Nutritional Support Process for a Patient with Short Bowel Syndrome in Conjunction with Panperitonitis: A Case Report
A 35-year-old man was admitted to the surgical ward through the Emergency Room (ER) at Gangnam Severance Hospital on May 20, 2011. He had no notable medical history except a laparoscopic appendectomy for acute appendicitis on May 4, 2011 at a local hospital. He was readmitted to the same hospital 8 days later on May 12 for complication-related reoperation and was under the observation when he developed acute abdominal pain, fever, surgical wound infection and both pulmonary effusions. The patient was immediately transferred to the Gangnam Severance Hospital and was diagnosed with panperitonitis. The X-ray result showed free air in the abdomen, which required him to undergo emergency reoperation. During the operation, perforation was found 50 cm above the terminal ileum and the patient had to undergo small bowel resection and anastomosis. He underwent an emergency exploratory laparotomy, irrigation and drainage, jejunostomy, and percutaneous endoscopic jejunostomy. An endto- end anastomosis at the resection site was difficult; thus, the surgeons performed jejunostomy at the proximal jejunum and inserted a feeding tube at the distal jejunum to attach the distal jejunum to the right anterior peritoneum ().\nAt the initial nutrition assessment upon admission, the patient was categorized as 'patient at high-risk of malnutrition' with serum albumin of 1.8 g/dL, lymphocytes of 0.73 × 103/µL and body mass index of 17.6. And also, before admittance to the Gangnam Severance Hospital, he had already experienced severe weight loss from 55 kg to 50.9 kg (7.5% weight loss) after the appendectomy. To correct his serum albumin level, the medical team injected seven packs of 20% albumin infusion and was able to recover the patient's serum albumin level to 3.6 g/dL; the patient had been receiving 50% of the minimum nutrition requirement through total parenteral nutrition (TPN) during early intensive care unit (ICU) days. The patient was referred to the nutrition support team on hospital stay day 5 and taking everything into consideration, he was classified as 'moderate malnutrition'.\nThe nutrition support team recommended the use of TPN given that enteral feeding was not a feasible option due to the surgery. Therefore, the patient received parenteral nutrition (2,180 kcal, 260 g of carbohydrate, 58 g of protein, 100 g of fat and 20 g of glutamine per day) through the right jugular line for 15 days after the surgery ().\nThe patient started oral feeding on hospital stay day 8 but nutrients were not properly absorbed because most of them were lost through the proximal jejunostomy.\nEnteral nutrition started on hospital stay day 22 through the jejunal feeding tube. Standard enteral nutrition formula (MediWell RTH has 1,000 kcal per 1,000 ml containing 140 g of glucose, 46 g of protein, and 30 g of fat) was provided. The amount of formula administered gradually increased from 300 kcal/300 ml to a maximum of 1,700 kcal/1,700 ml but the infusion rate and volume had to be frequently adjusted to address abdominal discomfort and frequent diarrhea but such changes did not fully improve the patient's condition ().\nMeanwhile, on hospital stay day 20, the medical and nutrition support team decided to re-administer the bolus that was lost through the proximal jejunostomy back into the jejunal feeding tube, which was expected to extend the contact time between the nutrients and shortened small intestine, thereby increasing absorption. This procedure was employed until the final surgery.\nAs the amount of standard enteral nutrition provided increased, there was an increase in diarrheal episodes. Following the recommendation of the nutrition support team, the patient started receiving hydrolyzed nutrition formula (MonoWell: 400 kcal per packet containing 50 g of glucose, 16 g of protein and 15 g of fat) on hospital stay day 55 that contains amino acids, which are more easily absorbed than intact proteins.\nTaking hypertonicity of the standard enteral nutrition formula into consideration, the hydrolyzed nutrition formula was given in lower concentration (0.5 kcal/ml) and was administered over 15 hours. This adjustment made a significant improvement in reducing diarrheal episodes. The volume was then gradually increased over a month and reached a daily average of 1,000 kcal and 40 g of protein. To complement the inadequacy of the enteral nutrition, a 1,000 kcal peripheral intravenous nutrition, containing 50 g of protein, vitamins and minerals, was provided until the final surgery.\nOn hospital stay day 66, the medical team desired to readminister standard enteral nutrition formula to stimulate normal digestive function of the small bowel but the patient continued to show maladjustment signs like diarrhea. Thus, the team provided continuous but a small volume of the standard enteral nutrition until the final surgery.\nDespite the administration of TPN after the initial surgery, the patient experienced rapid weight loss of about 3 kg over 3 weeks since the admission to the hospital. By the 21st day of hospitalization at Gangnam Severance Hospital, the patient weighed approximately 47 kg. However, through enteral and parenteral nutrition support, his weight stabilized and his blood lab values also returned to normal figures ().\nAt the final surgery on hospital stay day 85, the medical team removed the jejunal feeding tube, repaired the jejunostomy, eliminated a section of the edematous distal jejunum by 50 cm, and performed anastomosis of the distal jejunum and the healthy proximal jejunum. The patient switched from parenteral nutrition to liquid diet on hospital stay day 89 and was discharged on hospital stay day 97 when he was completely able to eat a regular meal instead of a liquid diet.