SICU Protocol for Short Bowel Syndrome

Original designer: Ri 林哲安Revised and presented by Ri 陳翌真Instructor: P 柯文哲

11/22/2004

Refernce AGA guideline: Short bowel syndrome and intestinal tra

nsplantationThis document presents the official recommendations of the American Gastroenterological Association (AGA) on Short Bowel Syndrome. It was approved by the Clinical Practice Committee on August 5, 2002 and by the AGA Governing Board on November 1, 2002. Published in Gastroenterology 2003; 124:1105. Copyright 2003 American Gastroenterological Association.

AGA technical review on Short bowel sundrome and intestinal transplantation Gastroenterology 2003; 124:1111-34.

Definition of SBS

Signs and symptoms resulted from intestinal resection : 1. less than 200cm of jejunum-ileum

remaining, or 2. 70-75% of the small intestine

resected .

Etiology of SBS

In adults : Crohn’s disease, mesenteric mesenteric ischemia, venous thrombosis, volvulus, trauma, complications of cancer therapy

In children and infants : intestinal atresia, gastroschisis, extensive aganglionosis, necrotizing enterocolitis

Patients of SBS can be divided into 2 distinct group:

1. with partial or intact colon in continuity

2. without colon in continuity

Problems in SBS

Nutrition, Volume 15, Issues 7-8, July-August 1999, Pages 633-637 Jeremy Mark Darby Nightingale

Managements for SBS

Nutritional support Fluid & electrolyte replacement Medication for possible complications Trophic and prokinetic therapy: Rando

mized, controlled trials have not shown glutamine and/or growth hormone to improve intestinal absorption.

PARENTERAL NUTRITION

Typically, patients who have undergone massive enterectomy require TPN, once hemodynamic stability has been achieved, for the first 7 to 10 days after surgery.

25 to 30 kcal/kg per day based on ideal body weight for adults

TPN

Dextrose is a monohydrate, providing 3.4 kcal/mL. The maximum dextrose infusion rate should be 5 to 7 mg/kg/min.

Blood glucose should be monitored at least daily, optimally QID, and should be <180 to 200 mg/dL; the addition of regular insulin to the TPN solution may be required. If insulin is required, it should be added to the TPN bag at an initial dose of 0.1 U/g dextrose;

Intravenous lipids are generally used to provide 20 to 30 percent of infused calories

Protein is supplied in the form of free amino acids and should be supplied at 1.0 to 1.5 g/kg per day.

Dietary Treatment When the patient’s fluid and

electrolyte balance has stabilized, bowel sounds have returned, and there is less than 2L/day of diarrhea, an elemental diet may be initiated

The goal is to provide patients with approximately 25 to 30 kcal/kg per day and 1.0 to 1.5 g/kg per day of protein.

Adapted from Gastroenterology 2003;124:1111-1134

Dietary treatment

Micronutrients, including water-soluble vitamins(B1, B2, B3, B6, B12, biotin, folate, C) and fat-soluble vitamins (A, D, E, K), and trace elements (Zn, Se) often require supplementation

Water-soluble vitamin deficiency is rare.

Managements for SBS

Nutritional support Fluid & electrolyte replacement Medication for possible complications Trophic and prokinetic therapy

Glucose–polymer-based oral rehydration solutions (ORS)

To decrease dehydration and to decrease TPN fluid requirements in patients with residual jejunum ending in a jejunostomy.

WHO: formulated by dissolving the following in 1 L tap water: NaCl (2.5 g), KCl (1.5 g), Na2CO2 (2.5 g), and glucose (table sugar, 20 g).

optimal Na concentration : at least 90 mmol/L, which is the usual concentration of small bowel effluent.

NTHU: Babyate oral electrolyte maintenance sol.

ORS with residual colon in continuity, ORS may still be of value,

but, provided sufficient Na is present in the diet, the amount of Na in the ORS may not be as critical since the colon readily absorbs Na and water against a steep electrochemical gradient.

For patients with no remaining jejunum, but who have residual ileum, the presence of glucose in the ORS is not critical because ileal water absorption is not affected by the presence of glucose

patients with SBS should be cautioned against consumption of plain water and should be encouraged to drink ORS whenever they are thirsty

Managements for SBS

Nutritional support Fluid & electrolyte replacement Medication for possible complications Trophic and prokinetic therapy

Complications of SBS

Diarrhea Cholerheic diarrhea / Steatorrhea Gastric Hypersecretion Nephrolithiasis D-Lactic acidosis

Diarrhea anti-motility agents, such as loperamide hydrochloride

Octeotide (100 mcg SC, tid, 30 minutes before meals) is req

uired. It should be used only if fluid intravenous requirements are >3 L daily (High output jejunostomy)

-The mechanism of action is unclear, but octreotide may be useful to slow intestinal transit time and increase water and sodium absorption.

-Octreotide reduces splanchnic protein synthesis, thereby reducing mucosal protein incorporation and villus growth rate, and may impair postresectional intestinal adaptation. There is also an increased risk for cholelithiasis in a patient group already predisposed to this problem

Steatorrhea Luminal digestion of lipid may be impaired bec

ause of impaired bile salt reabsorption related to resected ileum (>100 cm).

There is insufficient evidence to recommend the use of bile acid supplements to decrease steatorrhea; and they may worsen diarrhea.

