Background: An estimated 38% of patients with enterocutaneous fistulas (ECF) receive parenteral nutrition (PN) as part of the treatment plan, which is recommended for both low output fistulas ( < 200 mL/day) and high output fistulas (>1500 mL/day) (Ortiz et al, 2017). Timing of surgical fistula repair may be 12 months or longer from the initial injury, necessitating continuation of PN in the home setting (HPN), alongside wound care and other adjunct therapies. Common fistula comorbidities include fluid/electrolyte imbalance, anemia, malnutrition, and infection which may contribute to high hospital readmission rates of 29-31% (Brooks et al, 2021; Hatcihmonji et al, 2020).
Purpose: A home infusion pharmacy recognized the complex needs of those with fistulas on HPN and developed a home nutrition support team (HNST) comprised of a physician, dietitians, pharmacists, and nurses to round on patients with a diagnosis of enteric fistula and optimize care. This case study illustrates the efficacy of the HNST approach for one patient, and provides a blueprint for management of patients with fistulas on HPN.
Methods: Chart review was completed to outline the interventions and outcomes for a one patient on HPN between December 2023 - July 2024.
Results: A 25 year old identifying as male transitioned home with PN in December 2023 after an eight month hospitalization resulting from alcoholic necrotizing pancreatitis, during which the patient demonstrated intolerance to enteral nutrition and need for PN, with a 44.5 kg unintentional weight loss between March-June 2023. Two small bowel fistulas were identified in the eviscerated bowel in July 2023. PN was continued throughout the hospital stay. Upon hospital discharge, the HNST initiated weekly labs and monthly rounding. In addition to PN, oral diet was allowed as tolerated, and was primarily fluids and two small meals daily. Self-reported fistula output was very high at time of transition to home in December 2023, measuring 3300 mL/day. Medication changes were made to support reduction in output, including the addition of Propanolol and Lomotil, and a decrease in Loperamide dose. Hyperglycemia was also addressed first in January 2024 with a reduction in PN dextrose content, subsequently followed by monthly fingerstick and serum glucose review with changes to insulin and dextrose as indicated.
Variable oral intake without daytime insulin coverage added to the challenge of glycemic control, with PN and insulin running 12 hours nocturnally. Nutrition counseling to minimize simple sugars in the oral diet was implemented with the goals of reducing fistula output and improving glycemic control. Over an 8 month period, dextrose was reduced by 62% and amino acids were increased by 14% to better support glucose control and wound healing needs, respectively. Although it took several months for the patient to effectively implement dietary changes, a dramatic impact to output occurred starting in April, dropping from 3,000 mL/day to 2,000 mL/day.
As appetite and oral intake increased, the patient’s weight climbed, peaking at 86 kg in April before the patient, his parents, and his surgeon decided it would be best to avoid further weight gain. It was during this time that the patient began to implement nutrition changes recommended by the dietitian more seriously, with the support of his father, and made changes beyond reducing intake of high sugar beverages, to include more fruits and vegetables as tolerated, yogurt, and less fast food. The lipid dose was also discontinued in May to support weight & glycemic control. Over an eight month period, insulin in HPN was decreased by 11%.
Fistula output dropped to 1500 mL/day in June with continued support and reinforcement by the dietitian for reduction in simple carbohydrates from oral intake and consistent meal timing and frequency. Additional improvement in output to 750 mL/day occurred in July, as the patient continued to implement dietitian recommendations to increase nutrient density of foods and consume a minimum of 2-3 meals/day.
Discussion: With HNST intervention, glycemic control is improved, fistula output is reduced by 77% since initiation of HPN, adherence to recommended dietary changes improved, and weight is trending toward goal. Fistula repair surgery is planned for June 2025, pending continued improvements in clinical outcomes. Key components to be addressed during care of the fistula patient on HPN include: fistula output tracking; medication management; oral nutrition counseling interventions; blood glucose management with insulin and dextrose adjustments; and adequate protein intake from PN amino acids, dietary protein, or a combination of both.
Conclusions: HNST intervention, with special attention to nutrition counseling and adjustment of HPN and medications to meet changing needs, may have a significant impact on clinical outcomes during fistula management in the home setting.
