Intestinal Failure

Intestinal failure occurs when most of the intestine has to be removed surgically because of blockage of it's blood supply or because of diseases like Crohn's disease. Rarely it can also happen due to diseases which prevent the bowel from absorbing nutrients or due to paralysis of the normal contractions of the intestinal muscles which normally propel the food forward in the intestine.

Treatment of Intestinal Failure

Intestinal failure is normally treated by giving parenteral nutrition (giving carbohydrates, proteins, fats, vitamins and minerals in an intravenous solution). However intravenous feeding has to be given through a central venous line (an intravenous catheter placed into one of the large veins of the body like the jugular vein or the subclavian vein) and complications develop over a period of time.

Complications of Parenteral Nutrition

The central venous catheter tends to get infected over a period of time. These infections can be life-threatening and require admission to hospital and intravenous antibiotics and removal of the central line.

Over a period of time the central veins get clotted because of the presence of the catheter and it becomes more and more difficult to place a central venous catheter.

Long term parenteral nutrition damages the liver. The liver becomes more and more fatty, then begins to get damaged and scarred and finally develops cirrhosis with liver failure.

Who Needs an Intestinal Transplant?

1.  A patient with intestinal failure who has had 2 or more episodes of central line infection is the past 6 months or even one episode of central line infection with fungus.
2. When 2 or more major central viens have become clotted.
3. When the liver has been affected by parenteral nutrition and the liver function tests have become abnormal and imaging or liver biopsy show significant fatty change. Too long a delay at this point will result in liver failure and the patient will then need a liver and intestine transplant

Why is it so difficult?

An intestinal transplant is certainly the most difficult of the organ transplants, both technically and in terms of management of the patient after the transplant.

1. The patient has had mutliple abdominal operations in the past. There are dense adhesions in the abdomen and it is a long and bloody job to divide the adhesions and prepare the blood vessels of the patient to connect to those of the donor intestine.
2. The intestine has a lot of lymphatic tissue and is rejected briskly by the patients immune system. Preventing rejection requires very strong immunosuppression (much more than for liver, kidney, heart etc). This profound immunosuppression predisposes the patient to opportunistic infections.
3. There is no easy way to detect rejection. The intestine has to be biopsied frequently to look for rejection. Over a period of time the interval between biopsies can be increased.
4. Rejection is often accompanied by infection. The rejection damages the intestinal mucosa and allows bacteria that live in the intestine to enter the blood stream.