1. Dr. Henrik Csaba Horvath
Short bowel syndrome
Dr. Henrik Csaba Horvath
Bible class February 20, 2013

2. Definition of short-bowel syndrome
Management of gastric polyps
Definition of short-bowel syndrome
Loss of intestinal absorption from surgical resection,
congenital defect or diseases characterized by the inability to maintain
protein-energy, fluid, electrolyte, or micronutrient balances when on a
conventionally accepted, normal diet
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3. Which conditions can lead to a short-bowel syndrome?
Management of gastric polyps
Which conditions can lead to a short-bowel syndrome?
Physical loss of
portions of intestine
Loss of function c
Obstruction
Dysmotility
Surgical
resection
(volvulus)
Congenital
defect
Disease-associated
loss of absorption
(Crohn`s,
postirradiation)
Loss of bowel
or enterocyte mass
(trauma, infarction)
SBS-associated intestinal failure
Surgical resection: volvulus, intestinal pseudoobstruction
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4. Major causes of SBS in adults?
Management of gastric polyps
Major causes of SBS in adults?
Postoperative complications
Irradiaton/cancer
Mesenteric valvular disease (mesenteric ischemia)
Crohn`s disease
Trauma
Functional improvement can take up to 2 years
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5. Management of gastric polyps
Which factors are associated with worse prognosis in patients with SBS?
Total parenteral nutrition
< 50 cm intact bowel
Enterostomy
Radiation or ischemic enteritis
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6. Which factors have impact on the outcome of SBS?
Management of gastric polyps
Which factors have impact on the outcome of SBS?
Length of the
remaining intestine
Segment of intact bowel
(jejunum vs. ileum, colon continuity)
Presence/abscence of ileocaecal valve
Absorptive quality of
the remnant bowel
Outcome of SBS
Presence of residual
underlying disease
(e.g.Crohn`s)
State of other digestive organs
Efficacy of
nutrition support
Pharmacologic therapy
Age/BMI of
the patient
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7. How does affect the remnant length the risk of developing SBS?
Management of gastric polyps
How does affect the remnant length the risk of developing SBS?
Patients at highest risk of developing SBS are
Anastomosis
PLUS length of residual small intestine
Duodenostomy or jejunoileal
< 35 cm
Jejunocolic or ileocolic
< 60 cm
End jejunostomy
< 115 cm
Functional improvement can take up to 2 years
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8. Which impact has on absorption the resection of…
Management of gastric polyps
Which impact has on absorption the resection of…
Jejunum:
Loss of the major intestinal absorption area
Loss of digestive enzymes
Loss of GI feedback hormones (gastric emptying)
Ileum:
Loss of the absorption of jejunal secretion
Loss of absorption of vitamin B12
Loss of absorption of bile salts (fat malabsorption)
Functional improvement can take up to 2 years
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9. Which impact has the loss of ileocaecal valve?
Management of gastric polyps
Which impact has the loss of ileocaecal valve?
Dilatation of the small intestine
Slower motility
Bacterial overgrowth of the small intestine
Competition for nutrients,
inflammation, GI bleeding,
bacterial translocation ± endotoxaemia,
liver injury, D-lactic acidosis
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10. Which adaptive mechanisms occur in the residual intestine/ GI tract?
Management of gastric polyps
Which adaptive mechanisms occur in the residual intestine/ GI tract?
Mucosal hyperplasia (due to fat stimulated glucagon-like peptide receptor II)
Increased mucosal blood flow
Improved segmental absorption
Gastric hypersecretion
Increased pancreatobiliary secretions
Functional improvement can take up to 2 years
Up to 70% can do without TPN due to these mechanisms
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11. Importance of colon in compensation for the lack of intestine?
Management of gastric polyps
Importance of colon in compensation for the lack of intestine?
Increase reabsorption of water, electrolytes, short-chain fatty acids and GI secretions
Slow down the intestinal transit and stimulate intestinal adaptation by hormonal
regulation
Fermentation of malabsorbed carbohydrates by colonic bacteria
Functional improvement can take up to 2 years
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12. Measurement of the functional capacity of the small intestine?
Management of gastric polyps
Measurement of the functional capacity of the small intestine?
1. 48-hour nutritional balance test
analysis of daily absorption rate (intake-output)
prediction of intestinal failure: <1,4 kg wet weight/day
1170 kcal/day of energy
(Difficulties with duplicate food portions and accurate stool collections)
2. Fasting plasma citrulline concentration (>5 μmol/L)
(is synthetized by the small intestine, best practical measure of enterocyte function)
Citrullin : not-proteinogenic alpha amino-acid (in rind of watermelon)
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13. Two major groups of complications of SBS?
Management of gastric polyps
Two major groups of complications of SBS?
Early complications:
dehydration
electrolyte derangements (Mg, Ca, K)
Diagnosis:
urinary electrolyte levels (plasma can be normal!)
