Pediatric Annals

Management of Chronic Diarrhea with Parenteral Nutrition and Enteral Infusion Techniques

Marvin E Ament, MD

Abstract

Chronic diarrhea is a condition characterized by the passage of liquid to semi-liquid stools one or more times a day with or without the appearance of gross blood for a period of more than 14 days. In some individuals, it is continuous and in others, intermittent. Some children are not affected by it and gain weight and grow normally,1,2 while in others it may be debilitating, leading to chronic recurrent dehydration, electrolyte imbalance, hypoproteinemia, anemia, malnutrition, failure to gain weight and grow and, in rare instances, death.3

The management of chronic diarrhea always poses a problem for the physician faced with its management. The etiologies of chronic diarrhea are diverse and the physician may be faced with the dual problem of simultaneously establishing a diagnosis and treatment. In some instances, diagnosis is easily established and treatment is simple and easily prescribed. In others, diagnosis is easily established, but treatment is complex and may require intravenous support. Still others are difficult to diagnose and, as indicated above, treatment may be either similarly easily prescribed or difficult. A third group may be undiagnosable and treatment for them is supportive.

Parenteral nutrition has increasingly been used as a form of therapy for those with debilitating chronic diarrhea. 3'5 In most instances, it is supportive, allowing the intestine to heal from either recognized or unrecognized injuries, 3·4 to adapt and grow when foreshortened,6 and to provide nutrition indefinitely to those who have conditions which cannot be treated medically or surgically5 (Table 1).

In some of these conditions, the intravenous therapy will be limited to weeks, months and years. In others, it will be lifelong. 5 Some will require all while others will require only a portion of their nutritional support intravenously. In each instance, parenteral support should be provided only as long as necessary and only at a level to provide what the gastrointestinal tract cannot absorb.

CONDITIONS IN WHICH CHRONIC DIARRHEA MAY REQUIRE INTRAVENOUS NUTRITIONAL THERAPY (Table 1)

Short Bowel Syndrome

In many instances the physician knows from the patient's clinical condition and/or course the need for parenteral support. Short Bowel Syndrome is a condition in which knowing the small intestine's length post-resection can be helpful in determining the degree of support initially necessary,5,6 and whether drip infusion techniques with a dilute elemental formula may be beneficial.7

If 40 cm of small intestine and the ileocecal valve are intact following resection and reanastomosis, there is a greater than 90% chance that the patient's intestine will adapt and require parenteral support for only a limited period of time. Without the ileocecal valve but the same length of intestine, adaptation may take longer and a few patients may never adapt.

Adaptation has been reported in term infants and adults with as little as 12 to 15 cm of small intestine plus ileocecal valve. The more immature the infant at the time of resection, the greater the chance for adaptation because of the chance for growth. We have seen substantial adaptation with as little as 6 cm of small intestine in an infant weighing 1,000 g at birth.

Crohn's Disease

Patients with Crohn's disease may require total parenteral nutrition (TPN) on a long-term basis because of major intestinal resection or because of diffuse disease in the small bowel and/or colon, which does not respond to medical treatment.8 In either instance, patients have large volume diarrhea with or without malabsorption. Depending on the length of resection, the physician may decide a trial of enteral support alone may not be worthwhile.

Ulcerative Colitis

The purpose of parenteral support in this condition is to decrease the frequency of evacuation…

Chronic diarrhea is a condition characterized by the passage of liquid to semi-liquid stools one or more times a day with or without the appearance of gross blood for a period of more than 14 days. In some individuals, it is continuous and in others, intermittent. Some children are not affected by it and gain weight and grow normally,1,2 while in others it may be debilitating, leading to chronic recurrent dehydration, electrolyte imbalance, hypoproteinemia, anemia, malnutrition, failure to gain weight and grow and, in rare instances, death.3

The management of chronic diarrhea always poses a problem for the physician faced with its management. The etiologies of chronic diarrhea are diverse and the physician may be faced with the dual problem of simultaneously establishing a diagnosis and treatment. In some instances, diagnosis is easily established and treatment is simple and easily prescribed. In others, diagnosis is easily established, but treatment is complex and may require intravenous support. Still others are difficult to diagnose and, as indicated above, treatment may be either similarly easily prescribed or difficult. A third group may be undiagnosable and treatment for them is supportive.

