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Maximizing Absorption in Patients
with Short Bowel Syndrome
Carol Rees Parrish MS, RD
Nutrition Support Specialist
Digestive Health Center of Excellence
University of Virginia Health System
Charlottesville, VA
[email protected]
University of Wisconsin –Nutrition Grand Rounds
Learning Objectives
1) List clinical consequences of SBS.
2) Discuss rationale for the medications
commonly used in the management of
SBS.
3) Intervene in a stepwise fashion to
optimize hydration and nutritional
status.
Digestive Health Center of Excellence University of Virginia Health System
Digestive Health Center of Excellence University of Virginia Health System
Disclosures
Case 1
Consultant for:
72 y/o F presents to the GI nutrition clinic w/ SBS &
failure to thrive
 NPS Pharmaceutical
 PBM Pharmaceuticals
 PMH: Colon CA ’91  s/p sigmoid resection w/
chemo/XRT, s/p chole ’93, multiple SBO’s/adhesions 
2/07 extensive SB resection
 Meds include: questran – 1 TID, lomotil – 3 TID, 0.6 mL
tincture of opium TID, centrum silver, KCl sustained-release
tab, vitamin C, nexium capsule, metamucil
 Pert Labs:
•
Digestive Health Center of Excellence University of Virginia Health System
Case 1 cont.
 Ht - 5’0”
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IBW - 105#
128# (2/07) (also her usual body weight)
111# (4/07)
107# (5/07)
102# (6/07)
94# (8/07)
93# (11/07)
 PO diet: Regular, low sweets, low fat, 6 small fdgs
 Fluids: 10 glasses of water /day
 24 hour urine & ostomy output: 875 mL & 1440 mL
Digestive Health Center of Excellence University of Virginia Health System
B12: 191, 25-OH vitamin D: 14, RBC folate: 923, HCO3: 13
Digestive Health Center of Excellence University of Virginia Health System
Case 2
 35 y/o F presents for initial visit to the GI nutrition clinic w/
short bowel syndrome on TPN; one septic episode to date
 PMH: Ovarian cancer (stage IIIB), 4 bowel resections, s/p
chemo 4 years prior
 Ht = 5’3” wt = 98# UBW = 120#
 Meds: Estrase, TPN (1600 kcal, 80 pro, 1800 mL) / 14 hours
o
Occasionally she skips…
 PO diet: Regular; eats sporadically; has a busy, 5 y/o son to
chase; her goal: to see him start kindergarten and she has
decided to hold him back a year…
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Case 3
Gut Demographics16
 Duodenum ~ 25-30 cm (~ 10”)
 59 y/o M w/ SBS
 PMH: Crohn’s x 35 yrs & 4 resections w/ 3 ft of SB
and ¾ colon; osteoporosis
 Ht. 5’ 9” Wt. 63kg IBW: 70kg
 Stable on oral diet until recent Crohn’s
flare/obstruction requiring remaining colon leaving
him w/ a duodenostomy
 24 hr urine & stool output: 1200mL/ 5500mL/day
 On TPN & IV fluids…
•
•
 Length from the duodenojejunal flexure 
ileocecal valve averages ~ 23’ (700cm)
•
•
Digestive Health Center of Excellence University of Virginia Health System
Jejunum Attributes
Ileum
 > 90% of nutrient absorption - first 100-150cm
 Jejunal enterohormones:
CCK
 Functional “length” almost double jejunum
 Enterohepatic circulation of bile salts (~
95%)
• If > 100cm terminal ileum lost, bile salt pool
cannot be maintained:
• Pancreatic secretion & gall bladder contraction
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Secretin
•
Gastric inhibitory peptide (GIP)
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Vasoactive inhibitory peptide (VIP)
• Bicarbonate secretion
• Hepatic synthesis cannot keep up w/ losses
• Increasing steatorrhea and fat soluble vitamin loss
• Inhibits gastric secretion and motility
 Food-bound B12 absorption
 Ileal brake – slows transit in upper gut
• Inhibits gastrin and bicarbonate secretion
Digestive Health Center of Excellence University of Virginia Health System
Digestive Health Center of Excellence University of Virginia Health System
Colon Matters
Ileo-cecal Valve
 Junction of ileum and cecum
