case study on parenteral nutrition

Parenteral Nutrition

Welcome to the Parenteral Nutrition section! Throughout this section, an inpatient case study will be used to enhance your learning and comprehension of parenteral nutrition. You will learn what information to gather for your assessment, how to interpret that data to form a nutrition care plan, how to implement your patient’s care plan, and what to look for when following-up and evaluating your plan. As you progress through the content, please keep in mind that the nutrition care process model used here is dynamic and not a linear, step-by-step process. The case study used here is an example, and not all cases will follow the same path.

Learning Outcomes

By the end of the section you will be able to:

• Identify indications, contradictions, and routes of support to determine the requirement for parenteral nutrition.
• Identify the routes, sites of delivery, and delivery methods of parenteral nutrition.
• Identify how to gather clinical, anthropometric, biochemical, and dietary data necessary to complete a parenteral nutrition assessment.
• Determine a patients energy, protein, and fluid needs using data from the initial assessment.
• Interpret biochemical values, including sodium, potassium, phosphorous, calcium, magnesium, albumin, BUN/urea, and creatinine.
• Identify the role of a total parenteral nutrition (TPN) team or the interdisciplinary team.
• Choose an appropriate parenteral nutrition formulation and plan for a patient.
• Identify a patient a risk of refeeding syndrome and implement procedures to prevent it.
• Identify the complications of parenteral nutrition and understand the appropriate management procedures.
• Understand the key factors in appropriately monitoring the parenteral nutrition care plan.
• Evaluate the nutrition care plan using assessment data relevant to the patients concerns, including malnutrition, symptom management, parenteral nutrition changes, medications, supplements, and the medical plan.

Preparation for Dietetic Practice Copyright © by Megan Omstead, RD, MPH is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License , except where otherwise noted.

• Everyday Emulsions
• Relate level

Case Study: Lipid Emulsions and Parenteral Nutrition

Macronutrients such as carbohydrates, protein, and fat (lipid), are essential components of the human diet. Under normal circumstances, people are able to obtain the majority of these macronutrients by eating healthy foods. Our bodies ultimately absorb macronutrients from food in the small intestine, but not before our digestive processes prepare these macronutrients into absorbable compounds. For example, ingested dietary fat cannot just enter the small intestine — it is first acted on in the mouth, where mechanical and enzymatic processes begin to emulsify dietary fat, which is further acted upon in the stomach, also by enzymes and mechanical processes.

Figure 1: Lipid absorption process (source: wikimedia )

Once stomach contents are transferred to the small intestine, these partially emulsified dietary fats are exposed to bile, which finishes the emulsification process. Fully emulsified fat particles can now pass into the cells lining the small intestine, where they are packed up into tiny spheres of protein and fat called chylomicrons.

Figure 2: Chylomicron diagram (source: wikimedia )

From there, chylomicrons enter the bloodstream, allowing for the delivery of lipids to our tissues.

What happens when someone experiences issues with digestion and nutrient absorption?

There are instances of diseases or disorders related to impaired gut function that make it difficult or impossible for people to obtain adequate nutrition. When a patient is challenged by these issues, a common treatment is to supplement them through intravenous administration of nutrients, otherwise known as parenteral nutrition (PN) . A major component of PN mixtures include Intravenous Lipid Emulsions (ILE) , which provide patients with a source of essential fatty acids and non-protein calories. However, long-term use of ILEs has been associated with intestinal complications and liver disease. As such, scientists and clinicians have been working to engineer a better recipe for ILEs that can provide needed nutrition without harm.

Note: because PN is delivered through an IV, this mode of feeding bypasses the normal digestion processes that take place in the gastrointestinal tract. Instead, the ILEs contained in the PN are absorbed and processed by the small intestine and liver.

Reflect & Relate

What considerations do scientists and clinicians have to take into account when designing ILEs for nutrient delivery? How do people normally absorb fats? Think about the size and composition of chylomicron particles.  How are ILEs similar to chylomicrons that are normally produced by digestive processes? How are they different? How does ILE absorption differ from chylomicron absorption?   How does the lipid composition and type of emulsifying agent impact the effectiveness of ILE delivery?  How can long term ILE use potentially impact the intestinal and liver health of patients?  What other aspects related to emulsions are important to consider in this context? How can this relate to classwork in your setting? 

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Total Parenteral Nutrition, Multifarious Errors

Case objectives.

• Define parenteral nutrition (PN).
• Describe the PN-use process.
• Identify potential PN-related medication errors.
• Describe methods to reduce PN-related errors.

Case & Commentary—Part 1

A 3-year-old boy on chronic total parenteral nutrition (TPN) due to multiple intestinal resections was admitted to an academic medical center for anemia. At baseline, the boy was developmentally appropriate but quite fragile medically, with multiple recent admissions for anemia and infections. Unable to take anything by mouth, he was completely dependent on the TPN for his nutrition and fluid intake, and had been so for more than a year. The boy had been doing well at home when he began having small amounts of bloody output from his ostomy site. His mother (the patient's primary caretaker at home) brought him to the hospital and he was admitted for further evaluation of the anemia. At the time of admission he was continued on his home TPN regimen.

The patient described in this case was receiving parenteral nutrition (PN), a life-sustaining therapy for individuals who cannot maintain or improve their nutrition status through the oral/enteral route. Such therapy is used in patients of all ages and across care settings (from intensive care units to the home). More than 350,000 hospital stays per year include PN, and tens of thousands of patients continue PN use at home.( 1 ) During growth and development, PN is particularly important for children even when the PN solution does not provide the total nutrient needs of a patient. Anticipated adverse effects of PN include complications associated with intravenous access (e.g., thrombosis, bloodstream infection) and metabolic homeostasis (e.g., hyper- or hypoglycemia, fluid and electrolyte disorders). The risks associated with PN were addressed at a recent safety summit.( 2 )

High-Alert Medication, Complicated Process

What may be less well recognized is that PN has been characterized as a high-alert medication.( 3 ) High-alert medications, by definition, are those that involve risk for significant harm when used in error. As such, safeguards are required to minimize error risk from PN. Notably, a patient's daily PN admixture may contain at least 40 active ingredients, each with dosing implications and interaction potential.

