How to manage suspected jejunal dysfunction?

From the Guidelines

Managing suspected jejunal dysfunction requires a comprehensive approach, and the most effective strategy is to follow a step-by-step management plan that includes determining primary symptoms, excluding mechanical obstruction, evaluating contributing factors, and providing nutritional support, as outlined in the 2020 study published in Gut 1.

Key Components of Management

• Determine and order the primary symptoms
• Exclude mechanical obstruction (CT abdomen with oral contrast)
• Evaluate other contributing factors: drug therapy, psychosocial, and quality of life issues
• Nutritional assessment (BMI, percentage weight loss, and other anthropometric tests)
• Start nutritional treatment (consider/treat refeeding risks)

Nutritional Support

• A low-fat, low-fiber diet with small, frequent meals may be beneficial
• Supplement with medium-chain triglycerides that bypass jejunal absorption
• In cases of bacterial overgrowth, a course of antibiotics such as rifaximin (550 mg three times daily for 7-10 days) or ciprofloxacin (500 mg twice daily for 7-10 days) may be beneficial, as suggested by the 2023 ESPEN guideline on clinical nutrition in inflammatory bowel disease 1

Symptomatic Relief

• Anti-diarrheal medications like loperamide (2-4 mg after loose stools, maximum 16 mg/day) or diphenoxylate-atropine (2.5-5 mg 3-4 times daily) may be prescribed
• Enzyme supplements like pancrelipase can aid digestion when pancreatic insufficiency contributes to symptoms

Ongoing Management

• Regular review and reconsider diagnosis as the clinical situation changes
• Treat the predominant symptom/problem
• Consider surgical options if necessary, as outlined in the 2020 study published in Gut 1

Additional Considerations

• Restrict oral hypotonic fluids to less than 500 ml/day, as suggested by the 2006 guidelines for management of patients with a short bowel 1
• Give glucose/saline solution to sip (sodium concentration at least 90 mmol/l), as recommended by the 2006 guidelines for management of patients with a short bowel 1

From the Research

Management of Suspected Jejunal Dysfunction

To manage suspected jejunal dysfunction, several approaches can be considered based on the underlying cause and severity of the condition.

• Medical Therapy: For conditions like malignant bowel obstruction, a combination of octreotide, dexamethasone, and metoclopramide may provide rapid improvement in symptoms 2.
• Surgical Intervention: In cases of complications such as bleeding, perforation, obstruction, malabsorption, diverticulitis, blind loop syndrome, volvulus, and intussusception, surgical intervention may be necessary 3.
• Nutritional Management: For chronic intestinal pseudo-obstruction, nutritional management is crucial, involving the administration of special formulae and enteral delivery of nutrients through a nasogastric tube, percutaneous gastrostomy, or jejunostomy. In severe cases, parenteral nutrition may be required 4.
• Avoidance of Certain Procedures: In patients with a history of inflammatory bowel disease, abdominal irradiation, cancer, obstruction, and abdominal surgery, procedures like wireless capsule enteroscopy should be avoided due to the risk of complications 5.
• Monitoring and Diagnosis: Regular monitoring and diagnostic tests such as X-ray, CT scans, and enteroclysis can help identify conditions like enterolithiasis, which may cause intermittent small bowel obstruction 6.

Considerations for Specific Conditions

• Jejunal Diverticuli: Usually asymptomatic but can lead to complications that may require surgical intervention 3.
• Malignant Bowel Obstruction: Medical therapy can improve symptoms and bowel function 2.
• Chronic Intestinal Pseudo-obstruction: Requires a comprehensive approach including nutritional, pharmacological, and surgical therapies 4.
• Enterolithiasis: Should be considered in patients with intermittent small bowel obstruction and no history of abdominal surgery 6.