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  Enteral and Parenteral Nutrition
Question submitted on 11/14/07 by mscatrd to Mansi Shah:

I saw a 39 year old last week who had her stomach removed 
and was on TPN.  She claims that the TPN does not help her 
to gain weight (5'5" and 103 pounds) and causes swelling 
and bloating all over her body.  The swelling is so bad 
that she can't hold a pencil in her hand and she has to 
take lasix to remove fluid.  I don't deal with TPN, but 
this does not sound appropriate.  What do you think?  Any 
suggestions.  (She is refusing tube feedings)  Thanks
  Response provided on 11/15/07 by Mansi Shah:


The pt may be fluid overloaded with the TPN, however, I 
don't see how the TPN can cause abdominal bloating since 
it is not going through the GI tract. If she is 
complaining of abdominal bloating, maybe she needs to be 
evaluated for possible small bowel obstruction or an 
abscess. Placing a GTube for suction can help relieve the 
discomfort associated with fluid collection in the 
abdominal area if that is what is happening. 

How much of the patient's stomach was removed? Ideally, 
jejunal feeding should be chosen over TPN (unless JT feeds 
are not possible due to mechanical obstruction). Not using 
the gut (whatever is available) can increase risk of gut 

You also have to explain to the pt that there is 
obligatory wt loss after extensive surgery and given her 
fluid overload, it is difficult to assess how much wt she 
is gaining. Maybe the TPN does not provide adequate 
calories for wt gain. That needs to be evaluated.

If there is GI obstruction, placing a G-J tube may help, G 
port for suction, J-port for feeding and then TPN can be 
tapered off. Explain to the patient the benefits of tube 
feeding (maintain gut function/ prevent gut atrophy, 
maintain gut immunity, decreased risk of infections 
compared to TPN, ability to manage fluid better vs TPN) 
and see if she agrees. Definitely discuss all this with 
the medical team first. 

Let me know if I can help further. 

  Member's Response (mscatrd):

The patient had a total gastrectomy in 2006.  The amount 
of TPN she was taking recently was 1000cc for 16 hours/day 
4-5 days a week (every other day). She has dropped from 
130 lb to 103 since the spring.  The MD ordered high 
calorie, small, frequent meals, but she chews the food and 
spits it out.  I don't see how to increase calories 
without using a tube feeding. How can she eat orally with 
no stomach (dumping syndrome)?  She was told not to use 
dairy Any other suggestions?  Thank you for the above 

  Response provided on 11/15/07 by Mansi Shah:

Patients are able to eat even without a stomach, because 
the esophagus and intestine begin to adapt. However, there 
will be no reservoir for holding food and so dumping 
syndrome is a risk. That doesn't mean that the patient 
can't eat. They probably can't tolerate certain foods that 
cause dumping. 
1000cc is the volume of the TPN, how much calories and 
protein is the patient getting?, you could concentrate the 
same volume to give more calories without increasing 
I would still suggest a feeding tube to begin the 
transition process from TPN to TF, then TF with oral diet 
for pleasure. 


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