Definition and Types of Intestinal Failure · Definition and Types of Intestinal Failure . Jeremy...
Transcript of Definition and Types of Intestinal Failure · Definition and Types of Intestinal Failure . Jeremy...
![Page 1: Definition and Types of Intestinal Failure · Definition and Types of Intestinal Failure . Jeremy Nightingale . Consultant Gastroenterologist . St Mark’s Hospital . Intestinal Failure](https://reader033.fdocuments.us/reader033/viewer/2022041417/5e1c54d6e5778b52071b1332/html5/thumbnails/1.jpg)
Definition and Types of Intestinal Failure
Jeremy Nightingale Consultant Gastroenterologist
St Mark’s Hospital
![Page 2: Definition and Types of Intestinal Failure · Definition and Types of Intestinal Failure . Jeremy Nightingale . Consultant Gastroenterologist . St Mark’s Hospital . Intestinal Failure](https://reader033.fdocuments.us/reader033/viewer/2022041417/5e1c54d6e5778b52071b1332/html5/thumbnails/2.jpg)
Intestinal Failure - Definitions Reduction in functioning gut mass below the minimum amount necessary for adequate digestion and absorption of nutrients
Fleming CR and Remington M 1981
The reduction of gut function below the minimum necessary for the absorption of macronutrients and / or water and electrolytes,
such that intravenous supplementation is required to maintain health and / or growth
Pironi L et al 2014
Reduced intestinal absorption so that macronutrient and / or water and electrolyte supplements are needed to maintain health and /
or growth. Nightingale JMD 2001
![Page 3: Definition and Types of Intestinal Failure · Definition and Types of Intestinal Failure . Jeremy Nightingale . Consultant Gastroenterologist . St Mark’s Hospital . Intestinal Failure](https://reader033.fdocuments.us/reader033/viewer/2022041417/5e1c54d6e5778b52071b1332/html5/thumbnails/3.jpg)
Intestinal Failure
Reduced intestinal absorption causing malnutrition and / or dehydration
![Page 4: Definition and Types of Intestinal Failure · Definition and Types of Intestinal Failure . Jeremy Nightingale . Consultant Gastroenterologist . St Mark’s Hospital . Intestinal Failure](https://reader033.fdocuments.us/reader033/viewer/2022041417/5e1c54d6e5778b52071b1332/html5/thumbnails/4.jpg)
Problem
Intestinal Failure
Consequences
Treatment
Absorption • Short • Non-functioning • Obstructed • Leaking • Mucosal disease
Water and salt Nutrition
Undernutrition Dehydration
+/-
![Page 5: Definition and Types of Intestinal Failure · Definition and Types of Intestinal Failure . Jeremy Nightingale . Consultant Gastroenterologist . St Mark’s Hospital . Intestinal Failure](https://reader033.fdocuments.us/reader033/viewer/2022041417/5e1c54d6e5778b52071b1332/html5/thumbnails/5.jpg)
Fluid Balance Problems – only!
![Page 6: Definition and Types of Intestinal Failure · Definition and Types of Intestinal Failure . Jeremy Nightingale . Consultant Gastroenterologist . St Mark’s Hospital . Intestinal Failure](https://reader033.fdocuments.us/reader033/viewer/2022041417/5e1c54d6e5778b52071b1332/html5/thumbnails/6.jpg)
How do you assess the severity of intestinal failure?
![Page 7: Definition and Types of Intestinal Failure · Definition and Types of Intestinal Failure . Jeremy Nightingale . Consultant Gastroenterologist . St Mark’s Hospital . Intestinal Failure](https://reader033.fdocuments.us/reader033/viewer/2022041417/5e1c54d6e5778b52071b1332/html5/thumbnails/7.jpg)
Citrulline Crenn P et al. Gastroenterology 2000; 119: 1496-1505
![Page 8: Definition and Types of Intestinal Failure · Definition and Types of Intestinal Failure . Jeremy Nightingale . Consultant Gastroenterologist . St Mark’s Hospital . Intestinal Failure](https://reader033.fdocuments.us/reader033/viewer/2022041417/5e1c54d6e5778b52071b1332/html5/thumbnails/8.jpg)
Severity of Intestinal Failure
nutrition water / electrolyte Severe parenteral parenteral Moderate enteral enteral Mild oral supplements oral glucose / saline dietary adjustments sodium chloride
![Page 9: Definition and Types of Intestinal Failure · Definition and Types of Intestinal Failure . Jeremy Nightingale . Consultant Gastroenterologist . St Mark’s Hospital . Intestinal Failure](https://reader033.fdocuments.us/reader033/viewer/2022041417/5e1c54d6e5778b52071b1332/html5/thumbnails/9.jpg)
What are the causes of intestinal failure?