 Can control passage of ileal contents into
colon to increase nutrient-lumen contact time
 Prevents reflux of bacteria from colon into SB
setting the stage for small bowel bacterial
overgrowth
•
Proximal jejunum = <
104
cfu vs. colon w/
Jejunum ~ 200-300 cm (6-10’)
Ileum ~ 300-400 cm (10-13’)
 Colon ~ 160 cm (5’)
Digestive Health Center of Excellence University of Virginia Health System
•
Rarely resected
Pancreato-biliary secretions enter
1012
Digestive Health Center of Excellence University of Virginia Health System
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Can absorb up to 5-6 liters/day
Slows gastrointestinal transit (colonic brake)
Avidly absorbs sodium and chloride
Preservation of ~ ½ colon is equivalent to
adding ~ 50 cm SB back
 Nutrient salvage
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Fermentation of fiber into SCFA
Absorption of MCT oil
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The GI Balance Sheet:
SBS Defined19
Gastrointestinal Water Movement
Additions
Diet
Saliva
Stomach
Pancreas/bile
Intestine
Subtractions
Colointestinal resorption
NET STOOL LOSS
mL of water
2000
1000
2500
2000
1000
 100-120 cm (3-4 ft) without colon
 > 50 cm (1.6 ft) with colon
 60-75% SB resected
 My definition of SBS:
•
8900
100
Digestive Health Center of Excellence University of Virginia Health System
“Inadequate length, or functional bowel, to
support nutrient & fluid requirements for
that individual.”
Digestive Health Center of Excellence University of Virginia Health System
Factors Enhancing Outcomes &
Adaptation Potential8
 Length of remaining bowel
 Quality of remaining bowel
 Section/s of small bowel remaining
Ileum vs. jejunum
• Presence of ileo-cecal valve
• Intact colonic segment
 Age of patient
•
Digestive Health Center of Excellence University of Virginia Health System
Factors cont.
 Integrity of other organs:
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 Time elapsed since original insult
 Depending on interventions to date 
 Patient compliance
Digestive Health Center of Excellence University of Virginia Health System
Clinical Consequences of SBS
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Dehydration
Nephrolithiasis
Cholelithiasis
Electrolyte disarray
Metabolic acidosis21
Osteoporosis
Nutrient malabsorption
•
Progressive weight loss/malnutrition
 Medication malabsorption
Digestive Health Center of Excellence University of Virginia Health System
Stomach
Liver
Pancreas
Renal
Consequences cont.
 Gastric hypersecretion
 Motility changes
 Diarrhea
o
o
o
Steatorrhea
Small bowel bacterial overgrowth (SBBO)6
Cholerrheic diarrhea (bile salt diarrhea)
• Only in those with colonic segment
 Quality of life issues
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Data Collection20
Goals of Management
1) Provide nutrients, water and electrolytes
to maintain health and/or growth
 Know your patients anatomy
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•
2) Maximize adaptation
3) Prevent and treat complications
•
Op reports/ reliable drawing
Small bowel follow through - gives an idea
of gross anatomy transit time
Abdominal CT
5) *Reduce the severity of intestinal failure*
 Past medical/surgical history
 Admits for dehydration / kidney stones ?
Digestive Health Center of Excellence University of Virginia Health System
Digestive Health Center of Excellence University of Virginia Health System
4) Optimize quality of life
Data cont.
 Current medications – Review ALL
• Dosing/ form / over-the-counters too!
• Liquid meds; check for sugar alcohols
– Sorbitol, mannitol, xylitol, etc.
• Any sustained-or delayed release?
 3-5 day diet record:
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What & amounts of food/fluids consumed
Supplements (Ensure, Boost, etc.)
Protein powders, probiotics, herbals, etc.
