1. Case Report: Nutritional Management of Small Bowel Obstruction
By Christine Bannon
ARAMARK Dietetic Internships
December 14, 2014

2. Abstract Purpose: Follow the Nutrition Care Process
Case: 82 yr old female with small bowel obstruction (SBO) who required total parental nutrition (TPN)
Previous hospital visit for SBO – noninvasive treatment and low fiber
Hospitalized again for SBO secondary to adhesions
PMH: Uterine cancer requiring hysterectomy
TPN, lysis of adhesions, and right partial colectomy
Discharged after 15 days on oral low fiber

3. Disease Description – Small Bowel Obstruction
The small intestine is a complex organ that plays a major role in the absorption of nutrients
When contents of the intestine are blocked and unable to pass freely, this is considered a small bowel obstructions (SBO).
Signs & Symptoms
Abdominal distention
Constipation
Vomiting
Abdominal pain and cramps
Nausea
Diarrhea

4. Disease Description – Causes
Mechanical - characterized by the narrowing of the intestinal lumen
Inflammation or trauma to the bowel
Neoplasms
Adhesions (Most common)
Hernias
Volvulus (twisted bowel)
Compression from outside the intestinal tract
Nonmechanical - factors that interfere with the muscle action or innervation of the bowel
Paralytic ileus
Mesenteric embolus or thrombus
Hypokalemia

5. Evidence-Based Nutrition Recommendations
Title: Reoperation on the Abdomen Encased in Adhesions
Purpose: To determine the short and long-term outcomes after lysis of adhesions
Method: 40 patients who had recently undergone lysis of adhesions were contacted to evaluate the outcome
Results: 1 postoperative death, 24 early complications. 28 out of 31 had resolved SBO from the surgery
Long-term outcomes: all subjects able to tolerate oral feedings

6. Evidence-Based Nutrition Recommendations
Title: Burden of Adhesions in Abdominal & Pelvic Surgery: A Systematic Review and Metanalysis
Purpose: To estimate the burden of complications associated with abdominal adhesions
Method: Analysis of 196 papers from PubMed, Embase, and Central which reported incidences of adhesion related complications
Results: Increase risk of developing a SBO in open abdominal/pelvic surgery. Adhesive SBO associated with longer hospital stays.

7. Case Presentation
An 82 year old woman is admitted to the hospital after a night of worsening abdominal pain, nausea and vomiting.
Patient was recently admitted one month prior for a SBO which was treated conservatively with no invasive processors. Since then, patient has followed a low-fiber diet.
Once admitted, patient underwent a series of radiographs to diagnose her with another SBO and renal failure secondary to dehydration

8. Nutrition Case Process (NPC): Assessment
Past Medical History
Hypertension
High cholesterol
Type 2 diabetes mellitus
Hypothyroidism
Arthritis
Fractured spine and coccyx
Osteoporosis
Missing right kidney from birth
Reflux
Constipation
Hysterectomy from uterine cancer which was last treated with radiation in 2005

9. Food/Nutrition Related History
Lack of appetite for one week prior to admission
Follows a low-fiber diet which was prescribed to her since her last hospitalization for SBO
Lactose – intolerant
Home medications can be found in Table 1

10. Nutrition-Focused Physical Findings
No appetite at admission
No identified chewing/swallowing issues with good oral health
Trace bilateral edema in lower extremities
Appeared well nourished
No bowel movement for 2 days prior to admission

11. Anthropometric Measurements
4’ 9” (57”)
121 pounds (55kg)
BMI of 26.6 = overweight
IBW: 100 pounds
121% of IBW

12. Biochemical Data, Medical Test, and Procedures
Lab
Normal
Patient’s
Rationale
Sodium
133 (L)
Acute Renal Failure (AFR), dehydration
Potassium
3.4 (L)
Obstruction
Glucose
234 (H)
Acute inflammation
BUN
8-20
21 (H)
Dehydration, hypovolemia
Creatinine
2.1 (H)
ARF, dehydration, inadeq. dietary protein, reduced muscle mass
Magnesium
1.9
Indicates wnl
Phosphorous
Not tested
Albumin
1.9 (L)
Went through a series of x-rays and radiographs to confirm SBO diagnosis.
Labs were taken as followed:

13. Nutrient Needs 1138-1365 calories 55-69gm of protein
ml of fluid
Protein needs are elevated due to:
Moderate protein depletion (Albumin )
Mildly metabolically stressed
Nutritional needs are summarized in Table 2.

14. ARAMARK Nutrition Status Classification
Moderate nutritional risk (status 3)
4 points: GI obstructions
3 points: Vomiting
3 points: Poor appetite
Total of 10 points
Follow up in 3-5 days

15. Malnutrition Identification
Malnutrition diagnosed with 2 out of the 6 Characteristics
Intake (fair to poor longer than 1 week)
Weight loss
Loss of muscle mass
Loss of subcutaneous fat
Fluid accumulation
Functional status
Chronic vs. Acute Etiology
Inflammation is chronic and mild-moderate degree vs. inflammation is acute and severe degree

16. Malnutrition Identification (cont.)
Malnutrition diagnosed with 2 out of the 6 Characteristics
Intake – Patient reported consuming <75% of her estimated energy needs for longer than a week
Weight loss
Loss of muscle mass
Loss of subcutaneous fat
Fluid accumulation – edema noted in lower extremities
Functional status
Chronic vs Acute Etiology
Acute due to hypoalbuminemia (1.9)

17. NCP: Diagnoses
Altered Gastrointestinal Function (NC-1.4) related to small bowel obstruction as evidenced by abdominal distention, vomiting and lack of bowel movement.
Malnutrition (NI-5.2) related to small bowel obstruction as evidenced by fluid retention and oral energy intake < 50%-75% for one week.

18. NCP: Interventions Medical Interventions
Nasogastric tube was place for suction to prevent further nausea and vomiting
Right Partial Colectomy
Lysis of adhesions
Medications and their rationale the patient was placed on can be found on Table 3.

19. NCP: Interventions Nutrition Interventions Justification:
Parental Nutrition (ND 2.2)
Day 1 standard formula: 70gm amino acids, 150gm dextrose, 20gm lipid with 10gm zinc, 100mg thiamine, 1 mg folic acid, 500mg vitamin C, 60mg selenium
Provides: 990kcal (22kcal/kg ideal wt), 70gm protein (1.5gm/kg ideal wt)
Justification:
Malnourished
Enteral feeding can not be safely attempted
Nonfunctional gut
TPN expected to be needed for at least 7 days

20. NCP: Interventions
Additional consults were needed from nephrology due to patient’s acute renal failure(ARF)diagnosis
Nephrology findings:
ARF was secondary to dehydration
Intervention:
Intravenous fluid needed

21. NCP: Monitoring and Evaluation
Parenteral nutrition formula (FH )
Domain: FOOD/NUTRITION-RELATED HISTORY (FH)
Weight (AD-1.1.2)
Domain: ANTHROPOMETRIC MEASUREMENTS (AD)
Digestive system (mouth to rectum) (bowel function, bowel sounds) (PD-1.1.5)
Domain: NUTRITION-FOCUS PHYSICAL FINDINGS (PD)
Potassium (BD-1.2.7), Magnesium (BD-1.2.8), Phosphorus(BD ), Glucose, casual(BD-1.5.2)
Domain: BIOCHEMICAL DATA, MEDICAL TESTS AND PROCEDURES (BD)

22. Follow-Ups (F/U) F/U #1 (11/14) F/U #2 (11/15)
PES: Inadequate energy intake(NI-1.2) related to small bowel obstruction as evidenced by poor appetite.
Intervention: Parenteral Nutrition/IV Fluids (2.2) when able
Goal: Initiate PN when able
Achievement: PN was started
F/U #2 (11/15)
PES: Inadequate parenteral nutrition infusion (NI-2.7) related to day 1 standard TPN formula as evidenced by 72.5% of energy needs being met.
Intervention: Modify volume of parenteral nutrition (ND-2.2.4), Modify composition of parenteral nutrition(ND )
Modified TPN order: 70gm amino acids, 235gm dextrose, 30gm lipid with 10gm zinc, 100mg thiamine, 1 mg folic acid, 500mg vitamin C, 60mg selenium
Provides: 1380kcal (30kca/kg ideal wt), 70gm protein (1.5gm/ideal wt)
Goal: Meet 50-75% of nutritional needs
Achievement: PN order was modified and 100% of nutritional needs were reached

