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Treatment of intestinal failure: home parenteral nutrition

Nature Clinical Practice Gastroenterology & Hepatology volume 3, pages 492–504 (2006)Cite this article

Abstract

Intestinal failure can result from surgical resection, obstruction, dysmotility, congenital deficiencies or disease-associated loss of absorption. Before the development of intravenous feeding in the late 1960s, the condition was fatal, but by the 1990s approximately 40,000 patients were being successfully managed on long-term home parenteral nutrition (HPN) annually in the US. Survival on HPN depends on the nature of the underlying medical condition: over 80% of Crohn's disease patients survive for 5 years, but only 20% of cancer patients survive for 1 year. Although a patient's nutritional status is easy to maintain, there are serious long-term complications that arise from bypassing the gut and infusing nutrients directly into the systemic circulation. Catheter sepsis occurs about once per year (range 0–12 times). Abnormalities in liver function tests are common, but end-stage liver disease is rare. Central venous thrombosis develops in nearly all patients after 5 years. Although approximately 80% of patients on HPN are completely rehabilitated at home, their quality of life is impaired by the perpetual dependence on nocturnal intravenous infusions (every 8–12 h). In conclusion, HPN has allowed patients with previously fatal intestinal failure to survive and lead relatively normal lives at home, but their quality of life remains impaired by the dependence on intravenous infusions and complications that progress with time.

Key Points

  • Home parenteral nutrition (HPN) is a life-sustaining therapy for patients with short bowel syndrome or with other disorders that preclude enteral nutrition

  • Long-term parenteral nutrition should be used only when enteral feeding is not possible, or if caloric and nutrient needs are not adequately met by enteral feeding

  • The use of HPN in cancer patients is controversial; HPN should not be used in cancer patients with a poor prognosis

  • Complications are common in HPN patients and include sepsis, liver injury, and catheter-related thrombosis

  • The quality of life of HPN patients is comparable to that of patients with end-stage renal disease on dialysis

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Figure 1: A patient with short bowel syndrome and intestinal failure who has been managed with home parenteral nutrition since the early 1980s.
Figure 2: Distribution of diagnoses of the underlying disease in more than 5,000 home parenteral nutrition patients, reported to a voluntary registry between 1985 and 1992.
Figure 3: Sample algorithm for the evaluation of home parenteral nutrition patients who present with fever.
Figure 4: Severe liver disease associated with total parenteral nutrition.
Figure 5: Bilateral forearm venography image showing extensive central vein (subclavian and superior vena cava) thrombosis with collateral vein formation, in a patient after 10 years of home parenteral nutrition.

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  1. Fellow in Gastroenterology, Hepatology, and Nutrition,

    Daniel K Mullady & Stephen JD O'Keefe

  2. in the Division of Gastroenterology, Professor of Medicine and Director of the Center for Intestinal Health and Nutrition Support, Hepatology and Nutrition, University of Pittsburgh, PA, USA

    Daniel K Mullady & Stephen JD O'Keefe

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Correspondence to Stephen JD O'Keefe.

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Mullady, D., O'Keefe, S. Treatment of intestinal failure: home parenteral nutrition. Nat Rev Gastroenterol Hepatol 3, 492–504 (2006). https://doi.org/10.1038/ncpgasthep0580

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