Vitamins and minerals
Digestive Health Center of Excellence University of Virginia Health System
Strategic/Systematic Intervention
And More Data…
 Chief complaints of pt AND pts goals?
 If you don’t ask your pt, you won’t know…
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Need to gain weight?
Loss of sleep?
If ostomy--emptying bag too often?
No ostomy—sore bottom?7
Hassles of PN
• Septic episodes
• Infusion time
 Missing grandchild’s soccer games, time
share, etc.
Digestive Health Center of Excellence University of Virginia Health System
The Infamous Stool Hat
 One thing at a time
 24 hour fast
•
Differentiate osmotic vs. secretory
 Stop all “non-essential” meds and give via IV if
necessary to remove any osmotic contribution
they may have
 Baseline 24 hour:
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Urine output
Stool output
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Digestive Health Center of Excellence University of Virginia Health System
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Intervention cont.
 Qualitative (spot check) vs. Quantitative fecal fat
 24 - 72 hour quantitative fecal fat:
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Intervention cont.
Medications – always consider absorption
& utilization3,5,14,20,23
100 g fat diet (pt then needs to eat it)
Inform the patient what to expect
Concurrent diet record during collection
No procedures planned for 72 hours
•
Scheduled dosing; NOT “PRN”
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Is medication available at the local
pharmacy?
Consider form of medications
• Tab, capsule, suspension, sustained or
delayed-release
• Every 4, 6 or 8 hours
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• i.e., cannot be NPO, etc.
 72 hour collection may need to be repeated on
new regimen to determine efficacy
Digestive Health Center of Excellence University of Virginia Health System
Digestive Health Center of Excellence University of Virginia Health System
Intervention cont.
Intervention cont.
 Acid-reducing
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H2 blockers (ranitidine, famotidine)
Proton pump inhibitors (PPIs)
• Nexium, prevacid, etc.
• Form is important!
 Gut slowing
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• Imodium, lomotil
• Upscale to narcotics: codeine, (paragoric, tincture of opium) if
imodium/lomotil do not work (& stop them)
– Delayed release
– Solutab
– IV – if < 50cm of jejunum left or if > but poor quality
• Check pH of fresh jejunal or ileal ostomy effluent
30-60 minutes BEFORE meals!
Every 6 hours, NOT QID; take advantage of pt getting up
at night – pill/s at bedside premeasured
Start with:
•
– Should be > 6
Endpoint?
• Output drops too much (i.e., constipated/ stool too thick)
• Pt is nauseated, mental status changes, sleepy, etc.
Digestive Health Center of Excellence University of Virginia Health System
Digestive Health Center of Excellence University of Virginia Health System
Other Agents Tried, but?
 Oral glutamine
 Growth hormone
 Octreotide
 Clonidine
Jeppesen PB. Growth Hormone, glutamine and glucagon-like peptide 2
in short bowel syndrome. Practical Gastroenterology 2008;XXXII(11):37.
Digestive Health Center of Excellence University of Virginia Health System
GATTEX® (teduglutide)
 Glucagon-like peptide-2 (GLP-2) analog
o
o
Produced by intestinal enteroendocrine cells
Stimulates:
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o
Intestinal growth
Upregulates villus height in SB
Increases crypt cell proliferation
Decreases enterocyte apoptosis
’s capacity of remaining bowel mucosa to
absorb fluids & nutrients
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Maximizing Adaptation Intraluminal Nutrient Stimulation
Teduglutide cont.
 For adult patients with SBS dependent on PN
x 1 yr
 Daily dose is 0.05 mg/kg by SQ injection
 Results:
o
o
 Cephalic phase/saliva stimulates release epidermal
growth factor
 “Functional workload with whole foods stimulates:
• Biliary and pancreatic secretions
• Trophic effects of gut hormones
20% reduction in PN/IV or 1-2 days per week
Off PN
– Ex. Glucagon-like peptide-2 (GLP-2)
• Intestinal blood flow
• Innervation
 $295,000/year
O’Keefe SJ, et al. Safety and Efficacy of Teduglutide After 52 Weeks of
Treatment in Patients With Short Bowel Syndrome Intestinal Failure. Clin
Gastroenterol Hepatol 2013 Jan 17. [Epub ahead of print]
 Adaptive changes can take up to 1-2 years
Digestive Health Center of Excellence University of Virginia Health System
Digestive Health Center of Excellence University of Virginia Health System
Nutrition cont.