Even though the ingredients in PN may carry some risk, errors in the PN-use process may lead to even more safety hazards. The PN-use process refers to the numerous steps in providing PN therapy, including prescribing, order review, preparation (compounding) and labeling, dispensing, administration, monitoring, as well as ongoing patient assessment and documentation of each step.( 1 ) These steps also involve numerous clinicians and caregivers from several departments, if not more than one organization or facility. Without a standardized process and full collaboration, many opportunities for error arise.( 4 ) Although errors are known to occur, a limited number of publications discuss them. Such errors may easily result in PN ranking among the top causes of medication error, but very few organizations capture these or share them internally.( 5 ) Moreover, unlike other high-risk medications, such as insulin or anticoagulants, limited literature describes the errors associated with PN use. A lone prospective observational study at one institution identified 74 PN-related medication errors (16 per 1000 PN prescriptions), with most occurring during transcription (39%), preparation (24%), and administration (35%).( 4 ) Because this group had a nutrition support team that wrote the prescriptions, no PN ordering errors were identified that resulted in an incorrect admixture or subsequent patient harm. This structure is optimal but atypical, and mistakes in the PN prescription and in the PN order review process may contribute to additional harm and a significant number of errors not captured in this study. Nearly 10% of the errors identified resulted in or contributed to patient harm.( 6 )

Making PN Use Safer

In addition to standardization of the process and the expertise of those involved, the number of patients receiving PN is a critical factor. Most institutions manage fewer than 10 PN patients daily, and more than 80% manage 5 or fewer pediatric patients requiring PN.( 5 ) Although this number may reflect appropriate PN use in favor of enteral nutrition when indicated, it also reveals the limited experience with PN in many organizations. The expertise needed to safely manage patients requiring PN is analogous to the expertise expected in the drug-use process for cancer chemotherapy. Health care providers involved with PN should be knowledgeable and skilled in patient PN management and error prevention. Caregivers involved with PN should work within an interdisciplinary setting that includes certified nutrition support nurses, pharmacists, dietitians, and physicians.( 7 )

Despite being a complex and high-alert medication, only 58% of organizations have safeguards in place to prevent patient harm from errors in the PN-use process.( 8 ) Approaches to improving the safety of PN can encounter significant organizational challenges but can be successful when based on published practice guidelines and standards.( 9 ) To help organizations minimize errors when using use this complex therapy, practice guidelines and recommendations (based on evidence or generally accepted practices) are available from national organizations. The American Society for Parenteral & Enteral Nutrition (ASPEN) published the safe PN practice guidelines ( 10 ), but surveys have found that these guidelines have poor adherence.( 5,11,12 ) Meaningful reductions in error rates have been reported in a pediatric setting that adopted a standardized PN process.( 13 ) A revision of the 2004 ASPEN document is under way to provide graded, evidence-based clinical guidelines and a set of specific, actionable practice recommendations based on expert consensus.( 5 )

Transitions in Care and PN

Transitions in care create the opportunity for medication-related errors, which is certainly true for PN. One major contributing factor is the lack of prescription uniformity between institutions and across patient care settings; this variation is unmatched by any other medication in clinical practice. Myriad methods of ordering and labeling these complex PN preparations can be found. For example, varied units-of-measure can cause significant errors especially during transitions between hospital and home ( 14 ), at the least, errors involving the dosing of one or more of the dozens of active ingredients. Misinterpreted information from a PN label has led to error and patient harm in the transition from home to hospital.( 10 )

Ideally, one would hope the hospital described in the above scenario manages a high volume of patients on PN and adheres to the recognized national guidelines.( 10 ) Their staff members should be well-trained in all steps of the PN-use process, and the hospital should have a standardized process to reduce the risk for errors.

Case & Commentary—Part 2

On hospital day 2, the patient's serum sodium was noted by the team to be low at 130 mEq/L (normal 135–145 mEq/L). The team ordered to increase the amount of sodium in the TPN from 5.2 mEq/kg/day to 5.5 mEq/kg/day based on a standard formula. The new TPN with the increased sodium began infusing at 9:00 PM. Overnight, the boy complained of worsening abdominal pain, which was treated with increased doses of intravenous opiates. He also complained of headache (which he never had previously, per the mother) and was irritable and could not be consoled. In the morning, his labs were notable for serum sodium of 158 mEq/L, which was confirmed on recheck. At first, the acute hypernatremia was attributed to dehydration. On rounds, the resident caring for the patient examined the TPN bag to see how much sodium the boy was receiving. The TPN bag had a sodium concentration of 55 mEq/kg/day (a 10-fold increase of the intended sodium concentration of 5.5 mEq/kg/day). The TPN was immediately stopped and the boy was given free water intravenously to correct the severe hypernatremia. Correction took more than 48 hours. Fortunately, the boy did not experience any adverse consequences from the hypernatremia.

On formal review of the case, multiple errors led to the excess sodium infusion. This academic medical center had a functioning electronic health record (EHR) and computerized provider order entry (CPOE) system. However, due to the complexity of TPN orders, they were completed by hand and then scanned to the pharmacy to be entered by the pharmacist into the CPOE system. The order for the increased sodium was written appropriately on the paper order, which was scanned to the pharmacy. The pharmacist (who was specifically trained to enter TPN orders) inadvertently entered 55 mEq/kg/day into the computer. A second pharmacist (also trained in TPN) reviewed the order by standard protocol and did not catch the dosing error. The order was then sent to the contracted pharmacy that prepared the TPN for this hospital, and there an additional two TPN pharmacists did not recognize the error. Automatic warning flags popped up in the system regarding the high sodium dose but these were ignored and dismissed as this boy had more than 8 warnings each day for his TPN order, even when entered correctly.

Speaking with the pharmacists revealed that there was not only an error in transcription but they also had incorrectly perceived 55 mEq/ kg /day as 55 mEq/ L /day, an appropriate dose for an adult TPN order. Because of this, the TPN order was produced with the high sodium concentration and sent to the hospital. Two nurses verified the TPN order was accurate and appropriate at the bedside and also did not notice the error.

The error in this case involved a breakdown in oversight and system checks; breakdowns leading to medication errors is a familiar scenario.( 14 ) PN-related dysnatremia may be an all too common—though infrequently documented—error. As occurred in this case, multiple failures across the PN-use process are usually identified in retrospect as contributing to such errors. These can involve order entry and transcription errors, inappropriate abbreviations, dose designations or units-of-measure, PN component mix-ups (a bigger concern with ongoing shortages of many of these components), no warnings for catastrophic dose limits, catheter misconnections, and ineffective or nonexistent systems of independent double-checks.( 14 ) However, as happened here, the issue often begins with PN prescription.

A broad survey of institutions revealed that only 32.7% use a computerized order entry system (CPOE) system for PN.( 5 ) Even when CPOE is used for other medications, PN is seldom included. As in this case, most institutions still use handwritten orders requiring one or more error-prone transcription steps in the process. Available electronic health record (EHR) systems do not perform well when it comes to PN.( 16 ) Current CPOE systems need significant improvement in nutrition support content including decision support tools. Such tools would allow for real-time alerts to any macronutrient or micronutrient dosing below or above accepted values.( 5,16 ) Despite a number of obvious advantages over paper charts and handwritten orders, including the need for less order clarification or intervention, CPOE is of limited benefit if not built, customized, and subsequently optimized for all the users including those involved with PN.( 12,17 ) Significantly less order clarification/intervention is required when using an electronic system compared with handwritten.( 12,17 )

Fully integrating a CPOE system with pharmacy system can help prevent PN-related errors. Without such integration, PN should be prescribed using a standardized order template as an editable electronic document to avoid any handwritten orders ( Figure ). The need for any calculations or data conversion should also be avoided. Although unthinkable for most other medications, the need to specify the dose of each macronutrient and micronutrient to be included in the PN admixture varies considerably between institutions; mixed methods (mg/L for some contents, mg/kg/d for others) are sometimes even used within an institution.( 4 ) Due to the need for weight-based dosing of nearly everything, the use of mixed methods is more likely with pediatric patients. For example, electrolytes may be ordered either by salt or by ion, as well as varying units-of-measure (e.g., mEq or mmol per kg, per L, per day, or per total volume). The ordering process should include built-in decision support and alerts for when weight-based, population-specific dosing is out of range. In the absence of built-in decision support, the critical step of pharmacist review becomes paramount. In the present case, the need to specify the dose in mg/kg/day and the need to transfer the order from a paper form to the CPOE system contributed to the error.