Parenteral nutrition has increasingly been used as a form of therapy for those with debilitating chronic diarrhea. 3'5 In most instances, it is supportive, allowing the intestine to heal from either recognized or unrecognized injuries, 3·4 to adapt and grow when foreshortened,6 and to provide nutrition indefinitely to those who have conditions which cannot be treated medically or surgically5 (Table 1).

In some of these conditions, the intravenous therapy will be limited to weeks, months and years. In others, it will be lifelong. 5 Some will require all while others will require only a portion of their nutritional support intravenously. In each instance, parenteral support should be provided only as long as necessary and only at a level to provide what the gastrointestinal tract cannot absorb.

CONDITIONS IN WHICH CHRONIC DIARRHEA MAY REQUIRE INTRAVENOUS NUTRITIONAL THERAPY (Table 1)

Short Bowel Syndrome

In many instances the physician knows from the patient's clinical condition and/or course the need for parenteral support. Short Bowel Syndrome is a condition in which knowing the small intestine's length post-resection can be helpful in determining the degree of support initially necessary,5,6 and whether drip infusion techniques with a dilute elemental formula may be beneficial.7

If 40 cm of small intestine and the ileocecal valve are intact following resection and reanastomosis, there is a greater than 90% chance that the patient's intestine will adapt and require parenteral support for only a limited period of time. Without the ileocecal valve but the same length of intestine, adaptation may take longer and a few patients may never adapt.

Adaptation has been reported in term infants and adults with as little as 12 to 15 cm of small intestine plus ileocecal valve. The more immature the infant at the time of resection, the greater the chance for adaptation because of the chance for growth. We have seen substantial adaptation with as little as 6 cm of small intestine in an infant weighing 1,000 g at birth.

Crohn's Disease

Patients with Crohn's disease may require total parenteral nutrition (TPN) on a long-term basis because of major intestinal resection or because of diffuse disease in the small bowel and/or colon, which does not respond to medical treatment.8 In either instance, patients have large volume diarrhea with or without malabsorption. Depending on the length of resection, the physician may decide a trial of enteral support alone may not be worthwhile.

Ulcerative Colitis

The purpose of parenteral support in this condition is to decrease the frequency of evacuation in response to feeding and to decrease the cramps experienced by these patients, precipitated by feedings.9 The intravenous support provides nutrients to allow healing should the patient's condition remit in response to intravenous corticosteroid therapy and/or provides for reversal of and/or prevention of malnutrition while waiting for a decision on colectomy.

Intractable Diarrhea of Infancy

Patients with this condition may require intravenous support until a specific etiology is determined and treated, or until the injured mucosa heals in response to bowel rest. 3,4 Some of these patients never heal because the injury is irreversible or they have congenital failure of villi to develop. The majority occur either due to formula protein intolerance or to enteroviruses. Many can be fed enterally by continuous drip infusion of an elemental formula into the stomach.4

Severe Combined Immune Deficiency Disease

This condition is the severest of all the primary immune disorders. Patients typically become ill in the first months of life when they present with candidiasis in the form of thrush and skin rash. Systemic bacterial infections typically present between 1 and 3 months of age. Ninety percent of these individuals develop a progressive diarrhea and malabsorption syndrome and colitis. They generally progress to malabsorb almost all nutrients. Even if a specific cause is found, it may not respond to therapy. If they cannot be successfully transplanted, there is little chance for discontinuing parenteral support.

Radiation Therapy

Following radiation therapy and chemotherapy for neuroblastoma, WiImV tumors and other intraabdominal tumors, patients may develop direct injury to the mucosa, disruption or blockage of intra-abdominal lymphatics and a significant diarrhea with proteinlosing enteropathy (PLE) and anorexia. They may improve substantially with time, although the PLE may persist.

