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Short Bowel Syndrome
Donald F. Kirby, M.D.
Director, Center for Human Nutrition
Areas to Review
Short Bowel Syndrome Definition
Physiology Review
Mechanisms of Malabsorption
Treatment Options
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Short Bowel Syndrome
Definition
The reduction of the absorptive
surfaces of the intestine either
surgically +/or functionally reduced by
specific disease states that jeopardize
a person’s survival from a nutrition
and fluid and electrolyte standpoint.
Short Bowel Syndrome
What is Short??
Patient with <200cm of functional small bowel
Greatest nutritional risk – Just think “real short”
– Have duodenostomy or jejunoileal anastomosis
with <35cm residual small bowel (RSB)
– Jejunocolic or ileocolic anastomosis <60cm RSB
– End jejunostomy with <115cm of RSB
2 Subgroups – Colon in/not in continuity
– Having the Colon can be very important!
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Short Bowel Syndrome
Etiologies
Tumor
Trauma
Volvulus
Ischemia
Congenital
Crohn’s Disease
Strangulated hernias
“Functional” short bowel
Thrombosis/embolism of SMA
Diagnoses Leading to Short Bowel Syndrome in Adult IRTP Patients
Crohn's Disease
33.30%
Ulcerative Colitis
21.10%
Mesenteric
Vascular
Infarction 12.30%
Radiation
Enteritis
17.50%
Other 15.80%
Children – Add
Necrotizing Enterocolitis
Congenital intestinal anomalies
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“Functional” Short Bowel
Resulting from severe malabsorption
despite normal intestinal length
Examples
– Refractory sprue
– Chronic intestinal pseudo-obstruction
– Radiation enteritis
Normal Physiology - Overview
Small intestine measures
~12-20 ft or 350-600 cm.
7-9 L of fluid pass L of T,
stool loss only 100-200cc/d.
Villi line the lumen, which in
turn is lined by microvilli actual absorption of
nutrients.
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Sites of Absorption
Small Intestine
Carbohydrates
Fats
Proteins
Calcium
Magnesium
Trace elements
vitamins
Iron
Folate
Calcium
Fat soluble
vitamins
Water soluble
B vitamins
Vitamin B12
Bile salts
Magnesium
Short chain
Fatty acids
Small & Large Intestine
Water
Electrolytes
Normal Intake and Output
Oral intake - ~2 L
Salivary juice - ~1.5L
Gastric juice - ~2.5L
Biliary juice - ~0.5L
Pancreatic juice - ~1.5L
Intestinal juice - ~1L
About 8-9L in !!
Urinary losses – ~0.8-1.5L
GI losses – 1-200gm stool/day
Insensible losses - ~1L/day
– Lungs – increased with
hyperventilation
– Skin – evaporation + sweat
Rapid internal shifts of fluid –
3rd space
Fluid reabsorbed
- Small bowel ~7L (Maximum 12L)
- Colon ~1.4L (Maximum 5L)
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What do
these have
in common?
Real
Estate
Anatomical Considerations:
Jejunal Resection
Adequate absorption
unless >75% resected
Good ileal adaptation
Preserved absorption of
B12 and bile salts
Normal intestinal transit
Peptide YY present
Jeejeebhoy KN. CMAJ. 2002; 166:1297-1302.
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Anatomical Considerations:
Ileal Resection
Adequate absorption if
60 cm jejunum to colon
Malabsorption of bile salts
& vitamin B12
Poor jejunal adaptation
Rapid intestinal transit
Small bowel bacterial
overgrowth
Reduced Peptide YY
Messing B. Gastroenterology. 1999; 117:1043-1050.
Limited Ileal Resection
<100cm of ileal resection
Secretory diarrhea without steatorrhea
Loss of specialized bile acid resorption
Bile acids irritating to colon
Cholerheic Diarrhea – Rx cholestyramine
Can also see after cholecystectomy in
some patients with no resected bowel
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Enterohepatic Circulation of Bile Acids
Ileal Resection <100 cm
• Increased bile acids
in fecal water
• Cholestyramine
Ileal Resection >100 cm
• Depleted pool
• Steatorrhea
• Malabsorption
Cholerheic
Diarrhea
Anatomical Considerations:
Extensive Bowel Resection
100 cm SB to avoid PN
Large fluid losses
Nutrient malabsorption
Poor jejunal adaptation
Acid hypersecretion
Rapid gastric emptying
Rapid intestinal transit
Wilmore D. Best Pract Res Clin Gastroenterol. 2003; 17:895-906.
