Transcript Intestinal Failure - Acute Medicine Update 11

INTESTINAL FAILURE
Dr Mike Stroud FRCP
Senior Lecturer in Medicine & Nutrition
Consultant Gastroenterologist
Chair British Intestinal Failure Alliance
Intestinal Failure: Definition
The reduction of functioning gut mass to below
the minimum necessary for the absorption of
nutrients and/or water & electrolytes
Fleming & Remington, 1981
Nightingale, 2001
IF
ACUTE
CHRONIC
Partial/complete
Partial/complete
Reversible/irreversible
Reversible/irreversible
Types of Intestinal Failure
Type 1
Type 2
Type 3
SHORT TERM
MEDIUM TERM
LONG TERM
Self-limiting
intestinal failure
Significant &
prolonged PN
support
Chronic IF
(>28 days)
(long term PN
support)
Lal et al. AP&T 2006:24;19-31
INTESTINAL FAILURE
Type 1
• Surgical ileus
• Critical illness
• GI problems
–
–
–
–
–
Vomiting
Dysphagia
Pancreatitis
GI obstruction
Diarrheoa
– Oncology
• Chemo/DXT
• GVHD
Type 2
• Post surgery
awaiting
reconstruction
–
–
–
–
–
–
‘Disaster’
Crohns
SMA
Radiation
Adhesions
Fistulae
•
•
•
•
•
Type 3
Short Bowel
syndrome +/other pathology
Crohns +/-SBS
Radiation+/-SBS
Dysmotility
Malabsorption
– Scleroderma
– CV Immunodef
• Inoperable
obstruction
– Ca
Short Bowel Syndrome
Group
Small intestinal
resections
Massive intestinal
resection
EC fistula
Bypass surgery
Common
Uncommon
Crohn's disease
Post irradiation enteritis
Repeated surgery for
surgical comps
Infarction
(SMA/SMV
thrombosis)
SMA embolus
Massive volvulus
Desmoid tumour
High output
Gastric bypass (obesity)
Types of short-bowel
Jejunostomy
Jejuno- colic
Ileostomy
Ileo- colic
Gastric
emptying
• with
jejunostomy
GI
hormones
•gastrin, CCK,
PYY, GLP-2
Physiological
changes with
SBS
Gastric
secretions
•gastric acid
(hypergastrinaemia)
SB transit
time
• with
jejunostomy
Problems in short-bowel patients
• Nutritional
–
–
–
–
Macro-nutrient and energy deficiencies.
Water and sodium losses
Magnesium/potassium
Vitamin and trace element deficiencies.
• Other
– Bile salt diarrhoea
– Gall stones
– oxalate absorption from colon and renal stones.
– D-lactic acidosis
Length of
remaining
small bowel
>100 cm
No Colon
Colon
Many OK
OK
Vit A, D, E, Vit A, D, E,
K
K
Oral Na
50 – 100 cm
Oral Na
Usually OK
IV Na or Mg (adaptation)
HPN
<50 cm
HPN
? HPN
3
IV nutrition
IV fluid
2
Oral supplements
Intestinal balance (kg/d)
1
0
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
Jejunal length (m)
-1
-2
-3
r = 0.96
p <0.001
-4
-5
Nightingale, 1990
Variability of intestinal length
Technique
Author
Autopsy
Bryant, 1924
Laparotomy
n
Small intestinal length (m)
Mean
Range
3.0-8.5
Cook, 1974
6
421
3.2-5.2
Backman, 1974
32
643
4.0-8.5
Slater, 1991
38
500
3.0-7.8
Citrulline
Permanent IF
Transient IF
95% positive predictive value
in distinguishing transient
from permanent IF
Crenn P et al. Gastroenterology 2000; 119: 1496-1505
Salt and water in SBS
600
r = 0.96
p <0.001
Na output (mmol)
500
400
300
IV nutrition
IV fluid
oral supplements
200
100
0
0
1
2
3
4
5
6
7
8
9
Intestinal output (kg)
Nightingale, 1990
Potassium & magnesium
Potassium
• Negative K balance when
jejunum <50 cm
• Hyperaldosteronism in
chronic Na deficiency
Magnesium
• Deficiency is common
– 40% jejunum-colon pts
– 70% jejunostomy pts
• No correlation between Mg
balance & jejunal length
Treatment: High Output State
Drink little hypotonic fluid
Maximum 1L/day
Drink a glucose-saline solution Maximum 1L/day
Antimotility
Drug therapy
Antisecretory
Loperamide (up to 32mg QDS)
Codeine phosphate (up to 60mg QDS)
Omeprazole (40mg BD)
?Octreotide (50µg BD)
Magnesium supplements
Magnesium oxide
Vitamin D
Nutrition
Low residue diet
Jejunum
Hypotonic fluids
Water, tea, coffee, fizzy drinks, soup
Jejunal mucosa
Unable to maintain a Na
gradient >30-40mmol/L
Na
Jejunum
Decreasing fluid losses & increasing absorption
Electrolyte Mix
100mmol/l Na
Na+ + H20
X
Na
Sodium balance
Patient with jejunostomy at 100 cm
Sodium balance (mmol/day)
50
loperamide
codeine
electrolyte
25
0
electrolyte
-25
-50
codeine
loperamide
& codeine
-75
loperamide
-100
-125
ranitidine
control
Nightingale JMD et al. Clin Nutr 1992; 11: 101-5
E-mix recipe
Ingredient
Amount
Note
Glucose
20g
6 teaspoons
Salt
3.5g
1 level 5ml teaspoon
Sodium bicarbonate
2.5g
1 heaped 2.5ml teaspoon
Stir into 1L water & chill overnight: enjoy the next day!