Intestinal Lymphangiectasia

Although most patients with intestinal lymphangiectasia can be managed by low fat diet (<10% calories as triglycerides) and medium chain triglycerides (MCT) containing formulas, some do not respond to such therapy and continue to have large volume diarrhea and malabsorption when fed.9 They typically have associated lymphedema of the extremities or face. Intravenous support in such patients may help to control the diarrhea by reducing the exudation they experience. However, substantial protein loss may still continue.

Table

TABLE 1CONDITIONS IN WHICH INTRAVENOUS THERAPY MAY BE USED IN THE MANAGEMENT OF CHRONIC DIARRHEA

TABLE 1

CONDITIONS IN WHICH INTRAVENOUS THERAPY MAY BE USED IN THE MANAGEMENT OF CHRONIC DIARRHEA

Table

TABLE 2MANAGEMENT OF PATIENT WITH CHRONIC DIARRHEA REQUIRING PARENTERAL SUPPORT

TABLE 2

MANAGEMENT OF PATIENT WITH CHRONIC DIARRHEA REQUIRING PARENTERAL SUPPORT

Secretory Tumors

Secretory tumors are very rare in pediatric patients, parenteral support is often required in such patients even though theoretically all they should require would be fluid and electrolyte replacement therapy. 10 Parenteral support in such patients needs to be done, until the type of tumor can be determined and appropriate drugs found to block its effect or excise it. This is not always possible. Some patients may have congenital electrolyte transport defects in their intestine and have difficulty maintaining fluid balance without intravenous support.11

MANAGEMENT OF INTRAVENOUS AND ENTERAL NUTRITIONAL SUPPORT (Tables 2-4)

Placement of a central venous line will be required for the care of most of these patients. ,2 If there is doubt as to how long such support will be required, peripheral intravenous parenteral nutrition may be utilized for up to 2 weeks unless the repeat venipunctures to maintain the lines prove intolerable. The next step should be to establish the patient's nutritional, fluid and electrolyte requirements. Calories should be provided for maintenance of weight gain and growth. This level of support should be at a level equivalent to what would be required for the appropriate percentile of the individual. For example, if an individual is 5th percentile for weight for age and past evidence indicates that the patient was at the 50th percentile, we determine calories on that basis.

Energy calories are typically balanced to try to provide the maximum amount of lipid emulsion allowed for age. This is typically given as a 20% emulsion to reduce fluid volume. The remainder are given as concentrated dextrose.

Protein is given as a balanced amino acid solution at a level appropriate for age and needs.

Do not provide more than 2 to 2.5 g/kg/day of protein. Trace metals in the form of zinc, copper, chromium and selenium are added as needed. Extra zinc is provided for patients with large volume diarrhea because of the large losses which may occur.

Diarrhea stool water should be replaced as a separate solution. Typically .45 NS + 25 meqNa HC03/1 + 10 meq KCL/1 will meet the patient's needs. It should be replaced cc/cc each shift. Patient must be weighed daily for accurate management and stool and urine separated and measured as much as possible to ensure appropriate replacement. To estimate stool losses, diapers should be weighed before and after use. Since most standard diapers will vary little within one package-one may be weighed and that estimate used for subsequent ones. Whenever possible, a patient should be bagged for urine collection to avoid contamination of stool collection. Because of difficulty with bagging, especially in female infants, this may be done every third day to check more accurately on the patient's progress, and to minimize diaper rash.

Stool electrolytes in diarrhea stool water should be done at least once to determine if replacement therapy is appropriate.

If patient is hypoalbuminemic at a level of less than 3.0 g%, correction of the total body albumin deficit should be done to minimize the possibility of decreased oncotic pressure affecting urine output. Once the patient is rehydrated, weight gain should be equal to what is normally expected fot age in addition to what has been provided for deficit corrections.

