Intestinal Failure

Main subject categories: • Internal medicine • Colon & rectal medicine • Gastroenterology • Intestinal failure • PancreatitisThis is the second and fully updated edition of the successful volume on intestinal failure in adults and children. The book provides a comprehensive coverage of all aspects of intestinal failure: from acute and chronic intestinal failure management and treatment, to outcomes, consequences and problems of treatment. In addition, 20 new chapters have been added, covering acute and chronic pancreatitis, critical care and abdominal pain among other topics. Each of the chapters contains a section with top tips on the topic, summarizing the essential take-home messages. Highly educational, this book is a must have for gastroenterologists but is of use for all members of a hospital nutrition support team including nurses, dietitians and pharmacists, whom it will serve as a practical guide for management of intestinal failure both in the hospital and in an outpatient setting. Written by a multidisciplinary author team, this book brings this important subject to a wide readership. With extensive referencing the book provides a detailed overview of the topic, discussing the latest research in the subject and how this relates to current clinical practice and potential future treatments. Foreword to Second Edition Foreword to First Edition: 2001 Preface Acknowledgements Contents Abbreviations Part I: Introduction Historical Overview of Intestinal Failure Introduction Parallel Developments Advances in Knowledge Sites of Nutrient Absorption and Effect of Resection Fluid and Electrolyte Fluxes Effect of Malabsorption on the Colon Adaptation of the Residual Small Intestine After a Partial Resection Development of Surgical Practice Extensive Resection Construction of a Stoma Entero-Cutaneous Fistula Characterization of the Resection Surgical Treatment of Intestinal Failure Recognition of Medical Causes of Intestinal Failure Development of Treatment Enteral Nutrition (Table 2) Parenteral Nutrition (Table 3) Resection and Anastomosis Terminal Jejunostomy Pharmacological Treatment of Short Bowel Conclusion References Normal Intestinal Anatomy and Physiology Introduction Oesophagus Stomach Duodenum Volume of Gastrointestinal Secretions Jejunum and Ileum Length of the Small Intestine Digestion and Absorption in the Small Intestine Water, Sodium and Chloride Macronutrients Carbohydrate and Protein Lipid Nucleotides Micronutrients Vitamins Minerals Magnesium Calcium Iron Zinc Copper Ileocaecal Valve Colon Gastrointestinal Motility Stomach and Small Intestine Fasting Fed Colon Controlling Mechanisms Appetite Gastrointestinal Tract Gastrointestinal Hormones Ghrelin Gastrin Somatostatin Cholecystokinin Secretin Gastric Inhibitory Polypeptide Pancreatic Polypeptide Motilin Vasoactive Intestinal Peptide Neurotensin Peptide YY Glucagon-Like Peptides Pancreatic Glucagon Glucagon-Like Peptide-1 (GLP-1) Glucagon-Like Peptide-2 (GLP-2) Oxyntomodulin (OXM) Glicentin Kinetic Architecture of the Gut Crypt Proliferation Immunological Functions Organization of the Mucosal Immune System Antigen Sampling Dendritic Cells Gut Microbiome Comparative Anatomy References Definitions, Classification and Severity of Intestinal Failure Introduction Definition of Intestinal failure Classification of IF Expected Duration Disease Process, Residual Anatomy and Physiology Underlying Disease Severity of IF References Part II: Acute (Short and Medium Term Reversible) Intestinal Failure Postoperative Ileus Introduction Definition and Incidence of Ileus Burden of Ileus (Effect on Morbidity and Cost of Stay) Pathophysiology Risk Factors Prevention of PPOI Early Enteral Feeding Chewing Gum Epidural Anaesthetic Laparoscopy Alvimopan Prokinetic Agents Non-steroidal Anti-Inflammatory Drugs Coffee Treatment of Prolonged Postoperative Ileus Summary References Acute