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Intestinal

Rehabilitation for Adults

Section 1: Basics of Intestinal Rehabilitation

What is the basic anatomy and physiology of the gastrointestinal (GI) tract and its importance for short bowel patients?


Step 1: The gastrointestinal tract begins at the mouth where mechanical digestion begins. Saliva in the mouth functions to moisten and lubricate food before swallowing and to partially digest food particles.

Step 2: Food moves from the mouth, down the esophagus, and into the stomach.

Step 3: In the stomach, glands secrete hydrochloric acid, which helps digest food and destroy bacteria that enter the body with the food. Little nutrient absorption occurs in the stomach. The digested particulate matter, known as chyme, moves from the stomach into the first portion of the small intestine, the duodenum.

Step 4: Small Intestine

It is in the small intestine where most of the digestion and absorption of food occurs. Special enzymes breakdown carbohydrates, fat, and proteins into smaller components that the intestinal cells can absorb and use throughout the body for nutrients. The pancreas and liver also secrete substances into the small intestine to aid in the digestion of substances.

The small intestine has 3 parts:

1. Duodenum: Main section for absorption of iron and folate. This is also the section that bile and pancreatic enzymes enter the intestine to aid in digestion.

2. Jejunum: Major section of nutrient absorption.

3. Ileum: Major section of nutrient absorption. This is the only section of intestine that can absorb vitamin B12. If your child does not have his or her ileum, which is common in short bowel patients, they will require vitamin B12 supplementation.

Step 5: Food passes from the ileum through the ileocecal valve and enters the colon. The colon serves two main roles:

1. Acts as a storage chamber for undigested material.

2. Functions to reabsorb water.

Step 6: When initiated, contractions of the rectum and relaxation of the anal sphincter cause defecation, and stool is deposited.

Digestion and absorption rely on many components of proper contractions, enzymes, and cell function. If any of these functions are impaired, then the process may not proceed as planned, as seen in patients with intestinal failure.

For a handy graphic and overview of this process, find our 'Overview of Digestion' handout below.




What are predictive factors for successful intestinal adaptation and the ability to wean from TPN?


Predictors of intestinal adaptation and the ability to wean from parenteral nutrition include:

  • The length of the bowel remaining.
  • The anatomical section (i.e. location/ portion) of bowel that is remaining.
  • Presence or absence of the ileocecal valve.
  • Presence or absence of the colon.
  • Health of the remaining bowel (i.e. is there inflammation)

Since different parts of the bowel absorb different types of nutrients, the intestinal resection's anatomical location will determine which nutrient deficiencies to expect.




What is a basic overview of intestinal rehabilitation?


Enteral (i.e. passing through the intestine either via the mouth or tube feeding) is critical to maintain normal intestinal structure and function. In order to transition your child from parenteral to enteral nutrition (EN), the intestinal epithelium (lining) must adapt to optimize nutrition absorption.

Your team of surgeons, gastroenterologists, and dieticians will work with you to determine the optimal formula and diet to help the intestine adapt.

In general, carbohydrates may be poorly tolerated by intestinal failure patients as they are broken down by the gastrointestinal tract bacteria into small, osmotically (water) active organic acids that can cause a large amount of water to be drawn into the distal small intestine and colon, causing large fluid losses. Moderate amounts of fat are usually tolerated in the short bowel syndrome diet as well as protein.

You can become dehydrated quickly due to large fluid losses from a high output ostomy, persistent secretory diarrhea, or pseudo-obstruction resulting in large gastric and duodenal losses. In cases like these, an oral rehydration solution containing glucose and sodium may be recommended. You may be required to monitor your urine and stool output to assess your hydration status.

If you have short bowel syndrome or persistent diarrhea and require tube feedings, a continuous feed through a nasogastric (NG) tube or gastrostomy tube may be recommended. This permits constant saturation of the carrier proteins, thus taking full advantage of the limited absorptive area of the intestine.

It is important to understand that the transition from intestinal failure to adequate intestinal function and the ability to wean from parenteral nutrition to full enteral feeding can take weeks, months, and even years.




What is intestinal failure (IF)?


Short bowel syndrome may lead to intestinal failure. Intestinal Failure (IF) develops when your small intestine does not provide the necessary long term nutrition needed to sustain a normal life. This results in the need for additional long term nutrition to be delivered through large veins in the body. This is called "Parenteral Nutrition" or "PN."




