Short Bowel Syndrome/ High Output Stoma. Professor Simon Lal

Transcription

1

2 Short Bowel Syndrome/ High Output Stoma Professor Simon Lal

3 Case History: Background 46 year old female Crohn s disease 1996 Surgical history Right hemicolectomy Panproctocolectomy Small bowel resections x 2 Medical history 5-ASAs/Recurrent Steroids Azathioprine: intolerance Infliximab: anaphylaxis

4 Case History: Background Surgical history Right hemicolectomy Panproctocolectomy Small bowel resections x 2 46 year old female Crohn s disease 1996

5 Case History: Background Surgical history Right hemicolectomy Panproctocolectomy Small bowel resections x 2 46 year old female Crohn s disease 1996 November - December 2013 Ileostomy re-fashioned, complicated SI resection High output stoma Readmitted dehydrated surgeons advised to drink more

6 Case History: EAU year old female, high output stoma Thirst, lethargy, muscle cramps, dizzy Dehydrated. BP 85/50. Stoma output > 2.5 L. Wt = 43kg BMI = 16 Na K Urea Creat Alb CCa Phos Mg CRP <10 FY2 Plan: i.v. saline & i.v. magnesium. Aim for home tomorrow pending repeat bloods. Senior Review.

7 Does she require admission? Will she need long term HPN? SBS Why is her albumin normal? How correct Mg? How optimise fluid balance?

8 Does she require admission? SBS

9 SBS Why is her albumin normal?

10 Case History: Serum Albumin 46 year old female, high output stoma Thirst, lethargy, muscle cramps, dizzy Dehydrated. BP 85/50. Stoma output > 2.5 L. Wt = 43kg BMI = 16 Na K Urea Creat Alb CCa Phos Mg CRP <10 Poor nutritional marker Negative acute phase protein

11 Albumin in protein-calorie malnutrition without inflammation ** Smith G et al, Nutrition 1996;12(10):677.

12 What happened to his albumin?

13 What happened to his albumin?

14 SBS How optimise fluid balance?

15 Case History: Renal Function 46 year old female, high output stoma Thirst, lethargy, muscle cramps, dizzy Dehydrated. BP 85/50. Stoma output > 2.5 L. Wt = 43kg BMI = 16 Na K Urea Creat Alb CCa Phos Mg CRP <10 Dehydration & Renal impairment in SBS 1. Malnourished: Significant renal dysfunction. 2. Recurrent dehydration despite drinking more. Why?

16 A bit of physiology (!).

17 NORMAL: NET ABSORBER DRINK MORE ABSORB MORE SI < ~150cm NET SECRETOR Normal proximal secretion is not compensated by distal absorption DRINK MORE ABSORB LESS Thirst needs less drinking!

18 Fluid & Nutritional Assessment Fluid Nutrition Accurate fluid balance vital Intake Stoma Urine 48 hours NBM Minimal stoma loss. Urine Na best gauge of hydration status Urine sodium < 20mmol dehydration

19 Fluid & Nutritional Assessment Fluid Nutrition Accurate fluid balance vital Intake Stoma Urine 48 hours NBM Minimal stoma loss. Urine Na best gauge of hydration status Assessment Wt, BMI Anthropometry Hand-grip strength Diet history & food charts Dietitian best gauge of nutritional status!

20 SBS Treatment Restrict hypotonic fluid Drink glucose-saline solution < 1L/day ~ 1L/day Drug therapy Anti-motility Anti-secretory Loperamide (up to 16mg QDS) Codeine phosphate (up to 60mg QDS) PPI Stoma ph>5.5?octreotide Nutrition Dietetic Review BSG Guidelines, Gut, 2006 Lal S Alimen Pharm Ther 2006; 24: 19-31

21 SBS Treatment Restrict hypotonic fluid Drink glucose-saline solution < 1L/day ~ 1L/day SI < ~150cm NET SECRETOR Normal proximal secretion is not compensated by distal absorption BSG Guidelines, Gut, 2006 Lal S Alimen Pharm Ther 2006; 24: 19-31

22 SBS Treatment Restrict hypotonic fluid Drink glucose-saline solution < 1L/day ~ 1L/day

23 SBS Treatment Restrict hypotonic fluid Drink glucose-saline solution < 1L/day ~ 1L/day

24 SBS Treatment Restrict hypotonic fluid Drink glucose-saline solution < 1L/day ~ 1L/day Sodium content must be > 90mmol/L to achieve a POSITIVE sodium balance. Rodrigues et al. (1988) Clin Sci;74:69P Nightingale et al (1992) Gut; 33:

25 Oral Rehydration Solutions Na mmol/l K mmol/l Glucose mmol/l Volume ml WHO St Mark s Solution Dioralyte Powerade isotonic (214) sucrose & maltodextrin Powerade isotonic + ½teaspoon NaCl (214) sucrose & maltodextrin Double Strength Dioralyte

26 SBS Treatment Restrict hypotonic fluid Drink glucose-saline solution < 1L/day ~ 1L/day Drug therapy Anti-motility Anti-secretory Loperamide (up to 16mg QDS) Codeine phosphate (up to 60mg QDS) PPI Stoma ph>5.5?octreotide BSG Guidelines, Gut, 2006 Lal S Alimen Pharm Ther 2006; 24: 19-31

