Pseudo Obstruction

Case Study
Intestinal Rehabilitation

Josh Naumann
Dietetic Intern, University of Maryland College Park

Objectives
Overview of Condition
Meet the Patient
Nutrition Assessment
Plans
Summary

Overview of Condition

Intestinal Pseudo-Obstruction
Lack of peristalsis caused by nerve,
muscle, or interstitial cells of Cajal
defects
Identified as similar symptoms to bowel
obstruction however, no obstruction
exists
Movement of food, fluid, and air
through the intestines are affected
Symptoms include abdominal pain,
abdominal distension, bloating,
constipation, nausea, vomiting.

Prolonged symptoms include

malabsorption of nutrients, weight
loss, and bacterial overgrowth within
intestines

Diagnosis: Large bowel dilation without

physical obstruction seen using imaging
studies (x-ray, CT scan, barium enema,
upper GI and small bowel series)

Pseudo-Obstruction

Ileus

Lack of peristalsis in the

bowels without mechanic
obstruction

Lack of peristalsis in the

bowels without mechanic
obstruction

Caused by genetic
mutations affecting nerve,
muscle, or interstitial cells
of Cajal important for
intestinal contractions

Commonly caused by
abdominal surgery
Usually temporary and
resolves after several days

Treatment
Nutrition EN and/or PN to prevent malnutrition and weight loss
Medications
Antiobiotics to prevent bacterial overgrowth
To stimulate intestinal muscles
Anti-nausea

Decompression Using a tube through the nose into the stomach

or intestines to relieve pressure, may also be performed using a
colonoscopy
Surgery is a last resort and needed if symptoms are not relieved
using previous treatments
Intestinal Transplant

Intestinal Transplant
Affected portion of bowel is removed and replaced with
healthy bowel
Qualifications:
Catheter-related complications
Lack of central venous access options
Total parenteral nutrition-induced liver dysfunction and
liver failure
Poor quality of life on PN

Expensive and may lead to complications such as

infection or rejection

Nutritional Implications
Malabsorption
Weight loss
Constipation from lack of peristalsis
Anorexia as a result of N/V and constipation
Loss of microvilli in lumen from lack of stimulation
when PN is utilized

Meet AO

Male

Born March 28, 2009

AO was admitted after self-removing his

GJ-tube for:

Replacement of GJ-tube

Replacement of a broken Broviac central

catheter positive with Mucor infection
Fever of 37.8oC (100.04oF)

PMH: chronic intestinal pseudoobstruction, necrotizing enterocolitis

(NEC), total colectomy with ileostomy
placement, atonic bladder, urinary
retention, recurrent pyleonephritis,
chronic liver disease, and KPC sepsis.

Home Regimen:

TPN 2350 mL x 17 hours (D15.5%, P1.5 g/kg,

IL1 g/kg MWF) for 1494 kcals
GJT Alimentum 30 kcal/oz. @ 30 mL x 16
hours (480 mL, 480 kcals, P14.4 g)
Total 2830 mL (123 mL/kg, 3291 mL/m2), 86
kcal/kg, P2.1 g/kg

Nutrition Assessment

Anthropometrics
6 years, 11 months old
Weight 25.9 kg (57.1 lbs.)
Length 120.5 cm (47.4 in)
BMI 17.8 kg/m2

Growth Charts
Weight-for-age 79th percentile
Z-score of 0.79

Stature-for-age 44th percentile

Z-score of -0.14

Weight-for-stature 90th percentile

Z-score of 1.27

BMI 89th percentile

Z-score of 1.22
Classified as overweight
History of decompensation

2 to 20 years: Boys
Stature-for-age and Weight-for-age percentiles
Mothers Stature
Date

