Transcript Small Bowel Obstruction-Medical Nutrition Therapy Case Study

Samira Jones, PhD, MPH
Baptist Health Systems
Dietetic Internship
 Introduction-
Anatomy & Phys of Intestine
 Background-
SBO
 Hospital
Admission- “R.L.” Patient Profile
 Nutrition
Care Process- Pt. LOS in Hospital
 Summary/Conclusions
In adults, the small intestine is 19 ft. (6.5 m) and large intestine
is 4.9 ft. (15 cm).
A blockage in
normal downward
flow of intestinal
contents
 Mechanical Obstruction -
Crohn’s
Disease
7%
*Luminal
*Extramural
Misc.
11%
Adhesions
74%
Neoplasia
5%
Hernia
2%
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Epidemiology- Adhesiolysis accounts for
300,000 hospitalizations; 800,000 days of inpatient
hospital care, and $1.3 billion in healthcare costs
(2006).
Etiology- 75% are caused by post-operative
adhesions and hernia from prior GI surgery.
Pathophysiology- SBO may occur in as many as
15% of laparotomy pts. up to 2 yrs s/p procedure.
• Pts. Have high risk for re-current obstruction of 42% over
10 yrs. More than ½ SBO pts. require surgery with a 5%
mortality rate d/t complications.
 Clinical
Diagnosis
• Ultrasonography
• Intraluminal contrast studies
• CT scan
 Once
SBO is confirmed…
• Laparotomy is performed to differentiate
between simple and complicated obstruction,
severity, and location.
 Three
step approach
• Resuscitation
• Investigation
• Therapy
 Therapy-Treatment
• Lysis of Adhesions
• Bowel resection
 Motility
Agents
• Octreotide
• Metoclopramide
 Stool
softeners, laxatives
 Multiple
Pain Medications
 Carbohydrates-CHO
• Simple CHO rather than complex CHO
 Protein
• Severe malnutrition is rare
 Fats & Fat Soluble Vitamins
• Higher risk of malabsorption
 B-12
• High risk of malabsorption
 Fluids
• Challenging to manage with ostomies
 Electrolytes
• Alleviate Na/K+ imbalances
 NPO-TPN
• Bowel rest
 PO
• Clear Liquid
• Regular Liquid
• Small frequent meals & low fiber
*Individualized
 ADA
Nutrition Care Manual
Recommendations
• Calories: 25-30 kcal/kg IBW
• Protein: 1-1.2 or 1.2-1.4 g/kg IBW
• Fluids: 30 ml/kg or Per MD
 Ileostomy
• Physical placement
• Psychological adjustment
• Diet modification- Fluid and Output tracking
 R.L.
22 y.o., AA male; Adopted by foster
parents at age 2 yrs
• Non-ambulatory: Uses wheelchair
 Med
Hx: Cerebral palsy, Paraplegiamultiple BLE osteotomies for severe
contractures, Hiatal hernia-Nissen
fundoplication s/p 10 yrs, VP shunt s/p
20 yrs
• Prior UCDMC admissions- 3 since 2004
 Admit
date: 5/2/11
• Diagnosis: SBO with large hiatal hernia &
stomach in thoracic cavity (CT scan)
• Signs/Symptoms: PTA
 Pt. screened in from nursing for nausea & vomiting for
> 3 days
 Complained of left/right abdominal pain for several
days
 Poor intake and appetite > 5 days
 Nutrition
Assessment
• Diet order
• Anthropometrics
• Labs
• Diet history
• Estimated needs
 Nutrition
Diagnosis
 Nutrition Intervention- PES statement
 Nutrition Monitoring/Evaluation

Initial Nut Assessment 5/5/11- RD Intern
• Anthropometrics
 Wt.= 71.7 kg (standing scale); Ht= 5’6”=167.6 cm
 IBW= 64.5 kg; %IBW= 111
• Estimated Nutrition needs
 1612-1935 kcal/day
(25-30 kcal/kg IBW)
 64-97 g protein/day
(1.0-1.5 g/kg IBW)

Physical appearance: Abdominal distension

Labs: Na 131 L, Glu 115 H, BUN 2 L, ALT 68 H

Eating hx: Per parents, “pt. had good appetite
and ate typical American diet PTA. He likes
spaghetti, burgers & fries, ice cream, and ‘junk’
food.”
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Diet Order: NPO for GI surgery; TPN- AA 100 g,
Dex 150 g, lipids 20% 250 ml= 1410 kcal @ 58.75
ml/hr
PES: Inadequate oral intake r/t altered GI
function d/t small bowel obstruction, as
evidenced by nausea/vomiting 3 days PTA and
current NPO x 5 days. NI-2.1
Risk: High
Monitoring & Eval: Pt. will begin at 1400 kcal and
advance to goal of 1600 kcal/ml/day as
medically appropriate to meet estimated needs.

