Intestinal failure, whether occurring as a sudden catastrophe or more insidiously over years of symptoms and surgeries, can be devastating for patients and difficult to manage for physicians. “For both adults and children with the diagnosis, treatment can be complex, often requiring intensive nutritional support, management of wounds and central lines, surgical intervention and assistance with psychological and addiction issues,” says David Mercer, MD, PhD, an intestinal transplant surgeon and director of the Intestinal Rehabilitation Program at The University of Nebraska Medical Center (UNMC).
Broadly defined, intestinal failure (IF) is the inability to maintain a reasonable state of nutrition and hydration using the gut alone. In children, this is often the result of a problem at birth such as gastroschisis, necrotizing enterocolitis or intestinal atresia. In adults, IF can develop suddenly from problem such as intestinal volvulus or ischemia or more insidiously after multiple operations for inflammatory bowel disease or adhesive obstructions. “In some cases, while the intestinal appears intact, there is significant functional impairment, either from pain or poor motility, which prevents normal intake or digestion,” says Dr. Mercer.
Patients with IF may require nutritional supplements or even parenteral nutrition. “Symptoms such as pain, diarrhea or constipation, vomiting or bloating can be incapacitating for IF patients and often prevents them from working, going to school or enjoying life,” says Dr. Mercer. “These patients can be very difficult and time-consuming to manage, especially with complex surgical problems such as enterocutaneous fistulas. Many patients develop significant pain issues and narcotic tolerance.”
The Intestinal Rehabilitation Program at UNMC is a multidisciplinary team that collaborates to treat patients with symptoms ranging from chronic abdominal pain and malnourishment to complete loss of the small intestine. “We can see any patient who is not receiving 100 percent of their calories and hydration by mouth,” says Dr. Mercer. “In serious cases, the earlier patients are referred, the better they do.”
Treatment for each patient is strictly individualized using advanced medical and surgical techniques to restore gastrointestinal function and encourage intestinal adaptation. “It is our goal to have every patient, adult or child to be able to take 100 percent of their food and water by mouth,” says Dr. Mercer. “While this is not always achievable in every patient, we believe our experience and resources allow us to provide the best overall care for this population.”
Patients seen by the Intestinal Rehabilitation Program will receive a thorough anatomic, functional and nutritional assessment. Based on these results, a comprehensive treatment and care management plan will be developed and shared with the primary care physician. Some patients may require surgical correction of anatomic problems, lengthening procedures, home TPN management and management of IF-related symptoms. “The majority of basic care issues can continue to be managed by the primary care doctor,” says Dr. Mercer. “However, patients with complex nutritional issues may need closer management by our Intestinal Rehabilitation team.”