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Sodexo Dietetic Internship Case Study Yaniv Yarkoni, MS June 6, 2013.

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Presentation on theme: "Sodexo Dietetic Internship Case Study Yaniv Yarkoni, MS June 6, 2013."— Presentation transcript:

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


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