Short Bowel Syndrome
-
Type of intestinal failure
-
Intestinal failure – inadequate digestion and
absorption of nutrients
Main factors
-
Loss of absorptive surface
-
Rapid transit
Prevalence-
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3-4 million
-
15% of all intestinal resections
-
In 3/4th massive resection
-
In 1/4th recurrent resection
Intestinal length-
-
300 – 600 cm normal
-
Resection of half of it is well tolerated
-
SBS may develop if remnant <180cm
-
PN can be weaned off if-
o
120 cm without colon
o
60 cm with colon continuity
|
Intestinal
Length
|
Need
for Parenteral Nutrition
|
|
>180 cm
|
none
|
|
120-180 cm or 90 – 120 cm with colon
|
< 6 month
|
|
60 – 90 cm with colon
|
6 - 12 month
|
|
< 60 cm small intestine
|
permanent
|
-
Outcome not dependent entirely on length
-
It also depends on-
o
Location
o
Function
o
Status of other digestive organs
o
Ileo-caecal valves
o
Adaptive capacity
Reason for Ileal remnant doing
better than jejunal remnant:-
-
Special absorptive property for bile salts and
Vitamin B12
-
Hormone secretion
-
More adaptation
-
Presence of ileocaecal junction improves the
functional capacity
Other digestive organs:-
-
Stomach
-
Pancreatic secretions
-
Colon
-
Jejunocolic anastomosis (Type II anastomosis) is
equivalent to 30cm of additional small bowel.
-
Jejunoileocolic anastomosis (Type III) is
equivalent to additional 60 cm
-
End jejunostomy (Type I anatomy) 100 cm of
remnant is required to avoid permanent PN.
Intestinal adaptation-
-
Stimulated by exposure of the residual mucosa to
macronutrients
-
Remaining bowel increases in length and diameter
-
Hyperplasia of small intestinal mucosa with
increased number and size of crypts and villi
-
Develops over 1-2 years
-
Neurohormonal mediators-
o
Glucagon like peptide 1 and 2(GLP – 1 and GLP –
2), peptide YY(PYY) and neurotensin
Long term outcome-
-
Age
-
Underlying disease
-
Complications of management
Causes of Short Bowel Syndrome-
-
Surgery 25%
-
Radiation 24%
-
Mesenteric vascular disease 22%
-
Crohn’s
16%
-
Others 13%
|
Complications (SBS)
|
|
|
General
|
Specific
|
|
Malnutrition and weight loss
|
Cholelithiasis
|
|
Diarrhoea & Steatorrhea
|
Gastric hypersecretion
|
|
Vitamin and mineral deficiency
|
Nephrolithiasis
|
|
Fluid and electrolyte imbalance
|
Liver disease
|
Management:-
-
Control sepsis
-
Fluid and electrolytes
-
Nutrition
-
Maximise the function of remaining intestine
-
Prevent complications of underlying disease and
nutritional therapy
Acute phase (1 to 4 weeks) -
-
RL, amino
acids, Glucose, water soluble vitamins, trace elements
-
3rd day TPN
-
5th day enteral feed –
o
Iso-osmolar salt glucose solutions
o
MCT
o
Amino acids
Adaptation phase (1 week to 2 years)-
-
Oral intake gradually increased to 30 – 40 kcal/kg/day
-
Slowing of intestinal motility – Loperamide or
codeine
-
Suppression of gastric acid output PPI
-
Trace elements and vitamins
Maintenance phase-
-
Target absorption rate of 30 -40 kcal/kg/day
(ideal body weight)
-
About 45 – 60 kcal/kg/day must be ingested
-
Regular supplementation of viatmins, minerals
and trace elements
-
Calcium should be given generously by mouth
(800-1200mg/day)
Vitamins-
Vitamin
A 10,000-50,000/day
Vitamin B12 300microgram/day
Vitamin C 200
– 500 mg/day
Vitamin D 1600
microgram/day
Selenium 60
– 100 microgram/ day
Zinc 220
– 440 mg/ day
Nutrition-
-
Enteral nutrition as soon as possible
-
It helps in ADAPTATION
-
Optimal diet is controversial
-
Simple nutrients and partially hydrolysed diets
-
Concentrated sugars like fruit juices should be
avoided – they generate high osmotic load.
End ileostomy : no fat
restriction (30 – 40% energy)
Fat requirements as MCT (low digestion requirements)
With colon : 20 – 30% of calorie from fats
Drugs to inhibit
intestinal secretions-
-
H2 receptor antagonist
-
Somatostatin
-
Cholylsarcosine – synthetic bile acid improves fat
absorption without causing diarrhoea
|
Complication Prevention
|
|
|
Metabolic
|
TPN
related
|
|
Hypomagnesemia
|
Catheter sepsis
|
|
Hypocalcemia
|
Liver disease
|
|
Vitamin D deficiency
|
Bacterial overgrowth
|
|
Iron
|
Cholelithiasis
|
|
Selenium, Zinc, Copper
|
Nephrolithiasis
|
Preventing early
liver failure-
-
Avoid sepsis
-
Enteral nutrition
-
Mixed Fuel (<30% energy from fats)
-
UDCA
Non Transplant Surgical Option-
-
Restore intestinal continuity
-
Continued malabsorption (despite medical
therapy)
-
Need for
specialized nutritional support
-
Intestinal complications (obstruction and
fistulas)
Ostomy closure: (possible in 1/4th to 1/2)
-
Increase absorption
-
Prolongs transit time
-
Jejunocolic anastomosis is functionally
equivalent to adding 30 cm of small bowel
-
If small bowel remnant is less than 60 cm
problems of diarrhoea and perianal complications
Obstruction and
Fistulas:
-
Stricturoplasty- (Heinke-mikulicz type)
-
Serosal patch for fistula
Tapering procedures:
-
Dilated segments (Crohn’s diseases)
-
Aim to improve motility
-
It means reduction of circumference of intestine
by imbrication or excision of redundant part along the antimesenteric border.
To Decrease the transit time-
-
Artificial valves created by distal
intussusception of a segment of small intestine.
-
Ten-centimetre
reversed segments
Binachi’s lengthening technique
STEP – Serial Transverse Enteroplasty Procedure
Criteria for clinical
improvement:
-
Reducing (>25%) or discontinuing PN
requirements while maintaining bodyweight
-
Resolving a specific anatomical problem (eg
obstruction or fistula)
-
Ameliorating symptoms of malabsorption
(eg.diarrhoea or metabolic abnormalities such as hypocalcemia.
Intestinal transplant:
-
Mortality rate of patients on PN for benign
disease 5-25%/yr
-
15% at 3 years
-
Greatest for infants
