Improving quality of Life with Intestinal Rehabilitation

Intestinal rehabilitation is the process of slowly restoring the intestine’s ability to digest food and absorb nutrients. This is usually done through medicines, Diet and Surgery other than organ (intestine) transplant.

Who should try intestinal rehabilitation?

Intestinal rehabilitation is required if:

• They are on total parenteral nutrition (TPN) because of intestinal failure.
• They were able to stop TPN, but they still have trouble digesting and absorbing nutrients because of intestinal failure.

TPN is a complete form of nutrition given into the blood through a vein (intravenously) by a central line placed in the child’s chest, neck or groin.

A child may be on TPN if they have an intricate digestive condition that does not allow them to get all their nutrition by mouth or feeding tube. This includes children with short bowel syndrome, motility disorders, absorptive disorders or other conditions that can cause intestinal failure.

Some children on TPN get part of their nutrition by mouth or feeding tube; some take TPN only.

Why is intestinal rehabilitation used?

TPN is a lifesaver for patients who cannot absorb enough nutrition through their small intestine. But if TPN is used long-term, it can result in liver failure and life-threatening infections.

Our goals with intestinal rehabilitation are to:

•  End or reduce the need for TPN.
•  Children should start eating by mouth.
•  Prevent the need for intestine transplant if possible.

If intestinal rehabilitation does not work or is not an option for the children, intestine transplant may be the next step.

What does the Intestinal Rehabilitation Program do?

The specialists first look at:

• Children’s intestinal and liver health.
• Whether the children may be able to switch from TPN to eating by mouth or feeding tube. This can depend on factors like why the children have intestinal failure and how much of their intestine remains if part was removed by surgery.
• If we find that the children will benefit from intestinal rehabilitation, the children will take part in an intensive program over several month.

If  we find that the children will benefit from intestinal rehabilitation, the children will take part in an intensive program over several months. The intestinal rehabilitation team will:

• Evaluate the children’s intestinal function in detail.
• Take steps to reduce the risk of central-line infections while the children are on TPN.
• Create an individualized nutrition plan to find the diet that works best for the children body.
• Manage overgrowth of bacteria in the intestines.
• Perform nontransplant surgery, such as intestine lengthening or tapering where needed.
• Teach the children and family about how to care for the central line, how to manage day-to-day nutrition and what to expect.
• Depending on the children needs, the children may stay in the hospital for the first phase of intestinal rehabilitation. This will be followed by regular clinic visits. 

What happens after intestinal rehabilitation?

Once the child is able to eat by mouth and is off TPN, the specialists will keep seeing them in the Intestinal Rehabilitation Clinic for follow-up visits. Our focus at these clinic visits is to monitor the child’s growth; go over nutrition and feeding plans; and watch for anaemia, bacteria growth or other problems that can sometimes happen. On-going care from intestinal rehabilitation experts is important to keeping the children healthy.

Liver diseases in pregnancy

For healthcare providers liver diseases during pregnancy have a challenge. The liver diseases unique to pregnancy include hyperemesis gravidarum(HG), acute fatty liver of pregnancy (AFLP), intrahepatic cholestasis of pregnancy (ICP), and hemolysis and elevated liver enzymes and low platelets (HELLP) syndrome.

The diseases unique to pregnancy, pregnant women are also ingenuous to viral infections such as acute hepatitis A, hepatitis B, hepatitis C, hepatitis E. Out of these four viruses, only hepatitis B and C can lead to chronic disease, and therefore could be pre-existing. Hepatitis A and hepatitis E does not lead to chronic hepatitis. There are safe and effective vaccines against hepatitis A and B only but are not usually administered during pregnancy. Pregnant women have to be aware not to become infected during pregnancy. Both hepatitis A and E are transmitted through contaminated food and water (via the fecal-oral route).

Hyperemesis Gravidarum(HG)

Despite several hypotheses, the pathogenesis of liver disease in HG is not well understood. Over expression of cytokine-producing cells was implicated as a potential cause for pregnancy-related liver diseases such as preeclampsia and HG. Other hypotheses predicted damage to the liver resulting from impaired maternal or fetal mitochondrial fatty acid oxidation, implicating deficiency in long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) as a reason for accumulation of fatty acids in the placenta and eventually causing liver damage. Other report linked fetal deficiency of hepatic carnitine palmitoyltransferase I, the enzyme responsible for transporting long chain fatty acids from the cytoplasm of cells across the outer mitochondrial membrane, to HG.

Patients with HG usually require hospitalization for intravenous fluid replacement, anti-emetics, bowel rest, and possible parenteral nutrition.

Hyperemesis gravidarum is usually a reversible condition with no permanent damage to the liver and almost never fatal.

Intrahepatic Cholestasis of Pregnancy (ICP)

Intrahepatic cholestasis of pregnancy (ICP) is a reversible condition of cholestasis that happens usually in the third trimester. Findings such as pruritus, high serum bile acids levels, and abnormal liver function tests usually resolve after delivery.

Although ICP is a gentle condition for the mother, poor fetal outcomes can occur. In some studies ICP resulted in premature births up to 60%. Other complications such as fetal distress and intrauterine fetal death were reported at 61% and 1.6% respectively.