Parenteral fluids  nutrition
• Fluid & nutrition requirements are best
considered separately
• “Standard IVN” bags will not be sufficient
• Bags need to be tailored to requirements
• Requirements alter daily until steady state
Random urine Na: best measure of depletion
Recommended diet
Jejunostomy patients
Nutrient group Amount
Note
Energy
High
30-60 kcal/kg/day
Protein
High
0.2-0.25g N2/kg/day (80-100g protein)
Fat
High
Fibre
Low
Jejunocolic anastomosis
Nutrient group Amount
Note
Energy
High
30-60 kcal/kg/day
Protein
High
0.2-0.25g N2/kg/day (80-100g protein)
Fat
Low/moderate
according to degree of steatorrhoea
Fibre
Moderate/high
Oxalate
Low
Enteral feeding
X
Avoid elemental diets
• high osmolality (small molecules)
• low macronutrient & Na+ content
• high volume required to meet requirements
• No benefit over polymeric & will increase output
Oral nutrition + supplements (? With
added Na)
Aim
Maximise
macronutrients
& electrolytes
Sometimes enteral nutrition useful
• Usually supplementary overnight enteral feed
• Occasionally impaired swallow
Minimise
volume
Maximising GI function
Fistuloclysis & enteroclysis
• Infusion of feed into distal limb of ECF or loop stoma
• Promotes intestinal adaptation before reconstructive
surgery?
• Can replace IVN in selected patients
Lifelong HPN
Some patients can manage a good quality of life
Full time work
Holiday
Challenge
Manchester to London canoe
Surgical approaches
Restorative
surgery
Fistula repair
Restore
intestinal
continuity
Intestinal
lengthening
Intestinal
transplantation
Bianchi
technique
Small bowel
± colon
STEP
Other
abdominal
organs
+/Abdominal
wall
Intestinal lengthening
Bianchi technique
STEP
Serial Transverse EnteroPlasty
Liver
No liver
Glucagon-like Peptide 2
Naturally occurring 33 AA peptide
Production
Release
Receptors
Action
Intestinal L cells (ileum & colon)
stimulated by luminal nutrition
Mainly in jejunum & proximal ileum
Strong intestinotrophic properties
 Mucosal proliferation
 Nutrient absorption
 Intestinal perfusion
 Cytoprotection
 Bone density
>=20% reduction in HPN requirements
Teduglutide in HPN Patients
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
16/35
8/32
1/16
Low dose (0.05mg/kg/day)
High dose (0.1mg/kg/day)
Placebo
30
Jeppesen et al, Gut 2011:60(7):902-914
Summary
Understand the basic physiology
• Makes the management easy / possible
Multidisciplinary approach essential
• Medications, diet, fluid intake
• Stoma care crucial
• Psychological issues should not be overlooked
Optimise medical treatments
• Including PN were needed
Surgical approaches
• Assess if any bowel can be brought back into continuity
Long term outcome
• Balance life expectancy with quality of life for that patient
• Know your patients well to give them the best advice
Regional HPN &
IF Networks
IF in Southampton
•
Southampton has had NST for >25 years started
by Prof Alan Jackson
•
Long record (>20 yrs) as a regional centre for Type
3 HPN patients
•
Increasing number of specialist Type 2 referrals
since appointment of Andy King April 09
•
Specific 12 bedded IFU since Apr 2010
•
First Independent AHP PN prescribers in the UK
(2007 with published audit confirming excellent
outcomes which won National GSK Advanced
Practice Award
The UHS Intestinal Failure Unit
Opened April 2010
• 12 bed on Ward E8 within regional HPB surgical unit
• Adjacent to Surgical High Care
• IFU supported by extended multi-disciplinary healthcare team
• Majority Type 2/3 IF on IFU but no side rooms
• Some patients looked after in specialized areas e.g BM Tx/ITU
• IFU Nurse: patient ratio 1.25 wte nurses per bed
– 6 trained +2 assistants on an early shift
– 6 trained +1 assistant on a late shift
– 3 trained +2 assistants on a night.
