Nutritional and Medical Implications of
Short Gut Syndrome with
Multiple Nutrient Deficiencies
A Case Study
Regina M. Gill University of Maryland, College Park
Dietetic Intern
June 15, 2011
©
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Table of Contents
Executive Summary…………………………………..……………………………….……………………………………………….3
Case Report……………………………………………..………………………………………………………………………………….4
General Information...……………..………..………………………………….…..……………………………………4
Medical/Surgical Data..……………………………………………………………….…..................................4
Nutritional History………………………..……………………………………..…….……………………………………4
Hospital Course of Patient.………………………………………………………………………………………………………….8
Case Discussion……………………………………………………………………………………………………………………………9
Medical Considerations.……………………………………….………………………………………………………….9
Nutritional Therapy.……………………………………………………………………………………………………….12
Implications of Findings to the Practice of Dietetics……………………………………………………….12
Appendices
Appendix A – Figure of a Normal Gastrointestinal Tract...………………………..…..…………………………..13
Appendix B – Table 1: Hospital Medications ……………………...………………………………………………….….15
Table 2: Pertinent Laboratory Values……………………………………….…………………………..18
Glossary of New Terms…..………………………………………………………………………………………………………….19
References.……………………………………………………...............................................................................21
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Executive Summary
The digestive system is composed of a series of organs that are joined together stretching from the
mouth to the anus, better known as the gastrointestinal (GI) tract, to help break down food and absorb
nutrients that the body needs (3). Most of the organs in the GI tract are hollow to allow food to pass through
during the breakdown process via peristalsis, involuntary smooth muscle contractions. Once food is swallowed
and reaches the stomach, contents are pushed into the small intestine, a complex tube that extends 600 cm
(20 feet), where the final stages of digestion occur as a result of the secretion of juices from the liver and
pancreas, and then nutrients are absorbed, in the duodenum, jejunum, and ileum.
Short Bowel Syndrome (SBS) can be defined as “the loss of nutrient-, fluid-, and electrolyte-absorptive
capacity associated with partial or near-complete loss of the small intestine (4).” The reduction in absorptive
capacity leads to frequent diarrhea, steatorrhea, electrolyte imbalances, dehydration, weight loss, and
macronutrient and micronutrient deficiencies (5). In adults, a diagnosis of SBS is made when the small
intestine is less than 200 cm in length (8). SBS can be congenital or acquired from one or more major
resections of the small intestine (8).
Deficiencies of fat-soluble vitamins (A, D, E, and K) and essential fatty acids (omega-3 and omega-6) are
commonly seen in patients with SBS due to frequent diarrhea and fat malabsorption, which can be
exacerbated by certain medicinal treatments for diarrhea. Depending on which part of the small intestine is
resected, deficiencies of vitamin B, particularly vitamin B12 when the terminal ileum is removed, are possible.
There is no one specific treatment for SBS. If treatment is initiated, the goals should be to prevent
further nutrition-related consequences, such as diarrhea and dehydration, and “correct any preexisting
nutrient deficiencies (1).” Treatment for SBS should include high doses of multiple vitamin and mineral
supplements, but could also include total parenteral nutrition.
The following case study presents a 54 year-old female with a history of short bowel syndrome and
chronic lung disease who was admitted with respiratory failure, hypoxemia, and malabsorption. This report
discusses the nutritional and medical interventions for a patient with short bowel syndrome with multiple
nutrient deficiencies.
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Case Report
Patient Information
DP, a 54 year old white female, was admitted to Anne Arundel Medical Center with shortness of
breath. DP’s diagnoses at the time of admission were respiratory failure, dyspnea, hypoxemia, and
hypokalemia, interstitial lung disease (ILD), bilateral pneumonia, pulmonary infiltrates, hypoxia,
thrombocytopenia, and colovaginal fistula. The patient was admitted on March 27, 2011 and discharged on
April 11, 2011.
