Intestinal Failure

Question 1

What is the definition of intestinal failure?

Answer 1

• inability to maintain adequate nutrition or fluid status via the intestines
  => Pt can’t maintain protein-energy, fluid, electrolyte, or micronutrient balance
• Need IV supplementation to maintain health/ growth

Question 2

What are the potential causes of intestinal failure?

Answer 2

• obstruction
• dysmotility
• surgical resection
• congenital defect
• disease associated loss of absorption

Question 3

Describe the difference in time frame between acute and chronic intestinal failure

Answer 3

ACUTE = 2 weeks
CHRONIC = long term (e.g. due to short gut syndrome)

Question 4

There are 3 main types of intestinal failure. Which of these are acute and which are chronic?

Answer 4

Types 1+2 = ACUTE

Type 3 = CHRONIC

Question 5

What is the difference between Type 1 and 2 intestinal failure?

Answer 5

Type 1 = self limiting

Type 2 = significant and prolonged >28 days (requiring parenteral nutrition support)

Question 6

What can cause Type 1 intestinal failure?

Answer 6

• Surgical ileus

GI problems:

• Vomiting
• Dysphagia
• Pancreatitis
• obstruction
• Diarrheoa
• Oncology/Chemo/
• Graft Vs Host Disease

Question 7

What can cause Type 2 Intestinal failure?

Answer 7

Post surgery awaiting reconstruction:

• Crohns
• SMA
• Radiation
• Adhesions
• Fistulae

Question 8

What can cause Type 3 Intestinal failure?

Answer 8

• Short Bowel syndrome
• Crohns (+/-SBS)
• Radiation (+/-SBS)
• Dysmotility
• Malabsorption
• Scleroderma
• Inoperable obstruction (e.g. Cancer)

Question 9

How is Type 1 intestinal failure treated?

Answer 9

• Replace fluid + electrolytes
• Parenteral Nutrition if unable to tolerate oral food/fluids
• Acid Suppression: PPIs
• Octreotide
• Alpha hydroxycholecalciferol to preserve Mg2+
• Allow some diet / enteral feeding

Question 10

Where are Type 2 IF patients usually treated?

Answer 10

• Weeks/months of care in ICU/HDU

- Parenteral +/- some enteral feeding

Question 11

What is the management of choice for chronic IF?

Answer 11

Home parenteral nutrition

Question 12

How long is the small bowel normally and what does this reduce to in short bowel syndrome?

Answer 12

Normal = 250 – 1050 cm
(Males longer than females)

< 200 cm = Short Bowel

Question 13

Below what length of small bowel is an indication for home parenteral nutrition?

Answer 13

< 50 cm of small bowel

Question 14

What can cause patients to have many small sections of bowel removed that eventually results in short bowel syndrome?

Answer 14

• Crohn’s disease (COMMON)

(UNCOMMON)

• post irradiation enteritis
• repeated surgery for surgical complications

Question 15

What can cause patients to need a massive resection of bowel that results in short gut syndrome?

Answer 15

• SMA/SMV infarction
• SMA embolus
• volvulus
• desmoid tumour

Question 16

WHat different types of short bowel exist (due to previous surgical procedures)?

Answer 16

• Jejunostomy
• Ileostomy
• Jejuno- colic anastamosis
• Ileo- colic anastamosis

Question 17

What fluids are used in patients with shorter lengths of bowel, (50-100cm), compared to those with up to 200cm of bowel?

Answer 17

• Saline used for shorter bowel

- Oral glucose/saline solution (OGS) used at longer bowel lengths

Question 18

What different types of venous access can be used to deliver parenteral nutrition?

Answer 18

• Peripheral venous catheter
• Central Line
  => PICC (peripherally inserted central catheter)
  => Tunnelled catheter (Hickman line)
  => Vascuport

Question 19

What are the potential complications of parenteral nutrition?

Answer 19

• Sepsis
• SVC thrombosis
• Line fracture/ leakage/ migration
• Metabolic bone disease
• Nutrient toxicity/insufficiency e.g. Manganese
• Liver disturbance

Question 20

The long term survival of intestinal transplantation in CHRONIC IF is lower than those who receive home parenteral nutrition. TRUE/FALSE?

Answer 20

TRUE

Question 21

What expensive treatment can be used for patients with Short Bowel Syndrome?

Answer 21

Glucagon Like Pepetide-2 (teduglutide)

Question 22

What surgical procedures can be used to lengthen shortened bowel?

Answer 22

Bianchi procedure (longitudinal lengthening)

Serial Transverse Enteroplasty (STEP)

Question 23

Who is involved in a patient’s nutritional support team if they are on home parenteral nutrition?

Answer 23

Dr (gastroenterologist, surgeon)
Specialist Nurse
Dietitian
Pharmacist
Biochemist

Question 24

Small bowel transplantation is usually combined with which other organ transplant?

Answer 24

Liver

Question 25

What are the main indications for a Liver and Small Bowel transplant?

Answer 25

- Loss of venous access | - Liver disease