Nutrition: Oral Tips2,4,20
 Jejunostomies & proximal ileostomies
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Higher fat
Increased salt18
 Colon segment
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Lower fat
Avoid oxalate
Fiber is good
 Smaller, frequent meals, 6-8/day
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FODMAPs (Fermentable Oligo-,
FODMAPs cont.
Di, Mono-saccharides & Polyols)2
Poorly absorbed
Small, osmotically active particles
Rapidly fermented by intestinal bacteria
Physiologic consequences: osmotic load,
substrate for rapid bacterial fermentation,
changes in GI motility, altered GI flora
 Effects are additive w/ other poorly absorbed
CHO such as sorbitol.
 Symptoms: gas, bloating, distension & pain
Digestive Health Center of Excellence University of Virginia Health System
Concentrated sweets, highly osmotic foods/ fluids
Enteral stimulants such as ETOH & caffeine
Fermentable Oligo-, Di, Mono-saccharides & Polyols
(FODMAPs)2 
Digestive Health Center of Excellence University of Virginia Health System
Digestive Health Center of Excellence University of Virginia Health System
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Start with their usual and tailor it
Chew foods well
Lactose ?13
Medium chain triglycerides (MCT oil)9
Avoid:
 High fructose corn syrup (HFCS)
o
o
50-80% fructose
Use ’d > 1000% since 1970
 Examples of FODMAPs:
o
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o
o
o
Fruit/juices, honey, fructo-oligosaccharides (FOS)
Wheat, garlic, onion, rye, asparagus, artichokes
Sports & soft drinks/fruit beverages, jams/jellies, BBQ
sauce, sweet pickles/relish, etc.
Sorbitol, mannitol, xylitol, maltitol, isomalt, etc.
Lactose
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Vitamins/ Minerals
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Periodic assessment of:
• Vitamin A (negative acute phase reactant)
• Vitamin E
• 25-OH vitamin D
• Folate
• Ferritin (negative acute phase reactant)
• Zinc (serum levels unreliable), copper
– Stool output, physical exam, signs/symptoms
• Methylmalonic acid/ B12
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o
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We proceeded with a baseline lab, and systematically
began 2500 mcg tabs daily.
After a month my B-12 was elevated too high; we have
subsequently reduced them to 3 x week (M,W,F) and will
check another lab next month.
 After 20 years of injections, this alternative has been
not only a financial relief, but more important to me,
has eliminated scheduling and consuming 2 hours a
month of my time. Thank you so much!”
Digestive Health Center of Excellence University of Virginia Health System
Vitamins/ Minerals cont.
Vitamin D and Bone Health
Oral - ½ tab BID
IV ?
Liquid vitamin D – may need higher dose
More salt: ensure pt is not restricting for any reason
Magnesium
•
 “I discussed replacing monthly B-12 shots with oral
therapy with my GI.
Digestive Health Center of Excellence University of Virginia Health System
• Chewables vs. Liquid
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Oral Synthetic B1222
 Baseline bone density scan
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 If bile salt deficient, try lower fat product
 Pancreatic enzymes rarely needed
 Give some fiber if colon segment remaining
Sperti lamp (D/UV Lamp)
•
Tanning beds11
• 10 minutes, 3 x/wk x 6 months
Digestive Health Center of Excellence University of Virginia Health System
Parenteral1,12
Enteral10
 Infuse over time to ↓ nutrient load per cm bowel
•
• www.vitaminduv.com
Digestive Health Center of Excellence University of Virginia Health System
 Lower osmolality (300-600mOsm), polymeric,
some MCT-containing tube feeding
Direct sunlight
• 5-10 minutes avg. = 3000 IU D3
• Depends on time of day, season, skin sensitivity,
latitude
Crushed in applesauce/ bananas
Add liquid form to ORT and sip
Try giving dose alone at night right before bed
 Feed as high up as possible (i.e., stomach)
Consider endocrine consult if osteoporotic
 UV light exposure - arms and legs, trunk
 May need permanently
 Prior to discharge, consolidate IV’S to mimic
home regimen; largest bag holds 4 liters
•
How high can you run IV rate?
