Transcript File - Christine Bannon

Case Report: Nutritional
Management of Small
Bowel Obstruction
By Christine Bannon
ARAMARK Dietetic Internships
December 14, 2014
Abstract

Purpose: Follow the Nutrition Care Process

Case: 82 yr old female with small bowel obstruction (SBO) who required total
parental nutrition (TPN)

Previous hospital visit for SBO – noninvasive treatment and low fiber

Hospitalized again for SBO secondary to adhesions

PMH: Uterine cancer requiring hysterectomy

TPN, lysis of adhesions, and right partial colectomy

Discharged after 15 days on oral low fiber
Disease Description – Small Bowel
Obstruction

The small intestine is a complex organ that plays a major role in the absorption of nutrients

When contents of the intestine are blocked and unable to pass freely, this is considered a small
bowel obstructions (SBO).

Signs & Symptoms

Abdominal distention

Constipation

Vomiting

Abdominal pain and cramps

Nausea

Diarrhea
Disease Description – Causes

Mechanical - characterized by the
narrowing of the intestinal lumen

Inflammation or trauma to the bowel

Neoplasms

Adhesions (Most common)

Hernias

Volvulus (twisted bowel)

Compression from outside the
intestinal tract

Nonmechanical - factors that
interfere with the muscle action or
innervation of the bowel

Paralytic ileus

Mesenteric embolus or thrombus

Hypokalemia
Evidence-Based Nutrition
Recommendations

Title: Reoperation on the Abdomen Encased in Adhesions

Purpose: To determine the short and long-term outcomes after lysis of
adhesions

Method: 40 patients who had recently undergone lysis of adhesions were
contacted to evaluate the outcome

Results: 1 postoperative death, 24 early complications. 28 out of 31 had
resolved SBO from the surgery

Long-term outcomes: all subjects able to tolerate oral feedings
Evidence-Based Nutrition
Recommendations

Title: Burden of Adhesions in Abdominal & Pelvic Surgery: A Systematic Review
and Metanalysis

Purpose: To estimate the burden of complications associated with abdominal
adhesions

Method: Analysis of 196 papers from PubMed, Embase, and Central which
reported incidences of adhesion related complications

Results: Increase risk of developing a SBO in open abdominal/pelvic surgery.
Adhesive SBO associated with longer hospital stays.
Case Presentation

An 82 year old woman is admitted to the hospital after a night of worsening
abdominal pain, nausea and vomiting.

Patient was recently admitted one month prior for a SBO which was treated
conservatively with no invasive processors. Since then, patient has followed a
low-fiber diet.

Once admitted, patient underwent a series of radiographs to diagnose her with
another SBO and renal failure secondary to dehydration
Nutrition Case Process (NPC):
Assessment

Past Medical History

Hypertension

High cholesterol

Type 2 diabetes mellitus

Hypothyroidism

Arthritis

Fractured spine and coccyx

Osteoporosis

Missing right kidney from birth

Reflux

Constipation

Hysterectomy from uterine cancer which was last treated with radiation in 2005
Food/Nutrition Related History

Lack of appetite for one week prior to admission

Follows a low-fiber diet which was prescribed to her since her last
hospitalization for SBO

Lactose – intolerant

Home medications can be found in Table 1
Nutrition-Focused Physical Findings

No appetite at admission

No identified chewing/swallowing issues with good oral health

Trace bilateral edema in lower extremities

Appeared well nourished

No bowel movement for 2 days prior to admission
Anthropometric Measurements

4’ 9” (57”)

121 pounds (55kg)

BMI of 26.6 = overweight

IBW: 100 pounds

121% of IBW
Biochemical Data, Medical Test, and
Lab
Normal
Patient’s
Procedures
Sodium
Went through a series of
x-rays and radiographs
to confirm SBO
Potassium
diagnosis.
Glucose
 Labs were taken as
followed:
BUN

Creatinine
Magnesium
136-144
133 (L)
Acute Renal
Failure (AFR),
dehydration
3.6-5.1
3.4 (L)
Obstruction
234 (H)
Acute
inflammation
8-20
21 (H)
Dehydration,
hypovolemia
0.6-1.1
2.1 (H)
ARF, dehydration,
inadeq. dietary
protein, reduced
muscle mass
1.9
Indicates wnl
Phosphorous
Albumin
Rationale
Not tested
1.9 (L)
Acute
inflammation
Nutrient Needs

1138-1365 calories

55-69gm of protein

1138-1369ml of fluid

Protein needs are elevated due to:


Moderate protein depletion (Albumin 2.1 -2.7)

Mildly metabolically stressed
Nutritional needs are summarized in Table 2.
ARAMARK Nutrition Status Classification

Moderate nutritional risk (status 3)

4 points: GI obstructions

3 points: Vomiting

3 points: Poor appetite

Total of 10 points

Follow up in 3-5 days
Malnutrition Identification

Malnutrition diagnosed with 2 out of the 6 Characteristics
1.

