Short-bowel syndrome is a disorder clinically defined by malabsorption, diarrhea, steatorrhea, fluid and electrolyte disturbances, and malnutrition. The final common etiologic factor in all causes of short-bowel syndrome is the functional or anatomic loss of extensive segments of small intestine so that absorptive capacity is severely compromised.
After massive enterectomy in humans, the intestine adapts to ensure more efficient absorption per unit length. The main change is manifested as an increase in villous diameter and height which effectively increases the absorptive surface area. This process, termed adaption, is believed to start after surgery and continue for approximately 2 years. This adaptive mucosal hyperplasia occurs only if nutrients are present in the intestinal lumen. Thus, luminal nutrients are the most potent stimulus to intestinal adaptation.
short bowel syndrome depend on several factors:
-the length of the bowel removed
-the location of the bowel resected
-the integrity of the bowel remaining
-the presence of the colon
The lenght and location of the small bowel resected affect the enterohepatic circulation of the bile.
Typically, bile salts are reabsorbed in the terminal ileum,
if less than 100 cm of the ileum is resected, the liver can compansate for the loss absorptive capacity by producing an increased amount of bile salt, which enter the colon and cause bile-irretant diarrhea.
this diarrhea is treated with chelstyramine, which bind the excess salt and improves diarrhea.
if more than 100 cm of the small bowel is resected, including the terminal ileum, the liver can no longer compansate, this result in bile salt deficincy and steatorrhea.
this can managed by precribing diet that contains medium chain triglycerides.
When the jejunum is resected, the ileum is able to assume all the functions of the jejunum, however the opposite is not true, the jejunum is not able to compansate for the loss of the space specilaized function of the iluem.
ileal resection result in:
-diarrhea, from either excess or deficiency of bile salts
-B12 deficiency
-SIBO, from resection of the ileo-caecal valve
-gallstones, from disruption of the cholestrol pool
-calcium oxalate kidney stones
Early amagement of short bowel syndrome includes:
aggressive treatment with antidiarrheal agents
TPN
gastric acid suppression
later management includes:
low fat enteral diet, with progressive increase in charbohydrate
medium chain triglyceride
lactose restriction
treatment of bacterial overgrowth if present
Teduglutide (Gattex), an analog of naturally occurring glucagon-like peptide-2 (GLP-2), was approved by the FDA in December 2012 for adults with short-bowel syndrome who are dependent on parenteral support.
Somatropin (Zorbtive) is a recombinant human growth hormone is indicated to treat short-bowel syndrome in conjunction with nutritional support.
BSG Guidelines here
After massive enterectomy in humans, the intestine adapts to ensure more efficient absorption per unit length. The main change is manifested as an increase in villous diameter and height which effectively increases the absorptive surface area. This process, termed adaption, is believed to start after surgery and continue for approximately 2 years. This adaptive mucosal hyperplasia occurs only if nutrients are present in the intestinal lumen. Thus, luminal nutrients are the most potent stimulus to intestinal adaptation.
short bowel syndrome depend on several factors:
-the length of the bowel removed
-the location of the bowel resected
-the integrity of the bowel remaining
-the presence of the colon
The lenght and location of the small bowel resected affect the enterohepatic circulation of the bile.
Typically, bile salts are reabsorbed in the terminal ileum,
if less than 100 cm of the ileum is resected, the liver can compansate for the loss absorptive capacity by producing an increased amount of bile salt, which enter the colon and cause bile-irretant diarrhea.
this diarrhea is treated with chelstyramine, which bind the excess salt and improves diarrhea.
if more than 100 cm of the small bowel is resected, including the terminal ileum, the liver can no longer compansate, this result in bile salt deficincy and steatorrhea.
this can managed by precribing diet that contains medium chain triglycerides.
When the jejunum is resected, the ileum is able to assume all the functions of the jejunum, however the opposite is not true, the jejunum is not able to compansate for the loss of the space specilaized function of the iluem.
ileal resection result in:
-diarrhea, from either excess or deficiency of bile salts
-B12 deficiency
-SIBO, from resection of the ileo-caecal valve
-gallstones, from disruption of the cholestrol pool
-calcium oxalate kidney stones
Early amagement of short bowel syndrome includes:
aggressive treatment with antidiarrheal agents
TPN
gastric acid suppression
later management includes:
low fat enteral diet, with progressive increase in charbohydrate
medium chain triglyceride
lactose restriction
treatment of bacterial overgrowth if present
Teduglutide (Gattex), an analog of naturally occurring glucagon-like peptide-2 (GLP-2), was approved by the FDA in December 2012 for adults with short-bowel syndrome who are dependent on parenteral support.
Somatropin (Zorbtive) is a recombinant human growth hormone is indicated to treat short-bowel syndrome in conjunction with nutritional support.
BSG Guidelines here
Summary of BSG guidelines:
ReplyDeleteThe most common reasons for a short bowel in adults are:
-Crohn’s disease,
-superior mesenteric artery thrombosis
-irradiation damage.
A short bowel more commonly arises in women (67%) than men, possibly because women start with a shorter length of small intestine than men.
There are three main types of patient with a short bowel:
1- jejunoileal resection with jejunocolic anastomosis (jejunum-colon);
Patients often appear well after their resection except for diarrhoea/steatorrhoea, but in the following months may lose weight and become severely undernourished.
2- predominantly jejunal resection, and have more than 10 cm of terminal ileum and the colon remaining (jejunum-ileum);
Uncommon and rarely have problems of undernutrition and therefore do not often need nutritional support.
3- jejunoileal resection, colectomy, and formation of a stoma (jejunostomy).
Patients have problems of dehydration immediately after surgery due to large stomal water and sodium losses. This jejunal output is greatest after food and drink consumption.
Jejunum-colon and jejunostomy patients are most commonly encountered.
Physiological consequences:
1-GI motility:
Normal gastric emptying and transit time in Jujunum-colon patients but fast in jujunostomy.
This effect may be due to circulating plasma levels of peptide YY and glucagon-like peptide
(GLP-2) being high in those with a retained colon and low in jejunostomy patients.
2-GI secretions:
Jejunum-colon patients can reabsorb unabsorbed fluid in their colon but this is not the case for jejunostomy patients who lose much salt and water from their stoma.
If less than 100 cm of jejunum remains proximal to a jejunostomy the patient may lose more fluid than is taken by mouth.
3-Absorptive function:
Vitamin B12 and fat malabsorption occurs when more than 60–100 cm of terminal ileum have been resected.
Increased hepatic synthesis of bile salts cannot compensate for the loss of ileal surface area.
Unabsorbed bile salts may contribute to colonic secretion in patients with a remaining
colon.
Magnesium deficiency occurs due to reduced absorption because of chelation with unabsorbed fatty acids in the bowel lumen and to increased renal excretion (consequent on
secondary hyperaldosteronism).
4-Adaptive process:
Jejunum-colon patients may show a gradual reduction in nutritional requirements with time.
jejunostomy patients are unlikely to change with time.
Problems with Jujunum-colon patients:
1-Proteint energy malnutrition
2-Salt, water and Mg depletion
3-Vitamins and minerals def
4-Diarrhea
5-Confusion
6-Drug absorption
7-Gall stones
8-Renal stones
Problems with Jujunostomy:
1-Salt and water depletion
2-low Mg
3-Proteint energy malnutrition
4-Social problems
Alternative treatments:
1-Growth Factors
2-Surgical treatment
3-Intestinal Transplant
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