A 32-year-old man, with no pathological history of interest and no previous treatment, operated on for tearing of the splenic hilum, mesentery of the root of the jejunum and superior mesenteric artery (SMA) due to trauma. Resection of the right colon, ileum and 2/3 of the jejunum with jejunostomy and splenectomy was performed. After the postoperative period and undergoing TPN, progressive oral tolerance was started with sugar infusions, defatted broths, alkaline lemonade (WHO formula) to introduce small and frequent oral intakes of elemental enteral formula (Elemental 0.28 Extra liquid®) and 3 intakes of 5 grams of glutamine (Adamín G®) in order to stimulate trophism and adaptation of the enterocyte.
At 6 months, the 12 cm of jejunum is anastomosed with the left colon and cholecystectomy is performed to avoid further choleretic diarrhoea. From this point on, the objective is to maintain a stable nutritional status, a diuresis of more than 1 litre/day and control of diarrhoea, assessing daily balances and determining haematological and biochemical parameters twice a week.
Nutritional management
It is structured as follows:
a) Parenteral nutrition: TPN is replaced by 2 litres of Isoplasmar G® with the addition of an ampoule of 10 mEq of potassium/litre and the vitamin module (Addamel®) on alternate days with the trace element module (Cernevit®).
b) Oral enteral nutrition: 4-5 intakes of "Elemental 0.28 Extra Liquid" and 3 intakes of 5 g of "Adamín G®" are maintained interspersed with food.
c) Oral hydration: "alkaline lemonade" is given on demand and between meals.
d) Feeding: with progressive criteria, starting with easily digestible and easily absorbed foods and with less secretory stimulus to continue with those of greater difficulty. From a diet of simple carbohydrates and cooked starches, depending on the rhythm, volume and characteristics of the faeces, protein foods (skimmed dairy products, egg whites, fish and lean meats) are included, followed by the addition of oil, to then assess tolerance to cooked vegetables and pulses. In all cases, small, frequent and easy-to-prepare intakes are recommended.
e) Medication: to reduce chlorhydropeptide secretion and stimulate the secretion of water and pancreatic bicarbonate, omeprazole (40 mg/day) is combined with 2 capsules of pancreatic enzymes (Kreon 10,000®) with food intake to facilitate the digestibility of natural foods and their absorption.
The appearance of abdominal distention due to fermentation resulting from the excess HC in the first phase accelerated the transition to a normal, highly fractionated diet free of fried foods, animal fats and moderate HC, and the aerocolia was controlled. Three months after jejunocolic anastomosis, nutritional stability, diuresis and 4-6 liquid-pasty stools were maintained. He was discharged from hospital with the aforementioned treatment and with a reservoir for nocturnal fluid therapy of 1-2 litres of Isoplasmar G depending on diuresis.
He was evaluated by the intestinal transplant unit of the Ramón y Cajal Hospital in Madrid and 14 months after starting enteral nutrition, the indication for transplant was rejected due to his good nutritional status. Fluid therapy was suspended, maintaining diuresis above 1,200 mL/day, 3-5 stools of pasty or formed consistency (depending on the type of intake) and stable anthropometric and analytical parameters with hypolipaemia. The rapid loss of 7-8 kg after withdrawal of fluid therapy is noteworthy, finally stabilising at 64 kg, for a height of 175 cm and a usual weight of 70 kg.
She is independent and maintains moderate physical activity. She follows a free diet with frequent small meals, limited only by specific intolerances, and frequently drinks mineralised beverages. He has been prescribed: "Elemental 0.28 Extra Liquid" (800 kcal/day), 2 capsules of "Kreon 10.000®" with each meal, 2 tablets of "Supradyn®" (double the RDA for micronutrients) and 1.000 mcg of vitamin B12 im per month. During the course of the evolution, a depletion of vitamins D, B12 and folic acid was detected, which was corrected with the corresponding shock dose.
Tables I, II and III show the analytical determinations of nutrients carried out during the period from 6 months after the intervention to the last one carried out, where a stable and progressive nutritional state within normality is observed.