Intake (fair to poor longer than 1 week)
2.
Weight loss
3.
Loss of muscle mass
4.
Loss of subcutaneous fat
5.
Fluid accumulation
6.
Functional status
Chronic vs. Acute Etiology

Inflammation is chronic and mild-moderate degree vs. inflammation is acute and
severe degree
Malnutrition Identification (cont.)

Malnutrition diagnosed with 2 out of the 6 Characteristics
1.

Intake – Patient reported consuming <75% of her estimated energy needs for
longer than a week
2.
Weight loss
3.
Loss of muscle mass
4.
Loss of subcutaneous fat
5.
Fluid accumulation – edema noted in lower extremities
6.
Functional status
Chronic vs Acute Etiology

Acute due to hypoalbuminemia (1.9)
NCP: Diagnoses

Altered Gastrointestinal Function (NC-1.4) related to small bowel obstruction as
evidenced by abdominal distention, vomiting and lack of bowel movement.

Malnutrition (NI-5.2) related to small bowel obstruction as evidenced by fluid
retention and oral energy intake < 50%-75% for one week.
NCP: Interventions

Medical Interventions

Nasogastric tube was place for suction to prevent further nausea and vomiting

Right Partial Colectomy

Lysis of adhesions

Medications and their rationale the patient was placed on can be found on Table 3.
NCP: Interventions

Nutrition Interventions


Parental Nutrition (ND 2.2)

Day 1 standard formula: 70gm amino acids, 150gm dextrose, 20gm lipid with 10gm zinc,
100mg thiamine, 1 mg folic acid, 500mg vitamin C, 60mg selenium

Provides: 990kcal (22kcal/kg ideal wt), 70gm protein (1.5gm/kg ideal wt)
Justification:

Malnourished

Enteral feeding can not be safely attempted

Nonfunctional gut

TPN expected to be needed for at least 7 days
NCP: Interventions

Additional consults were needed from nephrology due to patient’s acute renal
failure(ARF)diagnosis

Nephrology findings:


ARF was secondary to dehydration
Intervention:

Intravenous fluid needed
NCP: Monitoring and Evaluation

Parenteral nutrition formula (FH-1.3.2.1)


Weight (AD-1.1.2)


Domain: ANTHROPOMETRIC MEASUREMENTS (AD)
Digestive system (mouth to rectum) (bowel function, bowel sounds) (PD-1.1.5)


Domain: FOOD/NUTRITION-RELATED HISTORY (FH)
Domain: NUTRITION-FOCUS PHYSICAL FINDINGS (PD)
Potassium (BD-1.2.7), Magnesium (BD-1.2.8), Phosphorus(BD-1.2.11),
Glucose, casual(BD-1.5.2)

Domain: BIOCHEMICAL DATA, MEDICAL TESTS AND PROCEDURES (BD)
Follow-Ups (F/U)


F/U #1 (11/14)

PES: Inadequate energy intake(NI-1.2) related to small bowel obstruction as evidenced by poor appetite.

Intervention: Parenteral Nutrition/IV Fluids (2.2) when able

Goal: Initiate PN when able

Achievement: PN was started
F/U #2 (11/15)

PES: Inadequate parenteral nutrition infusion (NI-2.7) related to day 1 standard TPN formula as evidenced by
72.5% of energy needs being met.

Intervention: Modify volume of parenteral nutrition (ND-2.2.4), Modify composition of parenteral nutrition(ND2.2.1)

Modified TPN order: 70gm amino acids, 235gm dextrose, 30gm lipid with 10gm zinc, 100mg thiamine, 1 mg folic acid, 500mg
vitamin C, 60mg selenium

Provides: 1380kcal (30kca/kg ideal wt), 70gm protein (1.5gm/ideal wt)

Goal: Meet 50-75% of nutritional needs

Achievement: PN order was modified and 100% of nutritional needs were reached
Follow-Ups (cont.)

F/U #3 (11/16)

PES: Altered nutrition-related laboratory values (phosphorous) (NC-2.2) related to
SBO as evidenced by phosphorus levels of 1.4.

