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Questions in the Gastroenterology and Liver Diseases Forum have been answered by Dr. Kevin Pho who is board certified in Internal Medicine and by doctors from Henry Ford Health System.
Question Title: Short Bowel Syndrome/Forum: The Gastroenterology and Liver Diseases Forum
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: I experienced a traumatic loss of all but 19" of small intestine s/p colectomy for a dysfunctional colon (very complicated medical/surgical hx, born with exstrophy of bladder). I have been on TPN now for 20 months. I have asked what criteria is used to decrease TPN and theres been little discussion about this. I currently cycle TPN 12h/d. Weight stable 118lbs. @ 5"3'. : The TPN does not bother me it has become a part of my life. But I just want to make sure my liver stays as healthy as possible. Am I being impatient? I fear long term complications to my liver. : What levels of LFT's should alert me. : I need the fluids for hydration.I receive 4.5L. total volume daily. Less than this and I experience Pylelonephritis (Ileal Conduit & Jejunostomy & Left Nephrectomy)Serum Creat. WNL. : I've had 6 UTI's this year usually occur q4-6w. : I also have been diagnosed with severe osteoporosis. Isn't it rather early at my age to have developed this with TPN only 20 months?(Currently on ERT). : 1. Where can I research TPN further ( I am a nurse ) : 2. Any suggestions for recurrent UTI's? : I've been to 3 Urologists at 3 different institutions. The only answer was hydration and Increased ascorbic acid in TPN to 1000mg. Its been 4 weeks since last UTI. so we'll see. : 3. What levels to expect with LFT's what is dangerous. : I am 40 years old and hope to live another 40! I just want to do everything I can to stay healthy. Dear Eydie, To determine whether or not you will be able to be weaned off of TPN it is important to consider the following: 1) Resection of up to 50% of small bowel in the midsection (jejunum) results in very little functional impairment while resection of the duodenum or ileum can result in severe malabsorption with serious clinical consequences. 2) the presence of a preserved ileocecal valve will allow for better recovery 3) The more bowel that is resected or the more residual bowel that is diseased the slower the recovery. Most patients with more than 50-75% of resected small bowel will require prolonged TPN and some will require life-long TPN. You should be encouraged that after massive small bowel resection an adaptation process occurs in the remaining bowel. It may take up to 2 years post-resection for full adaptation to occur. It has been shown that the most important mechanism in the adaptation process is the presence of nutrients in the intestinal tract. Therefore, even patients on TPN should be encouraged to eat food or drink enteral formulas as tolerated. Certain hormones and pancreaticobiliary secretions also play a role. You may be able to learn more about TPN from the Oley Foundation. Their phone number is 1-800-776-OLEY or (518)-262-5079. Their address is A-23 Hun Memorial, Albany Medical Center, Albany, N.Y. 12208. I don’t believe that the TPN alone can explain your osteoporosis. Osteoporosis related to TPN usually develops after years on TPN and the mechanism is not completely understood. The degree of elevation of liver enzymes alone are not a good enough indicator to decide how much liver injury is present. TPN induced liver disease is multifactorial. However, you may be able to prevent liver injury by avoiding hepatotoxic drugs and alcohol, decrease excessive glucose and calories from TPN formulas and to take in oral nutrients as tolerated. A liver biopsy (if clinically indicated) documenting inflammation, fibrosis or cirrhosis would give your physician a better idea as to how your liver is being affected by TPN. In certain cases patients with recurrent urinary tract infections are placed on low dose prophylactic antibiotic treatment. You would need to consult your physician to see if that would be right for you. I hope you find this information helpful. This response is being provided for general informational purposes only and should not be considered medical advice or consultation. Always check with your personal physician when you have a question pertaining to your health. If you wish to be seen at our institution please call 1-800-653-6568, our Referring Physicians’ Office and make an appointment to see Dr. Muszkat, one of our experts in Gastroenterology. HFHSM.D.-ym Dear Marie, Metabolic bone disease related to TPN is more often osteomalacia than osteoporosis. Osteomalacia may occur after 2-3 months on TPN. This can occur despite apparent improvement in overall nutritional status. As I mentioned before, the mechanism for this is unclear at this time. This may be related to altered vitamin D metabolism and increased urinary loss of calcium in patients on TPN (related to glucose loading or increased organic sulfates in TPN) as well as aluminum toxicity (rare in today's TPN solutions). Good luck to you. This response is for educational purposes only and should not be considered medical advice or consultation.
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