A 12-month old baby had midgut volvulus as a newborn which resulted in 25 cm of small intestine with an intact ileocecal valve. He requires long term total parenteral nutrition. Over the past six months, he has not been able to go beyond 10 mL/hr of continuous gastric feedings because of high volume diarrhea. His small bowel follow through and subsequent delayed films show contrast into the colon

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[size=20px]The most reasonable next approach to increase his ability to tolerate enteral feedings is

 

A serial transverse enteroplasty.

 

B intestinal transplantation.

 

C jejunal feeds.

 

D use of teleglutide.

 

E intravenous antibiotics.[/size]

A

A serial transverse enteroplasty.

The correct answer

A serial transverse enteroplasty.

 

Most infants with at least 35 cm of small bowel will eventually achieve full enteral nutrition. This particular patient has a short length of dilated small intestine on small bowel follow thorugh. He would likely benefit from a serial transverse enteroplasty (STEP). The report on the intermediate results following STEP is promising enabling children to tolerate feeds and grow. For the short bowel syndrome cohort, enteral tolerance was notably increased from 31% to 67% of calories.

 

Jejunal feeds may actually expose the nutrients to less absorptive intestinal surface and would be detrimental. Intestinal bacterial overgrowth has been associated with intolerance of feeds but is typically treated with enteral antibiotics such as metronidazole. Teleglutide is a glucagon like peptide 2 analog that has been shown in randomized controlled trials to enable better tolerance of feeds.

 

In September 2012, teleglutide received orphan drug designation for the treatment of short bowel syndrome from the European Medicines Agency (EMA) and U.S. Food and Drug Administration (FDA) for adult patients with short bowel syndrome. Its effects on children have not been analyzed. While intestinal transplantation could be the long term outcome for this child it would not be the first line surgical therapy in the scenario outlined.