NSIFT - Standards of in Hospital
Practice
2010: <20% good practice
UHS PN practice
2012/13
NSIFT involved in 99.6% of 427 patients
PN use in 66% and oral enteral in 33%
Catheter Related Sepsis
• Following opening of IFU protocols developed for Ix and Rx of CRS in
conjunction with microbiology.
• All cases of pyrexia in patients on PN are investigated
• Cases of infection in IF patients managed in conjunction with Microbiology
which provides daily consultant-led clinical ward rounds (lead IF micro
consultant Dr Adriana Basarab)
•
24 hour consultant microbiology on-call service with on-site specialist
laboratory service.
• All cases audited within monthly ‘Root-Cause’ process.
UHS Catheter Related Sepsis
Historical
(cases/1000 PN
days)
IFU
(cases/1000 PN
days)
Non-IFU
(cases/1000 PN
days)
2010-11
3.64
5.52
2011 – 12
1.28
8.06
2012 - 13
0.98
6.35
2005 - 08
10.01
HPN patients
Bath - 1
Bristol - 1
Reading - 2
Basingstoke - 6
Southampton - 34
Winchester - 3
Poole - 6
Worthing - 2
Chichester - 3
Dorchester - 2
Bournemouth - 8
IOW - 4
Portsmouth - 2
HPN Patients outcomes UKDDF 2012
Excellent quality outcomes
– CRS 1.42 per 1000 patient days
– catheter occlusion 0.31 per 1000
patient days.
60
Number of patients
50
40
30
Type 3 IF
Type 2 IF
20
10
0
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Year
IF outpatient clinics
•
Weekly MDT clinic for Type 2 and 3 IF patients
>10 years with joint med/surg review since 2009
•
Ad-hoc day-case review for urgent cases
(although lack clinical examination/procedure
room)
•
Paediatric IBD/IF Transition clinic with Mark
Beattie (President of BSPGHAN) every 6 months
•
Joint small bowel transplant assessment clinics
with Oxford (Prof Peter Friend + Mr Anil Vaidja)
every 6 months (2 x transplants)
•
Monthly OP clinic at Royal Bournemouth
Hospital for Dorset IF patients
•
Planning outreach clinic to serve Sussex patients
if designated
IF Regional out-patient experience
published in 2010
‘The value of multidisciplinary
nutritional gastroenterology clinics for
intestinal failure and other
gastrointestinal patients’ Frontline
Gastroenterology 2010; 1:178-181
Surgery for Intestinal Failure
• 44 patients over the 3 years
• 65% of patients were from the surrounding region
• Complex referrals:
• 30 enterocutaneous fistulae
• Of which 19 had laparostomies
• In 22 cases other organs were involved
•
•
•
•
5 urology
5 pancreatico-biliary
4 gastro-oesophageal
8 colorectal
Surgical Complexity
• 12 patients required
interventional
radiology placement
of large bore drains in
the acute phase of
their illness to drain
sepsis
• 19 patients had had 3
laparotomies or more in the 3
months prior to transfer
• 5 patients had
radiation enteritis
Surgery - Outcomes
• No in-hospital or 1-year mortality
• 1 patient (2.2%) unexpected return to ICU
• 0f 30 patients who were TPN dependant 29 of
patients are free of TPN (97%).
• 1 patient (3.3%) re-fistulated - this resolved
spontaneously
SHIFNET
The Southern Home Intestinal Failure Network
Northampton
Milton Keynes
Oxford
Bucks Trust
London
Stoke Newington
Reading
Bath
Slough
Swindon
Basingstoke
Salisbury
Winchester
Southampton
Dorchester
Portsmouth Chichester
Poole
Bournemouth
St Mary’s
Worthing
Better Patient Care
Shared protocols
Clinical Governance
Standardised audit
Education
Communication
Website
Type 3 Intestinal Failure
Case Presentation
Dr Trevor Smith
Nutrition Support & IF Team
University Hospital Southampton
Case Presentation
• 2004
• 22 year old male
• Presented with life threatening acute
abdomen
• SMA infarct
• Emergency laparotomy at local hospital
“Cut and Shut ?”
