Conference Presentation

1. SHORT GUT SYNDROME
(SGS) :
A MANAGEMENT CHALLENGE!
Muhammad Saaiq
DEPARTMENT OF SURGERY ,PIMS , ISLAMABAD.
Surgical Grand Round, Pakistan Institute of Medical
Sciences (PIMS), Islamabad. September 23, 2005.

2. INTRODUCTION
Adults 90-120 cm
Children 30-60 cm

3. CAUSES OF SGS :
INTESTINAL ATRESIA
MIDGUT VOLVULUS
NEC. ENTEROCOLITIS
CROHN’S
MESENTERIC VASCULAR DISEASE
CARCINOMA
RADIATION ENTERITIS/ REGIONAL ENTERITIS
TRAUMA
ILIOJEJUNAL BYPASS FOR OBESITY

4. FACTORS AFFECTING SEVERITY
1) EXTENT OF RESECTION / LENGTH
OF RESIDUAL SMALL GUT .
2) SITE OF RESECTION .
3) STATE OF THE RESIDUAL GUT .
4) ILEOCAECAL VALVE .
5) COLON .
6) ADAPTIVE CAPACITY OF THE
REMNANT GUT.
7) GENERAL FACTORS .

5. PATHOPHYSIOLOGY :
1) LOSS OF INTESTINAL ABSORPTIVE
SURFACE .
2) MORE RAPID INTESTINAL TRANSIT .
3) PRIMARY ILLNESS

6. NORMAL LENGTH OF GUT PARTS
PART OF GUT
LENGTH
MOUTH - PYLORUS
65 cm
DUODENUM
25cm
JEJUNUM&ILEUM
COLON
400-600cm
110cm

7. GUT TRANSIT TIME :
PART OF GUT
TR. TIME
STOMACH
* FLUIDS
OTHERS
SMALL GUT
LARGE GUT
30 min
Few hours
4-6 hours
6-12 hours

8. DAILY FLUID TURN-OVER IN GIT:
AMOUNT
EXOGENOUS INTAKE
ENDOGENOUS SECRETIONS :
Salivary
Gastric
Bile
Pancreatic
Intestinal
2 Litres
1.5 L
2.5 L
0.5 L
1.5 L
1 L
9 L

9. CLINICAL FEATURES :
DIARRHOEA
/ STEATORRHOEA
ELECTROLYTE IMBALANCE
MALNUTRITION
VITAMIN DEFICIENCY esp. B 12
GASTRIC ACID HYPERSECRETION
LIVER DYSFUNCTION
CHOLELITHIASIS
NEPHROLITHIASIS
BACTERIAL OVERGROWTH

10. ADAPTATION:
1) STRUCTURAL & FUNCTIONAL
CHANGES IN THE GUT .
2) ENTERAL NUTRIENTS ARE MUST .
3) ENTEROGLUCAGON HAS A ROLE

11. MANAGEMENT:
THE COURSE OF ILLNESS IS DIVIDED
INTO THREE PHASES:
1) IMMEDIATE POST-OP PHASE
2) TRANSITION PHASE
3) PHASE OF LONG- TERM
COMPLICATIONS

12. Manag.Contd:
IMMEDIATE POST-OP PHASE :
Critical care
Sepsis control
Maintenance of Fluid/Elec. Balance
Gastric acid suppression
Total parenteral nutrition
General care

13. TRANSITION PHASE :
Manag.Contd:
TPN-----EN / Home TPN
Role of Antimotility / Antisecretory agents
Dietary management:
Small frequent meals
Nutrients in simplest form
Separate solid nutrients from liquids
Avoid hyper-osmolar fluids
Restricted fat intake
Avoid high oxalate

14. MANAGEMENT OF LONG- TERM
COMPLICATIONS :
1) Correction of nutritional derangements
2) Catheter related problems
3) Cholelithiasis
4) Nephrolithiasis
5) Liver dysfunction
6) Bacterial overgrowth

15. ROLE OF
Manag.Contd:
SURGERY :
1) Restoration of intestinal continuity
2) Enteroplasty / Lengthening procedure
3) Slowing down rapid transit:
creating artificial valve
construction of anti-peristaltic segment
colonic interposition
construction of recirculatig loop
pacing with electrodes in retrograde fashion
4) Small gut / combined liver & small gut transplant
5) Management of complications

