I feel stupid! Someone plz answer my peds GI question

[FutureNurse2B]

Ok so I understand that short gut babies who are dependent on TPN and lipids cannot eat b/c their bowels can't absorb the nutrients, or they just dont work at all and sometimes the children can't swallow food. That is why a g-tube is an alternative to be used as a bypass. But what I want to know is, without a bowel transplant, how else will these kids be able to become normal children and eat? Is this problem permanent? Is a bowel transplant the only solution for this problem or does their bowels miraculously get better with time and heal itself? I feel silly b/c I should know this but its something I've always wondered and I'm very confused whether or not these kids will get better or not.

Please help my curiosity. :typing Thanks

[NotReady4PrimeTime, RN]

The small intestine is where virtually all of our nutrient-absorptive activity happens. If the entire small intestine is removed, we cannot survive without TPN. If only a portion of it is removed, generally less than 2/3 of the length, there may be enough absorption from enteral feeds to allow survival, but the diet will be very heavily supplemented and restrictive. However, this short bowel will not immediately be able to do the entire job of nutrient absorption post-operatively. It will take time for it to adapt to its new responsibilities and TPN will still be needed. The G-tube is needed because the elemental diet short-bowel syndrome demands smells and tastes HORRIBLE! The longer the segment of intestine remaining, the more likely the person is to be able to eat a wider variety of foods beyond the elemental diet. One of the consequences of short-bowel is frequent fat-filled diarrhea because the transit time through the segment is so rapid that little is removed so antidiarrheal medications may be prescribed. One of the adaptations the shortened segment experiences over time is a slowing of peristalsis to allow for better function. Fats are essentil for the absorption and use of many vitamins and minerals (A,D,E,K, B12, Ca++, Mg++, Fe, Zn and folate) so supplementation of these will also be necessary.

Did that help?

[FutureNurse2B]

Thanks Janfrn. I totally understood everything you said but I guess I wasn't clear on my question maybe. I wanted to know with these kinds of kids, what is the likelihood of them having a normal life or will they remain on tpn/lipids and Gtube for most of their lives? I see alot of these kids and just never understood if without a bowel transplant, what is left? Sorry for being unclear. I know I was kinda scatterbrained there for a minute

[NotReady4PrimeTime, RN]

I think your question was quite clear, but I guess you weren't able to read between the lines. The biggest thing is how much of their bowel is left. The more the better. And as children grow, their parts grow, so it is possible to live without a G-tube eventually. But there are thousands of children living "normal" lives who are fed by G-tube. TPN isn't a great choice for long term, so if they can be moved away from it that's best. It's really hard on the liver in the long term and a condition called TPN cholestasis (their bile doesn't flow out of the liver and causes scarring that leads to cirrhosis) can develop. That leads to a need for a multi-visceral transplant - liver and small bowel, but they usually will transplant the whole GI tract en bloc... fewer complications and better outcomes. Our hospital does multi-visceral transplants for kids, but they're pretty rare.

The ability to swallow food isn't something we're born with, exactly. Babies will suck and swallow right after birth, but if they don't have that chance, they will lose the ability to feed orally fairly quickly. It's possible to get that back later but it's a lot of work and isn't always a success. There are windows of opportunity as a baby develops where they learn the oro-motor skills to move food from the front of the mouth to the back and then swallow it. Watch a baby eating cereal for the first dozen times and you'll see a LOT of that cereal being pushed back out of the mouth, not so much because of the taste but because of something called tongue-thrust, which is a component of sucking. Older children who have never fed orally will have this same reflex, which will have to be overcome to get them taking food by mouth. Not impossible, just a lot of work... as long as their swallowing is normal so they aren't at risk for aspiration. Feeding orally should not be made into an unpleasant experience to be endured; so much of our pleasure in life is related to food, so we have to prevent aversion from developing. Children who are cognitively age-appropriate but require tubefeeds should be included at the table during meals for the social aspect.

If you're asking for percentages on how many short-bowel children eventually obtain all their nutrition from oral feeds, I can't give you that. There are just too many variables.

[FutureNurse2B]

Sorry. Gotcha, thanks a bunch.

[NotReady4PrimeTime, RN]

I hope all of that made sense.