Short Bowel Syndrome/ High Output Stoma - Acute … Bowel Syndrome/ High Output Stoma ... DRINK MORE ABSORB MORE ... Home Care nursing teams: adherence to catheter care

Short Bowel Syndrome/

High Output Stoma

Professor Simon Lal

Surgical history

Right hemicolectomy

Panproctocolectomy

Small bowel resections x 2

Case History: Background

Medical history

5-ASAs/Recurrent Steroids

Azathioprine: intolerance

Infliximab: anaphylaxis

46 year old female

Crohn’s disease 1996

Surgical history

Right hemicolectomy

Panproctocolectomy



46 year old female


Surgical history

Right hemicolectomy

Panproctocolectomy



46 year old female


November - December 2013

Ileostomy re-fashioned, complicated SI resection

High output stoma

Readmitted dehydrated surgeons advised to drink more

46 year old female, high output stoma

Thirst, lethargy, muscle cramps, dizzy

Dehydrated. BP 85/50.

Stoma output > 2.5 L.

Wt = 43kg BMI = 16

FY2 Plan:

i.v. saline & i.v. magnesium.

Aim for home tomorrow pending repeat bloods.

Senior Review.

Case History: EAU 2014

Na K Urea Creat Alb CCa Phos Mg CRP

129 4.9 12 154 49 1.94 1.3 0.48 5

133-146 3.5-5.3 2.5-7.8 44-97 35-50 2.2-2.6 0.8-1.5 0.7-1.0 <10

SBS

Does she require

admission?

Why is her albumin normal?

How optimise

fluid balance?

How correct

Mg?

Will she need long term HPN?

SBS

Does she require

admission?

SBS






Wt = 43kg BMI = 16


129 4.9 12 154 49 1.94 1.3 0.48 5

133-146 3.5-5.3 2.5-7.8 44-97 35-50 2.2-2.6 0.8-1.5 0.7-1.0 <10

Poor nutritional marker

Negative acute phase protein

Case History: Serum Albumin

Albumin in protein-calorie

malnutrition without inflammation

**

Smith G et al, Nutrition 1996;12(10):677.

What happened to his albumin?

What happened to his albumin?

SBS

How optimise

fluid balance?





Wt = 43kg BMI = 16


129 4.9 10 154 49 1.94 1.3 0.48 5

133-146 3.5-5.3 2.5-7.8 44-97 35-50 2.2-2.6 0.8-1.5 0.7-1.0 <10

Dehydration & Renal impairment in SBS

1. Malnourished: Significant renal dysfunction.

2. Recurrent dehydration despite drinking more.

Case History: Renal Function

Why?

A bit of

physiology

(!)….

NORMAL: NET ABSORBER

DRINK MORE ABSORB MORE

SI < ~150cm NET SECRETOR

Normal proximal secretion is not

compensated by distal absorption

DRINK MORE ABSORB LESS

Thirst needs less drinking!

Fluid & Nutritional Assessment

Fluid Nutrition

Accurate fluid balance vital

Intake

Stoma

Urine

48 hours NBM Minimal

stoma loss.

Urine Na best gauge of

hydration status

Urine sodium

< 20mmol

dehydration

Fluid & Nutritional Assessment

Fluid Nutrition

Accurate fluid balance vital

Intake

Stoma

Urine

48 hours NBM Minimal

stoma loss.

Urine Na best gauge of

hydration status

Assessment

Wt, BMI

Anthropometry

Hand-grip strength

Diet history & food charts

Dietitian best gauge of

nutritional status!

BSG Guidelines, Gut, 2006 Lal S Alimen Pharm Ther 2006; 24: 19-31

SBS Treatment

Drug therapyAnti-motility

Loperamide (up to 16mg QDS)

Codeine phosphate (up to 60mg QDS)

Anti-secretoryPPI Stoma pH>5.5

?Octreotide

Restrict hypotonic fluid < 1L/day

Drink glucose-saline solution ~ 1L/day

Nutrition Dietetic Review


SBS Treatment



SI < ~150cm NET SECRETOR

Normal proximal secretion is not

compensated by distal absorption

SBS Treatment



SBS Treatment



SBS Treatment



Sodium content must

be > 90mmol/L to

achieve a POSITIVE

sodium balance.

