Continuous enteral nutrition during the early adaptive stage of the short bowel syndrome

Abstract

Sixty-two patients with the short bowel syndrome (30-150 cm) were managed by continuous enteral nutrition (CEN) in the early adaptive phase. In all, 82 per cent were referrals from other units and 85 per cent of referrals had failure of one or more organ systems on admission. There were intra-abdominal abscesses in 41 per cent of patients and 37 per cent had an enterocutaneous fistula. The diet included polysaccharides, medium chain triglycerides and protein hydrolysates, mixed with a high-viscosity tapioca suspension. An elemental diet was used initially in 15 per cent of patients. Thirty-three patients had an interruption of the gastrointestinal tract by a temporary enterostomy. Chyme was re-infused into the distal intestine in 20 cases. 'Zero-time' was taken as the time of operation or, for referred patients treated conservatively, the date of admission. CEN was commenced at a mean of 14 days from zero-time. Total parenteral nutrition could be discontinued at a mean of 36 days and exclusive oral alimentation was resumed at a mean of 87 days. Patients with small bowel longer than 80 cm attained enteral autonomy earlier than patients with a shorter length. Mean faecal volume did not increase following institution of CEN, suggesting tolerance to the high-viscosity diet. In cases with re-infusion of enteric content, the distal circuit (length of distal small intestine 46 cm) was able to absorb 70 per cent of the volume re-infused (mean volume 2700 ml). Body weight and nutritional markers increased significantly during the course of CEN. This study suggests that enteral autonomy can be attained early in the short bowel syndrome, even under challenging conditions. Elemental formulae do not appear to offer a benefit over polymeric diets.

Nutrient intake from habitual oral diet in patients with severe short bowel syndrome living in the southeastern United States

“…High-fat diets in these patients increase losses of fluid and nitrogen, and result in higher fecal loss of energy (22,24). SBS patients without residual colon do not generally respond to a fat-restricted diet with decreased diarrhea volume; a more liberal use of dietary fat is important in these individual for adequate enteral caloric intake during PN weaning (7)(8)(21)(22). In patients with jejuno-or ileostomies high carbohydrate intake, especially simple sugars, worsen stomal effluents, whereas high-fat diets may increase ostomy fat loss but improve total energy absorption (21,25).…”

“…SBS patients without residual colon do not generally respond to a fat-restricted diet with decreased diarrhea volume; a more liberal use of dietary fat is important in these individual for adequate enteral caloric intake during PN weaning (7)(8)(21)(22). In patients with jejuno-or ileostomies high carbohydrate intake, especially simple sugars, worsen stomal effluents, whereas high-fat diets may increase ostomy fat loss but improve total energy absorption (21,25). Sipping of near-isotonic oral re-hydration fluids with a high content of sodium is essential in patients with jejunostomies, whereas patients with colon and ileostomies may tolerate hypotonic solutions as and additional sodium chloride added to food (2,8).…”

“…These and other as yet unrecognized effects of luminal food may enhance adaptive growth of residual bowel mucosa and ultimately decrease the need for PN in human SBS. Unfortunately, little data are available on the effects of diet on adaptive intestinal mucosal growth in human SBS (10,13,16,20,21). With regard to the effects of PN, one study showed that use of PN without enteral food in healthy adults induced small bowel mucosal atrophy that was reversed by enteral tube feeding (19).…”

“…A small case series in PN-dependent patients demonstrated small bowel villus atrophy during PN alone that was also reversed after a period of enteral refeeding (20). Levy et al showed that continuous in-patient enteral feeding (by tube and oral food) for several weeks immediately after massive small bowel resection in children and adults clinically enhanced gut adaptation as manifested by PN dependence (21). These studies demonstrate that small bowel mucosal growth and/or function in the human intestine, as in animal models, is dependent upon food in the intestinal lumen.…”

Short Bowel Syndrome

“…However, in seven patients with an end -jejunostomy, energy, carbohydrate, nitrogen, fat, electrolyte, fl uid, and mineral absorption, as well as stool weight, were similar regardless of whether a peptide -based enteral formula was provided. Based on this experience, the utility of peptide -based diets is largely without merit [21,22] .…”