Renuka Prasanth

Senior Clinical Dietician, Department of Clinical Nutrition & Dietetics, Kauvery Hospital, Chennai

Adhesive small bowel obstruction: Nutrition care process

Abstract

Adhesive small bowel obstruction (ASBO), is defined as the small bowel obstruction that results from adhesions that follow previous abdominal or pelvic surgeries.

Adhesions are scar tissue that form between two organs/ loops/ walls that are not normally connected to each other. Individuals who undergo open abdominal surgery may sometimes develop adhesions post-operatively, and these postoperative adhesions account for small bowel obstruction.

small-bowel-obstruction

Background

  1. Patients with SBS often have complex fluid, electrolyte, and nutritional management issues.
  2. Consequences of SBS include malabsorption of micronutrients and macronutrients, frequent diarrhoea, steatorrhea, dehydration, electrolyte imbalance, weight loss, and growth failure in children.
  3. Other complications include gastric hypersecretion, oxalate renal stones, and cholesterol gallstones.

Symptoms

The common signs and symptoms of short bowel syndrome may include:

  1. Diarrhoea
  2. Greasy, foul-smelling stools
  3. Cramping
  4. Bloating
  5. Heartburn
  6. Fatigue
  7. Weight loss
  8. Malnutrition
  9. Swelling (oedema) in the lower extremities.

Medical nutrition therapy

  1. Most patients who have significant bowel resections require Parenteral Nutrition (PN) initially to restore and maintain the nutrition status.
  2. The duration of PN and subsequent nutrition therapy shall be based on the extent of the bowel resection, the health of the patient, and the condition of the remaining GI tract.
  3. Enteral feeding provides a trophic stimulus to the GI tract; PN is used to restore and maintain nutrient status
  4. The more extreme and severe the problem, the slower the progression to a normal diet. Small, frequent mini meals (6 to 10 per day) are likely to be better tolerated than larger feedings.
  5. Tube feeding may be useful to maximize intake when a patient would not typically eat, such as during the night.

Because of malnutrition and disuse of the GI tract, the digestive and absorptive functions of the remaining GI tract may be compromised, and malnutrition would delay postsurgical adaptation.

Intestinal adaptation

  1. Short bowel syndrome (SBS) occurs after surgical resection, congenital defect, or disease of the bowel.
  2. The severity of SBS depends on the length and anatomy of the bowel resected, the health of the remaining mucosa as well as the presence of an intact stomach, pancreas and liver.
  3. During the two years after resection, the remnant bowel undergoes an adaptation process that increases its absorptive capacity.

Nutrition care process

1. Anthropometric Data

Biochemical-data

Subjective global assessment

Rating: B

Category: well-nourished but at risk

2. Biochemical data

Biochemical-data-2

3. Clinical data

Clinical-data-1
Clinical-data-2

Diet history

Diet habit: Non vegetarian

Food allergy: Nil

PES statement

Problem Etiology Symptom
Altered GI function Related to Underlying medical condition of the patient (ASBO) As evidenced by Abdominal pain and obstructed defecation.
pes-department

Medical nutrition therapy (Post-Op)

Energy: To provide adequate amounts of energy to meet post-surgery requirements and to maintain optimal nutritional status. A small frequent meal (6 meals) is recommended for effective absorption of nutrients. weight management is also necessary as obesity can complicate the underlying medical condition.

Carbohydrate: To provide adequate amount of carbohydrate to replenish energy reserves.

Protein: To provide a high protein diet to promote wound healing and to aid in tissue repair.

Fat: To provide moderate amounts of fat prevent unhealthy weight gain, medium chain triglycerides are recommended as they are easily absorbable.

Fibre: To limit the intake of fiber initially and gradually increase to promote satiety. Provide adequate amounts of soluble fiber as it is better tolerated and it reduces further inflammation.

Fluids: Adequate fluids should be consumed between meals rather than with meals to maintain hydration status.

Micronutrients: Micronutrient supplements are necessary to compensate losses. Vitamin B12, calcium, potassium and zinc supplements are commonly recommended. High oxalate foods rea restricted to avoid further.

Nutritional prescription

Nutritional-prescription

Diet history

Diet-history
Diet-history-1

Graphical representation – Diet history

Graphical-representation-Diet-history
Graphical-representation-Diet-history-1

Conclusion

A 64-year-old female presented with complaints of diffuse abdominal pain, nausea, and vomiting that had been noticeable for a few days. An anterior abdominal wall hernia with small bowel obstruction was revealed on CT abdomen. As a result, surgical management for the patient was planned. The patient had no other co-morbid conditions. The patient’s surgical history revealed that she had previously undergone ventral hernia mesh repair. Initially, the patient underwent laparotomy (scar excision, adhesiolysis, and anatomical repair) as part of her surgical management. The patient was then initiated with oral feeds. After a couple of days, a Gastrograffin study was planned for the patient due to complaints of persistent vomiting, abdominal distension, and altered bowel movements. As a result, the patient was scheduled for another procedure in which she underwent Re-laparotomy with adhesion release and ileum resection anastomosis. Following surgery, the patient was immediately started on TPN and gradually transitioned to oral feed. In the latter period, a high protein diet plan was planned for the patient, as well as a semi elemental formula (ONS) was prescribed. The patient’s condition gradually improved, and the adaptive phase showed better results. The patient was advised to follow a high protein diet at the time of discharge. The patient and the family members were counselled on high protein diet plan and diet chart given.

 

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