Rodrigues et al. (1988) Clin Sci;74:69P

Nightingale et al (1992) Gut; 33:759-761

Nammol/l

Kmmol/l

Glucosemmol/l

Volumeml

WHO 90 20 111 1000

‘St Mark’s Solution’ 90 0 111 1000

Dioralyte 60 20 90 200

Powerade isotonic 12 4 0 (214) sucrose & maltodextrin

600

Powerade isotonic+ ½teaspoon NaCl

85 4 0 (214) sucrose & maltodextrin

600

Double Strength Dioralyte

Oral Rehydration Solutions


SBS Treatment





?Octreotide



-125

-100

-75

-50

-25

0

25

50

Sod

ium

bal

ance

(m

mo

l/d

ay)

control

loperamide

codeineloperamide

& codeine

ranitidine

ORS

loperamide

codeine

ORS

Nightingale JMD et al. Clin Nutr 1992; 11: 101-5

Sodium balancePatient with jejunostomy at 100 cm


SBS Management





?Octreotide



Jejunostomy: recommended diet

Nutrient group Amount Note

Energy High 30-60 kcal/kg/day

Protein High 0.2-0.25g N2/kg/day (80-100g protein)

Fat High

Fibre Low


SBS Treatment





?Octreotide




SBS

How correct

Mg?





Wt = 43kg BMI = 16


129 4.9 10 154 49 1.94 1.3 0.48 5

133-146 3.5-5.3 2.5-7.8 44-97 35-50 2.2-2.6 0.8-1.5 0.7-1.0 <10

Magnesium

FY2 Plan:

i.v. saline & i.v. magnesium.

Aim for home tomorrow pending repeat bloods.

Senior Review.

Hypomagnesaemia: Management

Intravenous

MagnesiumNot sustained because rapidly excreted

Hypomagnesaemia: Management

Intravenous

MagnesiumNot sustained because rapidly excreted

Sodium/Water

DepletionCorrect (reduced 20 hyperaldosteronism)

Oral

Magnesium

Vitamin D

PPI Rare with chronic use Don’t forget

Mg Oxide or Aspartate

Mg glycerophosphate X

Dose titration

Vital

Intramuscular or high dose oral





Wt = 43kg BMI = 16


129 4.9 10 154 49 1.94 1.3 0.48 5

133-146 3.5-5.3 2.5-7.8 44-97 35-50 2.2-2.6 0.8-1.5 0.7-1.0 <10

Calcium & Potassium

Potassium

Hyperaldosteronism in chronic Na deficiency

Negative K+ balance if < 50cm small bowel

SBS


Dibb M et al. APT 37(6):587-603

Length matters….

~<100cm Small Bowel

Parenteral Support

Influenced by active disease

Influenced by colon in continuity

Surgical history

Right hemicolectomy

Panproctocolectomy


Post-op Small Bowel Length

46 year old female. Crohn’s disease 1996

Adult small bowel 3 - 8.5m

Males > Females

Post-op: How much remaining

not how much removed!

Not enough small bowel =

Home Parenteral Nutrition

Single lumen, PN Dedicated Tunnelled Catheter.

12-14 hours infusion up to 7 nights per week.

Patient or carer: 2-6 weeks training to administer.

Home Care nursing teams: adherence to catheter care protocol.

HPN

COMPLICATIONS

Catheter Infection

Venous Thromboisis

Hepato-biliary

Renal

Metabolic Bone Disease

Psychological

Dibb M, Teubner A, Theiss V, Shaffer J, Lal S APT 2013

CVC Longevity in Intestinal Failure

Repeated catheter loss failed

venous access: indication for a

small bowel transplant.

Ethos of meticulous catheter

care. Only access if trained to protocol

(unless medical emergency).

Dedicated to PN only.

No blood sampling.

Salford IFU: Lowest sustained CVC infection rate.

Longest surviving patient: 34 yrs.

Longest CVC: 16 yrs.

HPN Survival

ITx Survival

Dibb M et al. 2013 APT 37(6):587-603

Dibb M et al 2016 JPEN Epub ahead of print

Case History: Successful Outcome

~150 cm

Op notes (+ contrast study): ~150cm

No sign of active Crohn’s.

Stoma output < 1L, Urine Output >1L

<1L hypotonic fluid restriction

1L D.S. Dioralyte

Loperamide 32mg

Codeine 30mg qds

Omeprazole 20mg b.d.

Mg Aspartate 1 sachet t.d.s.

Vitamin D optimised

GP Blood monitoring.

Dietetic & Gastro Clinic Follow-up

Nutritional progress

Crohn’s prevention vigilance for

recurrence

Case History: Successful Outcome

~150 cm

Op notes (+ contrast study): ~150cm

No sign of active Crohn’s.

Stoma output < 1L, Urine Output >1L

<1L hypotonic fluid restriction

1L D.S. Dioralyte

Loperamide 32mg

Codeine 30mg qds

Omeprazole 20mg b.d.

Mg Aspartate 1 sachet t.d.s.

Vitamin D optimised

GP Blood monitoring.

Dietetic & Gastro Clinic Follow-up

Nutritional progress

Crohn’s prevention vigilance for

recurrence

SBS

Does she require

admission?


How optimise

fluid balance?

How correct

Mg?


Thank-you

Documents

Short Bowel Syndrome/ High Output Stoma - Acute … Bowel Syndrome/ High Output Stoma ... DRINK MORE ABSORB MORE ... Home Care nursing teams: adherence to catheter care