Fathers Stature
Age

Weight

Stature

BMI*

NAME
RECORD #

12 13 14 15 16 17 18 19 20
cm
AGE (YEARS)
95
90
75
50
25

in
62

February
14

S
T
A
T
U
R
E

60
58
56
54
52
50
48
46
44
42
40
38

March 6

cm

10 11

10
5

190
185
180
175
170
165

160

160

155

155

150

150

74
72
70
68
66

62
60

145
140

105 230

135

100 220

130

95

125

90

120

95 210
90 200
85

115

75

80
75

110
105

50

100

25

95

10
5

190
180
170
160

70

150 W
65 140 E
I
60 130 G

90

34

85

50 110

32

80

45 100
40 90

35

35

30

30

25

25

20

20

15

15

30

70
60
50
40
30
lb

S
T
A
T
U
R
E

64

36

80
W
E
I
G
H
T

in
76

10
kg

AGE (YEARS)
2

10 11 12 13 14 15 16 17 18 19 20

Published May 30, 2000 (modified 11/21/00).

SOURCE: Developed by the National Center for Health Statistics in collaboration with
the National Center for Chronic Disease Prevention and Health Promotion (2000).
http://www.cdc.gov/growthcharts

55 120

10
kg

80
70
60
50
40
30
lb

H
T

February
14
March 6

NAME

Weight-for-stature percentiles: Boys

Date

Age

Weight

RECORD #

Comments

Stature

kg
34
33

lb
76
72

32
31

68

30
29
97
95

lb
56
52
48

kg

27

26

26

25

44
40

25

90

24

85

24

23

75

23
22

22
50

21
20

25

19

64

28
60
56
52
48

21
20

10

44

19
40

18

18

17

17

16

16

15

15

14

14

13

13

12

12

11

11

10

10

20

20

lb

8
kg

8
kg

lb

36
32
28
24

STATURE

cm
in

80
31

85
32

33

90
34

35

95
36

37

100
38

39

105
40

Published May 30, 2000 (modified 10/16/00).

SOURCE: Developed by the National Center for Health Statistics in collaboration with
the National Center for Chronic Disease Prevention and Health Promotion (2000).
http://www.cdc.gov/growthcharts

41

110
42

43

115
44

45

120
46

47

36
32
28
24

February
14
March 6

2 to 20 years: Boys
Body mass index-for-age percentiles
Date

Age

Weight

Stature

NAME
RECORD #
Comments

BMI*

BMI
35
34
33
32
31
30
95

29
28

BMI
90

27

27

85

26

26

25

25
75

24

24

23

23
50

22

22

21

February
14

21
25

20

20
10

19

19

18

18

17

17

16

16

15

15

14

14

13

13

12

12

kg/m

kg/m2

AGE (YEARS)
2

10

11

12

Published May 30, 2000 (modified 10/16/00).

SOURCE: Developed by the National Center for Health Statistics in collaboration with
the National Center for Chronic Disease Prevention and Health Promotion (2000).
http://www.cdc.gov/growthcharts

13

14

15

16

17

18

19

20

March 6

Nutritional Needs
Estimated
Energy, fluid, and protein
was calculated to meet 80%
of of total home regimen
Energy 1579 kcals

Diet Order
TPN 3200 mL x 20 hours
(D11.5%, P0.8 g/kg, IL1 g/
kg MWF) for 1448kcals.
Energy 1448kcals

58.7 kcals/kg

55.9 kcals/kg

Fluids 2264 mL
84.2 mL/kg

Fluids 3200 mL
123.6 mL/kg

Protein 43.8 g
1.6 g/kg

Protein 21.4 g
0.8 g/kg

Additional Needs
IVF 45 mL/hour 0.9% sodium chloride
High due to the nutrients and fluids being lost through his
gastric output & to flush kidneys
I/O on 3/6 = 3682/3277 (3736 mL with insensible losses)
-54 mL balance
Gastric output = 1845 mL

Supplements
Iron To treat iron-deficiency anemia
Vitamin D

Lab Values
Lab

Reference Range

2/29

3/1

3/2

3/4

3/7

3/9

3/11

Hemoglobin
Hematocrit
Na+
K+
ClCO2
Glucose
BUN
Creatinine
Albumin
ALK
AST
ALT
Bilirubin
Calcium
Phosphorus
Magnesium
Triglycerides

