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Short bowel syndrome
- 1. Nuwan gunapala Trainee in general surgery
- 2. Introduction Epidemiology Etiology Pathophysiology Clinical features Management Prognosis Presentation overview
- 3. Short-bowel syndrome is a disorder clinically defined by Malabsorption Diarrhea Steatorrhea Fluid and electrolyte disturbances Malnutrition Due to functional or anatomical loss of extensive segments of small intestine so that absorptive capacity is severely compromised Introduction
- 4. No defined length of remaining bowel is identified although various literature mentioned controversial lengths. Less than 200 cm of viable small bowel or loss of 50% or more of the small intestine places the patient at risk for developing short-bowel syndrome. The average length of the adult human small intestine is approximately 600 cm and the range extends from 260 to 800 cm – Weser E. Nutritional aspects of malabsorption: short gut adaptation. Clin Gastroenterol. May 1983;12(2):443-61. [Medline]. Extensive segment
- 5. Intestinal failure associated with the inability to maintain protein, energy, fluid, electrolytes or micronutrient balances while on conventionally accepted normal diet. Short bowel syndrome and intestinal failure: consensus definitions and overview. O'Keefe SJ1, Buchman AL, Fishbein TM, Jeejeebhoy KN, Jeppesen PB, Shaffer J. Definition
- 6. Prevalence is not identified worldwide United Kingdom, the incidence of short-bowel syndrome which requires home TPN was 2 patients per million population United States, approximately 10,000-20,000 patients receive home-delivered TPN Prevalence in Spain 1.8 patients per 1 million population Epidemiology
- 7. Depends on age groups In adults Crohn’s disease Mesenteric ischemia - thrombosis and embolism of superior mesenteric vessels Radiation enteritis Iatrogenic – jejuno ileal bypass, now abandoned Neoplastic Motility disorders Trauma Etiology
- 8. Necrotizing enterocolitis Multilevel small-bowel atresia Midgut volvulus with ischemic bowel infarction Pediatric and neonatal age groups
- 9. About 90% of digestion and absorption of significant macronutrients and micronutrients are accomplished in the proximal 100-150 cm of the jejunum Symptoms occurs due to Loss of intestinal absorptive capacity Rapid intestinal transit Gastric hypersecretion and inactivation of digestive enzymes Loss of bile salts Pathophysiology
- 10. Functional or anatomical loss of small bowel surface area will reduce the absorption of intestinal contents leading to symptoms of SBS Loss of small bowel reduce pancreatic and biliary secretion and increase gastric secretion lowering the PH in small intestine which further impairs the action of digestive hormones
- 11. Impaired absorption will accumulate osmotically active particles in small bowel retaining more water results in diarrhea. Loss of ileum will results in reduced absorption of fats leading to steatorrhoea (reduction of bile salts) Role of ileocecal valve Increase transit time allowing more absorption Prevent colonization of small bowel from large bowel which will aggravate the diarrhea
- 12. Premorbid length of small bowel The segment of intestine that is lost The age of the patient at the time of bowel loss The remaining length of small bowel and colon, The presence or absence of the ileocecal valve. Other factors which affect outcome
- 13. Increases it water absorption capacity up to 5 times Colonized bacteria metabolize undigested carbohydrates to short chain fatty acids which can be absorb to utilize as somatic fuel. Increase absorption of oxalates and increase risk of urinary calculi formation Increases colonization of small bowel in the absence of ileocecal valve Place of colon
- 14. The physiologic changes and adaptation of patients with short-bowel syndrome can be viewed in three phases. 1. Acute phase 2. Adaptation phase 3. Maintenance phase Sundaram A, Koutkia P, Apovian CM. Nutritional management of short bowel syndrome in adults. J Clin Gastroenterol. Mar 2002;34(3):207-20. Adaptations to live without small bowel
- 15. The acute phase occurs immediately after massive bowel resection and may last up to 3-4 months. It is associated with malnutrition and fluid and electrolyte loss through the GI tract. Enteral feedings may also be initiated, but it should be relatively slow. Patients with less than 100 cm of small intestine will require TPN. Sundaram A, Koutkia P, Apovian CM. Nutritional management of short bowel syndrome in adults. J Clin Gastroenterol. Mar 2002;34(3):207-20. Acute phase
