drdr_anu@yahoo.com

1. SHORT BOWEL
SYNDROME
(SBS)
Dr dharma ram poonia

3. The gastrointestinal tract processes
8000-9000 mL of fluid per day, with
the vast majority of this derived from
endogenous secretions.
Fluid reabsorption by the healthy GI is efficient (98%), and only
100-200 mL are lost in fecal matter each day.
The great majority (80%) of this reabsorption occurs in the small
intestine.

4. The jejunum has taller villi,
deeper crypts, and greater
enzyme activity compared to the
ileum.

5. ABSORPTION OF NUTRIENTS THROUGH THE GI

7. SBS is a form of intestinal failure and is clinically defined by
malabsorption, diarrhea, steatorrhea, fluid and electrolyte
disturbances, and malnutrition.
SBS
A. ANATOMICAL B. FUNCTIONAL

8. A. ANATOMICAL SBS
Several different processes -- congenital and acquired:
1. Congenital intestinal atresia .
2. Massive enterectomy:
ð necrotizing enterocolitis,
ð extensive aganglionosis in infants
ð catastrophic vascular events
(mesenteric V or A thrombosis),
ð trauma,
ð midgut volvulus or
ð tumor resection.

9. A. ANATOMICAL SBS (CONT.)
ð < 115 cm of residual SI in the absence of colon
in continuity, or
ð < 60 cm of residual SI with colon in continuity.
ð For less confusion, a length which is less than 30% of the normal length
for age ( less than 200 cm for adults ) is the generally accepted definition
of SBS
However, SBS may be better defined by fecal energy loss than by
residual bowel length.

10. B. FUNCTIONAL SBS
ð Chronic intestinal obstructions
ð Chronic intestinal pseudoobstruction
ð Refractory sprue
ð Radiation enteritis
ð Congenital villus atrophy

11. Extent/ location of resection.
Presence or absence of colon
Presence /Absence of ICV.
Degree of adaptation in remaining bowel.
Extent of residual bowel disease or complications e.g.
adhesions, strictures

13. The prevalence is approximately 4 per year per million.
These figures reflect that with appropriate management,
many patients with SBS can be successfully weaned from
TPN with conventional techniques.

15. DEPEND ON RESECTED SEGMENT
JEJUNUM
BUT unfortunately, enzymatic digestion
suffers because of the irreplaceable loss of
enteric hormones produced by the jejunum.
ALSO, gastrin levels rise, causing gastric
hypersecretion. The high acid output from
the stomach injure the SI mucosa.
Additionally, the low intraluminal pH creates unfavorable conditions for
optimal activity of pancreatic enzymes.

16. ILEUM
Ileal resection severely decreases the
capacity to absorb water and electrolytes.
Continued loss of bile salts leads to fat
malabsorption, steatorrhea, and loss of fat-
soluble vitamins.
Peptide YY, released from L cells in the distal ileum and colon, slows
gastric emptying and intestinal transit. In the event of distal ileal and
colonic resection, this feedback inhibition is lost.

17. ILEOCECAL VALVE
Retention of the ileocecal valve plays a pivotal
role in massive small bowel resection.
If the ileocecal valve is lost, transit
time is faster, and loss of fluid and
nutrients is greater.
Furthermore, colonic bacteria can colonize the small bowel, worsening
diarrhea and nutrient loss.

18. COLON
Resident bacteria capacity to
Increasing colonic water
metabolize undigested CHO into
absorption as much as 5
POSITIVE SCFA. These are a preferred fuel
times its normal capacity.
source for the coloncytes & body.
Increasing the incidence
Small intestinal
NEGATIVE of urinary calcium
bacterial overgrowth.
oxalate stone formation.

20. Diarrhea (with or without steatorrhea) is an almost constant
clinical finding.
Significant weight loss, fatigue, malaise, and lethargy.
Dehydration, electrolyte imbalance, protein-calorie
malnutrition, and loss of critical vitamins and minerals

22. The intestine goes through a
complex series of adaptive
changes after the loss of a portion
of the gastrointestinal tract.

