Page 1049 - Small Animal Clinical Nutrition 5th Edition

1090 Small Animal Clinical Nutrition

Assess and Select the Food ment of the patient in a reasonable volume of food and stimu-
VetBooks.ir Parenteral nutritional support is often required initially to meet late adaptation of remaining small bowel segments. Dry foods
may be preferred because they may increase gastric retention
nutritional, fluid and electrolyte needs as patients with short
time; it takes longer to lower the digesta osmolality of dry foods
bowel syndrome recover from surgery.This is of particular ben-
efit in situations in which the remaining intestine does not have compared to moist foods (Chapter 54).
normal function (e.g., infiltrative disease), in patients that have A liquid monomeric food containing glutamine and soluble
a low body condition score (1/5 to 2/5) at the time of surgery fiber can be mixed with dry food during the first few days of
and in patients with complete or partial anorexia postoperative- recovery (Chapter 25). Such foods contain nutrients in readily
ly. Reestablishing normal intestinal function and stimulating absorbable forms and glutamine to fuel enterocyte hyperplasia.
adaptation should begin as soon as the patient tolerates food
enterally. Experimentally, intestinal adaptation did not occur in Assess and Determine the Feeding Method
dogs with short bowel syndrome fed only parenterally In contrast to feeding frequency commonly recommended for
(Feldman et al, 1976). Intestinal adaptation depends on using healthy animals (i.e., once or twice daily), patients with short
the remnant bowel, and not “bowel rest.” bowel syndrome usually require multiple smaller meals per day
Parenteral administration of nutrients can be used in con- to improve digestibility and prevent intestinal overload. Mul-
junction with enteral refeeding to meet the patient’s require- tiple (i.e., six to eight) small meals per day are recommended
ments. The combination of continuous enteral nutrition during the period of intestinal adaptation.
through a feeding tube (nasoesophageal, esophageal, gastrosto- The amount of food may need to be increased to help ani-
my or enterostomy) and partial parenteral nutrition can be used mals regain or maintain ideal body condition. Aggressive nutri-
in anorectic patients.A reduced fraction of the nutrient require- tional support is recommended for patients with body condi-
ments (typically up to 30%) are given enterally, which provides tion scores less than 3/5. Additionally, supplemental parenteral
nutrients and trophic factors for the adapting intestine. The feeding should be considered if the patient continues to lose
remaining nutrient requirements are provided parenterally.This weight despite consumption of what would normally be ade-
combination of feeding methods can be used in referral and quate calories. If parenteral support is used, infusion rates
primary care hospitals. should be calculated to meet the patient’s total caloric needs
Continuous enteral nutrition consists of providing the calcu- (Chapter 26). In some cases, total or partial parenteral nutri-
lated food volume at a constant rate over a prolonged period of tional support should be considered as an interim feeding
time (12 to 24 hours).Studies in normal dogs and cats show that method until the patient can meet its needs orally. Parenteral
continuous enteral nutrition is well tolerated (Abood and nutrition can be withdrawn gradually as intestinal function
Buffington, 1992; Chandler et al, 1996). Gravity drip, an intra- recovers and enteral feeding provides at least 70% of the
venous infusion pump or an enteral feeding pump can be used patient’s caloric needs. As mentioned above, intestinal adapta-
to administer the food. The remaining nutrients are provided tion did not occur in experimental dogs with short bowel syn-
parenterally. Because only part of the patient’s protein and drome when they were fed only parenterally (Feldman et al,
caloric needs are being met parenterally, partial parenteral nutri- 1976). Oral feedings or enteral infusions of glutamine-contain-
tion solutions are less hypertonic and may be administered ing foods should continue throughout the parenteral feeding
through a peripheral vein (cephalic or saphenous) if less than period to facilitate intestinal adaptation.
550 mOsm/l. This technique is less cumbersome and expensive
than parenteral nutrition, which provides full caloric and protein CONCURRENT MEDICAL THERAPY
needs, but requires central venous access. Partial parenteral
nutrition may provide 30 to 70% of the patient’s protein and Drugs commonly used in patients with short bowel syndrome
caloric requirements assuming the remaining requirements are include opiate antidiarrheal agents (e.g.,loperamide,diphenoxy-
met through enteral nutrition.The solutions used in partial par- late), antibiotics (e.g., tetracycline, tylosin) and bile salt binding
enteral nutrition are similar to those used for parenteral nutri- agents (e.g., cholestyramine, ursodeoxycholic acid). In addition,
tion, but more dilute glucose solutions are required. Providing octreotide, a long-acting analogue of somatostatin (Nehra et al,
20% calories as glucose and 80% as lipid reduces the osmolality 2001) has been recommended for use by some physicians in
of the final solution and thus reduces endothelial irritation. short bowel syndrome. This agent inhibits GI secretions and
Studies evaluating the use of partial parenteral nutrition demon- prolongs intestinal transit thus reducing diarrhea and fecal fluid
strate that complications are infrequent (Chan et al, 2002). loss. Glucagon-like peptide 2 has also been recommended due
Refeeding should begin with a food that has the appropriate to its trophic effect on the GI mucosa (Jeppesen et al, 2001).
levels of key nutritional factors for patients with short bowel The use of these compounds has not been investigated in veteri-
syndrome. Tables 59-2 and 59-3, provide the key nutritional nary patients with short bowel syndrome.
factor content of selected veterinary therapeutic foods market-
ed for malabsorptive-type GI diseases in dogs and cats, respec- REASSESSMENT
tively. These tables also include recommended levels of key
nutritional factors for comparison. Appropriate formulations Weekly determinations of body weight and condition and stool
will be energy dense enough to meet the daily energy require- evaluations are useful for assessing dogs with short bowel syn-