The patient, a 47-year-old man, presented with abdominal pain and shock. Imaging showed occlusion of the SMA and small bowel ischemia requiring resection of the jejunum, ileum, ascending colon and half of transverse colon, leaving only a short remnant. He required TPN, developed complications, and returned months later with new symptoms. Assessment found malnutrition, electrolyte imbalances, and infections. Management of short bowel syndrome focuses on nutrition, maximizing absorption, and preventing complications through medical and surgical interventions.

1. Absorption in intestine

2. The Patient
• 47 year old gentleman, chronic alcoholic, presented to the ED with
c/o abdominal pain, vomiting and obstipation for two days. He was
tachycardic and in shock, abdomen was tense and distended, bowel
sounds absent.
CECT abdomen showed a near total thrombotic occlusion of the SMA,
and features suggestive of small bowel ischemia.

3. SHORT BOWEL SYNDROME
Presented by: Anjaly Mohan
Moderator: Dr. Bharati Pandya
Dept of General Surgery
AIIMS Bhopal

4. Short Bowel Syndrome
• Malabsorption and malnutrition, which generally occur when less
than 180cm of functional intestine remains in adults
• Severity and clinical features dependent on several factors
• 75% cases – massive intestinal resection
• 25% cases – multiple sequential resections of SI
• Approx 2/3rd of patients survive that hospitalization
• Similar percentage are alive one year later

5. Etiology - Adults
• Acute mesenteric ischemia
• Arterial embolism, venous occlusion, shock
• Crohn’s disease
• Trauma
• Radiation enteritis
• Malignancy
• Recurrent intestinal obstruction

6. Etiology - Pediatric
• Necrotizing enterocolitis
• Intestinal atresia
• Gastroschisis
• Midgut volvulus
• Hirschsprung’s disease – Neuromuscular diseases of gut
• Congenital diseases of intestinal epithelium
Anatomic/surgical reductions of bowel

7. Pathophysiologic Changes
Loss of intestinal absorptive surface
More rapid intestinal transit
• Malabsorption Malnutrition and weight loss
• Diarrhea and steatorrhea
• Vitamin deficiency
• Electrolyte imbalance

8. Specific complications
• Nephrolithiasis - due to hyperoxaluria
• Cholelithiasis - secondary to altered bile salt and bilirubin metabolism
• Transient gastric hypersecretion
• Bacterial overgrowth – secondary to mechanical obstruction or
primary motor anomalies, reflux of colonic bacteria into SI due to
absent IC valve
• PN and its complications – catheter related, liver disease

9. Severity depends on
• Extent of resection
• Site of resection
• Underlying intestinal disease
• Presence/absence of ileum and ileocaecal valve
• Presence of colon
• Functional status of remaining digestive organs
• Adaptive capacity of intestinal remnant

10. Clinical Course
• Functional and structural adaptation of remaining intestine in the first
few months after resection
• Improved absorption of nutrients
• Decrease in diarrhea

11. Degree of adaptation depends on
• Extent and site of resection
• Provision of enteral nutrients
• Response to GI hormones and other regulatory polypeptides

12. The Patient
• He underwent exploratory laparotomy, and gangrenous bowel was
resected, almost the entirety of jejunum (35-40cm remnant), whole
of ileum, ascending colon, and half of transverse colon
• A jejuno-transverse colic anastomosis done
• Postoperatively - careful fluid and electrolyte management, iv
antibiotics and analgesics, parenteral and enteral nutrition, blood
thinners, psychosocial support and management of alcohol
withdrawal, regular monitoring and management by a
multidisciplinary team

13. The Patient
• He was discharged healthy ad stable a month later. Patient continued
taking TPN once a week, after the discharge, for about 2 months,
during which he encountered catheter related thrombophlebitis, but
without infection or sepsis
• He stopped coming due to inability to afford TPN and reported 4
months later.
• 6 months after the surgery, the patient returned with complaints of
abdominal pain, generalized weakness and body pain, swelling of
both legs, and was admitted

14. Clinical Assessment

15. Assessment of SBS patient
• Past medical record, surgical and pathological documentation
• Cause of SBS, anatomy and length of intestine, details of prior
surgical procedure
• Number of central lines and reasons they were changed
• Causal microorganisms for central line infections
• Nutritional assessment
• Parenteral and enteral intake, daily caloric requirements, macro &
micronutrient components of PN

16. Assessment of SBS patient
• S. electrolytes, LFT, GFR, S. Albumin, Prothrombin time, Vit B12, Fat
soluble vitamins, S. Ca, S. Citrulline
• Vaccination status
• Complete physical examination
• Focus on hydration status, nutritional status (ht, wt, BMI), type of central line,
signs of nutritional deficiencies, complication from PN like dermatitis, signs of
CLD

17. Management

18. EARLY MANAGEMENT
• Postoperative care
• Control of sepsis
• Maintain fluid and electrolyte balance
• Initiating nutritional support

19. Later Stage
• Maintain adequate nutritional status
• Maximise absorptive capacity of remaining intestine
• Prevent further complications
• Prevent complications of nutritional therapy

20. THERAPEUTIC GOALS
• Maintain nutritional status
• Maximize enteral nutrient absorption
• Prevent complications

21. Maintain nutritional status
• PN support in early postoperative period
• Early initiation of enteral nutrition, after ileus has subsided
• Transition from PN to EN
• Goals – maintain a stable body weight, fluid balance
• Metabolic monitoring
• Marked increase in GI fluid loss – further increases in enteral feeding
will not be tolerated
• Eventually reduce PN

