FUNCTIONAL SHORT GUT SYNDROME: A CASE CAPSULE

Functional short gut syndrome: A case capsule

Yamini Prakash¹, Renuka Devi.K², Kamali⁴, Nalini Sivakumar⁵

Lead clinical dietician, Department of Clinical Dietetics, Alwarpet unit, Chennai

Senior clinical dietician, Department of Clinical Dietetics, Alwarpet unit, Chennai

Clinical dietician, Department of Clinical Dietetics, Alwarpet unit, Chennai

Background

Functional Short gut syndrome is a group of problems related to poor absorption of nutrients. Short gut syndrome cannot absorb enough water vitamins, minerals, protein, fat, calories and other nutrients from food. Short gut (bowel) syndrome typically occurs in people who have

Had at least half of their small intestine removed and sometimes all or part their large intestine removed.
Significant damage of the small intestine.
Poor motility, or movement, inside the intestines.
Short bowel syndrome may be mild, moderate or severe depending on how well the small intestine is working.

Expected signs and symptoms

Bloating
Cramping
Fatigue, or feeling tired
Foul smelling stools
Heart burn
Too much gas
Vomiting
Weakness

Case presentation

Admission 1

D.O.A: 24/11/2022; D.O.D: 26/11/2022

A 41 years male, with the complaints of recurrent vomiting with abdomen distention diagnosed- small bowel obstruction with perforation peritonitis on 3/11/2022, underwent laparotomy with small bowel resection and ileostomy on 4/11/2022 in outside hospital, now came here for further management.

Patient came with the complaint of history of weight loss, vomiting, nausea, loose stools, and dysuria and also had complaints of weakness, fatigue, tiredness and the patient had a huge volume of output in via ileostomy.

The provisional diagnosis

Post Laparotomy status Small Bowel Resection with End of Illeostomy (Short Bowel Syndrome)

Admission 2

D.O.A: 3/1/2023; D.OD:6/1/2023

Patient came with the complaint of history of giddiness and fall sustained injury in right frontal region, swelling for 2 days back and also had a history of decreased urine output since 4 weeks.

No other complaints like vomiting, nausea, seizures. As diagnosed syncope 2nd degree postural hypotension and AKI. Treatment Plan: Electrocardiogram was taken which is normal and colonoscopy was planned.
Admission 3

D.O.A: 12/1/2023; D.O.D:24/1/2023

Patient came with the complaint of fever on and off for 2 days, he is a known case of crohnâ€™s disease – S/P ileostomy. Patient was on Home TPN since 1 week. Patient admitted for ileostomy reanastomosis. He is a known case of functional gut syndrome and s/p crohnâ€™s ileostomy bag in November 2022. Patient doesnâ€™t have any other gastric symptoms; necessary investigations were done TPN line was removed. Surgical gastroenterologist opinion obtained and planned for reanastomosis.

Nutrition Care Process

Anthropometric Data

Height	175cms
Weight	56.2kgs(24/11/2022)
BMI	18.3kgm2 According to WHO BMI classification patient falls under underweight category.
Ideal Body Weight	58kgs-73kgs

Biochemical Data: Admission 1

Vitals	24-11-2022	24-11-20222	24-11-2022
HB	11.6
PCV	36.7
WBC	13500
Platelets	4,47,000
Neutrophils	94.7
Lymphocytes	2
Monocytes	2.6
Basophils	0.4
Urea	26.9
Creatinine	0.79
Sodium	137.6
Potassium	6.7	5.2	5.98
Chloride	105.2
Bicarbonate	20.2
T. Bilirubin	1.15
D. Bilirubin	0.58
I. Bilirubin	0.57
SGOT (AST)	88.6
SGPT	184.7
T. Protein	7.27
Albumin	4.07
CRP	16.08
Magnesium	1.9

Biochemical Data: Admission 2

Vitals	03-01-2023	04-01-2023
HB	12.9
PCV	38.6	38.7
WBC	7100
Platelets	1,86,000
Neutrophils	79
Lymphocytes	6.9
Monocytes	11
Basophils	0.3
Urea	33.1
Creatinine	1.66	1.2
Sodium	133	137.4
Potassium	4.92	3.66
Chloride	84	64.3
Bicarbonate	38.6	28.2
T. Cholesterol	126
TGL	225.9
LDL	52.1
VLDL	45.2
CHOL/HDL	3.6
T. Protein	7.99
Albumin	5.17
Globulin	2.82
Ferritin	34.95
CRP	8.71

