Intestinal Rehabilitation

Intestinal rehabilitation refers to the process of optimizing bowel function so as to allow freedom from parenteral nutrition. The primary goal of the program is to eliminate or prevent the need for coartificial means of providing nutrition. The multi-disciplinary Intestinal Rehabilitation Program team at Northwestern provides comprehensive, individualized care utilizing state-of-the-art dietary, medical and, occasionally, surgical methods to achieve its goal. Our patients include: patients who struggle to maintain weight, hydration and nutritional status without relying on intravenous support; patients who require specialized tube feedings for fluid or nutrients; patients who need to reduce diarrhea and control the volume of stool output; and patients with intestinal failure secondary to factors listed above.

Those who should consider intestinal rehabilitation include patients:

• with short bowel syndrome
• with malabsorption syndrome
• with intestinal failure or severe gastrointestinal dysfunction
• seeking to reduce of eliminate the need for parenteral nutrition
• struggling to maintain their weight or nutritional status (including hydration) without relying on intravenous fluid
• having repeated episodes of inflammatory bowel disease which interferes with maintaining a normal nutritional status
• with chronic diarrhea, dehydration or weight loss due to malabsorption
• with intestinal disease (e.g., Crohn’s Disease, Radiation Enteritis)
• who need to reduce diarrhea and control stool output
• who need to gain weight

Our TPN Strategy

At our center, we are continuously looking for ways to successfully decrease patients' dependence on TPN. We have developed the following flow-chart to determine how to proceed with decreasing TPN use by one of our patients.
A review of the charts of 86 former patients who had received treatment at the Northwestern Intestinal Rehabilitation center showed that 20 (23%) were able to be completely weaned from TPN and30 (35%) had their TPN reduced significantly.	Graph: Success in Reducing PN Dependence - Previous Patients
We also reviewed the charts of 40 patients who are currently receiving treatment at our center. 11 (28%) have been completely weaned from TPN, 18 (45%) have had their TPN significantly reduced, and another 11 (28%) have not been able to reduce their TPN at this time.	Graph: Success in Reducing PN Dependence - Current Patients

News From the Intestinal Transplant Center Research Team...

Defining the Intestinal Rehabilitation Process

The process of Intestinal Rehabilitation (IR) has not been clearly defined. The purpose of an IR program is to optimize the function of the remaining small bowel, with the intent of eliminating or decreasing the patient’s dependence on parenteral nutrition (PN). We therefore have defined the process of Intestinal Rehabilitation based on a 4-stage algorithm with specific goals and timelines to improve the efficiency and utility of the process and to better define its relationship with intestinal transplantation.

Patients who meet the criteria for intestinal rehabilitation and/or intestinal transplantation are defined as follows:

1. Have been receiving, or are expected to receive, PN for > 1year
1. < 200 cm of small bowel
2. >200 cm with Crohns disease, radiation enteritis, desmoid tumor, familial Polyposis, CHIPS, mesenteric venous thrombosis
2. No active malignancy
3. No significant co-morbidities that exclude them as candidates for intestinal rehabilitation or transplanation

We defined our parenteral nutrition weaning algorithm and timeline into 4 phases:

1. Stabilization (1 month): Fluid and PN needs defined and their provision modified until stable state achieved. Diet, ORS, and antimotility drugs initiated and optimized. Intestinal rehabilitation candidacy determined and patient-specific plan created. Baseline parameters obtained.

2. Optimization (1-3 months): Surgical strategies (gut lengthening, reanastomosis, etc.), Hormonal strategies (rHGH, etc), Dietary re-education.

3. Weaning (1-3 months): Weekly PN weaning with goal of decreasing PN burden as much as possible. Includes weekly monitoring of weight, vital signs, urine/ stool output, fluid and dietary intake, BMP, anti-motility agent needs, clinical status and monthly monitoring of trace elements, vitamins, etc.

4. Triage (1-6 months): Evaluation of success or failure of PN weaning with 3 patient categories: (i) freedom from PN, (ii) partial PN reduction, (iii) no PN reduction. Intestinal transplantation is recommended to all category (iii) patients and in all category (ii) patients who experience life-threatening PN associated complications.

Using this defined approach in our IR program, we identified the patients who met criteria for intestinal rehabilitation and/or intestinal transplantation. Of the 29 patients who did not proceed to intestinal transplantation, 27 (93%) were either partially or completely weaned from parenteral nutrition support. A total of 12 patients (41%) no longer needed parenteral nutrition, and 14 patients (48%) had decreased dependence by calories, volume and/ or days per week. Of the 17 patients who were not completely weaned from parenteral nutrition, 13 had decreased calorie needs with an average requirement of 57% of the initial formula, 12 patients needed only 51% of their original volume requirements, and 13 had their number of days per week that they received PN decreased with an average 55% decrease in PN days per week.

When the patients were further divided into a subgroup of 21 who have a diagnosis of short bowel syndrome, 19 (90%) were able to achieve either partial or complete freedom from PN, with 7 patients (33%) completely weaned from PN, and an additional 12 (57%) with decreases to their PN dependence.

Of the total of 12 patients who have been completely weaned from PN, 5 have been off PN for 1-3 months, and 7 have been off PN for over 6 months. Only one patient had to be restarted on PN as she was having difficulty maintaining her hydration status. PN was restarted at 3 days/week, patient was followed closely with reeducation on meeting needs with oral intake. Once the patient was stabilized and intake was determined to be meeting needs, PN was discontinued. Pt has currently been off PN for 5 weeks and monitoring has continued with weekly contact and also regular clinic visits. No other patients have had to restart PN.

Patients who are weaned from parenteral nutrition are monitored weekly until stable, upon which time they are evaluated quarterly for one year to ensure they do not develop nutritional deficiencies. In patients for whom all appropriate avenues for achieving freedom from parenteral nutrition have been attempted, intestinal transplantation is recommended.

Defining a timeline and algorithm for an IRP is a critical step to a successful program. This facilitates the decision making process and streamlines patient care with timely and effective treatment approaches, and clearly identifies patients for whom intestinal transplantation should be considered.