RESUMO
An increasing number of patients have chronic intestinal failure (IF) or other problems needing nutritional support. These patients need regular input from gastroenterologists, nutrition nurse specialists and dietitians, but traditionally these healthcare professionals see them separately. Here the authors describe their experience of a combined regional nutritional gastroenterology clinic and outline strategies that can avoid the need for home parenteral nutrition (HPN) or intravenous fluids in most cases. Over a 1-year period, 73 patients attended their clinic, with the majority (74%) coming from their own catchment area of 500 000. Of the 63 patients with IF, 49 had short bowel syndrome. 38 of the patients with IF (60%) could be managed with dietary and pharmacological modifications alone, while eight (13%) needed enteral tube feeding and 17 (27%) HPN or intravenous fluids. However, only nine (53%) of the 17 patients referred from other centres specifically for HPN instigation actually needed HPN or intravenous fluids. Patient satisfaction with the combined multidisciplinary clinic was high, with 85% of patients preferring to be seen within this model of outpatient care, although questionnaire response rates were low. The authors have therefore shown that a multidisciplinary nutritional gastroenterology clinic can provide effective patient-centred care and can minimise the need for invasive and costly intravenous nutritional support. Clinics of this type should be an integral part of the current plans to implement regional IF services.
RESUMO
A twenty year old female was referred to hospital by her GP, after he received the results of blood tests taken earlier in the day. She had presented to him complaining of malaise, nausea and anorexia over a 3 day period. On the day of referral she had also become jaundiced with dark urine, but normal stool colour. There was no abdominal pain. She had no significant past medical history with no history of jaundice, liver disease or autoimmune conditions, and no apparent risk factors for blood-borne hepatitis infection. There was no relevant family history. She was taking no prescribed medication, had not taken any over the counter medication or herbal remedies. She denied excessive alcohol use or use of intravenous drugs in the past, although she was not specifically questioned on the use of other recreational drugs. She was a single mother and admitted to being under considerable stress recently. On examination she appeared well, apart from marked jaundice. There were no signs of hepatic encephalopathy or chronic liver disease. Abdominal examination revealed mild left upper quadrant tenderness, but no significant hepatomegaly. Liver function tests (LFTs) taken by her GP are shown in Table 1, revealing marked elevation of the Alanine Transaminase (ALT) (Table 1), with a relatively preserved albumin. Unfortunately her International Normalised Ratio (INR) had not been measured. An Ultrasound of the abdomen demonstrated a normal size liver with normal contour and texture with no other abnormality.