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Mechanisms of Malabsorption
Acid hypersecretion
Inactivation of endogenous
pancreatic enzymes
Rapid intestinal transit
No time to mix w/food in intestine
Decreased Peptide YY
Loss of surface area
Bacterial overgrowth
-Obstruction
-Sluggish peristalsis
-Loss of valve
- ↓ pH
Bile acid wasting
Secretion of secretin
and CCK (failure to
stimulate release of
pancreatic enzymes)
Deconjugation of bile acids
with impaired micelle formation
Therapeutic Opportunities
Acid Hypersecretion
Rapid Transit
Impaired Residual
Bowel
Loss of Surface Area
Bacterial Overgrowth
Bile Acid Wasting
H2RA or PPI
Slow Transit
Loperamide, Codeine,
Diphenoxylate, etc.
!Problem!
Adaptation – 2+ years!!
Use of antibiotics
Replace bile acids
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Pathophysiology of SBS
Altered Motility
Lack of surface area
Faster the transit time
Peptide YY works as “ileal brake”
– Secreted by enteroendocrine cells
– Located in ileum and colon
Can the Intestine Adapt?
Begins 24-48 hours after resection!
Villi increases in length → ↑absorptive area
Ileum adapts
– 2-3 years for maximal adaptation
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Therapeutic Key
Must begin to feed as
soon as possible to help
stimulate the gut
Role
RoleofofFeeding
Feeding
Enterally fed
Intravenously fed
Adaptation takes oral/enteral feeding
and
TIME
Change
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Factors Affecting the Severity of
Short Bowel Syndrome
<80% small bowel affected
Site of resection: jejunum
No other GI involvement
Time from onset > 1 year
Colon present and nondiseased;
ileocecal valve present
Rombeau JL, Rolandelli RH. Surg Clin North Am. 1980;60:1273-1284.
Acute Management
Fluid and Electrolyte balance – close monitoring
Nutritional Management
Goal is to achieve a positive nitrogen balance.
Caloric requirements need to be monitored and
reassessed frequently.
TPN maybe for short term or life-long.
PPI for PUD/Esophagitis prophylaxis.
Initial enteral feedings as tolerated.
Purdum PP III Kirby DF. JPEN 1991;15:93-100.
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Prognosis?
What do you
tell the
patient and
family?
Plasma Citrulline Concentrations
Non-protein Amino Acid produced by
intestinal mucosa
<20 micromol/L = permanent intestinal
failure in adults – 95% predictive value
<15 micromol/L = permanent intestinal
failure in children
Crenn P , et al Gastroenterology. 2000; 119:1496.
Santarpia L, et al. Ann Nutr Metab. 2008;53:137.
Fitzgibbons S, et al. J Pediatr Surg. 2009;44:928.
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Chronic Management
Electrolytes – continue to monitor
Trace elements – Iron, Copper, Zinc, Selenium,
Chromium, Manganese
Fat Soluble vitamins – ADEK
Vitamin B12
Periodic nutritional assessment
Attempt to wean – Encourage oral intake
Diarrhea – cholestyramine, somatostatin
MCT Oil (medium chained triglyceride)
Purdum PP III Kirby DF. JPEN 1991;15:93-100.
Short Bowel Syndrome
Treatment Goals
To assess the remainder of the intestine’s
ability to digest and absorb nutrients
• Can the patient maintain his/her fluid and
electrolytes?
• Can the patient eat enough to compensate for
maldigestion +/or malabsorption?
• Are trace elements being depleted?
• What is the role of TPN – short vs long-term?
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TPN Complications
Metabolic
– Electrolytes
– Vitamins
– Trace elements
Catheter-related
Complications of SBS
Metabolic
–
–
–
–
–
–
–
–
–
–
–
–
Anemia
Bile salt depletion
Bone Disease
Cholelithiasis
Dehydration
Diarrhea
D-lactic acidosis
HypoCa++,Mg++
Liver Disease
Oxalate Kidney Stones
Protein-calorie malnutrition
Vitamin and Trace mineral
deficiencies
Catheter (most common)
–
–
–
–
Air embolism
Breakage of catheter
Infection
Thrombosis
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Case
45 yo man on chronic
TPN presents to ED
Has fever, BP normal
c/o tenderness over
his tunneled catheter
Diagnosis?