Surgical Intestinal Failure. Sepsis and Enterocutaneous Fistula(s) Introduction Small Bowel Obstruction Aetiology and Pathogenesis Intestinal Fistulas Management Diagnosis and Management of Acute Intestinal Failure Diagnosis and Management of Abdominal Sepsis Wound Care Nutritional Support and Optimisation Enteral Nutrition Parenteral Nutrition Intestinal Mapping Prehabilitation Definitive Treatment Medical Therapy for Enterocutaneous Fistula(s) Outcome of Treatment for Acute Intestinal Failure References Mesenteric Ischemia Introduction Definition of Mesenteric Ischemia and Anatomy Pathophysiology Epidemiology Incidence Causes Prognosis Diagnosis of Mesenteric Ischemia Clinical Suspicion Biomarkers Diagnostic Imaging Vascular Imaging Findings Bowel Imaging Findings Prognostic Value of CT Treatment of Acute Mesenteric Ischemia Management in Dedicated Stroke Units Revascularization Endovascular Strategies Open Vascular Surgery SMA Embolectomy Retrograde SMA Bypass Retrograde Open SMA Stenting (ROMS) Intestinal Resection Non-invasive Predictors of Transmural Necrosis Surgical Approach Bowel Viability Assessment Damage Control Surgery Extensive Bowel Resection Follow-Up and Rehabilitation Post-ischemic Stenoses and Disorders Nutritional, Vascular and Intestinal Rehabilitation Reanastomosis of Defunctioned Bowel Conclusion References Crohn’s Disease Introduction Epidemiology of Intestinal Failure in Crohn’s Disease Mechanisms of Intestinal Failure in Crohn’s Disease Alternatives to Surgery in Crohn’s Disease Reducing Postoperative Morbidity in Abdominal Surgery for Crohn’s Disease Reducing the Risk of Recrudescent Disease After Surgery for Crohn’s Disease Management of Type II Intestinal Failure in Crohn’s Disease Management of Type III Intestinal Failure in Crohn’s Disease References Peritoneal Adhesions and Encapsulating Peritoneal Sclerosis Adhesions What Are They? Adhesions in the Context of General Surgery Abdominal Pain Intestinal Obstruction Morbidity During Future Operations Cost to Healthcare Services Adhesions in the Context of Intestinal Failure Diagnosis Diagnosing Adhesions Diagnosing Adhesive Intestinal Obstruction Prevention Surgical Technique Topical Biochemical Agents Systemic Agents Management in the Context of Intestinal Failure Encapsulating Peritoneal Sclerosis The Peritoneum Structure, Physiology and Function Classification and Aetiology of EPS The Pathophysiology of Development of EPS Secondary Peritoneal Sclerosing Conditions Not Related to Peritoneal Dialysis Primary EPS Diagnosis of EPS Diagnostic Tests and Pathway for Suspected EPS Imaging in EPS Laparoscopy Histologic Features of EPS Histology of Non-renal EPS Treatment of EPS Medical Therapy for EPS Steroids Tamoxifen Immunosuppression Novel Agents Caveats in Medically Treating EPS Surgery for EPS Preoperative Preparation and Planning Surgical Technique Localised EPS The Management of Advanced Cases Where Enterolysis and Peritonectomy Is Not Possible Recurrent EPS Encapsulating Peritoneal Sclerosis in Children Dietary Therapy (to Avoid Obstructive Symptoms with Adhesions and EPS) Definitions Low Fibre Low Residue Causes of Bowel Obstruction Fluid and Electrolytes Micronutrients General Advice: Chew and Teeth Medications Fibre Containing Enteral Nutrition References Bone Marrow and Haemopoietic Stem Cell Transplantation Introduction Terminology Autologous Allogeneic Sources of Haemopoietic Stem Cells Peripheral Blood Stem Cells Bone Marrow Umbilical Cord Blood Indications Gastrointestinal Complications Pre-engraftment Complications Nausea and Vomiting Mucositis Infective and Neutropenic Colitis Hepatic Complications Infection Drugs and Therapeutics Complications Beyond 2–3 Weeks Infection Graft vs. Host Disease Acute Graft Versus Host Disease (aGvHD) Chronic Graft Versus Host Disease Other Late Effects Nutritional Support References Non-surgical Cancer Treatments Introduction