- 16. The adaptation phase generally begins 2-4 days after bowel resection and may last up to 12-18 months. During this second phase, up to 90% of the bowel adaptation may occur. Villous hyperplasia Increased crypt depth Intestinal dilatation occur. Early continuous feedings with a high viscosity elemental diet may reduce the duration of TPN. Adaptation phase
- 17. The absorptive capacity of the GI tract is at its maximum. Some patients may still require TPN. In other patients, nutritional and metabolic homeostasis can be achieved by small meals and supplemental nutritional support for life. Maintenance phase
- 18. Weight loss, fatigue, malaise, and lethargy Vitamin A - night blindness and xerophthalmia Vitamin D - paresthesias and tetany Vitamin E - paresthesias, ataxic gait, and retinopathy Vitamin K depletion - easy bruisability or prolonged bleeding Vitamin B12, folic acid - Anemia Calcium and magnesium - paresthesias and tetany Low zinc levels - anorexia and diarrhea Clinical features
- 19. Temporal wasting Loss of digital muscle mass Peripheral edema Dry and flaky skin Prominent ridges in nail Lingual papillae are blunted or atrophic Physical signs
- 20. Management of SBS is progressed through several phases Management goals varies depending on phases Initial phase To stabilize critically ill patient Controlling sepsis Fluid and electrolyte balance Initiation of nutrtional support Management
- 21. As patient is recovered from acute stage primary goal of management is to maintain nutritional status To maximize the absorptive capacity Prevent complications of PN and short bowel syndrome
- 22. Preserving the intestinal remnant Improve the function of remnant bowel Augmenting the intestinal length Intestinal transplantation Management options
- 23. Goal is to return patients to as normal lifestyle as possible with as little dependence on parenteral nutrition as can be achieved. Intestinal rehabilitation is the process of enhancing intestinal absorption and function through the use of modified diet, enteral nutrition, oral rehydration solution, antimotility and antisecretory agents, antibiotics and growth factors. Medical rehabilitation
- 24. PN support in the early post operative period Provision of energy substrate, protein, fluid, electrolytes, minerals, vitamins and micronutrients 25-30 kcal/kg per day 1 to 1.5 g of proteins per day Maintain nutritional status
- 25. Should started as early as possible when ileus is settled Help to maximize absorptive capacity and to reduce the complications related to PN Patients with small bowel more than 180 cm will not require PN Patients with small bowel more than 90 cm with colon require PN less than 1 year duration Less than 60cm of small bowel might require permanent PN depending on colon length Long-term survival and parenteral nutrition dependence in adult patients with the short bowel syndrome.Messing B1, Crenn P, Beau P, Boutron-Ruault MC, Rambaud JC, Matuchansky C. Enteral feeding following surgery
- 26. Continuous enteral feeding may permit greater absorption of nutrients than intermittent enteral feeding Continuous enteral nutrition during the early adaptive stage of the short bowel syndrome. Levy E1, Frileux P, Sandrucci S, Ollivier JM, Masini JP, Cosnes J, Hannoun L, Parc R.
- 27. Hyposmolar diets are started initially to reduce the intestinal fluid loss High protein high carbohydrate diets are recommended for maximum absorption Providing nutrient as their simplest form improves absorption Di and tri peptide sugars Medium chain tri glycerides Addition of pectin increase transit time and reduce water loss Maximize absorptive capacity
- 28. Early enteral nutrition Provision of long chain fatty acid and fiber Glutamin – trophic to the gut as well as act as fuel for enterocytes Meal itself act as endocrine stimulation for adaptation via various hormones and growth factors Glutamine and the preservation of gut integrity. van der Hulst RR1, van Kreel BK, von Meyenfeldt MF, Brummer RJ, Arends JW, Deutz NE, Soeters PB. Maximize adaptive capacity
- 29. To minimize diarrhoea and GI secretion Narcotics – codeine, diphenoxylate and loperamide Diminished action over time Progressive dosage Drug holidays AGA technical review on short bowel syndrome and intestinal transplantation. AUBuchman AL, Scolapio J, Fryer J Antimotility and antisecretory drugs
- 30. PPI and H2 receptor blockers reduce gastrointestinal secretion Clonidine also reduce fluid loss (alpha 2 receptor agonist) Pre biotics and pro biotics also proven to improve absorption Potential benefits of pro- and prebiotics on intestinal mucosal immunity and intestinal barrier in short bowel syndrome.Stoidis CN1, Misiakos EP2, Patapis P2, Fotiadis CI2, Spyropoulos BG3.