23. Changes associated with adaptation
Morphological Functional
Macroscopic
 Dilatation
 Thickening
 Increase in length
Microscopic Absorption
 Villus: increase height &  CHO & Ptn : increase
diameter absorption per unit length
 Crypt: elongation  Electrolytes: upregulation of
 Epithelial cell life cycle: increase sodium-glucose transporter
proliferation; decrease apoptosis
Protein content
 Increase RNA content
 Increase DNA content

24. This process is generally thought to occur over 1-2 years in humans,
although there are isolated reports of patients being weaned from TPN
after 5-7 years.
Oral food intake and, to a lesser extent, intragastric and intrajejunal
feeding are important stimulants to intestinal hypertrophy as with no
luminal nutrition there is significant mucosal hypoplasia.

25. Factor Experimental Human
Growth hormone Increase bowel length and function per unit Low dose beneficial in the short term
length
Effects are probably mediated via insulin-
like growth factors
 Insulin-like growth factors
IGFI Increase crypt cell and smooth muscle No human trials
proliferation
Associated increases in binding protein,
IGFBP5 also stimulate proliferation.
 Epidermal growth factors
Increase enterocyte proliferation and No human trials
decrease apoptosis.
 Glucagon-like peptides
GLP2 Increase in crypt cell proliferation. Effects Improves absorption of carbohydrate, and increases body weight
may be mediate by enteric nervous system compared with placebo, in patients with no colon.
Other factors
 HGF Increase in DNA content, mass and No human trials
function of resected intestine
 KGF Increase epithelial cell proliferation, No human trials
decrease apoptosis
 Neurotensin Increase villus height—may act via pro- No human trials
glucagon derived peptides
 Leptin Increase carbohydrate absorption No human trials
 Interleukin 11 Increase epithelial proliferation No human trials
Increase absorption at high doses

27. 2. DIARRHEA
3. LACTIC ACIDOSIS
4. HEPATOBILIARY COMPLICATIONS
5. METABOLIC BONE DISEASE
6. RENAL CALCULI
7. INFECTIONS

28. Fluid & electrolyte imbalance
steatorrhea
.Wt loss and malnutrition
Minerals def: Ca, Mg, Iron, zinc, B12, fat soluble vit.
Malabsorption of CHO & protein
Gastric acid hyper secretion
Complications related to TPN

29. As a result of poor motility and dilated bowel.
It impairs absorption and augment diarrhea.
The 13C-xylose breath test is used for diagnosis of overgrowth.
Antibiotic treatment is useful.
2. DIARRHEA
Due to many factors as hyperosmolar load, malabsorption of
carbohydrates, bacterial overgrowth, gastric hypersecretion and bile
acid stimulation of colonic enterocytes.
Trials of cholestyramine, cycling of oral antibiotics, alterations in
nutritional support, and H-2 blocking agents should be considered in
such patients.

30. 3. LACTIC ACIDOSIS
May result from a combination of factors :
☼ Carbohydrate malabsorption with increased delivery of nutrients to
the colon
☼ High carbohydrate intake
☼ Colonic flora of the type to produce d-lactic acid
☼ Altered colonic motility allowing time for the nutrients to undergo
fermentation, and
☼ Impaired d-lactate metabolism.
4. HEPATOBILIARY COMPLICATIONS
Include cholestasis, steatosis, and cholelithiasis. Cholestasis is the most
common and the major predictor of death.
Multiple factors may predispose to them:
Prematurity or overfeeding in infants,
 PN dependence,
 Absence of enteral stimulation for gall bladder contraction,
 SBS, and recurrent sepsis .

31. 5. METABOLIC BONE DISEASE:
Prolonged use of TPN does not allow for a sufficient amount of calcium
and phosphorus to be adequately ingested
Additionally, associated cholestasis may prevent the body from making
adequate amounts of Vitamin D.
All of this may lead to poorly mineralized bones.
6. RENAL CALCULI:
Loss of fluids with the development of a relative dehydrated state.
With bone resorption, excess calciuria develops.
Patients with ileal resection, unabsorbed fatty acids in the intestinal
lumen will bind up calcium, and leave oxalate to be absorbed, with the
potential for deposition into the kidney.