Cytotoxic Chemotherapy Effect of Cytotoxic Chemotherapy on Normal Tissues Effect of Cytotoxic Chemotherapy on the Gastrointestinal Tract Nausea and Vomiting Mucositis Chemotherapy Induced Diarrhoea Chemotherapy Induced Constipation Hormone (Endocrine) Therapy Small Molecule Inhibitors and Monoclonal Antibodies Effect of Targeted Therapies on Gastrointestinal Tract Immunotherapy Effect of Immunotherapy on the Gastrointestinal Tract Investigation and Management of Patients on ICPIs Specific Examples Immune-Related Colitis Radiotherapy Effect of Radiotherapy on the Gastrointestinal Tract Oropharyngeal/Oesophageal Mucositis Pelvic Radiation Disease Effects of Chemotherapy on Radiation Toxicity Nutrition Support Effect of Cancer on Nutritional Status Systemic Anti-Cancer Treatment and Nutritional Status Nutrition Support During Systemic Anti-Cancer Treatment Multi-Modal Interventions Specific Nutrients and Their Influence in Cancer Can Diet Influence Gastrointestinal Symptoms of SACT? Are Dietary Restrictions Required in SACT? Summary References Bacterial Overgrowth and Enteric Infections Small Intestinal Bacterial Overgrowth The Gut Microbiota: A Key Player in Homeostasis The Gut Microbiota in Short Bowel and Intestinal Failure Definition of SIBO Pathogenesis of SIBO Dysmotility Altered Anatomy Hypochlorhydria Immune Deficiencies Impact of Co-morbidities SIBO: Consequences and Complications (Tables 2 and 3) Bacterial Translocation and Sepsis Diagnosis of SIBO Therapy of SIBO (Table 4) Surgery Nutrition Prokinetics Antibiotics Prebiotics and Synbiotics Probiotics Enteric Infections and Intestinal Failure Human Immunodeficiency Virus (HIV) Enteropathy Infections in Common Variable Immunodeficiency Other Infections References Extensive Mucosal Disease: Coeliac Disease and Eosinophilic Enteritis Introduction Coeliac Disease Epidemiology Manifestations of Coeliac Disease Oslo Classification of Coeliac Disease Pathogenesis of Coeliac Disease Diagnosis of Coeliac Disease Serology Histology Criteria for Diagnosis of Coeliac Disease Treatment Gluten-Free Diet Oats in Gluten-Free Diet Nutrient Replacement Novel Therapies Complications and Associations of Coeliac Disease Non-responsive Coeliac Disease Coeliac Disease and other Immunological Disorders Neurological Manifestation Refractory Coeliac Disease Ulcerative Jejunitis Malignancy Eosinophilic Enteritis Diagnosis Clinical Characteristics and Natural History of Patients with Eosinophilic Enteritis Treatment Diet Corticosteroids Azathioprine Biologics Other Treatments References Intestinal Failure in Critical Care Introduction Definition and Etiology Screening and Assessment of Malnutrition Nutritional Targets Macronutrients Micronutrients The Best Route: Enteral Vs Parenteral Nutrition Enteral Nutrition Parenteral Nutrition Special Conditions Monitoring References Eating Disorders in Adults Basic Information Definitions Epidemiology Different Presentations of Eating Disorders Acute Nutritional Deficiency Suicidal Behaviour and Self-Harm Family Distress and Anxiety Safeguarding Concerns Electrolyte and Micronutrient Imbalance Hypokalaemia Managing Hypokalaemia Hypoglycaemia Renal Insufficiency Refeeding Syndrome Fractures Gastrointestinal Symptoms Amenorrhoea and Infertility Psychiatric Symptoms Eating Disorders in the Clinic: Summary and Concluding Remarks References Intestinal Failure in Children: A Paediatric Surgical Perspective Introduction Definition Aetiology of Short Bowel Initial Medical Management Enhancing the Physiology of Adaptation Delivering Safe Parental Nutrition Liver Disease Catheter Related Bloodstream Infections (CRBSIs) Managing the Complications of Short Bowel Disruption to Enterohepatic Circulation of Bile Acids Bacterial Overgrowth Rapid Intestinal Transit Hyperacidity Surgical Management The Initial Laparotomy Necrotising Enterocolitis Refeeding Autologous Intestinal Reconstruction