Follow-up assessment: RD Intern 5/10/11

Diet order: NPO-TPN 1602 kcal @ 66 ml/hr providing
280 g Dex, 100 g Amino acids, and 28 g Lipid

Labs: Na 131 L, Glu 111 H, BUN 7 L
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PES: Increased nutrient needs r/t altered GI function
as evidenced by pt. currently on TPN because of NPO
> 8 days. NI- 5.1
Risk: High
Monitoring & Eval: Pt. will meet 1000% of estimated
needs at goal TPN rate to preserve LBM while unable
to meet PO nutrition.
9
days post hospital admission: 5/11/11
• Laparospopic Lysis of adhesions
• Hiatal hernia repair
 Checked Fundoplication- Functional
• Bowel Exploration- MD discovered 50 cm of dead
ileum*
 Follow-up
assessment- RD 5/16/11
 Diet
order: NPO-TPN (100 g AA, 280g Dex,
250 ml 20% lipids)= 1852 kcal @ 66.6 ml/hr
(up from 58.4 ml/hr from last assessment)
 Labs: Glu
162 H
 PES: Altered
GI fxn r/t to GI surgery as
evidenced by KUB findings of severe
postoperative ileus. NC-1.4
7
days s/p GI surgery (2)
• Externalization of VP Shunt
9
days s/p GI surgery (3)
• Laparotomy
• Abdominal washout
• End Ileostomy- lower left quadrant



Diet order: NPO-TPN = 100 g of AA, 280 g Dex
and 250 ml of 20% lipids daily = 1852 kcal/d
Labs: Glu, TG, Na, K all WNL; Phosphorus slightly
elevated but pharmacy aware and was
addressing it.
RD recommendations:
• Once GI status permits, Osmolite 1.0 @ 10 ml/hr
advancing 10-20 ml/hr every 6-8 hrs. as tolerated.
Goal= 70 ml/hr, provides 1780 kcals, 75 g protein, 1411 ml
free water; flushes and fluids per MD.
• Taper PN with goal to discontinue as EN increases.
• Modified diet- Low fiber diet once medical status permits.
 Diet
order: NPO-TPN= 100 g of AA, 280 g
Dex and 250 ml of 20% lipids daily, provides
1602 kcals
 Labs: Glu
142 H
 Osteomy
output= 710 ml
 RD recommendations:
• Advancement to low fiber diet once GI status
permits.
• Continue PN, but taper with goal to D/C as PO intake
improves.
• Monitor total energy intake over next 5 days for goal
of 1600 kcals, 77 g protein
 Pt. NG
tube removed
 Diet order: PO diet- Regular, low residue
over 24/48 hrs, and PN at same level
 Output= 1150 ml; 970 ml (1 day prior)
 RD
recommendations:
• Pt. tolerated 100% CL diet and 1 meal of regular
diet w/ no complaints of nausea/vomiting, so PN
recommended to d/c with continual
advancement to PO at adequate level to meet
needs.
 Conversion
of ventriculoperitoneal (VP)
shunt to ventricular atrial (VA) shunt d/t
pt. experiencing hydrocephalus
 Diet
order: PO- Modified puree diet
 Meds: Imodium, Gas-X, Metamucil
 Pt. parents
requested puree diet b/c they
believe pt. would tolerate it better d/t
smoother texture (pt. with poor dentition)
and not completely eating whole foods.
 Output= 550 ml
 RD recommendations:
• Provide Ensure plus TID and supplemental EN if
inadequate nutrition remains b/c pt. meeting ~65%68% of estimated kcal & protein needs from current
PO intake over last 5 days.
 Diet
order: 75-90 g CHO controlled diet
 Pt. parents
provided with Ostomy nutrition
education handout. Parents advised of foods
to avoid like simple CHO and to consume
small, freq meals, and importance of
electrolyte balance and adequate hydration
while pt. has ileostomy.
 Output=
1350 ml
 Pt. weight
status unable to be assessed d/t
shifts in fluid status.
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Diet order: Low fiber, Pediasure TID, snacks
(bananas, white bread PB&J sandwich, tea-BRAT
diet) TID
Wt. 147 # =66.5 kg
Output= 1400 ml
Meds: Protonix, Metamucil, Lomotil, Imodium,
Gas-X
RD rec’d: Pt. will meet at least 70% of est. needs
with current diet. D/C metamucil b/c of its
effects on high ostomy output. Provide MV
supplement and monitor fluids. Ostomy output
should estimate < 1 L per 24 hrs.
 Malnutrition
is common in patients with
partial or complete SBO.
 In
complicated SBO cases, the patient
may end up with an ostomy if part of the
bowel is removed or resected.
 MNT
for SBO has to be individualized
based on the location, type, and severity
of obstruction (partial, complete).
 Several
factors must be considered
before diet advancement is made to
ensure optimal nutrition for the patient.
 Even
when a team is assertive with
delivery of nutrition, the role of the RD is
still crucial to monitor the adequacy of
the intake and appropriateness of the
order.
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Foster NM, McGory ML, Zingmond DS and Ko CY. Small Bowel Obstruction:
A population-based appraisal. Journal of American College of Surgeons,
2006; 203: 170-176.
Agresta F, Piazza A, Michelet I, Bedin N, and Sartori A. Small bowel
obstruction- Laparascopic Approach. Surgical Endoscopy, 2000; 14: 154156.
Miller G, Boman J, Shrier I, and Gordon PH. Etiology of Small Bowel
Obstruction. American Journal of Surgery, 2000; 180:33-36.
Kulaylat MN and Doerr RJ. Small Bowel Obstruction Surgical Treatment:
Evidence- based and Problem-oriented. National Library of Medicine,
National Institutes of Health, 2001: Washington, D.C.
Ihedioha U, Alani A, Modak P, Chong P, and O'Dwyer PJ. Hernias are the
most common cause of strangulation in patients presenting with small bowel
obstruction. Hernia, 2006; 10: 338-340.
Mahan LK and Escott-Stump S. Krause's Food & Nutrition Therapy, 12th
Edition. 2008; copyright Saunders Elsevier, St. Louis, Missouri.