(Content sponsored by Boston University)
By Julie Stefanski MEd, RDN, CSSD, LDN, CDE
Active in competitive sports, 16-year-old Sara was headed to volleyball practice when the abdominal pain became too much. A bowel obstruction related to undiagnosed Crohn’s disease led to her first small bowel resection. A little more than a year later, adhesions from the first surgery along with progression of her inflammatory bowel condition led to a second bowel obstruction. This time the significant necrotic tissue required removal of more than 60% of her remaining intestine. Beyond recovery from surgery, a diagnosis of short bowel syndrome signifies that the way Sara’s body processes nutrition may be permanently effected.
Short bowel syndrome, also known as short gut or intestinal failure is a lifelong challenge for patients. Removal of extensive sections of the intestine, whether due to inflammatory bowel disease as in Sara’s case, a congenital condition, cancer or another life threatening situation creates a complicated set of both physical and psychological problems. The typical intestine of an adult, which averages approximately 25 feet in length, collects vital nutrients, electrolytes and fluid. Even with 50% of the bowel removed, patients can often adapt to post-surgical changes and continue to maintain adequate nutrition and hydration via an oral route. When more than 75% of the bowel has been surgically removed, the capacity of the intestines to absorb fluid and nutrients just isn’t sufficient and specialized nutrition support is often required.
The period following a significant bowel resection is often a time of trial and error. An interdisciplinary team including physicians, registered dietitians, nursing, pharmacy and behavioral health staff all play a role in evaluating the strengths and barriers present, which may impact a patient’s ability to maintain adequate nutrition. Factors such as age, intestinal remnant length and the presence or absence of the ileocecal valve, along with interventions utilized to promote intestinal adaptation in the acute recovery phase are, all key predictors of health outcomes.
SBS patients, commonly faced with diarrhea, significant nutrient and electrolyte deficiencies and loss of fat in the stool, can quickly become dehydrated or have unplanned weight loss. Although patients are typically allowed to eat by mouth once they move beyond the immediate post-op period, the rapid transit time of the ingested food and liquids does not allow adequate absorption by the remaining GI tract. Even with the use of diet modifications, oral electrolyte solutions and medications to enhance the absorptive capacity of the intestine, intravenous hydration or parenteral nutrition may still be required.
Use of long-term PN has been a life-saving intervention for many SBS patients, but it unfortunately comes with its own unique risks and complications. While the significant expense of PN is typically covered by insurance, extended use of nutrition delivered intravenously includes PN induced liver disease along with blood based infections. Loss of nourishing oneself by mouth and the need for continuous infusions of PN can also have a major emotional impact on survivors of SBS, thus leading to feelings of social isolation and depression.
RDNs play a vital role in preventing malnutrition and dehydration through the use of nutrition assessment, nutrition focused physical exam and a detailed review of the surgical procedure if available. Knowledge of the primary areas of absorption for vital nutrients such as essential fatty acids, minerals such as magnesium, and vitamins such as B12, is paramount when working with SBS patients to determine supplemental or complete specialized nutrition support needs while providing appropriate medical nutrition therapy for the patient.
In Sara’s case, the development of a close working relationship with her RDN helped her to understand how the surgery permanently impacted her digestive needs. Through medical nutrition therapy Sara learned how she could make appropriate dietary choices including regular use of an oral electrolyte solution along with avoidance of hypertonic fluids, which can lead to fluid loss in an SBS client. With good interdisciplinary care and close monitoring, a year after her last surgery Sara was able to wean the use of PN to several infusions per week to meet total macro and micronutrient needs along with oral food and hydration to maintain and support her nutrition status.
Using an expert interdisciplinary, interprofessional team and featuring video vignettes of actual patients like Sara, Boston Medical Center’s web-based activity aims to provide dieticians and other clinicians with a better understanding of best practices in intestinal rehabilitation in patients with SBS. The expert panel explores key issues and questions frequently encountered in clinical practice in SBS treatment and management in both acute and outpatient settings.
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