TPN and persistent, severe nausea

[dr_dave]

70 yr old white female.  66", 120 lbs.  Had modified masectomy in 1991 with a return 2003 in her stomach and ovaries.  Gastrectomy done in July, 2003.  Nausea has persisted since surgery.

Has been on TPN for 6+ months.  Infused @ 55ml/hr, 24 hrs, then bag changed.  2L bag has 15 U/L, 30mg Reglan, INFUVITE 10ml added.  Base formula is Dextrose 70%, Travasol 10%, Intralipid 20%.  Enlarged liver noted.

0.5ml Phenergan given twice daily via PICC line without relief.

Tends to sleep most of the day (12-14 hrs).  Usually takes 0.5 mg Ativan by mouth prior to nigth sleep.

Family believe TPN mix is root cause.  High dextrose and lipids likely caused the enlarged liver (cirrosis?) since she doesn't seem to be processing that amount daily.

She has been hospitalized 3 times for infections related the first feeding tube and subsequent PICC line.  All the chemo anti-nausea tried without relief.

Psych or physio?  Both, I'm sure, but does TPN level seem right now?  Sure, right after surgery to help regain strength, but seems like less via TPN and more by mouth would be preferred.

Ideas?

[Kevin Pho, MD]

Although it may be possible, I am unaware of an obvious TPN cause causing an enlarged liver.  As has been mentioned in the comments, oral feedings should be initiated if possible as it is always more beneficial to use the gut.  

Regarding the nausea, you may want to inquire about various causes of dyspepsia (ulcers, inflammation of the upper digestive tract and GERD).  Gastroparesis may also be considered, which is sometimes associated with surgery.  A gastric emptying scan would  be the test of choice to evaluate for this.

If enteral feeding cannot be tolerated, you may want to inquire about the possibility of a PEG tube if this is a long-term situation.

These options may be discussed with your gastroenterologist.

Followup with your personal physician is essential.

This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.

Thanks,
Kevin, M.D.

[dr_dave]

She's had just about every test they can think of w/o success.  Liver series, gall bladder tests, endoscopy, and more that I likely don't know about.

So, physio seems unlikely.  I've read one article about hypnotherapy in treating IBS, and this seemed like an avenue to follow.  Unfortunately, she won't do anything unless the docs tell her to (and I AM a doc!  Well, Ph.D., but my bro is a D.M.D and very sharp, and she won't listen to either of us!).

Comments on hypnosis/psychological interventions?

[surgeon]

a groshong catheter is used for intravenous feedings; tubes into the intestine would not generally cause blood infection, unless there was some sort of leak and a secondary infection. Feeding tubes in the intestine are really not a direct risk for bloodstream infection, so I'd assume there was some sort of technical issue which would not likely repeat itself. However, it's really impossible to understand such complex situations from afar. I'd still opt, in a long-term situation, for enteral feeding whenever possible.

[surgeon]

If she can't take food orally, feeding is much better utilized thru the gut than via TPN; it would seems there's no reason she couldn't have a feeding tube placed (surgically or otherwise), and receive enteral feedings. In the long run it's safer, cheaper, more effective.

[dr_dave]

Her first feeding tube was a Groshan (sp.?) catheter into the small intestine.  Resulted in a rather severe blood infection and a switch to the PICC.  Had nausea with that one as well.