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Wong C, Lucas B, Wood D. Patients' experiences with home parenteral nutrition: A grounded theory study. Clin Nutr ESPEN 2018; 24:100-108. [PMID: 29576346 DOI: 10.1016/j.clnesp.2018.01.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 11/22/2017] [Accepted: 01/17/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND & AIMS Parenteral nutrition (PN) provides nourishment and hydration as an intravenous infusion to patients with intestinal failure (IF). The aim of the study is to generate theory that explains the experiences of adult patients living with home parenteral nutrition (HPN) and complex medication regimens. METHODS A grounded theory methodology was used to explore the experiences of twelve patients receiving HPN. A semi-structured interview was conducted and recorded in each participant's home setting. Each interview was transcribed verbatim. The simultaneous process of data collection and analysis was followed reflecting the principles of the constant comparative approach. RESULTS A total of 15 patients gave written consent, with 12 of them agreeing to be interviewed. All the participants had previously undergone surgery as a result of chronic ill health or sudden illness. Analysis revealed two core categories: stoma and HPN, and these were supported by the subcategories: maintaining stoma output, access to toilets, managing dietary changes, maintaining the HPN infusion routine, access to technical help to set up an HPN infusion, mobility with HPN equipment and general health changes. The strategy of living with loss was demonstrated by all the participants, and this was supported by the action strategies of maintaining daily activities and social interactions. CONCLUSIONS This study generates new understanding and insight into the views and experiences of patients receiving HPN in the UK. The findings from these participants have been shown to resonate with the Kubler-Ross Model [1] of the five stages of grief. The theory of living with loss was generated by the use of a grounded theory methodology. This small scale exploratory study reveals opportunities for improvements in practice to be considered by the nutrition support team (NST) and other healthcare professionals involved in the patient's hospital stay prior to discharge on HPN.
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Affiliation(s)
- Christina Wong
- Department of Pharmacy, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Herries Road, Sheffield S5 7AU, UK.
| | - Beverley Lucas
- Faculty of Health Studies, University of Bradford, Richmond Building, Richmond Road, Bradford BD7 1DP, UK
| | - Diana Wood
- Bradford School of Pharmacy, University of Bradford, Richmond Building, Richmond Road, Bradford BD7 1DP, UK
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Bioelectrical impedance vector analysis as a useful predictor of nutritional status in patients with short bowel syndrome. Clin Nutr 2017; 36:1117-1121. [DOI: 10.1016/j.clnu.2016.07.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Revised: 07/15/2016] [Accepted: 07/19/2016] [Indexed: 01/19/2023]
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Matarese LE, O'Keefe SJ, Kandil HM, Bond G, Costa G, Abu-Elmagd K. Short Bowel Syndrome: Clinical Guidelines for Nutrition Management. Nutr Clin Pract 2017; 20:493-502. [PMID: 16207689 DOI: 10.1177/0115426505020005493] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Intestinal failure is a condition in which inadequate digestion or absorption of fluid, electrolytes, and nutrients leads to dehydration or malnutrition. The most common cause of intestinal failure is short bowel syndrome (SBS) defined as <200 cm of functional small intestine. SBS may result from congenital abnormalities or from surgical resection. For the past 3 decades, patients with severe SBS were managed with home parenteral nutrition (HPN). With the emergence of new therapies, the clinician now has multiple options to treat these patients. These include intestinal rehabilitation regimens whereby patients are treated with specialized oral diets, soluble fiber, oral rehydration solutions (ORS), and trophic factors to enhance absorption. There are also a variety of surgical techniques available to preserve intestinal length. Small bowel and multivisceral transplantation has evolved during the last decade to be a valid therapeutic option for those patients who cannot be rehabilitated or who fail HPN. These are interrelated services designed to offer the patient the best therapeutic options to meet their individual needs. This article reviews the principles associated with the nutrition management of this very complex and diverse group of patients.
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Affiliation(s)
- Laura E Matarese
- Intestinal Rehabilitation and Transplant Center, Thomas E. Starzl Transplantation Institute, UPMC Montefiore, 7 South, 3459 Fifth Avenue, Pittsburgh, PA 15213, USA.