Medical and Surgical Data
DP’s past medical history is significant for short bowel syndrome (SBS), chronic malabsorption, chronic
diarrhea, colovaginal fistula, deep vein thrombosis (DVT), pernicious anemia, Lupus anticoagulant disorder
(hypercoagulable state), osteopenia, rheumatoid arthritis, mycobacterium avium-intracellulare complex
(MAC), and lung infection. Pertinent past surgical history includes three colon surgeries with a large amount of
the small and large intestines removed, hysterectomy, and cosmetic surgery for non-healing wound.
Nutritional History
Food and Nutrient history:
DP’s diet history includes hot chocolate with marshmallows for breakfast and her only meal of the day, dinner,
is usually a frozen meal. She stated that her appetite is good, but she only eats at dinnertime because food
runs straight through her causing diarrhea and she does not want to worry about running to the bathroom
when she is out of the house. She does like to eat out at restaurants close to home, such as Applebee’s and
Famous Dave’s. DP has no known drug or food allergies. DP usually takes a multivitamin/mineral supplement
in addition to supplements of vitamin A, D, and E, as well as Tums. DP revealed that although she should be
taking the supplements, she has not been able to afford them recently. She does not consume commercial
nutrition beverages such as Ensure, nor has she ever had nutrition support. DP has been seen previously by a
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Registered Dietitian that recommended small, frequent meals to help with the diarrhea. She followed the
recommendation for a while, but is no longer following because she claims that it does not work for her.
Anthropometric Measurements:
DP has had fluctuations in her weight for many years. Prior to her colon surgeries, DP weighed 202 lbs.
After the first surgery in 1992, she lost 100 lbs. in a year and her weight dropped to 102 lbs. She recovered
well and regained her weight and went back to work for five years until she had second bowel surgery (1998),
after which she lost nearly 100 lbs. again. DP stated that her usual body weight over the last few years has
been 134 lbs and she would like to stay at that weight.
1992 1993 1998 1999 2009 2011 (admit)
202 lbs. 102 lbs. 202 lbs. 105 lbs. 134 lbs. 117 lbs.
(Weight history self-reported with the exception of weight on day of admission.)
Biochemical Data and Medical Tests:
See Appendix A for laboratory results and medications, dosages, and dates of administration. A number of
diagnostic tests were performed on DP.
• Strep Pneumoniae antigen, urine – 3/27/2011: Negative for S. Pneumoniae antigen.
• Legionella antigen, urine – 3/27/2011: Negative for L. Pneumophila serogroup 1.
• Chest CT Angiography Thoracic – 3/28/2011: Results show bilateral alveolar interstitial infiltrates
suggesting inflammatory process such as pneumonia. There is no evidence of pulmonary embolism
and the thoracic aorta shows no evidence of an aneurysm.
• Chest CT with IV contrast – 04/02/11: The findings show no pulmonary emboli but much more
extensive ground glass infiltrates. Considering the circumstances, this may indicate a progression of
pneumonia.
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• Stool culture of intestinal feces – 4/1/2011: Results showed no growth of enteric pathogens after a
48-hour incubation period.
• Chest X-ray – 4/1/2011: Results showed no evidence of a specific pneumonic infiltrate.
• 4/5/2011: Improved appearance from 4/1/2011 with partial clearing of the lungs.
• Pneumocystis Carinii Stain for the detection of Pneumocystis carinii pneumonia – 4/1/2011: Results
were negative.
• Chest X-ray computed tomography (CT) scan without contrast – 4/11/2011: The findings showed
improvement in the ground-glass infiltrates but also showed fluid at the left lung base and prominent
interstitial disease.
Nutrition-Focused Physical Findings:
During the admitting physical exam, DP showed signs of generalized malaise and severe dyspnea. Her
blood pressure was 146/94 millimeters of mercury (mmHg), heart rate was 103 beats per minute, respiratory
rate was 20 breaths per minute, and temperature was 96.7°F. DP appeared thin and ill. Her hair was thin and
falling out, she had decreased night vision, and had red bumps on her skin, which appeared to be due to
hyperkeratosis, an excessive development of keratin in hair follicles. She was experiencing bilateral scattered
wheezes and bilateral crackles with decreased air entry into her lungs. She had no complaints of nausea,
vomiting, or diarrhea, although she has chronic diarrhea that she manages with medication. After admission, a
bronchoscopy was performed on DP to confirm the presence of mycobacterium avium complex. The results
were found to be positive for M. avium complex rRNA.
