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home - Nutrition - Clinical Conditions and Nutrition - Intestinal Failure Written by Dr Sebastian Zeki
Methods GMP
Knows the role of nutrition as therapy for active IBD SCE 1
Knows the role of dietary alteration in treatment of symptoms of IBD
e.g. low residue diet for stricturing disease
SCE, CbD 1
Knows the mechanism of nutritional deficiency in IBD, the importance
of gut preservation, and the role of nutritional support in IBD
SCE, CbD 1
Understands the circumstances when nutritional support should be
provided by enteral or parenteral routes, and to know the various
methods of delivery
SCE, CbD 1
Understands the possible methods of maximising bowel preservation
including appropriate medical therapy, endoscopic therapy and bowel
preserving surgery
SCE, CbD 1,3
Uses enteral feed as therapy for active disease in appropriate
patients, and to alter diets as appropriate to improve symptoms
SCE, mini-CEX, CbD 1
Can use enteral and parenteral nutrition appropriately to support
patients with active IBD and to prevent substantial malnutrition
mini-CEX, CbD 1
Can perform colonoscopic balloon dilatation to prevent the
requirement for resection, and to understand when to refer for
enteroscopic dilatation or for a surgical opinion
Explains to patients and relatives the importance of nutrition as
treatment and support
mini-CEX, PS 1,3,4
Can work with the MDT to ensure all treatment decisions maximise
bowel length
CbD 1,3
Liaises with dieticians and other healthcare professionals to ensure
that all patients have appropriate nutritional support


Appreciates that preserving bowel length is important
Knows how to use immunomodulating or biological drugs to treat IBD
so as to maintain a maximum bowel length and avoid resections that
may result in a short bowel

Knows endoscopic and surgical techniques that avoid bowel being
resected (e g balloon dilatation and sphincteroplasty)

Knows the dietary therapies available to reduce disease and
symptoms (e g for intermittent obstruction l giving a liquid or low fibre

Appreciates that preserving bowel length is important
Can use immunomodulating or biological drugs to treat IBD so as to
maintain a maximum bowel length and avoid resections that may
result in a short bowel

Can empathise with and appreciate the needs of patients with IBD
Works within the multidisciplinary NST and also with the IBD nurses
and surgeons

Discuss any issue relating the disease honestly with the patient
carers friends and family


Knows the causes of small bowel infarction
Knows the difference between arterial and venous gut infarction
Understands the problems and timing of anastomosing the small
bowel onto the colon

Knows the different methods of imaging the vascular supply to the gut
(e g CT angiography digital subtraction angiography angiograms

Is able to investigate the causes of a small bowel arterial or venous

Can identify other co-existing vascular problems
Can choose the appropriate route for nutritional support (EN or PN)
Be able to feed into defunctioned gut (fistuloclysis) when appropriate
Works within the multidisciplinary NST and with the vascular
surgeons and Haematologists
Appreciates there may be other co-morbidities that limit treatment
Can discuss disease-related issues honestly with the patient carers
friends and family



Knws the principles of normal post operative care including early fluid
management (avoiding excessive saline) and having a knowledge of
when to start nutritional support

Appreciates the reasons why surgical wounds and anastomoses can
break down

Knows the stages of development of an enterocutaneous fistula and
thus the appropriate fluid/nutritional management at each stage

Understands how complex abdominal wounds are dressed (e g
wound manager bags)

Understands what is meant by a frozen abdomen and sclerosing

Knows why intestinal obstruction occurs and the ways in which it can
be managed

Knows why abdominal surgery is best avoided 0- 00 days after the
last abdominal operation

Knows the principles of enhanced recovery after surgery (ERAS)
(including reducing insulin resistance and saline excess)

Can institute an appropriate investigation plan for occult sepsis
Can assess whether an enterocutaneous fistula is likely to close

Is able to prescribe appropriate pain relief (often with the pain team)
Can assess fluid losses and thus give appropriate fluid replacement
Appreciates the principle of later restorative surgery
Is able to arrange the appropriate tests for mapping the remaining gut
(both that is in and out of circuit)

Gives appropriate psychological care with the psychological medicine

Helps a patient to be physically and emotionally well so they are able
to tolerate more surgery if necessary or be able to cope at home

Can feed into defunctioned gut (fistuloclysis) when appropriate
Understands role of tissue viability nurses and can integrate care with

Explains to patients their anatomy the principles of intended
treatment and any procedures


