Intestinal Transplantation

Transcription

1 Release date December, 2006 Authrs Stuart S. Kaufman Gerge V. Mazariegs Jrge D. Reyes Intestinal Transplantatin Facts abut intestinal transplantatin. American Sciety f Transplantatin Cmmerce Parkway, Suite C Munt Laurel, NJ Phne: Fax: ast@ahint.cm The infrmatin presented and pinins expressed herein are thse f the authrs and d nt necessarily represent the views f the Sciety.

2 Intestinal Transplantatin The Nrmal Intestinal Tract The digestive tract breaks fd dwn int small pieces. The bdy absrbs these pieces t create energy. The digestive tract is a hllw tube and is divided int several parts. Each part has a special purpse. These parts are as fllws: The esphagus. This is the tube that mves fd frm the muth int the stmach. The stmach. It mainly stres fd befre it enters the small intestine. The small intestine. This is where mst fd is brken dwn and absrbed int the bdy. The large intestine (r cln). It absrbs the water frm digested fd and frms slid stls. The small intestine is abut 7 t 8 feet lng in newbrn infants and grws t abut 20 feet by adulthd. The small intestine is made up f three parts: The first part is the dudenum, which is abut 12 inches lng in adults. It is cnnected t the stmach. Pancreas and liver (bile) fluids drain int the dudenum. The middle f the small intestine is the jejunum, which makes up abut half f the small intestine. The lwer small intestine is called the ileum. Intestinal Failure The small intestine is the mst imprtant part f the digestive system. Mst peple can live withut a stmach r large intestine, but it is harder t live withut a small intestine. When all r mst f the small intestine has t be remved r stps wrking, nutrients must be put directly int the bld stream (intravenus r IV) in liquid frm. These nutrients are called ttal parenteral nutritin r TPN. When a persn has intestinal failure, they will always need TPN, because the digestive tract will nt get better ver time. Causes f Intestinal Failure There are tw types f intestinal failure: 1. The small intestine may be t shrt t digest fd crrectly. This is called shrt bwel syndrme. 2. The small intestine r ther parts f the digestive tract are nt wrking right. When the intestine is t shrt, a persn may have a lt f bwel mvements. They may nt get enugh nutrients and lse t many bdy fluids. This is why they need TPN. Infants can have intestinal failure fr different reasns than lder children and adults. Causes f shrt bwel syndrme in infants are: Birth defects that require remval f abnrmal intestine. Part f the bwel can die fr n knwn reasn (Necrtizing enterclitis). This is rare, but can happen in infants wh were brn t early. Things that can damage the intestine and cause shrt bwel syndrme in lder persns are: Radiatin treatment fr cancer that is near the intestine Nt enugh bld flw t the intestine because f hardening f the arteries. 2

