts Avoid soy, spinach, legumes, wheatLiquid or chewable vit / min supplementCanned or cooked vegetables Avoid creamed veg., legumes Examples
12
Presentation of Patient 42 y.o. white female (EG), state prisoner Ht=64” Wt=165# BMI=28 IBW=132# UBW=198# C/O diarrhea, abdominal pain, nausea, vomiting for 3 days and a 30# loss/6 mos. (15%=significant) Prominent ileocecal valve w/ distal ileum Only small portion bowel removed Patient does not technically fit into SBS cat Nutrition Diagnosis: Inadequate P-E intake R/T abdominal pain and nausea AEB 30# wt. loss/6 mos
13
Past Medical History Breast Ca ‘02, cholecystectomy ‘12 Cholecystitis, bipolar D., PTSD, depression, borderline personality, generalized anxiety disorder, and a history of suicide attempts Loose BM’s, fecal incontinence, N/V Trouble tolerating solids, tolerating liquid diet Hospitalized for IV after not tolerating regular diet Screened Oct ‘12 due to length of stay but D/C
14
Medical Hospital Course June’12 CAT Scan Disclosed some abnormality at ileocecal valve Malignant mass tumor was considered Aug ’12 Upper GI Exam Reflux disclosed, no delayed transit, need to R/O IBD (Crohn’s D.) Sept ’12 Repeat CAT Confirming abnormal ileocecal area Biopsy taken to R/O C.D. Oct ’12 Repeat Colonoscopy Large bulging ileocecal valve; Well-differentiated neuroendocrine tumor Biopsy taken to R/O C.D. Dec ’12 Right Hemicolectomy Removal of malignant tumor of cecum area: total 35cm long specimen Removal of R ascending colon, partial hepatic flexure, distal ileum, cecum & lymph nodes.
15
Right Hemicolectomy Procedure
16
Nutrition-Related Lab Values Chemistry (Reference Range) 12/17/1212/14/1212/13/1212/12/1212/11/1211/03/12 Weight (lb.) 162 165 169 Na (136-145mmol/L) 138 132 ↓ 137 135 K (3.5-5.1 mmol/L) 3.83.4 ↓ 3.5 3.8 Chloride (98-107 mmol/L) 103102 98 BUN (6-20 mg/dL) 3 ↓6 7 11 3 ↓ Creatinine (0.5-0.9 mg/dL) 0.42 ↓0.44 ↓ 0.51.51.70 0.62 Glucose (70-99 mg/dL) 116108 116 85 94 Calcium (8.4-10.2 mg/dL) 8.4 8.5 8.7 Albumin (3.5-5.1 G/DL) 3.4 3.8 Hemoglobin (12-16 g/dL) 10 ↓11 ↓ 13 10 ↓ 12.5 12 Hematocrit (37-47%) 31 ↓32 ↓ 38.3* 35 ↓ 36.4 ↓ 35 ↓ *Lactated Ringer’s solution IV was used 12/13 which reflect better H/H, K still low
17
Actual Diet Progression Rx: Gradually advance to a regular diet Clear liquids 12/11 NPO 12/12 Clear liquids 12/14 Regular diet 12/15
Similar presentations
© 2024 SlidePlayer.com Inc.
All rights reserved.