What is intestinal adaptation and why is this important for intestinal rehabilitation?


Intestinal adaptation is the bowel's ability to 'adapt' or adjust to the changes that have occurred within the intestine. The intestine compensates for lost function in one area of the intestine by adapting at another site. Intestinal adaptation is a slow process and can take up to two years to complete. Intestinal rehabilitation relies on intestinal adaptation to successfully wean from parenteral nutrition (PN). The following occur during intestinal adaptation:

  • The diameter of the bowel increases.

  • The surface area to absorb nutrients increases by increasing the number and size of the intestinal villi (the finger-like projections from the intestinal lining).

  • The movement of contents through the bowel slows, increasing the time contents spend in contact with the intestinal wall.




What is intestinal rehabilitation?


  • Before pursuing a transplant, intestinal rehabilitation is usually attempted in patients with intestinal failure.
  • Intestinal rehabilitation is the process of restoring nutritional autonomy in patients with short bowel syndrome and intestinal failure. This means weaning from PN and onto oral feedings to the point in which one can live life without PN and the associated complications.
  • There are multiple components to intestinal rehabilitation, and all therapies focus on maximizing the absorptive capacity of the bowel.




What are the components of intestinal rehabilitation?


1. Diet modification 2. Oral Rehydration Therapy 3. Vitamin and Mineral Supplements 4. Medications 5. Surgical Procedures




Who is on an intestinal rehabilitation team?


At an intestinal rehabilitation center, you will have a team of clinicians to support you through your journey. Typically on an intestinal rehabilitation clinical team, you will find a:

  • Surgeon
  • Gastroenterologist
  • Nutritionist or Dietician
  • Social Worker
  • Clinical Nurse Coordinator
  • Advanced Practice Nurse
  • Mid-Level Providers
  • Pharmacist





Section 2: Diet and Hydration

Carbohydrates


Carbohydrates are an essential energy source in the diet, but for patients with short bowel syndrome, the type and amount of carbohydrate consumed must be limited to avoid exacerbating diarrhea. Simple carbohydrates, or sugar, have an osmotic effect: this means water is drawn into the intestine and will increase your diarrhea. Avoid simple sugars, such as cookies, doughnuts, fruit juices. Complex carbohydrates are well-tolerated and should be roughly 50-60% of the diet (with a colon) and 40-50% of the diet (without a colon). Examples include bread, pasta, rice.




Fiber


Two types of fiber: Soluble Fiber:

  • Include soluble fiber in your diet.
  • Soluble fiber helps to slow movement through the intestine.
  • Soluble fiber passes from the small intestine undigested into the colon, where colonic bacteria ferment it.
  • One of the byproducts of fermentation is butyric acid which is a valuable source of calories, improves the integrity of lining cells, and enhances absorption of water and salt.
  • If consumed excessively, it may contribute to gas, bloating, and malabsorption.
  • Examples: Metamucil®, Benefiber®, Nutrisource®, pectin, guar gum, oatmeal, barley, legumes.
Insoluble Fiber:
  • Avoid insoluble fiber, which tends to hold water in the intestine, increasing diarrhea.
  • Insoluble fiber increases transit time and movement of stool through the intestine.
  • Examples: vegetable stems, fruit and vegetable skins, seeds.




Protein


Protein is a very important nutrient to maintain and rebuild tissues. It is recommended that protein is about 20% of dietary calories. Try to include protein with every meal. Foods high in protein include things such as chicken breast, turkey, eggs, cheese, and yogurt.




Fat


Fat is an important source of energy for the body and it provides insulation and protection for internal organs. Fat also supplies essential fatty acids and fat-soluble vitamins (A, D, E, and K). The recommendation is for fat to be 20-30% of dietary calories with a colon and 30-40% of diet without a colon. Short bowel patients should prioritize polyunsaturated fats as these contain essential fatty acids (EFAs), or fatty acids that the body cannot make.




