J.M.D. Nightingale

Guidelines for management of patients with a short bowel

### 1.1 Aim These guidelines aim to help clinicians manage patients who have had an intestinal resection that leaves a short length (about 2 m or less) of small bowel remaining. ### 1.2 Development The preliminary guidelines were compiled from the literature and a first document was drafted by Dr J Nightingale and modified by members of the Small Bowel and Nutrition Committee under the chairmanship of Dr B Jones. A section on “intestinal transplantation” was written by Dr Woodward and added with the approval of the Small Bowel and Nutrition Committee. The resulting document was shown to clinicians at the intestinal units of Hope and St Mark’s Hospitals. Professor A Forbes made recommendations, which have been incorporated. The article was reviewed by the patient organisation PINNT (patients on intravenous or nasogastric nutritional therapy) and modifications made to result in the current document. The guidelines conform to the North of England evidence based guidelines development project.1 The grading of each recommendation is dependant on the category of evidence supporting it. Recommendations based on the level of evidence are presented and graded as: ### 1.3 Scheduled review The content and evidence base for these guidelines should be reviewed within five years of publication. We recommend that these guidelines are audited and request feedback from all users. ### 1.4 Service delivery Patients with a short bowel are not common but should be managed by a multidisciplinary team headed by a clinician with expertise in …

Hepatobiliary, renal and bone complications of intestinal failure

Abnormal liver function tests in patients with intestinal failure (IF) may be due to the underlying disease, IF or the treatments given (including parenteral nutrition (PN)). PN-related liver disease in children usually relates to intrahepatic cholestasis and in adults to steatosis. Steatosis may be consequent upon an excess of carbohydrate, lipid or protein, or upon a deficiency of a specific molecule. Pigment-type gallstones are common in adults and children with IF; these develop from biliary sludge that forms during periods of gallbladder stasis. Ileal disease/resection, parenteral nutrition, surgery, rapid weight loss and drugs all increase the risk of developing gallstones. Gallstone formation may be prevented by reducing gallbladder stasis (oral/enteral feeding or prokinetic agents), altering bile composition, or by means of a prophylactic cholecystectomy. Calcium oxalate renal stones are common in patients with a short bowel and retained functioning colon and are consequent upon increased absorption of dietary oxalate; they are prevented by a low-oxalate diet. An osteopathy may occur with long-term parenteral nutrition.

Management of patients with a short bowel

There are two common types of adult patient with a short bowel, those with jejunum in continuity with a functioning colon and those with a jejunostomy. Both groups have potential problems of undernutrition, but this is a greater problem in those without a colon, as they do not derive energy from anaerobic bacterial fermentation of carbohydrate to short chain fatty acids in the colon. Patients with a jejunostomy have major problems of dehydration, sodium and magnesium depletion all due to a large volume of stomal output. Both types of patient have lost at least 60 cm of terminal ileum and so will become deficient of vitamin B(12). Both groups have a high prevalence of gallstones (45%) resulting from periods of biliary stasis. Patients with a retained colon have a 25% chance of developing calcium oxalate renal stones and they may have problems with D(-) lactic acidosis. The survival of patients with a short bowel, even if they need long-term parenteral nutrition, is good.

Knowledge about the assessment and management of undernutrition: a pilot questionnaire in a UK teaching hospital

BACKGROUND & AIMS The detection, prevention and treatment of undernutrition in hospitals is often poor. This study assesses the knowledge about undernutrition of staff in a UK teaching hospital. METHODS Twenty nine doctors, 65 final year medical students, 45 nurses, 11 dietitians, and 11 pharmacists anonymously completed a questionnaire of 20 multiple choice questions. One of five possible answers was considered correct. Twelve questions were about adult nutritional assessment and requirements, five about oral/enteral nutrition and three about parenteral nutrition. RESULTS Dietitians scored significantly more (median 16) than the other groups (doctors: seven, medical students: eight, nurses: seven and pharmacists: nine) (P < 0.0001). Medical students scored more than doctors (P < 0.001). Examples of areas in which knowledge could be improved are: 67% respondents thought the prevalence of hospital undernutrition to be less than 30%. While 91% of respondents correctly chose a well 70 kg man to need about 2000 kcal/day, only 23% knew that approximately the same amount was needed for a febrile post-operative patient. Sixteen percent knew antibiotic treatment to be the most common reason for enteral feeding-related diarrhoea. CONCLUSIONS Knowledge about the assessment and management of undernutrition among doctors, medical students, nurses and pharmacists was poor. This questionnaire provides a framework for teaching and auditing the effectiveness of an educational program.

