SHORT BOWEL SYNDROMESHORT BOWEL SYNDROME Abdulwahab TelmesaniAbdulwahab Telmesani

Associate Professor Of Pediatrics Associate Professor Of Pediatrics

Umm Al-Qura UniversityUmm Al-Qura University

DefinitionDefinition

MalabsorptionMalabsorption

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Shortened BowelShortened Bowel

EtiologyEtiology

Primary:Primary: (Abnormal anatomically) (Abnormal anatomically)Born with short bowelBorn with short bowelCongenital anomalies Congenital anomalies e.g. Multiple Artesia's, Gastroschisise.g. Multiple Artesia's, Gastroschisis

SecondarySecondary::NECNECHirschsprung diseaseHirschsprung diseaseIschemiaIschemiaRadiationRadiationTumorsTumors

Crohns’sCrohns’s

JejunumJejunum

Long villi →Large absorptive surface Long villi →Large absorptive surface areaarea

High concentration of enzymes andHigh concentration of enzymes and

transport carrier transport carrier Large tight junction →Porous to large Large tight junction →Porous to large

moleculemolecule

IleumIleum

Short villi →Less absorptive capacityShort villi →Less absorptive capacity Small tight junction →Less porous and Small tight junction →Less porous and

increased absorption for fluid & electrolyteincreased absorption for fluid & electrolyte Specific function of absorption of B12 and Specific function of absorption of B12 and

bile salts (specific receptors)bile salts (specific receptors) Synthesis of hormones e.g.Enteroglucagon Synthesis of hormones e.g.Enteroglucagon

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negative gastrin feedbacknegative gastrin feedback

Ileocecal valveIleocecal valve

Stops reflux of bacteriaStops reflux of bacteria Regulate fluid and nutrient exitRegulate fluid and nutrient exit

AdaptationAdaptation

Ileum > JejunumIleum > Jejunum

AdaptationAdaptation

Hyperplasia, Increased crypts and villiHyperplasia, Increased crypts and villi DilatationDilatation Increased Absorption capacityIncreased Absorption capacity

Adaptive factorsAdaptive factors

Entral feed:Entral feed:Direct stimulationDirect stimulation

Upper GI secretionUpper GI secretion Trophic GI hormoneTrophic GI hormone

Hormonal regulation:Hormonal regulation:Enteroglucagon, Neurotensin, SecretinEnteroglucagon, Neurotensin, SecretinCholicystokinin,Epidermal growth factors(EGF)Cholicystokinin,Epidermal growth factors(EGF)IGF-I + GHIGF-I + GH

Adaptive factors(Contd.)Adaptive factors(Contd.)

ProstaglandinProstaglandin PolyaminesPolyamines Intracellular regulation (Genetic)Intracellular regulation (Genetic)

Nutrients stimulate adaptation Nutrients stimulate adaptation better better

Long chain fatty acidLong chain fatty acid 3-Omega fatty acids (fish oil)3-Omega fatty acids (fish oil) FibersFibers GlutamineGlutamine

ManagementManagement

ManagementManagement

TPNTPN Replace losses (Electrolyte & fluid)Replace losses (Electrolyte & fluid) Introduction of Enteral feedIntroduction of Enteral feed

TPNTPN

Gradual introduction with monitoring Gradual introduction with monitoring

of blood chemistry,LFT &lipidsof blood chemistry,LFT &lipids

Replace lossesReplace losses

Losses from :Losses from :

NG, gastrostomy, diarrhea, OstomyNG, gastrostomy, diarrhea, Ostomy Appropriate fluid (based on lost Appropriate fluid (based on lost

electrolyte)electrolyte) Replace losses through separate Replace losses through separate

infusion pumpinfusion pump

Enteral feedingEnteral feeding

Continuous enteral infusion Continuous enteral infusion

(can use portable)(can use portable) Breast Milk/Predigested formulas as a Breast Milk/Predigested formulas as a

startstart Progress to solidsProgress to solids Wean TPN as enteral feeding Wean TPN as enteral feeding

increasesincreases

Guide to advancing enteral Guide to advancing enteral feedingfeeding

Diarrhea not getting worseDiarrhea not getting worse

> 50% or 40ml/kg/day> 50% or 40ml/kg/day Stool reducing substances (pH < 5.5)Stool reducing substances (pH < 5.5)

ComplicationsComplications

Bacterial overgrowthBacterial overgrowth DiarrheaDiarrhea Nutritional deficiencyNutritional deficiency TPN related liver diseaseTPN related liver disease Catheter related Catheter related

Bacterial overgrowthBacterial overgrowth

More that 10More that 1055 bacterial growth in upper bacterial growth in upper intestineintestine (facultative bacteria & anaerobes)(facultative bacteria & anaerobes)

Causes:Causes: stagnation, dilatation, lost ileocaecal valvestagnation, dilatation, lost ileocaecal valve

Bacterial overgrowth Bacterial overgrowth cont.cont.