Types of Fluids


Hyper-Osmolar

  • These are fluids that contain sugar (glucose) and minimal salt (sodium).
  • These types of fluids cause water to be drawn into the intestine, causing watery diarrhea.
  • Examples: Juice, sugary soda drinks.
  • Should be avoided by short bowel patients to prevent dehydration.
Iso-Osmolar
  • These are fluids that contain electrolytes (sodium, potassium) and glucose in the same concentration as the body's extracellular fluid.
  • These types of fluids do not cause water to be drawn into the GI tract- ideal for short bowel patients.
  • Examples are oral rehydration solutions like Pedialyte® or G2®
Hypo-Osmolar
  • These are fluids that contain little to no sugar (glucose) and salt (sodium).
  • The GI tract partially absorbs these types of fluids.
  • Examples: Water, sugar-free drinks
Check out our types of fluids sheet for more information. Find it under our December Topic of the Month Tab. Access by signing up as a site member.




What is Oral Rehydration Therapy (ORT)?


  • In addition to maintaining nutrient intake, you also maintain hydration status.
  • To maintain hydration status there must be an equal amount of input and output of fluids.
  • Fluid imbalance occurs when there is either a fluid deficit, such as losing fluid with diarrhea, or fluid surplus, such as retaining water with heart failure.
  • As a short bowel patient, you are at a high risk for fluid deficits and electrolyte abnormalities due to their large amounts of diarrhea, causing a significant loss of water and sodium.
  • Rehydration with just water and/or water+sodium will result in the continued loss of fluids.
  • The use of oral rehydration solutions (ORS) can help solve this problem.




Oral Rehydration Solutions (ORS)


Oral rehydration solutions (ORS) are a mixture of water, sodium (possibly other salts), and glucose (sugar) that utilize a unique sodium-glucose transport mechanism across the intestinal cell wall.

  • This results in the absorption of Na+, creating a gradient, and water follows.
  • There are numerous formulations, flavors, and types of ORS.
  • ORS solutions may be purchased or can be homemade.
  • Commercial examples include: Pedialyte,® DripDrop, Ceralyte,® or Liquilyte®.
  • The solutions contain the proper amunt of salt, sugar, and fluid to restore the fluid, potassium, and sodium that is lost from the excessive diarrhea (i.e. iso-osmolar as described above).
Check out our types of fluids sheet for more information. Find it under our December Topic of the Month Tab. Access by signing up as a site member.




General Diet Tips for Short Bowel and Intestinal Rehabilitation Patients


  • Eat small, frequent meals 6-8 times per day. Try to include protein with each meal.
  • Chew food well, which helps to increase digestion and absorption of nutrients.
  • Supplement appropriate vitamins and minerals, as reccomneded by your team.
  • If you have a colon, limit intake of oxalate to avoid formation of kidney stones.
  • Try to avoid high sugar drinks and desserts, which draws more water into the intestine and increases diarrhea.
  • Limit your fluids at mealtime because fluids can increase output, push food through the bowel faster, and hinder nutrient absorption.
    • A general rule is to limit fluids to 1/2 cup (4 oz) during a meal.
    • Consume the rest of their fluids in between meals throughout the day, with at least a one hour buffer from food.




Why is it important to try and introduce oral foods early after a bowel resection?


Food moving through the digestive tract is one of the strongest stimulators of intestinal adaptation and release of trophic (growth) factors. If you rely solely on parenteral nutrition, your body will not release these important growth stimulators, reducing the likelihood of successful intestinal adaptation and the ability to wean from PN.





Section 3: Medications

Possible Medications for Intestinal Rehabilitation


1. Anti-diarheal medications or medications that help decrease ostomy output. 2. Anti-secretory/ anti-acid medications 3. Bile acid binders 4. Antimicrobials 5. Growth Hormone 6. Glucagon-Like Peptide 2 (GLP-2) Analog




Anti-Diarrheal/Motility and Medications that Decrease Output


Anti-diarrheal medications slow down the movement of contents through the intestine. This increases the time contents spend in contact with the intestinal wall, thus, increasing absorption. Examples include:

  • Loperamide (Imodium®)
  • Diphenoxylate/atropine (Lomotil®)
  • Codeine
  • Tincture of opium
  • Octreotide: This is the man-made form of a hormone called somatostatin. It functions to slow down the action of the small intestine, decrease small bowel secretions, and enhances the absorption of water and salts. It helps to decrease your ostomy output and diarrhea if extremely high.