Cholestyramine is not useful in patients with >100 cm of ileal resection, and it may actually worsen steatorrhea because of the binding of bile salts.

Gastric hypersecretion H2 antagonists and proton pump inhibitors Massive small bowel resection is associat

ed with hypergastrinemia during the initial first 6 months after surgery.

High-dose H2 antagonists and proton pump inhibitors reduce gastric fluid secretion, and fluid losses during the first 6 months post-enterectomy.

H2 blocker v.s PPI Effect of intravenous ranitidine and omeprazole on intestinal absorp

tion of water, sodium, and macronutrients in patients with intestinal resection. Gut. 1998 Dec;43(6):763-9.

N=13, small bowel<100cm IV Omeprazole 40mg bid

Ranitidine 150mg bid for 5 days RESULTS: Omeprazole increased median intestinal wet weight absorptio

n compared with no treatment and ranitidine (p<0.03). The effect of ranitidine was not significant.

-Four high responders continued on omeprazole for 12-15 months, but none could be weaned from parenteral nutrition.

CONCLUSION: Omeprazole increased water absorption in patients with, but did not allow parenteral nutrition to be discontinued. Absorption of energy, macronutrients, electrolytes, and divalent cations was not improved.

H2 blocker v.s. PPI Effect of omeprazole on intestinal output in the

short bowel syndrome.Aliment Pharmacol Ther. 1991 Aug;5(4):405-12.

N=11 Oral omeprazole 40mg QD the 7 patients with a net secretory output of flui

d, there was a mean reduction in wet weight of 0.66 kg/24 h (range -0.16 to 1.45 kg/24 h; P less than 0.05)

Renal stones Normally, oxalate in the diet binds to dietary calcium and i

s excreted in the stool. However, in the presence of significant fat malabsorption,

dietary calcium preferentially binds to free fatty acids, rendering the oxalate free to pass into the colon. Dietary oxalate is absorbed to a minimal extent in the small intestine

Once absorbed into the colon, oxalate is renally filtered, where it binds to calcium, resulting in hyperoxaluria and calcium oxalate nephrocalcinosis and nephrolithiasis.

in patients with SBS who have colon in continuity, oxalate should be restricted in the diet.

Oral Ca supplements also may be of value for the prevention of Ca-oxalate nephrolithiasis.

Bacterial overgrowth Resection of the ileocecal valve may allow colo

nic bacteria to populate the small intestine, resulting in bacterial overgrowth.

bacteria compete for nutrients with the enterocytes.

Treatment can be undertaken with oral metronidazole, tetracycline, or other antibiotics.

D-lactic acidosis D-lactic acidosis sometimes occurs in malabsorbed patients

with short-bowel syndrome and is characterized by recurrent episodes of encephalopathy and metabolic acidosis.

The characteristic neurologic abnormalities and the presence of metabolic acidosis raises a diagnostic suspicion, and the

diagnosis : serum level of D-lactic acid is greater than 3 mmol/L.

Standard treatment consists of restricting oral carbohydrates or fasting, correction of metabolic acidosis, and a long-term suppression of pathogenic floras with antibiotics. treatment for D-lactic acidosis.

i.v. bicarbonate, and metronidazole to suppress the overgrowth of colonic lactobacilli responsible for the metabolic crisis.

SICU protocol for SBS Outcome prediction: <100 cm small bowel TPN >100 cm small bowel,

<100 cm small bowel + colon,100~150 cm small bowel + partial colon Partial TPN

>100 cm small bowel + colon TPN generally not required

SICU protocol for SBS

1. TPN 25 to 30 kcal/kg/day (protein 1.0 to 1.5 g/kg/day) for 7~10 days.

(initially, TPN 25mL/hr + maintenance fluid, then increase gradually)

2. IVF with ….Replacement fluid? 3. Babyate oral electrolyte maintenance

sol. 4~6 btl QD whenever thirsty (ORS)

4. Omeprazole (Losec) (PPI for gastric hypersecretion) for 6 months.PO: 40mg bidIV: 40mg bid

5. Loperamide HCL (Imodium) (for diarrhea)PO: 4 mg (2 capsules), followed by 2 mg after each loose stool, up to 16 mg/day (8 capsules), maintenance dose should be slowly titrated downward to minimum required to control symptoms (typically, 4-8 mg/day in divided doses)

6. Octreotide (Sandostatin) (If high output jejunostomies that need fluid intravenous requirements >3 L daily )100 mcg SC, tid, 30 minutes before mealsDiarrhea: I.V.: Initial: 50-100 mcg every 8 hours; increase by 100 mcg/dose at 48-hour intervals; maximum dose: 500 mcg every 8 hours

7. If stestorrhea, cholestyramine Oral (dosages are expressed in terms of anhydrous resin): 4 g 1-2 times/day to a maximum of 16-24 g/day (and a maximum of 6 times/day)

8. For bavterial overgrowthMetronidazole 500mg q6H or q8H, PO or IVTetracycline 250~500mg q6H PO

9. If d-lactic acidosis-correct thiamine deficiency if presents-IV Sodium bicarbonate to correct acidosis-Metronidazole 500mg q6H 0r q8H, PO or IV

10. Oral Ca supplementPO: 800-1200mg/day

11.in patients with SBS who have colon in continuity, oxalate should be restricted in the diet.

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