10.7-13.4 g/dL
32.2-39.8%
133-143 mmol/L
3.3-4.7 mmol/L
97-107 mmol/L
16-25 mmol/L
54-117 mg/dL
6-17 mg/dL
0.2-0.79 mg/dL
3.6-5.2 g/dL
191-450 units/L
10-47 units/L
24-49 units/L
<0.8 mg/dL
9.0-10.1 mg/dL
3.2-6.1 mg/dL
1.5-2.2 mg/dL
30-110 mg/dL

9.9
27.1
137
4.2
104
22
115
11
0.65
2.7
485
70
146
0.6
9.0
3.6
1.9
130

134
4.1
103
20
138
18
0.74
8.9
4.4
1.9
-

136
4.1
104
22
139
24
0.78
2.9
541
112
203
0.9
9.1
4.5
1.9
-

138
4.3
106
20
96
8
0.52
2.8
576
158
266
1.0
9.4
4.3
1.7
-

9.6
26.8
136
3.7
101
23
117
18
0.62
2.9
661
115
249
1.0
9.6
4.2
1.9
117

135
3.8
99
26
108
23
0.76
2.7
648
112
241
0.9
9.9
3.8
2.1
-

132
3.8
95
26
117
20
0.83
2.9
684
111
214
0.9
9.7
3.7
1.8
-

This table represents AOs hematology and chemistry lab values from 2/29-3/11. Dates when labs were not taken were removed from table for space purposes.

Lab
Hemoglobin
Hematocrit

Reference Range

2/29

3/1

3/2

3/4

3/7

3/9

3/11

10.7-13.4 g/dL
32.2-39.8%

9.9
27.1

9.6
26.8

Hemoglobin & hematocrit are low indicating anemia, AO is

currently receiving ferrous sulfate to correct.

BUN
Creatinine

6-17 mg/dL
0.2-0.79 mg/dL

11
0.65

18
0.74

24
0.78

8
0.52

18
0.62

23
0.76

BUN is elevated and creatinine is trending up due to

nephrotoxic effects of amphotericin B liposomal medication.

20
0.83

Lab
ALK
AST
ALT
Bilirubin

Reference Range

2/29

3/1

3/2

3/4

3/7

3/9

3/11

191-450 units/L
10-47 units/L
24-49 units/L
<0.8 mg/dL

485
70
146
0.6

541
112
203
0.9

576
158
266
1.0

661
115
249
1.0

648
112
241
0.9

684
111
214
0.9

Liver function enzymes are elevated and continue to trend up

due to prolonged TPN causing secondary liver failure.

Glucose
Triglycerides

54-117 mg/dL
30-110 mg/dL

115
130

138
-

139
-

96
-

117
117

108
-

Glucose and triglycerides are elevated due to dextrose and

lipids from TPN.

117
-

Medications
Medication

Dosage

Amphotericin B
Liposomal
Erythromycin + NS

137.5 mg, 68.75 mL in

D5W
130 mg, 2.6 mL in 23.4
mL of NS q 6 hours

Gentamicin + NS

120 mg, 3 mL in 247 mL

NS q 48 hours

Linezolid

260 mg, 130 mL q 8 hours

Metronidazole (Flagyl)

250 mg, 1 tablet TID

Pantoprazole

26 mg, 32.5 mL daily

Prucalopride
SulfamethoxazoleTrimeth Oprim
(Bactrim)

1.5 tablets

Actions
Antifungal medication that treats most
severe fungal infections.
An antibiotic used to treat bacterial
infections. It may also be used to stimulate
gut motility.

