1. Mini Case Study Presesntation Hilary Smith November 18, 2014

2. Patient BC 76 y/o female, lives with husband Admitted 11/11/14 CC: lethargy, falling at home, decreased appetite, anorexia, and drainage from her abdomen Has enterocutaneous fistula

3. Prior Medical History SBO Chronic diarrhea Pancreatitis Hepatitis C Endometriosis Arthritis HTN Recent history of: CDiff Bowel Resection Cholecystectomy Liver biopsy Partial small bowel resection x 2

4. Past NWH Consults Admitted 1/2/12 SBO, D/C with high fiber diet and follow-up outpatient colonoscopy, 1/6/12 Admitted 12/13/13 SBO, D/C with regular diet 12/16/13 Admitted 7/30/14 Recurrent SBO. Had surgery 8/1 – small bowel resection CT scan of her abdomen and pelvis revealed small bowel enterocutaneous fistula, 8 days post-op MD ordered NPO and TPN

5. Past NWH Consults Continued MD wanted to attempt conservative management to close the fistula since she was so close to her actual operative date Plan: placement in rehabilitation. Rehabilitation accepted and D/C NWH 8/19/14. 8/16/14 NWH Surgical consult – Plan: Continue on TPN until fistula closes 9/11/14: Rehabilitation facility thought a new hole was in her incision NWH Surgeon: Tracking of fluid up through subcutaneous tissue, did not believe there was a second fistula

6. Past NWH Consults Continued 9/25/14 NWH Surgeon thought the fistula may have closed. No ostomy bag discharge. Surgeon wanted her on clear liquids x 1 week. If she tolerated and no drainage from fistula site, wanted to try and wean her off TPN and get her out of the rehab facility. 10/2/14 developed PICC line infection at rehab NWH Surgeon wanted clear liquids x 1 more week and Ensure TID, still wants rehab to wean pt off TPN 10/23/14 tolerating diet at rehab. Surgeon recommended increase po intake and protein supplements, if tolerating, wean off TPN and D/C rehab. Admitted 11/11/14 to NWH

7. Anthropometrics Height: 154 cm Weight: 55kg (11/12) BMI: 23.2 Normal %IBW: 104% IBW: 52.5 kg UBW: 55kg (per pt)

8. Labs Mg 1.6 low Phos 1.2 low Glucose 134 high Albumin 2.9 low Vitamin D 18.9 low TSH3 0.240 low C difficile: +antigen, -toxin, +amplified 11/12/14

9. Pertinent Medications D5NS + KCl @120 ml/hr Vancomycin Flagyl Magnesium sulfate Zofran PRN

10. Nutrition/Fluid Needs Calorie needs – Mifflin St. Jeor Weight used: 55kg (admit wt) Activity factor: 1.4 to 1.5 1368-1466 kcal/day Protein Needs 1.3-1.5 g/kg 72-83g/day Fluid Needs 30 ml/kg 1650 ml/day

11. Can She Meet Her Needs? Clear liquid diet Vital AF 1.2 TID 850 kcal, 53g protein Ensure Clear BID 400 kcal, 14g protein Total: 1250 kcal, 67g protein 89% of calorie needs, 86% protein needs offered from supplements

12. RD/Intern Visit 11/13/14, Consult for nutrition assessment Pt says poor appetite since last surgery in August Was D/C from rehab 10 days PTA Pt says she may have gained weight on TPN On clears diet and PO Vital AF 1.2 TID, pt making good attempt at intake

13. PES Statement Altered GI function as related to abdominal wall fistula as evidenced by limitation to clear liquid diet and supplements

14. Assessment and Plan Status: Severe Level 4 Monitor supplement and diet tolerance Add Ensure clear apple BID to increase calorie and protein intake Pt may need TPN if fistula output is high

15. Current Status PPN ordered 11/15/14 Started TPN 11/17/14 @ 2100 via PICC Clinimix E 5/15 @ 53 ml/hr 63g protein, 188g CHO Lipid frequency: 5x/weekly; serum triglycerides mildly elevated @ 177. Care manager: cycle TPN for D/C, fistula is draining less.

16. Literature Support – Enterocutaneous Fistulas Treatment should concentrate initially on correction of fluid and electrolyte imbalances, drainage of collections, treatment of sepsis and control of fistula output No evidence that bowel rest results in increased rates of fistula closure Enteral should be used if possible, but high-output small bowel fistulas usually require PN due to feeding intolerance, lack of access to the GI tract, or increased fistula output BC has High output: drains more than 500 ml/day Operative repair should be performed when spontaneous closure does not occur Should be delayed for at least 3 months

17. Literature Support – How to Diagnose C. diff Stool culture in symptomatic patient Use a 2-step strategy 1. Use enzyme immunoassay to detect glutamate dehydrogenase (GDH) as initial screening 2. Use the cell cytotoxicity assay or toxigenic culture as the confirmatory test for GDH-positive stool specimens only Alternative: use polymerase chain reaction test

18. BC’s Results Positive: C Diff Antigen Indicates presence of C Diff Negative: C Diff Toxin C diff toxin absent, or specimen is below the detection limit of the test Positive: C Diff Amplified Indicates presence of C Diff toxin B gene Uses polymerase chain reaction to detect Sensitivity: 98.79%; specificity: 90.82%

19. Questions?????

20. References 1. Overview of Enteric Fistulas, UpToDate 2. Nutrition and Management of Enterocutaneous Fistula, British Journal of Surgery 3. Clinical Practice Guidelines for Clostridium difficile infection in Adults: 2010 Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA)