January 13, 2023
Dietitians are registered health professionals who evaluate scientific evidence about food and nutrition and translate it into practical strategies. In the context of intestinal failure caused by short bowel syndrome or a proximal enteroatmospheric fistula a Dietitian is ideally placed to help patients as part of a multi-disciplinary team that could include intensivists, surgeons, pharmacists, gastroenterologists and the patient themselves.
Intestinal failure has been characterised as “the reduction of gut function below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, such that IV supplementation is required to maintain health and/or growth” (Pironi et al., 2015). It is often characterised by diarrhoea or a high output stoma and patients with this condition are at risk of malnutrition, dehydration, electrolyte disturbances and micronutrient deficiencies caused by malabsorption.
In the hospital setting, preventing dehydration and malnutrition is key to maintaining patient health. Intravenous fluids will often be required to rehydrate the short bowel patient and then a decision will have to be made on how to feed the patient. Parenteral nutrition (PN) is the most likely source of nutrition in the early stages of hospital admission, and this will help to maintain the hydration and nutritional status of the patient.
After bowel resection the gut can adapt, and this process can begin soon after surgery and last for up to 2 years. The ileum can lengthen, increase diameter and increase villi size as well as upregulating transporters and brush border enzymes. The jejunum shows more modest changes and will adapt as well. Enteral nutrition is key to this process and so even if your patient is being fed intravenously trickling some enteral feed into the gut is very important.
To give the best chance of managing on an oral diet, opioid-based pharmaceuticals such as loperamide and codeine can be used to slow gut transit and optimise absorption. These must be taken half an hour before food and high doses may be required.
The sodium concentration of small bowel fluid is 80-140mmol/L and so hypotonic fluids (e.g. water) can cause sodium losses and may have to be restricted. Oral rehydration solutions can be used to optimise fluid absorption e.g. St. Marks Solution, double strength Dioralyte™ in the UK or Electral (6 sachets per 1000mL) in New Zealand.
The reality is that many patients will need long term PN and may be discharged home on it. PN is an expensive therapy (Parris et al., 2014) and has potentially catastrophic risks attached to it such as line sepsis and thrombus so patients must be trained in line management by experienced clinicians. Quality of life may be low in this cohort for many reasons such as recurrent hospital admissions, inability to eat and reliance on artificial nutrition.
Alternatives for some patients are available however. Distal enteral tube feeding has been used for many years in centres such as Salford Royal in the UK. A standard polymeric feed is fed into the distal bowel and can provide complete or trophic nutrition. Access to the distal bowel is needed in a stable and sepsis free patient. There must also be evidence of bowel integrity.
Chyme reinfusion (CR) has been used since the 1970’s (Lévy et al). Traditionally extracorporeal CR systems have been used where the chyme is collected and reinfused into the distal bowel thus restoring bowel continuity and reversing gut atrophy. This process can be time consuming and unpleasant however it has been shown that CR can increase weight and improve liver function with few complications and a study by Picot et al., 2020 showed that 89% of patients treated with CR were able to stop PN. As with distal feeding, access to the bowel downstream is required and there must be radiological evidence of bowel integrity.
The Insides® System is an easy-to-use and minimally invasive device that utilizes a magnetic connection across the wall of an ostomy appliance to a pump within. It can increase patient independence and allows them to go home without the need for PN or IV fluids. For patients transitioning back to an oral diet it is recommended they:
• Start slowly with small meals
• Chew their food well and follow a low fibre diet
• Titrate the chyme reinfusion slowly
This transition can take as little as 2 weeks but it is important to go at the pace of the individual as moving too fast may cause unpleasant side effects such as bloating, nausea or abdominal discomfort.
Chyme reinfusion is therefore safe, well validated and can reduce or remove the need for intravenous nutrition. By restoring bowel continuity improvements in nutrition and hydration can be improved with the added benefits of better quality of life for the patient and lower costs for the health providers.
Intestinal Failure Dietitian
This blog will briefly detail what a stoma is, their purpose, and the common types of stomas and how they are brought up to the abdomen...