Guidelines for management of patients with a short bowel

Under review.

Aim
These guidelines aim to help clinicians manage patients who have had an intestinal resection that leaves a short length (about 2 m or less) of small bowel remaining.

Development
The preliminary guidelines were compiled from the literature and a first document was drafted by Dr J Nightingale and modified by members of the Small Bowel and Nutrition Committee under the chairmanship of Dr B Jones. A section on “intestinal transplantation” was written by Dr Woodward and added with the approval of the Small Bowel and Nutrition Committee. The resulting document was shown to clinicians at the intestinal units of Hope and St Mark’s Hospitals. Professor A Forbes made recommendations, which have been incorporated. The article was reviewed by the patient organisation PINNT (patients on intravenous or nasogastric nutritional therapy) and modifications made to result in the current document. The guidelines conform to the North of England evidence based guidelines development project.1 The grading of each recommendation is dependant on the category of evidence supporting it. Recommendations based on the level of evidence are presented and graded as: A: requires at least one randomised controlled trial of good quality addressing the topic of recommendation (evidence categories Ia and Ib); B: requires the availability of clinical studies without randomisation on the topic of recommendation (evidence categories IIa, IIb and III); and C: requires evidence from expert committee reports or opinions or clinical experience of respected authorities in the absence of directly applicable clinical studies of good quality (evidence category IV).

Scheduled review
The content and evidence base for these guidelines should be reviewed within five years of publication. We recommend that these guidelines are audited and request feedback from all users.

Service delivery
Patients with a short bowel are not common but should be managed by a multidisciplinary team headed by a clinician with expertise in managing these patients. If managed appropriately, there may be an improved quality of safe care and also considerable cost savings. On occasions, patients thought to need long term parenteral nutrition may be weaned from it with appropriate advice. As patients (particularly with a short bowel and jejunostomy) may rapidly become dehydrated or septic (if having parenteral nutrition), they and indeed any patient needing artificial nutritional support should have rapid access to medical expertise (advice, clinics, or inpatient treatment).

Patients’ experience

Patients with a short bowel should each be managed as an individual; they are all different in diagnosis, remaining bowel length/function, and psychosocial characteristics.
Patients will become experts in coping with their condition and management. All decisions should all be made in conjunction with them. They are often more knowledgeable about their condition than the clinicians, nurses, and dieticians, and this should be respected.
Facilities for looking after these patients should be able to deal with the physical, emotional, psychological, social, and quality of life issues.
Techniques needed for home parenteral nutrition should be taught by competent, patient, and keen staff who can convey the confidence required to undertake the therapy successfully and safely.
Patients need to know that the aseptic technique for parenteral nutrition will be used whenever their feeding line is accessed, which is vital for safety and peace of mind.
Patients should be referred rapidly to places of expertise if management is difficult or unsuccessful. There should be clinicians, specialist nurses, and dieticians available to discuss or see the patients at all times. Healthcare professionals should be familiar to the patient and know their history, thus eliminating the need for time consuming explanations.
There should ideally be dedicated beds for nutrition patients to ensure they are not cared for by healthcare professionals unfamiliar with their specialist needs.
A 24 hour helpline should be in place so that emergencies are dealt with immediately and appropriately.
Written and audiovisual material may help a patient cope, as will meeting other patients with similar problems.
All patients who require home parenteral nutrition, whether short or long term, should receive information about the patient support group PINNT.
Where appropriate, patients should be offered contact numbers for the relevant support group which represents their specific disease (for example, National Association for Colitis and Crohn’s disease (NACC)).
Follow up appointments should be as deemed appropriate to the multidisciplinary team and patient, and ideally the patient should not have to travel long distances for expert care. The appointment should be with experienced and familiar staff, thus enabling continuity of care.
Staff should be aware of the latest research and developments and should make patients aware of any which may apply to them.