A survey found that 23.1% of organizations do not dedicate pharmacist time to review and clarify these orders.( 5 ) The pharmacist should not only be trained to enter a PN order, but should be specifically knowledgeable in performing both a clinical review (e.g., dosing) and a pharmaceutical review (e.g., compatibility) of each PN order daily. Pharmacist interventions for all prescribing errors should then be documented in the permanent record. When knowledgeable pharmacists are involved, pediatric PN prescribing errors are identified and resolved at frequencies similar to those with other complex medications.( 17 )

Fewer than 10% of institutions have an interfaced electronic system for seamless transfer of a PN order from prescriber to pharmacy and the automated compounding device (ACD) that mixes the PN.( 5 ) Error rates for preparing complex admixtures (including PN) are 22% to 37% depending on method of preparation.( 15 ) ACDs are designed with the ability to provide users with alerts for dosing errors, however many institutions do not make full or appropriate use of these. Several reported PN-specific cases resulted from failure to incorporate built-in dosing limits in the ACD.( 15 ) These limits prevent inadvertent catastrophic electrolyte doses from being included in the preparation, but require the software to be appropriate for patient age and weight. In addition to optimizing the ACD, standard operating procedures should be in place to independently double-check every step in the preparation process.

Multiple warnings occurred daily with this patient's PN order, and ignoring them contributed to the error in this case. No warning flags should be ignored or dismissed no matter whether they appear each day; each should be recognized, clarified, and documented by the pharmacist. One PN-related fatality occurred when an infant received a 1000-fold excess of zinc because of a mix-up in units and another when an infant received a 60-fold overdose of sodium.( 15,18 ) The mix-up of dosing nutrients per kg or per day in another pediatric case was identified during PN infusion but before any adverse effect occurred.( 19 ) When not automated, a second pharmacist should be involved in evaluating the original order against what has been transcribed, prepared, and labeled for dispensing. Some have argued that institutions should use commercially available pre-made PN formulations (not mixed from scratch at the institution). Unfortunately, commercially available pre-made PN formulations are not safer in the absence of a standardized PN-use process.( 20 )

The final steps in the PN-use process are administration of PN and ongoing monitoring. In this case, the nurses checked the solution against the incorrectly entered order. Instead, nurses administering PN should independently check the label against the original order. If any of the ingredients listed on the label are out of sequence or have a different dose or units than the original order, then the process should stop for clarification back up the chain through the pharmacy to the prescriber. Patient safety is worth the time it takes to verify the order. It is the responsibility of the involved prescriber, pharmacist, nurse, and dietitian to recognize and report all PN-related medication errors—whether they reach the patient or not.

The use of a CPOE system with decision support that interfaces with the pharmacy computer system thereby averting a transcription step would have prevented this patient's PN error. In the absence of such a system, required documentation of the pharmacist's review to include comparing the dose of each component against an age-appropriate table of accepted values would have also made the error less likely. Furthermore, had the nurses checked the PN label against the original order, the error may have been caught at this late step in the PN-use process.

Take-Home Points

• PN is a high-alert medication requiring safety-focused policies, procedures, and systems.
• Institutions should incorporate all appropriate ASPEN clinical guidelines and best practices documents.
• Providers should take the opportunity to enhance patient safety and reduce PN-related medication errors by becoming directly involved in the oversight of this therapy.
• Institutions should collect and report all errors associated with PN internally and externally (through the ISMP Medication Errors Reporting Program ); further information is available on the ASPEN Web site .
• Providers should document each step in the PN-use process so that any errors can be evaluated and corrective actions taken to improve the process.

Joseph I. Boullata, PharmD, RPh, BCNSP

Pharmacy Specialist, Clinical Nutrition Support Services

Hospital of the University of Pennsylvania

Professor, Pharmacology & Therapeutics

University of Pennsylvania, School of Nursing

Philadelphia, PA

Faculty Disclosure: Dr. Boullata has declared that neither he, nor any immediate member of his family, have a financial arrangement or other relationship with the manufacturers of any commercial products discussed in this continuing medical education activity. In addition, the commentary does not include information regarding investigational or off-label use of pharmaceutical products or medical devices.

1. Boullata JI. Overview of the parenteral nutrition use process. JPEN J Parenter Enteral Nutr. 2012;36:10S-13S. [go to PubMed]

2. Andris DA, Mirtallo JM, Guenter P, eds. ASPEN parenteral nutrition safety summit. JPEN J Parenter Enteral Nutr. 2012;36(2 Suppl 2):1S-62S. [Available at]

3. ISMP's List of High-Alert Medications. Horsham, PA: Institute for Safe Medication Practices; 2012. [Available at]

4. Sacks GS, Rough S, Kudsk KA. Frequency and severity of harm of medication errors related to the parenteral nutrition process in a large university teaching hospital. Pharmacotherapy. 2009;29:966-974. [go to PubMed]

5. Boullata JI, Guenter P, Mirtallo JM. A parenteral nutrition use survey with gap analysis. JPEN J Parenter Enteral Nutr. 2013;37:212-222. [go to PubMed]

6. Sacks GS. Safety surrounding parenteral nutrition systems. JPEN J Parenter Enteral Nutr. 2012;36:20S-22S. [go to PubMed]

7. Köglmeier J, Day C, Puntis JWL. Clinical outcome in patients from a single region who were dependent on parenteral nutrition for 28 days or more. Arch Dis Child. 2008;93:300-302. [go to PubMed]

8. ISMP Medication Safety Alert! Acute Care Edition. Results of ISMP survey on high-alert medications: differences between nursing, pharmacy, and risk/quality/safety perspectives. February 9, 2012;17:1-4. [Available at]

9. Boitano M, Bojak S, McCloskey S, McCaul DS, McDonough M. Improving the safety and effectiveness of parenteral nutrition: results of a quality improvement collaboration. Nutr Clin Pract. 2010;25:663-671. [go to PubMed]

10. Mirtallo J, Canada T, Johnson D, et al; Task Force for the Revision of Safe Practices for Parenteral Nutrition. Safe practices for parenteral nutrition. JPEN J Parenter Enteral Nutr. 2004;28:S39-S70. [go to PubMed]

11. O'Neal BC, Schneider PJ, Pedersen CA, Mirtallo JM. Compliance with safe practices for preparing parenteral nutrition formulations. Am J Health Syst Pharm. 2002;59:264-269. [go to PubMed]

12. Seres D, Sacks GS, Pedersen CA, et al. Parenteral nutrition safe practices: results of the 2003 American Society for Parenteral and Enteral Nutrition survey. JPEN J Parenter Enteral Nutr. 2006;30:259-265. [Available at]

13. AHRQ Health Care Innovations Exchange. Standardized ordering and administration of total parenteral nutrition reduces errors in children's hospital. Rockville, MD: Agency for Healthcare Research and Quality; November 28, 2012. [Available at]

14. Kumpf VJ, Tillman EM. Home parenteral nutrition: safe transition from hospital to home. Nutr Clin Pract. 2012;27:749-757. [go to PubMed]