• Extensive intestinal
ischaemia
• Extensive SB and
colonic resection
• End Jejunostomy 20cm
from DJ flexure
• Mucous fistulae to
‘50cm’ colon
• Discharged home after long admission, including
ITU with multi-organ failure
Medical Issues: 2004-2008
• High stomal losses (5-6 l/day)
– Limited oral intake
– Antisecretory and antimotility agents
– Dietary manipulation
• 6 litre iv fluid requirement
– 4 litres PN & 2 litres 0.9% saline
– 555 mmol sodium per day
• Weight stable at 67kg
– BMI 20
– Unable to gain weight; physically very weak
Medical Issues: 2004-2006
• Behavioural problems
– Depressed/socially isolated
– Psychiatry review in UHS and community
– ?related to cerebral damage during critical illness
• Recurrent line infections
– Multiple interruptions to nutrition
• IFALD
– ALT 72; ALP414; Bili 10
• Osteoporosis
Therapeutic options considered
• Intestinal lengthening procedure
– Only 20cm of jejunum therefore not possible
• Intestinal transplantation assessment
– Assessed in Cambridge
– Turned down because of mental health issues
Therapeutic interventions in
Southampton
• Taurolidine line locks
– Significant reduction in admissions for line sepsis
Taurolidine significantly reduces the
incidence of catheter related blood stream
infections in patients on home parenteral
nutrition.
J Saunders, M Naghibi, T Smith, A King, Z Leach
and M Stroud
Southampton NIHR Biomedical Research Centre,
Southampton General Hospital, Southampton, UK.
Southampton indications for taurolidine
Results
*per 1000 patient days HPN
Therapeutic interventions in
Southampton
• Taurolidine line locks
– Significant reduction in admissions for line sepsis
• Reconstructive surgery
– Re-anastamosis of jejunum to remaining colon
– 20cm + 50cm colon
– High risk of intractable diarrhoea
– Distal colostomy considered
Surgery in 2008
•
•
•
•
4 years after initial event
Anastamosed 20 cm of jejunum to 30cm of colon
End sigmoid colostomy
Uneventful recovery
– 12 days in hospital
– HPN dependent
• IF team not very optimistic that surgery would
radically change prognosis:
– nutritional balance, line complications, liver
Life after surgery: 2009
• Stoma losses ↓ >50%
• IV fluids requirements ↓ to 4.1L per day
• LFTs normalised
• Weight gain
– no change to PN protein/energy
• Functional improvement
• Huge improvement in QOL
Results
Date
June
2006
May 07
Weight
(kg)
67.5
67.7
BMI
20.8
Fluid
input
(litres)
July 2009
Jan 2010
66.9
70.5
75
20.8
20.6
21.8
23.1
6.1
6.1
6.1
4.1
4.1
Stoma
output
(litres)
5-6
5-6
3.5
2.5
2
ALT iu/l
72
67
14
16
23
ALP iu/l
414
152
94
96
104
Bil mmol/l
10
14
10
8
11
10-57
-
-
85
Urine Na 10-78
mmol/l
Nov
08 Jan 2009
Surgery
Mechanisms underlying the benefits of
jejuno-colic anastamosis
• Improved sodium & water resorption
• Decreases in hyperaldersteronism
– ↓ urinary potassium losses
– ↑ potassium availability to form lean body mass
• Adaptive small bowel changes
– GLP2 peptide from colon
– ↑ absorptive capacity
• Reduced small bowel transit times
– Peptide YY acting as a ‘colonic brake’
• Nitrogen & energy recovery by the rejoined colonic
segment
Progress in 2009
• Clinically and subjectively much improved
• Transplant assessment
– Reviewed in joint clinic in Southampton
– Admitted for assessment in Oxford
– Deemed unnecessary
– But, why did he have a mesenteric infarct?
Patent Foramen Ovale
Current health 2010-2014
• HPN dependent, but rarely uses saline
• Eating, with manageable stomal losses
• Maintains healthy weight
• Decreased line infections
– fewer connections and taurolidine
– Last admission for CRS May 2012 after fighting......
• Better quality of life
– Time off IV infusions
– Expert in poisonous snakes and spiders!!
• Has avoided transplantation
Current health 2010-2014
• LFTs – normal
• Micronutrient screen – normal
• Bone health
– Osteoporosis treated with IV Zolendronic acid
– T score now -1.8
– T score -2.7 in 2006
• Mental health
– Stable, with easy access to CMH team