This document discusses short bowel syndrome, which results from surgical resection or congenital defects that leave less than 200cm of small intestine. It causes an inability to maintain nutrition from a normal diet. Causes in adults include surgery, radiation, cancer, and diseases. In children, causes include birth defects affecting the intestines. Consequences include malnutrition, diarrhea, vitamin deficiencies, and electrolyte abnormalities. Management involves specialized diets, oral rehydration solutions, medication to slow transit or aid absorption, and in severe cases, intestinal transplantation. Surgical techniques can also increase surface area or slow transit to improve absorption.

1. SHORT BOWEL SYNDROME
DR.BARUN KUMAR
UNIT IIA, GENERAL SURGERY
IPGMER

2. 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

3. Causes of Short Bowel Syndrome
Adults :
– Postoperative
– Irradiation
– Cancer
– Mesentric vascular
disease
– Crohn disease
– Trauma
– Desmoid tumours
Childrens :
– Gastroschisis
– Necrotizing enterocolitis
– Midgut volvulus
– Intestinal atresia

4. 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

5. Pathophysiology

6. 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

7. .
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)

8. .
D.LOSS OF ILEOCECAL VALVE:
SMALL INTESTINAL DILATTATION AND SLOWER
MOTILITY LEADING TO BACTERIAL
OVERGROWTH
BACTERIAL OVERGROWTRH IN TURN LEADS TO
MANY COMPLICATIONS SUCH AS:
Competition of nutrients, bacterial translocation,
endotoxemia, liver injury, D-lactic acidosis

9. .
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

10. 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

11. 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

12. 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

13. Maintenance phase
 Absorptive capacity is maximum during this phase
 Nutritional metabolic homeostasis can be achieved with
oral feeding

14. 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

15. 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

16. 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

17. Diet and Fluid Suggestion
COLON 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 intake
High biologic values
same
Fiber Soluble soluble
Fluids ORS and/or hypotonic ORS
Oxalate Restrict _______

18. 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

19. 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

20. SURGICAL TREATMENT :
INTESTINAL
TRANSPLANT
SURGICAL TREATMENT
OPTIONS
NONTRANSPLANT
OPTIONS
TO SLOW INTESTINAL
TRANSIT
TO INCREASE
INTESTINAL AREA

21. 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 distally
2.Interposition of colon in antiperistaltic or isoperistaltic
direction (8-24cms of colon can be used)
3.Intestinal valves
4.Retrogade Electrical pacing

22. ,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

23. LONGITUDINAL INTESTINAL LENGTHENING AND
TAILORING (LILT) contd.
Contraindications:
• Intestinal diameter <3cm
• Residual intestinal length <40cm
• Length of dilated bowel <20cm
• Hepatic failure

25. 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

26. SERIAL TRANSVERSE ENTEROPLASTY contd.

27. 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

28. 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

29. complications
technical
• Anastomosis leak
• Perforation
• Hepatic artery thrombosis
• Infectious comlications
Transplant rejections
• Acute
• chronic

31. Thank you