Intestinal Rehabilitation, Episode 1: What is intestinal rehabilitation?

Until recently, there was no standardized definition for intestinal failure.

Intestinal failure is a functional problem where gut function is insufficient to absorb enough nutrients, fluids, and calories to support survival and, in children, growth.

Earlier recognition and taking advantage of the gut's adaptive biology are time dependent.

An intestinal rehabilitation program is a multidisciplinary collaborative patient care paradigm that brings coordinated care for children with intestinal failure through comprehensive management of their specialized nutrition and other associated needs, as defined in recent ASPEN guidelines.

Intestinal rehabilitation streamlines care and improves communication between family and care providers through an amalgamation of experts providing holistic, comprehensive, coordinated care.

Intestinal rehabilitation depends on key factors: nutrition in the gut, nutrition in the body, and healing.

Pattern recognition from multiple expert eyes observing a patient over time is essential in intestinal rehabilitation.

Short bowel syndrome is by far the most common category of intestinal failure in pediatric patients.

Causes of short bowel syndrome are usually related to neonatal disorders including congenital anomalies (intestinal atresia, malrotation, volvulus, gastroschisis, long segment Hirschsprung disease) or acquired diseases (necrotizing enterocolitis).

Motility disorders occur when abnormalities of the intestinal muscle itself or the nerves controlling that muscle prevent coordinated propulsion of food and stool, making patients dependent on intravenous support.

Enteropathies or congenital diarrheas are conditions where the patient has all of their bowel but the mucosal lining that digests and absorbs does not work, leading to hypersecretion and profuse fluid losses.

Some patients will have elements of two or all three categories of intestinal failure; for example, gastroschisis can involve short bowel, inflammation affecting absorption, and motility issues.

Although most intestinal failure patients are infants or babies, older pediatric patients can develop intestinal failure from inflammatory bowel disease, Crohn's disease complications, trauma, malignancy, or vascular thrombosis leading to gut loss.

Families reach intestinal rehabilitation programs at three time points: prenatal diagnosis (typically atresia with cystic fibrosis or gastroschisis), postnatal acquired problems (volvulus or NEC), and later diagnosis after discharge when patients fail to progress.

Innovation comes from multiple approaches to a problem and different visions; bringing in more expertise leads to better outcomes.

Transitioning older children with intestinal failure into their late teen years and beyond is a major obstacle currently not being met.

The intestinal rehabilitation team includes dietitians (understanding nutritional needs), social work, nurse practitioners, pharmacy, interventional radiology, pathology, and subspecialties including endocrinology and nephrology.

Improved survival has revealed chronic comorbidities not previously seen to the same extent because patients did not live long enough, including renal dysfunction, metabolic bone disease, neurocognitive issues, and quality of life concerns.