Review article: Short bowel syndrome: treatment options Published in journal of coloproctology j coloproctol (rio j). 2016;36(4):262–272

1. Journal Club Meeting Aug.2017
Review article:
Short bowel syndrome: treatment options
j coloproctol (rio j). 2 0 1 6;3 6(4):262–272

2. • This review was based on original scientific
articles searched in MEDLINE via PubMed, in
Portuguese, English, and Spanish language,
with a time limit from 1991 to 2015

3. Short Bowel
Syndrome
Occurs when anatomical
length of the remaining
small intestine is
< 200
Intestinal Failure
Loss of absorptive capacity
Intestinal
Fistula
Functional
Definition

4. Etiology
Etiology of SBS
Babies Children Adults
Necrotizing
enterocolitis
Post surgical
complications
Inflammatory bowel
disease
Intestinal congenital
anomalies
Malignancies Mesenteric
ischemia
Trauma malignancies
Post surgical
complications

5. Patho-physiology
Mal-absorption
Loss of
 Fluid
 Electrolytes
Mal-nutrition
Loss of
 Macronutrients
•CHO
•Lipids
•Proteins (less)
Macronutrients
•Fat soluble vitamins
•Water soluble vitamins (less)
•Trace elements

6. Patho-physiology
Loss of intestinal absorption surface is the only factor
affect the manifestation of SBS ?
No
Loss of specific
sites
Colon
•More fluid loss
•Loss of its bacteria to
digest CHO into SCFAs
Ileum
•Loss of bile salts
Loss of intestinal
hormones
Loss of ileo-cecal
valve
•Loss of “ ileal brake”
(↓ peptide YY)
•Increased intestinal
transit
•↓CCK
•↓Pancreatic enzymes
•Faster gastric empty
•↑Gastrin

7. Patho-physiology

8. Adaptation
This phenomenon takes place in a period of about 2 years, and is
divided into three phases: acute, adaptive, and maintenance phases
Acute
Phase
4 wks
Adaptive
phase
1-2
yrs
Maintenance
phase
˃ 2
yrs
Structural changes
•↑ wall thickness & diameter.
•hypertrophy of villi.
•mucosal cells.
•local angiogenesis.
Motility changes
•Reduced
•Jejunum˃ileum
Functional changes
•↑in carrier proteins.
•↑ in the levels of PYY.
•↑ of the enzyme activity.

9. Treatment
In the postoperative period begin with PN (at least in the first 7–10 days) as a
until there is hemodynamic stabilization with a switch when-ever is possible, to
enteral nutrition (EN) and later to an oral diet
Nutritional treatment
The established diet should be rich in complex CH, essential fatty acids (FA), and
long-chain triglycerides (TG). Protein should correspond to 20% of the diet
N.B
SBS + presence of colon (jejuno-colic) → diet rich in CHs and poor in lipid
(Medium chain TGs is preferred)
SBS+ ileostomy → diet 30-40% Lipid (and avoid MCTGs)
①

10. Parenteral Nutrition
Treatment
PN should provide about 20–35 kcal/kg/day and should consist of:
lipids (20–40%, up to 1 g/kg/day).
CHs (in the form of glucose (2.5–6 g/kg/day to 7 g/kg/day).
protein (1.5 g/kg/day).
Home Parenteral Nutrition :
Is indicated in situations where patients require prolonged PN, but without
requiring hospitalization.
Patients should be clinically stable and have secured a suitable hospital or
specialized center support,

11. Enteral Nutrition
Treatment
Continuous tube feeding
either alone or in combination with oral feeding, increases the absorption of
macronutrients at intestinal level versus oral feeding.
This happens because the continuous administration of nutrients results in
persistent luminal stimulation.
must be started gradually, once the hemodynamic stability is obtained,
diarrhea <2 L/day, and with the intestinal activity restored.
Nutritional Supplements
Ca, Mg, Iron, Zinc
Vitamins A,D,E,K + B12 , C

12. Treatment
Pharmacological treatment②
Diarrhea
Loperamide (Imodium) ©
Gatric hypersecrtion
Proton pump inhibitors
Antibiotics
to control bacterial growth
Probiotics & prebiotics
increase intestinal adaptation, reduced
bacterial translocation, and restored the
intestinal bacterial flora
Somatotropin, the
recombinant form of GH
Teduglutide, the
recombinant human
analog of GLP-2
↓
Have intestino-trophic
effect

13. Surgical treatment③
Treatment
↑ length/surface
area of absorption
1. Longitudinal Intestinal
Lengthening and
Tailoring (LILT)
technique
2. serial transverse
enteroplasty (STEP)
Prolong intestinal
transit time
1. Reversal of segments of
the small intestine
(RSSI)
2. Colon interposition
3. Valves and sphincters
Intestinal
transplant
In cases where the medical treatment is not
effective