Short Bowel Syndrome

Anne Aspin 2010

Definition
Rickham (1967) an extensive resection to
maximum of 75cm

Kuffer (1972) 15cm with ileocaecal valve

- 38cm without ileocaecal valve

Dorney (1985) 11cm with I/C valve or 25cm

without I/C valve

Introduction
Most common cause of intestinal failure.
NEC, Congenital atresia, Gastroschisis and
volvulus.

Promote adaptive response through

enteral feeding and careful management of TPN.

The Digestive System

Digestion starts in the mouth
Moisten by saliva (contains Pytalin),
begins to turn starch to sugar.

In stomach food churned mixes with

gastric juices.

Gastric juices
Acid reaction
Kills bacteria Controls pylorus

 Gastric juices:
- Rennin coagulates milk - Hydrochloric Acid Converts Pepsinogen to Pepsin. - Pepsin turns protein to peptone

 Food is released in small amounts by

relaxation of the sphincter passing onto Duodenum.

Food further digested by Trypsin, Amylase

and Lipase.

Digestion completed in small intestine.

Intestinal juices.
Enterokinase pancreatic trypsinogen Peptidase polypeptide to amino acid Maltase - maltose} Sucrase sucrose} to glucose Lactase Lactose} Lipase Fats to fatty acids and glycerol

 Onto large intestine where fluids and

nutrients are re absorbed.

Waste fluids taken by blood stream to

kidneys to be filtered

Small intestine
Convoluted tube from pyloric sphincter to
the junction of ileo caecal valve Mucus membrane has circular folds to increase surface area for absorption.

Villi which contain blood and lymph vessel. Supplied with tubular glands secreting
intestinal juice.

Absorption
Proteins, Carbohydrates and Fats through
villi in small intestine.

Fats in the form of fatty acids and glycerol

are absorbed by cells covering villi. Pass into lymph within villi drained by lymphatic capillaries.

Ileo Caecal valve.

The Caecum lies in the right ileac fossa.
The Ileum opens into the Caecum through
the Ileo-Caecal valve.

This is a sphincter which prevents the IC

contents passing back into the Ileum.

What is SBS
Reduced bowel surface area for
absorption of nutrients together with rapid transit of intestinal contents.

TPN reduced as enteral feeds are

introduced.

Need to promote intestinal adaptation.

Motility
The IC valve and colon is important to
slow intestinal transit.

Proteins, Fats and Carbohydrates are

absorbed almost completely within first 150cm of small bowel.

 Jejunum most of electrolyte absorption

Ileum is the only site for absorption of Vit
B12 and bile salts.

After resection.
Increase gastric emptying.
Ileal resection, increased transit time An intact IC valve prolongs gut transit, loss of
this causes an increase.

If colon resected transit increases.

 Duodenal resection malabsorption of

Iron, Calcium and Folic Acid.

Jejunal resection If extensive resection,

lactose intolerence

Ileal resection Some diarrhoea due to

bile salts being incompletely absorbed.

Gastric Hypersecretion
After abdominal surgery, gastric hypersecretion occurs in 50% cases.

This impairs digestion of lipids by lowering

intraluminal PH and inactivating the pancreatic enzymes.

Also stimulates peristalsis.

How does the bowel adapt?

Cellular hyperplasia Villous hypertrophy Intestinal lengthening Altered motility Hormonal changes

Takes approx 2 years

to reach max effect.

Management of SBS.
Total TPN Gradual introduction of enteral feeding. Fluid and electrolyte balance Fluid replacement if stool, gastric aspirate
or ostomy losses are high Reducing substances above1% contra indicate increasing enteral feeds.

Weaning off TPN

Cycling one hour off, line lock with
Gentamycin. Build up to off all day.

Complications.
Bacterial overgrowth Anaemia Bile salt depletion Bone disease Cholestasis Diarrhoea Hypocalcaemia

Complications (cont)
Hypomagnesaemia Liver fibrosis Renal stones Protein malnutrition Trace mineral deficiency Vitamin deficiency, A, D, E, K, B12

Central line complications

Infection Thrombosis Break in catheter Air embolus Tissue necrosis Malposition Cardiac tamponade

Bacterial Overgrowth
Bloating, cramps, diarrhoea,
gastrointestinal blood loss.

Treat with sugar free Metronidazole and

Trimethoprim

Watery diarrhoea
Loperamide
Malabsorption of bile acids. Pectin

Surgery
Further resection might be avoided by
tapering, strictureplasty or serosal patching.

Patients with dilated segments proximal to

tight anastomosis resect and taper improves bacterial overgrowth by improving flow.

Tapering

Bowel lengthening
Cutting bowel longitudinally, preserve
blood supply to both sides and create a segment of bowel twice length, half diameter without loss of mucosal surface area.

Bowel lengthening

Antiperistaltic small intestine segment

Colonic interposition

Medical management
Pectin (water sol, non cellulose dietary
fibre which promotes intestinal adaptation)

Ranitidine (PH > 4)

Loperamide (slow gut transit time)

Cholestyramine (binds bile salts)

It takes approximately two years to achieve some normal diet

Thank you

References
Bentley D, Lifschitz C, Lawson M (2001). Necrotising Entercolitis And Short Bowel Syndrome. http://www.naspghan.org/wmspage.cfm?porm1=130 Koglmeier J, Day C, Puntis J (2008). Clinical outcome in patients from a single region
who were dependent on parenteral nutrition for 28 days or more. Archives of Disease in Childhood. 93 (4) : 300 - 302 Martin G, Wallace L and Sigalet D (2004). Glucagon like Peptide -2 Induces Intestinal Adaptation in Parenterally Fed Rats with Short Bowel Syndrome. American Journal of Physiology. Gastro-intestinal and Liver Physiology. 286: G964-G972 McMahon M, Leviller J and Chescheir N (1996). Prenatal Ultrasonographic Findings Associated with Short Bowel Syndrome in Two Fetuses with Gastroschisis. Obstetrics and Gynaecology. 88: 676-678 Seidner D and Matarese L (2003). Selected topics in Gastrotherapy. Case 2: Short Bowel Syndrome : Etiology, Pathophysiology and Management. The Cleveland Clinic Center for Continuing

Sinden A, Sutphen S (2003) Nutritional Management of Paediatric Short Bowel

Education

Syndrome. Nutrition Issues in Gastroenterology. Series #12 p28-48 Warner B, Vanderhoof J and Rayes J (2000). Whats New In The Management of Short Gut Syndrome in Children. Division of Paediatric Surgery. Department of Surgery. American College of Surgeons. p725-736