Manifestations:Manifestations: Deconjugation of bile → MalabsorptionDeconjugation of bile → Malabsorption Lactose intolerance → Diarrhea, Lactose intolerance → Diarrhea,

bloating, crampsbloating, cramps Lactic acidosis →CNS symptomsLactic acidosis →CNS symptoms Inflammation →Ileitis, colitisInflammation →Ileitis, colitis

Bacterial overgrowth(Contd.)Bacterial overgrowth(Contd.)

Diagnosis: Aspiration of intestine for C&SDiagnosis: Aspiration of intestine for C&S

Breath hydrogen testBreath hydrogen test Treatment:Treatment:

Antibiotics:Antibiotics:CommonlyCommonly TMP-SMX + TMP-SMX + MetronidazoleMetronidazole

Frequent defecationFrequent defecation

SurgicalSurgical

DiarrheaDiarrhea

Causes: Causes:

Osmotic loadOsmotic load

Elevated gastrinElevated gastrin

Treatment: Treatment:

Revise enteral feedsRevise enteral feeds

CholestyramineCholestyramine

H2 blockersH2 blockers

Nutritional deficiencyNutritional deficiency

Fat soluble vitamin A,D,E,KFat soluble vitamin A,D,E,K Zinc (low serum alkaline phosphatase)Zinc (low serum alkaline phosphatase) Trace elementsTrace elements B12B12 Micronutrients e.g. carnitine, choline, Micronutrients e.g. carnitine, choline,

taurinetaurine

TPN liver diseaseTPN liver disease

Hepatocellular damageHepatocellular damage Cholestasis,CholelethiasisCholestasis,Cholelethiasis SepsisSepsis

Catheter related Catheter related complicationcomplication

SepsisSepsis

Improper catheter careImproper catheter care

bacterial overgrowth →bacteremiabacterial overgrowth →bacteremia

ThrombosisThrombosis

Surgical managementSurgical management

Treat anastomosis strictures:Treat anastomosis strictures:Tapering enteroplasty, stricturoplastyTapering enteroplasty, stricturoplasty

Increased length: Increased length: Intestinal transection (Bianchi Intestinal transection (Bianchi procedure)procedure)

Surgical management Surgical management cont.cont.

Increased intestinal transit:Increased intestinal transit:-Colon interposition-Colon interposition-Creation of valve-Creation of valve

TransplantationTransplantation

TransplantationTransplantation

Getting better survivalGetting better survival Not yet a standard procedureNot yet a standard procedure Problem with rejectionProblem with rejection Post-immunosuppressant Post-immunosuppressant lymphoproliferativelymphoproliferative disordersdisorders

Transplantation cont.Transplantation cont.

Indicated when You are against the Indicated when You are against the wallwall

-Major liver disease secondary to -Major liver disease secondary to TPNTPN

-Intolerance to feeding-Intolerance to feeding

-Catheter sepsis, thrombosis and no -Catheter sepsis, thrombosis and no sitesite

for insertionfor insertion

SBS In the SBS In the NeonatesNeonates

Correlates of good outcomeCorrelates of good outcome

Use of breast milkUse of breast milk Use of Amino acid based formulasUse of Amino acid based formulas Percentage of enteral calories at 6 WKsPercentage of enteral calories at 6 WKs Residual small bowel length at SxResidual small bowel length at Sx The year of SxThe year of Sx

Androsky et al 2001Androsky et al 2001

Correlates with low Peak Correlates with low Peak Bilirubin LevelBilirubin Level

Early Closure of OstomyEarly Closure of Ostomy Enteral Calories at 6 WKsEnteral Calories at 6 WKs Less Gm +ve InfectionsLess Gm +ve Infections Use of Casein hydrolysate formulasUse of Casein hydrolysate formulas

Androsky et al 2001Androsky et al 2001

Correlations Between:Correlations Between: Early enteral feeding and the Early enteral feeding and the subsequent weaning of TPNsubsequent weaning of TPN

Sondheimer et al 1998Sondheimer et al 1998

Length of the small bowel Length of the small bowel at Sx and discontiuation of at Sx and discontiuation of TPNTPN

A correlation between amino acid A correlation between amino acid basedbased

formula and weaning from TPN wasformula and weaning from TPN was

observedobserved

Bines et al 1999Bines et al 1999

ConclusionsConclusions

Early introduction of enteral feedingEarly introduction of enteral feeding Use of BREAST MILK / Hydrolysate Use of BREAST MILK / Hydrolysate

formulasformulas Early closure of the OSTOMIESEarly closure of the OSTOMIES Use of improved types of TPN solutionsUse of improved types of TPN solutions Stringent care of the TPN cathetersStringent care of the TPN catheters Watch and treat bacterial over growthWatch and treat bacterial over growth

DONEDONE