Treatment of intestinal failure: home parenteral nutrition

Abstract

Intestinal failure can result from surgical resection, obstruction, dysmotility, congenital deficiencies or disease-associated loss of absorption. Before the development of intravenous feeding in the late 1960s, the condition was fatal, but by the 1990s approximately 40,000 patients were being successfully managed on long-term home parenteral nutrition (HPN) annually in the US. Survival on HPN depends on the nature of the underlying medical condition: over 80% of Crohn's disease patients survive for 5 years, but only 20% of cancer patients survive for 1 year. Although a patient's nutritional status is easy to maintain, there are serious long-term complications that arise from bypassing the gut and infusing nutrients directly into the systemic circulation. Catheter sepsis occurs about once per year (range 0-12 times). Abnormalities in liver function tests are common, but end-stage liver disease is rare. Central venous thrombosis develops in nearly all patients after 5 years. Although approximately 80% of patients on HPN are completely rehabilitated at home, their quality of life is impaired by the perpetual dependence on nocturnal intravenous infusions (every 8-12 h). In conclusion, HPN has allowed patients with previously fatal intestinal failure to survive and lead relatively normal lives at home, but their quality of life remains impaired by the dependence on intravenous infusions and complications that progress with time.

Parenteral Nutrition and Intestinal Failure

“…Choice of access often depends on the patient and institution, as well as local cost differences between access strategies. PICC lines are easiest to insert and remove, but have higher rates of local complications, malposition, and occlusion and may be preferred for situations where HPN will be required for less than 3–6 months [3,42,43]. Ports may be preferred for cosmetic reasons, but require needle puncture of the skin [43].…”

Management and Complications of Short Bowel Syndrome: an Updated Review

“…Furthermore, antibiotic therapy followed by thiamine repletion corrected this deficit implicating SIBO as a potential mechanism [47]. SIBO is also described in SBS patients [4], and perhaps thiamine deficiency and acute Wernicke's encephalopathy described in both groups of patients have a common etiology. However, it is to be noted that an early peak in breath hydrogen may be more likely a signal of rapid intestinal transit rather than an indicator of SIBO, and therefore, such testing is not recommended in patients with SBS though small studies report utility of this testing [48].…”

“…Loss of bile salts from lack of ileal reabsorption combined with decreased gall bladder emptying induced by reduced oral intake of nutrients and decreased CCK production all serve to promote gallstone formation [4]. Small series of SBS patients suggest that nearly 100 % of patients will develop symptomatic gallstone disease over time, and arguments for prophylactic cholecystectomy have been proposed [80].…”

“…Readers are referred to comprehensive reviews from 2003 [3] and 2006 [4,5] for more extensive background on the development and maturation of the concept of care of This article is part of the Topical Collection on Small Intestine * Robert E. Carroll rcarroll@uic.edu the home PN patient. This review will focus on developments over the last 10 years with the goal of updating the reader to new advances in our understanding of the care and feeding of the SBS patient.…”

The future developments in nutrition

“…This remains rare, with the UK HPN point prevalence reported as 8.4 per million in 2010 9. Crohn's disease is the major cause of type 3 IF, and it is notable that cancer is a smaller indication for HPN in the UK when compared to healthcare practices elsewhere (eg, USA) 16. The reason for this difference is unclear, but it is plausible that the indications for HPN in the UK will change over the next few years, perhaps with an increased prevalence of HPN for patients with active cancer, as has been witnessed in one of the national intestinal failure units (IFUs) in recent years (unpublished observations).…”