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Jonkers DMAE. Microbial perturbations and modulation in conditions associated with malnutrition and malabsorption. Best Pract Res Clin Gastroenterol 2016; 30:161-72. [PMID: 27086883 DOI: 10.1016/j.bpg.2016.02.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Accepted: 02/02/2016] [Indexed: 02/06/2023]
Abstract
The intestinal microbiota is a complex ecosystem, which can be considered an accessory organ. It involves complex microbe-microbe and host-microbe interactions with indispensable functions for the human host with regard to the intestinal epithelium and barrier function, the innate and adaptive immune system, and its large metabolic capacity. Saccharolytic fermentation results in the production of short chain fatty acids, which exert an array of beneficial effects, while proteolytic fermentation leads to an increase in potentially harmful metabolites. In addition, numerous other microbial metabolites are being produced with various intestinal as well as extra-intestinal effects. Their generation depends on the composition of the microbiota as well as the availability of substrates, which both vary along the GI tract. Diet impacts the intestinal microbiota composition and activity in early infancy as well as in adults. Microbial perturbations have been demonstrated in subjects with under-nutrition and/or malabsorption. The bidirectional interactions between the microbiome, nutrient availability and GI function, can contribute to a vicious circle, further impairing health outcome in conditions associated with malnutrition and/or malabsorption. Integrated multivariate approaches are needed to further unravel the complex interaction between microbiome, diet and host factors, as well as possible modulation thereof by prebiotics or probiotics. The present overview will briefly outline the composition and function of the intestinal microbiota, its association with nutrient intake and availability, and will address the role of the intestinal microbiota in malnutrition and malabsorption.
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Affiliation(s)
- Daisy M A E Jonkers
- Division Gastroenterology-Hepatology, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Center+, Maastricht, The Netherlands.
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Wong C, Lucas B, Wood D. Patients’ experiences with home parenteral nutrition: a literature review: Table 1. Eur J Hosp Pharm 2014. [DOI: 10.1136/ejhpharm-2014-000481] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Affiliation(s)
- Elaine Cronin
- Royal Free Hospital, London and Community Stoma Care Nurse, Salts Healthcare
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Affiliation(s)
- Elaine Cronin
- Royal Free Hospital, London and Community Stoma Care Nurse for Salts Healthcare
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Barclay AR, Beattie LM, Weaver LT, Wilson DC. Systematic review: medical and nutritional interventions for the management of intestinal failure and its resultant complications in children. Aliment Pharmacol Ther 2011; 33:175-84. [PMID: 21091524 DOI: 10.1111/j.1365-2036.2010.04514.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Intestinal failure (IF) affects a growing number of children due to increasing numbers of preterm infants surviving intestinal resection for necrotising enterocolitis and improving surgical techniques for congenital gut anomalies. Parenteral nutrition (PN) is the mainstay of therapy; enteral nutrition may have trophic effects on the gut. AIM To review systematically evidence for the effectiveness of medical and nutritional interventions in the treatment of IF in children. METHODS Retrieval of data from studies of patients aged <18 years and receiving >28 days of PN. Outcome measures were improvement in intestinal function, intestinal adaptation, growth, prevention and treatment of IF-associated liver disease, and mortality. Cochrane Database (November 2009), MEDLINE (1950-November 2009) and CINAHL (1982-November 2009) electronic database searches were made using keyword and subject headings (MeSH): IF, Short Bowel Syndrome (SBS), PN and Child. The level of the evidence (EL) was assessed using SIGN (Scottish Intercollegiate Guidelines Network) methodology (http://www.sign.ac.uk). RESULTS From 1 607 620 hits, 720 abstracts were reviewed. Thirty-three original articles were included. No studies were of high methodological quality. CONCLUSIONS The evidence base for medical and nutritional interventions in paediatric IF is limited and of poor quality. In the absence of randomised-controlled trials, this evidence base can improve through case control and cohort research; and with better multiagency communication, the study of inter-centre differences is possible. Achievable short-term goals would include the study of: optimal ursodeoxycholic usage, novel intralipid formulations, cycled enteral antibiotics, enteral probiotics and new enteral feeding strategies.
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Affiliation(s)
- A R Barclay
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Sick Children, Glasgow, UK.
