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Intestinal Failure

Intestinal Failure (IF) comprises a group of disorders with many different causes, all of which are characterised by an inability to maintain adequate nutrition via the intestines. It is characterised not only by the inability to maintain protein-energy balance, but also results in difficulties in maintaining water, electrolyte or micronutrient balance1.  

Intestinal failure is sub-classified into 3 types depending upon the duration of nutritional support required and the reversibility of the original pathology:

Type 1 and Type 2: common, usually reversible and requires short-term parenteral nutrition.
Type 3: rare, irreversible and requires home parenteral nutrition1

Short bowel syndrome is a subcategory of IF and is defined as less than 200cm of small intestine 2
There are 3 common types of surgical resection:
1. Jejunoileal resection: these are common and it is unusual for these patients to have problems with nutrition 4.
2. Jejunocolic anastomosis: the presence of the colon in continuity is a huge advantage as the colon can absorb water and sodium and results in a slower intestinal transit time which in turn aids fluid and nutrient absorption 3.
3. Jejunostomy: Patients have immediate problems post operatively due to the large intestinal losses leading to fluid and sodium depletion. Patients who have a jejunstomy will have problems maintaining fluid and sodium balance 4.   

Dietary management of short bowel associated intestinal failure and intestinal insufficiency

A patient with a jejunostomy will feel thirsty due to the volume of fluid and quantity of sodium lost via their stoma.  Each litre of jejunal efflux lost contains approximately 100mmol/L of sodium5.  A stoma output of over 2 litres per day is classed as a high output stoma 6 and in patients with a jejunostomy, outputs of 4 - 5 litres per day are not uncommon 7.  

A common mistake in the management of these patients is to advise them to drink more fluids e.g. tea, coffee, squash, fruit juice to replace the fluid they have lost.  A prospective study conducted at a large teaching hospital in the UK reported that prior to the formation of a Nutrition Support Team in their hospital, patients with a high output stoma were often inappropriately advised to increase their intake of normal fluids 6.  Commonly consumed drinks contain the incorrect level of glucose and sodium required by patients who have a short bowel. Incorrect glucose levels without the presence of sodium can actually increase stoma output further thereby driving a vicious cycle of high stoma output resulting in dehydration and a strong thirst. Best practice is for patients to take 1,000ml of a high sodium-glucose drink and to limit their intake of other fluids to 500-1,000ml per day 89.

Glucodrate™ is a tropical flavoured, powdered blend of carbohydrate, high in sodium and low in other electrolytes. Glucodrate is a food for medical purposes that has been specifically designed to be used in the dietary management of short bowel-associated intestinal failure and intestinal insufficiency. Glucodrate must be used under medical supervision. Electrolyte and bicarbonate levels should be monitored when initiating this product.

1. Carlson G, Gardiner K, McKee R, MacFie J, Valzey C. The surgical management of patients with acute intestinal failure. Issues in Professional Practice. 2010. 
2. Nightingale, J., J. M. Woodward, B. Small and G. Nutrition Committee of the British Society of (2006). Guidelines for management of patients with a short bowel. Gut 55 Suppl 4: iv1-12
3. Nightingale, J. (1994). Clincial problems of a short bowel and their treatment. Proceedings of the Nutrition Society 53 (02): 373-391
4. Nightingale, J. M., J. E. Lennard-Jones, E. R. Walker and M. J. Farthing (1990). Jejunal efflux in short bowel syndrome. Lancet 336(8718): 765-768.
5. Baker, M. L., R. N. Williams and J. M. Nightingale (2011). Causes and management of a high-output stoma. Colorectal Dis 13(2): 191-197.
6. Beaugerie, L., J. Cosnes, F. Verwaerde, H. Dupas, P. Lamy, J.-P. Gendre and Y. L. Quintrec (1991). Isotonic high sodium oral rehydration solution for increasing sodium absorption in patients with short bowel syndrome. The American Journal of Clinical Nutrition 53: 769-772.
7. Lal, S., A. Teubner and J. L. Shaffer (2006). Review article: intestinal failure. Alimentary Pharmacology & Therapeutics 24(1): 19-31.
8. Nightingale, J. (2003). The medical management of intestinal failure: methods to reduce the severity. Proceedings of the Nutrition Society 62(03): 703-710.

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