15. Cohen MR. Safe practices for compounding of parenteral nutrition. JPEN J Parenter Enteral Nutr. 2012;36(Suppl 2):14S-19S. [go to PubMed]

16. Vanek VW. Providing nutrition support in the electronic health record era: the good, the bad, and the ugly. Nutr Clin Pract. 2012;27:718-737. [go to PubMed]

17. Hilmas E, Peoples JD. Parenteral nutrition prescribing processes using computerized prescriber order entry: opportunities to improve safety. JPEN J Parenter Enteral Nutr. 2012;36(Suppl 2):32S-35S. [go to PubMed]

18. ISMP Medication Safety Alert! Acute Care Edition. Another tragic parenteral nutrition compounding error. April 21, 2011;16:1-3. [Available at]

19. ISMP Medication Safety Alert! Acute Care Edition. Mismatched prescribing and pharmacy templates for parenteral nutrition (PN) lead to data entry errors. June 28, 2012;17:1-3. [Available at]

20. Poh BY, Benjamin S, Hayward TZ III. Standardized hospital compounded parenteral nutrition formulations do not guarantee safety. Am Surg. 2011;77:e109-e111. [go to PubMed]

Figure. Electronic PN Order Form

This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers

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Can supplementation of tryptophan in parenteral nutrition increase melatonin and alleviate inflammatory response?

Affiliations.

• 1 Osmangazi University, Faculty of Medicine, Department of General Surgery - Eskişehir, Turkey.
• 2 Eskişehir City Hospital, Department of General Surgery - Eskişehir, Turkey.
• 3 Kütahya Health Sciences University, Faculty of Engineering and Natural Sciences, Department of Biochemistry - Kütahya, Turkey.
• 4 Osmangazi University, Faculty of Medicine, Department of Biostatistics - Eskişehir, Turkey.
• PMID: 38655993
• PMCID: PMC11042831
• DOI: 10.1590/1806-9282.20230826

Objective: Endogenous melatonin is produced from tryptophan which is an essential amino acid. Besides its role in the regulation of sleep patterns, melatonin has anti-inflammatory effects. In this case-control study, we aimed to compare tryptophan and melatonin levels and their relationship with the inflammatory response, specifically serum interleukin-1, interleukin-6, and c-reactive protein levels following major abdominal surgery in patients with food restriction and who receive parenteral nutritional therapy.

Methods: We enrolled 40 patients between the ages of 18 and 65 years in the study. We collected blood and urine samples 48 h before the operation and on postoperative days 1, 3, and 5.

Results and conclusion: The tryptophan levels in the experimental group were higher than in the control group but failed to reach any statistical difference. Melatonin levels were increased in both groups following the surgery compared with preoperative levels. The increase in the experimental group was statistically different 3 days after the surgery. The difference in the level of interleukin-1 between the control and the experimental groups was greatest on postoperative day 3. On postoperative day 3, the interleukin-6 level in the treatment group was slightly higher than in the control group. We did not find any difference in the levels of c-reactive protein between the groups. As a result, the levels of tryptophan and melatonin were increased in the parenteral nutrition group, irrespective of the postoperative inflammatory response.

• C-Reactive Protein* / analysis
• Case-Control Studies
• Dietary Supplements
• Inflammation / blood
• Interleukin-1 / blood
• Interleukin-6* / blood
• Melatonin* / blood
• Melatonin* / urine
• Middle Aged
• Parenteral Nutrition* / methods
• Postoperative Period
• Time Factors
• Tryptophan* / blood
• Young Adult
• C-Reactive Protein
• Interleukin-6
• Interleukin-1

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Case report: Nutrition therapy and side-effects monitoring in critically ill coronavirus disease 2019 patients

Hanxiao chen.

a West China School of Medicine, Sichuan University, Chengdu, 610041, P. R. China

b Department of Clinical Nutrition, West China Hospital, Sichuan University, Chengdu, 610041, China

c Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, 610041, China

d Department of Intensive Medicine, Chengdu Public Health Clinical Medical Center, Chengdu, 610066, China

e Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu 610041, China

f Department of Clinical Nutrition, Chengdu Public Health Clinical Medical Center,Chengdu,610066,China

Yuwei Zhang

An outbreak of pneumonia proved to be infected by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), named Coronavirus Disease 2019 (COVID-19) by World Health Organization (WHO), has rapidly and widely spread to the whole world, affecting thousands of people. COVID-19 patients have poor gastrointestinal function and microecological disorders, which lead to the frequent occurrence of aspiration pneumonia, gastric retention, and diarrhea. In the meanwhile, it takes a certain period of time for nutrition therapy to reach the patient's physiological amount. Refeeding syndrome and hypoglycemia may occur during this period, causing the high risk of death in critical patients. Therefore, we reported the nutrition therapy and side-effects monitoring as well as the adjustment of the nutrition therapy of 2 critical COVID-19 patients, thus provide clinical evidence for nutrition therapy and prevention of the side effects.

Introduction

In December 2019, a cluster of cases of pneumonia of unknown pathogen was identified in Wuhan, Hubei, China 1 . The pathogen was quickly revealed as a novel betacoronavirus named as severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2), and the pneumonia was named as coronavirus disease 2019 (COVID-19) by World Health Organization (WHO) 2 . WHO declared the outbreak of the disease as a public health emergency of international concern (PHEIC) on 30 January 2020 2 . COVID-19 is highly contagious and has rapidly spread to the world, affecting more than 180 countries and over 15,000,000 people 3 . Investigations are blooming worldwide to better understand all aspects of patients infected with SARS-Cov-2 in order to control the COVID-19 epidemic. As far as we know, general treatment including nutrition therapy is a prerequisite for COVID-19 4 but it has always been overlooked during clinical practice. Nutrition support is a fundamental stone to improve the patients’ body metabolism and strengthen their immune system, especially for the elderly critical patients. In this 2-case report, we aimed to investigate the nutrition therapy and side-effects monitoring of 2 critical COVID-19 patients, and further provide more information of the nutrition therapy of COVID-19.

