Lecture 14: SBS

Question 1

what are potential complications from fistula?

Answer 1

sepsis, fluid/electrolyte imbalances, malnutrition, hemorrhage, pain, anxiety, death

Question 2

most low-output ECFs will close within 4 wks of presentation, this is called _______

Answer 2

spontaneous closure

Question 3

what are cornerstones of ECF (enterocutaneous fistula) management?

Answer 3

SOWATS: sepsis control, optimization of nutr status, wound care, assessment of fistula anatomy, timing of surgery, surgical strategy

Question 4

when fistula first diagnosed, go-to nutrition therapy:

Answer 4

PN

Question 5

PN is indicated for fistula when:

Answer 5

originating from pancreas, high output from jejunum/ileum, proximal fistula where distal EN access not feasible, output can’t be collected in way that protects skin

Question 6

when is EN / PO indicated?

Answer 6

low output fistula, esophageal/gastric/duodensl fistula, proximal jejunal fistula with distal enteral access, distal ileal or colonic fistulas

Question 7

temporary loss of GI motility is called:

Answer 7

ileus

Question 8

most common complication of abdominal surgery:

Answer 8

post operative ileus

Question 9

post op ileus usually resolve after __ h

Answer 9

24-72

Question 10

other causes of ileus?

Answer 10

inflammation/SIRS, infection, certain drugs

Question 11

symptoms of ileus:

Answer 11

nausea, vomiting, ab distention, delayed passage of flatus and stool

Question 12

treatments for ileus:

Answer 12

NG suction, IV fluids/electrolytes, minimal sedative use

Question 13

For ileus, PO diets and early EN can be intiated within ____ h after surgery; if EN not possible for longer period (__ days), then PN warranted

Answer 13

6; 7

Question 14

what is SBS?

Answer 14

condition resulting from surgical resection, congenital defect, or disease associated loss of absorption, characterized by inability to maintain protein-energy, fluid, electrolyte balances when on normal diet

Question 15

how big is bowel?

Answer 15

half a badminton court

Question 16

what is intestinal failure?

Answer 16

reduction of gut function below minimum necessary for absorption of macros and/or water and electrolytes, such that IV supplementation is needed

Question 17

prognosis for SBS depend on:

Answer 17

how much of bowel length reduced, types of bowel segments involved in SBS

Question 18

__ jejunum is primary site of ____absorption

Answer 18

proximal; water sol vit, CHO, pro

Question 19

intercellular junctions of jejunal epithelia are ____ while ileum has ____ intercellular junctions

Answer 19

porous; tighter

Question 20

ileum is primary site of ____ absorption and _____ recirculation

Answer 20

b12; enterohepatic (bile)

Question 21

PN dependence in SBS likely when:

Answer 21

end jejunostomy (<100cm small bowel left), jejunocolonic anastomosis (<60cm small bowel with colon intact)

Question 22

common cause SBS in kids:

Answer 22

congenital malformation, severe infection, small bowel resection

Question 23

common cause SBS in adults?

Answer 23

2ndary to serial/massive small bowel resections, condition related (crohn’s, mesenteric vascular insufficiency), post surgery complications, malignancy, trauma

Question 24

what is gastroschisis?

Answer 24

part of bowel is outside of body

Question 25

what is intussusception?

Answer 25

tube going inside a tube

Question 26

necrotizing entercolitis found in:

Answer 26

premature babies

Question 27

clinical manifestations of SBS include malabsorption of ______ which leads to malnutrition characterized by _____

Answer 27

macronutrients, vitamins, fluid, electrolytes, trace elements; hypovolemia, hypoalbuminemia, metabolic acidosis, diarrhea, steatorrhea, wt loss, dehydration

Question 28

factors that affect clinical/metabolic status of pt with SBS

Answer 28

extent and site of resection, presence/absence of ileocecal valve, function and health of remaining GI tract, active and course of underlying disease, patient age, presence or absence of colon in continuity with small bowel

Question 29

mechanisms of malabsorption:

Answer 29

acid hypersecretion, loss of SA, rapid intestinal transit, impaired residual bowel, bacterial overgrowth, bile acid wasting

Question 30

why gastric acid hypersecretion?

Answer 30

loss of small bowel segments-->decreased gut hormones-->continued acid secretion/accelerated gastric emptying (dumping)

Question 31

what does gastric acid hypersecretion cause?