33. 7. INFECTIONS:
Sepsis is a common complication of centrally infused PN with fever and
sudden glucose intolerance are suggestive of its develpoment.
Catheter-related infections remain the main cause of sepsis in patients
receiving PN.
The most important factors in reducing the incidence of septic
complications are placement of catheters under strict aseptic conditions
and meticulous care of the catheter sites.

36. II. PHARMACOLOGIC
ENHANCEMENT OF BOWEL
ADAPTATION
III. SURGICAL MANAGEMENT

37. I. MEDICAL MANAGEMENT
OF SBS
1. Fluid and Electrolyte Management
2. Macronutrients and Dietary Therapy
3. Micronutrient and Trace Metal Supplementation
4. Drugs

38. Maintain hydration
Replete electrolytes
Replete nutrient deficiencies
Maximize the utilization of existing gut
Promote bowel adaptation
Preserve quality of life

39. 1. Fluid and Electrolyte Management
Fluid and electrolyte management is the most critical part of medical
management.
Patients may often be weaned successfully from TPN, yet still require
fluid and electrolyte support.
Fluid and electrolytes could be given parentraly or as ORS.
The least costly option for ORS is to formulate the solution recommended
by the WHO at home.
The patient is instructed to mix:
 2.5 g of NaCl (table salt), In 1 L of
 20 g of glucose (table sugar), tap water
 1.5 g of KCl (requires prescription), and
 2.5 g of Na2CO2

40. The use of solutions with less sodium may result in increased sodium loss.
Therefore, patients should be strongly encouraged to avoid "plain" water
consumption when thirsty and to substitute ORS.
TWO REMARKS
The need for ORS is not as critical for patients with
COLON colon in continuity because the colon readily
in continuity absorbs sodium, even against a strong
electrochemical gradient.
Because ileal water absorption is unaffected by
JEJUNUM
glucose, the glucose concentration of the ORS in
resection
patients with resected jejunum is less important.

41. 2. Macronutrients and Dietary Therapy
Most patients will require TPN for the first 7-10 days following massive
enterectomy.
Enteral nutrition with polymeric formulas should be introduced
gradually because the ultimate goal is to enhance intestinal adaptation
and render patients free of TPN.

42. HOME PN
Unfortunately, some patients are
extremely difficult or impossible to
wean from parenteral nutritionand
and maintained on “home PN or
HPN”
HOME
PN
Common characteristics of these patients:
 Very short remaining small bowel segments (<60 cm),
 Loss of the colon,
 Loss of the ileocecal valve, or
 Small bowel strictures with stasis and bacterial overgrowth.

43. HOME PN
Patients should have their PN cycled to infuse over 10-12 hours during
the overnight period.
This strategy permits the patient to be ambulatory, allows the patient
to work, and improves overall quality of life.
Small ambulatory pumps that easily fit into a backpack along with the
PN solution are available for ambulatory infusion and travel.
PN should be infused via a single lumen catheter that is used only for
PN to reduce the risk of catheter-related infection.

44. 3. Micronutrient and Trace Metal supplementation
Patients with SBS will have decreased fat-soluble vitamin absorption
and will require relatively large doses of replacement therapy
Vitamin K deficiency may occur in patients with colectomy because
colonic bacteria synthesize 60% of daily vitamin K requirements
Water-soluble vitamin deficiency is uncommon.
Trace metals, such as zinc and selenium, are lost in fecal effluent; thus,
deficiencies may develop.

45. OF NO VALUE IN SBS
A. Oral Elemental or free amino acid-based formulas: There is
limited, if any benefit, from the use of them and animal
investigations have suggested that use may be associated with ileal
atrophy.
B. Glutamine: No role for supplementation in the enhancement of
intestinal adaptation and improvement of fluid and/or nutrient
absorption.

