Intestinal Failure with Dr. Brad Warner
With Dr. Brad Warner · hosted by Dr. Ian Glenn & Dr. Todd Ponsky · StayCurrentMD
Part of
Intestinal Rehab 109 itemsIntestinal Failure 29 itemsShort Bowel Syndrome 10 itemsIntestinal Transplant 4 itemsMotility / Pseudo-obstruction 7 itemsEtiologies (Gastroschisis/NEC/Atresia/Volvulus) 75 itemsAbdominal Wall Defects 49 itemsColorectal / ARM & Hirschsprung 252 itemsHirschsprung disease 98 items
Cued at 22:33 · stops at 23:18 · press play
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Intestinal failure is an umbrella term for when the small intestine is unable to absorb or digest enough nutrition to support the patient entirely by oral or enteral feeding
The intestine of a newborn or fetus doubles in length in the last trimester of gestation
A 24-25 week premature infant with 20-25 cm of bowel will likely increase to at least 50 cm just on the basis of growth alone
For a neonate with ileocecal valve and entire colon, 10-15 cm of small intestine is a ballpark figure for potential viability
Without the colon and ileocecal valve, at least 15-20 cm of small intestine would be needed for potential viability in a neonate
In adult studies, patients with less than 50 cm of intestine have about 40% mortality after 5-10 years
According to Pediatric Intestinal Failure Research Consortium data, of children on TPN for more than several months due to short gut syndrome: 25% die, 25% need transplant, and 50% can wean off TPN
Common causes of death in intestinal failure include liver failure, septic episodes from central line or bacterial overgrowth, variceal bleeding from liver disease, and loss of IV access
Intestinal adaptation in humans probably takes place over about a year or two after small bowel resection
The goal of management is to wean TPN and push enteral feeding, accepting stool outputs of up to 40 cc per kilo per day as the limit
The most common reasons children develop short gut syndrome are necrotizing enterocolitis, gastroschisis, midgut volvulus, and atresias
For TPN, target about 100-120 calories per kilo per day for total calories, with about 50% from glucose and remainder from fat and protein
Shoot for about 2-3 g of protein per kilo per day and about 2-3 g of fat per kilo per day in TPN
Begin enteral feeding as soon as feasible after resection and reanastomosis when they start stooling, generally starting with slow continuous drip
With continuous drip feeding, nutrient transporters are upregulated and ability to get more nutrition in may be advantageous
Want a baby to gain about 20-30 g a day, which approximates in utero progression for a newborn
Lipid reduction strategy takes fat from 2-3 g per kilo per day given daily down to about 1 g per kilo per day delivered twice or 3 times a week, which has been effective in reducing TPN-associated cholestasis
Omegaven is a fish oil-based fat containing primarily omega-3 fatty acids that are anti-inflammatory, compared to soybean-based intralipid with omega-6 fatty acids that are pro-inflammatory
When fish oil (omegaven) is introduced to children getting jaundiced, there has been demonstrated significant fall in their jaundice levels
SMOF lipid contains soybean-based lipid (essential fatty acids), medium chain triglycerides (more easily digested), olive oil, and fish oil, and has recently been FDA approved in the United States
Breast milk is the best choice for neonates because it contains proper fat, growth factors like EGF and IGF, and milk oligosaccharides that enhance adaptation
Complex formulas fed enterally may stimulate adaptation better than elemental formulas by causing secretion of enterotrophic hormones to a greater extent
There is a threshold percentage of enteral calories that prevents onset of liver damage from TPN, with 90% enteral feeding having far less risk of TPN-related cholestasis than 10% enteral
Time to consider surgical intervention is when enteral tolerance plateaus and then declines (going backward rather than forward), or with multiple sepsis episodes plus abdominal distention and dilated bowel loops, or when child starts getting jaundiced
Dilated bowel loops can cause subclinical portal bacteremia contributing to jaundice, and bacterial overgrowth causes secretory diarrhea that impairs enzyme function
More than 4-5 centimeters of bowel dilation with failure to advance enteral feeds or going backward is an indication for surgical intervention
If a child has over 100 centimeters of intestine, less than 5-10% should require TPN, suggesting there may be an underlying motility or mucosal problem
For bowel lengthening, need less than 100 cm (ideally less than 50 cm) of intestine and bowel that is at least 4-5 cm dilated
The STEP (serial transverse enteroplasty) procedure has emerged as the most commonly performed lengthening operation
The Bianchi procedure takes advantage of the V-shaped blood supply bifurcation before reaching the bowel wall, allowing creation of two tubes each supplied by one arm of the V
STEP procedure is easier to perform with less risk of injuring mesenteric blood supply because you only cut partially across the bowel at right angles
STEP can redilate requiring redo procedures, and outcomes are not as good if you have to redo a STEP compared to never needing a redo
You can do a Bianchi and then later do a STEP on top of it, but you cannot do a Bianchi once a STEP has been done
In a case where a STEP was acting as a brake causing dysmotility, removing the distal stepped bowel allowed the patient to completely wean off TPN
Would taper a child with dilated bowel who had at least 90-100 centimeters of intestinal length
Strategies for TPN cholestasis include bile salts (chenodeoxycholic acid), changing lipid composition, and increasing enteral feeds
Dan Teitelbaum's trial of cholecystokinin to promote bile flow and mitigate TPN cholestasis did not work
Dilated bowel is a nidus for infection encouraging translocation of bacteria and endotoxin into portal circulation, damaging the liver
Medical management of bacterial overgrowth includes oral antibiotics (Cipro, Flagyl), probiotics (lactobacilli), prebiotics, and potentially fecal transplantation
The gut bacteria in short gut syndrome become more efficient, creating an obesogenic-like microbiome that helps adapt by encouraging greater absorption and digestion
In mouse studies, oral vancomycin to knock out gram-positive organisms completely prevented hepatic steatosis after bowel resection
Teduglutide (GLP-2 analog) has been shown in randomized prospective trials in adults to reduce TPN requirements by about 1-2 liters per week
Teduglutide is not yet approved for children in the United States, with concerns about malignancy risk due to promoting proliferation
Growth factors shown to promote adaptation in animal studies include EGF, HB-EGF (demonstrated by Gail Bessner), interleukins, and growth hormone with glutamine
Growth hormone and glutamine combinations in patients have shown primarily mixed results and are expensive
Survival for small bowel transplant is about 50-60% at 5 years, with one-year survivals now above 70-80%
The intestine is highly immunogenic, filled with white cells and macrophages that mount a huge graft-versus-host response, requiring industrial strength immunosuppression
Ethanol locks for central lines have significantly reduced the number of sepsis episodes in patients with short gut syndrome who have Broviac catheters
Multidisciplinary teams including pharmacists, nutritionists, surgeons, GI doctors, ID specialists, and interventional radiologists improve survival in intestinal failure patients, as demonstrated in series from Boston, Michigan, and Texas