From the Guidelines
Acute gastrointestinal failure requires immediate fluid resuscitation with balanced crystalloids, correction of electrolyte abnormalities, and nutritional support to prevent morbidity, mortality, and improve quality of life. The management of acute gastrointestinal failure involves a multifaceted approach that addresses the underlying cause of the condition while providing supportive care.
Key Components of Management
- Initial treatment should focus on fluid resuscitation with balanced crystalloids (such as Lactated Ringer's solution at 20-30 ml/kg) to enhance visceral perfusion, as recommended by the World Society of Emergency Surgery 1.
- Correction of electrolyte abnormalities is crucial, and nasogastric decompression should be initiated to prevent further complications.
- Nutritional support is essential, and enteral nutrition should be initiated as soon as possible, starting at 10-20 ml/hour and advancing as tolerated.
- For patients with hemodynamic instability, vasopressors like norepinephrine (starting at 0.05-0.1 mcg/kg/min) may be necessary, but should be used with caution.
- Proton pump inhibitors (such as pantoprazole 40mg IV daily) are recommended for stress ulcer prophylaxis.
- Antibiotics should be administered if infection is suspected, with broad-spectrum coverage initially (such as piperacillin-tazobactam 4.5g IV every 6 hours plus metronidazole 500mg IV every 8 hours), then narrowed based on culture results.
Monitoring and Follow-up
- Monitoring should include regular assessment of abdominal examination, fluid balance, electrolytes, and inflammatory markers.
- Patients undergoing revascularization should have surveillance imaging and long-term anticoagulation, as recommended by the World Society of Emergency Surgery 1.
- A multidisciplinary approach, including a general surgeon, vascular surgeon, interventional radiologist, and intensivist, is essential for optimal management of acute gastrointestinal failure 1.
From the Research
Definition and Classification of Acute Gastrointestinal Failure
- Acute gastrointestinal injury (AGI) has been defined and has evolved into a concept of gastrointestinal dysfunction score (GIDS) built on the model of Sequential Organ Failure Assessment (SOFA) score, ranging from 0 (no risk) to 4 (life threatening) 2.
- Intestinal failure (IF) occurs when intestinal absorptive function is inadequate to maintain hydration and nutrition without enteral or parenteral supplements, and has been classified into three types depending on duration of nutrition support and reversibility 3.
- Type 1 IF is commonly seen in the peri-operative period as ileus and usually spontaneously resolves within 14 d, while Type 2 IF is uncommon and is often associated with an intra-abdominal catastrophe, intestinal resection, sepsis, metabolic disturbances and undernutrition 3.
Management of Acute Gastrointestinal Failure
- Evaluating the risk with the Nutrition Risk Screening (NRS) score is the first step whenever addressing nutrition therapy, and nutritional management needs to be individualized but always including prevention of undernutrition and dehydration, and administration of target essential micronutrients 2.
- The use of fibers in enteral feeding solutions has gained acceptance and is even recommended based on microbiome findings, while parenteral nutrition whether alone or combined to enteral feeding is indicated whenever the intestine is unable to process the needs 2.
- A systematic approach to management of gastrointestinal problems is recommended, including monitoring and management based on complex assessment of different gastrointestinal symptoms and feeding intolerance 4.
Treatment of Acute Gastroenteritis-Related Nausea and Vomiting
- Ondansetron has been shown to be a more effective drug in the treatment of nausea and vomiting associated with acute gastroenteritis, with a shorter observation time and less recurrent admission to the emergency department compared to metoclopramide 5.
- Metoclopramide use has been associated with side effects such as weakness-numbness and akathisia, while no side effects were observed due to ondansetron use 5.
Prevention and Recent Advances
- Many cases of acute intestinal failure are preventable, and improvements in understanding and preventing paralytic ileus through changes in postoperative care may facilitate recovery of gastrointestinal function after abdominal surgery 6.
- Recent developments have focused on the mechanisms of paralytic ileus and preventive strategies, usually as part of programmes of 'fast-track' or 'enhanced recovery' care, and on the optimum management of patients with severe abdominal sepsis 6.