What nutritional support is required following small bowel (intestinal) resection?

From the Guidelines

Nutritional support following small bowel resection should prioritize parenteral nutrition (PN) for the first 7-10 days, providing 25-33 kcal/kg and 1-4 l/day, depending on stomal/stool losses, as stated in the ESPEN guidelines on parenteral nutrition: gastroenterology 1.

Key Considerations

• The primary goal in the early phase after massive enterectomy is to assure hemodynamic stability by providing water and electrolytes, with nutritional therapy introduced only after the patient is hemodynamically stable 1.
• Parenteral nutrition should not be started until the patient is hemodynamically stable and fluid/electrolyte balance has been reached, with intravenous lipids accounting for 20-30% of infused calories 1.
• As the bowel recovers, enteral nutrition should be gradually introduced, starting with isotonic formulas at low rates and advancing as tolerated.
• Oral intake should begin with small, frequent meals that are low in fat, lactose, and oxalate while high in protein.

Specific Supplementation

• Fat-soluble vitamins (A, D, E, K) may be necessary, as well as vitamin B12 (1000 mcg monthly injections if terminal ileum was resected) 1.
• Calcium (1200-1500 mg daily), magnesium (200-400 mg daily), and zinc (15-30 mg daily) supplementation may also be required.

Long-term Support

• Patients with extensive resection may require lifelong specialized nutrition support, including home PN for those with short bowel syndrome, with regular monitoring of nutritional status, electrolytes, and micronutrients essential for adjustments 1.
• The nutritional approach must be individualized based on the extent and location of resection, as proximal small bowel resection affects different nutrient absorption than ileal resection.

From the FDA Drug Label

The most common reasons for intestinal resection leading to SBS were vascular disease (34%, 29/85), Crohn's Disease (21%, 18/85), and "other" (21%, 18/85). The mean length of remaining small intestine was 77.3±64. 4 cm (range: 5 to 343 cm). At baseline, the mean (± SD) prescribed days per week for PN/I.V. infusion was 5.73 (±1. 59) days.

The nutritional support needed following small bowel resection includes Parenteral Nutrition (PN) or Intravenous (I.V.) support.

• The mean reduction in PN/I.V. volume was 4.4 Liters for GATTEX-treated patients (from pre-treatment baseline of 12.9 Liters) versus 2.3 Liters for placebo-treated patients (from pre-treatment baseline of 13.2 Liters/week) 2.
• Twenty-one patients on GATTEX (54%) versus 9 on placebo (23%) achieved at least a one-day reduction in PN/I.V. support 2.
• Ten patients were weaned off their PN/I.V. support while on GATTEX treatment for 30 months 2.

From the Research

Nutritional Support Following Small Bowel Resection

The nutritional support needed following small bowel resection depends on various factors, including the length of the remaining small bowel and the extent of intestinal adaptation.

• Patients with short bowel syndrome may require long-term parenteral nutrition support 3.
• The type of diet and vitamin supplements prescribed depend on the site of resection, with a low-oxalate diet and calcium supplements recommended for patients with ileal resection and a preserved colon 4.
• Parenteral nutrition (PN) is a life-saving intervention for patients where oral or enteral nutrition cannot be achieved or is not acceptable, and its essential components include carbohydrates, lipids, amino acids, vitamins, trace elements, electrolytes, and water 5.
• The prognosis after resection depends on the extent and location of resection, the presence of a colon, the function of the residual intestinal mucosa, and the extent of intestinal adaptation 6.

Factors Influencing Nutritional Support

Several factors influence the nutritional support needed following small bowel resection, including:

• The length of the remaining small bowel, with a statistically significant correlation between the length of the remaining small bowel and the necessary duration of nutritional support 7.
• The presence of intraluminal nutrients and various trophic peptides and hormones, which influence intestinal adaptation 6.
• The clinical status and risk of complications, which should be considered when providing parenteral nutrition 5.

Strategies for Optimizing Nutritional Support

Strategies for optimizing nutritional support following small bowel resection include:

• Weaning patients off parenteral nutrition by optimizing the adaptive process 3.
• Providing a diet that is not restricted in terms of fat, with the addition of cholestyramine if necessary 4.
• Monitoring and early management of imbalances to prevent and mitigate potential complications of parenteral nutrition 5.