23. Follow-Ups (cont.) F/U #3 (11/16)
PES: Altered nutrition-related laboratory values (phosphorous) (NC-2.2) related to SBO as evidenced by phosphorus levels of 1.4.
Intervention: Recommend modify composition of parenteral nutrition (ND-2.2.1). Recommend mineral supplement therapy (phosphorous) (ND )
Goal: Meet 50-75% of nutritional needs
Achievement: Phosphorus was repleted. Dextrose was unchanged and serum glucose remained elevated

24. Follow-Up (cont.) F/U #4 (11/17) F/U #5 (11/18)
PES: Parenteral Nutrition Administration Inconsistent with Needs (NI-2.10) related to SBO as evidenced by elevated glucose in the 200’s.
Intervention: Recommend modify composition of parenteral nutrition (ND-2.2.1) (decreased dextrose, increased lipid). Nutrition-Related Medication Management (ND-6) to add 0.15units of insulin/gm of dextrose.
Modified TPN order: 1800mls total volume, 75ml/hr X 24 hrs. 70gm protein, 200gm dextrose, and 42gm lipid. Provides: 1380kcal (30kcal/kg ideal wt) and 70gm protein (1.5gm/kg ideal wt)
Goal: Blood Glucose >200
Achievement: PN modified. Additional insulin was added. Blood glucose improving in upper 100’s but remains elevated.
F/U #5 (11/18)
PES: Impaired nutrient utilization (NC-2.1) related to ileus as evidenced by no bowel movement
Intervention: Continue Parenteral Nutrition/IV Fluids (2.2)
Achievement: PN was continued at recommended rate

25. Follow-Up (cont.) F/U #6 (11/20) F/U #7 (11/21)
PES: Altered Gastrointestinal Function (NC-1.4) related to small bowel obstruction as evidenced by lack of bowel movement/sound.
Intervention: Continue Parenteral Nutrition/IV Fluids (2.2)
Goal: Meet 50-75% of nutritional needs
Achievement: PN was continued at recommended rate. (+) Hypoactive bowel.
F/U #7 (11/21)
Achievement: PN was continued at recommended rate

26. Follow-Up (cont.) F/U #8 (11/22) F/U #9 (11/23)
PES: Altered Gastrointestinal Function (NC-1.4) related to small bowel obstruction as evidenced by nausea and lack of bowel movement.
Intervention: Continue Parenteral Nutrition/IV Fluids (2.2)
Goal: Meet 50-75% of nutritional needs
Achievement: PN was continued at recommended rate. Hypoactive bowel sounds heard. Patient begins to have flatus.
F/U #9 (11/23)
PES: Inadequate oral intake (NI-2.1) related to TPN order as evidenced by clear liquid diet.
Intervention: Begin Clear liquid diet(ND ) while continuing Parenteral Nutrition/IV Fluids (2.2) at goal rate.
Achievement: Patient tolerating clear liquids well. Small bowel movement is noted.

27. Follow-Up (cont.) F/U #10 (11/24) F/U #11 (11/25)
PES: Inadequate oral intake (NI-2.1) related to TPN order as evidenced by clear liquid diet.
Intervention: Advance to Full liquid diet (ND ) when able. Modify rate of parenteral nutrition (ND-2.2.3) to 40ml/hr.
Goal: Meet 50-75% of nutritional needs.
Achievement: Diet advanced to full liquid diet. TPN rate was reduced.
F/U #11 (11/25)
PES: Inadequate oral intake (NI-2.1) related to TPN order as evidenced by full liquid diet.
Intervention: Advance to General/healthful diet (ND-1.1) when able. Modify rate of parenteral nutrition (ND-2.2.3) to be discontinued completely.
Achievement: Diet advanced to regular for lunch. TPN order was discontinued.