On Feb 1, 2020, a 78-year-old female was diagnosed as critical COVID-19, severe malnutrition, stage 5 chronic kidney disease (CKD), grade 3 hypertension (extremely high risk), hypertension heart disease with congestive heart failure, and bacterial pneumonia. The Nutrition Risk Screening 2002 (NRS-2002) score was 5, and the Mini Nutritional Assessment short form (MNA-SF) score was 1, which showed that the patient was at nutritional risk. Then a comprehensive nutritional assessment was given, the Subjective Global Assessment (SGA) score was 3, and the Mini Nutritional Assessment (MNA) score was 4.5, indicated the patient was malnutrition. As the patient was lying in bed, the calf circumference, which was 29 cm, was measured instead of body weight ( Table 1 ). The total energy demand of the patient was 1400 kcal per day. The patient was given enteral nutritional emulsion (TPF) through nasogastric tube (NGT), 500 mL, bid, energy dense was 1.5 kcal/mL and energy supply was set at 1500 kcal on the second day of admission. Unfortunately, under this nutrition therapy, the patient had frequent occurrence of gastric retention and diarrhea along with hypophosphatemia (lowest blood phosphorus level was 0.22 mmol/L) due to poor gastrointestinal tolerance. The patient received routine blood glucose monitoring after admission, postprandial blood glucose tests were normal but fasting blood glucose was low, fluctuated between 4–5 mmol/L. Therefore, nutrition therapy was adjusted by reducing the amount of feeding, applying the continuous pump feeding at the speed of 100mL/h and probiotic therapy simultaneously. However, there was no improvement in diarrhea and gastric retention. The patient had persistent low blood glucose levels during the night with a lowest blood glucose level of 3.2 mmol/L. Then, nutritional treatment was switched from TPF to rice water, but still, the patient had no improvement in diarrhea and gastric retention. On the 11 th day after admission, trophic feeding was given for the patient through nasojejunal tube (NJT), 50 ml, tid, energy dense was 0.3 kcal/mL, continuous pump feeding at the speed of 15ml/h, total feeding time per day was about 10 h. At the same time, total parenteral nutrition was also applied, providing 500 kcal for the patient. Under this combined treatment, the patient's gastrointestinal tolerance and bowl movements finally improved, and later parenteral nutrition (PN) was stopped when enteral nutrition (EN) can ensure sufficient nutrition supply on the 17 th day after admission ( Table 2 ).

Nutrition Evaluation of 2 cases

NRS-2002, Nutrition Risk Screening 2002; MNA-SF, Mini Nutritional Assessment short form;SGA, Subjective Global Assessment; MNA, Mini Nutritional Assessment.

Nutritional characteristics of case one

NGT, nasogastric tube; NJT, nasojejunal tube.

An 81-year-old male patient was diagnosed as critical COVID-19, severe malnutrition, severe pneumonia, type I respiratory failure, and septic shock. Nutritional status of this patient was careful evaluated and detailed information was listed in Table 1 . The total energy demand of the patient was 1200 kcal per day. The patient was given EN through NGT, 500 mL, Qd, energy dense was 0.9 kcal/mL, continuous pump feeding at the speed of 100 ml/h on the 12 th day after admission. But the patient had frequent occurrence of gastric retention, diarrhea and fever, for which aspiration pneumonia cannot be ruled out. He also had persistent low blood glucose levels during the day, fluctuating between 2.9–5.7 mmol/L. Therefore, individualized enteral therapy was applied, 200 ml, bid, energy dense was 0.5 kcal/mL, continuous pump feeding at the speed of 50mL/h, energy supply was 191 kcal along with probiotic therapy on the 20 th day after admission. Maintaining this treatment for 7 days, the patient had no gastric retention and diarrhea was improved significantly. So we increased the amount of EN to 200 ml, Qd, energy supply was 381 kcal, and the patient did not experience gastric retention or diarrhea. Since the patient had a gastric retention volume of 300 ml, light yellow in color on the 34 th day after admission, we decreased the amount of EN to 200 ml, bid, energy supply was 191 kcal. On the 35 th day after admission, the patient presented gastric retention (465 ml), diarrhea (3 times a day, 150 g in total, yellow watery stool) and fever. Accordingly, we maintained the probiotic therapy and replaced the EN with the PN, with an energy supply of 285 kcal ( Table 3 ). At present, the patient is still under a status of insufficient energy supply because the of critical COVID-19, limited capacity, limited PN support, and the decreased heart rate as well as the unstable vital signs of the patient during several attempts to place the NJT.

Nutritional characteristics of case two

NGT, nasogastric tube.

We report 2 cases of elderly and critical COVID-19 patients. Both of the patients had severe malnutrition and poor gastrointestinal function. The adverse effects of the antiviral drugs and antibiotics may cause dysbiosis and further aggravate gastrointestinal dysfunction of the patients. As a result, the patients had frequent occurrence of gastric retention and diarrhea, and the possibility of aspiration pneumonia. The first patient was fed through NGT but her nutritional status did not have significant improvement due to frequent occurrence of gastric retention and diarrhea. Therefore, early probiotic therapy and PN were given. After replacing NGT with NJT, the patient's intestinal tolerance improved and nutrition therapy finally meet the patient's need, and PN was stopped. The second patient also received EN through NGT, however, he presented gastric retention and diarrhea for about one month. The patient is still under a poor nutritional status because the limited PN and failed attempt to place NJT. But probiotic therapy was effective for diarrhea.

In clinical practice, the height and weight of patients could not be directly measured because the patients had disorders of consciousness and poor physical function. So their ideal weight were not indicated, which posed challenges on the determination of actual energy and protein requirements. Before the outbreak of COVID-19, we could use body composition analyzers or metabolic carts to measure the basal or resting metabolic rate of patients. However, due to the strong contagious nature of SARS-Cov-2, these equipment were inconvenient to bring into isolation wards. Therefore, we used alternative measurements, such as calf circumference, which can effectively reflect the nutritional status of elderly patients. Then MNA-SF, MNA, survey of daily intake, laboratory examination and physical examination were performed to comprehensively assessing the nutritional status of patients. Based on the patient's condition and with reference to "Chinese Dietary Reference Intakes (2013 Edition)", as well as previous clinical experience on the treatment of critically ill patients, we determined the energy and protein requirements of patients and gave them nutrition therapies accordingly.

In comparison of the two patients, we witnessed the frequent occurrence of gastric retention in both cases, which may lead to poor absorption of nutrition and malnutrition, fluctuations in blood glucose, and bacterial infection 5 . We not only focused on the gastric residual volume, but also paid attention to clinical signs. In case 1, the patient vomited several times, and the vomit was white stomach contents. Physicians should pay close attention to early symptoms of gastric retention like nausea, postprandial fullness, heartburn, early satiety, bloating, and abdominal pain that may occur before vomiting 6 . Early probiotics therapy could help restore the natural balance of the gut microbiota as well as reduce the side effects, such as gastric retention and diarrhea. Although gastric access should be adopted as the standard approach to initiate EN, in patients with feeding intolerance or gastric retention that could not be solved with prokinetic drugs, postpyloric feeding should be performed 7 . For patients who are at high risk for aspiration, instead of gastric feeding, postpyloric feeding should be used if feasible 7 , 8 . 2016 ASPEN guideline 9 also suggested that if the retention volume exceeds 250 ml, 2 times per day, prokinetics should be added, and if the retention volume exceeds 500 ml, the nasogastric feeding should be suspended or changed to nasojejunal feeding. Ultrasound was an effective way to determine gastric residual volume, especially in the monitoring of critically ill patients. However, currently, based on the condition of COVID-19 wards, unless it was necessary medical equipment, most of the large equipment was not allowed to enter the wards. We have always wanted to put the body composition analyzer and the metabolic cart into the ward, but failed under our clinical conditions. Gastrostomy should be considered if the patient needs long-term feeding and is at high risk for complications as well. But critical COVID-19 patients are always combined with other serious infections, physicians should weigh the further increased the risk of infection and the benefit of gastrostomy before procedure.