Biochemical Data: Admission 3

Vitals	12-01-2023	15-01-2023	17-01-2023	23-01-2023
HB		8.8		8.4
PCV		25.8		24.3
WBC				5000
Platelets		85,300		414000
Neutrophils				84
Lymphocytes		4.3		6.2
Monocytes		9.4		6.6
Basophils		0.8		0.2
Urea		14.5		12
Creatinine		0.76		0.67
Sodium		143		144
Potassium		3.5		3.13
Chloride		111.1		107.2
Bicarbonate		23.2		29.4
T.Bilirubin				0.47
D.Bilirubin				0.24
I.Bilirubin				0.23
SGOT (AST)				38.8
SGPT				30.6
T. Protein				5.48
Albumin				2.88
Globulin				2.6
S. Uric Acid		3.88
S. Phosphorus		4.15		2.93
S. Calcium				7.91
SAP				67.6
PTT			13
INR			1.14
C			11.4
RBC				2.95
MCH				28.5
MCV				82.2
MHC				34.7
Dengue IgG	POSITIVE
CRP	50.7

Clinical Data- first two admissions

Chief Complaints	Drastic weight loss, loose stools, nausea, vomiting, fatigue, tiredness and weakness.
Diagnosis	Post Laparotomy status small bowel resection with end of ileostomy short bowel syndrome.
History of Past Illness	Laparotomy with small bowel resection and ileostomy on 4/11/2022.
Plan of Treatment	Medical Management Peripheral TPN @ 30ml/ hourly adequate oral soft high protein diet

Vitals: Admission 1

BP	90/60mg
Pulse	104bpm
RespirationRate	18b/min
Spo2	97%
Temperature	98.1F
CBG	106mg/dl
GCS	E4 V5 M6
Vitals	03-01-2023	04-01-2023	05-01-2023	06-01-2023
BP	80/60	105/60	100/60	100/60
Pulse	78/bpm	80/bpm	68/bpm	68/bpm
RR	20b/min	20b/min	20b/min	20b/min
Temperature	98.1F	98.1F	98.1F	98.1F
SPO2	100%	98%	100%	100%
CBG	125mg/dl
GCS	15/15

Vitals: Admission -2

Vitals

12/1

13/1

14/1

15/1

16/1

17/1

18/1

19/1

20/1

21/1

22/1

23/1

110/80

100/70

110/70

125/80

130/80

120/80

130/80

Pulse

128/BPM

84/BPM

82/BPM

81/BPM

82/BPM

85/BPM

74/BPM

20/BPM

Temp

104.3F

98.4F

99.2

98.4F

SPO2

98%

97%

CBG

112mg/dl

104mg/dl

98mg/dl

GCS

15/15

Vitals: Admission – 3

Dietary Assessment

Diet Habits	Vegetarian No Onion Garlic
Food Allergies	Nil
Energy	2000kcals(30kcals/kgIdealbodyweight)
Protein	87g(1.2g/kgIdealbodyweight)
Carbohydrate	60%ofTotalCalories
Fat	25%ofTotalCalories
Fluids	Liberal
Salt	6grams/day
Micronutrients	AsperRDA

Patient was following normal diet due to frequent output in ileostomy bag was high. Patient family was feeding him every 30 minutes like chocolates, beverages, and juices etc.

Medical Nutrition Therapy

Subjective

GlobalAssessment

Severely Malnourished

(complaints of weight loss 8kgs in past 1 week)

Nutrition Prescription

Diet Compliance: Oral Nutrition Supplement and Total Parenteral Nutrition was initiated as a part of nutrition prescription Oral soft bland diet plan was initiated and educated to patient and family.

PES Statement

Problem

Etiology

Symptom

Altered

Function

Relatedto

Short

Bowel

Syndrome

evidenced

Weight Loss,

tired Ness,

loose Stools,

fatigue

and weakness

Hospital Diet History – Admission 1

Day	Date	TypeofDiet	Energy (kcals)	Protein(g)	Remarks
1	24-11-2022	TPN@30ml/hrlyinitiatedwithONS-2timesaday+oralsoft blanddiet Totalvolume:660ml(TPN Oraldiet	1064kcals	35g	Bowelopeningassoonasfoodintake.Bowelrestwassuggested
2	25-11-2022	TPN @60ml/hr increased + ONS – 2 times a day + soft bland dietTotal volume: 1340ml (TPN) Oral diet	1838kcals	64g	Only2ndhourlyoralfeedssuggested
3	26-11-2022	TPN@40ml/hrlymodified+ONS-2timesaday+softblanddiet	1845kcals	70g	StoppedTPN,oralsoftsolidhighproteinMCTRichDietwaseducatedondischarge

Hospital Diet History – Admission 2

Days	Date	Typeofdiet	Energy	Protein	Remarks
1	03-01-2023	NPO			For colonoscopy
2	04-01-2023	High protein diet + ons thrice a day	1300kcal	44gms	TPN initiated with high protein diet
3	05-01-2023	High protein diet + tpn initiated + ons thrice a day	1759kcal	70gms	Intake was fair No GI symptoms
4	06-01-2023	High protein diet + tpn initiated + ons thrice a day	2010kcal	84gms	Suggested to follow home tpn for next 7 days and suggested follow low fat high protein mct based diet