Aims of AIR Timing of AIR AIR Procedures Longitudinal Intestinal Lengthening Technique Serial Transverse EnteroPlasty Spiral Intestinal Lengthening and Tailoring Outcomes of AIR and Choice of Technique Controlled Intestinal Expansion Summary References Part III: Chronic (Long-Term) Intestinal Failure Physiology and Problems of a Short Bowel Background Length of Small Intestine Assessment of Residual Small Intestine Anatomical Length Functional Length Anatomical Considerations of Remaining Bowel Ileum or Jejunum Ileocaecal Valve Colon Causes of a Short Bowel Types of Patient with a Short Bowel Bowel Length and Fluid/Nutritional Support Physiological Changes Gastrointestinal Motility Gastric Emptying Small Bowel Transit Gastrointestinal Secretions Salivary Secretion Gastric Secretion Pancreatico-biliary Secretions Gastrointestinal Hormones Changes in Intestinal Microbiome Changes in Absorption Clinical Problems and Their Treatment Presentation Undernutrition Water and Sodium Losses Clinical Assessment/Monitoring Treatment of Water and Sodium Depletion Magnesium and Other Micronutrients Selenium Vitamin B12 Deficiency Other Vitamin and Mineral Deficiencies Diarrhoea (Jejunum–Colon Patients) Confusion Drug Absorption Adaptation Gallstones Social Problems Other and Future Treatments Preventative Measures Survival References Chronic Small Bowel Dysfunction Introduction Conditions that Mimic or Can Contribute to the Presentation Organic Obstruction Opioid and Other Drug Effects on the Bowel Functional Gastrointestinal Disorders Psychological/Psychiatric Problems Anorexia Nervosa Avoidant/Restrictive Eating Psychiatric Disorders and Psychological Distress Effect of Undernutrition on Gut Function Hypermobile Ehlers-Danlos Syndrome (EDS) (Joint Hypermobility Syndrome or Ehlers-Danlos Syndrome Hypermobility Type) Pathophysiology Classification of Chronic Small Intestinal Dysmotility Myopathies Primary Myopathies Familial Acquired-Autoimmune Myopathy Jejunal Diverticulosis Secondary Myopathies Systemic Sclerosis (Scleroderma) and Other Connective Tissue Disorders Amyloidosis Chronic Irradiation Damage Muscular Diseases Neuropathies Primary Neuropathy Congenital/Familial/Developmental Autoimmune Infective Secondary Neuropathy Generalised Neurological Disorders Paraneoplastic Drugs/Toxins Idiopathic Physiological Consequences of Severe Small Intestinal Dysmotility Impairment of Coordinated Gut Contractions and the Migrating Myoelectric Complex Gut Stasis Bacterial Overgrowth and Malabsorption Problems of Undernutrition Clinical Features of Chronic Small Intestinal Dysmotility and Management Plan History, Examination and Blood Tests Myopathy Neuropathy Radiological Tests Radioisotopic Investigations Endoscopic Tests Non-invasive Investigations of Gut Transit Manometry Pathology and Histology Treatments Underlying Condition Specific Drug Treatments of Symptoms Constipation Pain Vomiting Diarrhoea: Bacterial Overgrowth and Bile Salt Malabsorption Bloating/Distension Neuromodulation (Pacemakers) Nutritional Support Dietary Adjustments/Fluid Management Vitamin/Mineral Deficiencies Enteral Nutrition Parenteral Support Surgical Options Bypass Surgery and Enteric Resections Small Intestinal Transplantation Psychosocial Treatments Outcomes Conclusions References Pelvic Radiation Disease and the Gastrointestinal Tract Why Patients Develop Symptoms Epidemiology of Radiation Damage to Gut Is Bowel Morbidity Adequately Documented? Diagnosis and Management Physiological Model of Symptoms Initial Assessment Loose Stool or Diarrhoea Small Bowel Bacterial Overgrowth Bile Acid Malabsorption Carbohydrate Malabsorption Risk of Second Cancers Steatorrhoea Radiation-Induced Pancreatic Insufficiency Free-Fatty-Acid Malabsorption Faecal Incontinence, Urgency, Tenesmus, Mucus Discharge, and Frequency of Defaecation Rectal Bleeding Endoscopy Thermal Coagulation Formalin Nonendoscopic