Another important and well recognized issue that we need to notice is refeeding syndrome (RFS) caused by the reintroduction of feeding after a period of fasting or starvation 10 . Physicians and nutritionists should evaluate the risk factors of RFS before introduction of nutrition therapy 11 . If the patient had any of the RFS-related risk factors, then careful monitoring during refeeding should be applied and the feeding regimen needs to be adjusted accordingly. Refeeding should be started with an individualized, low-dose, low-concentration plan (trophic feeding), and vitamin supplementation should be given immediately 11 . If EN was not satisfying, which referred to situations when enteral nutrition alone is unable to meet at least 60% of energy and protein requirements after 7–10 days 9 , early total parenteral nutrition should be considered to avoid the occurrence of complications like RFS during hospitalization.

A plasma glucose concentration less than 3.9 mmol/L (70  mg/dL) is generally accepted as an alert value of neuroendocrine responses to falling glucose in non-diabetes patients 12 , 13 . Since hypoglycemia is associated with higher in-hospital mortality because of the increased disease burden 14 , 15 , early detection and careful management is required for effective clinical practice. For critically ill patients, compared with a blood glucose target of 7.8–10.0 mmol/L (140–180 mg/dL), blood glucose concentration of 4.4–6.1 mmol/L(80–110 mg/dL) was associated with a greater chance of developing hypoglycemia and a higher mortality rate 16 . We summarized the characteristics of blood glucose of the first patient as nocturnal hypoglycemia. This patient had suffered hunger and malnutrition for a long time. After the placement of a nasogastric tube on the second day of admission, he was given high-energy, high-protein EN therapy. But the patient rapidly developed gastrointestinal side effects and hypophosphatemia. Therefore, the EN treatment only provided limited improvements on the nutritional status of the patient, thus lead to the frequent hypoglycemia at night. After adjusting the nutrition therapy, the patient's intestinal tolerance gradually improved and his blood glucose level returned to normal. In case two, the patient had low blood glucose level during the day. Due to the frequent occurrence of gastric retention, EN treatment was settled at 7:00 and 22:00. Since the patient was placed in a prone position to assisted expectoration in the afternoon, EN was not performed, and nutrition support was limited because the patient underwent PN and bedside hemodialysis simultaneously. As a result, the patient had persistent hypoglycemia during the day. We noticed that nutrition therapy often takes a long time to meet the patient's physiological needs, especially in elderly patient with critical COVID-19. So we should pay attention to the patient's blood glucose level. Moreover, critical COVID-19 patients may have a relatively high risk of sudden death for the reason that most of them had underlying comorbidities 17 , such as cardiovascular disease, chronic obstructive pulmonary disease (COPD), CKD, obstructive sleep apnea-hypopnea syndrome (OSAHS), etc. Therefore, blood glucose of critical patients should be controlled between 7.8–10 mmol/L(140–180 mg/dL), more attention should be paid and appropriate nutritional support is needed to avoid the occurrence of asymptomatic hypoglycemia in critical patients with random blood glucose of 4.4–6.1 mmol/L(80–110 mg/dL). Besides, continuous glucose monitoring should be initiated if available.

In summary, we reported the nutrition therapy of 2 critical patients with SARS-Cov-2 infection. This report highlights the importance of appropriate nutrition therapy and side-effects monitoring for the critical COVID-19 patients, in order to ensure their nutrition supply and elevate patients’ general status to overcome the disease.

This work was supported by Sichuan Provincial Finance Department and Science & Technology Department of Sichuan Province [grant number 2020YFS0005], National Natural Science Foundation of China [grant number 82070660], and Department of Science and Technology of Sichuan Province [grant number 20QYCX0100].

Declaration of Competing Interest

The authors declare that there is no conflict of interest.

Acknowledgments

• Case report
• Open access
• Published: 25 April 2024

Postoperative delayed massive bleeding in gastric cancer: a case report

• Zhongting Lu 1   na1 ,
• Chenhui Qin 2   na1 ,
• Mingxuan Zhang 1 &

Journal of Medical Case Reports volume  18 , Article number:  218 ( 2024 ) Cite this article

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Postoperative delayed bleeding of gastric cancer is a complication of radical gastrectomy with low incidence rate and high mortality.

Case presentation

This case report presents the case of a 63-year-old female patient of Mongolian ethnicity who was diagnosed with gastric malignancy during a routine medical examination and underwent Billroth's I gastric resection in our department. However, on the 24th day after the surgery, she was readmitted due to sudden onset of hematemesis. Gastroscopy, abdominal CT, and digital subtraction angiography revealed postoperative anastomotic fistula, rupture of the duodenal artery, and bleeding from the abdominal aorta. The patient underwent three surgical interventions and two arterial embolizations. The patient’s condition stabilized, and she was discharged successfully.

Currently, there are no specific guidelines for the diagnosis and treatment of pseudoaneurysms in the abdominal cavity resulting from gastric cancer surgery. Early digital subtraction angiography examination should be performed to assist in formulating treatment plans. Early diagnosis and treatment contribute to an improved overall success rate of rescue interventions.

Peer Review reports

Introduction

Postoperative bleeding in gastric cancer carries a high risk and can lead to poor prognosis, prolonged hospitalization, increased financial burden for patients, and other complications [ 1 , 2 ]. Delayed bleeding, typically occurring more than 24 h after surgery, is considered a late complication [ 3 , 4 ]. In rare cases, bleeding may occur even more than one month postoperatively, often involving the intra-abdominal or gastrointestinal regions. Due to its unpredictable timing, inconspicuous location, slow bleeding rate, and relatively small volume, delayed bleeding poses challenges, particularly when it occurs after discharge, making timely intervention difficult. Herein, we present a case report of a patient who experienced sudden hematemesis 24 days after gastric cancer surgery.

A 63-year-old female patient of Mongolian ethnicity, without any family history of hereditary diseases, was admitted to our department for treatment of gastric antral carcinoma detected by physical examination.She had a history of hypertension for 6 years, which was poorly controlled despite regular oral medication with candesartan. At presentation, physical examination showed stable vital signs and no obvious abnormalities in abdominal and other physical examinations. Gastric CT showed thickening of the antrum mucosa, visible ulcer formation, clear boundary between the lesion and the surrounding normal gastric wall, and enlarged lymph nodes near the antrum (Fig.  1 ). One week later, she underwent a “Laparoscopic D2 Modified Radical Gastrectomy for Gastric Cancer” without requiring blood transfusion. The postoperative pathological diagnosis revealed signet ring cell carcinoma of the gastric antrum (Lauren classification: diffuse type) with a maximum tumor diameter of 2.4 cm, infiltrating the deep muscular layer. There was no evidence of vascular tumor embolus or neural invasion. Metastasis was observed in the right cardia lymph nodes and upper pyloric lymph nodes. Immunohistochemistry results showed CDX-2 (+), HER2 (0), E-Cad (+), CD31 (no intravascular tumor embolus), D2-40 (no lymphatic vessel tumor embolus), S-100 (no neural invasion), Ki-67 (60%), CK-Pan (+), and AB-PAS (+). The patient made a successful recovery and was discharged on the 12th postoperative day.

