SHORT BOWEL SYNDROME

DR.BARUN KUMARUNIT IIA, GENERAL SURGERY

IPGMER

INTRODUCTION:

A TYPE OF INTESTINAL FAILURE WHICH RESULTS FROM EITHER • SURGICAL RESECTION (USUALLY OCCUR WHEN TOTAL

BOWEL LENGTH IN SITU <200CM)• CONGENITAL DEFECTS • DISEASE ASSOCIATED LOSS OF ABSORPTION

CHARACTERIZED BY INABILITY TO MAINTAIN PROTEIN-ENERGY, FLUID, ELECTROLYTE, OR MICRONUTRIENT BALANCE WHEN ON A NORMAL DIET

Causes of Short Bowel SyndromeAdults :

– Postoperative– Irradiation– Cancer– Mesentric vascular

disease– Crohn disease– Trauma– Desmoid tumours

Childrens :– Gastroschisis – Necrotizing

enterocolitis – Midgut volvulus– Intestinal atresia

Pathophysiologic Consequences of Massive Resection

GENERAL• Malnutrition and weight loss• Diarrhea and steatorrhea• Vitamin and mineral

deficiencies• Fluid and electrolyte

abnormalities

SPECIFIC• Gastric hypersecretion• Cholelithiasis• Liver disease• Nephrolithiasis

Pathophysiology

Consequences of site specific resection

A. JEJUNAL RESECTION:• LOSS OF DIGESTIVE ENZYMES- INITIAL AND

TEMPORARY REDUCTION IN NUTRIENT ABSORPTION• LOSS OF PHYSIOLOGICAL GASTROINTESTINAL FEEDBACK

MECHANISM- RAPID GASTRIC EMPTYING

B.Duodenal resection• PROTEIN , CHO, FAT MALDIGESTION• CA, MG, IRON, FOLATE MALABSORPTION • FAT SOLUBLE VIT DEFICIENCY

.

C.ILEAL RESECTION• REABSORPTION OF SECRETED FLUID BY SMALL

INTESTINE LOST- NET SECRETORY RESPONSE• LOSS OF B12 ABSORPTION• LOSS OF ENTEROHEPATIC CIRCULATION- BILE

SALT DEFICIENCY AND FAT MALABSORPTION• LOSS OF ILEAL-COLONIC BRAKE (PEPTIDE YY,

GLP-1, NEUROTENSIN)

.

D.LOSS OF ILEOCECAL VALVE:SMALL INTESTINAL DILATTATION AND SLOWER MOTILITY LEADING TO BACTERIAL OVERGROWTHBACTERIAL OVERGROWTRH IN TURN LEADS TO MANY COMPLICATIONS SUCH AS:Competition of nutrients, bacterial translocation, endotoxemia, liver injury, D-lactic acidosis

.E. LOSS OF COLON• COLON IN CONTINUITY IS IMPORTANT AFTER A

MASSIVE SMALL BOWEL RESECTION AS COLON ADAPTS FOR THE ABSORPTIVE FUNCTIONS OF SMALL INTESTINE

• FERMENTATION OF MALABSORBED CARBOHYDRATES TO SHORT CHAIN FATTY ACIDS BY COLONIC FLORA

PROGNOSIS• LENGTH OF BOWEL REMAINING• PRESENCE OF COLON• INTACT ILEOCECAL VALVE• INTACT DUODENUM• COMORBODITIES AND UNDERLYING CAUSE

(CROHNS DISEASE, RADIATION ENTERITIS, PSEUDO-OBSTRUCTION)

ROLE OF CITRULLINE: <20uMOL/L indicative of permanent intestinal failure

Phases Of SBS

• Acute Phase Immediately after bowel resection and lasts for 1-3 months Ostomy output greater than 5 liters per day Life threatning dehydration and electrolyte imbalances Extremely poor absorption of all nutrients Development of hypergastrenemia and hyperbilirubinemia

Adaptation phase

Begins 12 – 24 hours after resection and last up to 1-2 years 90% adaptation occurs during this phase Enterocyte, villus hyperplasia and increased crypt depth

ocurrs resulting in increased absorptive area Luminal nutrition is essential for adaptation and should be

initiated as early as possible Parenteral nutrition is essential through out this period

Maintenance phase

Absorptive capacity is maximum during this phase Nutritional metabolic homeostasis can be achieved with

oral feeding

COMPLICATIONS OF SHORT BOWEL SYNDROME

EARLY:• DEHYDRATION• ELECTROLYTE

IMBALANCE- slow replacement

• Hypergastrinemia

LATE:A)METABOLIC COMPLICATIONS-• Micronutrient deficiency• B12, EFA deficiency• Bacterial overgrowth• High oxalate levels