Intestinal Failure

Feed RoutesParenteralPeripheralMidlinePICCHickman/ Broviac/Groshong (all tunnelled)EnteralShort term feedingFine bore nasoenteral tube(FBT)nasogastricnasoduodenalnasojejunalDouble lumen nasoenteral tubeLong term feedingCervical pharyngostomyGastrostomy-Surgical-PEG-RIG-Lap gastrostomyDuodenostomyJejunostomy-Surgical-PEJ-Jej through PEG-Needle catheter jejunostomy-Cuffed tube jej-Subcut jejButtonsPorts 1) Calculate total energy RequirementBasal Metabolic Rate(BMR)- Harris-Benedict equation (kcal/day)Men 66+(13.7x weight (kg))+ (5x Height (cm))- (6.8xage(yr))Female 655+(9.6x weight (kg))+ (1.8x Height (cm))- (4.7xage(yr))Additional factors to add: Stress factor for disease (+13% for every degree rise in body temperature)- Physical activity (+10% for inactive patients)- Growth/ repletion- Dietary induced thermogenesis2) Calculate amino acid requirement:0.15-0.30 gN/kg/dayAdd repletion (0.1 gN per kg weight lost)3) Calculate amino acid energy: gN x 274)Calculate maximum amount of fat allowed (2g fat/kg)5) Calculate CHO energy as: Total energy- (fat energy + amino acid energy)6) Calculate fat: CHO calorie ratio and ensure it is about 40:607) Check safety of derived glucose, amino acid and lipid infusion rates8) Calculate/ estimate volumes of water, sodium, potassium, Mg, Calcium and phosphate Type ComplicationInsertion Nasal damage, intra-cranial insertion, pharyngeal/oesophageal pouch perf. bronchial placement, precipitate variceal bleeding. PEG/PEJ insertions – bleeding, intestinal/colonic perforation.Post insertion trauma Discomfort, erosions, fistulae and strictures.Displacement Tube falls out’, bronchial administration of feedReflux Oesophagitis, aspirationGI intolerance Nausea, bloating, pain, diarrhoeaMetabolic Refeeding syndrome, hyper-glycaemia, fluid overload, electrolyte disturbance. Complica-tionsCatheter RelatedNutritional and MetabolicOrgan Function Infection (Exit site/ Tunnel infection)Thrombosis- thrombinolysis for 48 hours then heparinOcclusion- fibrin or blood thrombus (tx with urokinase lock) or lipid block or amorphous debris (tx with HCl)Mechanical Liver (steatosis/ cholestasis/ cirrhosisGallbladder- sludge and gallstoneIntestine- Bact overgrowth/ Inc permeability/ Microbial translocationImmune- SuppressionRenal- ImpairmentSkeletal- osteoporosis/malacia/ High PTH Feeding Regimes/ Routes Decide When To Give Nutritional Support How to Give What To Give The problems with giving NICE Guidelines on Needing nutritional supportIf.....1. BMI < 18.5 kg/m22. Unitentional weight loss >10% in last 3-6 months3. BMI <20 kg/m2 and unintentional wight loss >5% in last 3-6 months4. Those who have eaten little or nothing for > 5 days or unlikely to eat little or nothing in the next 5 days or longer5. Those with a poor absorptive capacity and/or high nutrient losses and/or increased nutritional needs from causes such as catabolism.Choosing enteral vs parenteral-TPN is indicated for any patient who is not expected to eat sufficiently for 3-5 days in severe malnutrition, 5-7 days in mild or moderate malnutrition, and 7-10 days in well-nourished patientsSurgical patients:Pre-op: 3 days TPN if malnour-ished, 7 days is very malnour-ishedPost-op:Day 1- no feedDay 2 Oral intake at 50% of requirementsDay 3-5 continue to meet 50% intake- if cant at day 5 then TPN Macronutrients GivenCarbohydratesGlucoseFructose and sorbitolXylitolAmino-acidsLipidsSoybean/ sunflower (=triglyceride based)Olive oil containingMCT’s (from coconut oil)n3 fatty acidsLCT and MCTFish oil basedMicronutrients GivenHow to precribeElectrolytes Given Acute deficienciesHypophosHypocalcaemiaHypoglycaemia Chronic deficienciesEFAD-dermatitis, hair loss, delayed wound healing Zinc- dermatitis, depression, diarrhoeaCopper- Neutropoenia and anaemiaChromium- Diabetes, neuropathySelenium- MyopathyWater soluble vits- Anaemia, cardiomo, neuro, encephalopathyFat soluble vits- weak, bleed, night blindMagnesium OverfeedingHyperglycaemiaHyperosmolarHypercapneaSteatosisInc sympathetic activityFluid retentionFat overload syndromeHypercholHyperTGHypercalcaemia Enteral feeding Parenteral Feeding Written by Dr Sebastian Zeki

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