Introduction Short gut secondary to surgical resection often requires post-operative total parenteral nutrition. We present a case of ischaemic gut secondary to a paraduodenal hernia. Post-operative nutritional requirements were met using enteral feeding via a feeding jejunostomy and recycling end jejunostomy effluent.
Methods Case: A female presented with abdominal pain and metabolic acidosis. A double contrast abdominal computer topography scan revealed necrotic small bowel secondary to an internal hernia into the right paraduodenal fossa. She was found to have 180 cm of infarcted jejunum and ileum. After resection of this segment an end jejunostomy was formed along with a closed mucus fistula from proximal ileum. 50 cm proximal to this a feeding jejunostomy/ileostomy was constructed. Early jejunal feeding with elemental feed was commenced on day 1. Loperamide and codeine were added to slow intestinal transit and promote absorption. On day 5, bile excreted via her jejunostomy was recycled via her feeding jejunostomy. Her enteral feed was changed from elemental to modular on day 8 and sandostatin commenced. Her nutritional markers improved on this regime and despite having only 50 cm of jejunum proximal to her stoma, outputs were low and her electrolytes remained normal. She put on weight post-operatively and proceded to closure of her stomas at 6 months.
Conclusion Discussion: Internal hernias are rare and commonly present with small bowel obstruction. Paraduodenal hernias are the most common form and can be either left or right sided. Normal small intestinal length varies between about 275 cm to 850 cm with nutritional or fluid supplementation required for patients with <200 cm. This lady had a post-operative bowel length of 225 cm. The majority of gastrointestinal secretions are reabsorbed in the upper jejunum and patients with jejunostomies often have large volume stomal output. We used loperamide and codeine to slow intestinal transit, aid absorption and prevent fluid and electrolyte imbalance. Limited reports of bile-jejunostomy recycling were found in the literature and to our knowledge no cases have been reported of patients with short bowel being managed using recirculation of jejunal effluent and enteral nutrition in isolation. In this case, jejunostomy fluid was collected and immediately recycled via a feeding ileostomy eliminating the need for parenteral nutrition. Success was shown by improvement in nutritional status and weight gain.
Conclusion This case exemplifies the effective use of jejunostomy output recycling to reduce water and electrolyte loss and aid fat absorption in a patient with short gut thus preventing the use of parenteral nutrition.
Competing interests None declared.