Hyperalimentation in the Management of Chronic Inflammatory Intestinal Disease ~ RICHARD E.-DEAN, M . D . , t

MANUEL M . CAMEOS, M . D . , $

gARBlE BARRETT

Grand Rapids, Michigan

a variety of clinical experiences using this method of nutritional support, called "hyperalimentation."2, 5, 7. 8 Although hyperalimentation has been used widely in treatment of gastrointestinal problems, few reports deal specifically with chronic intestinal disease and the use of hyperalimentation.4, 6, 9 Ferguson-Droste-Ferguson Hospital and Ferguson Clinic specialize in the diseases of the colon and rectum and follow a large number of patients who have Chronic inflammatory disease of the bowel. This study was derived from the hospital records of patients admitted during 1974.

CHRONIC INFLAMMATORY DISEASE Of t h e

bowel presents many challenges and frustrations to the clinician accepting responsibilities for the care of these patients. Nutritional deficiencies are frequent components of the patients' problems. These deficiencies may result from a combination of factors, ranging from anorexia secondary to systemic toxicity to the problems of malabsorption. Attempts to improve the nutritional state by concentrated diets are often associated with increased gastrointestinal fluid loss and little improvement in the metabolic state. Intravenous administration of 5 per cent dextrose and electrolyte solutions further compounds the existing deficiencies through gluconeogenesis of endogenous protein. In 1968, Dudrick et aI.a reported their experience with a nutritionally balanced parenteral solution capable of producing normal weight gain and development in growing puppies for prolonged periods (44 weeks). T h i r t y patients who had complicated gastrointestinal problems were also included in this classic paper. Since that time, numerous investigators have described

Material

Hospital records of all patients receiving hyperalimentation fluids, at FergusonDroste-Ferguson Hospital during 1974 were reviewed. T h e r e were 88 such patients. T h e group included 16 patients with chrorlic inflammatory bowel disease, who are the subject of this report, as well as eight patients who had the primary diagnosis of diverticulitis of the colon, seven with colonic cancer, and seven with gastrointestinal problems resulting from trauma, radiation, intestinal obstruction and pancreatitis. Tile 38 patients received a total of 1,908 liters of hyperalimentation fluid. T h e diagnosis of chronic inflammatory disease of the bowel was established on the basis of histologic studies in all but four of the 16 cases studied. In these four cases the diagnosis was based on x-ray findings and clinical manifestations. Eleven patients

* Read at the annual meeting of the Midwest Surgical Association, Itasca, Illinois, September 4, 1975. J-Department of Surgew, College of Human Medicine, Michigan State University and Grand Rapids Area Medical Education Center. ++Active staff, Colon and Rectal Surgery, Ferguson Clinic. Address reprint requests to Dr. Campos: Ferguson Clinic, 72 Sheldon Avenue, S.E., Grand Rapids, Michigan 49502.

601 Dis. CoL &Reet. October 1976

Volume 19 Number 7

602

DEAN, ET

had Crohn's disease. Eight of the 11 had extensive disease involving both large and small intestines; one had the disease process limited to the terminal ileum and in the other two the disease involved only the large bowel. Five patients who had chronic ulcerative colitis were treated with hyperalimentation. One of the five was admitted with toxic megacolon and another had been treated six weeks prior to admission for toxic megacolon at another hospital. Of the 16 patients in this study, nine were male and seven, female. T h e average age was 33 years, with a range of 14 to 62 years. T h e r e were two types of indications for hyperalimentation. Five patients were given hyperalimentation for nutritional reasons. T h r e e of these five patients were provided parenteral nutrition in preparation for planned surgical procedures, and two were treated for the "short-bowel syndrome" resulting from their disease. A group of 11 patients was treated by hyperalimentation for bowel rest. T h r e e of these patients had intestinal cutaneous fistulas, four were treated for prolonged ileus, and four received hyperalimentation for intractable diarrhea. Method Hyperalimentation was administered through a central venous catheter introduced under surgical conditions through the subclavian route. Chest x-rays were

Dis. Col. & Rect. October 1976

AL.