Gastric Computed tomography revealed mucosal thickening and ulceration in the gastric antrum, with para-antrum lymph node metastasis(arrows)

On postoperative day 24, the patient was readmitted with sudden abdominal pain accompanied by hematemesis (approximately 300 ml) and fever (temperature reaching 39 °C). Physical examination revealed abdominal wall tension, a 5 cm scar in the midline of the abdomen, absence of gastric and intestinal peristalsis waves, tenderness localized to the upper abdomen, weakly positive rebound tenderness, no palpable masses, negative shifting dullness, and increased bowel sounds. Esophagogastroduodenoscopy showed an ulcerated surface in the residual gastric body with a large amount of blood clots attached centrally, no hematoma around the anastomosis site, irregular ulcers, no anastomotic stenosis, and unobstructed efferent loop (Fig.  2 ). Emergency “exploratory laparotomy and abdominal drainage” was performed. Intraoperatively, dense adhesions were observed in the peritoneum, and a small amount of fluid accumulation was seen in the abdominal cavity after blunt dissection, without gastric contents or blood clots. The residual gastric anterior wall was tightly adhered to the liver and transverse colon, with no evidence of residual gastric fistula or bleeding sites as indicated by the gastroscopy. No active bleeding was found during exploration, and 400 ml of blood was transfused intraoperatively. Postoperatively, a consultation with the nutrition department was requested to provide guidance on enteral and parenteral nutrition for the patient. The patient's condition remained stable, and there was an increase in hemoglobin levels compared to before the surgery.

Esophagogastroduodenoscopy revealed ulcers on the surface of the remnant stomach, with a large number of blood clots in the center, and irregular ulcers at the anastomosis

On the 10th day after the first emergency surgery, the patient experienced sudden hematochezia with an estimated blood loss of approximately 400 ml. Considering the possibility of chronic intraperitoneal bleeding, a second emergency surgery was performed, involving “complete resection of the residual stomach and Roux-en-Y esophagojejunostomy”. Intraoperatively, exploration revealed necrotic perforation in the posterior wall of the residual stomach, with the bleeding point located near the gastric artery. Approximately 100 ml of blood was lost during the procedure, and 700 ml of packed red blood cells and 350 ml of plasma were transfused. The postoperative pathological examination indicated partial gastric tissue with focal dilated and congested blood vessels, necrosis, and hemorrhage within the gastric mucosa. Focal mucosal glandular hyperplasia and some glands showed low-grade epithelial dysplasia. The patient was transferred to a ward for intensified monitoring, and serial blood tests were conducted to assess the situation. Nutritional support was provided through parenteral routes.

On the 10th day after the second emergency surgery, the patient had dark red bloody drainage of approximately 800 ml from the right abdominal drain, with visible blood clots. To investigate the cause, a third emergency surgery was performed, involving “placement of a duodenal residual end tube and repair of esophagojejunostomy leakage”. Intraoperatively, the posterior wall of the esophagojejunostomy was found to be necrotic and ruptured, and a 3 mm leak was observed in the residual end of the duodenum. Active bleeding was located on the posterior wall of the esophagojejunostomy. Approximately 1700 ml of blood was lost during the procedure, and 2000 ml of blood and 800 ml of plasma were transfused. After three emergency surgeries, the patient was transferred to the special ward for intensified care. The patient had poor physical recovery due to the impact of the surgeries, and prolonged parenteral nutrition resulted in inadequate absorption of essential nutrients in the intestines.

On the 20th day after the third emergency surgery, there was another episode of intra-abdominal bleeding. A vascular surgery consultation was requested, and an emergency surgery was performed. Intraoperatively, angiography showed bleeding from the superior mesenteric artery, and “embolization of the posterior duodenal artery” was performed (Fig.  3 ). The procedure was successful. The next day, there was another episode of intra-abdominal bleeding. In two emergency surgeries performed by vascular surgery, extravasation of contrast agent was observed from the proximal segment of the abdominal aorta, and no extravasation was observed from the site of the original embolization of the superior mesenteric artery. “Placement of a stent in the abdominal aorta” was performed (Fig.  4 ), and after 10 min of observation, no blood was drained from the patient's drainage bag. The procedure was completed, and the patient returned to the ward. During the course of treatment, multiple consultations were requested from relevant departments to assist in diagnosis and treatment. After careful diagnosis and treatment, the patient’s condition stabilized, hemoglobin levels returned to normal, and the patient was able to ambulate. The patient’s nutrition was transitioned from parenteral to enteral feeding. One month later, the patient was discharged. Physical examination revealed well-fixed abdominal bandage, no tenderness or rebound tenderness in the abdomen, and no positive signs on further examination. The incision had healed, the right abdominal drain was unobstructed, draining serosanguinous fluid of 100 ml, and the duodenal T-tube was in place, draining brownish-yellow fluid of 40 ml.

Angiography revealed hemorrhage from the superior mesenteric artery ( a ), and posterior duodenal artery embolization was performed ( b )

Angiography revealed contrast agent spillover in the proximal celiac trunk, but no contrast agent spillover at the original embolization of the duodenal artery ( a ). Celiac trunk artery stent implantation was performed ( b )

After the patient's discharge, we conducted timely case discussions, and blood tests were performed before and after each surgery (Table  1 ). During the 1-month, 6-month, and 1-year follow-up visits after the surgery, there was no recurrent active bleeding at the surgical site, and the patient’s mental state was good. The diet primarily consisted of liquid food. Chemotherapy was initiated 1 year after the surgery.

Delayed postoperative bleeding after gastric cancer surgery can be caused by multiple factors. How to reduce the occurrence of intra-abdominal and anastomotic bleeding after gastric cancer surgery while ensuring radical resection of the tumor has always been a hot topic of concern for scholars both domestically and internationally. Currently, the reported incidence of postoperative bleeding complications after radical gastric cancer surgery is 1% to 4% in the literature. Although the incidence is not high, it is associated with a relatively high mortality rate of approximately 10% to 20% [ 5 , 6 , 7 ]. One of the reasons for postoperative bleeding is rupture and hemorrhage of intra-abdominal vessels, including the left gastric artery, gastroduodenal artery, splenic artery, and abdominal aorta. The main reasons for these complications are excessive pursuit of vessel skeletonization during lymph node dissection, resulting in injury to the vascular system and surrounding nerve plexus, chronic electrocautery damage to the external membrane of the vessels during electrocautery procedures, local septicemia and infection due to perforation caused by chronic electrocautery damage to the external membrane or full-thickness injury, erosion of adjacent vessel walls by digestive juices in cases of leakage from the residual duodenum, inappropriate ligature of blood vessels leading to rupture and injury of the intima, and formation of pseudoaneurysms with subsequent rupture and hemorrhage [ 7 , 8 , 9 ]. The mortality rate associated with rupture of pseudoaneurysms after gastric cancer surgery has been reported to be over 50% [ 8 ].

Postoperative gastric acid secretion is generally reduced in patients with gastric cancer, and the use of postoperative acid-suppressing drugs further lowers the incidence of peptic ulcers [ 10 ]. In this case, the delayed postoperative bleeding in the patient was due to the formation and rupture of pseudoaneurysms. The patient had a history of poorly controlled hypertension, poor acid tolerance in the excluded jejunum, long-term chronic blood impact, and poor postoperative nutritional absorption. Sudden changes in blood pressure led to vascular rupture and anastomotic fistula, resulting in the influx of a large amount of digestive juice into the abdominal cavity, causing local septicemia. Under the influence of inflammation and trauma, pseudoaneurysms of the left gastric artery were formed. After partial gastrectomy, the patient developed esophagojejunostomy fistula and residual duodenal fistula, leading to the formation of pseudoaneurysms in the abdominal aorta and gastroduodenal artery.

