SHORT BOWEL SYNDROME A MANAGEMENT DILEMMA

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SHORT BOWEL SYNDROMEA MANAGEMENT DILEMMA

• Vic Vernenkar, D.O.
• Department of Surgery
• St. Barnabas Hospital

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Definition

• Short Bowel Syndrome is defined as any of the
  malabsorptive conditions stemming from massive
  resection of the small bowel with or without an
  attendant resection of the colon.
• Clinically manifested by malnutrition, weight
  loss, steatorrhea, and diarrhea arising from
  decreased absorptive capacity.

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Severity of Symptoms

• Extent of resection
• Site of resection
• Underlying intestinal disease
• Presence or absence of ileocecal valve
• Functional status of remaining digestive organs
• Adaptive capacity of intestinal remnant

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History

• 1880- First massive resection of SB by Koeberle,
  with 205 cm removed.
• 1888- Senn states that removal of 1/3 of SB can
  be done without development of marasmus.
• 1935- Flint demonstrated that 50 can be safely
  removed with no metabolic conseq.
• 1950- 70 resection feasable with adequate
  support, presence of ileocecal valve.

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Etiologies of Massive Resections

• 1800- Early 1900- strangulated hernias.
• 1935- Volvulus, incarcerated hernia, mesenteric
  thrombosis.
• 1970- Infarcted small bowel.
• Today- Crohns accounts for 50, followed by
  mesenteric thrombosis, radiation enteritis,
  volvulus, and trauma.

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Pathophysiology

• The problem
• Nutrition
• Bile acids, steatorrhea, fat malabsorption
• Presence or absence of colon
• Gallstones and renal stones
• Loss of regulatory function
• D-Lactic acidosis

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Postoperative Phases

• Phase I (Acute) profuse diarrhea, massive fluid
  and electrolyte losses. Can last 1-3 mos as
  patients bowel undergoes hypertrophy,
  elongation, hyperplasia.
• Phase II (Adaptation) Period of gut adaptation.
  Lasts 1-2 years.
• Phase III (Maintenance) Maximal adaptation.

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Theraputic Goals

• Maintenance of nutritional status
• Maximization of enteral nutrient absorption
• Prevention of complications

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Nutrient Absorbtion

• Fats
• Carbohydrates
• Protiens

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Total Parenteral Nutrition

• Initial hydration and electrolyte support
• Vitamins
• Calories
• Carbohydrate, protien, and fluid requirements
• Glutamine

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Phase Specific Treatment

• Acute Phase Focus on fluid and electrolytes
• TPN on day three to day four
• Start enteral support early
• Adaptation Phase Steadily increasing enteral
  support
• Correlation between remnant and nutritional
  prognosis
• Maintenance Phase Transition to oral diet

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Enteral Support

• Start with water, clear soups, gradually
  increasing to diluted solution of defined diet
  with simple amino acids, short chain peptides.
  Use medium chain TGL. Avoid conc. sugars,
  caffeine, etoh.
• Elemental vs Polymeric diets
• Pectin
• Avoidance of oxalate

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Helpful Medications

• Loperamide, codeine and other opiates
• H-2 Blockers, proton pump inhibitors
• Somatostatin/Octreotide
• Cholestyramine
• Clonidine

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Preventing Complications

• Catheter-related sepsis
• TPN-induced liver disease
• Prophylactic cholecystectomy?
• Bacterial overgrowth

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Adaptation

• Mechanisms
• Parenteral support
• Hormones

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Surgical Considerations

• Above all, preserve intestinal remnant.
• Methods to delay transit time.
• Methods to increase absorptive area.
• Transplantation

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Delay Transit

• Valves and Sphincters
• Antiperistaltic Segments
• Small Intestine
• Colon
• Recirculating Loops
• Intestinal Pacing

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Increase Absorption

• Intestinal tapering and lengthening
• Mucosal harvest

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Transplantation

• Problem
• History
• Advances
• Studies
• The ideal candidate

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Summary

• Short Bowel Syndrome increasingly common
• Malnutrition is avoidable with early TPN/enteral
  support
• Diet individualized
• Minimize complications, diagnose early
• Surgical management includes preserving length,
  Improving function
• Transplatation is evolving as a promising
  alternative