28. Discharge Care No driving X 6 weeks No lifting/baths
Outpatient F/U in 2 weeks
Wear abdominal binder when out of bed X 2 months
Ice for discomfort
Low-fiber diet

29. Conclusion
SBO is a serious medical and nutritional concern that can lead to lengthy hospital stays. Clinicians needs to monitor GI function daily in order to prevent GI atrophy
TPN plays an essential role in the management of electrolytes and can supply adequate nutrients when enteral feedings can not be done
Patients should be routinely cautioned on the risk and complications associated with adhesions before undergoing any abdominal or pelvic surgery

30. Appendix Medication Rationale Tylenol extra strength, 500mg Pain
Calcium Carbonate, 500mg
Calcium supplement, antacid
Coreg, 6.25mg BID
Beta-blocker for hypertension and heart health
Vitamin D3, 1000units
For osteoporosis
Plavix, 75mg
Blood thinner
Levofloxacin, 250mg
Antibiotic
Levothyroxine, 75mg
Synthetic thyroid hormone for hypothyroidism
Lisinopril, 20mg
ACE inhibitor
Flagyl, 500mg q 8hrs
Omeprazole, 40mg
Proton pump inhibitor for GI ulcers, heart burn, GERD
Zofran, 4mg q 6hrs
Nausea, Vomiting
Florastor
Probiotic
Simvastatin, 40mg
Statin
Ambien, 5mg
Gamma-aminobutyric acid for insomnia
Appendix
Table 1

31. Appendix Anthropometric Data Height Weight IBW IBW% BMI 57” 121# 100#
Table 2
Anthropometric Data
Height
Weight
IBW
IBW%
BMI
57”
121#
100#
121%
24.95
Nutrient Needs
REE
Protein
45.45 kg x 25 kcal/kg = 1138 kcal
45.45 kg x 30 kcal/kg = 1365kcal
kcal/day
45.45kg x 1.2 g/kg = 55 g
45.45 kg x 1.5 g/kg = 69 g
55 – 69 g/day

32. Appendix Medication Rationale Vitamin D3 Bone health Heparin
Anticoagulant
Sliding Scale Insulin
Control serum glucose
Levothyroxine
Synthetic thyroid hormone for hypothyroidism
Lopressor
Control high blood pressor
Protonix
Proton-pump inhibitor to manage reflux
Sodium Chloride flush
Provides additional fluid and electrolyte balance
Table 3

33. Appendix Table 4 Domain Problem/Nutrition Diagnosis Etiology
Signs/Symptoms
Clinical (NC-1.4)
Altered Gastrointestinal Function
Related to
small bowel obstruction
As evidenced by
abdominal distention, vomiting and lack of bowel movement.
Intake (NI-5.2)
Malnutrition
fluid retention and oral energy intake < 50%-75% for one week.

34. References
1. Mahan LK, Escott-Stump S. Krause’s Food & Nutrition Therapy. 13th ed. St. Louis, MO: Saunders Elsevier; 2011:9-10/
2. Kulaylat MN, Doerr RJ. Small Bowel Obstruction – Surgical Treatment. National Library of Medicine Accessed December 14, 2014.
3. Lucey J. Small Bowel Obstruction. NYU Langone Medical Center Accessed December 12, 2014.
4. Harris EA, Kelly AW, Pockaj BA et al. Reoperation on the Abdomen Encased in Adhesion. The American Journal of Surgery. 2002:184 (6): dio:
5. Ten Broek RPG, Issa Y, van Santbrink EJP, et al. Burden of adhesions in abdominal and pelvic surgery: systematic review and met-analysis. BMJ : British Medical Journal 2013;347:f5588. doi: /bmj.f5588.
6. Width M, Reinhard T. The Clinical Dietitian’s Essential Pocket Guide. Philadelphia, PA: Lippincott Williams and Wilkins; 2009.

35. References
7. ARAMARK Healthcare. Assessment and education policy #2: Nutrition status classification worksheet. Patient Food Services: Policies and Procedures, Volume IV; 2007.
8. White JV, Guenter P, Jensen G et al. Consensus Statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition). Journal of Parenteral and Enteral Nutrition. 2012: 36(3): DOI: /
9. American Dietetic Association. Pocket Guide for International Dietetics & Nutrition Terminology (IDNT) Reference Manual. 3rd ed. Chicago, IL
10. Bordeianou L, Yeh D. Overview of management of mechanical small bowel obstruction in adults. UpToDate. management-of-mechanical-small-bowel-obstruction-in-adults . Accessed December 7, 2014.