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LEARNING OBJECTIVES

After completing this case study, the reader should be able to:

  • Describe how a bowel obstruction can lead to nutritional, fluid, and electrolyte abnormalities.

  • Characterize the severity of malnutrition based on subjective and objective patient data.

  • Identify potential complications related to parenteral nutrition (PN) in patients with malnutrition (eg, refeeding syndrome) and steps to avoid or manage such complications.

  • Design a patient-specific PN prescription that is based on the nutritional diagnosis and other subjective and objective patient data.

  • Construct and evaluate appropriate monitoring parameters for a hospitalized patient receiving PN.

PATIENT PRESENTATION

Chief Complaint

“My stomach hurts and I can’t keep down any food or water.”

HPI

Steven Brown is a 49-year-old man familiar to the GI Surgery Service with a history of a ventral hernia, hypertension, dyslipidemia, and type 2 DM. He presented to the ED earlier today with abdominal pain, nausea, vomiting, and inability to tolerate PO intake. Approximately 2 months ago, he underwent an exploratory laparotomy with small bowel resection and primary anastomosis for repair of a ventral hernia with incarcerated small bowel. His postoperative course was complicated by an anastomotic leak, peritonitis, and sepsis, and he was ultimately discharged to home after a 3-week hospital stay. For the past 4 days, he has had worsening abdominal pain and has been unable to tolerate any PO intake. His last bowel movement was 6 days ago. He has lost ~25 lb (~11 kg) from his weight prior to his surgery 2 months ago. This weight loss includes ~14 lb (~6.5 kg) since his prior discharge due to poor appetite and limited PO intake at home.

The surgical team decides to admit Mr Brown to the hospital. On admission, they obtain an abdominal CT scan, which demonstrates dilated loops of small bowel consistent with a small bowel obstruction (SBO) and negative for anastomotic leak or abscess. The team believes this SBO is likely due to adhesions from his prior surgery.

PMH

  • Ventral hernia

  • Hypertension

  • Dyslipidemia

  • Type 2 DM

PSH

Exploratory laparotomy, small bowel resection with primary anastomosis for repair of ventral hernia with incarcerated small bowel 2 months ago

FH

Remarkable for DM in his mother, HTN and CAD in his father

SH

Married, lives with his wife; construction worker. Drinks two to three alcoholic beverages per week; quit smoking 2 years ago, 25 pack-year history prior to quitting.

ROS

Reports feeling thirsty, no appetite. Complains of moderate abdominal pain, nausea, and vomiting. Also complains his abdomen feels “crampy” and ...

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