The medical management of intestinal failure: methods to reduce the severity

A new definition of intestinal failure is of reduced intestinal absorption so that macronutrient and/or water and electrolyte supplements are needed to maintain health or growth. Severe intestinal failure is when parenteral nutrition and/or fluid are needed and mild intestinal failure is when oral supplements or dietary modification suffice. Treatment aims to reduce the severity of intestinal failure. In the peri-operative period avoiding the administration of excessive amounts of intravenous saline (9 g NaCl/l) may prevent a prolonged ileus. Patients with intermittent bowel obstruction may be managed with a liquid or low-residue diet. Patients with a distal bowel enterocutaneous fistula may be managed with an enteral feed absorbed by the proximal small bowel while no oral intake may be needed for a proximal bowel enterocutaneous fistula. Patients undergoing high-dose chemotherapy can usually tolerate jejunal feeding. Rotating antibiotic courses may reduce small bowel bacterial overgrowth in patients with chronic intestinal pseudoobstruction. Restricting oral hypotonic fluids, sipping a glucose-saline solution (Na concentration of 90-120 mmol/l) and taking anti-diarrhoeal or anti-secretory drugs, reduces the high output from a jejunostomy. This treatment allows most patients with a jejunostomy and > 1 m functioning jejunum remaining to manage without parenteral support. Patients with a short bowel and a colon should consume a diet high in polysaccharides, as these compounds are fermented in the colon, and low in oxalate, as 25% of the oxalate will develop as calcium oxalate renal stones. Growth factors normally produced by the colon (e.g. glucagon-like peptide-2) to induce structural jejunal adaptation have been given in high doses to patients with a jejunostomy and do marginally increase the daily energy absorption.

Causes and management of a high‐output stoma

Aim  Patients with a high‐output stoma (HOS) (> 2000 ml/day) suffer from dehydration, hypomagnesaemia and under‐nutrition. This study aimed to determine the incidence, aetiology and outcome of HOS.

Short bowel syndrome

Nine patients with short bowel syndrome and high intestinal output received octreotide either intravenously (50-100 micrograms t.i.d.) or subcutaneously (100 micrograms b.i.d.) on 2 test days. In the 6 patients with net secretory output, there was a reduction in mean daily intestinal output of 0.5-5.0 kg; total daily intestinal output of sodium and potassium was also reduced significantly. Of the 3 patients with a net absorptive state, there was a worsening of output in 2 and no improvement occurred in the other. Two patients with net secretory output received long-term octreotide therapy, allowing a reduction in daily intravenous fluid intake of 1.0-1.5 litres.

Survey on the use of adalimumab as maintenance therapy in Crohn's disease in England and Ireland

Introduction Adalimumab is effective in inducing and maintaining response/remission in patients with Crohns disease either naive to biological therapies or after secondary failure of infliximab. Aim To present the first ‘real-life’ survey data from England and Ireland on the use of adalimumab. Method A retrospective audit conducted through a web-based questionnaire in England/Ireland. Results We analysed data on 61 patients (35 female, 26 male) with a median age of 33 years (range 17–71 years) and an average follow-up of 8 months. The maximal maintenance dose was 40 mg every other week in 84% of patients, 40 mg weekly in 13% and 80 mg weekly in 3%. Maintenance adalimumab achieved remission in 57% of patients. The ongoing response rate was 83.6%. An additional 8% had a secondary loss of response after an average of 8.4 months (range 2–17). Adverse effects were observed in 23% of patients: of which there was local pain in 29%, infection in 36%, headaches in 14%, leucopenia (on azathioprine) in 7%, a painful rash in 7% and serum-sickness-type reaction in 7%. Adverse events led to discontinuation in two patients. Conclusion This English/Irish audit shows an acceptable response/remission and safety profile of adalimumab in the treatment of Crohns disease. In contrast to earlier data from Scotland, dose escalation was only observed in 16% of patients. The majority of responders were steroid-free at follow-up.

Mesenteric Infarction: Clinical Outcomes After Restoration of Bowel Continuity.

Introduction: Patients who have a bowel resection for mesenteric infarction may require parenteral nutrition (PN). This study primarily aimed to determine the aetiological factors for a mesenteric infarction and the effects of restoring bowel continuity on the long-term PN requirements. Methods: A retrospective review of data on patients treated for mesenteric infarction from 2000 to 2010. Results: A total of 113 patients (61 women, median age 54 years) were identified. Seventy-four (65%) had a superior mesenteric artery thromboembolism, 25 (22%) had a superior mesenteric vein thrombosis, and 4 (3%) had superior mesenteric artery stricture or spasm. Patients younger than 60 years most commonly had a clotting abnormality (n = 23/46, 50%), whereas older patients had a cardiological risk factor (n = 11/17, 65%). All patients with a jejunostomy required long-term PN. Fifty-seven (49%) patients had restoration of bowel continuity (colon brought into circuit). After this, PN was stopped within 1 year in 20 (35%), within 2 years in 29 (50%) patients and within 5 years in 44 (77%) patients (P = 0.001). Conclusions: A thrombotic tendency is the main etiological factor in most patients younger than 60 years. An anastomosis of the remaining jejunum to the colon can allow PN to be stopped.

Gastrostomy placement in patients with Crohn's disease.

&NA; Crohns disease often involves the stomach, yet a permanent enterocutaneous fistula does not usually occur, after a percutaneous endoscopic gastrostomy is removed from a patient with Crohns disease. This is because the factors that are related to the non‐closure of a fistula are absent or have been treated (distal bowel obstruction, abdominal sepsis, undernutrition, poor gastric blood supply or abnormal serum levels of C‐reactive protein and albumin).