Small bowel syndrome

1. NOVIANI
SHORT BOWEL SYNDROME

2. Pendahuluan
 SBS
 small bowel resection
 uptake of nutrient/fluids
insufficient
 Wide variation
 SBS (+)  intestinal failure (+)
Intestinal failure (+)  SBS (+/-)

3. Aetiology SBS
 Mesenteric vascular occlusion
 Resected Crohn’s disease
 Complications of abdominal surgical
prosedures
 Malignancy
 Major abdominal trauma, volvulus,
strangulation of the bowel, radiation
enteritis, sclerosing peritonitis, multiple
bowel fistula
 Children  gastroschisis, necrotizing
enterocolitis, intestinal atresia

4.  Small intestine :300–1000 cm (mean 635 cm)
 The colon : 160 cm
 The bowel is equipped with a large functional
reserve
 Patients can usually compensate for resections
of ≤50% of bowel length
 Bowel resections of >75%
 dietary modification
 Severe cases
 partial or complete support with PN/IV fluids
 Resections of the proximal bowel
 duodenum & proximal jejunum
 better tolerated because of ileal
compensation and adaptation

5.  Colon may ↑ its uptake of water to 5L/ 24 hr
 extensive jejunal resection may result
moderate diarrhoea
 Total resection ileum
 greater malabsorption & diarrhoea
 ↑ vol fluid entering the colon
 excess bile salts & unabsorbed fats  colon
 bile salts diarrhoea & steatorrhoea
 Preservation of the colon  bacterial digestion
& fermentation of soluble fiber & unabsorbed
CHO  SCFA (5% total energy)
 SCFA (butyrate)  fuel for colonocytes

6. Clinically SBS:
 Diarrhoea
 Steatorrhoea
 Weight loss
 Dehydration
 Malnutrition
 Malabsorption
 Hypoalbuminemia
 Metabolic acidosis

7. SEVERITY SBS
 The extend & site resection
 Ileo-caecal valve +/-
 The function & health remaining GIT
 The activity & course underlying disease
 The process of adaptation remaining
intestine
 The age of the patient
 +/- colon in continuity with the small bowel

8.  The importance of ileo-caecal valve :
- slows intestinal transit
- prevent bacterial colonisation
 ↑ absorption of fluids & electrolytes
 ↑ absorption of the remaining small bowel

10.  Digestion & absorption
macronutrients 
duodenum – the first
120-150 cm of normal
jejunum
 80% fluid (6-8 L)
absorbed in the
jejunum & ileum
 Terminal ileum  abs
vit B12 & bile salts
 1,5 L fluid enters the
colon  all except 150
ml is absorbed

12.  Tappenden K. Pathophysiology of Short Bowel Syndrome: Considerations of
Resected and ResidualAnatomy. JPEN J Parenter Enteral Nutr. 2014.

13.  Tappenden K. Pathophysiology of Short Bowel Syndrome: Considerations of
Resected and Residual Anatomy. JPEN J Parenter Enteral Nutr. 2014.

14. Complications of SBS
1. Gastric acid hypersecretion
Normally jejunum secretion  gastric
inhibitory polypeptide, vasoactive intestinal
polypeptide (inhibitory hormones)
 jejunum resection  gastrin level rise 
gastric hypersecretion
 diarrhoea, impair absorption
 proton pump inhibitor iv
 adaptive phase : 3-6 months post
operation/longer

15. 2. D-lactic acidosis
Th/ : CHO restriction & non-absorbable AB
(elimination of colonic bacteria)
3. Nephrolithiasis & oxalate nephropathy
 Intake Ca ↑, oxalate ↓
4. Cholelithiasis
5. Liver function disorders

17. Diet for SBS based on
remnant anatomy

18. Oral Rehydration Solutions
(ORS)
–1 Liter ofWater
–4 tablespoons of sugar
–¾teaspoon of salt
–Sugar free artificial sweetner
–Optional:
•1 tspnbaking powder (1/2 tspnbaking
soda)
•½tspnof 20% potassium chloride

19. PN and IV Fluid in SBS
 20–35 kcal/kg/day
 CHO dan lipids  1 g/kg/day
 Carbohydrates :
- dextrose
- 100-120 gr/day
 Lipid :
- 20-40% of total calories
-To prevent EFA deficiency
 1%–2% of total calories ω-6
 0.5% of total calories ω-3

20.  Protein :
- 186 mg/kg/d : essential amino acids
- 1-1,5 gr/kg/day
- 25%–30% of total protein intake
 Fluid :
- end-jejunostomy  high stomal outputs
 fluid needs to > 3 L/d
- For patients receiving nocturnal PN
 additional IV fluids
 as normal saline during the day
 prevent intermittent dehydration and
injury to the kidney.

21. EN in SBS
 Oral diet & tube feeding
 As soon as feasible after resection to promote
intestinal adaptation
 Indication :
 Diarrhea is limited to <2 L/d
 Hydration & electrolytes are stable
 Bowel activity has resumed
 continuous tube feeding, alone or in
combination with oral feeding
 ↑intestinal macronutrient absorption
compared with oral feeding alone in the
postoperative period.

22.  Polymeric diets  more commonly
administered to patients with SBS unless
severe malabsorption is present
 Caloric intake
 increased by at least 50% over a typical
diet  compensate for malabsorption
associated with SBS
 rich in complex carbohydrates

23. SBS and Colon in Continuity
 Low in oxalates and high in calcium to lower the
probability of nephrolithiasis
 Soluble fiber (eg, pectin)
 solidify stool, increase colonic transit time, and as
a substrate for colonic fermentation into SCFAs
 Insoluble fibers such as wheat bran
 decrease gastrointestinal transit time
 less benefit diets
 >3 L/d diarrhea
 very high in either type of fiber  restricted
 fiber has the potential to impede fat and mineral
absorption

24. SBS & Jejunostomy/Ileostomy
 40%–50% total calories  from complex
CHO
 higher fat diet  (30%–40% of calories) than
patients with a colon in continuity
 MCT  ↓ carbohydrate and protein
absorption  avoided
 Soluble fiber (dietary or supplements)
 to thicken ostomy effluent

25. Nutrition Supplements
 Magnesium and zinc
 depleted with diarrhea or excessive ostomy
output
 Calcium citrate > calcium carbonate
 Poor absorption of fat-soluble vitamins (eg,
vitamins A, D, and E)
 need to be supplemented
 Large ileal resections
 vitamin B12 supplementation
 1000-μg monthly injection

26. Vitamin & Mineral

27. PN / IV Fluid Weaning
 Successful PN/IV weaning 
- greater length of remaining bowel
- presence of a colon in continuity
- higher fasting plasma citrulline levels
 Two methods for weaning :
 the number of PN/IV days is slowly
decreased
 the volume of PN/IV delivered during each
session is reduced.

28.  Nutrition & fluid intake must be optimized
before initiating the weaning program 
- obtain 80% of daily energy requirements
through oral nutrition while maintaining
body weight
- electrolyte levels must be stable
- urine production >1 L/d and ≥0.5 mL/kg/h
on PN/IV-free nights
- enteral balance (oral fluid intake minus stool
output) between 500 and 1000 mL/d

29. Monitoring
 Blood levels of electrolytes and minerals
 assessed weekly
 Vitamin and trace element status
 evaluated every 1–3 months during the
weaning process

30. TERIMA KASIH