3 Crhn s disease, an illness that causes damage t the intestine Remval f the intestinal tract because certain stmach tumrs had t be remved When the Digestive Tract Des Nt Wrk Prperly There are tw main reasns the intestine may nt wrk prperly: The inner lining f the intestine is nt wrking. This inner lining is where the pieces f fd are brken dwn even smaller and taken int the bldstream. The ther type f functinal intestinal failure is called pseud-bstructin. The intestine acts as if there is a blckage, but there is nne. It can develp in children r adults. Patients with pseud-bstructin have prblems with bwel mvements and experience severe nausea and vmiting, particularly when they try t eat. What is intestinal transplantatin? Transplantatin is a surgery t put a dnated rgan frm smene wh has died int a persn wh needs it. A part f small intestine can be transplanted int a persn. If needed, ther rgans can be transplanted at the same time. The first time dctrs tried transplanting intestine, it did nt wrk well because the patients immune systems rejected the new intestine. The bdy s immune system prtects it frm disease and freign substances. The bdies f the transplanted patients treated the new intestine as a freign substance. Nw, there are medicatins t help prevent the immune system frm rejecting the transplant. Why wuld smene need an intestinal transplant? Giving nutritin t a persn thrugh their veins (TPN) can cause serius prblems if it needs t be dne fr a lng time. If a persn cannt take TPN and cannt digest fd, they will starve. Sme prblems that can happen with TPN: We d nt knw the reasn, but almst half f peple treated fr a lng time with TPN get prblems with their liver. In sme peple, the liver prblems can be severe r can even cause them t die. TPN has t be given in a very large vein. TPN can damage these large veins and there are nly 6 veins large enugh t use. If all f these are damaged, there is n way t feed the patient, s when three large veins becme damaged, dctrs begin t cnsider an intestinal transplant. Putting TPN int the large veins can cause serius infectins. If this happens a lt, it may be time fr an intestinal transplant. Why are sme peple nt able t have an intestinal transplant? In sme patients, the prblems caused by the transplantatin are nt wrth the benefit. That happens in these situatins: The patient may die frm the surgery because f ther serius illnesses Have tumrs near the intestine that cannt be cmpletely remved Have serius infectins at the time f surgery Have serius prblems with their immune system, including immune deficiency syndrme (AIDS) Because f prblems like these, each patient is checked by a dctr t decide if a transplant wuld be gd fr them. 3

4 Hw is an intestinal transplant dne? Organs used in the transplantatin are called grafts. Intestinal grafts ften cme frm smene wh has died. An intestinal transplant is a difficult prcedure. It is a difficult prcedure because scar tissue frm earlier surgery may make it hard t replace the ld, damaged intestine and because a large amunt f bleeding can happen during the surgery. The part f the riginal intestine that des nt wrk is remved. The surgen usually attaches ne end f the graft t the end f the riginal intestine. Smetimes, the upper end f the graft is cnnected directly t the stmach. If a stmach and intestine are transplanted tgether, the stmach is attached t the esphagus at ne end and the end f the intestine is attached either t the large intestine r, if needed, ges t a hle (stma) leading utside the bdy (a clstmy). Waste that cmes ut f the intestine thrugh the hle ges int a bag (a clstmy bag). After the Surgery Is Dne In many ways, care after an intestinal transplant is the same as after any big peratin. Yu will be given fluids thrugh the veins, gd nutritin t help healing, and antibitics and antiviral drugs t reduce the chance f infectin. Anti-rejectin drugs are given because the immune system naturally tends t attack a transplanted rgan as if it were a dangerus virus r bacteria. Organ rejectin is mst cmmn within the first three t six mnths after transplant. It is imprtant t take the medicatin exactly as the dctr instructs. This helps make sure the transplant wrks and makes it less likely that the patient will get an infectin r ther prblems. Anti-rejectin drugs: The medicines that help yur bdy accept the new intestinal transplant are the same drugs used fr ther transplants. Yur dctr may chse yur medicatin frm many drugs. Sme f these drugs are: Tacrlimus. This ne is used the mst ften. Crticsterids. Antibdies that blck sme f the actin f the immune system. Mycphenlate mfetil (Cellcept ) and sirlimus, als knwn as rapamycin (Rapamune ). Because f the new drugs used tday t help the bdy accept a transplant, mst patients d well with the transplant. Nutritin after the transplant: Yu might be able t begin eating as sn as a few days t tw weeks after surgery Until yu can eat, liquids are given by muth, int yur vein (IV), r feeding tube. TPN may be needed fr a while after surgery, but is decreased as the patient begins t eat. The gal is t have yu able t eat within fur t six weeks after the transplant. Sme patients may need fluid given thrugh the vein fr several mre mnths. Infants wh have never eaten slid fd befre the transplant ften will nt eat well after transplant and may need tube feeding with a liquid diet. Lw-allergy frmulas are used at first because anti-rejectin drugs may cause fd allergies. Slid fd may be added later. Mst fd is easy t digest. Yu may see increased stls (diarrhea) after drinking sweet liquids like juice r after eating fried fds. Eventually, mst pediatric patients can eat r drink milk prducts. 4

