Page 16 - To keep a balance in disease specific intestinal insufficiency. Diagnostics and practical nutritional aspects - Nicolette Wierdsma

Chapter 1
Motive
In 2004, shortly after each other, two patients were admitted to the Gastroenterology and Surgical ward of the VU University Medical Center. Both had active Crohn’s disease due to which they had undergone repeated massive and recurrent small intestine resection. As a consequence, they ended up with a short bowel syndrome, clinically comprising liquid diarrhea, malnutrition (weight loss and vitamin/mineral deficiencies) and need for Total Parenteral Nutrition (TPN).
The question arose whether it would be possible to (completely) wean them from TPN. In other words, whether the absorptive capacity of the remnant small bowel was sufficient to enable reintroduction of full enteral or even oral nutrition. Literature search on intestinal absorptive capacity after radical small bowel surgery and the diagnostic tools to assess absorptive capacity failed to provide an answer to our clinical question.
This induced feelings of insufficiency and disappointment in both patients as well as dietitians and physicians due to lack of appropriate information. The urge to understand the altered absorptive capacity, and possible adaptation, resulted in (re)developing and applying a new ‘old’ method for clinical practice by quantifying fecal nutritional (energy) losses in these patients. It proved to be a labor intensive method, but allowed for a comprehensible and intelligible insight into the ‘accountancy’ of patients’ energy and subsequently their nutritional balances.
The test-derived data, associated with primarily authority-based knowledge of (im)possibilities of the remnant small bowel capacity, provided a basis for further clinical work-up. With the right nutritional (hyperalimentative) supply, education and patients’ motivation, it seemed to be possible to wean both patients from TPN. And appreciatively, it worked out as hoped; nowadays, 10 years later, both patients have a reasonable quality of life, their short bowel function has adapted, and they can manage without TPN.
Our clinical motto became ‘if the gut works, use it’, but how to know if indeed it works? The challenge remained how to quantify how well the gut works. That’s how the ideas presented in this thesis were born.
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