Table

TABLE 3MANAGEMENT OF PATIENT WITH CHRONIC DIARRHEA RECEIVING PARENTERAL NUTRITION

TABLE 3

MANAGEMENT OF PATIENT WITH CHRONIC DIARRHEA RECEIVING PARENTERAL NUTRITION

Table

TABLE 4MANAGEMENT OF FLUID, ELECTROLYTE, BLOODAND PROTEIN DEFICITS

TABLE 4

MANAGEMENT OF FLUID, ELECTROLYTE, BLOODAND PROTEIN DEFICITS

If patient is anemic from ongoing blood losses, as in ulcerative colitis, this must be corrected as it occurs. Hemoglobin and hematocrit should be kept above 10 g% and 30% respectively. If the patient is anemic due to decreased RBC production from illness or slower gastrointestinal losses, then consideration should be given to providing the patient with packed red blood cells.

Enteral Nutrition

Feeding may be done orally or enterally by drip infusion into the stomach. This in part depends on the patient's age and willingness to tolerate a feeding tube. It may be easiest to start orally and offer a fixed volume of feeding on a set schedule. Volume and strength of feeding can be increased in response to volume of stool output and/or malabsorption. If enteral support does not increase stool output, then either the volume or strength of the feeding used may be increased. Normal stool weight in a fully fed infant weighing up to 10 kg is 20 g/kg/day. Children and adults do not typically have more than 200 g/day under similar circumstances.

If the volume of stool increases to a value of more than 40 g/kg in response to feeding, feeding should not be advanced further, but held at that level until a decreasing trend in stool output is seen. If none is seen within 72 hours, either the concentration of the feeding should be reduced, the volume of feeding reduced, or the type of feeding changed. If this fails, then a trial using a continuous drip infusion may be done by placement of a silastic nasogastric feeding tube.

If this type of tube is used an elemental type of formula may be the best to use, since it is less likely to occlude the tube.

Again the volume and strength of formula infused continuously each hour should be changed in relationship to volume of stool output and/or the degree of malabsorption.

Whether one uses continuous drip infusion oral feedings, reduction in volume of parenteral nutrition should be started once stool volume is reduced. Reduction in volume of TPN should be equivalent to amount of increase in volume of enteral support.

Optimally, a change from continuous infusion to bolus feeding should not be tried until the patient is completely weaned from TPN.

Change from continuous infusion to bolus feeding should also be done in a methodical way.4,7 An example of this would be to give the first 15 minutes feeding of each hour for 5 minutes - none for 10 minutes, then for the remainder of the hour by drip infusion at the usual rate.

If tolerated, the following schedule might be to give 20 minutes worth of feeding over 5 minutes, then 25 minutes etc., up to 30 minutes. Then 35 minutes worth of feeding over 10 minutes, 40 minutes with over 10 minutes, up to 60 minutes worth over 10 minutes. Then 2 hours worth of feeding can be given over 20 minutes, and then 3 hours worth over 30 minutes. Once this is achieved, it is very likely that the diet may be expanded. In some patients diet may be expanded restricting only those things which may be likely to be malabsorbed, such as lactose and lactose containing foods.

In certain instances, this may not be possible because of the bowel disease itself, and in others because of its length.

If a patient requires hospitalization for nutritional support for more than 2 weeks and is likely to require it for more than a month, nutritional support at home becomes a likely prospect to reduce medical costs and developmental delay from prolonged hospitalization.

In such instances, the patient is converted from a 24hour infusion to a 10 to 12-hour one. 5·8 This is done by gradually reducing the number of hours of infusion by 1/day as the rate of infusion per hour is increased. To prevent reactive hypoglycemia, the rate of infusion is gradually reduced in the last 30 minutes by cutting the rate in half twice and by flushing the catheter at the end with heparin.

Enteral tube feedings may also be done at home either with use of silastic nasogastric tubes or by use of a gastrostomy.

Management of chronic diarrhea with either intravenous or enteral therapy is not difficult. It takes preciseness and excellent nursing care, whether at home or in the hospital. There is no question that such therapy has materially altered the outcome of those children who have required it.