B)TPN RELATED PROBLEMS:• liver dysfunction• Catheter related problems

MANAGEMENT

A.EARLY GOALS:• Begin TPN within 24 hrs• TPN requirements generally persists for the

next 7-10 days• Measurement and replacement of fluid and

electrolyte losses every 2 hrs• Monitoring of blood glucose levels

B.ENTERAL NUTRITION• Started after initial stabilization of patient• TRICKLE FEEEDING: continuous feeding stimulates adaptation

process• Initial feeding should be 5% of the patients total calorie

requiremnt• This is gradually increased every 3 to 7 days and weaning of TPN

done simultaneously• Consider elemental diet if there is an underlying inflammatory

process• Soluble fibers to slow down intestinal transit time if colon is intact• Successful weaning indicated by amount of enteral fluid loss

which reflects the degree of carbohydrate malabsorption

Diet and Fluid SuggestionCOLON PRESENT COLON ABSENT

Carbohydrate 50%-60% of caloric intakeComplex carbohydrate

40%-50%

Fat 20%-30% caloric intake 30%-40%

Ensure adequate essential fats MCT/LCT

LCT

Protein 20%-30% caloric intakeHigh biologic values

same

Fiber Soluble soluble

Fluids ORS and/or hypotonic ORS

Oxalate Restrict _______

C.ORS• To decrease dehydration and to decrease TPN fluid requirements in

patients with residual jejunum ending in a jejunostomy

• Optimal Na concentration : at least 90 mmol/L, which is usual concentration of small bowel effluent, adding glucose promote further active salt absorption

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

D. PHARACOLOGICAL ADJUNCTS

• ANTIMOTILITY AGENTS: loperamide, diphenoxlate, clonindine, codeine

• OCTREOTIDE : inhibits pancreatic secretion and decreases intestinal transit time. Should be only considered if >3litres of iv fluids required

• CHOLESTYRAMINE for bile acid malsbsorption• GLUTAMINE : helps in adaptation process

SURGICAL TREATMENT :

INTESTINAL TRANSPLANT

SURGICAL TREATMENT OPTIONS

NONTRANSPLANTOPTIONS

TO SLOW INTESTINAL TRANSIT

TO INCREASE INTESTINAL AREA

NONTRANSPLANT OPTIONS

A. TO SLOW INTESTINAL TRANSIT TIME

1.SEGMENTAL REVERSAL OF SMALL BOWEL:• approx 10cms can be reversed as longer length tends

to obstruct• The reversed segment placed distally2.Interposition of colon in antiperistaltic or isoperistaltic direction (8-24cms of colon can be used)3.Intestinal valves4.Retrogade Electrical pacing

,

B. TO INCREASE INTESTINAL AREA

1.LONGITUDINAL INTESTINAL LENGTHENING AND TAILORING (LILT)• Used mainly in children (dilated residual intestine

with dysmotility and bacterial overgrowth)• Intestine and its mesentric arterial blood supply

is divided longitudinally along its mesentric border, creating a double lumen which is reanastomosed.

• Increases the function but not the surface area

LONGITUDINAL INTESTINAL LENGTHENING AND TAILORING (LILT) contd.

Contraindications: • Intestinal diameter <3cm• Residual intestinal length <40cm• Length of dilated bowel <20cm• Hepatic failure

2.SERIAL TRANSVERSE ENTEROPLASTY

• Series of transverse anastomosis to increase intestinal area

• One large tube is converted into a narrower zigzag

• Alters area to volume ratio

SERIAL TRANSVERSE ENTEROPLASTY contd.

B.INTESTINAL TRANSPLANT

CONSIDERED IN PATIENTS WITH• life threatening complications of intestinal failure• those destined for lifelong TPN• where native intestine must be removed (tumor)• Overt liver failure due to TPN• Thrombosis of 2 or more central veins• 2 or more episodes catheter related sepsis in a year• Single ep of line related fungemia, septic shock, ards

B.INTESTINAL TRANSPLANT contd.

• Entire length of small intestine is usually anastomosed side to side with ileostomy

• Can be combined with liver transplant• Enteral feeding can be started after

establishment of postoperative intestinal motility but supplemental iv fluids can be required upto 1 year

complications

technical• Anastomosis leak• Perforation• Hepatic artery thrombosis• Infectious comlications

Transplant rejections• Acute• chronic

Thank you