From
StayCurrentMD
Intestinal Rehabilitation, Episode 3: Enteral Autonomy, Part 2
With Dr. Paul Wales
Chapter 1 of 7 · Fundamentals
Nutritional principles
Introduction and nutritional principles for enteral autonomy
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Nutritional choices including elemental versus semi-elemental versus intact macronutrient diet selection are guided by residual anatomy and functional status
Inadequate caloric support results in poor growth, impaired healing, and diminished adaptive response
Bowel heals with adhesions which bring blood supply to the bowel and help it heal
Placing a tube beyond the pylorus at time of surgery while allowing NG decompression of the stomach, later changed to gastrostomy tube, has been beneficial at Cincinnati Children's
Refeeding through a tube is done best and allows standardized nursing feeding practices
High ostomy outputs without feeding are an indication to feed, as long as the child can be hydrated, though this presents a clinical challenge
After massive bowel resection, patients can be hypergastrinemic with elevated acid secretion for 6 to 12 months due to loss of distal bowel and hormonal feedback
Acid blockade (H2 blocker or PPI) can decrease gastric volume in the short term
Acid blockade carries risk of bacterial overgrowth by losing the acid barrier
Prokinetic therapy options include intravenous agents (metoclopramide, erythromycin) or enteral agents (domperidone, cisapride) to improve gastric emptying and motility
Increased secretions result from thick, leaky mucosa which requires delivery of luminal nutrients to heal
Serum bicarbonate above 20 indicates feeding is generally safe even with high ostomy outputs (40-60 cc/kg), and acetate can be added to TPN for hydration support
Enteral antibiotics are often cycled for bacterial overgrowth treatment in an empiric and ad hoc manner
Anti-secretory or anti-diarrheal medications to decrease losses include octreotide, clonidine, and loperamide
Antibiotic treatment should have defined endpoints and duration rather than empiric two-week courses when the child is not showing clinical signs of illness
Surgical procedures to promote adaptation fall into three categories: restoring continuity, affecting motility, and lengthening the bowel
Closing a stoma immediately recruits more bowel
As bowel becomes increasingly dilated, its motility becomes impaired
Restoring bowel caliber to normal improves motility, clearance, decreases bacterial overgrowth, allows mucosal healing, and improves absorption
Bowel tapering can be performed on the anti-mesenteric side or the dilated segment can be resected if the patient has adequate length
Bowel lengthening procedures include the Bianchi procedure (longitudinal intestinal lengthening, available since 1980) and the serial transverse enteroplasty (STEP)
The most important factor for efficacy of both Bianchi and STEP procedures is that they taper the bowel
STEP differs from anti-mesenteric tapering or resection by preserving all available mucosa without removing any
In patients who are shorter with dilated bowel segments where resection is undesirable, STEP or Bianchi become options to preserve all mucosa while addressing dilatation
Bowel lengthening procedures redistribute rather than increase surface area; ongoing dilatation and bowel growth in infants and young children eventually result in more surface area through downstream adaptive responses
It takes approximately 6 months to see changes in absorption after bowel lengthening procedures, as demonstrated in published absorption studies measuring fecal fat, alpha-1 antitrypsin clearance, xylose, and citrulline
An upper GI study can rule in a problem but does not rule out a problem; a normal upper GI does not exclude an anatomical problem
Implementation of a feeding protocol is associated with achieving full enteral autonomy in a shorter time period, based on literature from Chris Duggan's group at Boston
Dilated bowel with impaired motility leads to stool stasis, mucosal inflammation, barrier damage allowing bacterial translocation, potential sepsis, and malabsorption
The new ASPEN guidelines define enteral autonomy as independence from parenteral support for 12 weeks