Client History:
DP has not worked since 1998 as a Geriatric Nurse Practitioner due to her medical complications.
Currently, DP lives in low income housing, receives Medicare, Medicaid, and SNAP (food stamp) benefits ($124
per month), and buys foods that she can afford. Her family is very supportive and visited her often while in the
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hospital. DP smoked two packs of cigarettes per day for 25 years, but quit in early 2008. DP has no specific
cultural attitudes that influence her dietary intake. DP’s physical activity level is sedentary, mainly due to
symptoms of hypoxemia with exertion.
Nutrition Diagnosis: Nutrition Care Process
Initial Nutrition Diagnosis with NCP code:
Patient assessed with predicted suboptimal nutrient intake (NI-5.11.1) related to a physiological condition
associated with increased need for a nutrient due to altered metabolism as evidenced by presence of a
condition for which research shows an increased prevalence of insufficient nutrient intake in a similar
population.
Initial Intervention with NCP code:
Vitamin and Mineral Supplements: Vitamin (ND-3.2.3) A (1), D (3), E (4)—Increasing intake of vitamins to
prevent and resolve nutrient deficiency related to malabsorption.
Nutrition Monitoring with NCP Code:
Fat and cholesterol intake: Essential fatty acids (FH-1.5.1.8)—Increase intake of EFA to prevent and resolve
nutrient deficiency. Recommendation was made for patient to eat a slice of toast with margarine, a
convenient source of linoleic acid, an essential fatty acid, every morning.
Nutrition Prescription:
Source Calorie requirements Protein requirements Fluid requirements
Facility standards 1500 kcals/day* 46 g/day 1500 ml/day
ADA Evidence Analysis
Library
N/A N/A N/A
Online nutrition care
manual (1)
1500 kcals/day 46 g/day 1500 ml/day
*Mifflin-St. Jeor Equation (MSJE) with a stress factor of 1.3
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Hospital Course of Patient
Medical Treatment:
DP had a number of medical treatments during the course of her stay in the hospital. She received
nebulization respiratory therapy treatments with Levalbuterol (Xopenex) and Ipratropium (Atrovent) nearly
every four hours daily for respiratory failure. A Peripherally Inserted Central Catheter (PICC) line was placed on
3/31/11.
Nutritional Treatment:
DP received an oral general diet order during the entire length of time that she was admitted to
AAMC. Her dietary intake was 25-50% on the day of the initial nutrition assessment. At the two subsequent
follow-up visits on 4/5/11 and 4/8/11, her dietary intake was 50-75%. DP’s dietary intake increased over the
course of her stay, and on some days she ate nearly all of her meal. Although DP had a good appetite and her
body mass index was normal for her height (22.5 kg/m2), her hemoglobin and hematocrit were both below
normal levels all but two days during her admission, and her physical signs and symptoms indicated a poor
nutritional status due to several nutrient deficiencies, particularly fat-soluble vitamins and essential fatty acids.
Due to the SBS causing chronic diarrhea, DP was taking Cholestyramine (Questran), a medication that
comes as a powder and then is mixed with liquid that is typically used for lowering cholesterol levels in the
blood, but also used to manage diarrhea, such as in DP’s case (2). Cholestyramine decreases absorption of
essential fatty acids and fat-soluble vitamins as well as other medications and supplements causing a drug-
nutrient interaction. Taking the cholestyramine with SBS may exacerbate malabsorption. For this reason, high
dosage vitamin and mineral supplements were recommended to reduce nutrient deficits of vitamins A, D, E,
and essential fatty acids, particularly omega-3 fatty acid. On 4/5/11, DP was started on the appropriate
supplements (please refer to appendix B).
