Dietetic Management of Short Bowel Syndrome

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Dietetic Management of Short Bowel Syndrome

• Ali Singer
• Gastroenterology Specialist Dietitian
• Frenchay Hospital

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Content

• Definition
• Physiology
• Management
• Case Study

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Definition

• The reduction of functioning gut mass to below
  the minimum necessary for the absorption of
  nutrients and/or water and electrolytes
  Fleming
  Remington, 1981

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Variability in Intestinal Lengths

• Small intestinal length at autopsy
• 3-8.5m Bryant, 1924
• Shorter in women
• SBS more common in women (67)
• Small intestinal length at laparotomy
• n mean (cm) range (cm)
• Cook, 1974 6 421 320-521
• Backman, 1974 32 643 400-846
• Slater, 1991 38 500 302-782

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Record of Intestinal Length

• Length removed often recorded
• Length remaining is more important
• Laparotomy
• SB contrast studies (less accurate)
• Nutritional/fluid supplements needed if
• lt 200cm SB

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Causes of SBS

• Commonest causes
• Crohns
• Superior mesenteric
• artery thrombosis
• Irradiation

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SBS Anatomy

• Mid-SB resection
• Uncommon
• Rarely problems
• Jejunocolic anastomosis
• Usually fluid balance maintained
• Nutritional issues when SB lt100cm
• Jejunostomy/high output enterocutaneous fistula
• Large stoma/fistula water and sodium losses
• Dehydration
• /- nutritional problems

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Types of Short Bowel
Pt Groups Jejunum Ileum Colon Nutritional needs
Jejunum - ileum Resected Intact Intact Rarely need nutrition
Jejunum -colon Resected Intact Gradual undernutrition Adaption occurs lt50cm may need TPN
Jejunostomy Intact Resected / Absent Absent Fluid electrolyte losses No adaption lt100cm IV saline lt75cm IV nutrition also
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Normal GI Physiology

• Ileum
• Active Na/H2O absorption
• Less leaky
• Na absorption
• Large conc. gradient
• Not dependent on H2O movement
• Not coupled to gluc/AA absorption
• Increased by Aldosterone

• Jejunum
• Na/H2O secretion 1st 100cm
• Leaky
• Na absorption
• Small conc. gradient only
• Dependent on H2O movement
• Coupled to gluc/AA absorption
• Maximal Na absorption when Na 120mmol/l

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Normal GI Physiology
Liquid Vol secreted (L) Vol absorbed(L)
External Food drink 2
Salivary glands Saliva 0.5-1
Stomach Gastric juice 2-3
Pancreas Pancreatic juice 0.5-0.8
Liver Bile 0.5-0.9
Jejunum Passive proximal secretion distal absorption 1-2 1-2
Ileum Active absorption 2-5, vit B12, bile salts
Colon Large capacity
External Faeces 400
Total 6.5-9.7 3-9
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Gastrointestinal Motility

• Jejunal-colon
• NORMAL

• Jejunostomy
• FAST

Peptide YY and GLP-2 (glucagon-like peptide 2)
are released when food passes the terminal ileum
and caecum that act as ileal and colonic braking
mechanisms this is lost in jejunostomy
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Physiological Consequences

• Increased gastric emptying
• Increased SB transit
• Increased gastric secretions (first 2 wks)
• Resection of ileal colonic braking mechanism
• Changes in GI hormones
• Reduced peptide YY, glucagon like peptide 2
• Increased gastrin

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Critical Lengths
Critical SB length Note
Jejunostomy 100cm More needed if diseased bowel
Jejunocolic anastomosis 50cm Depends on amount of residual colon
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Nutritional Support and Bowel Length
Jejunal length Jejunum-colon Jejunostomy
0 - 50 cm Parenteral nutrition Parenteral nutrition and saline /- Mg
51 - 100cm Oral / Enteral nutrition Parenteral nutrition and saline /- Mg
85 - 100cm Parenteral saline
101 - 150cm None Oral / enteral nutrition and glucose / saline solution
151 - 200cm None Oral / enteral glucose / saline solution
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• lt200cm restrict oral hypotonic fluids, sip
  glucose - saline supplement (100mmol/L Na, like
  jejunostomy fluid)
• lt100cm parenteral saline
• lt50cm parenteral nutrition and saline

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GI Secretions

• Jejunum colon
• Reabsorb unabsorbed fluid in colon
• Jejunostomy
• Salt and water loss from stoma
• lt100cm jejunum losses gt oral intake
• Rapid sodium fluxes occur in jejunum
• If water/solutions of lt90mmol/L sodium are drunk
  a net efflux of sodium into the bowel lumen
  occurs until 100mmol/L is reached

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Absorptive Functions

• B12 and fat malabsorption occur if gt60-100cm
  terminal ileum resected
• Increased hepatic synthesis of bile salts cannot
  compensate unabsorbed bile salts contribute to
  colonic secretion
• Magnesium deficiency
• Chelation of unabsorbed fatty acids reduces
  absorption
• Increased renal excretion secondary
  hypoaldosteronism

