Download - Short bowel syndrome
Short bowel syndrome
Nuwan gunapalaTrainee in general surgery
Introduction Epidemiology Etiology Pathophysiology Clinical features Management Prognosis
Presentation overview
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
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
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
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
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
Necrotizing enterocolitis Multilevel small-bowel atresia Midgut volvulus with ischemic bowel infarction
Pediatric and neonatal age groups
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
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
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
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
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
The physiologic changes and adaptation of
patients with short-bowel syndrome can be viewed in three phases.1. Acute phase2. Adaptation phase3. 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
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
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
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
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
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
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
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
Preserving the intestinal remnant Improve the function of remnant bowel Augmenting the intestinal length Intestinal transplantation
Management options
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
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
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
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.
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
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
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
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.
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
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
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
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
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
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
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
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
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
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
Intestinal remnant length Intestinal function Diameter of the intestinal remnant
Type of surgery depend on
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
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 VanderhoofShould intestinal continuity be restored after massive intestinal resection? Nguyen BT1, Blatchford GJ, Thompson JS, Bragg LE.
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.
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
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)
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
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
Yang feng suffering SBS following resection of small bowel due to diverticulosis, 1st Chinese to survive successfully following Small bowel transplantation
Yang Feng, the first Chinese alive who received a small intestine
transplant holds his bride at the wedding
Medscape Current Management of the Short Bowel
SyndromeJon S. Thompson, MDcorrespondenceemail, Rebecca Weseman, RD, Fedja
A. Rochling, MB, BCh, David F. Mercer, MD, PhD
References