22. Maximize enteral nutrient absorption
• Initially, high carbohydrate, high protein diet
• Fat requires more digestion, except MCTs
• Ability to absorb nutrients improves with time, hence diet should be
modified continually
• Restrict fat to 20-30% of caloric intake
• Lactase deficiency
• Oxalate restriction (tea, coffee, nuts, chocolate, soy products, sweet
potatoes)

23. • For jejunal remnants, isotonic feeding
• Ingestion of glucose-electrolyte ORS with at least 90mmol/L of Na

24. Medical treatment of short bowel
• Slow transit
• Loperamide, Lomotil, Narcotics
• Reduce GI secretion
• H2 receptor antagonists, PPIs, Octreotide, Clonidine
• Avoid octreotide on long term – steatorrhea, cholelithiasis, inhibits
adaptation
• Cholestyramine, when diarrhea is due to unabsorbed bile salt in colon

25. Medical treatment of short bowel
• Treat bacterial overgrowth
• Antibiotics
• Probiotics
• Prokinetics
• Treat pharmacologically
• Growth hormone
• Teduglutide (GLP2 agonist) – increases crypt proliferation, reduces crypt cell
apoptosis

26. Prevent Complications
Metabolic complications
• Risk of dehydration and renal dysfunction
• BUN/Creatinine often a poor indicator, Measure GFR
• Hypocalcemia
• Poor absorption and binding due to intraluminal fat
• Ca, Mg, Vit D supplementation
• W/F hyperglycemia and hypoglycaemia in PN
• Metabolic acidosis and alkalosis
• D-lactic acidosis – Lactobacilli colonize and concert CHO to D-lactate

27. Prevent Complications
• Specific nutrient deficiencies
• Iron and vitamin deficiencies
• Micronutrients – Se, Zn, Cu
• Fatty acid deficiency
• PN related
• Fluid and electrolyte disturbances
• Silent renal insufficiency
• IFALD
• Organ dysfunction – skeletal system (osteopenia, osteoporosis), intestine
(bacterial overgrowth, translocation), neurologic(memory disturbance), GB
(cholelithiasis), liver (steatosis, cholestasis, fibrosis, cirrhosis)

28. Prevent Complications
Catheter Related
• Catheter related sepsis
• Attention to technique and meticulous patient education
• Catheter thrombosis
• Difficult vascular access

29. Prevent Complications
PN-induced liver disease
• Multifactorial process
• More frequently in children
• Steatosis, cholestasis, eventually cirrhosis
• Increase enteral nutrition, avoid overfeeding, lipid minimization,
prevent specific deficiencies

30. Prevent Complications
Bacterial overgrowth
• Impaired motility or stasis
• Secretory diarrhea may occur
• Suspected when a patient’s absorptive capacity and stool habits
change acutely
• If mechanical obstruction or blind loop – surgery
• Primary motor abnormality – intermittent antibiotic therapy
• Colonization of lumen with probiotics

31. Prevent Complications
Cholelithiasis
• 30-40% of SBS patients
• Long term PN – altered hepatic bile metabolism, GB stasis
• Ileal resection – bile acid malabsorption, lithogenic bile -> cholesterol
stones
• Provide nutrients enterally, whenever possible
• Requires surgical treatment
• May be done prophylactically, while doing laparotomy for other
reasons

32. Prevent Complications
Nephrolithiasis
• Normally, oxalate is bound to Ca in the intestinal lumen, hence not
absorbed
• Decreased availability of Ca – reduced intake, binding by intraluminal
fat
• Hence, free oxalate in lumen – absorbed in colon - forms ca oxalate in
urine
• Diet low in oxalate, min intraluminal fat, supplement Ca porally,
maintain high urinary volume
• Cholestyramine – binds oxalic acid in colon

33. Prevent Complications
Gastric hypersecretion
• Massive intestinal resection – parietal cell hyperplasia,
hypergastrinemia
• Usually transient
• Presumably involves loss of an inhibitor from resected intestine
• Hyperacidity – exacerbates malabsorption and diarrhea
• H2 receptor antagonists, PPIs

34. SURGICAL MANAGEMENT
Goals:
• To slow intestinal transit
• Reversing intestinal segments
• Interposing colonic segments into SI
• To improve the function of existing intestine
• Stenotic segments – strictureoplasty
• Dilated segments – tapering enteroplasty
• Intestinal lengthening procedures
• Intestinal transplantation

35. Cautious patient selection
• Worsening malabsorption
• Patients stable on EN, going into risk of requiring PN, or going into
malabsorption
• PN associated complications

36. Bianchi Procedure
Longitudinal intestinal lengthening

38. STEP Procedure
Serial Transverse EnteroPlasty

42. Intestinal Transplantaion

43. • Final available therapy for patients with intestinal failure or SBS, who
in general have failed PN therapy

47. The Patient
• PR – 96/min, BP – 80/50mm of Hg, RR – 18/min
• P/A – Scaphoid in shape, healed scar of previous surgery see, no
dilated veins, visible peristalsis, no guarding or rigidity, BS +
• Hb-6.5g/dL, TC-16,600/uL, N92L03M05, Plt-2.81L/uL, Hct – 20.9%
• FBS – 101mg%
• BUN/Creat – 22.17/0.85mg/d
• T.Bil/D.Bil – 0.63/0.09U/L
• Tot.Prot/alb – 6.5/3.9
• S. Na+/K+ – 133/2.7mmol/L
• S. Ca++ – 3.5mg/dL

48. References
• Maingot’s Abdominal Operations 13th Edition
• Current Surgical Therapy 12th Edition, Cameron et al
• Sabiston Textbook of Surgery 20th edition

49. THANK YOU
FOR YOUR TIME