SHORT BOWEL SYNDROME: Katie Grabow

ISU Dietetic Intern

FINAL CASE STUDY Memorial Medical Center

April 25, 2019
 SHORT BOWEL SYNDROME (SBS)
•SBS: inadequate absorptive capacity due to reduced length or
decreased functional bowel following bowel resection.
• Typical SB= 600 cm (20 ft)
• SBS< 200 cm of SB
• Case study patient had 60 cm of SB remaining
•Adaption: SB adapts to compensate for resect bowel
• Dilation
• Villi height/depth increase increased surface are without change in
length

Causes: Symptoms: Treatment:

Bowel resection secondary Abdominal pain, bloating, Prevalence: Medications, surgery,
to bowel strangulation, vomiting, diarrhea, Very rare; 3 out of 1 intestinal transplant,
Crohn’s, ischemia, birth steatorrhea, etc. million people have SBS nutrition intervention
defects and/or support
MNT FOR SHORT BOWEL SYNDROME
•Considerations:
• Where was the resection/what remains?
• What nutrients are most likely to be malabsorbed?
• How healthy is this patient at baseline?

•Oral:
• Small, frequent meals (4-6 per day)
• Avoid foods and drinks high in sugar
• Avoid caffeine and alcohol
• May be intolerable to high fat foods
• Drinks between meals, not with meals
• Micronutrient supplementation
• Oral rehydration therapy

•EN:
• Provides trophic stimulus for residual GI
• Hydrolyzed formula

•PN:
• Often required (depends on what part of SB remains)
• Many patient initially on TPN while hospitalized to optimize nutrition
• Some patients may require chronic TPN
 WHIPPLE PROCEDURE
•Procedure to remove the head of the
pancreas, the duodenum, the gallbladder, and
the bile duct; organs reattached (Billroth II)
•Potential Problems:
• Dumping syndrome
• Delayed gastric emptying
• Diabetes (decreased insulin production)
• Micronutrient malabsorption
• Bacterial growth

•MNT post-Whipple
• Similar to SBS
• Pancreatic enzyme replacement therapy
 CASE STUDY PATIENT INFORMATION
Name: F.Y. Date of Admission: 4/8/19
Age: 82 Unit: ICU
Gender: Male PMH: Whipple procedure secondary to
Height: 173 cm (5’8”)
pancreatic pseudoaneurysm (April F.Y.
2018), gastroparesis, dysphagia, GJ
Weight at Admit: 55.2 kg tube

BMI: 18.5 kg/m² (underweight) Estimated nutritional needs:

 1337 kcals (Penn State)
IBW: 70 kg  67-81 g protein (1.25-1.5 g/kg admit wt)
% IBW: 79% Admitted due to: ab pain x 6 hrs
Wt Loss PTA: -8.9 kg (14%) < 1 month
 INITIAL ASSESSMENT
4/9:
• Pt with bowel ischemia- underwent exploratory laparotomy, lysis of adhesions, and bowel resection
on 4/8.
• Pt remains intubated following procedure-requiring Levophed @ 10mcg/min.
• -70 lbs x 1 year (since Whipple procedure), -19 lb x 2 weeks.
• TPN recommended at this time due to lack of bowel function.

•Diagnosis: Severe protein calorie malnutrition in the context of chronic illness

related to chronic illness (pancreatic pseudoaneurysm Whipple) as evidenced by
weight loss >5% x 1 month, severe loss of subcutaneous fat and muscle mass.
• Altered GI function
• Impaired nutrient utilization
• Inadequate oral intake
• Swallowing difficulty
FOLLOW-UP VISITS
4/11: Pt remains intubated, no longer requiring pressor support. Initiation of
TPN. Concerns for refeeding. Check fat soluble vitamins, zinc.
1 L Clinimix E 5/15 + 100 mL lipids (910 kcals, 50 g protein).

4/12: Pt returned to OR today- only 60 cm of SB distal to J-tube remain.

Tolerating TPN. Vit D returned low. Additional fat soluble vitamin labs
pending.
1.5 L Clinimix E 5/15 + 100 mL lipids (1265 kcals, 75 g protein).

4/13: Magnesium low, sodium high. Continue same TPN as currently

infusing. Consider TPN advancement pending electrolyte values
tomorrow.

4/14: Wean trial initiated. Sodium trending up. Potassium low (replete
outside of TPN per MD). Advance TPN to goal.
1.5 L Clinimix E 5/15 + 250 mL lipids (1565 kcals, 75 g protein).
4/15: Pt was extubated yesterday, but remains NPO. C diff positive.
Sodium elevated. BG 153-188 mg/dl x24 hours  will increase to
moderate insulin sliding scale. Tolerating TPN at goal. No bowel function at
this time. EER updated (1380-1656 kcals per 25-30 kcal/kg).

4/16: Pt tolerating TPN at goal. Now with ileostomy output. Begin trying
meds through J tube today. NGT discontinued. Downgraded to IMC.
Sodium levels trending down.

4/17: Pt tolerating TPN at goal. MD to manage TPN from this point. J-tube
for meds. Fat-soluble vitamin and zinc labs retuned low. Recommend Vit
A 25,000 units daily x 10 days, Vit D 10,000 units daily, Vit E 100 units
daily for maintenance, Zinc sulfate 220 mg daily x 10 days.

4/19: Pt remains on TPN at goal. Electrolytes WNL.

4/22: Pt remains on TPN at goal. Magnesium low. Downgraded to

general floor yesterday. Will begin cycling TPN in preparation for future
discharge.
CURRENT STATUS REPORT
•Peripheral edema-requiring Lasix
•Hypoglycemia-sliding scale currently on hold
•SLP consulted for evaluation of swallow safety of ice chips/popsicles for comfort
 Pt and family refused consult
•Possibly discharging home in the next few days
•TPN dependent
 REFLECTION
What would I have done
What did I learn?
differently?
•Obtained a better understanding of •Trial trickle TFs to promote gut
SBS and the role of a RD in the care function question efficacy
process of these patients
•Continue to cycle down TPN to 12
• Refreshed my knowledge of some hour rate (pending BG levels)
metabolism and MNT concepts
specific to disease state •Check vitamin A, D, E, & zinc labs
•Learned about micronutrient again to ensure absorption if no
supplementation; doses for repletion improvement shown, consider IV
micronutrient supplementation
•Discovered the difficulties that occur
with changes in Pt’s care team (who
manages TPN?)
THANK YOU! Questions?
REFERENCES
Academy of Nutrition and Dietetics. Whipple Surgery Nutrition Therapy. n.d.
Jeejeebhoy, K. Short bowel syndrome: A nutritional and medical approach. Canadian
Medical Association Journal. 2002; 166(10). 1297-1302
Mayo Clinic Staff. (2018, March 27). Whipple procedure. Retrieved from
https://www.mayoclinic.org/tests-procedures/whipple-procedure/about/pac-20385054
National Institute of Diabetes and Digestive and Kidney Diseases. (2015, July 01).
Short Bowel Syndrome. Retrieved from https://www.niddk.nih.gov/health-
information/digestive-diseases/short-bowel-syndrome
Thompson JS, Rochling FA, Weseman RA, Mercer DF. Current management of short
bowel syndrome. Current Problems in Surgery. 2012;49(2):52–115.
Walls, A. An overview of short bowel syndrome management: Adherence, adaption,
and practical recommendations. Journal of the Academy of Nutrition and Dietetics.
2013; 113(9). 1200-1208.