Therapies Medicine Antibiotics Sucralfate Enema Hyperbaric Oxygen Surgery Preventing Radiation Injury: Future Perspectives Somatostatin Analogues Growth Factors and Growth Factor-Like Agents Agents Acting on the Toll-Like Receptor 5 Pathway Endothelial Protectants γ-Tocotrienol Pentoxifylline +/− Vitamin E Interleukin-11 (IL-11, Oprelvekin) OrbeShield®/Beclomethasone 17,21-Dipropionate (BDP) Myeloid Progenitor Cells (MPC) Enterade®/Amino Acid-Based Oral Rehydration Solution Human Microbiome References Problems After Gastric Surgery Introduction and Background Undernutrition Following Gastric Surgery Direct Effects of Gastric Surgery Weight Loss and Dietary Restriction Gastric Emptying Gastric Sieving The Small Intestine After Gastric Surgery Pancreatic Function Overall Effects of Gastric Surgery on Absorption of Nutrients Protein Carbohydrates Fats Micronutrients In Combination Bacterial Overgrowth Dumping Syndrome Post-vagotomy Diarrhoea Anaemia Following Gastric Surgery Iron Deficiency Vitamin B12 Deficiency Folate Deficiency Metabolic Bone Disease Other Complications of Gastric Surgery Neoplasia in the Residual Stomach Failure to Regain Weight Lost in the Absence of any Overt Explanation Summary References Surgery for Obesity and Its Consequences Introduction Bariatric and Metabolic Procedures Historic Operations: Jejuno-Ileal and Jejuno-Colic Bypass Operations Involving the Stomach Only Gastroplasty Gastric Banding Sleeve Gastrectomy Gastric Plication Operations Involving the Stomach and Small Bowel Roux-en-Y Gastric Bypass (RYGB) One Anastomosis Gastric Bypass (OAGB) Other Operations Endoscopic Bariatric and Metabolic Therapies Consequences of Bariatric Surgery Early Post-operative Complications Medium/Late Gastrointestinal Complications Vomiting Gastro-oesophageal Reflux Anastomotic Complications: Ulceration, Stenosis, Perforation Dumping Cholelithiasis Mineral, Vitamin and Protein Deficiency References Intestinal Failure in Childhood Introduction Causes of Intestinal Failure The Short Bowel Syndrome Definition and Etiology Management of SBS The Many Faces of Intestinal Microbiota in Short Bowel Syndrome Colonic Bacterial Metabolism The Trophic Role of the Colon Colonic Hypermetabolism and D-Lactic Acidosis Small Intestinal Bacterial Overgrowth Peri-Anastomotic Ulcerations Non-transplant Strategies for Enhancing Intestinal Capacity Autologous Bowel Reconstruction Hormonal Therapy and Other Adaptive Treatments Outcome of SBS and Long-Term Growth Neuro-Muscular Intestinal Diseases Hirschsprung Disease Chronic Intestinal Pseudobstruction Diagnosis Management Congenital Enteropathies Microvillous Inclusion Disease Congenital Tufting Enteropathy THE Syndromic Diarrhea/Trichohepatoenteric Syndrome (SD/THE) Deletion of the Percc1 Gene Intestinal Failure Associated Liver Disease Causes and Mechanisms of IFALD Intravenous Lipid Emulsions and Liver Disease Long Term Management of Intestinal Failure Home Parenteral Nutrition Intestinal Rehabilitation Centers and Multidisciplinary Team Intestinal Transplantation Conclusion References Part IV: Consequences of Intestinal Failure Consequences of Undernutrition and Dehydration Introduction Survival Undernutrition in Intestinal Failure Consequences of Undernutrition General Biochemical Psychological and Neurological Apathy/Depression Intellectual Performance/Sleep Appetite Skeletal Muscle Function Respiratory Cardiovascular and Sympathetic Nervous System Gastrointestinal Immunological Thermoregulation Wound Healing Endocrine and Bone Growth and Development Fluid and Electrolytes Albumin Prealbumin Serum Cholesterol Refeeding Under Hydration/Dehydration Survival with Dehydration Symptoms and Signs of Dehydration References Refeeding Problems Definition History Evidence for RFS in Clinical Practice Pathophysiology and Biochemistry of Refeeding Biochemistry of Starvation Biochemical Changes of Refeeding