Patient was readmitted with symptoms of abdominal pain and hematemesis of 300 ml, suggesting the presence of a bleeding point in the jejunum and rupture of the anastomosis. Post-gastric cancer surgery, intra-abdominal adhesions are prone to occur, and the influx of blood and digestive juices into the abdominal cavity worsens the adhesions. Conservative treatment is not feasible due to the patient's poor baseline condition, as it can lead to rapid onset of hemorrhagic shock or septic shock, posing a significant risk. Therefore, symptomatic treatment is necessary to control bleeding and abdominal infection, and once the patient's condition stabilizes, surgery can be performed to address the residual gastric fistula and intra-abdominal blood vessels. After three surgical procedures to manage abdominal infection, anastomotic fistula, and bleeding, there is a persistent risk of ruptured vessel due to long-term abdominal infection and surgical trauma. Following the management of the primary symptoms, it is crucial to promptly perform digital subtraction angiography to identify the site of vessel rupture or weakness and provide timely intervention, which can yield beneficial treatment outcomes. However, embolization for hemostasis has limitations and is generally more effective for arterial bleeding, while its efficacy for venous bleeding is suboptimal [ 11 ]. In this case, the patient did not undergo digital subtraction angiography in a timely manner after the stabilization of their condition but rather underwent the examination 20 days after the onset of symptoms. Although the intervention was performed promptly, avoiding further deterioration, it also increased the patient's risks. This experience provides valuable lessons for the management of similar diseases in the future, in order to prevent the recurrence of the same mistakes.

In this case, both surgery and arterial embolization are indispensable. The simultaneous implementation of these two treatment modalities enhances the success rate in treating delayed massive bleeding following gastric cancer surgery, reduces patient suffering, and prolongs survival. The patient’s ability to be cured and discharged in this case can be attributed to a multidisciplinary approach, with tumor surgery as the main driver and multiple consultations with departments such as vascular surgery, gastroenterology, anesthesia, and radiology. Ultimately, a relatively comprehensive treatment plan was developed, and with the assistance of a multidisciplinary team, the patient's condition was stabilized and they were able to be discharged smoothly.

In cases of unexplained delayed bleeding following gastric cancer surgery, prompt identification and determination of the underlying causes are crucial. A multidisciplinary approach should be adopted to develop a systematic treatment plan at an early stage. When the patient's condition permits, digital subtraction angiography should be performed promptly to precisely locate the source of bleeding and initiate appropriate interventions.

Availability of data and materials

All data generated or analysed during this study are included in this published article.

Abbreviations

Computed tomography

Esophagogastroduodenoscopy

Marrelli D, Pedrazzani C, Neri A, et al . Complications after extended (D2) and superextended (D3) lymphadenectomy for gastric cancer: analysis of potential risk factors. Ann Surg Oncol. 2007;14(1):25–33. https://doi.org/10.1245/s10434-006-9063-3 .

Article   PubMed   Google Scholar  

Li QG, Li P, Tang D, Chen J, Wang DR. Impact of postoperative complications on long-term survival after radical resection for gastric cancer. World J Gastroenterol. 2013;19(25):4060–5. https://doi.org/10.3748/wjg.v19.i25.4060 .

Article   CAS   PubMed   PubMed Central   Google Scholar  

Darnis B, Lebeau R, Chopin-Laly X, Adham M. Postpancreatectomy hemorrhage (PPH): predictors and management from a prospective database. Langenbecks Arch Surg. 2013;398(3):441–8. https://doi.org/10.1007/s00423-013-1047-8 .

Article   CAS   PubMed   Google Scholar  

Wente MN, Veit JA, Bassi C, et al . Postpancreatectomy hemorrhage (PPH): an International study group of pancreatic surgery (ISGPS) definition. Surgery. 2007;142(1):20–5. https://doi.org/10.1016/j.surg.2007.02.001 .

Park JY, Kim YW, Eom BW, et al . Unique patterns and proper management of postgastrectomy bleeding in patients with gastric cancer. Surgery. 2014;155(6):1023–9. https://doi.org/10.1016/j.surg.2014.01.014 .

Huang Q, Gao K, Zhai RY. Endovascular management of two episodes of late intraperitoneal hemorrhage following laparoscopic gastrectomy for gastric cancer. Mol Clin Oncol. 2014;2(4):549–52. https://doi.org/10.3892/mco.2014.288 .

Li Z, Jie Z, Liu Y, Xie X. Management of delayed hemorrhage following radical gastrectomy for gastric carcinoma patients. Hepatogastroenterology. 2012;59(118):2016–9. https://doi.org/10.5754/hge11825 .

Kim DY, Joo JK, Ryu SY, Kim YJ, Kim SK, Jung YY. Pseudoaneurysm of gastroduodenal artery following radical gastrectomy for gastric carcinoma patients. World J Gastroenterol. 2003;9(12):2878–9. https://doi.org/10.3748/wjg.v9.i12.2878 .

Article   PubMed   PubMed Central   Google Scholar  

Sugimoto H, Kaneko T, Ishiguchi T, et al . Delayed rupture of a pseudoaneurysm following pancreatoduodenectomy: report of a case. Surg Today. 2001;31(10):932–5. https://doi.org/10.1007/s005950170039 .

Liu Y, Li D, Wen A. Pharmacologic prophylaxis of stress ulcer in non-ICU patients: a systematic review and network meta-analysis of randomized controlled trials. Clin Ther. 2020;42(3):488-498.e8. https://doi.org/10.1016/j.clinthera.2020.01.008 .

Junfu W, YongLin XH, et al . Clinical analysis and prevention of delayed postoperative bleeding in D2 radical gastrectomy for gastric cancer. Chin J Clin Oncol. 2016;43(06):245–9.

Google Scholar  

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Acknowledgements

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Grant Name: Clinical Study on the Prognosis and Influencing Factors of Single-Incision Laparoscopic Radical Gastrectomy for Gastric Cancer. Grant Number: 2021BEG03087.

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Zhongting Lu and Chenhui Qin have contributed equally.

Authors and Affiliations

Graduate School, Ningxia Medical University, Ningxia, China

Zhongting Lu & Mingxuan Zhang

The General Hospital of Taiyuan Central Hospital, Shanxi, China

Chenhui Qin

Department of Surgical Oncology, Tumor Hospital, The General Hospital of Ningxia Medical University, Ningxia, China

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ZL and CQ drafted the manuscript, conceived the study and corrected the manuscript. TL provided the relevant images. ZL, CQ and MZ contributed to collecting clinical data and confirmed the authenticity of all the raw data. All authors read and approved the final manuscript.

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Correspondence to Tao Li .

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Lu, Z., Qin, C., Zhang, M. et al. Postoperative delayed massive bleeding in gastric cancer: a case report. J Med Case Reports 18 , 218 (2024). https://doi.org/10.1186/s13256-024-04531-1

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Received : 13 January 2024

Accepted : 22 March 2024

Published : 25 April 2024

DOI : https://doi.org/10.1186/s13256-024-04531-1

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