Case Report: Nutritional Management of Adhesive Small Bowel Obstruction

Kate Eichen ARAMARK Dietetic Internship December 22, 2013

Contents
Disease Description

Evidence Based Nutrition Recommendations

Case Presentation Nutrition Care Process Conclusion Calculations References

Disease Description
Caused by the growth of adhesions, or fibrous bands,
postoperatively in the abdomen

Adhesions can form from surgery, inflammation,

abdominal trauma, or can be congenital. Most commonly from surgeries in the lower abdomen and
pelvis region Develop in 93-100% of transperitoneal surgery patients

Signs and Symptoms of SBO

Vomiting, pain, constipation, and distention Decreased appetite, weight loss, intolerance of food by
mouth

Evidence Based Nutrition Recommendations for PN

Assessing Appropriateness of Parenteral Nutrition Usage
in an Acute Hospital

1191 patients over 6 years Preset list of criteria to evaluate use of PN

Diagnosis, GI malfunction, evidence of precluded GI access

Determined if appropriate and unavoidable, appropriate

and avoidable, or inappropriate

Smyth N, Neary E, Power S, Feehan S, Duggan S. Assessing appropriateness of parenteral nutrition usage in an acute hospital. Nutrition In Clinical Practice: Official Publication Of The American Society For Parenteral And Enteral Nutrition [serial online]. April 2013;28(2):232-236.

Results
Appropriate and unavoidable- 82%

Appropriate and avoidable- 13%

Inappropriate- 5%

Throughout study, all results significantly improved This study determined that SBO are appropriate and
unavoidable for need of parenteral nutrition

Evidence Based Recommendations

Early Parenteral Nutrition in Critically lll Patients With Short-Term
Relative Contraindications to Early Enteral Nutrition. From 2006-2011 studying 686 patients in the ICU which were
temporarily contraindicated from EN and were started on early PN

Results show that mortality rate between early PN and standard

care group were very similar. Early PN group rated higher in a survey which measured improvement in quality of life

ICU length of stay was similar but early PN patients required less
time to be intubated. This study shows that PN does have some benefits from being
started early. PN should only be used when it is permanently indicated however.

Doig G, Simpson F. Early parenteral nutrition in critically ill patients with short-term relative contraindications to early enteral nutrition: a full economic analysis of a multicenter randomized controlled trial based on US costs. Clinicoeconomics And Outcomes Research: CEOR [serial online]. July 22, 2013;5:369-379

Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient
Determine when EN or PN are needed PN is appropriate:

After 7 days in the hospital when EN is inappropriate If malnutrition is present and EN is inappropriate Major GI surgery EN not meeting needs within 7-10 days of use

McClave S, Martindale R, Cresci G, et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN. Journal Of Parenteral And Enteral Nutrition [serial online]. May 2009;33(3):277-316.

Interpretation
There are not recommendations for specific GI issues

Nutrition support route can differ within the same

disease state based on the previously mentioned criteria

These guidelines prove that PN is the correct

intervention using these qualifications: Presence of malnutrition, GI surgery, and inadequate
enteral nutrition

Case Presentation
47 year old Amish female presents to the ER with
nausea, vomiting large amounts of bilious and feculent matter, abdominal pain and distention, status post PEG tube placement a week prior.

PEG tube placed due to decreased oral intake, weight

loss and intolerance of PO diet, done against her doctors recommendation Tube feeds not tolerated at home

Symptoms lead to diagnosis of probable small bowel

obstruction

Past Medical History

Relevant for adhesions: hysterectomy,
cholecystectomy, appendectomy, partial colectomy, and colostomy

Celiac disease, malnutrition, GERD, osteoporosis,

depression, rectal prolapse, hypoglycemia, hypothyroidism, hypokalemia, IBS, colitis, vitamin D deficiency, and lactose intolerance

Assessment
Client History
Patient is uninsured and is reliant on family to pay
medical bills Lives with her sister who is her primary caregiver

Food/Nutrition Related History

Celiac disease and lactose intolerance Only tolerated corn meal and eggs prior to admission After PEG tube placement, didnt tolerate any feeding.

Relevant Medications

Assessment
Nutrition-Focused Physical Findings
Loss of 14 pounds in 2 months due to poor appetite and N/V Abdomen distended, hypoactive bowel sounds and very little
output from colostomy Stage 2 sacral ulcer

Anthropometric Measurements

53 86 pounds BMI=15.23 IBW= 115 pounds, %IBW=75% 14% body weight loss in 2 months

Assessment
Biochemical Data
Abnormal values include decreased calcium and
prealbumin

Medical Tests/Procedures
NG tube placed to reduce nausea and vomiting CT scan to confirm diagnosis of small bowel obstruction

Nutrient Needs
Based on ideal body weight

Calories: 25-30 calories/kg=1308-1569

Protein: 1.3-1.5 g/kg due to low prealbumin and wound
healing= 68-78 grams

Fluid: 1 ml/kcal= 1308-1569 ml.

ARAMARK Nutrition Status Classification

History: 4 points for consumption of <50% of needs for
> 2 weeks

Feeding Modality: 0 points (only NPO 1 day) Wt. Loss: 4 points for >7.5% loss in 3 months

Wt. status: 4 points for BMI of <16

Serum prealbumin: 2 points for PAB of 11.4 Dx: 4 points for GI obstruction Total: 18 points= Severe nutritional compromise

Malnutrition Identification
Starvation malnutrition due to lack of inflammation

Malnutrition is severe and is in the context of chronic

illness due to poor intake over long period of time, loss of >7.5% weight in 3 months, and severe loss of muscle mass and body fat

Nutrition Diagnoses
Inadequate oral intake (NI-2.1) related to nausea and
vomiting, abdominal pain and distention, and poor appetite as evidenced by 14% weight loss in 2 months, low prealbumin, need for enteral nutrition prior to admission, and need for current NPO diet order.

