J Korean Surg Soc.  2012 Sep;83(3):171-174. 10.4174/jkss.2012.83.3.171.

Enteral nutrition associated non-occlusive bowel ischemia

• Gwon JG
• Lee YJ
• Kyoung KH
• Kim YH
• Hong SK

• KMID: 2212290
• DOI: http://doi.org/10.4174/jkss.2012.83.3.171

Abstract

We describe two patients, with no previous history of vascular problems but poor lung function, who experienced septic shock due to bowel ischemia. Both were fed an enteral formula rich in fiber using a feeding tube and experienced septic shock with regular enteral feeding. Surgical finding showed hemorrhagic ischemia in the bowel. The pathologic finding suggests these changes may have been due to inspissations of bowel contents, which may put direct pressure on the mucosa of the bowel wall, leading to local impairment of mucosal and submucosal blood flow with subsequent bowel necrosis. Bowel ischemia may have been precipitated by an increased mesenteric blood flow requirement in combination with a metabolically stressed bowel. Patients in the intensive care unit fed a fiber-rich enteral formula may have inspissated bowel contents, leading to bowel ischemia, suggesting that the use of fiber-rich formula should be limited in patients at high-risk of bowel ischemia.

Keyword

Enteral nutrition; Acute mesenteric ischemia; Intensive care units; Sepsis

MeSH Terms

Enteral Nutrition
Humans
Intensive Care Units
Ischemia
Lung
Mucous Membrane
Necrosis
Sepsis
Shock, Septic
Vascular Diseases
Ischemia
Vascular Diseases

Figure

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  Fig. 1 Gross operative finding. Small bowel is filled with mud like, inspissated bowel contents.

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  Fig. 2 Histologic finding. We can see intestinal wall thinning and diffuse flattening with hemorrhagic necrosis of mucosal layer and crypt dropout by direct pressure from the bowel lumen (H&E, ×40).

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  Fig. 3 Diffuse ischemic change of mucosal layer was seen on sigmoidoscopic findings.

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  Fig. 4 Histologic finding. There was no evidence of vasculitis or thrombus in vessels with congestion of submucosa. This means no evidence of acute vessel occlusion with hematoxylin and eosin stain (×100).

Reference

1. Munshi IA, Steingrub JS, Wolpert L. Small bowel necrosis associated with early postoperative jejunal tube feeding in a trauma patient. J Trauma. 2000. 49:163–165.

2. Minard G, Kudsk KA. Is early feeding beneficial? How early is early? New Horiz. 1994. 2:156–163.

3. Alexander JW. Nutrition and translocation. JPEN J Parenter Enteral Nutr. 1990. 14:5 Suppl. 170S–174S.

4. Adam S, Batson S. A study of problems associated with the delivery of enteral feed in critically ill patients in five ICUs in the UK. Intensive Care Med. 1997. 23:261–266.

5. Tramonte SM, Brand MB, Mulrow CD, Amato MG, O'Keefe ME, Ramirez G. The treatment of chronic constipation in adults. A systematic review. J Gen Intern Med. 1997. 12:15–24.

6. Lee JS, Auyeung TW. A comparison of two feeding methods in the alleviation of diarrhoea in older tube-fed patients: a randomised controlled trial. Age Ageing. 2003. 32:388–393.

7. Bohlen HG. Intestinal tissue PO2 and microvascular responses during glucose exposure. Am J Physiol. 1980. 238:H164–H171.

8. Serpa LF, Kimura M, Faintuch J, Ceconello I. Effects of continuous versus bolus infusion of enteral nutrition in critical patients. Rev Hosp Clin Fac Med Sao Paulo. 2003. 58:9–14.

9. Emery EA, Ahmad S, Koethe JD, Skipper A, Perlmutter S, Paskin DL. Banana flakes control diarrhea in enterally fed patients. Nutr Clin Pract. 1997. 12:72–75.

10. Mosenthal AC, Xu D, Deitch EA. Elemental and intravenous total parenteral nutrition diet-induced gut barrier failure is intestinal site specific and can be prevented by feeding nonfermentable fiber. Crit Care Med. 2002. 30:396–402.