Clinical Manifestations of Refeeding Hypophosphataemia Thiamine Deficiency Return of Activity to the Cell Membrane Sodium/Potassium Pump Hypokalaemia Hypomagnesaimia Moderate Abnormalities of Liver Function Other Metabolic/Clinical Abnormalities Infection Who Is at Risk of Refeeding Problems How to Detect a Patient at Risk of Refeeding Problems Why Is Refeeding Hypophosphataemia More Common with Oral/Enteral Feeding Than with Parenteral Feeding? Treatment of Patients at Risk of Refeeding Problems Energy Phosphate Replacement Thiamine, Other Vitamins and Trace Elements Electrolytes (Potassium and Magnesium) Fluid Conclusion References Intestinal Failure Associated Liver Disease Introduction The History of IFALD, Epidemiology and Outcome Definitions Histopathology Pathophysiology of IFALD in Adults Pathophysiology of IFALD in Children Detecting IFALD Managing IFALD in Children and Adults Intestinal Transplantation for IFALD References Acid-Base Disturbances Introduction Normal Acid-Base Balance Physiology of Acid-Base Balance in IF/SB patients Detection of ABD Anion Gap and Types of Metabolic Acidosis Normal Serum Anion Gap (Non gap) Acidosis: Table 1 High Serum Anion Gap Acidosis: Table 2 Acid-Base Disturbances in Intestinal Failure Metabolic Acidosis in IF Oral Treatments in IF Enteral Feeds Metabolic Acidosis Caused by Infusion Fluids Loss of Gastric Acid Production: Effect on Acidosis Urinary Diversion to Colon or Ileum Thiamine Deficiency Hypophosphataemia D-lactic Acidosis Treatment Options in D-lactic Acidosis Metabolic Alkalosis: Table 3 Respiratory Acidosis Respiratory Alkalosis Drug Therapy During IF Consequences of ABD Metabolic Acidosis Acidosis and Metabolic Bone Disease Metabolic Alkalosis Incidence of ABD Refeeding Syndrome Scenarios Leading to ABD Cramps During PN Infusions Guidelines and ABD ASPEN Recommendations 2014 ESPEN Guidelines 2016 Renal Impairment in IF References Gallstones in Intestinal Failure Introduction Epidemiology of Gallstones in Intestinal Failure Inflammatory Bowel Disease Short Bowel Parenteral Nutrition Biliary Sludge in PN and Crohn’s Disease Pathogenesis of Gallstone Disease Supersaturation of Bile Nucleation and Crystallization Gallbladder Contractility Biliary Sludge Intestinal Microbiota Pathogenesis of Gallstones in Intestinal Failure Ileal Disease/Resection Fasting and Parenteral Nutrition Is gallbladder Stasis Alone Sufficient to Cause Gallbladder Disease in Patients Receiving PN? Type of Feed Surgery Rapid Weight Loss Drug Treatments Cholecystectomy and Sphincterotomy Medical Prevention and Dissolution Therapies Changing Bile Composition Ursodeoxycholic Acid Increase Gut Transit or Change Intestinal Microflora Prevent Biliary Stasis (Promote Gallbladder Emptying) Oral Diet, Cholecystokinin, Rapid Amino Acid Infusions Aspirin and Non-steroidal Anti-inflammatory Drugs References Nephrolithiasis and Nephrocalcinosis Introduction History and Epidemiology Pathophysiology Influence of Dietary Calcium Intake on Oxalate Bioavailability Enteric Hyperoxaluria Pathogenesis of Oxalate Nephropathy Mechanisms of Stone Formation Hypocitraturia Low Urine pH Low Urine Volume Low Urine Magnesium Effect of the Gut Microbiome Vitamin Malabsorption Uric Acid Kidney Stones Complicating Ileostomy Dietary Sources of Oxalate Acute Oxalate Nephropathy Dietetic Advice for Patients with Enteric Hyperoxaluria Investigation Biochemistry Differential Diagnosis Kidney Biopsy Treatment High Fluid Intake Treatment of Enteric Hyperoxaluria Bile Acid Sequestrants Restriction of Dietary Oxalate Intake Oxalate ‘Binders’ to Reduce Bio-availability of Dietary Oxalate Calcium Salts Aluminium Salts Lanthanum Carbonate Sevelamer Magnesium Citrate Supplementation Thiazide-Type Diuretics Biotherapy Enzyme Therapy Prevention of Inflammation Caused by Crystalline Calcium Oxalate Reduction of Hepatic Synthesis of Oxalate Treatment of Kidney Failure: Dialysis and Kidney Transplantation Treatment of Uric Acid Stones Complicating Ileostomy Surgical Aspects of Kidney Stones Renal Colic Stones in the Kidney Stone Dissolution Therapy Extracorporeal Shockwave Lithotripsy (ESWL) Uretero-renoscopy Percutaneous Nephrolithotomy (PCNL) Choice of Treatment Follow-up References Bone and Joint Disease Introduction Clinical Features Histology Pathogenesis Diagnosis and Follow Up (Table 3) Prevention and Treatment (Table 4) Joint Diseases and Enterophatic Arthritis References Intestinal Adaptation Introduction Hyperphagia Morphologic Adaptation Patients with Jejunum–Colonic Anastomosis or Jejunostomy Functional Adaptation Patients with Jejunum–Colonic Anastomosis, Ileostomy or Jejunostomy Timing of Adaptive Changes Mediators of Intestinal Adaptation Intraluminal Nutrients Intestinal Secretions Glucagon-Like Peptide-2 Epidermal Growth Factor Insulin-Like Growth Factor-I Peptide YY Growth Hormone Other Potential Mediators of Intestinal Adaptation Aminoguanidine Intestinal Microbiome Intestinal Maladaptation References Part V: Assessment and Treatment of Intestinal Failure Assessment of Nutritional and Fluid Status Introduction Nutritional Screening Nutritional Assessment Anthropometric Measurements Body Mass Index and Percentage Weight Loss Mid-arm Muscle Circumference Body Composition Isotope Dilution Dual-Energy X-Ray Absorptiometry Bioelectrical Impedance Analysis Computed Tomography and Magnetic Resonance Imaging Air Displacement Plethysmography Ultrasound Clinical Assessment of Nutritional Status History Physical Examination Anthropometric Assessment Fluid Status Evaluation for Specific Nutrient Deficiencies Laboratory Tests Functional Assessment Hand Grip Strength Biomarkers: Serum Proteins Subjective Global Assessment Illustrative Cases Global Leadership Initiative on Malnutrition (GLIM) Conclusions About Nutritional Assessment Assessment of Fluid Status Underhydrated (Hypovolaemic, Extracellular Fluid Depletion) Overhydrated (Hypervolaemic, Increased Extracellular Fluid) Appendix 1 Appendix 2 Appendix 3 MID-ARM MUSCLE CIRCUMFERENCE (MAMC) Appendix 4 MID-ARM MUSCLE CIRCUMFERENCE (CM) PERCENTILES References Radiology in Intestinal Failure Introduction Imaging Modalities Plain Films: Conventional and Digital Radiography (CR & DR) Fluoroscopy Barium Follow Through Fistulography Contrast Enemas Other Procedures Computed Tomography CT-Enterography Magnetic Resonance Imaging MR Enterography Ultrasound Common indications for Imaging in Intestinal Failure Sepsis Small Bowel Obstruction Identification of Obstruction Plain Abdominal Radiograph Findings CT Technique and Findings Adhesions Crohn’s Disease Hernias Complicated SBO: Closed Loop Obstruction Post-operative Ileus Gut Ischaemia CT Findings: Arterial vs Venous Ischaemia Arterial Venous Management Assessing Length of Small Bowel Intra-operative Barium Follow Through CT Enterography MR Enterography Novel Techniques Assessment of Quality of Small Bowel Mapping Distal Bowel for Distal Feeding and Pre-operative Assessment Motility Assessments Fistula Tract Mapping Fistulography Barium/Water Soluble Contrast Follow-Through CT MRI Ultrasound Malignancy and ECFs Abdominal Wall Assessment References Insertion, Types and Care of Enteral Feeding Tubes Introduction Access Routes to the Gut Nasoenteric Feeding Nasogastric Tubes Material Diameter Length Insertion of Nasogastric Tubes Checking Position of Nasogastric Tubes Aspiration Chest/Abdominal Radiography Laryngoscopy Problems Nasoduodenal and Nasojejunal Tubes Insertion of Nasoduodenal/Jejunal Tubes Bedside Placement Self-Propelling Tubes Electromagnetic Guided Tubes Other Techniques Image Guidance Insertion Endoscopic Insertion Post Insertion of Jejunal Feeding Tube Securing a Nasoenteric Tubes with a Nasal Loop (Bridle) Cervical Pharyngostomy and Oesophagostomy Gastrostomy Feeding Endoscopically Placed Gastrostomy