Download Short Bowel Syndrome

Short Bowel Syndrome
Anne Aspin 2010
Definition
• Rickham (1967) – an extensive resection to
maximum of 75cm
• Kuffer (1972) – 15cm with ileocaecal valve
- 38cm without ileocaecal valve
• Dorney (1985) – 11cm with I/C valve or 25cm
without I/C valve
Introduction
• Most common cause of intestinal failure.
• NEC, Congenital atresia, Gastroschisis and
volvulus.
• Promote adaptive response through
enteral feeding and careful management
of TPN.
The Digestive System
• Digestion starts in the mouth
• Moisten by saliva (contains Pytalin),
begins to turn starch to sugar.
• In stomach food churned mixes with
gastric juices.
Gastric juices
• Acid reaction
• Kills bacteria
• Controls pylorus
• Gastric juices:
- Rennin coagulates milk
- Hydrochloric Acid – Converts Pepsinogen to
Pepsin.
- Pepsin turns protein to peptone
• Food is released in small amounts by
relaxation of the sphincter passing onto
Duodenum.
• Food further digested by Trypsin, Amylase
and Lipase.
• Digestion completed in small intestine.
Intestinal juices.
• Enterokinase – pancreatic trypsinogen
• Peptidase – polypeptide to amino acid
• Maltase - maltose}
• Sucrase – sucrose} to glucose
• Lactase – Lactose}
• Lipase – Fats to fatty acids and glycerol
• Onto large intestine where fluids and
nutrients are re absorbed.
• Waste fluids taken by blood stream to
kidneys to be filtered
Small intestine
• Convoluted tube from pyloric sphincter to
the junction of ileo – caecal valve
• Mucus membrane –has circular folds to
increase surface area for absorption.
• Villi which contain blood and lymph vessel.
• Supplied with tubular glands secreting
intestinal juice.
Absorption
• Proteins, Carbohydrates and Fats through
villi in small intestine.
• Fats in the form of fatty acids and glycerol
are absorbed by cells covering villi. Pass
into lymph within villi drained by lymphatic
capillaries.
Ileo Caecal valve.
• The Caecum lies in the right ileac fossa.
• The Ileum opens into the Caecum through
the Ileo-Caecal valve.
• This is a sphincter which prevents the IC
contents passing back into the Ileum.
What is SBS
• Reduced bowel surface area for absorption
of nutrients together with rapid transit of
intestinal contents.
• TPN reduced as enteral feeds are
introduced.
• Need to promote intestinal adaptation.
Motility
• The IC valve and colon is important to
slow intestinal transit.
• Proteins, Fats and Carbohydrates are
absorbed almost completely within first
150cm of small bowel.
• Jejunum – most of electrolyte absorption
• Ileum is the only site for absorption of Vit
B12 and bile salts.
After resection.
• Increase gastric emptying.
• Ileal resection, increased transit time
• An intact IC valve prolongs gut transit, loss of
this causes an increase.
• If colon resected transit increases.
• Duodenal resection – malabsorption of
Iron, Calcium and Folic Acid.
• Jejunal resection – If extensive resection,
lactose intolerence
• Ileal resection – Some diarrhoea due to
bile salts being incompletely absorbed.
Gastric Hypersecretion
• After abdominal surgery, gastric hypersecretion occurs in 50% cases.
• This impairs digestion of lipids by lowering
intraluminal PH and inactivating the
pancreatic enzymes.
• Also stimulates peristalsis.
How does the bowel adapt?
•
•
•
•
•
Cellular hyperplasia
Villous hypertrophy
Intestinal lengthening
Altered motility
Hormonal changes
• Takes approx 2 years
to reach max effect.
Management of SBS.
• Total TPN
• Gradual introduction of enteral feeding.
• Fluid and electrolyte balance
• Fluid replacement if stool, gastric aspirate
or ostomy losses are high
• Reducing substances above1% contra
indicate increasing enteral feeds.
Weaning off TPN
• Cycling – one hour off, line lock with
Gentamycin.
Build up to off all day.
Complications.
• Bacterial overgrowth
• Anaemia
• Bile salt depletion
• Bone disease
• Cholestasis
• Diarrhoea
• Hypocalcaemia
Complications (cont)
• Hypomagnesaemia
• Liver fibrosis
• Renal stones
• Protein malnutrition
• Trace mineral deficiency
• Vitamin deficiency, A, D, E, K, B12
Central line complications
• Infection
• Thrombosis
• Break in catheter
• Air embolus
• Tissue necrosis
• Malposition
• Cardiac tamponade
Bacterial Overgrowth
• Bloating, cramps, diarrhoea,
gastrointestinal blood loss.
• Treat with sugar free Metronidazole and
Trimethoprim
Watery diarrhoea
• Loperamide
• Malabsorption of bile acids.
• Pectin
Surgery
• Further resection might be avoided by
tapering, strictureplasty or serosal
patching.
• Patients with dilated segments proximal to
tight anastomosis – resect and taper
improves bacterial overgrowth by
improving flow.
Tapering
Bowel lengthening
• Cutting bowel longitudinally, preserve
blood supply to both sides and create a
segment of bowel twice length, half
diameter without loss of mucosal surface
area.
Bowel lengthening
Antiperistaltic small intestine
segment
Colonic interposition
Medical management
• Pectin (water sol, non cellulose dietary
fibre which promotes intestinal
adaptation)
• Ranitidine (PH > 4)
• Loperamide (slow gut transit time)
• Cholestyramine (binds bile salts)
It takes approximately two years to
achieve some normal diet
Thank you
References
• Bentley D, Lifschitz C, Lawson M (2001). Necrotising Entercolitis
• And Short Bowel Syndrome. http://www.naspghan.org/wmspage.cfm?porm1=130
• Koglmeier J, Day C, Puntis J (2008). Clinical outcome in patients from a single region
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who were dependent on parenteral nutrition for 28 days or more. Archives of Disease
in Childhood. 93 (4) : 300 - 302
Martin G, Wallace L and Sigalet D (2004). Glucagon – like Peptide -2 Induces
Intestinal Adaptation in Parenterally Fed Rats with Short Bowel Syndrome. American
Journal of Physiology. Gastro-intestinal and Liver Physiology. 286: G964-G972
McMahon M, Leviller J and Chescheir N (1996). Prenatal Ultrasonographic Findings
Associated with Short Bowel Syndrome in Two Fetuses with Gastroschisis. Obstetrics
and Gynaecology. 88: 676-678
Seidner D and Matarese L (2003). Selected topics in
Gastrotherapy. Case 2: Short Bowel Syndrome : Etiology,
Pathophysiology and Management. The Cleveland Clinic Center for Continuing
Education
• Sinden A, Sutphen S (2003) Nutritional Management of Paediatric Short Bowel
•
Syndrome. Nutrition Issues in Gastroenterology. Series #12 p28-48
Warner B, Vanderhoof J and Rayes J (2000). What’s New In The Management of
Short Gut Syndrome in Children. Division of Paediatric Surgery. Department of
Surgery. American College of Surgeons. p725-736