Case
45 yo man on chronic
TPN presents to ED
Has fever, BP normal
c/o tenderness over
his tunneled catheter
Diagnosis?
Treatment?
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Three Types of Vascular
Access Infections
Exit site
Tunnel or Pocket
Access device
Catheter Exit Site Infection
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Oxalate Nephrolithiasis
Normal
circumstances
Colon
After extensive bowel resection
Colon
Oxalate
+
Calcium
Free
oxalates
Fat
+
Ca
Kidney
Excretion
Malabsorption
Calcium oxalate stones
Additional Challenge
Medication Delivery
Oral
Nasal
Sublingual/Buccal
Subcutaneous
Intramuscular/depot
Intravenous
Pulmonary
Topical
–
–
–
–
–
Eye/Ear
Rectal/Vaginal
Implantable
Mucous Membrane
Skin
Ointment
Transdermal
Cream
McFadden MA, DeLegge MH, Kirby DF. JPEN 1993;17:180-186.
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Other Options
Intestinal Rehabilitation Techniques
Pharmacologic adaptation
– Growth hormone + Glutamine
– Glucagon-like peptide-2 (GLP-2)
– Teduglutide (GLP-2 analogue - awaiting FDA
approval)
Nontransplant Surgery
Small bowel transplantation
Multiple organ transplantation
Intestinal Rehabilitation &
Transplant Program (IRTP)
To enhance absorptive capacity, improve nutritional
status, and reduce need for PN through the use of:
Diet
Medications
Additional fiber
Enteral nutrition
Oral rehydration solutions
Growth factors
Specialized nutrients
Reconstructive surgery
Small bowel or multivisceral transplant
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Medications for SBS
and Intestinal Failure
Antidiarrheals
H2 blockers
Somatostatin analogue
2-adrenergic receptor antagonist
Bile acid therapy
Probiotics
Proton pump inhibitors
Pancreatic enzymes
Prebiotics
Growth hormone
Antimicrobials
Glucagon-like peptide 2
Small Intestine
Bacterial Overgrowth
Causes:
- Obstruction
- Sluggish peristalsis
- Loss of valve
- ↓pH
Ileocecal valve:
-Prevents retrograde flow
of bacteria
Treatment:
-Probiotics
-Antibiotics
-Prebiotics
Diagnosis:
- SB aspirate
- Hydrogen breath test
Symptoms
- Gas, bloating, diarrhea, constipation
steatorrhea
-Weight loss, nutrient deficiency
- Fishy body odor, feculent smelling breath,
pungent stool odor
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Growth Hormone +/- Glutamine
Several trials have been done
Regimen is considered controversial
Results not consistent
Intensive dietary teaching important here
Recombinant Human
Growth Hormone (r-hGH)
Many trials have been performed with varying
results, but have yielded criteria
–
–
–
–
SBS with 50-200cm SM and no colon
>15cm jejunum-ileum and >30% colon
>90cm jejunum-ileum and <30% colon
Stable condition* and BMI >17
Expensive ~$20,000 for 4 weeks therapy
Therapy should be done 6-12 months after
onset of SBS
*Multiple criteria
Nutr Clin Pract 2005;20:503-508.
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Glucagon-like peptide -2
Enteroendocrine peptide released in
response to luminal contents
GLP-2 Analog (Teduglitide [Gattex])
– Awaiting FDA approval
Question – True Patient
45 yo F who with h/o volvulus
- Resected “most of the small bowel”
and has 50% of Colon
- Now 2 months postop
- TPN catheter removed by managing
surgeon
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#2
Since removal of her catheter 2 weeks ago
– Lost 10 lbs
– Cramping of hands and legs
– Feeling a little light-headed
– Labs
Potassium 2.6
Calcium 6.8 (albumin 3.4)
Phosphorus 0.8
Magnesium 0.5
BUN/Creat – 30/2.0 (discharge 12/1.0)
#3
What would you do?
1. Tell her to drink orange juice and Gatorade™
2. Write a prescription for potassium, magnesium
and tell her to chew Calcium – see her in 1
month
3. Arrange to restart her TPN next week
4. Admit her to fix fluids and electrolytes and
likely restart parenteral nutrition
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#3
What would you do?
1. Tell her to drink orange juice and Gatorade™
2. Write a prescription for potassium, magnesium
and tell her to chew Calcium – see her in 1
month
3. Arrange to restart her TPN next week
4. Admit her to fix fluids and electrolytes and
likely restart parenteral nutrition
Thank You!
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