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Nutritional goals for DP include high dosage vitamin and mineral supplementation to reduce nutrient
deficits of vitamins A, D, and E along with a multivitamin/mineral and small frequent meals that are low in fat
except for essential fatty acids, and no fruit juices (which may exacerbate the diarrhea).
Case Discussion
Medical Considerations
The digestive system is composed of a series of organs that are joined together stretching from the
mouth to the anus, better known as the gastrointestinal (GI) tract, to help break down food and absorb
nutrients that the body needs (3). See figure 1 for an illustration of the digestive system and all of its organs.
Most of the organs in the GI tract are hollow to allow food to pass through during the breakdown process via
peristalsis, involuntary smooth muscle contractions. The pancreas and liver assist with digestion and
absorption by producing and secreting necessary digestive juices and enzymes (3).
Food digestion begins when food is chewed, mixed with salivary amylase, an enzyme found in saliva, to
begin breaking down starch from carbohydrate foods, and then swallowed. The food then travels down the
esophagus by peristalsis to the stomach. In the stomach, the food and liquid are mixed with digestive juices
(hydrochloric acid, pepsin for protein breakdown, and gastric lipase for fat breakdown), to continue the
digestive process (4). From there, the contents of the stomach are pushed into the small intestine, a complex
tube that extends 600 cm (20 feet), where the final stages of digestion occur as a result of the secretion of
juices from the liver and pancreas, and then nutrients are absorbed, in the duodenum, jejunum, and ileum.
The pancreas plays an integral role in digestion and absorption because it secretes proteolytic enzymes to
break down protein, amylase to break down starch, and lipolytic enzymes to break down fats (4). Once the
nutrients are absorbed, the undigested portion of food, such as fiber, is pushed into the colon to be excreted.
SBS can be defined as “the loss of nutrient-, fluid-, and electrolyte-absorptive capacity associated with
partial or near-complete loss of the small intestine (4).” The reduction in absorptive capacity leads to frequent
diarrhea, steatorrhea, electrolyte imbalances, dehydration, weight loss, and macronutrient and micronutrient
10
deficiencies (5). Once a significant portion of the small intestine is lost, the residual function is determined by
the mucosal surface area; this area “determines absorptive capacity and is functionally related to the number
and height of villi and microvilli (4).”
Deficiencies of fat-soluble vitamins (A, D, E, and K) and essential fatty acids (omega-3 and omega-6) are
commonly seen in patients with SBS due to frequent diarrhea and fat malabsorption, which can be
exacerbated by certain medicinal treatments for diarrhea. Depending on which part of the small intestine is
resected, deficiencies of vitamin B, particularly vitamin B12 when the terminal ileum is removed, are possible.
When dietary fat is eaten but not emulsified to an absorbable state by bile salts as it travels the length
of the small bowel, fat will be malabsorbed causing fatty, foul-smelling stools, steatorrhea. Not only will the
fat be unabsorbed, but also the fat-soluble vitamins. This can cause the body to become depleted of essential
fatty acid stores as well as the fat-soluble vitamins (6). “Essential fatty acids are fats required by the body that
cannot be synthesized by other nutrients, and must be either absorbed in sufficient quantities through the
gastrointestinal tract or given intravenously (6).” The physical signs and symptoms of essential fatty acid
deficiency are “flaky, dry skin, patchy red areas on the skin, alopecia, brittle nails, easy bruising, bleeding
tendencies, diarrhea, delayed wound healing, and increased incidence of infections and illnesses (6).” It is
recommended that a tablespoon of safflower or soybean oil (both contain linoleic acid) be used at every meal
or snack to prevent essential fatty acid deficiency (6). Studies show that there is an inverse relationship
between linoleic acid status and inflammation (7). It is important for patients with fat malabsorption to take
fat-soluble vitamin supplements, preferably in chewable form.
Vitamin A deficiency can cause detrimental effects on the body, such as xerophthalmia (dryness of the
eye), night blindness (impaired adaptation to darkness), follicular hyperkeratosis (thickening of the hair
follicles), and keratinization of the skin as well as the mucous membranes in the respiratory and GI tracts (4).
