SHORT BOWEL SYNDROME

Case Presentation By : Thomas Philip

MATERNAL DATA25 yrs old lady G3 P0 A2, 30 weeks admitted in labour room with uterine contractions.

Type of Delivery- LSCS

BABY DATA30 Weeks baby of X

-Apgar 5,7 and 8

-Gasped not cried , Intubated and shifted to 307

Birth Weight - 1.620 kg

After starting feed baby had abdominal distension, kept NPO and X-ray taken it was perforated NEC .Surgery done. Exploratory laporotomy with resection of small bowel with ileostomy done uneder GA. After surgery feed restarted but not tolerating. Diagnosed as SBS

WHAT IS SHORT BOWEL SYNDROME? Short bowel syndrome is a condition in which the body cannot absorb enough fluids and nutrients because part of the small intestine is missing (usually due to prior surgery or illness), or is not working properly.

NORMAL BOWEL ANATOMY

What does the small intestine do?The small intestine is a part of the digestive system. The small intestine has three sections:

The duodenum, which is located next to the stomach (shortest section)The jejunum, which lies between the duodenum and the ileumThe ileum, which is the longest section and connects to the large intestine (colon)(The ileocecal valve forms a barrier between the ileum and the large intestine to prevent the contents of the large intestine from flowing back into the small intestine.)

The small intestine is where the absorption of fluids, proteins, carbohydrates (starches and sugars), iron, fats, vitamins, and minerals (such as calcium, sodium, and potassium) takes place. If the duodenum and a portion of the jejunum have been removed by surgery, the ileum can take on their role in absorbing nutrients. But if a substantial part of the jejunum or the ileum is removed, it is more difficult to obtain adequate nutrition. In these cases, nutrients usually have to be provided in a form other than food.Children need more calories than adults because they are still growing. If a child is born with portions of the small intestine missing, it can lead to serious problems.

What causes short bowel syndrome?

Short bowel syndrome can occur as a congenital (present at birth) condition. For example, the small intestine might be abnormally short at birth, a section of the bowel might be missing, or the bowel does not form completely before birth (intestinal atresia).

In other cases, patients develop conditions in which a large section of the small intestine has to be removed by surgery. In newborns, especially premature infants, necrotizing enterocolitis (the inflammation and loss of blood flow to the intestine, leading to severe damage) is the most common cause of short bowel syndrome.

Other causes include:Crohn's disease (the intestine becomes inflamed and scarred); in this condition SBS occurs primarily in patients who have undergone extensive surgery to the small bowelIntussusception (part of the intestine is folded into another part and compromises the blood flow to the involved portion of the intestine)

Injury to the intestine due to:

volvulus (twisting of the intestine) trauma (injury)gastroschisis (when the intestines develop outside the body prior

to birth)narrowing or obstruction of the intestines tumorsblood clots or abnormal blood flow (ischemia) affecting the

circulation to the intestine.

What are the symptoms of short bowel syndrome?Symptoms of short bowel syndrome include:Diarrhea. Watery diarrhea is the most common symptom of short bowel syndrome in infants and children.BloatingExcessive gas /or foul-smelling stoolPoor appetiteWeight loss or inability to gain weightFatigueVomiting

Other complications can occur as a result of short bowel syndrome, including:

DehydrationVitamin, mineral, and electrolyte shortage or imbalanceMalnutritionSevere diaper rash caused by frequent diarrheaAbnormal eating habitsKidney stones or gallstones caused by abnormal calcium or bile absorptionBacterial overgrowth (high levels of bacteria in the intestine).

Surgical options can be explored in certain situations in SBS.

In some cases surgery can be done to improve the functional length of intestine by various procedures such as Intestinal transplantation involves placing a donor small intestine into the patient. 

What is the prognosis (outlook) for patients who have short bowel syndrome?The prognosis for infants and children who have short bowel syndrome can be good, depending on the residual length of the intestine. However, they will need lifelong follow-up care.

MEDICAL CARETPNEXCESSIVE FLUID LOSSES – Need adequate fluid and electrolyte replacementMALABSORPTION- Extensive jejunal resection leads to carbohydrate malabsorptoin. The undigested food produce an osmotic diarrhea. Extensive resection of the ileum may lead to severe malabsorption of bile salt and vitamin B12 . bile salt malabsorption produces a choleretic diarrhea.

MOTILITY DISTURBANCESGASTRIC ACID HYPERSECRETION

SURGICAL CARE- Mainly related to venous acces like central line insertion.Surgery may be required for gastrostomy tube placement to provide for enteral access

DIETEnteral therapy- in infants with massive small bowel resection , enteral nutrition is initiated very quickly by using elemental formulas. Srarting with formulas that are either one fourth or one half strength, depending on the patients tolerability. MCTs are important in the dietary management of patients with SBS because they are readily absorbed in the stomach and proximal small bowel. The advancement of enteral feeds is based on the patients tolerance.

PARENTERAL THERAPYProvide parenteral nutrition to patients with massive intestinal resections as soon as possible. The clinical factors that are associated with prolonged( >2 y ) parenteral nutritional requirement include the following.

Residual bowelLimited absorptive functionBowel adaptationDysmotilityBowel length (<40cm)Absent ileocecal valveColon resetionBacterial overgrowth(Leads to vitamin B12 deficiency and lactic

acidosis)

SPECIFIC NUTRIENT REQUIREMENTMultivitamin and minerals are preferentially administred parenterally in patients with extensive small bowel resections.The successful nutritional management of patients with short bowel syndrome has increased long term survival rates.

MEDICATIONAtibiotics- to prevent small bowel bacterial overgrowthMetronidazole- used to prevent intestinal small bowel bacterial over growthGentamycin- aminogycoside antibiotic for gram negative coverageRanitidine-reduces gastic acid secretion, gastric volume and hydrogen concentration.Omepraszole- decreses gastric acid sectionsPhenobarbital- improves bile acid independent flowCholestyramine- effective in reducing the choleretic diarrhea in patients with SBSLoperamide- actes on intestinal muscles to inhibit peristalsis and slow intestinal motility. That increases the loss fluid and electrolytes.Fat soluble vitamins-vitamin A,D,E,K,(ADEK PAEDIARIC DROPS)

NURSING CARE

Treat the baby as infected case to prevent infection.Position comfortablyRecord v/sMaintain I/O chartSpecially to observe for dehydrationCare of ET tube and proper suctionCare of surgery site (wound care)Assess the pain related to surgeryOffer reassurance and encouragement to parents

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