46. 4. Drugs
☼ H2 antagonists or oral PPI
During the initial 6 months after massive
enterectomy, gastric hypersecretion develops.
High-dose IV H2 antagonists or oral PPI
should be prescribed during this period.
☼ Antimotility agents
Fluid losses can be controlled with antimotility agents as loperamide,
codeine or octreotide
However, octreotide use should be discouraged because studies have
suggested that octreotide inhibits intestinal adaptation and increases the
risk for cholelithiasis.

47. Medication malabsorption could
occur, therefore, increased doses of
orally administered medication is
required.

48. II. PHARMACOLOGIC
ENHANCEMENT OF BOWEL
ADAPTATION

49. TWO MAIN DRUGS
A. GLP-II
More recently, a synthetic analogue of GLP-II -- teduglutide -- was found
to be associated with increased villus height and fluid absorption, both of
which regressed once the medication was discontinued.
B. GH
A recent double-blind, randomized, controlled trial showed that the use of
GH could reduce TPN by approximately 2 L/week.
This is translated into a reduction of 1 night of infusion.
It is unclear whether these effects were related to improved absorption or
to appetite stimulation, but this study led to the FDA approval of GH
injections for the treatment of TPN-dependent SBS.

50. III. SURGICAL MANAGEMENT
OF SBS
A. NONTRANSPLANT SURGERY
B. INTESTINAL TRANSPLANTATION

51. A. NONTRANSPLANT SURGERY
Residual colon should be reanastomosed to the residual small bowel to
restore intestinal continuity as soon as the patient is stable for surgery.
Surgical procedures to slow intestinal transit have been done, including:
The creation of recirculating loops
 Reversed segments
 Longitudinal intestinal lengthening and tailoring (Bianchi procedure)
 Colonic interposition between small-bowel segments and
 Insertion of intestinal valves
All have been described in case reports or small-case series only and the
outcome has been less than desirable, and little long-term follow-up has
been reported.

52. Bowel lengthening procedures reserved
, for those patients who
after 6 months of bowel adaptation, are
tolerating more than half of their
feeds enterally and would therefore have a
greater chance of successfully
becoming fully enterally fed following a
.lengthening procedure
Complications of bowel-lengthening
procedures are high, including
anastomotic and staple line leaks, bowel
obstruction from adhesions or
ischaemic strictures, bleeding, abscess
.formation, and death

53. Serial Transverse
Enteroplasty (STEP)
NEW SURGERY described
recently , can both lengthen and
taper the small intestine in some
patients. Initial results found
promising
creates a series of “v” shapes from the
existing intestine, forming an accordion-like
effect that increases bowel length and
gives nutrients more time to be absorbed.
This procedure does not require the
.removal of any additional intestine
The longer, thinner intestine is thought to function more efficiently and lead to
better absorption of food.

54. The Bianchi procedure longitudinal intestinal
lengthening and tailoring
((LILT
divides part of the bowel lengthwise into. 1
two narrower tubes; 2. which are then
separated and joined end to end. 3. The
.result is a longer but narrower bowel

55. B. INTESTINAL TRANSPLANTATION
It is not an alternative to long-term TPN. It
is reserved only for patients who
are unable to have TPN, usually due to
TPN-related liver disease or
difficulty with venous access for TPN
.administration

56. B. INTESTINAL TRANSPLANTATION
Isolated intestinal Combined intestine-liver
transplantation transplantation
Considered for patients with
Is the only alternative for
significant liver disease that has
patients who have developed
not yet progressed to cirrhosis.
end-stage liver disease related
Also, for those with significant fluid to SBS or long-term TPN
losses and who have episodes of therapy.
frequent, severe dehydration despite
appropriate medical management.

57. More-recent transplantations have superior survival as
experience improves, and immunosuppressive regimens
continue to be perfected.

58. IN CONCLUSION
Proper management of these patients requires knowledge of nutrient
digestion, assimilation and metabolism, hepatology, nephrology,
infectious diseases, psychiatric issues, social issues, radiology, and
surgery.
Isolated intestine and multivisceral transplantation are the most rigorous
surgeries performed today.
Therefore, the care of such patients is best served in experienced facilities.