Respiratory infections and impaired immunity can occur as a result of keratinization.
The prevalence of SBS in the United States in unclear. In 1992, it was estimated that 40,000 people
had intestinal failure and received home total parenteral nutrition (TPN) (4,8). This data showed that 26% of
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those patients had SBS. However, this data did not consider patients who did not require TPN or those
successfully weaned from TPN (8). In adults, a diagnosis of SBS is made when the small intestine is less than
200 cm in length (8). SBS can be congenital or acquired from one or more major resections of the small
intestine (8). This is usually related to trauma to the abdominal region, inflammatory bowel disease, primarily
Crohn’s disease, radiation therapy for genitourinary or gynecologic malignancies, volvulus, and complications
of surgery (6).
There is no one specific treatment for SBS. If treatment is initiated, the goals should be to prevent
further nutrition-related consequences, such as diarrhea and dehydration, and “correct any preexisting
nutrient deficiencies (1).” Studies suggest that administering exogenous growth hormone, supplemental
glutamine, and a modified fiber-containing diet could enhance nutrient absorption (9). Byrne et al. (9) has
reported that this combination demonstrated statistically significant increases in absorption of calories,
protein, carbohydrate, and water and sodium, which resulted in significantly decreased stool output. Fat
absorption, however, did not change. Treatment for SBS should include high doses of multiple vitamin and
mineral supplements. Refer to Appendix B to view the supplements taken by DP. The prognosis for patients
with SBS varies. The nutrient absorptive capacity can improve over time with proper nutritional and medical
interventions.
DP has typical characteristics of SBS and compares quite closely with usual findings in the literature in
regard to having chronic diarrhea, physical signs and symptoms of deficiencies of essential fatty acids, fat-
soluble vitamins, and vitamin B12, and the need for vitamin and mineral supplementation. The keratinization
that DP has, as a result of vitamin A deficiency, could ultimately be contributing to the worsening condition of
her lung disease. One difference in DP’s case is that she is not on TPN nor has she ever been. Most articles
that address SBS dietary management focus on TPN dependence or supplemental TPN to maintain good
nutrition status. However, long-term TPN has several complications and may inhibit bowel adaptation (10).
Improvements in DP’s nutritional status will also help to decrease complications of her lung disease; and an
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oral diet high in essential fatty acids with ample vitamin and mineral supplementation, along with tincture of
opium to control diarrhea, would be a good start.
Nutritional Therapy
An oral diet is recommended to promote bowel adaptation; a process which includes villus
hyperplasia, increases in the number of transporters per cell, diameter, and villus height, in order to optimize
bowel absorptive capacity (10,6, 8). Small, frequent meals are generally recommended. Certain foods should
be avoided in patients with SBS, such as concentrated sweets like fruit juices, soft drinks, and desserts, caffeine
and alcohol, and dairy products. These foods and beverages can increase fluid loss and exacerbate diarrhea
(6). Most patients who have undergone major bowel resections will receive TPN initially, first 7-10 days (5, 8).
Enteral nutrition is also used to promote bowel adaptation. “The role of enteral feedings is to provide a
trophic stimulus to the GI tract; parenteral nutrition is used to restore and maintain nutrient status (5).” TPN is
recommended and necessary for patients with less than 100 cm of bowel and a non-functioning colon (8).
Medium-chain triglycerides (MCTs) are commonly used in patients with SBS to improve fat absorption and
decrease steatorrhea; however, they do not supply essential fatty acids and absorption only occurs in patients
with a preserved colon (10).
The nutritional therapy recommended for DP was very similar to that recommended in the literature.
DP has had SBS since 1998. Unlike many patients with SBS, DP never received enteral or parenteral nutrition
support after the bowel resection. DP has maintained an oral diet. During her hospital stay, she received a
regular diet, but was encouraged to decrease intake of fruit juices and lactose, and increase her intake of foods
containing essential fatty acids, like margarine and salad oils.