obtained immediately following this procedure to determine the position of the catheter and to identify complications. Catheter care was completed on alternate days using strict aseptic surgical technique. H y p e r a l i m e n t a t i o n fluids were prepared in the pharmacy d e p a r t m e n t using 500 ml of a 10 per cent hydrolysate protein solution and 500 ml of a 50 per cent dextrose sohttion. Thirty-five milliequivalents of sodium chloride, 20 m E q potassium chloride, and 2 m E q magnesium sulfate were added to each liter of hyperalimentation solution. T h e nutritional components of this solution are listed in T a b l e 1. A balanced vitamin solution (MVI) was added to I liter of h y p e r a l i m e n t a t i o n fluid daily. In addition, the patient received 0.4 m g folic acid and 100 t~g vitamin Br, daily. Additional potassium and sodium were included in the sohttions when needed. All fluids were administered through a gravity-flow system at an average rate of 150 ml/hr. Fluid rates were reduced during the initiation of hyperalimentation and were tapered off over two days at the termination of hyperalimentation. All patients were monitored closely while receiving hyperalimentation (Table 2). Patients who had chronic inflammatory disease of the bowel and were receiving hyperalimentation were treated with A C T H or prednisone ~ind antibiotics when indicated. All antibiotics were administered according to culture and sensitivity

TABLE l. Hyperalimenlatiott Solution (1,000 ml) Nutritional Components of Basic Solution Protein equivalent (nitrogen 6.5 g) Calories Sodium Potassium Calcium Magnesium Chloride Phosphate

Additives 3740 g 1,020 30 mEq 15 mEq 5 mEq 2 mEq 22 mEq 30 mEq

35 mEq 20 mEq 2 mEq 55 mEq

Total

65 35 5 4 77 30

mEq mEq mEq mEq mEq mEq vx

Volume 19 Number 7

ItYPERALIMENTATION

IN I N F L A M M A T O R Y I N T E S T I N A L DISEASE

Monitoring the Patient Receiving Hyperalimentation

results and were limited to 7-10-day courses of therapy.

TABLE 2.

Results

1. W e i g h daily

T h e average length of hospitalization for the 16 patients was 39 days. T h e longest period of hospitalization was 93 days, and the shortest, ten days. T h e 16 patients averaged 14 days of hyperalimentation, with a range of four to 72 days. T h e average weight gain of this group of patients was 9 pounds. A m a x i m u m weight gain of 20 t)ounds was recorded for one patient in this group. Seven o~ the 11 patients who had Crohn's disease underwent 12 operative procedures during their hospitalization. One of these patients was operated upon four times during his 83 days of continuous hospitalization. One of the five patients who had chronic ulcerative colitis underwent total proctocolectomy; a chest tube was inserted in a second patient. Of the entire group of 16 patients who had chronic inflammatory bowel disease, seven were discharged from the hospital without undergoing an operation. One patient developed pneumothorax following central venous catheterization, wh,ich necessitated insertion of a chest tube. Complications of hyperalimentation included significant glycosuria in four patients. One patient developed Candida albicans septiceulia, which was fatal. Discussion T h e use of hyperalimentation in the management of patients who have chronic inflammatory disease of the bowel has been limited in this study to those patients requiring nutritional support unavailable by the usual oral route or to situations where bowel rest would contribute greatly in the m a n a g e m e n t of complications resulting from chronic inflammatory intestinal disease. T h e 16 patients reviewed in this study represent only a segment (10 per

60~

2. T e s t u r i n e for sugar a n d acetone every.slx h o u r s 3. Measure blood s u g a r a n d daily, t h e n every third day

