Refeeding syndrome (RS) is a life-threatening condition first described in severe malnourished prisoners of the Second World War1. This syndrome is defined as electrolyte and fluid shifts associated with metabolic abnormalities developed during nutritional support. RS hallmark is hypophosphatemia, but also includes hypomagnesemia, hypokalemia, vitamin deficiencies, abnormal glucose metabolism and fluid retention. Prolonged fasting is the most important risk factor and RS may be precipitated by oral, enteral or parenteral nutrition4,5.
The authors describe a case of RS in the gastroenterology ward exemplifying the importance of recognizing this underreported condition in patients with digestive pathology under nutritional therapy.
An 82 year-old female was admitted due to recurrent vomiting during 10 days. Her past medical history included cerebrovascular disease, diabetes and hypertension. On hospital admission she was febrile, dehydrated and presented low body mass index (20.8 kg/m2). Initial evaluation revealed acute kidney injury (creatinine 4.1 mg/dl), hypokalaemia (K+ 3.2 mg/dl), hyperphosphatemia (Pi 5.4 mg/dl) and normal serum sodium and magnesium. Fluid and electrolyte replacement were immediately started but vomiting persisted. Nasogastric intubation revealed stasis (1800 cc/24h). Upper gastrointestinal endoscopy detected lumen narrowing in second/third duodenum parts. CT scan identified a heterogeneous mass in the pancreatic head causing Wirsung duct dilation and duodenal compression (Figure 1). Surgical resection was ruled out considering the advanced age and poor performance status. Palliative care with gastroduodenal self-expandable metallic stent (SEMS) placement was scheduled.
Enterocutaneous fistulas represent a connection between the gastrointestinal tract and adjacent tissues. Among them, there is a subdivision - the enteroatmospheric fistulas, in which the origin is the gastrointestinal tract in connection with the external environment through an open wound in the abdomen. Due to the high output in enterocutaneous fistulas, the loss of fluids, electrolytes, minerals and proteins leads to complications such as sepsis, malnutrition and electrolyte derangements. The parenteral nutrition has its secondary risks, and the fistuloclysis, that consist in the infusion of enteral feeding and also the chyme through the distal fistula, represents an alternative to the management of these patients until the definitive surgical approach.
To evaluate the current evidence on the fistuloclysis technique, its applicability, advantages and disadvantages for patients with high output fistulas.
A systematic literature search was conducted in May 2020 with the headings “fistuloclysis”, “chyme reinfusion” and “succus entericus reinfusion”, in the PubMed, Medline and SciELO databases. Results: There were 29 articles selected for the development of this narrative synthesis, from 2003 to 2020, including reviews and case reports.
Fistuloclysis is a safe method which optimizes the clinical, nutritional, and immunological conditions of patients with enteroatmospheric fistulas, increasing the chances of success of the reconstructive procedure. In cases where the definitive repair is not possible, chances of reducing or even stopping the use of nutrition through the parental route are increased, thus representing a promising modality for the management of most challenging cases.
Developed by Surya MKT