Implications of Findings to the Practice of Dietetics
Short bowel syndrome is a devastating disorder of the gastrointestinal tract. Patients with SBS have a
number of nutritional complications and deficiencies. Treating a condition such as this requires critical
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thinking and knowledge of medical nutrition therapy to make nutritional recommendations in the patient’s
best interest considering all factors. This case report shows how critical medical nutrition therapy was in
treating DP’s condition. Without the knowledge of dietitians, DP’s nutrient deficiencies might have gone
undiagnosed. DP was admitted to the hospital for complications due to her lung disease; however, the
nutrition team discovered that she had nutrient deficiencies as a result of SBS that were ultimately impacting,
and possibly worsening, her lung disease. It is crucial to balance medical and nutritional therapy to provide the
patient with the best, individualized care.
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Appendix A
Source: http://www.search.com/reference/Gastrointestinal_tract
Figure 1.
Gastrointestinal tract
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Appendix B
Table 1. Hospital Medications
Medication
Dosage Dates of
Administration
Medical Function Nutrition Side Effects
Acetaminophen
(Tylenol)
650 mg 3/27-4/11
Every 6 hours
PRN
Analgesic Caffeine increase rate
of absorption & effect
Albuterol 5% 2.5 mg 3/28
Every 4 hours
Bronchodilator Sore/dry throat,
anorexia
Alprazolam (Xanax) 0.25 mg 3/28-4/11
Every 4 hours
Antianxiety Increased weight and
appetite
Azithromycin
(Zithromax) IVPB
500 mg
250 mL 3/27-3/28
Daily
Antibiotic Stomatitis w/ IV, N/V,
diarrhea, abd pain
Caspofungin
(Cancidas)
70 mg
50 mg
3/29 Daily
3/30-4/3
Antifungal N/V, dyspepsia or
Diarrhea
Cefepime
(Maxipime)
1 g 3/28-4/3
Every 8 hours
Antibiotic Anorexia, oral
candidiasis, sore
mouth
Cholestyramine
(Questran)
1 packet 3/27-4/8
2 times daily
Antihyperlipidemic,
Antidiarrheal
May decrease
absorption of fat, fat-
soluble vitamins, Ca,
Fe, Zn, Mg, Fol
Cyanocobalamin
(Vitamin B12)
1000
mcg/mL
Every 30 days B complex vitamin Caution with Fol
supplement
Enoxaparin
(Lovenox)
60 mg 3/28-4/9
Every 12 hours
Anticoagulant N/A
Ethambutol
(Myambutol)
400 mg 3/27-4/4
2 times daily
Tuberculosis
treatment
Anorexia, abd pain,
N/V
Famotidine (Pepcid) 20 mg 3/28-4/5
2 times daily
Antigerd Decreased gastric acid
secretions, increased
gastric pH, N/V
Fentanyl
(Sublimaze)
50 mcg 4/1
Every 1 hour
Analgesic Anorexia
Fluconazole
(Diflucan)
100 mg 3/27-3/29
2 times daily
Antifungal Dry mouth, N/V,
diarrhea, dyspepsia
Folic acid tablet 1 mg 3/27-4/11
3 times daily
B Complex Vitamin,
antianemic
N/A
Furosemide (Lasix) 40 mg 4/5 Loop Diuretic Anorexia, increased
thirst
Hydrocortisone 3/27-4/11 Anti-inflammatory Increased appetite
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rectal cream 2.5% 2 times daily and weight
Hydroxychloroquine
(Plaquenil)
200 mg 3/27-4/11
Daily
Antiarthritic
(rheumatoid)
Anorexia, decreased
weight
Ipratropium
(Atrovent) 0.02%
0.5 mg 3/28-4/11
Every 4 hours
Bronchodilator Dry mouth,
metallic/bitter taste
Levalbuterol
(Xopenex) nebulizer
solution
1.25 mg 3/28-4/11
Every 4 hours
Bronchodilator Increased appetite,
sore/dry throat
Methylprednisolone
sodium succinate
(solu-medrol)
125 mg 4/2-4/8
Every 6 hours
Anti-inflammatory Increased appetite