Intervention: Recommend modify composition of parenteral nutrition (ND-2.2.1).
Recommend mineral supplement therapy (phosphorous) (ND-3.2.4.6)

Goal: Meet 50-75% of nutritional needs

Achievement: Phosphorus was repleted. Dextrose was unchanged and serum
glucose remained elevated
Follow-Up (cont.)

F/U #4 (11/17)

PES: Parenteral Nutrition Administration Inconsistent with Needs (NI-2.10) related to SBO as evidenced by
elevated glucose in the 200’s.

Intervention: Recommend modify composition of parenteral nutrition (ND-2.2.1) (decreased dextrose,
increased lipid). Nutrition-Related Medication Management (ND-6) to add 0.15units of insulin/gm of
dextrose.


Modified TPN order: 1800mls total volume, 75ml/hr X 24 hrs. 70gm protein, 200gm dextrose, and 42gm lipid.
Provides: 1380kcal (30kcal/kg ideal wt) and 70gm protein (1.5gm/kg ideal wt)

Goal: Blood Glucose >200

Achievement: PN modified. Additional insulin was added. Blood glucose improving in upper 100’s but
remains elevated.
F/U #5 (11/18)

PES: Impaired nutrient utilization (NC-2.1) related to ileus as evidenced by no bowel movement

Intervention: Continue Parenteral Nutrition/IV Fluids (2.2)

Achievement: PN was continued at recommended rate
Follow-Up (cont.)


F/U #6 (11/20)

PES: Altered Gastrointestinal Function (NC-1.4) related to small bowel obstruction as evidenced by lack of
bowel movement/sound.

Intervention: Continue Parenteral Nutrition/IV Fluids (2.2)

Goal: Meet 50-75% of nutritional needs

Achievement: PN was continued at recommended rate. (+) Hypoactive bowel.
F/U #7 (11/21)

PES: Altered Gastrointestinal Function (NC-1.4) related to small bowel obstruction as evidenced by lack of
bowel movement/sound.

Intervention: Continue Parenteral Nutrition/IV Fluids (2.2)

Goal: Meet 50-75% of nutritional needs

Achievement: PN was continued at recommended rate
Follow-Up (cont.)


F/U #8 (11/22)

PES: Altered Gastrointestinal Function (NC-1.4) related to small bowel obstruction as evidenced by
nausea and lack of bowel movement.

Intervention: Continue Parenteral Nutrition/IV Fluids (2.2)

Goal: Meet 50-75% of nutritional needs

Achievement: PN was continued at recommended rate. Hypoactive bowel sounds heard. Patient begins to
have flatus.
F/U #9 (11/23)

PES: Inadequate oral intake (NI-2.1) related to TPN order as evidenced by clear liquid diet.

Intervention: Begin Clear liquid diet(ND-1.2.8.3) while continuing Parenteral Nutrition/IV Fluids (2.2) at goal
rate.

Achievement: Patient tolerating clear liquids well. Small bowel movement is noted.
Follow-Up (cont.)


F/U #10 (11/24)

PES: Inadequate oral intake (NI-2.1) related to TPN order as evidenced by clear liquid diet.

Intervention: Advance to Full liquid diet (ND-1.2.8.4) when able. Modify rate of parenteral
nutrition (ND-2.2.3) to 40ml/hr.

Goal: Meet 50-75% of nutritional needs.

Achievement: Diet advanced to full liquid diet. TPN rate was reduced.
F/U #11 (11/25)

PES: Inadequate oral intake (NI-2.1) related to TPN order as evidenced by full liquid diet.

Intervention: Advance to General/healthful diet (ND-1.1) when able. Modify rate of
parenteral nutrition (ND-2.2.3) to be discontinued completely.

Goal: Meet 50-75% of nutritional needs.

