Intestinal Failure - Chyme Reinfusion Therapy

You have been provided with this leaflet as you may be due to start using a process of chyme reinfusion therapy, using the ‘Insides™ System’.

The information contained in this leaflet will explain why you have been advised to use this system and gives advice on how to set up and use the equipment to reinfuse chyme back into your bowel. Advice is also given on suggested changes to your diet and fluid intake.

What is Chyme?

Chyme is formed in the stomach and intestines when you eat and drink and is made up of partly digested food and digestive secretions, including bile and pancreatic enzymes. Chyme is the output that you will see in your stoma or fistula bag.

Normally chyme would be reabsorbed further down in your gut and provides nutrition and hydration. However, when you have a fistula or stoma it leaves the body early meaning that you do not absorb it, and this can leave you at risk of dehydration and malnutrition.

What is chyme reinfusion therapy (CRT)?

CRT is a technique by which chyme collected in your stoma or fistula bag from the upstream bowel is reinfused back into the downstream part of the bowel to provide hydration, salts and nutrition. Chyme is pumped back into the bowel using a battery powered device, called the ‘Insides™ System’, which sits on the outside of the stoma or fistula bag. This has been created by a company called ‘The Insides™ Company.’

Why is CRT beneficial?

• CRT puts the nutrients and fluid back into the gut allowing them to be absorbed, and thus reducing the risk of dehydration and malnutrition
• There is evidence to show that infusing chyme into your distal bowel can improve the function of the bowel and prepare it for surgery, so that your bowel will begin to work sooner after surgery
• It may also be possible to reduce the amount of parenteral nutrition, IV fluids or electrolytes you are receiving as CRT allows for nutrition, fluid, and salts to be reinfused back into the bowel
• CRT allows for liver enzymes to continue to be produced to breakdown food, which along with a reduction in PN can help in reducing long-term liver damage.
• As chyme is reinfused back into the bowel there is little or no need to continually empty your stoma bag which some patients prefer.
• Fluid restrictions will be relaxed as the fluid you drink will be reinfused back into the bowel and absorbed
• You will be able to relax some previous dietary restrictions and introduce more sugar back into the diet if desired
• CRT may also help to reduce the dose of medications you require e.g., loperamide and codeine phosphate

How to set up CRT using the Insides™ System

There are three main components to the system which are:

The tube, which is placed inside your stoma or fistula into the downstream bowel and sits inside your stoma bag. Should this become dislodged then you must contact the outreach team on the Intestinal Failure Unit.

The pump, which is placed on the end of the tube and sits submerged in the chyme in your stoma bag. This can get blocked with food debris and may need cleaning or replacing if this happens.

The driver is a hand held device which is held on the outside of your stoma bag and activiates the pump to drive chyme from the stoma bag into the lower part of the bowel through the stoma/ fistula.

Diagram to illustrate the CRT process

Reproduced here with the kind permission from the Insides Company 2023.

It is important that any chyme left in the stoma bag for over 7 hours is discarded down the toilet and not re-infused to prevent any harmful bacterial growth entering the bowel.

STAGE 1 - Liquid diet, including sugary drinks/fizzy drinks/supplements

Initially you will be advised to have a couple of days of liquid diet to ensure that CRT is working well. You may have been previously restricting your fluid intake to help control your stoma or fistula output, but it is now possible to relax this as the pump reinfuses fluid into the bowel further down; you will also be able to include sugary drinks. Your dietitian may prescribe nutritional supplement drinks during this stage to be sure that you are meeting your nutritional requirements.

You may experience some tummy discomfort and bloating within the first week as your bowel gets used to having hydration and nutrition pass through it again. Medication can be prescribed to help with this. We would advise that you do not exceed rate 3 on the driver to help alleviate these symptoms. We would recommend using the driver every 30-45 minutes initially so that your bag does not become too full.

You may experience your first bowel movement within a couple of days of using the pump and it is important to let the team know when you do. The frequency of bowel movements may increase as you use CRT more and this shows that the process is working.

STAGE 2 - Soft/Minced diet

After a couple of days, you can move on from a liquid diet and choose softer/minced foods that will go through the pump easily. Suitable foods are listed below, and your dietitian will also discuss this with you in further detail.

Cereals

Foods you may include:

• Softer breakfast cereals with milk, eg cornflakes, rice krispies®, Weetabix® and porridge.

Foods to avoid:

• Crunchy cereals or those with nuts added e.g., muesli, bran flakes, puffed wheat, shredded wheat, Crunchy Nut Cornflakes®, Fruit and Fibre®, granola

Potatoes

Foods you may include:

• Peeled and well-cooked potatoes i.e., Mashed or potatoes that can easily be mashed with a fork.