![Page 10: Definition and Types of Intestinal Failure · Definition and Types of Intestinal Failure . Jeremy Nightingale . Consultant Gastroenterologist . St Mark’s Hospital . Intestinal Failure](https://reader033.fdocuments.us/reader033/viewer/2022041417/5e1c54d6e5778b52071b1332/html5/thumbnails/10.jpg)
INTESTINAL FAILURE Specialist IF and HPN services (adult) definition no 12
ACUTE CHRONIC
Fistula / Obstruction
Dysfunction Short bowel Gut bypass
Dysmotility Jejunum-colon Jejunostomy Enteritis Enteritis
Dysfunction
Chemotherapy Infection Irradiation Crohn’s disease
Ileus
Type 1 Short-term
Type 3 Long-term
Type 2 Medium-term
![Page 11: Definition and Types of Intestinal Failure · Definition and Types of Intestinal Failure . Jeremy Nightingale . Consultant Gastroenterologist . St Mark’s Hospital . Intestinal Failure](https://reader033.fdocuments.us/reader033/viewer/2022041417/5e1c54d6e5778b52071b1332/html5/thumbnails/11.jpg)
INTESTINAL DYSMOTILITY
Obstruction Psychosocial Narcotic Bowel Syndrome Anorexia nervosa
IBS SMA syndrome
Opiates Undernutrition
Myopathy Neuropathy
Primary Hollow visceral myopathy
Jejunal diverticulosis
Secondary Systemic sclerosis
Ehlers-Danlos Syndrome Amyloid, Irradiation Muscular diseases
Primary Hirschprung’s Autoimmune
Infective
Secondary Neurological diseases
Paraneoplastic (Thymoma) MNGIE Drugs
![Page 12: Definition and Types of Intestinal Failure · Definition and Types of Intestinal Failure . Jeremy Nightingale . Consultant Gastroenterologist . St Mark’s Hospital . Intestinal Failure](https://reader033.fdocuments.us/reader033/viewer/2022041417/5e1c54d6e5778b52071b1332/html5/thumbnails/12.jpg)
Severe Intestinal Failure in 117 In-patients Kennedy JF et al. Clin Nutr 2002; 21 (suppl 1): 35
n (%) Short term - Type 1 Ileus 17 (15) Chemotherapy / GVHD 12 (10) HIV 4 (3) Medium term - Type 2 Fistula / anastomotic leak 35 (30) Small bowel obstruction 28 (24) Long term - Type 3 High output stoma / short bowel 18 (15) Other 3 (3)
![Page 13: Definition and Types of Intestinal Failure · Definition and Types of Intestinal Failure . Jeremy Nightingale . Consultant Gastroenterologist . St Mark’s Hospital . Intestinal Failure](https://reader033.fdocuments.us/reader033/viewer/2022041417/5e1c54d6e5778b52071b1332/html5/thumbnails/13.jpg)
The Lennard - Jones Intestinal Failure Unit St Mark’s Hospital
Dedicated ward of 20 beds. Funded by NHS England (nationally commissioned service)
![Page 14: Definition and Types of Intestinal Failure · Definition and Types of Intestinal Failure . Jeremy Nightingale . Consultant Gastroenterologist . St Mark’s Hospital . Intestinal Failure](https://reader033.fdocuments.us/reader033/viewer/2022041417/5e1c54d6e5778b52071b1332/html5/thumbnails/14.jpg)
Reasons for Referral to an Intestinal Failure Unit
Ischaemia Surgical
Complications Crohn’s Disease
![Page 15: Definition and Types of Intestinal Failure · Definition and Types of Intestinal Failure . Jeremy Nightingale . Consultant Gastroenterologist . St Mark’s Hospital . Intestinal Failure](https://reader033.fdocuments.us/reader033/viewer/2022041417/5e1c54d6e5778b52071b1332/html5/thumbnails/15.jpg)
Aetiology of New Patients Admitted to Intestinal Failure Units 2014 - 15
0
5
10
15
20
25
30
35
40
45Salford St Mark's
![Page 16: Definition and Types of Intestinal Failure · Definition and Types of Intestinal Failure . Jeremy Nightingale . Consultant Gastroenterologist . St Mark’s Hospital . Intestinal Failure](https://reader033.fdocuments.us/reader033/viewer/2022041417/5e1c54d6e5778b52071b1332/html5/thumbnails/16.jpg)