and weight
Metronidazole
(Flagyl)
250 mg 4/1-4/6
Every 8 hours
Antibiotic Dry mouth, N/V,
candidiasis, diarrhea
Midazolam (Versed) 1 mg/mL 4/1-4/4 Antianxiety Decreased weight and
appetite
Morphine 4 mg/mL 2-4 mg 3/30-4/11
Every 4 hours
PRN
Analgesic, narcotic N/V, constipation,
diarrhea, decreased
gastric motility
Naloxone (Narcan) 0.4 mg 4/1-4/9
Continuous
Opioid Antagonist N/V
Nitrofurantoin
(Macrobid)
100 mg 3/28 Antibiotic N/V, abd pain,
dyspepsia, diarrhea
Omega-3 acid ethyl
esters (Lovaza)
1 gm 4/11 –
4/5/2012
(Continue after
discharge)
2 times daily
Fish oil,
antihyperlipidemic
Taste changes/after
taste, dyspepsia,
belching
Ondansetron
(Zofran) injection
5 mg 3/27-4/11
Every 6 hours
PRN
Antiemetic,
Antinauseant
Abd pain,
constipation,
diarrhea, dry mouth
Opium tincture
10 mg/mL (1%)
2.7 mL 3/27-4/10 Antidiarrheal N/V, dizziness,
drowsiness,
constipation
Pancrelipase (Lip-
Pro-Amyl) (Creon
12000)
2 caps 3/27-4/11
Before meals
& at bedtime
Pancreatic enzyme
replacement
N/V, constipation,
diarrhea, abd cramps
Pantoprazole
(Protonix)
40 mg 4/6-4/11
Every morning
before
breakfast
Antigerd Diarrhea, nausea, abd
pain, decreases
gastric acid secretion
Potassium chloride
SA (K-DUR) tablet
40 mEq 3/27-3/28
Every 6 hours
Electrolyte
Replacement
GI irritation,
Nausea/Vomiting
(N/V), abdominal
(abd) pain, diarrhea
Thera vitamin 4/11 – Multivitamins Constipation,
17
(Multivitamins) 4/5/2012
(Continue after
discharge)
Daily
diarrhea, upset
stomach
Vitamin A 10,000
units
4/11 –
4/5/2012
(Continue after
discharge)
Daily
Fat soluble vitamin Adequate fat, vitamin
E and protein needed
for absorption
Vitamin D
(Ergocalciferol-D2)
50,000
units
3/27-4/11
Daily
Vitamin Anorexia, decreased
weight, increased
thirst, increases Ca
absorption.
Vitamin E 400
units
4/11 –
4/5/2012
(Continue after
discharge)
Daily
Fat soluble vitamin High PUFA intake
increases
requirements
Warfarin
(Coumadin)
5 mg
2.5 mg
1 mg
4/5 Nightly
4/6
4/7-4/11
Anticoagulant N/V, cramps, taste
changes. Intake of vit
K is essential
Zolpidem (Ambien) 5 mg 3/27-4/11
Nightly PRN
Sleep aid Dry mouth, N/V,
cramps, diarrhea
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Table 2. Pertinent Lab Values
Mar Apr
27 28 29 30 31 1 2 3 4 5 6 7 8 9 10 11 Normal
Range
NA 143 138 142 144 146 135-146
mmol/L
K 3.0 4.4 3.5 2.7 3.9 3.2-5.0
mmol/L
CL 111 111 115 109 107 101-111
mEq/L
CO2 23 23 17 27 29 21-31
mEq/L
BUN 6 5 21 11 11 5-20
mg/dL
CREAT 0.7 0.6 0.7 0.5 0.5 0.6-12
mg/dL
WBC 6.9 10.4 8.4 12.6 11.1 8.7 8.3 11.4 9.4 13.0 9.8 10.6 10.8 12.9 13.4 5-10 mm3
HGB 11.4 14.0 11.4 11.3 11.3 11.2 11.6 11.1 10.8 12.7 11.7 10.8 11.0 11.4 10.6 12-15 g/dL
HCT 34.4 41.3 34.1 33.9 34.2 34.8 35.2 33.4 32.6 37.0 34.2 31.9 32.6 33.8 31.7 35%-47%
GLUC 99 170 151 148 70-115
mg/gL
INR 5.0 1.5 1.2 1.2 1.2 1.6 2.0 2.1 2.3 1.9
*Values in red are not within normal limits
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Glossary of New Terms*
Colovaginal fistula –an abnormal tube-like connection between the colon and the vagina
Deep vein thrombosis (DVT) – a blood clot that forms in a vein deep in the body
Duodenum – the first part of the small intestine, between the pylorus and the jejunum; it is 8 to 11
inches in length
Enteral nutrition – when a liquid food mixture (formula) containing protein, carbohydrates, fats,
vitamins and minerals, is given through a tube into the stomach or small intestine; also known as tube