•
May need to give “IV chasers” before or after
TPN run at home
Over what period of time?
• Rates of 399mL/hr
•
• 10-14 hours
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Digestive Health Center of Excellence University of Virginia Health System
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Hydration !
Parenteral cont.
 Nocturnal vs. daytime infusion
IV backpacks
•
 Over time, may be able to decrease daily
volume and run time or give 1-2 days off
per week
 Consider urine output at night
How often are they getting up to urinate?
o
• Are they sleep deprived?
Common Causes of Increased Stool Output
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Clostridium difficile (“C. Diff.”) infection24
Other GI infection
Initiation of a new medication
Sudden discontinuation of an important
medication that helps decrease losses
 Drinking too much fluid in some patients
Digestive Health Center of Excellence University of Virginia Health System
Digestive Health Center of Excellence University of Virginia Health System
Signs of Dehydration
 Thirst!
 Decrease in urination
o
Urine output is < five cups (40 ounces or
1200mL) per day
• Note: 1 cup = 8 ounces
 Urine looks dark in color
 Rapid weight loss
 Dry mouth, sticky or thick saliva
Digestive Health Center of Excellence University of Virginia Health System
Digestive Health Center of Excellence University of Virginia Health System
Fluids/Hydration
Dehydration cont.
 Stool output that is more than the total
amount of fluid you drink
 Feeling tired all the time
 Kidney stones17
 Worsening kidney function
o
Rise in BUN/creatinine ratio (late)
 Poorly controlled diabetes mellitus
Digestive Health Center of Excellence University of Virginia Health System
 Avoid hypotonic/hypertonic fluids such as:
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Water, tea/coffee, fruit juices, EToH, sport drinks, sodas
 Separate solids from liquids; take small amounts of
fluids with meals, sip more between meals
 Oral rehydration therapy (ORT)
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Start with 1 liter/day—no sense sending 2-3 L until you
know pt with take it!
 Trial of nocturnal nutrition or ORT via tube15
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Infuse slowly over time
 Addition of IV fluids as last resort
Digestive Health Center of Excellence University of Virginia Health System
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Commercial ORT Solutions
Products
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Pedialyte
Wal-Mart (Parent’s Choice)
Target (Pedia Electrolyte)
WHO formula
•
Cost/L (2010)
Jianas Brother’s (carton of 100)
 Ceralyte (if buy case of 260)
 CVS (Pediatric Electrolyte Oral
Maintenance Solution)
 DripDrop
$5.49
$3.50
$3.54
$0.55
On-Line Resources
UVAHS GI Nutrition Website:
www.ginutrition.virginia.edu with links to:

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$2.60

$4.49
$4.99
Digestive Health Center of Excellence University of Virginia Health System
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
Nutrition Articles in Practical Gastroenterology
Clinician’s Guide to Short Bowel Syndrome--2005
Professional Education
Nutrition Support Traineeship & Weekend Warrior Programs
e-journal club
Webinars
Nutrition support blog
Patient education materials
Digestive Health Center of Excellence University of Virginia Health System
More Resources
 Patient’s Guide to Managing a Short Bowel
•
www.shortbowelsupport.com
 Oley Foundation
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http://www.oley.org or (800) 776-OLEY
 Oxalate and Hyperoxaluria Foundation
•
http://www.ohf.org/diet.html
Digestive Health Center of Excellence University of Virginia Health System
Digestive Health Center of Excellence University of Virginia Health System
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