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Broadbent AM, Heaney A, Weyman K. A Review of Short Bowel Syndrome and Palliation: A Case Report and Medication Guideline. J Palliat Med 2006; 9:1481-91. [PMID: 17187557 DOI: 10.1089/jpm.2006.9.1481] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
While patients with short bowel syndrome are not common in palliative care, they can present challenges for palliative care professionals. The case presented highlights a specific difficulty encountered. Many medications are poorly absorbed from a short bowel and alternative routes of administration need to be considered. A search was conducted to identify reviews, reports, and other articles from January 1960 to February 2004. MEDLINE, Cochrane Library, and CINAHL (Cumulative Index of Nursing and Allied Health Library) and MIMs (Medimedia Australia) databases were searched. A review of major textbooks was also conducted. Information on the site of absorption, time to peak plasma concentration, alternate routes, and pharmacokinetic information is summarized and presented in table form. This case report and review should assist practitioners with the palliative management of patients with short bowel syndrome.
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Affiliation(s)
- Andrew Mark Broadbent
- Department of Palliative Care, Braeside Hospital, Sydney, New South Wales, Australia.
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Liu X, Nelson DW, Holst JJ, Ney DM. Synergistic effect of supplemental enteral nutrients and exogenous glucagon-like peptide 2 on intestinal adaptation in a rat model of short bowel syndrome. Am J Clin Nutr 2006; 84:1142-50. [PMID: 17093168 DOI: 10.1093/ajcn/84.5.1142] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Short bowel syndrome (SBS) can lead to intestinal failure and require total or supplemental parenteral nutrition (TPN or PN, respectively). Glucagon-like peptide 2 (GLP-2) is a nutrient-dependent, proglucagon-derived gut hormone that stimulates intestinal adaptation. OBJECTIVE Our objective was to determine whether supplemental enteral nutrients (SEN) modulate the intestinotrophic response to a low dose of GLP-2 coinfused with PN in a rat model of SBS (60% jejunoileal resection plus cecectomy). DESIGN Rats were randomly assigned to 8 treatments by using a 2 x 2 x 2 factorial design and maintained with either TPN or PN for 7 d. The 3 main treatment effects were the following: transection or resection (TPN alone), +/- SEN (days 4-6), and +/- GLP-2 (100 mug . kg body wt(-1) . d(-1)). RESULTS The treatments induced differential growth of duodenal and jejunal mucosa. Significant differences in villus height, crypt depth, dry mass, and concentrations of protein and DNA were observed between the treatments and TPN alone (SEN: 15-59% increase; GLP-2: 14-84% increase; and SEN + GLP-2: 63-160% increase). Plasma concentrations of bioactive GLP-2 were significantly greater with GLP-2 infusion (TPN alone: 25 +/- 9 pmol/L; SEN: 29 +/- 10 pmol/L; GLP-2: 59 +/- 31 pmol/L; SEN + GLP-2: 246 +/- 40 pmol/L) and correlated with mucosal growth. Jejunal sucrase activity (in U/cm) was significantly greater with SEN than without SEN. SEN + GLP-2 induced dramatic mucosal growth and greater plasma concentration of GLP-2 (SEN x GLP-2 interaction, P < 0.0001). Resection significantly increased expression of proglucagon mRNA in colon. CONCLUSIONS Combination treatment with SEN and GLP-2 induced a synergistic response resulting in greater mucosal cellularity and digestive capacity in parenterally fed rats with SBS. This shows that SEN improve the intestinotrophic response to exogenous GLP-2, possibly by stimulating enterocyte proliferation and differentiation.
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Affiliation(s)
- Xiaowen Liu
- Department of Nutritional Sciences, University of Wisconsin-Madison, Madison, WI, USA
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Richardson L, Banerjee S, Rabe H. What is the evidence on the practice of mucous fistula refeeding in neonates with short bowel syndrome? J Pediatr Gastroenterol Nutr 2006; 43:267-70. [PMID: 16878000 DOI: 10.1097/01.mpg.0000228111.21735.02] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
A systematic review of literature was performed on the practice of mucous fistula refeeding in neonates with short bowel syndrome. No randomised controlled studies were identified. Case series reports of 30 infants showed improved weight gain (from -2.36 +/- 1.24 to 21.06 +/- 3.02 g/d) and reduced need for total parenteral nutrition. Randomised controlled trials are required to establish the benefits of mucous fistula refeeding in this condition.
