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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
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
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