Principles of nutrition therapy for short-bowel syndrome

Key issues in addressing the clinical and humanistic burden of short bowel syndrome in the US

BACKGROUND

The purpose of this analysis was to provide a concise report of the literature on the burden of intestinal failure associated with short bowel syndrome (SBS-IF) in adults, focused on clinical and humanistic issues important to clinicians and payers.

SCOPE

A literature search was performed using the National Library of Medicine PubMed database ( http://www.ncbi.nlm.nih.gov/pubmed ) with the search term 'short bowel syndrome' limited to adult populations and English-language reports published from January 1, 1965, to January 18, 2013. Citations were assessed for relevance and excluded articles focused on single case studies, colon fermentation, absorption of medications with PN/IV, surgical technique, mesenteric artery complications/surgery, and transplantation focus. Additional hand searches were performed using the terms 'short bowel syndrome' AND 'cost', and 'home parenteral nutrition' AND 'cost', along with the exclusion criteria described above.

FINDINGS

Despite advances in management in recent decades, SBS-IF continues to carry a high burden of morbidity and mortality. In the absence of sufficient intestinal adaptation following resection, many patients remain dependent on long-term parenteral nutrition and/or intravenous fluids (PN/IV). Although potentially life saving, PN/IV is costly, invasive, and associated with numerous complications and deleterious effects on health and quality of life. Surgical interventions, especially intestinal transplantation, are costly and are associated with substantial morbidity and high mortality. New therapies, which show promise in promoting intestinal rehabilitation and reducing dependence on PN/IV therapy, are the subject of active research.

CONCLUSIONS

Overall, the available literature suggests that although SBS-IF affects a relatively small population, the clinical and humanistic burden is significant, and there is an unmet need for effective therapeutic options that target the underlying problem of inadequate absorptive capacity of the remaining intestine. Consequently, many patients with SBS-IF remain dependent on long-term PN/IV support, adding to the burden imposed by the underlying disorder.

Nutritional support in critically ill patients with cancer

Nutritional depletion is a common problem seen in critically ill patients with cancer and is associated with increased morbidity and mortality. Infection and injury activate a cascade of metabolic events that leads to a poor nutritional state and wasteful energy consumption. The goals of nutritional support entail minimizing starvation, preventing nutrient deficiencies, supporting or improving immune function, and facilitating tissue repair and wound healing. Further understanding of the metabolic changes of illness will improve effective regulation of the inflammatory events occurring in critically ill patients. Multiple clinical parameters are available to assess the nutritional status in critically ill patients, but no standard recommendations can be made at this time. The use of these parameters can be appropriate, provided that their limitations are understood clearly. The development and standardization of objective parameters to identify patients at risk or with subclinical malnutrition are needed. Enteral and parenteral feedings are safe and effective methods to deliver nutrients to critically ill patients with cancer who are unable to ingest adequate amounts orally. Early nutritional support should be instituted in the appropriate clinical setting. Specialized nutritional solutions and supplements require careful consideration in patients with renal, hepatic, cardiac, or pulmonary disorders. The unselective use of nutritional support is not indicated in well-nourished patients with cancer undergoing surgery, chemotherapy, or radiotherapy in whom adequate oral intake is anticipated. Nutritional support remains an important adjunctive therapy in the overall management of critically ill patients. Continued clinical investigations in nutrition are necessary to identify other groups of patients who can benefit from nutritional interventions.

Dietary recommendations to prevent and manage chronic pediatric health conditions: adherence, intervention, and future directions

This review provides a summary of the dietary aspects of pediatric health conditions. Within each condition, dietary recommendations are reviewed, and adherence rates, factors affecting adherence, and known interventions are reported. Findings indicate that knowledge is necessary but not sufficient for dietary change. Interventions specifically targeting diet appear more promising than interventions aimed at global treatment adherence. Behavioral interventions and group treatment modalities also appear promising. Recommendations for future research include a systematic assessment of barriers to dietary adherence across populations, integration of the research on normative development of eating behavior in childhood, and the application of this information to the design and implementation of future treatment.

Intestinal adaptation in short bowel syndrome without tube feeding or home parenteral nutrition: report of four consecutive cases

Because home total parenteral nutrition (TPN) is not available to most of the Brazilian population, an alternative treatment for short bowel syndrome was evaluated. Four patients ages 40-65 y (mean: 53.75 +/- 10.59), three with mesenteric thrombosis, and one with Crohn's disease were studied. The average length of the remaining small bowel in these patients was 54.5 +/- 6.4 cm; the ileocecal valve was preserved in 3 cases. A progressive step diet was used for intestinal adaptation. Administration of pectin was started at the beginning of the special oral diet (step 1), followed by medium-chain triacylglycerols (MCTs) and complex, nonfermentable sugars (step 2); coconut oil (47% MCTs) and simple sugars (step 3); and long-chain triacylglycerols and lactose (step 4). TPN was interrupted at step 3 or 4 when the energy content of the diet reached 150% of the patient's resting energy expenditure, if serum albumin and weight were stable or increasing, and if the frequency, amount, and consistency of stools remained unchanged. Nutritional follow-up showed that patients responded well to this approach; also, patients returned to their previous professional activities. Thus, enteral formulas were not essential for gastrointestinal adaptation. Home TPN should not be indicated on the basis of strict criteria, but rather when a patient fails to adapt to a progressive, special oral diet.