Days	Diet	Energy (Kcals)	Protein (G)
DAY1	Tpn+oralhighproteinsoftsoliddiet 1100kcals+500kcal/50g+25g	1600kcals	75g
DAY2	Tpn+oralhighproteinsoftsoliddiet 1100kcals+750kcal/50g+35g	1850kcals	85g
DAY3	Tpn+oralhighproteinsoftsoliddiet 1100kcals+700kcal/50g+38g	1800kcals	88g
DAY4	Tpn+oralhighproteinsoftsoliddiet 1100kcals+800kcal/50g+40g	1900kcals	90g
DAY5	Tpn+oralhighproteinsoftsoliddiet 1100kcals+900kcal/50g+45g	2000kcals	95g
DAY6	Tpn+oralhighproteinsoftsoliddiet 1100kcals+900kcal/50g+40g	2000kcals	90g
DAY7	Tpn+oralhighproteinsoftsoliddiet 1100kcals+1000kcal/50g+55g	2100kcals	105g

Home Care Nutrition

Advised TPN (total parental nutrition) – 1

Hospital Diet History: Admission – 3

Days	Date	TypeofDiet	Energy	Protein	Remarks
1	13-1-2023	HighProteinDiet+ONS	1847Kcal	72g	Intakewasgood
2	14-1-2023	HighProteinDiet+ONS	2609Kcal	85g
3	15-1-2023	HighProteinDiet+ONS	2062Kcal	70g
4	16-1-2023	NPOforsurgery	nil	nil	PostedforIleostomyclosure
5	17-1-2023	NPOpostoperatively	nil	nil
6	18-1-2023	NPOpostoperatively	nil	nil
7	19-1-2023	NPOpostoperatively	nil	nil
8	20-1-2023	Oralclearliquiddietstartedat30ml/hourly	100Kcal	2g
9	21-1-2023	OralClearLiquiddiet	250Kcal	10g	oralliquidsprogressed
10	22-1-2023	OralLiquiddiet	440Kcal	19g	Oralsoftdietmodified
11	23-1-2023	Highproteinsoftdietmodified	500Kcal	26g	StartedONSThriceaDay
12	24-1-2023	Highproteinsoftdietmodified	1000Kcal	55g	Educatedpatientandfamilyabouthighproteindietondischarge

Nutrition Intervention Goals

Short Term Goals

To improve oral intake and to prevent nutrition deficiencies.
To control inflammatory markers.
To use high protein diet, Tpn and other oral semi elemental supplementation. If needed.

Long Term Goals

To facilitate nutrition well-being of the patient.
To promote quality life of the patient.

Anthropometric Data

Height	175 cms
Weight	62kgs(13/1/2023)
BMI	20.2 kg/m2 According to WHO BMI classification patient falls under Normal weight category
Ideal Body Weight	58kgs to 73 kgs

Summary

A X 41 years male underwent laparotomy with small bowel resection and ileostomy on 4/11/2022 in outside hospital, now came with the complaint of history of weight loss, vomiting, nausea, loose stools, dysuria and also had complaints of weakness, fatigue, tiredness and the patient said that whatever he takes orally and output in the ileostomy bag was high.

Patient was following normal diet due to frequent output in ileostomy bag was high. Patient family was feeding him every 30 minutes like chocolates, beverages, and juices. But his SGA was Severely Malnourished, Had complaints of weight loss 8 kgs in past 1 week, as a part of nutrition plan Oral Nutrition Supplement and Total Parenteral Nutrition was initiated with
Oral soft bland diet with small frequent meals High protein Mct rich diet was educated to family and patient on discharge.

On 2nd admission, patient complaints of giddiness and fall sustained injury in right frontal region, swelling for 2 days back and also had a history of decreased urine output since 4 weeks. No other complaints like vomiting, nausea or seizures. Diagnosed as syncope 2nd degree postural hypotension and AKI. Electrocardiogram was normal and Colonoscopy finding was Diversion Colitis, Crohn’s, S/P Ileostomy.

There is increase in the weight and his ileostomy output was reduced when compare to previous admission. Patient diet initiated with TPN and oral high protein Mct rich diet. while discharge patient and family educated on same and Prescribed Home parenteral nutrition for 1 week and recall of High Protein Diet was recorded and followed up at home.

On 3rd admission, patient complaints of fever on and off for 2 days, he is a known case of crohnâ€™s disease S/P ileostomy was on TPN. Patient admitted for ileostomy re anastomosis. He is a known case of functional gut syndrome and s/p crohns ileostomy bag in November 2022. Necessary investigations revealed that elevated CRP and Dengue IgG was positive. TPN line was removed patient underwent re anastomosis post procedure was uneventful. Pre and post procedure oral intake was monitored regularly and patient tolerated the feeds well, patient improved clinically and symptomatically hence discharged with High protein Diet.

KCH Clinical Dietician Team.

FUNCTIONAL SHORT GUT SYNDROME: A CASE CAPSULE