5 Testing fr rejectin f the transplant: There is n bld test t determine if rejectin f the intestinal transplant is taking place, and there may nt be symptms when rejectin is just beginning. An instrument called an endscpe is ften used t take samples (bipsies) f the transplanted intestine sn after the peratin. This instrument is passed int the intestine thrugh the stma. Bipsies may be taken weekly r mnthly in the beginning, when the risk f rejectin is highest, and then maybe nce a year after the first year. If the patient als has a liver transplant, bld tests will check fr liver damage and t see if a liver bipsy is needed. If a bipsy des shw rejectin, treatment is started in the hspital, and may include high dses f a crticsterid (methylprednislne) and increased dses f tacrlimus. Mre tests may be dne t see if the cnditin has imprved r if ther medicatins are needed. In a few cases f severe rejectin, the graft may have t be remved and anther transplant perfrmed, but this is rare. Preventin f infectin: The risk f infectin is high after an intestinal transplant. This is because the graft cannt be sterilized (cleaned f all germs) befre it is placed int the patient. Als, the intravenus (IV) tubes in the large veins must be left in place fr a while and can cause infectin. T help decrease the chance f infectin, the patient is given antibitics. The anti-rejectin drugs make sme cmmn virus infectins dangerus t a patient wh has gtten a transplant. Mst Transplant Centers give antiviral drugs fr several weeks r mnths after transplant. Peridic bld tests are als run after transplant t lk fr tw f the cmmn viruses, cytmegalvirus (CMV) and Epstein-Barr Virus (EBV). After the Patient Ges Hme Many f the things that were dne in the hspital must als be checked at hme t make sure the transplant cntinues t functin well. These things include: Checking the patient s vital signs: temperature, heart rate, and bld pressure. A fever r higher heart rate may be an early sign f infectin r nt enugh fluids (dehydratin). Checking the patient s bdy weight Hw much fluid the patient is drinking (r getting by IV) and hw much slid fd the patient is eating. Stl utput. Diarrhea r having less stl utput may be a sign f a serius prblem that needs immediate medical attentin. Intestinal transplantatin is difficult and prblems happen ften. Many Transplant Centers require patients t live near their Transplant Center fr several mnths after surgery. After returning hme, yu can g back t yur regular dctr fr help with what t eat, bld pressure, and fluids. Hwever, mst Transplant Centers prefer t help yu with the antirejectin drugs. The Transplant Center may als make sure tests are dne if there are prblems with the graft. Mst Transplant Centers als want t be tld f any majr change in cnditin, hspitalizatin, r a visit t an Emergency Department. Frequent bld tests are an imprtant part f pst-perative care. Befre returning hme chse a lcal lab fr testing. In the beginning, bld tests are dne nce a week r mre. After a while, testing is dne nce every ne r tw mnths. Test results are sent t the Transplant Center. 5

6 Medicatins at Hme T keep the new part f the intestine healthy, yu must take several drugs at the crrect times. Drugs that are needed are: Anti-rejectin drugs t prevent rejectin f the transplant. Drugs t prevent infectins that are cmmn in patients taking anti-rejectin drugs. Extra nutritin (nutritinal supplements) and medicines are ften needed even if the intestinal transplant is wrking well. Bld thinners t prevent bld clts. Drugs fr high bld pressure. Sme medicatins, particularly anti-rejectin drugs, are taken frever; thers are required fr nly a shrt perid f time after transplant. Anti-rejectin drugs have many side effects. They must be taken exactly as prescribed t be effective. T little medicatin allws the immune system t destry the new intestine. T much medicatin interferes with fighting infectin and causes ther side effects. Taking dses at the wrng time can reduce the drug s effectiveness. After awhile, if there are n signs f rejectin, the patient may be able t take fewer drugs. Hwever, rejectin can still happen even thugh medicatins are taken prperly; in that case mre drug therapy will be needed. The fllwing can be signs f transplant rejectin. If any f these ccur, call the dctr: Diarrhea r increased fluid cming frm the stma Lss f appetite r weight lss Swelling and pain in the abdmen Nausea and vmiting Bld in the fluid cming frm the stma r in the stl Change in clr r appearance f the stma If yu have a fever and n ther illness Swelling r unusual redness f the stma The patient needs tests if any f these things happen. Preventing Infectin at Hme Drugs that prevent rejectin decrease the bdy s ability t fight serius infectins. Yu can prtect yurself after leaving the hspital in several ways: Check yur temperature if yu feel warm. If yu have a fever, swllen lymph glands, cughing, nighttime sweats, r new snring, there may be an infectin and yu shuld ntify yur dctr. Get the bld tests that the dctr rders. Take all the medicatins exactly the way the instructins say. 6