Typical Acute Intestinal Failure Patient (Type 1 – Short-term)
5 - 14 days post laparotomy Increasing oedema (albumin 15 g/l) High nasogastric aspirates
![Page 17: Definition and Types of Intestinal Failure · Definition and Types of Intestinal Failure . Jeremy Nightingale . Consultant Gastroenterologist . St Mark’s Hospital . Intestinal Failure](https://reader033.fdocuments.us/reader033/viewer/2022041417/5e1c54d6e5778b52071b1332/html5/thumbnails/17.jpg)
Post Operative Dysmotility (“Ileus”)
• Fluid / electrolytes - excess
• Sepsis
• Drugs - opiates
• Surgical techniques
![Page 18: Definition and Types of Intestinal Failure · Definition and Types of Intestinal Failure . Jeremy Nightingale . Consultant Gastroenterologist . St Mark’s Hospital . Intestinal Failure](https://reader033.fdocuments.us/reader033/viewer/2022041417/5e1c54d6e5778b52071b1332/html5/thumbnails/18.jpg)
Salt / Water Balance after Surgery Lobo DN et al. Lancet 2002;359:1812-8
Colon cancer resections
Normal / Surgical (n=10) > 3 L water and 154 mmol Na / 24 hr
Restricted / Medical (n=10) < 2 L water and 77 mmol Na / 24 hr
![Page 19: Definition and Types of Intestinal Failure · Definition and Types of Intestinal Failure . Jeremy Nightingale . Consultant Gastroenterologist . St Mark’s Hospital . Intestinal Failure](https://reader033.fdocuments.us/reader033/viewer/2022041417/5e1c54d6e5778b52071b1332/html5/thumbnails/19.jpg)
Salt / Water Balance after Surgery Lobo DN et al. Lancet 2002;359:1812-8
Normal Restricted Surgical Medical p Weight change (kg - day 2) + 3 0 0.0001 Gastric emptying (day 4) Liquid T 50% (min) 110 74 0.017 Solid T 50% (min) 175 73 0.028 Flatus (day) 4 3 0.001 Stool (day) 7 4 0.001 Solid food (day) 7 4 0.002 Complications 7 1 0.01 Hospital stay (days) 9 6 0.001
![Page 20: Definition and Types of Intestinal Failure · Definition and Types of Intestinal Failure . Jeremy Nightingale . Consultant Gastroenterologist . St Mark’s Hospital . Intestinal Failure](https://reader033.fdocuments.us/reader033/viewer/2022041417/5e1c54d6e5778b52071b1332/html5/thumbnails/20.jpg)
Typical Acute Intestinal Failure Patient (Type 2 – Medium-term)
0 - 6 months post laparotomy Enterocutaneous fistula / wound dehiscence
![Page 21: Definition and Types of Intestinal Failure · Definition and Types of Intestinal Failure . Jeremy Nightingale . Consultant Gastroenterologist . St Mark’s Hospital . Intestinal Failure](https://reader033.fdocuments.us/reader033/viewer/2022041417/5e1c54d6e5778b52071b1332/html5/thumbnails/21.jpg)
4 months PN
![Page 22: Definition and Types of Intestinal Failure · Definition and Types of Intestinal Failure . Jeremy Nightingale . Consultant Gastroenterologist . St Mark’s Hospital . Intestinal Failure](https://reader033.fdocuments.us/reader033/viewer/2022041417/5e1c54d6e5778b52071b1332/html5/thumbnails/22.jpg)
Jejunum-colon Jejunostomy
Typical Chronic Intestinal Failure Patients (Type 3 – Long-term)
Short Bowel
![Page 23: Definition and Types of Intestinal Failure · Definition and Types of Intestinal Failure . Jeremy Nightingale . Consultant Gastroenterologist . St Mark’s Hospital . Intestinal Failure](https://reader033.fdocuments.us/reader033/viewer/2022041417/5e1c54d6e5778b52071b1332/html5/thumbnails/23.jpg)
What is the normal small bowel length?
