T.M.H. A 60-year-old woman was referred to us in August 1999 to assess the need for home nutritional support with PN because she had severe malnutrition, fluid and electrolyte disorders and progressive intolerance to nutrition PN.
The pathological history and treatment received are described in Table I.
1.
Pending admission, the patient came to the emergency department on October 4, 1999 with intestinal subocclusion and electrolyte disturbances, being rehydrated and admitted to the surgery service with NP, installing treatment with catheter.
Upon admission, the patient was cachectic, with a height of 162 cm, weight 37 kg, BMI 14.2 kg/m2; (previous weight disease 62 kg · BMI 23.6 kg/m2), with associated oedema
The analytical parameters are shown in Table II.
1.
Digestive feeding was attempted confirming intolerance for nausea and vomiting requiring PN maintenance.
Persistence of the underlying condition was confirmed by abdominal CT scan, which showed lesions suggestive of CRE with gastric disfunction and various jejunal loops.
Digestive transit showed ileal stenosis so it was decided to perform a surgical approach on November 8, 1999.
As surgical findings there is great dilation of the jejunal loops and adhesions of the rest of the loops.
We performed lysis and resection of 70 cm of small intestine at the level of the intestinal wall, with termino-terminal anastomosis, remaining, a bowel of 160 cm of the loop ileocautery and transverse iliac valve (IVC).
The pathological study of the specimen reported marked fibrosis at the level of the subserosa and serosa and adhesions of loops, compatible with CRE.
The consequences are a clinical case of short bowel syndrome (SBS).
No subsequent complications were treated in our service for clinical and nutritional control.
Subsequent complementary examinations confirmed the following: Fibrogastroscopy: minimal hiatus hernia.
Opaque enema: ascending, transverse colon and part of normal descending colon.
IVC is exceeded, the terminal ileum is normal.
Abdominal X-ray: abdominal disfunction and air-fluid levels.
Small bowel transit: slow intestinal transit with loops, edematous, with significant atonia, conserved folds and normal caliber terminal ileum.
Difficulty in establishing a specific area responsible for suboptimal seizures.
Colonoscopy through tapering: minimal erythematous areas suggestive of angiodysplasia by radiotherapy, without signs of bleeding, and intubation of IVC was not possible.
Nutritional treatment
Persistence of the underlying condition was maintained daily PN varying the formula according to the clinical situation, digestive losses and analytical parameters.
From November 1999 to hospital discharge (4 February 2000) received an amino acid solution with glutamine (Glamin, Fresenius laboratories), with a nitrogen contribution of 14 to 16 g of laboratory lipids per day; glucose 250 to 300 g.
Calcium 200-250 mEq; Potassium 60-100 mEq; calcium 8 mmol; magnesium 8 mmol; chromium-9 100 mmol; zinc
After 79 days of exclusive PN, the patient had good general condition and clinical stability initiating oral elemental nutrition (Element 028 ExtraR laboratory SHSR) with subsequent standard polyhydric diet (SEMR).
The initial volume was 250 ml day with good metabolic and digestive tolerance, which allowed a rapid increase (500 ml of volume every 3-4 days) and a decrease in the number of weekly infusions progressively increasing from 7 to 4 lipids at discharge.
Water, infusions and rehydration solutions were also administered orally.
Daily energy was 1,000 kcal standard diet and 860 kcal elemental diet.
Losses due to illness stabilized at a daily average of 1,500 ml.
Prior to discharge, two family members of the patient were trained in home PN (HPN) care: aseptic management of the catheter and nutritional bag, parameters to control, symptoms for which our service and pharmacological treatment.
The weight at hospital discharge was 47,200 kg with a BMI of 18 kg/m2.
Ambulate remained stable only, reducing the number of infusions of HPN to 3 weekly, 1 lipid, and 2 last month.
HPN was definitively suspended on 14 July 2000.
Nitrogen intake ranged from 9 to 12 g, glucose was maintained at 200 g and 50 g lipids (the day it corresponded).
Vitamins and trace elements were administered at standard doses except selenium and zinc that followed their usual pattern.
He followed the pattern of diets polymeric and elemental formula as well as hospitalization, tolerating an average energy intake with elemental diet of 1136-1290 kcal/day and total diet of 2,300 kcal/day between 1,136-1.
When PN was discontinued, her weight was 58,600 kg with a BMI of 23 kg/m2.
Digestive losses ranged between 1,600 cc and 2,300 cc day being their subjective state of well-being.
Allocation with oral diet
The clinical stability encouraged us to start the oral diet, which was very positive at the beginning, maintaining the formula diets to ensure the nutritional status.
Progression was slow to confirm digestive tolerance.
The schedule is presented in Table III.
1.
Until 19 February 2001, she has eaten a daily meal of rice or Maizena semolina with boiled, fainted, or light-colored egg cooked with a spoon of olive oil and gluten.
Special low lactose milk and a gluten-free soup paste ration wounded with glued vegetable broth, or gluten-free food paste (15% protein) supplemented with dried cheese are introduced.
The diet was divided into 4 meals a day, according to the model: 'Discharge: lactose low milk' (PresidentR) with dextrinated cereals.
Tomorrow: apple juice or 2 gluten-free cookies.
Eat: rice beet with boiled hake, paste with cracked cheese or small paste soup with vegetable broth and cooked egg white.
Scene: special low lactose milk made from Maizena and egg white or semolina of rice with boiled fish.
During the months of April and May the number of meals increased to five daily meals adding low lactose milk with cereals in the snack.
All were well preserved, with possible food expansion and changes in the kitchen after June.
Animal protein: chicken breast, gambling and fishing for un ground flat, whole egg in the form of a magro cured hammer.
Cells and cereals: potato and carrot in puré with raw olive oil, rice wounded and soup, bread and gluten-free cookies.
Store in a refrigerator (2°C - 8°C) and raw: banana and pears mature.
Tolerance and patient satisfaction have been encouraging, allowing at the end of the first year without PN a variability of foods that allows more complete intakes.
It maintains five daily meals with an energy intake calculated at approximately 1,500 calories and 60 g protein per day.
Nutritional supplementation is fixed at 1,000 kcal standard formula and 430 kcal elemental formula daily.