Nutrition-Implications
Nephrotoxicity

Providing addition fluid. Side effects

include nausea, constipation, diarrhea, and
vomiting that could cause weight loss and
poor appetite.
An antibiotic used to treat bacterial
Providing additional fluid. Side effects
infections.
include nausea, constipation, diarrhea, and
vomiting that could cause weight loss and
poor appetite.
An antibiotic used to interfere with
Side effects include nausea, constipation,
proteins needed for bacterial growth.
diarrhea, and vomiting that could cause
weight loss and poor appetite.
An antibiotic used to treat infectious
Side effects include nausea, constipation,
bacteria of the reproductive system and GI diarrhea, and vomiting that could cause
tract.
weight loss and poor appetite.
Proton pump inhibitor to decrease
May limit absorption of vitamin B12 with
production of gastric acids.
long-term use
A high affinity 5HT4 receptor agonist that Improves chronic constipation.
accelerates small bowel function and
stimulates peristalsis.
An antibiotic used to treat UTIs, ear
Side effects include nausea, constipation,
infections, and bronchitis.
diarrhea, and vomiting that could cause
weight loss and poor appetite.

PES Statement
Altered GI function (NC-1.4) related to poor bowel
motility as evidenced by 1845 mL gastric output & NPO
status.
Reasoning:
GI dysmotility due to the intestinal pseudo-obstruction,
anything administered through the GI tract will be unable to
pass normally through the intestines causing back up

Nutritional Significance:
Removal of fluids to prevent complications such as aspiration
from occurring

Plans/Goals

Plans
Oral Nutrition - Remain NPO
Enteral Nutrition - Reinitiate home regimen Alimentum when stable to 2 mL/hour for the
first 2 days. Increase to 5 mL/hour with toleration and low residuals until matching
home regimen.

Tube advancement:

Positive output balance

Not visually dehydrated

Weight gain
No diaper rash (does not apply)

No increase in stooling

Parenteral Nutrition - Adjust TPN based on lab values, begin to reduce TPN to improve
liver function by decreasing overall kcals by 5 mL/hour for every 10 mL/hour of EN
started. Reduce to match home regimen.
Labs/Studies - Continue to monitor electrolytes for acid-base balance, liver function
enzymes, and BUN/creatinine for evaluating nephrotoxicity in order to readjust TPN
order.
Growth Weight maintenance

Keep AO above 75th percentile for BMI to reduce risk of decompensating

Future Plans
Patients mother is refusing intestinal transplant
Seeking use of prucalopride to stimulate gut motility
Will remove AO from public school as she believes this is the
source of Broviac infection
Goal: Send patient home on regular TPN & EN regimen

Summary
Pseudo obstruction
Nutritional implications
Treatment options
AO treatment
Future plans

Thank You
Special thanks to Hannah Leu & Aly Smith for their wealth of
knowledge & sacrificing their time!

References

Troppmann C, Gruessner RWG. Surgical Treatment:

Evidence-Based and Problem Orient.
http://www.ncbi.nlm.nih.gov/books/NBK6902/.
Accessed March 11, 2016.
Quigley EMM. Prucalopride: safety, efficacy and
potential applications. Therap Adv Gastroenterol.
2012; 5(1): 23-30.
Digestive Diseases: Intestinal Pseudo-obstruction.
National Institute of Diabetes and Digestive and Kidney
Diseases Web site.
http://www.niddk.nih.gov/health-information/healthtopics/digestive-diseases/intestinal-pseudoobstruction/Pages/facts.aspx. Created February 2014.
Accessed March 11, 2016.

Batke M, Cappell MS. Adynamic ileus and acute colonic

pseudo-obstruction. Med Clin North Am. 2008; 92(3):
649-70.

Emmanuel AV, Kamm MA, Roy AJ, Kerstens R,

Vandeplassche L. Randomised clinical trial: the efficacy
of prucalopride in patients with chronic intestinal
pseudo-obstruction - a double-blind, placebocontrolled, cross-over, multiple n = 1 study. Aliment
Pharmacol & Ther. 2012; 35(1): 48-55.

Photos Credits Courtesy of:

Slide 4:
http://radiopaedia.org/cases/colonicpseudoobstruction

Slide 10 http://www.gutmed.health.nz/gut-conditions/crohn-sdisease/

Slide 26: https://en.wikipedia.org/wiki/Prucalopride