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Affiliation(s)
- Lydia Richardson
- Brighton & Sussex Medical School, University of Brighton, Falmer, UK
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Abstract
Short bowel syndrome (SBS) is the predominant cause of intestinal failure and is thus associated with a high degree of morbidity and mortality. One of the reasons this occurs is the dramatic reduction in nutrient absorptive capacity. Of the many causes of SBS, the most common cause is extensive surgical resection. The impressive ability of the bowel to adapt functionally and morphologically is critical for decreasing morbidity and mortality in these patients. The degree of adaptation is vital in decreasing the dependence on parenteral nutrition (PN) and for improving patient quality of life and long-term outcome. Provision of appropriate and sufficient nutritional and fluid support is essential for the management of these patients. The primary goal is to prevent or eliminate the need for PN. Recent developments have promoted a greater understanding of the process of intestinal adaptation. Various intestinal trophic factors have been recognized. These efforts have led to the early development of hormonal therapy to stimulate intestinal adaptation and enhance intestinal absorption. Intestinal transplantation remains an option for those who have developed life-threatening complications from PN and cannot be managed using more conservative techniques.
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Affiliation(s)
- Christian Jackson
- Division of Gastroenterology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
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Nauth J, Chang CW, Mobarhan S, Sparks S, Borton M, Svoboda S. A Therapeutic Approach to Wean Total Parenteral Nutrition in the Management of Short Bowel Syndrome: Three Cases Using Nocturnal Enteral Rehydration. Nutr Rev 2004; 62:221-31. [PMID: 15212323 DOI: 10.1111/j.1753-4887.2004.tb00044.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Short bowel syndrome is characterized by severe dehydration and malnutrition and requires total parenteral nutrition (TPN). Prolonged TPN has serious complications. Caloric requirements can be met orally but oral fluid replacement is problematic. Noncompliance and an inability to discontinue TPN earlier increase the likelihood of complications. Discontinuation of parenteral support requires an assessment of gastrointestinal anatomy and absorption capacity. Fluids must be replaced independently of feedings because the osmotic gradients decrease fluid absorption. Nocturnal enteral rehydration is an intervention using oral rehydration solutions through percutaneous endoscopic gastrostomy tubes at night. Patients given nocturnal enteral rehydration discontinued TPN earlier and had improved fluid absorption.
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Affiliation(s)
- Justin Nauth
- Department of Internal Medicine, Loyola University Medical Center, Maywood, IL, USA
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Affiliation(s)
- Jon S Thompson
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska 68198-3280, USA
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Koffeman GI, van Gemert WG, George EK, Veenendaal RA. Classification, epidemiology and aetiology. Best Pract Res Clin Gastroenterol 2003; 17:879-93. [PMID: 14642855 DOI: 10.1016/s1521-6918(03)00099-4] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Intestinal failure and its most important cause, short-bowel syndrome (SBS), are rare clinical entities leading to a vast complex of symptoms and complications with significant morbidity and mortality. Both conditions occur as the result of a massive reduction in enteral nutrient absorptive capacity. Disease manifestation is based on aetiological and anatomical characteristics such as remaining intestinal length and the presence of a functionally intact colon. Congenital and perinatal conditions, for example, intestinal atresia, necrotizing enterocolitis (NEC) and intestinal volvulus are the most important causes in children. The aetiology in adults is based on diseases inducing loss of intestinal function or loss of intestinal surface area after extensive surgical resections. The most frequent causes are mesenteric infarction, radiation enteritis and Crohn's disease. Knowledge of the epidemiology of intestinal failure and SBS is limited, being mainly based on the extrapolated figures of home parenteral nutrition centres and single-centre studies. At present, the incidence of SBS is estimated to be 2-5 per million.
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Affiliation(s)
- Geert I Koffeman
- Paediatric Surgical Centre Amsterdam, Academic Medical Center, Amsterdam, P.O. Box 22700, 1105 AZ, Amsterdam, The Netherlands.
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