7 Avid getting germs: Avid peple wh have infectins -- especially chicken px, a cld r flu, mnnuclesis (mn), r tuberculsis (TB). Transplant patients wh were arund smene with an infectin shuld tell their Transplant Center dctr right away. Take antibitics befre and after dental wrk r ther types f medical treatments, if yur dctr recmmends it. Wash yur hands very well, especially befre eating, after tuching bjects that carry germs (mney, drknbs, and public telephnes), and after using the bathrm, especially in public restrms. Avid cmpst piles, cnstructin sites, damp hay, and rtting plants, fruits, and vegetables. Wear glves during activities such as gardening. Wear shes when utdrs. Cver yur bdy, including arms and legs, when hiking. Sme vaccines use live virus (pli, tuberculsis, measles) and are bad fr a persn wh is n anti-rejectin drugs. D nt get these vaccines and avid peple wh have recently had any f them. Get tetanus shts as needed (in case f an animal bite r a dirty cut, fr example). Get a flu sht every year. D nt share razrs, tthbrushes, r eating and drinking utensils. Practice safe sex. Use a cndm. Having many sex partners increases the chance f getting an infectin, s it is best t nly have sex with yur lng-term partner r yur spuse. Drink nly treated city r bttled water. If yu are nt sure the water is clean, as the lcal water authrities (phne numbers are listed n the mnthly water bill) r the EPA Safe Water Htline at (800) If yu are arund animals and pets: Avid cntact with animal urine, stl, r vmit, especially bird drppings. Wash hands well after tuching pets. D nt allw huse pets t ram freely utside, especially cats, because they may catch infectins utdrs that they can give t humans. Getting Back int a Nrmal Rutine Sleep. Transplant recipients smetimes develp the urge t sleep during the day and stay awake at night. Avid lng daytime naps; that will make it easier t sleep at night. Regaining Strength. Transplant recipients are ften weak right after transplantatin. Exercise rather than rest is usually the best way t regain strength. If pssible, exercise under the care f a Physical Therapist. Swimming in a chlrinated pl is usually kay after drainage and feeding tubes have been remved and all wunds and tube sites have healed. Mst patients shuld be able t g back t wrk r schl after an intestinal transplant. Driving. Adult intestinal transplant patients are usually able t drive after surgery, but first check with the Transplant Center. Sme medicatins slw reflexes, and reduce yur ability t see r make gd driving decisins. If the dctr says it is kay t drive, fasten yur seatbelt. The seatbelt will nt hurt the intestine transplant. 7

8 Alchl. Mst Transplant Centers advise against drinking alchl after an intestinal transplant. Medical Alert Identificatin. Many Transplant Centers suggest wearing medical alert identificatin, such as a pendant r bracelet sld under the brand name MedicAlert (Tel: r service@medical-id.cm). This kind f ID tells thers abut the transplant if the patient cannt talk. The ID shuld say what the transplant is, fr example, "Intestine Transplant" r "Intestine and Liver Transplant." It shuld als say that the patient is "On Immunsuppressants" (the anti-rejectin drugs) and any ther imprtant medical infrmatin. 8