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Hypomagnesaemia
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Clinical Picture
Water Na Mg Nutrition
Thirst Low BP/ postural hypotension Urea/ Creatinine/ Potassium Daily body weight Fluid balance/ stoma output Low urine volume Urine Na 1-2/7, then weekly, as OP 2-3 monthly Depletion if urine Na lt10mmol Thirst Low BP/ postural hypotension Urea/ Creatinine/ Potassium Daily body weight Fluid balance/ stoma output Low urine volume Urine Na 1-2/7, then weekly, as OP 2-3 monthly Depletion if urine Na lt10mmol Serum magnesium High stoma output Sx in Mg lt 0.6mmol/L BMI lt18.5kg/m2 Mid-arm muscle circumference lt19cm lt22cm men
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Adaptive Processes

• Hyperphagia increased food intake
• Structural adaption
• increasing absorptive area
• Functional adaption
• slowing gastrointestinal transit (gastric
  emptying and small bowel transit)
• Occurs in jejunum-colon patients due to high
  peptide YY and GLP-2, leads to increased jejunal
  absorption of macronutrients (glucose, water, Na,
  Ca) and overtime may no longer need TPN

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Jejunum-Colon Pts

• Post resection
• Parenteral fluids and nutrition (helps surgical
  repair, ileus recovery and avoids deficiencies)
• 6/12 PPI
• Multivitamin
• Long term
• Undernutrition
• Diarrhoea due to malabsorption
• Vitamin/mineral deficiency

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Undernutrition

• gt50 of energy from diet malabsorbed
• High energy foods, sip feeds /- NG/PEG feed if
  fails TPN. Improves over time.
• Long term TPN
• Absorption of lt33 oral energy intake
• Absorption 30-60, high energy requirements
• Large volume stomal output / diarrhoea
• High carbohydrate, normal fat, low oxalate diet
• Topical sunflower oil for essential fatty acids

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The Fat Dilemma
But high carbohydrate without fat is unpalatable
and fat yields twice as much energy as
carbohydrate also a low fat diet risks essential
fatty acid deficiency.
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Deficiencies

• Common
• B12 deficiency replace
• Selenium deficiency replace
• Magnesium deficiency replace if occurs
• Vitamins D, E, A, K and essential fatty acids
  replace

• Rare
• Potassium deficiency
• Zinc deficiency rare unless large stool volumes
• Water and sodium rare as absorbed well in colon,
  if occurs sips of glucose saline drink

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Other complications

• Diarrhoea
• Limit food intake
• Consider loperamide 2-8mg 30mins pre meals,
  codeine 30-60mg 30mins pre meals
• If gt100cm terminal ileum resected cholestyramine
  for bile salt malabsorption and reduced oxalate
  absorption
• Confusion
• Hypomagnesaemia, thiamine deficiency, lactic
  acidosis (restrict mono / oligo saccharides) and
  hyperammonaemia (inadequate citrulline
  manufacture, Tx is arginine)

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• Drug absorption
• warfarin, digoxin, thyroxine, loperamide and if
  lt50cm jejunum omeprazole may not be absorbed
• Gallstones (calcium bilirubinate stones)
• Bilary stasis. Therefore occurs in 45,
  especially men
• Tx IV amino acids, enteral feed, cholecystokinin
  injections, NSAIDS, ursodeoxycholicacid,
  metronidazole, cholecystectomy
• Renal stones (calcium oxalate stones/nephrocalcino
  sis/CRF)
• Occurs in 25 largely due to increased colonic
  absorption of oxalate
• Social

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Ca Oxalate Renal Stones
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Jejunostomy Patient Issues

• Salt and water depletion
• May be large volume of stomal output
• Greater volume lost after food or fluids
• GI secretion ? 4L/day, majority absorbed in
  jejunum therefore more fluid losses via stoma if
  short jejunum
• Jejunostomy fluid contains 100mmol/L Na, 15mmol/L
  K
• If given hypotonic fluids ? 100mmol/L the mucosa
  allows leaking of fluid and electrolytes into the
  lumen
• Low sodium levels are NOT SIADH but sodium
  depletion, this is resolved when urine Na ?
  30mmol

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Jejunostomy Patient Issues

• Hypokalemia
• Rare, occurs when lt50cm jejunum
• Usually due to secondary hypoaldersteronism from
  Na depletion
• Can be due to hypomagnesaemia causing potassium
  channel dysfunction and increased renal potassium
  secretion which responds to Mg not K supplements
• Hypomagnesaemia
• B12 deficiency, confusion, drug absorption, and
  gall stones
• Nutritional

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High Output Jejunostomy

• Exclude other causes of a high output
• Stage1 Establish stability
• Stage 2 Establish oral intake
• Introduce enteral food/fluid/feed
• Stage 3 Rehabilitation
• Stoma care, HPN training, social issues
• Stage 4 Long term care

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Other Causes

• Intra-abdominal sepsis
• Partial/intermittent bowel obstruction
• Enteritis (clostridium, salmonella)
• Recurrent disease in remaining bowel (Crohns,
  irradiation)
• Bacterial overgrowth
• Suddenly stopping drugs (steroids, opiates)
• Giving prokinetics (metoclopramide)
• Coeliac
• Hyperthyroidism