Achievement: Diet advanced to regular for lunch. TPN order was discontinued.
Discharge Care

No driving X 6 weeks

No lifting/baths

Outpatient F/U in 2 weeks

Wear abdominal binder when out of bed X 2 months

Ice for discomfort

Low-fiber diet
Conclusion

SBO is a serious medical and nutritional concern that can lead to lengthy
hospital stays. Clinicians needs to monitor GI function daily in order to prevent
GI atrophy

TPN plays an essential role in the management of electrolytes and can supply
adequate nutrients when enteral feedings can not be done

Patients should be routinely cautioned on the risk and complications associated
with adhesions before undergoing any abdominal or pelvic surgery
Appendix
Table 1
Medication
Rationale
Tylenol extra strength,
500mg
Pain
Calcium Carbonate,
500mg
Calcium supplement, antacid
Coreg, 6.25mg BID
Beta-blocker for hypertension and heart health
Vitamin D3, 1000units
For osteoporosis
Plavix, 75mg
Blood thinner
Levofloxacin, 250mg
Antibiotic
Levothyroxine, 75mg
Synthetic thyroid hormone for hypothyroidism
Lisinopril, 20mg
ACE inhibitor
Flagyl, 500mg q 8hrs
Antibiotic
Omeprazole, 40mg
Proton pump inhibitor for GI ulcers, heart burn,
GERD
Zofran, 4mg q 6hrs
Nausea, Vomiting
Florastor
Probiotic
Simvastatin, 40mg
Statin
Ambien, 5mg
Gamma-aminobutyric acid for insomnia
Appendix

Table 2
Height
57”
Weight
121#
Anthropometric Data
IBW
IBW%
100#
121%
Nutrient Needs
BMI
24.95
REE
Protein
45.45 kg x 25 kcal/kg = 1138 kcal
45.45 kg x 30 kcal/kg = 1365kcal
45.45kg x 1.2 g/kg = 55 g
45.45 kg x 1.5 g/kg = 69 g
1138-1365 kcal/day
55 – 69 g/day
Appendix

Table 3
Medication
Rationale
Vitamin D3
Bone health
Heparin
Anticoagulant
Sliding Scale Insulin
Control serum glucose
Levothyroxine
Synthetic thyroid hormone for
hypothyroidism
Lopressor
Control high blood pressor
Protonix
Proton-pump inhibitor to
manage reflux
Sodium Chloride flush
Provides additional fluid and
electrolyte balance
Appendix

Table 4
Domain
Problem/Nutrition
Diagnosis
Etiology
Signs/Sympto
ms
Clinical (NC1.4)
Altered
Gastrointestinal
Function
Related to
small bowel
obstruction
As evidenced
by
abdominal
distention,
vomiting and
lack of bowel
movement.
Intake (NI-5.2)
Malnutrition
Related to
small bowel
obstruction
As evidenced
by
fluid retention
and oral energy
intake < 50%75% for one
week.
References

1.
Mahan LK, Escott-Stump S. Krause’s Food & Nutrition Therapy. 13th ed. St.
Louis, MO: Saunders Elsevier; 2011:9-10/306-309.

2.
Kulaylat MN, Doerr RJ. Small Bowel Obstruction – Surgical Treatment.
National Library of Medicine. 2001. http://www.ncbi.nlm.nih.gov/books/NBK6873/ .
Accessed December 14, 2014.

3.
Lucey J. Small Bowel Obstruction. NYU Langone Medical Center.
http://www.med.nyu.edu/content?ChunkIID=96913 . Accessed December 12, 2014.

4.
Harris EA, Kelly AW, Pockaj BA et al. Reoperation on the Abdomen Encased
in Adhesion. The American Journal of Surgery. 2002:184 (6): 499-504. dio:
12488146.

5.
Ten Broek RPG, Issa Y, van Santbrink EJP, et al. Burden of adhesions in
abdominal and pelvic surgery: systematic review and met-analysis. BMJ : British
Medical Journal 2013;347:f5588. doi:10.1136/bmj.f5588.

6.
Width M, Reinhard T. The Clinical Dietitian’s Essential Pocket Guide.
Philadelphia, PA: Lippincott Williams and Wilkins; 2009.
References

7.
ARAMARK Healthcare. Assessment and education policy #2: Nutrition status
classification worksheet. Patient Food Services: Policies and Procedures, Volume
IV; 2007.

8.
White JV, Guenter P, Jensen G et al. Consensus Statement: Academy of
Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition:
Characteristics Recommended for the Identification and Documentation of Adult
Malnutrition (Undernutrition). Journal of Parenteral and Enteral Nutrition. 2012:
36(3): 275-283. DOI: 10.1177/0148607112440285

9.
American Dietetic Association. Pocket Guide for International Dietetics &
Nutrition Terminology (IDNT) Reference Manual. 3rd ed. Chicago, IL. 2011.

10. Bordeianou L, Yeh D. Overview of management of mechanical small bowel
obstruction in adults. UpToDate. http://www.uptodate.com/contents/overview-ofmanagement-of-mechanical-small-bowel-obstruction-in-adults . Accessed
December 7, 2014.