Malabsorption and Poor

Feed Tolerance: What is the

Problem?
dr Luther Theng,Sp.N
What is the Problem?
Defining Malabsorption and Poor Feed Tolerance

Malabsorption:
Impaired absorption of macro- and/or micro-nutrients from the gastrointestinal
(GI) tract due to pathological interference with the normal physiological
sequence of digestion, absorption and transport of nutrients

Maldigestion:
Incomplete digestion of food due to impaired secretion or absence of
digestive enzymes

Poor Feed Tolerance:

Symptoms of maldigestion and/or malabsorption found in patients receiving
nutritional support
Signs and Symptoms

The most common signs and symptoms of

malabsorption and poor feed tolerance are
(Collins C et al., 2012):

Diarrhoea
Nausea
High gastric residual volumes
Abdominal distension and cramps
Reflux
Steatorrhoea
The Causes of Malabsorption and Poor Feed Tolerance

Medical condition Medication Nutrition

• Pancreatic insufficiency • Laxatives • Type of feed
• Coeliac disease • Antibiotics • Feeding rate
• Inflammatory bowel disease • Non-steroidal anti- • Feeding volume
• Short bowel syndrome inflammatory drugs • Feeding route
• Liver disease or hepato-biliary • Proton pump inhibitors
disorders
• Antiarrhythmics
• Bowel fistulae
• Antihypertensives
• Cerebral palsy
• Drugs containing magnesium
• Infection and sorbitol fillers
• Diabetes

(Stroud M et al., 2003; Collins C et al., 2012; Young NL et al., 2011)

So What? The Consequences of Malabsorption
and Poor Feed Tolerance
So What? The Consequences of Malabsorption
and Poor Feed Tolerance
So What? The Consequences of Malabsorption
and Poor Feed Tolerance
Malabsorption and Poor Feed Tolerance: In Summary

Affects a large number of patients, in a wide variety of clinical situations

Presents as a number of symptoms, the most common being diarrhoea,

nausea and vomiting

Has consequences for patient outcomes and healthcare resources

 Identification and Nutritional
Management of Malabsorption and Poor
Feed Tolerance
Working Quickly –
The Importance of Early Identification
Identification
Identification
Identification
Management
Management Goals

Therapeutic goals should be set before a management strategy is identified

Goals will depend on the individual patient and their needs and could
include the following:

Optimise GI tolerance
Improve/maintain nutritional status
Achieve good compliance
Enhance QoL
Replace losses
Management Strategy
Specific Symptom Management Considerations
Upper GI symptoms - vomiting, posseting, reflux and
high aspirates
Specific Symptom Management Considerations
Specific Symptom Management Considerations
Specific Symptom Management Considerations
Meeting Nutritional Management Goals
Meeting Nutritional Management Goals
Meeting Nutritional Management Goals
Working Together – The Importance of the Multidisciplinary Team
(MDT)

An integrated medical, surgical and dietetic approach utilising

the MDT is essential to deliver the best patient outcomes

Are the gastro What effect has surgery Is the current feeding
symptoms due to patient’s had on the patient’s rate appropriate for
current medication? absorptive capacity? this patient?
Consult the Consult the Consult the
pharmacy team surgical team dietetic team
VITAL’S SOLVE
FOR FEEDING INTOLERANCE

VITAL® 1.5 kcal is a peptide-based formula (‘ready to hang’)

that is designed to promote tolerance in patients who have or are at
risk of feeding intolerance.
The Vital Differences – Peptide-based Protein