- 31. GLP – 2 Increase intestinal absorption and adaptation Produce by enteroendocrine cells in small intestine Shown to increase absorption and increase villous height and crypt depth Still undergoing further studies Short Bowel Patients Treated for Two Years with Glucagon-Like Peptide 2 (GLP-2): Compliance, Safety, and Effects on Quality of Life P. B. Jeppesen,1,* P. Lund,1 I. B. Gottschalck,1 H. B. Nielsen,2 J. J. Holst,3 J. Mortensen,4 S. S. Poulsen,3 B. Quistorff,3 and P. B. Mortensen1 Newer therapies
- 32. Complications of short bowel syndrome Therapy related Diarrhea and steatorrhea Metabolic abnormalities Nutritional deficiencies Infectious complications Liver disease Physiologic Cholelithaisis Nephrolithiasis Gastric hypersectretion Bacterial overgrowth Prevent complications
- 33. Supplementation of vitamin D calcium and magnesium Treat bacterial over growth in small bowel which can cause metabolic acidosis Prevent catheter related sepsis PN related liver disease – multifactorial Maximizing enteral calories Avoid over feeding Prevent specific nutrient deficiencies Measures to prevent complications
- 34. Due to stasis, obstruction and absence of iliocecal valve Reduce absorption by villous blunting Duodenal aspiration and culture is diagnostic Poorly absorbed antibiotics are preferable for treatment Obstruction can be surgically corrected. Small bowel bacterial overgrowth
- 35. Occur in 1/3rd of patients Due to increase bile stasis, and reduction of bile salt absorption which leads to cholesterol stones Early enteral feeding reduce the stasis and occurrence of bile stones Intermittent CCK injections prevent stasis Consider prophylactic cholecystectomy when laparotomy is being performed for other reasons. Cholelithiasis
- 36. Increase risk in colon preserved patients Binding of non absorbed FFA with calcium releases free oxalate which are soluble and absorbed in colon Free oxalate bind with calcium and form stones in urine To prevent Low oxalate diet Reduce intraluminal fat Oral calcium supplement Cholestyramine binds with oxalic acid in colon Nephrolithiasis
- 37. Due to loss of inhibiting factors from the small bowel Exacerbate malabsorption and diarrhea Causes peptic ulcer disease Prevention by PPI and H2 receptor blockers, which continue up to 1 year postop Gastric hyper secretion
- 38. Re operation surgery is required in half of the patients Aim is to preserve the intestinal remnant length Avoid resection much as possible Surgical options available Intestinal tapering for dilated segments Strictureplasty Serosal patching Recruitment of isolated or bypassed bowel segment Surgical therapy
- 39. Half of the patients can maintain nutrition only on enteral nutrition and doesn’t require surgery But surgery should be consider if they are having following worsening malabsorption Increased requirement for parenteral nutrition Disabling symptoms related to malabsorption Other half who is stable on TPN can undergo surgery in the aim of weaning off from PN When to consider surgical treatment
- 40. Intestinal transplant should be consider in patients who are having persisting and recurrent complications while totally depend on PN. Many such patients will die prematurely
- 41. Intestinal remnant length Intestinal function Diameter of the intestinal remnant Type of surgery depend on
- 42. Adults with remnant more than 120cm Initial conservative management But when dilatation occurs – due to obstruction caused by adhesions of stricture at anastomotic site, surgery is done for adhesiolysis and strictureplasty If necessary non functional short segment resection
- 43. Patients with marginal remnant, 60 -120cm They have rapid transit Reversing 10 – 15 cm segment yielded good results Other options Creation of artificial valves – not successful Retrograde intestinal pacing with electrodes Surgical approach to short-bowel syndrome. Experience in a population of 160 patients. J S Thompson, A N Langnas, L W Pinch, S Kaufman, E M Quigley, and J A Vanderhoof Should intestinal continuity be restored after massive intestinal resection? Nguyen BT1, Blatchford GJ, Thompson JS, Bragg LE.
- 44. Patients with short remnant length < 60 cm with dilated bowel Goal is to preserve the functional length and luminal diameter When the dilatation is progressive in the absence of obstruction – adaptive dilation and attempted medical management are unsuccessful surgical intervention is indicated.
- 45. Longitudinal lengthening – Bianchi procedure Allocate terminal blood vessels anatomically to the either side of the bowel wall Longitudinal transection of the bowel Anastomosis of two limbs More than 100 cases reported Improvement is see in 80% of patients 20% complications – anastomotic leak, ischemia Long term benefit in 50% of patients 10% underwent intestinal transplant Sudan, D., Thompson, J.S., Botha, J. et al, Comparisons of intestinal lengthening procedures for patients with short bowel syndrome. Ann Surg. 2007;246:593–604. Intestinal lengthening surgeries
- 46. Repeated applications of linear stapling device from opposite directions in zig sag fashion Requires diameter at least 4 cm Recurrent dilatation can managed in similar fashion 80% of patients improve clinically 5% undergone subsequent intestinal transplant STEP is preferable than Bianchi procedure Kim, H., Fauza, D., Garza, J. et al, Serial transverse enteroplasty (STEP): a novel bowel lengthening procedure. J Pediatr Surg. 2003;38:425–429. Yannam, G., Sudan, D., Grant, W. et al, Intestinal lengthening in adults with short bowel syndrome. J Gastrointest Surg. 2010;14:1931–1936. Serial transverse enteroplasty(STEP)
- 47. Indicate in patients with SBS with life threatening complications Recurrent central venous catheter infections Progressive liver failure Progressive loss of central venous access Intestinal transplant
- 48. 2000 of transplants done in US by 2012 75% of patients are younger than 18 years 1 year graft survival is 89% in adults But children less than 1 year of age it is 69% Patients survival rates are similar at 1 and 5 year after transplant After one year of surgery 90 % of patients are independent from PN Intestine Transplantation in the United States, 1999–2008 Mazariegos, G. V.; Steffick, D. E.; Horslen, S.; Farmer, D.; Fryer, J.; Grant, D.; Langnas, A.; Magee, J. C. [less] 2010-04
- 49. Yang feng suffering SBS following resection of small bowel due to diverticulosis, 1st Chinese to survive successfully following Small bowel transplantation
- 50. Yang Feng, the first Chinese alive who received a small intestine transplant holds his bride at the wedding
- 51. Medscape Current Management of the Short Bowel Syndrome Jon S. Thompson, MDcorrespondenceemail, Rebecca Weseman, RD, Fedja A. Rochling, MB, BCh, David F. Mercer, MD, PhD References
- 52.