TECHNIQUE FOR ENTERAL DRIP INFUSION IN CHRONIC DIARRHEA

1 . Choose appropriate formula for problem - elemental formulas are best.

2. Pass silastic nasogastric tube.

3. Begin with 5% of patient's required fluid needs.

4. Infuse continuously over 24 hours.

5. Increase either volume or strength of feeding as tolerated - 5%, 10% increments per day are best.

6. Weigh all stools and test for pH, reducing sugars and occult blood.

7. Continue to advance volume of formula as long as malabsorption does not develop or if stool volume remains unchanged.

8. Reduce volume of TPN cc/cc as enteral feedings are tolerated.

9. Change from continuous infusion to bolus feedings after TPN is discontinued. Change a fraction of each hour's feeding to be given over 5 minutes - then the remainder of the volume over the remaining time. Increase volume/5 minutes until 30 minutes worth of feeding is given over 5 minutes and 1 hours worth over 10 minutes.

REFERENCES

1. Cohen SA, Hendricks KM, Mschis R, et ah Chronic non-specific diarrhea: Dietary relationships. Pediatrics 1979; 64:402-407.

2. Davidson M, Wasserman R: The irritable colon of childhood. J ftdiulr 1966; 69:1027-1038.

3. Larcher VF, Shepherd R, Freancis MM, et al: Protracted diarrhea in infancy: Analysis of 82 cases with particular reference to diagnosis and management. Arch Dis Child 1977; 52:597-605.

4. Greene HL, McCabe DR. Mcrenstein GB: Protracted diarrhea and malnutrition in infancy: Changes in intestinal morphology and disaccharidase activities during treatment with total intravenous nutrition or elemental oral diets, J Pediutr 1975; 87:695-704.

5. Cannon RA, Byrne WJ, Ament ME, et al: Home parenteral nutrition in infants. J Pediatr 1980;96:1098-1104.

6. Bohane TD, Haka-Ikse K, Biggar WD, et al: A clinical study of young infants after small intestinal resection. ) Pediatr 1979; 94:552-558.

7. Christie DL, Ament ME: Dilute elemental diet and continuous infusion technique tor management of short bowel syndrome. J Pediatr 1975; 87:705-708.

8. Strobel CT, Byrne WJ, Ament MD: Home parenteral nutrition in children with Crohn's disease: An effective management alternative. Gastroenterology 1979; 77:277-279.

9. Vardy PA, Lebenthal E, Shwachman H: Intestinal lymphangiectasis: A reappraisal. Pediatrics 1975; 55:842-851.

10. Dickinson RJ, Ashton MG, Axon ATR, et al: Controlled trial of intravenous hyperalimentation and total bowel rest as an adjunct to the routine therapy for acute colitis. Gastroenterolog} 1980; 79:1199-1207.

11. Krejs GJ, WaUhJH, Morawski SG, et al: Intractable diarrhea: Intestinal perfusion studies and plasma UlP concentrations in patients with pancreatic cholera syndrome and surreptitious ingestion of laxatives and diuretics. American Journal of Digestive Diseases 1977; 22:280-288.

12- Castro-Gago M, Pavow P, Rodrigo R, et al: Prostaglandin synthetase inhibitor in congenital chloridorrhea. Arch Dis Child 1981; 56:238-243.

TABLE 1

CONDITIONS IN WHICH INTRAVENOUS THERAPY MAY BE USED IN THE MANAGEMENT OF CHRONIC DIARRHEA

TABLE 2

MANAGEMENT OF PATIENT WITH CHRONIC DIARRHEA REQUIRING PARENTERAL SUPPORT

TABLE 3

MANAGEMENT OF PATIENT WITH CHRONIC DIARRHEA RECEIVING PARENTERAL NUTRITION

TABLE 4

MANAGEMENT OF FLUID, ELECTROLYTE, BLOODAND PROTEIN DEFICITS

10.3928/0090-4481-19850101-09

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