Nutrient Standard Formula Vital Formula

Protein Intact Peptide
Fat Blend Low MCT/High LCT High MCT/Low LCT

MEDIUM CHAIN TRIGLYCERIDES

PEPTIDES
• Lipids that are small enough to be water soluble with little
• Easily absorbable by enterocytes
or no bile salt.
• Uptake of peptides remain active in critical illness
• Can be directly absorbed by the intestinal epithelial cells,
• Of benefit to ICU patients with impaired GI function a benefit to patient with impaired fat digestion
(pancreatitis, SBS)
• Quickly absorbed and metabolized by the liver without
• Found to improvement in serum proteins
the assistance of carnitine
• Reduced incidence of hypoalbuminemia -related
• Can be utilized as substrate for energy hence may be used
diarrhea
for “protein sparing”
1) Fussel St. Contemporary Nutrition Support. Practice: A clinical Guide, 2nd ed. WB Saunders, PA 2003; 1)R.H.Rolandelliet. Al. Nutrition. In: Clinical Nutrition: Enteral and tube feeding. J.L. Rombeau, R.H. Rolandelli. W.B.
2)Ziegler, F. Gut 1990;31:1277-1283; 3)Brinson, RR.CritCare Med 1989;17:367-370; 4)Hegazi and Saunders Company, 1997; 2)Marks, DB. Basic Medical Biochemistry. William & Wilkin, Baltimore,MD,1996.; 3)Hegazi
WischmeyerCritical Care 2011, 15:234 and WischmeyerCritical Care 2011, 15:234
Vital 1.5 kcal is scientifically designed with specialized
features that help promote tolerance

Reference: 1. Bach AC, et al. Am J Clin Nutr. 1982;36:950-962. 2. Bach AC, et al. Clin Nutr. 1989;8:223-
235.
Vital 1.5 kcal is scientifically designed with specialized
features that help promote tolerance

Reference: 1. Bach AC, et al. Am J Clin Nutr. 1982;36:950-962. 2. Bach AC, et al. Clin Nutr. 1989;8:223-
235.

*Based on independent UK based taste test research involving 108 adults, comparing Vital 1.5kcal, Peptamen Vanilla Bottle and Survived OPD Drink; **Subject to countries’ regulation. Abbott Nutrition. Data on File.
Vital – Summary of Clinical Evidence

* Studied using Vital HN. Both Vital HN and Vital 1.5 are peptide-based formulas. **Studied using Vital AF 1.2. Both Vital AF 1.2 and Vital 1.5 are peptide-based formulas.
References:1. Seres DS, et al. Clin Nutr.2017;36(3):706-709. 2. Brinson RR, et al. Crit Care Med.1988;16(2):130-6. 3. El-Kersh K, et al. J Crit Care.2018;43:108-113.
Vital – Summary of Clinical Evidence

Improvement in Nutritional Status

Nelson 2019 – A pilot intervention study to evaluate compliance to a peptide-based oral nutritional supplement in an adult population with impaired gastrointestinal function
 Vital – Summary of Clinical Evidence

Improvement in nutritional status and Gastrointestinal tolerance

• Observasi, Multi Center

• To evaluate the effect of ONS Vital 1.5 Kcal to nutritional
status 90 adult (≥18 years old) with malnutrition or risk
(Skor ‘MUST’ ≥ 2*) and has GI Intolerance symptoms
• Patient receive Vital 2 x 220 ml for 12 weeks

End Resutl:’
69% improvement in nutritional status (‘MUST‘Score) 75% Improvement in Gastrointestinal tolerance
Malabsorption and Poor Feed Tolerance: In Summary
Early identification is crucial to support
better patient outcomes
Combined nutritional and medical
interventions can aid management of
specific symptoms
The right feed via the right route will help
ensure nutritional goals are met
An MDT approach will support better
management and improved patient
outcomes

(Collins et al., 2012)

Conclusion

Malabsorption and poor However, if signs are

feed tolerance affect a identified quickly and
large number of patients, appropriate management

1in a wide variety of

clinical situations, and
have far reaching
steps are taken, feeding
can be maintained, thus
improving the patients’
consequences for both
the patient and the MDT nutritional intake and
clinical outcomes
Conclusion

Finding the right feed for the

patient is an important
consideration – a feed and
feeding route, which meets all
nutritional requirements and
is well tolerated will improve
compliance and support
improved patient outcomes
Thank You