What is the approach to diagnosing and managing intestinal failure?

From the Guidelines

Diagnosing and managing intestinal failure requires a comprehensive multidisciplinary approach focused on identifying the underlying cause, providing nutritional support, and addressing complications, as outlined in the ESPEN practical guideline on clinical nutrition in chronic intestinal failure 1.

Key Components of Diagnosis and Management

• Initial diagnosis involves clinical assessment, laboratory tests (including liver function, electrolytes, and micronutrient levels), and imaging studies to determine the extent and cause of intestinal dysfunction.
• Management begins with parenteral nutrition (PN) to provide essential nutrients, typically administered through a central venous catheter with a tailored formulation of proteins, carbohydrates, lipids, vitamins, and minerals based on individual requirements.
• Enteral nutrition should be introduced as tolerated to maintain gut integrity.
• Medications commonly used include antidiarrheal agents, antisecretory drugs, proton pump inhibitors, and antimicrobials for bacterial overgrowth.

Surgical Interventions and Complications

• Surgical interventions may include bowel lengthening procedures, strictureplasty, or intestinal transplantation in severe cases.
• Complications requiring vigilant monitoring include catheter-related infections, PN-associated liver disease, metabolic disturbances, and D-lactic acidosis.

Long-term Management

• Long-term management focuses on optimizing remaining bowel function through dietary modifications, intestinal adaptation support with growth factors like teduglutide, and gradual weaning from PN when possible.
• The approach to managing intestinal failure is supported by guidelines from ESPEN on parenteral nutrition in adult patients with chronic intestinal failure 1, and the American Gastroenterological Association medical position statement on short bowel syndrome and intestinal transplantation 1.

Recent Guidelines and Recommendations

• Recent guidelines emphasize the importance of a multidisciplinary team approach in managing patients with severe chronic small intestinal dysmotility, including the use of parenteral nutrition and surgical interventions as needed 1.
• These guidelines aim to provide a logical approach to determining the underlying diagnosis and tailoring treatments for each individual patient, with the goal of improving health and quality of life outcomes.

From the Research

Classification of Intestinal Failure

• Intestinal failure (IF) is the inability of the gut to absorb necessary water, macronutrients, micronutrients, and electrolytes sufficient to sustain life and requiring intravenous supplementation or replacement 2.
• IF can be classified into acute (types 1 and 2) and chronic (type 3) forms, with acute IF lasting for weeks to a few months and chronic IF lasting for months to years 2.

Diagnosis of Intestinal Failure

• The diagnosis of IF is based on the inability of the gut to absorb necessary nutrients and fluids, and the need for intravenous supplementation or replacement 2.
• The underlying condition leading to IF, such as short bowel syndrome, congenital diseases of enterocyte development, and severe motility disorders, must be identified and managed 3.

Management of Intestinal Failure

• The management of IF requires a multidisciplinary approach, involving surgeons, gastroenterologists, dietitians, pharmacists, and nurses 4, 5, 3, 6.
• Nutrition approaches should aim to facilitate transition from parenteral nutrition (PN) to enteral nutrition, as prolonged use of PN is associated with severe morbidity and mortality 5.
• Surgical procedures, such as longitudinal intestinal lengthening and tapering (LILT) or serial transverse enteroplasty (STEP), can increase mucosal surface area and enhance intestinal adaptation 4, 5.
• Medications may be used to alleviate symptoms of diarrhea, bacterial overgrowth, and gastrointestinal dysmotility 5.
• Intestinal transplantation may be considered in selected cases, such as those with irreversible IF or complications of PN 3.

Complications of Intestinal Failure

• Complications of IF include thromboembolic phenomenon, central venous catheter-related bloodstream infection, IF-associated liver disease, and metabolic bone disease 2.
• Liver disease may develop with subsequent end-stage liver cirrhosis in patients with IF, requiring combined liver-intestine transplantation 3.
• Catheter-related sepsis and/or extensive vascular thrombosis may impede the continuation of a safe and efficient PN, and may also require intestinal transplantation in some selected cases 3.