16. CONCLUSION

17. THANK YOU

18. CASE
PRESENTATION

19. NAME : ABC
AGE : 14 YRS
GENDER : MALE
ADDRESS : PIND DAD KHAN
DOA : 09/04/2004
PRESENTING COMPLAINTS :
SEVER DIFFUSE ABDOMINAL PAIN : 1
DAY
VOMITING
: 1 DAY
CONSTIPATION
: 1 DAY

20. HISTORY OF PRESENT
ILLNESS
PATIENT WAS IN USUAL STATE OF HEALTH
DEVELOPS SEVERE GRIPPING DIFFUSE
ABDOMINAL PAIN OF SUDDEN ONSET
CONTINOUS IN NATURE
AGGREVATED BY MOVEMENT
NO RELIEVING FACTOR.
HE HAS 3 BOUTS OF VOMITING WITH IN
TWO HOURS OF ONSET OF PAIN ,
GREENISH IN COLOUR WITH BLOOD TINGE
IN IT .

21. ASSOCIATED SYMPTOM : ABSOLUTE
CONSTIPATION
TWO MONTH BACK HE EXPERIENCED
AN EPISODE OF MILD DULL ACHING
PAIN IN UMBILICAL REGION LASTED
FOR 4 HOURS , CONSULTED DOCTOR
LOCALLY WHO ADVISED ANALGESIC
THAT RELIEVED HIS SYMPTOM

22. PERSONAL HISTORY :
7th CLASS STUDENT
WITH GOOD APPETITE PREVIOUSLY ,
NORMAL SLEEP , NONSMOKERB , NON
ADDICTED
PAST HISTORY
:UNREMARKABLE
FAMILY HISTORY
:
SOCIOECNOMIC HISTORY :
MEDICATION HISTORY
:

23. EXAMINATION :
GPE :
BP 100/70
PULSE : 104/ MIN
T : 100 * F
R / RATE : 24 / MIN
ABDOMEN : MILD DISTENSION
TENDER ALL OVER ABDOMEN
BS NEGATIVE
PR:UNREMARKABLE.

24. SYSTEMIC
EXAMINATION
CVS
CNS
GUS
RESPIRATORY
MSS
ALL ARE UNREMARKABLE

25. INVESTIGATIONS
PLAIN X-RAY ABDOMEN : DILATED GUT
LOOP , NO PNEUMOPERITONEUM
U/S ABDOMEN : DILATED GUT LOOPS ,
MINIMAL AMOUNT OF FREE FLUID IN
PERITONIAL CAVITY
BCP : TLC :12500
RFT , SE , LFTs , S.AMYLASE , PT/APTT
ALL WERE WITH IN NORMAL LIMITS

26. PLAN OF MANAGMENT
PATIENT KEPT NPO
PASSED NG TUBE
I/V FLUID
I/V ANTIBIOTICS
EXPLORATORY LAPROTOMY

27. EXPLORATORY
LAPROTOMY
INCISION : LOWER MID LINE
FINDINGS :
PERITONIAL CAVITY FILLED
WITH GANGRENOUS SMALL GUT . 80%
OF JEJUNUM , ILEUM BEING TIGHTLY
TWISTED TWICE AROUND LONG LOOSE
MESENTERY THAT CONTAINED A
BENIGN LOOKING LUMP (12 *10*6 cm )
ABOUT3cm FROM MESENTERICBORDER
OF THE JUNCTION OF JEJUNUM &ILEUM

28. PROCEDURE:
THE GANGRENOUS SMALL GUT (
ABOUT 340 cm) WAS RESECTED
LEAVING BEHIND HEALTHY 75cm
JEJUNUM & 10cm ILEUM .
THE REMNANT STUMPS WERE
PARTIALLY ANASTOMOSED &
BRING OUT AS COMBINED STOMA
THROUGH RIGHT LOWER
ABDOMEN

29. POST OPERATVE
MANAGMENT
I/V ANTIBIOTC
TPN
ACID SUPPRESSANT
STOMA WAS REVERSED AFTER 8 WEEKS
PATIENT STARTED ON ORAL FEED
AFTER 1 WEEK .
HE IS NOW TOLERATING ENTERAL FEEDS
& GAINING WEIGHT .

30. BIOPSY REPORT:
HISTOPATHOLOGY REVEALED
BENIGN LIPOMA

31. LIPOSITES

33. CAPSULE OF LIPOMA

34. FOUR LAYERS OF GUT ON
LIPOMA

35. CONGESTION OF GUT
WALL

36. CONGESTION

37. CONGESTED BLOOD
VESSELS IN LIPOMA

38. THANK YOU