feeding
Enterectomy – Excision of a portion of the intestines
Follicular hyperkeratosis – a skin condition that results from excessive development of keratin in the
hair follicles
Gastric lipase – an enzyme found in the stomach that breaks down fat
Gastrointestinal (GI) tract – a tube that extends from the mouth to the anus in which food moves
through to be digested and absorbed
Hydrochloric acid – a fluid formed in the stomach to aid in digestion
Hyperkeratosis – an overgrowth of the horny layer of the epidermis
Hypoxemia – Decreased oxygen tension (oxygen concentration) of arterial blood
Ileum – the lower three fifths of the small intestine from the jejunum to the ileocecal valve
Interstitial Lung Disease (ILD) – a disease of the lower respiratory tract characterized by
inflammation and disruption of the walls of the alveoli
Jejunum – the second portion of the small intestine extending from the duodenum to the ileum
Keratinization – the process of keratin formation that takes place within the keratinocytes as they
progress upward through the layers of the epidermis of skin to the surface stratum corneum
Lipotytic enzymes – enzymes that break down triglycerides into glycerol and free fatty acids
Lupus anticoagulant disorder (hypercoagulable state) – a blood disorder in which antibodies attack
plasma proteins thus leading to a high risk of clotting
20
Medium-Chain Triglycerides (MCT) – triglycerides with 8 to 10 carbon atoms; they are digested and
absorbed differently than the usual dietary fats and, for that reason, are used in treating
malabsorption
Mycobacterium avium-intracellulare complex (MAC) – an atypical mycobacterium that causes
systemic bacterial infection in patients with advanced immunosuppression
Night blindness – decreased ability to see at night or in darkness
Osteopenia – a significant decrease in the amount of bone mineral density normally found in a
population or group
Pepsin – the chief enzyme of gastric juice, which converts proteins into proteases and peptones
Pernicious anemia – a decrease in red blood cells as a result of inadequate vitamin B12 absorption
Proteolytic enzymes – enzymes (trypsin, chymotrypsin, and carboxypeptidase) that break down
proteins into peptides, proteases, peptones, and amino acids
Rheumatoid arthritis – a chronic systemic disease marked by inflammation of multiple synovial joints
Steatorrhea – fatty stools
Total parenteral nutrition (TPN) - when a liquid food mixture (formula) containing protein,
carbohydrates, fats, vitamins and minerals, is given through a tube into the vein
Villi – Plural of villus
Villus – A small fold or projection that covers the mucous membrane surface of the small intestine
Volvulus – a twisting of the bowel on itself, causing obstruction
Xerophthalmia – conjunctival dryness with keratinization of the epithelium following chronic
conjunctivitis and in disease caused by vitamin A deficiency
*(11)
21
References
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Disease > Diseases and Conditions of the Lower GI Tract > Bowel Surgery > Bowel Resection.
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http://nutritioncaremanual.org/topic.cfm?ncm_heading=Nutrition%20Care&ncm_toc_id=144
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bowel syndrome. Journal of Parenteral and Enteral Nutrition. 1995;19:296-302.
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