BUN

three

times

4. Measure s e r u m electrolytes then every third day

three

times daily,

5. Do SMA 12/60 analysis every seven days

cent) of the 160 patients admitted to Ferguson-Droste-Ferguson Hospital with chronic inflammatory disease of the bowel during 1974. All but one of the patients in the study group had been hospitalized more than once in the past. In one case, this admission represented the patient's fifty-sixth hospitalization for problems related to chronic inflammatory disease of the bowel. Disease involvement was extensive in this group of patients. Eight of the 11 patients who had Crohn's disease had involvement of both colon and small intestine. T h e disease process was limited to the colon in two cases; in only one patient was the disease limited to the small intestine. All b u t one of the patients in this group had undergone repeated intestinal resections prior to this admission. Four of the patients selected for hyperalimentation in 'the chronic ulcerative colitis group had complications of the disease (toxic megacolon, one; fulminating exacerbation of acute ulcerative colitis, two; protracted ileus, one), and in one patient hyperalimentation was used in preparation for total proctocolectomy. One patient in this g r o u p died. T h i s patient had undergone m a n y intestinal resections for Crohn's disease in the preceding 15 years. His total intestinal length was 22 cm of small intestine and 18 inches of colon. H e was admitted with upper gastrointestinal bleeding, requiring 16 units of blood prior to undergoing a se-

Dis. CoL &Rect. October 1976

DEAN, ET AL.

604

lective vagotomy a n d pyloroplasty for advanced d u o d e n a l ulcer. Postoperatively, the p a t i e n t developed necrosis a n d dehiscence of the u p p e r a b d o m i n a l wall with dehiscence of the gastrotomy incisions. W i t h p r o l o n g e d h y p e r a l i m e n t a t i o n , the w o u n d s developed h e a l t h y g r a n u l a t i o n a n d showed evidence of healing. After two m o n t h s of c o n t i n u o u s h y p e r a l i m e n t a t i o n , Candida albicans was c u l t u r e d from the blood a n d the tip of the central v e n o u s catheter. H y p e r a l i m e n t a t i o n was discont i n u e d a n d a p p r o p r i a t e a n t i b i o t i c therapy was i n i t i a t e d . N u t r i t i o n was p r o v i d e d by tube feedings. E i g h t e e n days later r e n a l failure developed a n d the p a t i e n t subseq u e n t l y died as a result of " s e q u e n t i a l systems [ailttre. ''1 Conclusion Sixteen p a t i e n t s who h a d a d v a n c e d c h r o n i c i n f l a m m a t o r y disease of the bowel were treated with h y p e r a l i m e n t a t i o n to 1) restore a n d i m p r o v e n u t r i t i o n , a n d 2) provide bowel rest. A n average weight g a i n of 9 p o u n d s was recorded for this g r o u p of p a t i e n t s even t h o u g h n i n e of the 16 h a d 14 surgical procedures p e r f o r m e d d u r i n g the study. O n e p a t i e n t i n the study developed Candida albicans septicemia a n d subsequently died. A s t a n d a r d h y p e r a l i m e n t a t i o n formula, delivery system, a n d p a t i e n t m o n i t o r i n g

m e t h o d have been u t i l i z e d effectively i n this study to achieve the m a x i m u m n u t r i tional benefits with m i n i m a l hazards to p a t i e n t welfare. References 1. Baue AE: Multiple, progressive, or sequential systems failure: A syndrome of the 1970's (editorial). Arch Surg 110: 779, 1975 2. Dudrick SJ, Wilmore DW, Vars HM, et al: Can intravenous feeding as the sole means of nutrition support growth in the child and restore weight loss in an adult? An affirmative answer. Trans South Surg Assoc 80: 370, 1968 3. Dudrick sJ, Wilmore DW, Vars HM, et al: Long-term total parenteral nutrition with growth, development, and positive nitrogen balance. Surgery 64: 134, 1968 4. Fischer JE, Foster GS, Abel RM, et al: Hyperalimentation as primary therapy for inflammatory bowel disease. Am J Surg 125: 165, 1973 5. Kaplan MS, Mares A, Quintana P, et al: High caloric glucose-nitrogen infusions: Postoperative management of neonatal infants. Arch Surg 99: 567, 1969 6. Marshall F II: Hyperalimentation as a treatment of Crohn's disease. Am J Surg 128:652, 1974 7. Rush BF Jr, Richardson JD, Griffen WO Jr: Positive nitrogen balance immediately after abdominal operations. Am J Surg 119: 70, 1970 8. Sail S, Brofman B, Stone ML: Nutritional support of patients with intravenous hyperalimentation. Am J Obstet Gynecol 114: 500, 1972 9. Vogel CM, Corwin TR, Baue AE: Intravenous hyperalimentation in the treatment of inflammatory diseases .of the bowel. Arch Surg 108: 460, 1974