Role of diet and fluids

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For reasons previously discussed, SBS patients would be expected to differ in their response to dietary manipulation depending upon their bowel anatomy, specifically, the presence or absence of a colon [36, 37]. Norgaard and colleagues compared the effect of a high carbohydrate (60%), low fat (20%) diet with a high fat (60%), low carbohydrate (20%) diet in a small number of SBS patients with a colon in continuity [37]. They found that the high carbohydrate, low fat diet reduced fecal calorie loss and increased overall energy absorption (69% vs. 49%). In addition, the high carbohydrate, low fat diet seemed to result in improved wet weight absorption. In contrast, when they compared the same diets in SBS patients without a colon, they found that the high carbohydrate, low fat diet resulted in no improvement in energy or wet weight absorption [37]. Both McIntyre et al. and Woolf et al. have also demonstrated that end-jejunostomy patients do not benefit from dietary modifications [36, 38]. Indeed, a constant proportion of dietary fat is absorbed in the end-jejunostomy patient; therefore, more is absorbed when more is consumed. Because nitrogen absorption is least affected by the decreased absorptive surface in SBS patients, no change in dietary protein is generally necessary and, specifically, the use of peptide-based diets in these patients is unnecessary.

Because of the limited experimental evidence relevant to humans regarding the importance of luminal nutrients in the management of SBS, there is limited consensus on the importance of the oral diet in the management of SBS. Nevertheless, clinical experience confirms the important role that diet plays in the successful management of these patients and further suggests that with appropriate follow-up and compliance, this can result in the long-term reduction of PN

needs while maintaining nutrition and hydration status in some SBS patients. The long-term success of an optimized diet requires extensive education and monitoring to maintain compliance and needs to be translated into foods and meal patterns that meet the individual's preferences, lifestyle and, in children, developmental age [39]. The establishment of daily calorie and fluid intake goals for the patient followed by careful follow-up and adjustments based on tolerance as determined by the development of symptoms, stool output, micronu-trient levels, weight and hydration status is critical. Individual calorie goals can generally be estimated using the calculated resting energy expenditure (e.g., Harris-Benedict estimation) multiplied by activity and malabsorption factors. In general, most stable adult SBS patients absorb only about one-half to two-thirds as much energy as normal; thus, dietary intake must be increased by at least 50% (i.e., hyperphagic diet). The increased quantity of food tends to best tolerated when consumed throughout the day in five to six meals periods. Supplemental tube feeding may be useful in selected patients of any age to meet their calorie needs, particulary when trying to wean PN [40]. Clinical experience suggests that nocturnal gastric tube feeding of a semi-elemental or polymeric formula administered continuously via an infusion pump in small quantities may be better tolerated than bolus tube feeding due to greater absorption of nutrients and a reduced occurrence of osmotic diarrhea. In infants and children, small oral feedings should be used in conjunction with tube feeding as they are necessary at developmentally appropriate times to prevent eating disorders, such as oral food aversion, that may arise later.

The optimal fluid components of the diet also depend upon the remaining bowel anatomy (Table 8.3). Because of the regional differences in water and sodium handling described previously, those SBS patients without a colon generally require the use of a glucose-electrolyte oral rehydration solution (ORS) to enhance absorption and reduce secretion, whereas most of those patients with a colon can maintain adequate hydration without excessive fluid loss with hypotonic fluids. Nevertheless, ORS may still be of value in the SBS with a colon and, as long as sufficient sodium is present in the diet, the amount of sodium in the ORS may not need to be as great. The ingestion of an ORS with a sodium concentration from 90 to 120mEq/l has been shown to provide optimal jejunal absorption [41, 42]. Examples of such solutions include Oral Rehydration Salts (Jianas Brothers Packaging Co., Kansas City, MO; [email protected]) and Cera-Lyte (CeraProducts, LLC, Jessup, MD; www.ceralyte.com). One to three liters of such fluid daily, sipped throughout the day, may

Table 8.3

Diet and Fluid Recommendations in Short Bowel Syndrome

Table 8.3

Diet and Fluid Recommendations in Short Bowel Syndrome

Colon present

Colon absent

Carbohydrate

50-60% of caloric intake

40-50% of caloric intake

Complex carbohydrates

Complex carbohydrates

Fat

20-30% of caloric intake

30-40% of caloric intake

Ensure adequate essential

Ensure adequate essential

fats

fats

MCT/LCT

LCT

Protein

20-30% of caloric intake

20-30% of caloric intake

Fiber

Net secretors

Net secretors

Soluble

Soluble

Oxalate

Restrict

No restriction needed

Fluids

ORS and/or hypotonic

ORS

Avoid hyperosmolar

Avoid hyperosmolar

MCT = medium-chain triglycerides LCT = long-chain triglycerides ORS = oral rehydration solution