Answer 31

damage to mucosa, interfere with pancreas enzyme activity

Question 32

if ____ cm terminal ileum resected, bile synthesis is upregulated to compensate losses and bile entering colon interferes with fluid absorption so _____ occurs

Answer 32

<100; water diarrhea

Question 33

if ____ cm terminal ileum resected, amt unrecycled bile lost > max rate hepatic synth, causing ______

Answer 33

>100; bile insufficiency, fat malabsorption, steatorrhea

Question 34

what is SIBO?

Answer 34

presence of excess bacteria in small intestine (>10^5-10^6 organisms/mL)

Question 35

what is normal concentration of bacteria in gut?

Answer 35

<10^3 organisms/mL

Question 36

gram ____ coliforms produce mucosa damaging toxins impacting absorption

Answer 36

negative

Question 37

microorgs that prefer metabolize _______ produce bloating

Answer 37

CHO to SCFAs and gas

Question 38

processes predisposing to SIBO:

Answer 38

diminished gastric acid secretion, small intestine dysmotility, disturbances in gut immune function, anatomical abnormalities of GIT

Question 39

resection of ____ may promote retrograde transit of clonic bacteria into small bowel , causing SIBO

Answer 39

ileocecal valve

Question 40

SIBO can result in:

Answer 40

microscopic mucosal injury, alteration in bile salt absorption, intestinal malabsorption

Question 41

symptoms associated with SIBO:

Answer 41

ab pain/discomfort, bloating, distension, diarrhea, gas, weakness (non specific)

Question 42

clinical manifestations of SIBO:

Answer 42

wt loss, steatorrhea, vit/mineral deficiency, excess folate, hypoproteinemia, decreased xylose absorption

Question 43

goals in SBS:

Answer 43

maintain adequate nutrition

Question 44

what you need to know to determine nutr therapy for SBS:

Answer 44

site of resection, how much left, health of bowel, presence of colon/ileocecal valve/ostomy/bowel complications/strictures/chronic obstruction/fistula

Question 45

PN indicated for SBS if:

Answer 45

end jejunostomy w/ <100cm jejunum left; functional colon intact w/ <60cm of jejunum left

Question 46

patients with < __% of colon may benefit from ___

Answer 46

50; ORS (iso-osmolar) like milk, diluted juice, some EN formulas, commercial or homemade ORS

Question 47

hyperosmolar should be ____ and hypoosmolar should be restricted to ____oz/d

Answer 47

avoided; 4-6

Question 48

structural changes that occur in intestinal adaptation

Answer 48

hyperplasia, angiogenesis, bowel dilation, bowel elongation

Question 49

functional changes that occur in intestinal adaptation (1-2 yrs):

Answer 49

^ transporters/cell, accelerated crypt cell diferentiation, slower transit time, ^ nutr/fluid absorption

Question 50

hydration factors to consider before weaning from PN:

Answer 50

reduce only if pt achieve daily fluid intake goal consistently, U/O exceeds 1L/d and at least 0.5 mL/kg/h on nights w/o PN

Question 51

if U/O can't be measured, look at _____

Answer 51

surrogate lab markers of hydration (BUN, creatinine, urine sodium and osmolarity)

Question 52

meeting at least ___% of energy goal without symptoms that limit oral intake before weaning from PN?

Answer 52

80

Question 53

no more than ___ kg loss of BW between PN reductions

Answer 53

1.5 (remember edema)

Question 54

what is enteral balance?

Answer 54

oral fluid intake minus stool and u/o

Question 55

before weaning from PN, what should enteral balance be?

Answer 55

positive (>500mL/d)

Question 56

factors to consider before weaning off PN ?

Answer 56

hydration, energy goal, body weight, lab values, enteral balance

Question 57

meds commonly used in SBS?

Answer 57

acid suppression agents (H2 receptor antagonists, PPIs), antimotility/antidiarrheal agents (loperamide), antisecretory agents (octreotide)

Question 58

examples of bowel related complications?

Answer 58

malabsorptive diarrhea, malnutrition, fluid/electroyte disturbances, micronutrient deficiency, EFA deficiency, SIBO, D lactic acidosis, oxalate nephropathy, renal dysfunction, metabolic bone disease, acid peptic disease, anastomotic ulceration/stricture, bowel obstruction

Question 59

what is prioritization matrix?

Answer 59

prioritize pt for screening/assessment by RD (ensure right pt receive right care at right time and serve better manage allocation of time and resources, support safe provision of pt care and clinical cross-coverage, facilitate transfer of accountability

Question 60

what are the goals in SBS?

Answer 60

maintain adequate nutrition, maintain adequate hydration, maintain electrolyte balance, support bodily functioning