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

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Presentation on theme: "Short bowel syndrome Dr. Henrik Csaba Horvath Bible class February 20, 2013."— Presentation transcript:

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

2 Titel der Präsentation / Name Referent/-in2 Klinik- bzw. Direktionsname 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

3 Titel der Präsentation / Name Referent/-in3 Klinik- bzw. Direktionsname 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

4 Titel der Präsentation / Name Referent/-in4 Klinik- bzw. Direktionsname Major causes of SBS in adults? Postoperative complications Irradiaton/cancer Mesenteric valvular disease (mesenteric ischemia) Crohn`s disease Trauma

5 Titel der Präsentation / Name Referent/-in5 Klinik- bzw. Direktionsname Which factors are associated with worse prognosis in patients with SBS? Total parenteral nutrition < 50 cm intact bowel Enterostomy Radiation or ischemic enteritis

6 Titel der Präsentation / Name Referent/-in6 Klinik- bzw. Direktionsname Which factors have impact on the outcome of SBS? Presence/abscence of ileocaecal valve Outcome of SBS Length of the remaining intestine Segment of intact bowel (jejunum vs. ileum, colon continuity) Absorptive quality of the remnant bowel Presence of residual underlying disease (e.g.Crohn`s) Age/BMI of the patient State of other digestive organs Efficacy of nutrition support Pharmacologic therapy

7 Titel der Präsentation / Name Referent/-in7 Klinik- bzw. Direktionsname How does affect the remnant length the risk of developing SBS? AnastomosisPLUS length of residual small intestine Duodenostomy or jejunoileal< 35 cm Jejunocolic or ileocolic< 60 cm End jejunostomy< 115 cm Patients at highest risk of developing SBS are

8 Titel der Präsentation / Name Referent/-in8 Klinik- bzw. Direktionsname Which impact has on absorption the resection of… Loss of the major intestinal absorption area Loss of digestive enzymes Loss of GI feedback hormones (gastric emptying) Jejunum: Ileum: Loss of the absorption of jejunal secretion Loss of absorption of vitamin B 12 Loss of absorption of bile salts (fat malabsorption)

9 Titel der Präsentation / Name Referent/-in9 Klinik- bzw. Direktionsname 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

10 Titel der Präsentation / Name Referent/-in10 Klinik- bzw. Direktionsname 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 Up to 70% can do without TPN due to these mechanisms

11 Titel der Präsentation / Name Referent/-in11 Klinik- bzw. Direktionsname 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

12 Titel der Präsentation / Name Referent/-in12 Klinik- bzw. Direktionsname Measurement of the functional capacity of the small intestine? 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)

13 Titel der Präsentation / Name Referent/-in13 Klinik- bzw. Direktionsname Two major groups of complications of SBS? dehydration electrolyte derangements (Mg, Ca, K) Diagnosis:urinary electrolyte levels (plasma can be normal!) Treatment:sustained correction due to slow cellular uptake TPN-related bacterial overgrowth micronutrient deficiency metabolic Early complications: Late complications:

14 Titel der Präsentation / Name Referent/-in14 Klinik- bzw. Direktionsname TPN-related late complications of SBS are… gallstones, cirrhosis (IFALD) end-stage liver cirrhosis in 15% of pts after one year TPN 100% mortality rate within 2 yrs infection: one-third of deaths in 50% 5-yr-mortality rate in SBS thrombosis (v. cava superior): 0.2/1000 catheter days 1. Due to bypass first pass liver metabolism: 2. Catheter-associated complications: steatosischolestasis

15 Titel der Präsentation / Name Referent/-in15 Klinik- bzw. Direktionsname 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

16 Titel der Präsentation / Name Referent/-in16 Klinik- bzw. Direktionsname Which are the most common micronutritient deficiencies as late complications of SBS? 2. fat-soluble vitamins (A,D,E,K) 3. vitamin B folate (if >60 cm of terminal ileum resected) (if proximal jejunum resected) 1. Mg, Ca, Zn, Se MicronutrientsRecommended dose /day Vitamin A units Vitamin B12300 μg/month Vitamin C mg Vitamin D1600 U Vitamin E30 IU Vitamin K10 mg/week Calcium mg MagnesiumAs needed IronAs needed Selenium μg Zinc mg BicarbonateAs needed

17 Titel der Präsentation / Name Referent/-in17 Klinik- bzw. Direktionsname The most common metabolic complications of small- bowel syndrome? 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) 1.Metabolic acidosis 2.Hyperoxaliuria (nephrolithiasis, chronic renal failure) 3.Hyperammoniaemia 4.Metabolic bone disease (osteoporosis, osteomalacia)

18 Titel der Präsentation / Name Referent/-in18 Klinik- bzw. Direktionsname 3 key points of management? 1.Nutrition / Supplementation of micronutrients 2.Maintaining fluid, electrolytes and acid/base balance 3.Avoid complications Calories to be supplied : kcal/kg/day Proteins to be supplied: g/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.

19 Titel der Präsentation / Name Referent/-in19 Klinik- bzw. Direktionsname Pharmacologic adjuncts in the management? 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 1. glucagon-like peptide-2 (teglutide): promotion of adaption Cheng TT et al :Clinical and Experimental Gastroenterology 2011:4 189–196

20 Titel der Präsentation / Name Referent/-in20 Klinik- bzw. Direktionsname Two categories of surgical treatment options? 2. transplant1. non- transplant 1.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) Aims of non-transplant surgical treatments?

21 Titel der Präsentation / Name Referent/-in21 Klinik- bzw. Direktionsname Surgical treatment of short bowel syndrome Indications for intestinal transplants? 1.Impending or overt liver failure (ESLD) 2.Thrombosis of major central venous channels 3.Frequent central line-related sepsis (>2 episodes/year) 4.Frequent severe dehydration 5.Diffuse mesenteric venous thrombosis with complications

22 Titel der Präsentation / Name Referent/-in22 Klinik- bzw. Direktionsname Intestinal transplantation for SBS Which effect has the combined transplant on the rejection rate of intestinal transplants? Major complications and cause of death after intestinal transplantation? Acute and chronic rejection rate is lower in combined transplants (liver+intestine, multivisceral) Sepsis, MOF, rejection

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