Anti-Acid and Anti-Secretory Medications


These medications decrease the amount of stomach acid the stomach produces. In children with a short bowel, it is common for the stomach to secrete excess acid, known as gastric hypersecretion. This can lead to increased diarrhea, heartburn, ulcers, poor digestion, and other issues. Your child's team may recommend taking one of these medications to help with these signs and symptoms. Examples include:

  • H2 blockers: famotidine (Pepcid®), ranitidine (Zantac®)
  • Proton-pump inhibitors: omeprazole (Prilosec,® Losec®)
  • Octreotide
  • Clonidine




Bile Acid Binders


These function to bind excess bile salts, which can worsen short bowel syndrome malabsorption. They can help with bile salt diarrhea, but must be taken carefully because they can also affect your ability to absorb fat-soluble vitamins and nutrients. An example is cholestyramine.




Antimicrobials


It is common for individuals short bowel syndrome to get small intestinal bacterial overgrowth. This is treated with an antimicrobial agent or regimen. Your team will recommend the best antimicrobial treatment. Probiotics may also be suggested to help with SIBO.




Growth Hormone


Growth hormone, known as somatropin, is made by the pituitary gland in the brain. When released into the body, it promotes the growth and maintenance of organs and tissues. It has been made into a synthetic form. When injected into an individual's with short bowel, it has been shown to enhance intestinal adaptation and increase absorption of fluids and nutrients.




GLP-2


Glucagon-Like Peptide-2 (GLP-2) (Teduglutide, Gattex®): GLP-2 is a substance usually produced naturally by the human body. Gattex® is an injectable analog that is FDA approved for children >1 year of age with short bowel syndrome and dependent on PN. Function: Improves absorption of fluids and electrolytes by increasing the absorptive surface of the small intestine. The goal of starting the medication is to help you wean completely from PN.





Section 4: Surgical Procedures

What are the main goals of intestinal rehabilitation surgical procedures?


The last component of intestinal rehabilitation is reconstructing an individual's native bowel via various surgical techniques. The methods either try to optimize the function by lengthening or tapering the dilated bowel or slowing the transit, increasing the time the food and fluid comes in contact with the bowel wall, hopefully increasing absorption of nutrients. Surgery may involve procedures which:

  • Narrow a dilated segment of the small intestine.
  • Slow the time it takes for food to travel through the small intestine.
  • Lengthen the small intestine.
  • Prevent blockage and preserve the length of the small intestine.




Bianchi Procedure


The dilated short bowel is divided in half (cut along its length) and sewed one end to the other, therefore, creating a longer, narrower tube with a smaller diameter.




Serial Transverse Enteroplasty Procedure (STEP)


This involves lengthening dilated small bowel by creating a row of alternating slits in the small intestine and stapling the V-shaped cuts shut, creating a zig-zag like tube. The benefit of the STEP is that it can nearly double the bowel's length, greatly enhancing the amount of time nutrients spend in contact with the absorptive intestinal surface.




What happens if I fail intestinal rehabilitation and am unable to wean from PN?


If you are unable to wean from PN using intestinal rehabilitation therapies, your team may recommend an intestinal transplant. Please visit our site here for a complete overview of intestinal transplantation.





Section 5: Additional Resources

Helpful Downloads from Transplant Unwrapped


Sign-Up or Log-In to Access: 1. Short Bowel Syndrome (SBS) and Intestinal Rehabilitation Handbook. 2. The Digestive System: A brief overview of the important parts of the digestive tract and how they relate to short bowel. 3. Short Bowel Syndrome At-a-Glance for Adults. 4. The Best Fluids for Intestinal Patients.




Transplant Unwrapped: Support Programs


Consider participating one (or all!) of the Transplant Unwrapped Support Programs to ask questions and learn from the personal experiences of patients, caregivers, and other members of the intestinal community. 1. Ambassador Program: For one-on-one support. 2. Facebook Support Group: Moderated discussion group. 3. Ask the Expert: Ask our panel of experts your burning questions. 4. Virtual Support Sessions: Monthly virtual support sessions for patients and caregivers.




Transplant Unwrapped: Learn From Others


Learn From Others: Read stories, watch interviews, and listen to audio from numerous members of the intestinal community on a variety of topics. Useful for This Section: Learn from Others- Webinars- Short Bowel and Intestinal Rehabilitation presented by Dr. Khanna.




Page References


References here.