27 Sodium balance (mmol/day) Sodium balance Patient with jejunostomy at 100 cm loperamide codeine ORS -25 ORS codeine loperamide & codeine -100 loperamide ranitidine -125 control Nightingale JMD et al. Clin Nutr 1992; 11: 101-5

28 SBS Management Restrict hypotonic fluid Drink glucose-saline solution < 1L/day ~ 1L/day Drug therapy Anti-motility Anti-secretory Loperamide (up to 16mg QDS) Codeine phosphate (up to 60mg QDS) PPI Stoma ph>5.5?octreotide Nutrition Dietetic Review

29 Jejunostomy: recommended diet Nutrient group Amount Note Energy High kcal/kg/day Protein High g N 2 /kg/day (80-100g protein) Fat High Fibre Low

30 SBS Treatment Restrict hypotonic fluid Drink glucose-saline solution < 1L/day ~ 1L/day Drug therapy Anti-motility Anti-secretory Loperamide (up to 16mg QDS) Codeine phosphate (up to 60mg QDS) PPI Stoma ph>5.5?octreotide Nutrition Dietetic Review BSG Guidelines, Gut, 2006 Lal S Alimen Pharm Ther 2006; 24: 19-31

31 How correct Mg? SBS

32 Magnesium 46 year old female, high output stoma Thirst, lethargy, muscle cramps, dizzy Dehydrated. BP 85/50. Stoma output > 2.5 L. Wt = 43kg BMI = 16 Na K Urea Creat Alb CCa Phos Mg CRP <10 FY2 Plan: i.v. saline & i.v. magnesium. Aim for home tomorrow pending repeat bloods. Senior Review.

33 Hypomagnesaemia: Management Intravenous Magnesium Not sustained because rapidly excreted

34 Hypomagnesaemia: Management Intravenous Magnesium Sodium/Water Depletion Oral Magnesium Vitamin D PPI Not sustained because rapidly excreted Correct (reduced 2 0 hyperaldosteronism) Mg Oxide or Aspartate Mg glycerophosphate X Dose titration Vital Intramuscular or high dose oral Rare with chronic use Don t forget

35 Calcium & Potassium 46 year old female, high output stoma Thirst, lethargy, muscle cramps, dizzy Dehydrated. BP 85/50. Stoma output > 2.5 L. Wt = 43kg BMI = 16 Na K Urea Creat Alb CCa Phos Mg CRP <10 Potassium Hyperaldosteronism in chronic Na deficiency Negative K + balance if < 50cm small bowel

36 Will she need long term HPN? SBS

37 Length matters. ~<100cm Small Bowel Parenteral Support Influenced by active disease Influenced by colon in continuity Dibb M et al. APT 37(6):

38 Post-op Small Bowel Length 46 year old female. Crohn s disease 1996 Surgical history Right hemicolectomy Panproctocolectomy Small bowel resections x 3 Adult small bowel 3-8.5m Males > Females Post-op: How much remaining not how much removed!

39 Not enough small bowel = Home Parenteral Nutrition Single lumen, PN Dedicated Tunnelled Catheter hours infusion up to 7 nights per week. Patient or carer: 2-6 weeks training to administer. Home Care nursing teams: adherence to catheter care protocol.

40 Catheter Infection Psychological Venous Thromboisis HPN COMPLICATIONS Metabolic Bone Disease Hepatobiliary Renal Dibb M, Teubner A, Theiss V, Shaffer J, Lal S APT 2013

41 CVC Longevity in Intestinal Failure Repeated catheter loss failed venous access: indication for a small bowel transplant. HPN Survival ITx Survival Ethos of meticulous catheter care. Only access if trained to protocol (unless medical emergency). Dedicated to PN only. No blood sampling. Salford IFU: Lowest sustained CVC infection rate. Longest surviving patient: 34 yrs. Longest CVC: 16 yrs. Dibb M et al APT 37(6): Dibb M et al 2016 JPEN Epub ahead of print

42 Case History: Successful Outcome Op notes (+ contrast study): ~150cm No sign of active Crohn s. Stoma output < 1L, Urine Output >1L ~150 cm <1L hypotonic fluid restriction 1L D.S. Dioralyte Loperamide 32mg Codeine 30mg qds Omeprazole 20mg b.d. Mg Aspartate 1 sachet t.d.s. Vitamin D optimised GP Blood monitoring. Dietetic & Gastro Clinic Follow-up Nutritional progress Crohn s prevention vigilance for recurrence

43 Case History: Successful Outcome Op notes (+ contrast study): ~150cm No sign of active Crohn s. Stoma output < 1L, Urine Output >1L ~150 cm <1L hypotonic fluid restriction 1L D.S. Dioralyte Loperamide 32mg Codeine 30mg qds Omeprazole 20mg b.d. Mg Aspartate 1 sachet t.d.s. Vitamin D optimised GP Blood monitoring. Dietetic & Gastro Clinic Follow-up Nutritional progress Crohn s prevention vigilance for recurrence

44 Will she need long term HPN? Does she require admission? SBS Why is her albumin normal? How correct Mg? How optimise fluid balance?

45 Thank-you