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Gutsy Issues in Nutrition

Judy Suneson, RD, LD, CNSD & Carol Ireton-Jones, PhD, RD, LD, CNSD

Eating is natural, isn’t it? But what if you are on Total Parenteral Nutrition (TPN)? In most cases, eating is good for you even if you are on TPN. Even small amounts of food can be beneficial to the gastrointestinal tract. Sometimes, however, it may not be. It will be most helpful to look at your own situation because everyone responds differently.

What happens when you eat? Lots!!! Food stimulates gastric acid production which also stimulates peristalsis. The pancreas secretes digestive enzymes. Too much acid secretion in the stomach can cause the digestive enzymes to be inactivated. All of this increases gastrointestinal output. What’s wrong with increased output? Increased output may occur in the form of diarrhea. Diarrhea can mean that your losses are greater than your TPN replacement so there may be a need to take in extra fluid.

Can I eat too much at any one time? Absolutely! The shorter the gut the faster the movement through the gastrointestinal tract and therefore less nutrients can be absorbed. If you have eaten a lot of food at one time, you have probably already noticed that.

In the style of David Letterman, the following list outlines the Top Ten Things to Know About Eating If You Are on TPN:

  1. First and foremost -- Enjoy your food!
  2. Don’t overdo anything -- you may overwhelm your digestive system.
  3. Beverages should be low in sugar because fluids empty from the stomach faster than solid food. Try: Gatorade, or Crystal Light or Sugar-free Koolaid sweetened with NutraSweet. Avoid diet beverages sweetened with sorbitol or xylitol as these sweeteners are not absorbed and may stimulate stool output. Fruit juices should be diluted and are best when they don’t have sugar added to them (such as most cranberry juices, “fruit punches” and “fruit juice cocktails”). To include juices in your diet, try mixing grapefruit juice and Fresca, or orange juice and diet Sprite. By doing this you decrease the amount of concentrated sugar in these beverages.
  4. Beverages should be sipped continuously with the largest amounts taken between meals and smaller amounts taken with meals.
  5. Include sources of soluble fiber like bananas, rice, applesauce, toast, tapioca, and oatmeal. Foods containing large amounts of insoluble fiber may or may not be tolerated depending upon your risk of intestinal obstruction. Foods with higher insoluble fiber are green, leafy vegetables and whole grains such as high fiber cereals and breads -- all greater than 3 grams per serving.
  6. Eat small frequent meals rather than large meals.
  7. Fatty foods (i.e. eggs, sausage, whole milk diary products and fried foods) may be better tolerated in the morning rather than later in the day.
  8. Unless you have been told otherwise by your physician, it is okay to salt foods and to eat salty foods, since loss of gastrointestinal fluid is also loss of salt.
  9. You can eat the foods that you like unless they make you sick. Try small amounts first!
  10. Caffeine can be a potent gastric stimulator and increase output by causing diarrhea. This should be considered not only in coffee intake but in soft drink intake as well.

 

Practicing Good Eating Habits

The following case study demonstrates how one patient with short bowel syndrome improved her nutritional intake by decreasing output (slowing intestinal transit time), working with a dietitian with training in nutrition support and a gastroenterologist, and using the principles described above.

Sally is 40 years old with short bowel syndrome as a result of numerous operations for Crohn’s disease. She has approximately six feet of remaining small intestine ending with a jejunostomy. Her last operation was eight years ago. She has not had a major recurrence of her Crohn’s disease since. The absorption in her remaining small bowel gradually adapted over these years, allowing her to reduce her need for TPN from seven nights per week for the first three years after surgery to five nights per week for the next three years. However, after six years of hooking up, Sally was eager to further decrease her dependence on TPN. She realized this depended on reducing her ostomy output and thus was motivated to change her diet. With the help of a dietitian with training in nutrition support, and careful attention to her medications and diet, Sally was able to gradually decrease her TPN to three nights per week in the past two years.

As is often typical of short bowel patients, Sally was not aware that what she ate made much difference to her ostomy output. She began keeping a careful nutritional intake record which included foods and liquids consumed as well as measures of her ostomy output. She reviewed this with her dietitian and gastroenterologist at regular intervals.

The intake record showed Sally avoided foods and beverages after disconnecting from her TPN in order to decrease the volume of her ostomy output. By late morning or early afternoon, though, she would begin copious drinking. Her favorite was Dr. Pepper. She often consumed more than a six pack per day. After reviewing her intake and output records, she recognized that as she began drinking, there was a definite increase in her ostomy losses. Sally wasn’t convinced that the high sugar content of the beverages made much difference, but she decided to embark on a trial of caffeine-free liquids and noticed this made a consistent improvement. Encouraged by this success, Sally gradually converted to sugar-free beverages for the majority of her intake. She began drinking an oral rehydration solution as well, and only occasionally treated herself to a regular Dr. Pepper.

The dietitian also pointed out that Sally drank large amounts of beverages with her meals. Since this practice can promote rapid transit through the bowel, the dietitian suggested Sally decrease the quantity of fluid with meals and sip most fluids between meals instead. Again Sally was encouraged that these changes decreased her output and began to show more interest in other areas of her diet.

Another chief complaint of Sally’s was her very watery ostomy output which led to frequent trips to the bathroom to empty her appliance. Again, closer inspection of her nutritional intake revealed this happened after eating salads. Lettuce and other greens may increase the water content of the stool. Therefore Sally was instructed to limit her salad intake and to try to include some foods with soluble fiber (see number five on the Top Ten list above) to decrease her losses. In addition, Sally consulted with her physician regarding the best anti-diarrheal agents to use on a routine basis.

 

The Results

After adjusting her intake as described above, Sally was able to decrease her ostomy output to a more manageable level and reduce her TPN dependence to three nights per week. In the TPN she gets water-miscible forms of fat soluble vitamins, divalent cations and vitamin B12 for which she is still at risk of malabsorption.

Sally’s story is a simplified example of what it takes to alter nutritional intake and output. Certainly a perfect diet for short bowel syndrome does not exist. Every person is an individual and every gut is different as well. Each diet will need to correspond to what the patient has in terms of bowel length, disease activity and time lapse since surgery. In addition, it should be noted that change is not likely to happen overnight, but often takes time and attention to detail. Sally’s story points to the value of developing a specific nutrition plan for the patient with short bowel syndrome with a registered dietitian with a background in nutrition support and experience with malabsorptive disorders.

Judy Suneson is a registered and licensed dietitian specializing in gastrointestinal disorders at Baylor University Medical Center’s John S. Fortran, MD Center for Digestive Disease in Dallas, Texas. Carol Ireton-Jones received her PhD in Nutrition from Texas Woman’s University and is a registered and licensed dietitian and Director, Nutrition Program Management, for Coram Healthcare.

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This website is an educational resource. It is not intended to provide medical advice or recommend a course of treatment. You should discuss all issues, ideas, suggestions, etc. with your clinician prior to use. Clinicians in a relevant field have reviewed the medical information; however, the Oley Foundation does not guarantee the accuracy of the information presented, and is not liable if information is incorrect or incomplete. If you have questions please contact Oley staff.

 

Updated in 2015 with a generous grant from Shire, Inc. 

 

This website was updated in 2015 with a generous grant from Shire, Inc. This website is an educational resource. It is not intended to provide medical advice or recommend a course of treatment. You should discuss all issues, ideas, suggestions, etc. with your clinician prior to use. Clinicians in a relevant field have reviewed the medical information; however, the Oley Foundation does not guarantee the accuracy of the information presented, and is not liable if information is incorrect or incomplete. If you have questions please contact Oley staff.
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