Foods to avoid:

• Potato skins, potato wedges, chips, roasted potatoes

Rice, pasta and other

Foods you may include:

• Well cooked rice, pasta, and spaghetti with a sauce to help moisten it.
• Noodles, couscous, rice noodles.

Foods to avoid:

• Grains or pasta cooked al dente without a sauce

Cake and biscuits

Foods you may include:

• Cakes without nuts, seeds or dried fruit added. Custard/cream added to make soft
• Biscuits dipped into drinks to make soft

Foods to avoid:

• Harder cakes or biscuits with added nuts, seeds or dried fruit.
• Fruit scones, Christmas cake and mince pies.

Fruit

Foods you may include:

• Soft fruit with all pips, pith and skin removed, e.g., banana, ripe soft pear, peach, melon, lychees, tinned or stewed fruit

Foods to avoid:

• Fruit with skin, pips or seeds that remain attached e.g., raspberries, strawberries, blueberries, blackberries, blackcurrants, passion fruit, kiwi fruit, pomegranate, apple, mango
• Coconut, all dried fruit, figs, prunes
• Pineapple, oranges, tangerines, satsumas

Vegetables

Foods you may include:

• Vegetables that are peeled and well-cooked, with stringy or tough bits removed e.g turnip, carrot, butternut squash, sweet potato, parsnip, swede, pumpkin, beetroot*
• Skinned and deseeded: tomatoes, courgette, marrow, cucumber, aubergine, roasted pepper
• Tomato puree or passata
• Well-cooked florets of cauliflower and broccoli (stalks removed)
• Garlic puree, onion salt, finely chopped herbs

*remember that this will turn your stoma output red.

Foods to avoid:

• Vegetable skins and raw vegetables
• Peas, mange tout, sugar snap peas, sweetcorn, baked beans, broad beans, string or french beans
• Salad vegetables e.g., lettuce, olives

Meat, Fish and Protein alternatives

Foods you may include:

• Meat/meat substitutes that can be mashed with a fork such as minced meat in cottage/Shepheard pie

Foods to avoid:

• Beans (including baked beans), pulses, lentils, nuts, seeds
• Pies or pastries
• Tough pieces of meat that require lots of chewing and can’t be mashed with a fork

Milk and Dairy products

• Milk (fresh, evaporated or condensed). Cream, crème fraiche
• Cheese, cottage cheese, cream cheese, cheese spreads
• Smooth, low sugar yoghurt (no bits), plain yoghurt, fromage frais, Ice cream

Foods to avoid:

• Muesli or nut yogurts, yogurts with whole fruit

Miscellaneous

• Crisps that are softer and easily melt in the mouth
• Shredless marmalade or seedless jam
• Lemon curd or honey
• Marmite, smooth nut butter
• Condiments e.g. Tomato sauce, brown sauce, soy sauce, mayonnaise, stock cubes.
• Treacle, syrup
• Fizzy and sugary drinks

Foods to avoid:

• Any chocolate containing fruit, nuts or seeds added
• Popcorn
• Marmalade with shreds, or jam with seeds. Crunchy nut butter
• Hard sweets that don’t dissolve in the mouth

STAGE 3 – ‘normal’ texture diet

Once you are feeling confident with CRT then it is possible to introduce ‘normal’ textured foods back into the diet, your dietitian will go through this in more detail with you. Usually this means that your diet and fluid intake is a lot less restrictive than without CRT and is one of the great advantages. This is assessed on an individual basis and will be advised by your dietitian.

Who should I contact for any problems?

Whilst on the ward you must ask any questions and raise any problems you have with the team, and the best suited member of the team will be sure to answer them for you. If you go home on CRT then below is a list of who you may need to contact:

For problems related to your eating and drinking or supplement prescription:
Hospital dietitian:
Name:
Telephone number:

For problems related to the equipment:
Outreach team Name:
Telephone number:

Intestinal Failure Unit, ward H8
0161 206 4521 or 0161 206 5364

Troubleshooting

Nausea, distention, stomach cramps - Reduce rate of chyme pump to see if this helps. Contact your dietitian.

Diarrhoea - Reduce rate of chyme pump to see if this helps. Contact your dietitian.

Reflux of enteral feed back into stoma bag - Contact the Intestinal failure outreach nurse or dietitian.

Constipation and/or abdominal distention - Contact the Intestinal failure outreach nurse or dietitian. Do not increase feed rate further.

Blocked pump - You should have been shown how to replace this yourself but if you have any further questions contact the outreach team.

In need of further equipment i.e. pumps, or tubes - Contact the outreach team or dietitians and they should be able to get some sent out to you.