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Stage 1 Establish Stability

• Severe dehydration Na depletion
• Keep patient NBM
• IV normal saline (2-6L/day)

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Treat the Cause

• Intraabdominal sepsis / abscess
• Partial / intermittent bowel obstruction
• Strictures placement / muscle tunnel / adhesions
  / crohns / ischaemic fibrosis / radiotherapy
• Enteritis clostridium / salmonella / rota virus
• Recurrent disease Crohns / irradiation
• Sudden stopping of drugs steroids / opiates
• Drugs prokinetics / metoclopramide / metformin /
  PPI / statin
• Diet lactose intolerant / coeliac

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Stage 2 Establish Oral Intake

• Restrict oral fluids to lt500ml/day
• Hypotonic (water, tea, coffee, squash, alcohol)
• Hypertonic (fruit juices, coca cola, sip feeds)
• Drink a glucose-saline solution lt500ml/day

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Hypotonic Fluids 0 mmol Na
High Output 100 mmol/L Na

• Leaky
• Small conc. gradient only
• Dependent on H2O movement

Na 140 mmol/L
jejunum
Unable to maintain Na gradient
Electrolyte Mix 90 mmol Na/L
Smaller volume 100mmol/L Na
Na 140 mmol/L
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Oral Rehydration Therapy
Na (mmol/L) K (mmol/L) Glucose (mmol/L) Volume (ml)
WHO 90 20 111 1000
Electrolyte mix 90 0 111 1000
Dioralyte 60 20 90 200
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Recipe ORS

• 20g (6 teaspoons) glucose
• 3.5g (1 level 5ml teaspoon) salt
• 2.5g (1 heaped 2.5ml spoon) sodium bicarbonate
• 1L water
• Add cordial, chill and drink through a straw

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Drug Therapy

• Antisecretory
• Omeprazole decreases gastric acid secretion
• Ranitidine/cimetidine
• Octreotide decreases intestinal secretions

• Antimotility
• Loperamide upto 64mg PO o.d as decreased
  enterohepatic circulation
• Codeine
• Lomotil

• Vit/min supplements
• B12, selenium, Mg2, vit A, D, E, K

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Parenteral Therapy

• 0.51L saline sc /- 4mmol MgSO4
• 1-3/week
• 1L saline IV /- 4-12 mmol MgSO4
• gt 3/ week
• IVN

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Outcome Aims

• Clinical
• No thirst or signs of dehydration
• Acceptable strength, energy and appearance
• Measures
• Gut loss lt2L/day
• Urine volume gt800ml/day
• Urinary Na gt20 mmol/L
• Normal serum Na, Mg2 and K
• Body weight within 10 of normal

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Stage 3 Rehabilitation

• Transfer to IF unit
• Wound healing
• Stoma care
• HPN training
• 1st patient 1978
• Longest 27 years
• Mean age 50.2 years (19.9 76.9)
• 27 new patients per year per unit
• Social issues

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Stage 4 Long-Term Care

• 3 monthly multidisciplinary clinics
• IF unit
• Shared care with local hospital

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Outcome 1 year after starting HPN (467 patients)
BANS 1996-2000
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Mr J background information

• 72 male ? UC (1961)
• Pan-protocolectomy (1962)
• Refashioned/Re-sited Ileostomy (1993)
• s/b Dr Kaskey, Renal Physician 2º renal
  impairment and kidney stones
• Referred from renal dietetic clinic (pt initially
  attempted to resist a referral!)

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Issues
High output ileostomy output (estimated up to
2.5L per day)
Dehydration (? UO, ? urine Na)
Renal impairment stone formation
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Assessment Concerns

• Renal impairment
• stage 4 CKD
• Poor seal on stoma bags
• Not leaving house when stoma active

Biochem Result
Na 134
K 3.5
Ur 20.0 ?
Creat 233 ?
eGFR 25 ?
Uric Acid 0.64
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Intervention
Intervention Rationale
1. Add salt to meals Increase Na intake ( serum Na)
2. Low fibre diet ? Insoluble fibre residue through bowel
3. Restrict hypotonic fluids to 1L/d Avoid drawing H20 ( Na) into the bowel
4. St Marks Fluid 1L/d Promote H20/ Na absorption
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5. Loperamide 4m.g qds Anti-motility agent
6. Forceval o.d
7. Check Mg and if deplete, convert Mg-glycerophosphate to Mg-oxide On Mg supplements but levels not checked Mg oxide has less diarrhoeal effect
8. Refer to MXL Specialist f/u
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Outcomes

• Outcome measures
• Biochemistry

Biochem 09.08.07 03.04.08
Na 134 142
K 3.5 4.7
Ur 20.0 12.9
Creat 233 202
eGFR 25 29
Uric Acid 0.64 0.41
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Outcomes

• Reduction in stoma output
• ? from 2.5 L to lt 1L /d
• Thickened output (watery ? porridge-like
  consistency)
• Pt satisfaction
• Practicalities in day-to-day management of stoma
• Follow-up
• Sole Dietetic f/u
• Renal physicians happy with progress

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• Thank-you
• Any Questions?