Intestinal failure.

The recognition of intestinal failure (IF) as a distinct clinical entity over the past 20 years has primarily come about through the emergence of increasingly successful treatment based on use of intravenous nutrition delivered both in hospital and at home. Intestinal failure has many and varied causes, and may be complete or partial, acute and short lived, or chronic and permanent. If the latter, lifetime dependence on parenteral nutrition will usually be indicated and where possible patients are trained in the techniques of home parenteral nutrition (HPN). The success of HPN is itself primarily dependent on meticulous catheter care protocols. Sufficient numbers of such patients have now been entered into randomized controlled trials for there to be an evidence base for this aspect of IF treatment. The balanced delivery of nutrients, especially when an enteral component is included, can prevent many of the complications, such as liver and bone disease, recorded as being associated with prolonged total parenteral nutrition. However, nutritional balance is difficult to achieve in the presence of total gut resection, multiple intestinal fistulas or persisting sepsis. Surgical approaches involving bowel lengthening and reversed loops are indicated in selected patients. They have limited success and carry with them the risk of further loss of precious residual bowel. Greatest promise is held out by intestinal transplantation, but the problems associated with the powerful immunosuppression required reduce the value of this treatment. Specialized referral units for patients with severe and persistent IF can produce a high percentage of clinically effective and cost-effective outcomes.