![Page 24: Definition and Types of Intestinal Failure · Definition and Types of Intestinal Failure . Jeremy Nightingale . Consultant Gastroenterologist . St Mark’s Hospital . Intestinal Failure](https://reader033.fdocuments.us/reader033/viewer/2022041417/5e1c54d6e5778b52071b1332/html5/thumbnails/24.jpg)
Small Bowel Length
275 - 850 cm
![Page 25: Definition and Types of Intestinal Failure · Definition and Types of Intestinal Failure . Jeremy Nightingale . Consultant Gastroenterologist . St Mark’s Hospital . Intestinal Failure](https://reader033.fdocuments.us/reader033/viewer/2022041417/5e1c54d6e5778b52071b1332/html5/thumbnails/25.jpg)
Chronic Intestinal Failure - Short Bowel Jejunum-colon
Previous bowel resections
Weight loss and diarrhoea (steatorrhoea)
![Page 26: Definition and Types of Intestinal Failure · Definition and Types of Intestinal Failure . Jeremy Nightingale . Consultant Gastroenterologist . St Mark’s Hospital . Intestinal Failure](https://reader033.fdocuments.us/reader033/viewer/2022041417/5e1c54d6e5778b52071b1332/html5/thumbnails/26.jpg)
Chronic Intestinal Failure - Short Bowel Jejunostomy
Previous bowel resections Ileostomy diarrhoea
dehydration + / - hypomagnesaemia
![Page 27: Definition and Types of Intestinal Failure · Definition and Types of Intestinal Failure . Jeremy Nightingale . Consultant Gastroenterologist . St Mark’s Hospital . Intestinal Failure](https://reader033.fdocuments.us/reader033/viewer/2022041417/5e1c54d6e5778b52071b1332/html5/thumbnails/27.jpg)
Small Bowel Length and Long-term Nutrition / Fluid Gouttebel MC et al. Dig Dis Sci 1986; 31: 718-723.
Nightingale JMD et al. Gut 1992; 33: 1493-7. Messing B et al. Gastroenterology 1999; 117: 1043-1050
Jejunostomy Jejunum-colon
Jejunum (cm) Nutrition Fluid Nutrition 0 - 50 Parenteral Saline Parenteral 51 - 100 Parenteral * Saline Oral / Enteral 101 - 150 Oral / Enteral OGS None 151 - 200 None OGS None
OGS: Oral (or enteral) glucose / saline solution *: at 85 - 100 cm may need parenteral saline only
![Page 28: Definition and Types of Intestinal Failure · Definition and Types of Intestinal Failure . Jeremy Nightingale . Consultant Gastroenterologist . St Mark’s Hospital . Intestinal Failure](https://reader033.fdocuments.us/reader033/viewer/2022041417/5e1c54d6e5778b52071b1332/html5/thumbnails/28.jpg)
Summary - Intestinal Failure
1. Reduced gut absorption Causes dehydration +/- malnutrition Need macronutrients +/- water/electrolytes 2. Short (1), medium (2) and long term (3) 3. Short bowel – jejunum-colon or jejunostomy
![Page 29: Definition and Types of Intestinal Failure · Definition and Types of Intestinal Failure . Jeremy Nightingale . Consultant Gastroenterologist . St Mark’s Hospital . Intestinal Failure](https://reader033.fdocuments.us/reader033/viewer/2022041417/5e1c54d6e5778b52071b1332/html5/thumbnails/29.jpg)
Nightingale JMD and Woodward JM. Gut 2006; 55 (suppl IV) Nightingale JMD 2001: ISBN 1 900 151 936