Problems After PEG Insertion Direct Puncture Gastrostomy Insertion Endoscopically (Push Technique) Radiologically Percutaneous Radiological Gastrostomy (PRG) Surgical Gastrostomy Button Gastrostomy Post-pyloric Feeding Percutaneous Gastrojejunostomy Direct Percutaneous Endoscopic Jejunostomy (D-PEJ) Surgical Needle Jejunostomy Distal Enteral Feeding Care of a Patient Receiving Enteral Feeding Skin Care Mouth Care Care of the Feeding Tube Gastric Aspirates Feeding Regimen Starter Regimens/Feeding Rates Energy/Composition Feeding Method Drugs Contamination of Feeds Patient Position Equipment Pumps Drip Stands Dry Goods Disconnecting an Enteral Feed Discharge Planning Monitoring Psychosocial Implications Problems of Enteral Tubes Accidental and Elective Tube Removal/Replacement Accidental Removal Elective/Planned Removal Burried Internal Flange (Buried Bumper) References Formulation and Administration of Enteral Feeds Introduction History, Ingredients and Manufacturing Stability Formulations Oral (or Sip) Feeds Tube Feeds Protein Glutamine Arginine Nucleotides Carbohydrate Lipids Vitamins and Minerals Osmolality Feeding Routes/Administration Delivery Techniques Tube Blockage Diarrhoea Administration and Compatibility of Drugs with Enteral Nutrition Feed Contamination Other Feeding Options That Need Microbiological Monitoring References Access for Parenteral Support Introduction Indication of PN Preserving Venous Access PN Composition Central and Peripheral Vein Nutrition Catheter Materials (Types and Size) Choice of Catheter Peripherally Inserted Central Catheter Implanted Subcutaneous Port Preparation Marking of Catheter Exit Site Place for Procedure WHO Surgical Safety Checklist Venous Anatomy Assessment New Methods Equipment Ultrasound Local Anaesthetics/Sedation Consent and Exit Site Position Insertion of Large Vein Central Venous Catheter Internal Jugular Veins Subclavian Vein Femoral Vein Cardiac and Transhepatic Insertion of a Central Catheter Large Vein Catheter Insertion Unable to Advance Guide Wire Securing the Catheter (Excluding Implantable Port) After Catheter Insertion Complications of Large Vein Cannulation Counter Puncture Venous Wall Tear Malposition Artery Puncture Haematoma Pneumothorax Air/Catheter Embolism Nerve Injuries Thoracic Duct Damage Peripherally Inserted Central Catheter (PICC) Insertion Small-Vein Nutrition Managing Access with Complications Catheter Related Blood Stream Infections (CRBSI) Exit Site Infection Occluded and Fractured Catheter (Rewiring) Thrombosis Acute Thrombosis Chronic Thrombosis Other Considerations Pacing Wires Haemodialysis Chemotherapy and PN Removal of a Feeding Catheter Arteriovenous Fistulae for Venous Access in HPN Patients References Formulation of Parenteral Nutrition Regimens Introduction Components of a PN Solution Protein Energy Carbohydrate Advantages Disadvantages Lipid Advantages Disadvantages Electrolytes Micronutrients Trace Elements Vitamins Water Peripheral Parenteral Nutrition Formulations Compounding Standards and Regulations Stability and Compatibility of PN Solutions Physical Incompatibility Electrolytes The Buffering Capacity of Amino Acids and Inorganic Phosphate Other Possible Causes of Precipitation Intravenous Lipid Emulsions Chemical Degradation Vitamin C (Ascorbic Acid) Oxidative Degradation Vitamin B1 (Thiamine) Reduction Vitamin A (Retinol) Photodegradation Drug Additions to PN Mixtures H2 Antagonists Heparin Insulin FDA Recommendations for Compounding During the Covid 19 Pandemic and Other Particles [75] PN Administration After Compounding Practical Tips for Maintaining Stability During PN Administration Procedures to Follow Before PN Administration Parenteral Nutrition Education and Training References Designing Parenteral and Enteral Regimens Introduction Parenteral Nutrition Regimens The Overall PN Regimen Anatomical Considerations Initial Stabilisation of PN R