Treatment:
sustained correction due to slow cellular uptake
Late complications:
TPN-related
bacterial overgrowth
micronutrient deficiency
metabolic
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14. TPN-related late complications of SBS are…
Management of gastric polyps
TPN-related late complications of SBS are…
1. Due to bypass first pass liver metabolism:
steatosis
cholestasis
gallstones, cirrhosis (IFALD)
end-stage liver cirrhosis in 15% of pts after one year TPN
100% mortality rate within 2 yrs
IFALD: intestinal failure-associated liver disease
2. Catheter-associated complications:
infection: one-third of deaths in 50% 5-yr-mortality rate in SBS thrombosis (v. cava superior): 0.2/1000 catheter days
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15. Bacterial overgrowth-related late complications of SBS are…
Management of gastric polyps
Bacterial overgrowth-related late complications of SBS are…
1. carbohydrate malabsorption
2. sepsis due to bacterial localisation
3. decreased absorption of fatty acids due to interference with chilomicron formation
4. loss of absorptive capacity due to inflammatory response
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16. Management of gastric polyps
Which are the most common micronutritient deficiencies as late complications of SBS?
2. fat-soluble vitamins (A,D,E,K)
3. vitamin B12
4. folate
(if >60 cm of terminal ileum resected)
(if proximal jejunum resected)
1. Mg, Ca, Zn, Se
Micronutrients
Recommended dose /day
Vitamin A
units
Vitamin B12
300 μg/month
Vitamin C mg
Vitamin D
1600 U
Vitamin E
30 IU
Vitamin K
10 mg/week
Calcium mg
Magnesium
As needed
Iron
Selenium μg
Zinc mg
Bicarbonate
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17. The most common metabolic complications of small-bowel syndrome?
Management of gastric polyps
The most common metabolic complications of small-bowel syndrome?
Metabolic acidosis
Hyperoxaliuria (nephrolithiasis, chronic renal failure)
Hyperammoniaemia
Metabolic bone disease (osteoporosis, osteomalacia)
gram-positive colonic bacteria
ferment carbohydrate to D-lactic acid
Acidic environment
short-chain fatty acids
proliferation of the flora
Metabolic acidosis (encephalopathy, headaches, ataxia, dysarthria)
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18. 3 key points of management?
Management of gastric polyps
3 key points of management?
Nutrition / Supplementation of micronutrients
Maintaining fluid, electrolytes and acid/base balance
Avoid complications
Calories to be supplied:
Proteins to be supplied:
g/kg/day
25-30 kcal/kg/day
40-50% carbohydrates
20-30% proteins
20-40% lipids
Continous PN
Cyclic/discontinous PN
Continous enteral
Bolus enteral
Intravenous fluid
Oral rehidration fluid
(glucose-polymer based with sodium)
ORS ±
oral electrolyte suppl.
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19. Pharmacologic adjuncts in the management?
Management of gastric polyps
Pharmacologic adjuncts in the management?
1. glucagon-like peptide-2 (teglutide): promotion of adaption
2. loperamid, diphenoxylate, codein: anti-motility agents
3. octreotid: increasing the small bowel transit time (but also inhibits pancreatic secretions) only if > 3 L of iv. fluid intake is required
4. cholestyramine: binding bile salts in steatorrhea secondary to bile acid malabsorption
Cheng TT et al :Clinical and Experimental Gastroenterology 2011:4 189–196
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20. Two categories of surgical treatment options?
Management of gastric polyps
Two categories of surgical treatment options?
1. non- transplant
2. transplant
Aims of non-transplant surgical treatments?
Preserve intestinal remnant
minimize resrection, restore intestinal continuity, recruit additional intestine
2. Slow intestinal transit
(segmental reversal of intestine, colonic interposition)
3. Increase intestinal surface
(LILT = longitudinal intestinal lengthening and tailoring
with longitudinal devision of intestine and blood supply at the mesenteric border)
STEP = serial transverse enteroplasty)
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21. Surgical treatment of short bowel syndrome
Management of gastric polyps
Surgical treatment of short bowel syndrome
Indications for intestinal transplants?
Impending or overt liver failure (ESLD)
Thrombosis of major central venous channels
Frequent central line-related sepsis (>2 episodes/year)
Frequent severe dehydration
Diffuse mesenteric venous thrombosis with complications
3-year survival rate is better in combined transplantation
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22. Intestinal transplantation for SBS
Management of gastric polyps
Intestinal transplantation for SBS
Which effect has the combined transplant
on the rejection rate of intestinal transplants?
Acute and chronic rejection rate is lower in combined transplants
(liver+intestine, multivisceral)
Major complications and cause of death after intestinal transplantation?
Sepsis, MOF, rejection
3-year survival rate is better in combined transplantation
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