Feeling the Impact of Long-Term Total Parenteral Nutrition

Excerpt

A 21-year-old male, with known short bowel syndrome (42 cm jejunum with colon, no ileocecal valve) secondary to surgical therapy of mid-jejunal atresia and total parenteral nutrition (TPN) dependence, was evaluated in the Emergency Department with a one-day history of acute, severe, epigastric pain. He reported no nausea, vomiting, or diarrhea. His past medical history was significant for multiple abdominal surgeries (jejunal atresia repair, tapering jejunoplasty following stricture at the jejuno-colonic anastomosis), cholelithiasis (Fig. 1a), infections of central venous catheters, small bowel bacterial overgrowth, and acute pancreatitis. His medications included calcium carbonate, cholecalciferol, ciprofloxacin, fluticasone, loperamide, multivitamins, omega 3-6-9 fatty acids, potassium chloride, rifaximin, and ferrous sulfate. On examination, the patient was afebrile and had normal vital signs and abdominal examination. Laboratory values were notable for lipase 20 U/L, total bilirubin 1.6 mg/dL, AST 57 U/L, ALT 63 U/L, and alkaline phosphatase 244 U/L. Abdominal ultrasound revealed a 1.9-cm non-obstructing gallstone near the neck of the gallbladder, without common bile duct (CBD) dilation at 6 mm. After receiving hydromorphone and a “GI Cocktail” (antacid, viscous lidocaine, and anticholinergic), his pain improved, and he was discharged to home.

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