Altered GI function (NC-1.4) related to small bowel

obstruction as evidenced by nausea and vomiting, abdominal pain and distention, need for NG tube placement for decompression, and current need for NPO diet order.

Nutritional Diagnoses
Increased nutrient needs (protein) (NI-5.1) related to
wound healing as evidenced by stage 2 sacral ulcer and low prealbumin.

Interventions
Parenteral Nutrition/IV fluids (ND-2.2): Concentration (ND2.2.2) If unable to advance to PO diet, recommend 2.4 liters standard
PVN, which will provide 1536 calories (100% of needs) and 102 grams protein (131% high end needs) Goal: 100% of calorie and protein needs will be met with standard PVN.

Enteral nutrition (ND-2.1): Rate (ND-2.1.3)

If able to resume tube feeds, recommend 1 can of Osmolite 1.5
at 0800, 1200, 1600, and 2000 (4 total) with 1 packet of prosource a day with 150 ml. water flush after each bolus. Goal: pt. will tolerate tube feeds with <500 ml. residuals

Interventions
Medical food supplements (ND-3.1): commercial
beverage (ND-3.1.1) Provide the patient with ensure clear TID, which is a
known tolerable preference from a previous admission. Goal: pt. will consume >50% of supplements

General/healthful diet (ND-1.1)

Transition to gluten and lactose free PO diet as medically
feasible. Goal: pt. will consume >50% of meals

Interventions
Nutrition education- Content (E-1) Recommended
modifications (E-1.5)
Per M.D. request, provide diet education on high calorie, high
protein food items

Goal: pt. will verbalize understanding of material

Collaboration and referral of nutrition care (RC-1

Collaboration with other providers (RC-1.4) Goal: pt. will verbalize understanding of diet plan after
discharge Collaborate with attending M.D. on case to determine plan after discharge and to calculate if needs will be met based on said plan

Monitoring and Evaluation

FH-1.1.1 Monitor energy intake
PO intake vs. PVN vs. EN

FH-4.1 Food and nutrition knowledge AD-1.1 Body composition/growth/weight history

BD-1.2 Electrolyte and renal profile

BD- 1.11 Protein profile BD-1.13 Vitamin profile PD-1.1 Nutrition focused physical findings

Follow up: Day 2 of admission

Pt. remained NPO, and was still experiencing N/V

PVN recommendations were calculated and written in

her chart

Spoke with her RN who reported PVN being needed,

but they needed to look into the cost first

Follow up: Day 4 of admission

Cost of TPN out of pocket is about $700/day

Family had to decided

Patient had a PICC line placed just in case

Follow up: Day 7

Laparotomy performed after follow up on day 4 in
hopes of avoiding TPN

Over the weekend the patient restarted tube feeds at a

very slow continuous rate to test tolerance

Pt. also began a PO diet N/V and abd. distention resolved with surgery Met with the attending physician who wanted to make
sure she was going to be eating enough calories at home

Continued
The plan for home was to bolus feed can of Osmolite
1.5 in the morning, and can at night, in addition to drinking ensure clear 3 times a day and eating high calorie, high protein foods whenever possible

I provided diet education to the patient about high

calorie, high protein, gluten free, and lactose free.

The patient was very optimistic about the diet related

plan of care

Conclusion
While the patient was discharged on an oral diet,
supplements, and 1 can of tube feed, her adhesive small bowel obstruction can very easily reform and TPN may be a requirement in the near future.

This case allowed me to follow a very interesting, wide

spectrum case which taught me immensely.

Calculations
Anthropometric Calculations based on ideal body weight of 52.3 kg.

References

1. Attard J, MacLean A. Adhesive small bowel obstruction: epidemiology, biology and prevention. Canadian Journal Of

Surgery. Journal Canadien De Chirurgie [serial online]. August 2007;50(4):291-300.

2. Menzies D, Ellis H. Intestinal obstruction from adhesionshow big is the problem? Ann R Coll Surg Engl1990;72:603. 3. Smyth N, Neary E, Power S, Feehan S, Duggan S. Assessing appropriateness of parenteral nutrition usage in an acute hospital. Nutrition In Clinical Practice: Official Publication Of The American Society For Parenteral And Enteral Nutrition [serial online]. April 2013;28(2):232-236. 4. Doig G, Simpson F. Early parenteral nutrition in critically ill patients with short-term relative contraindications to early enteral nutrition: a full economic analysis of a multicenter randomized controlled trial based on US costs. Clinicoeconomics And Outcomes Research: CEOR [serial online]. July 22, 2013;5:369-379 5. McClave S, Martindale R, Cresci G, et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN. Journal Of Parenteral And Enteral Nutrition [serial online]. May 2009;33(3):277316. 6. Charney, P, Malone A, ADA Pocket Guide to Nutrition Assessment. Chicago, IL; 2013: 69-92 7. Academy of Nutrition and Dietetics. Pocket Guide for International Dietetics & Nutrition Terminology (IDNT) Reference Manual: Standardized Language for the Nutrition Care Process . Chicago, IL; 2013. 8. Pronsky Z, Crowe J. Food Medication Interactions 16th Edition. Pennsylvania: Food-Medication Interactions; 2010.