MCT = medium-chain triglycerides LCT = long-chain triglycerides ORS = oral rehydration solution be needed to maintain adequate hydration. While fluid composition is less important in those with a colon, adequate dietary sodium should be provided [43]. Regardless of bowel anatomy, hyperosmolar fluids such as regular soda and fruit juices should be avoided, as they will aggravate stool losses. While lacking evidence to support this practice, clinical experience suggests that those patients who tend to experience bowel movements shortly after eating (i.e., dumping) may benefit from avoiding drinking fluids during meals [38]. Parenteral fluids will be necessary if the ostomy output continues to exceed fluid intake ("net secretors").

The provision of complex macronutrients in the diet of SBS patients is preferred (Table 8.3). Complex carbohydrates reduce the osmotic load and potentially exert a positive effect on the adaptation process. Because the proximal jejunum is rarely resected in SBS patients, lactose is generally well tolerated [44] and should not be restricted unless the patient is clearly intolerant, as milk-based products provide an important source of calories and calcium. Concentrated sugars, fruit juices in particular, should be avoided as they generate a high osmotic load and potentiate stool output. With respect to protein, those with high biological value such as those found in beef, pork, poultry and fish are preferred. For reasons described previously, the restriction of fat to 20%-30% of the daily calories is recommended in only those adult

SBS patients with a colon. This results in a reduction in steatorrhea, magnesium and calcium loss and a reduction in oxalate absorption. Normally, dietary oxalate binds to calcium and is excreted in the stool; however, in the setting of fat malabsorption, calcium binds to fatty acids leaving oxalate free to pass into the colon to be absorbed and then filtered by the kidney. In the kidney, oxalate binds to calcium, resulting in oxalate nephropathy. Therefore, oxalate restriction is important in those SBS patients with a colon in order to decrease the risk of oxalate nephropathy that may occur in up to 25% [27]. Examples of foods and beverages high in oxalates are listed in Table 8.4 [1].

Medium-chain triglycerides (MCT) are an alternative energy source and are absorbed from both the small and large intestine. In a randomized, controlled, crossover study, 19 SBS patients (10 with colon and 9 without colon) were assigned to a long-chain triglyceride (LCT) or a MCT + LCT group [45]. The diet enriched with MCT resulted in improved overall energy and fat absorption in the patients with a colon only. The improvement in fat absorption in the group without a colon was offset by malabsorption of the other macronu-trients. MCTs do not require digestion by pancreatic enzymes for their absorption and may be useful in the presence of bile acid or pancreatic insufficiency [45]. However, clinical experience suggests MCTs are not well tolerated long term. Furthermore, MCT have a slightly lower caloric density than LCT (8.3 vs. 9kcal/g), do not contain essential fatty acids, exert a greater osmotic load in the small bowel and have less stimulatory effect on adaptation compared to LCT. The provision of essential fatty acids (e.g., safflower oil and soybean oil) is important

Table 8.4

Examples of Oxalate-Containing Foods and Beverages

Beverages

Colas, tea, instant coffee, draft beer, ovaltine, cocoa Nuts

Almonds, peanuts, cashews, pecans, nut butters Fruits

Apricots, cherries, figs, concord grapes, orange, pear, rhubarb, strawberries, prunes, lemons Vegetables

Artichoke, baked and green beans, beets, red cabbage, okra, green peppers, parsley spinach, tomatoes Other

Grits, bran cereal, tofu, black olives, chocolate, French fries, whole wheat bread as deficiencies are common, particularly in the setting of low fat diets and fat malabsorption [46]. Finally, soluble fiber supplementation may be useful given its potential effect on enhancing adaptation and slowing gastric emptying; although it may result in increased gas and bloating for the patient [1]. The energy derived from bacterial fermentation of soluble fiber, yielding short chain fatty acids that are absorbed in the colon, may be substantial [47]. While anecdotal reports of dietary supplementation with soluble fiber suggest improvement in nitrogen absorption [48], others have described an adverse effect of soluble fiber on fat and glucose absorption [49, 50].

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