1. Dietetic Management of Short Bowel Syndrome
Ali Singer
Gastroenterology Specialist Dietitian
Frenchay Hospital

2. Content
Definition
Physiology
Management
Case Study

3. Definition
The reduction of functioning gut mass to below the minimum necessary for the absorption of nutrients and/or water and electrolytes Fleming & Remington, 1981

4. Variability in Intestinal Lengths
Small intestinal length at autopsy:
3-8.5m Bryant, 1924
Shorter in women
SBS more common in women (67%)
Small intestinal length at laparotomy:
n mean (cm) range (cm)
Cook,
Backman,
Slater,

5. Record of Intestinal Length
Length removed often recorded
Length remaining is more important:
Laparotomy
SB contrast studies (less accurate)
Nutritional/fluid supplements needed if
< 200cm SB

6. Causes of SBS Commonest causes: Crohns Superior mesenteric
artery thrombosis
Irradiation
Causes of SBS

7. SBS: Anatomy Mid-SB resection: Jejunocolic anastomosis:
Uncommon
Rarely problems
Jejunocolic anastomosis:
Usually fluid balance maintained
Nutritional issues when SB <100cm
Jejunostomy/high output enterocutaneous fistula:
Large stoma/fistula water and sodium losses
Dehydration
+/- nutritional problems

8. Types of Short Bowel Pt Groups Jejunum Ileum Colon Nutritional needs
Resected
Intact
Rarely need nutrition
Jejunum -colon
Gradual undernutrition
Adaption occurs
<50cm may need TPN
Jejunostomy
Resected / Absent
Absent
Fluid & electrolyte losses
No adaption
<100cm IV saline
<75cm IV nutrition also

9. Normal GI Physiology Ileum Jejunum Active Na+/H2O absorption
Less leaky
Na+ absorption
Large conc. gradient
Not dependent on H2O movement
Not coupled to gluc/AA absorption
Increased by Aldosterone
Jejunum
Na+/H2O secretion 1st 100cm
Leaky
Na+ absorption
Small conc. gradient only
Dependent on H2O movement
Coupled to gluc/AA absorption
Maximal Na+ absorption when [Na+] 120mmol/l

10. Normal GI Physiology Liquid Vol secreted (L) Vol absorbed(L) External
Food & drink 2
Salivary glands
Saliva
0.5-1
Stomach
Gastric juice
2-3
Pancreas
Pancreatic juice
Liver
Bile
Jejunum
Passive proximal secretion & distal absorption
1-2
Ileum
Active absorption
2-5, vit B12, bile salts
Colon
Large capacity
Faeces
400
Total
3-9

11. Gastrointestinal Motility
Jejunal-colon:
NORMAL
Jejunostomy:
FAST
Peptide YY and GLP-2 (glucagon-like peptide 2) are released when food passes the terminal ileum and caecum that act as ileal and colonic braking mechanisms; this is lost in jejunostomy

12. Physiological Consequences
Increased gastric emptying
Increased SB transit
Increased gastric secretions (first 2 wks)
Resection of ileal & colonic braking mechanism
Changes in GI hormones
Reduced peptide YY, glucagon like peptide 2
Increased gastrin

13. Critical Lengths Critical SB length Note Jejunostomy 100cm
More needed if diseased bowel
Jejunocolic anastomosis
~50cm
Depends on amount of residual colon

14. Nutritional Support and Bowel Length
Jejunal length
Jejunum-colon
Jejunostomy cm
Parenteral nutrition
Parenteral nutrition and saline +/- Mg cm
Oral / Enteral nutrition cm
Parenteral saline cm
None
Oral / enteral nutrition and glucose / saline solution cm
Oral / enteral glucose / saline solution

15. <200cm: restrict oral hypotonic fluids, sip glucose - saline supplement (100mmol/L Na, like jejunostomy fluid)
<100cm: parenteral saline
<50cm: parenteral nutrition and saline

16. GI Secretions Jejunum – colon Reabsorb unabsorbed fluid in colon
Jejunostomy
Salt and water loss from stoma
<100cm jejunum: losses > oral intake
Rapid sodium fluxes occur in jejunum
If water/solutions of <90mmol/L sodium are drunk a net efflux of sodium into the bowel lumen occurs until 100mmol/L is reached

17. Absorptive Functions
B12 and fat malabsorption occur if >60-100cm terminal ileum resected
Increased hepatic synthesis of bile salts cannot compensate; unabsorbed bile salts contribute to colonic secretion
Magnesium deficiency
Chelation of unabsorbed fatty acids reduces absorption
Increased renal excretion; secondary hypoaldosteronism

18. Hypomagnesaemia

19. Clinical Picture Water Na Mg Nutrition Thirst
Low BP/ postural hypotension
Urea/ Creatinine/ Potassium
Daily body weight
Fluid balance/ stoma output
Low urine volume
Urine Na 1-2/7, then weekly, as OP 2-3 monthly
Depletion if urine Na <10mmol
Serum magnesium
High stoma output
Sx in Mg < 0.6mmol/L
BMI <18.5kg/m2
Mid-arm muscle circumference <19cm:
<22cm men

20. Adaptive Processes Hyperphagia; increased food intake
Structural adaption:
increasing absorptive area
Functional adaption;
slowing gastrointestinal transit (gastric emptying and small bowel transit)
Occurs in jejunum-colon patients due to high peptide YY and GLP-2, leads to increased jejunal absorption of macronutrients (glucose, water, Na, Ca) and overtime may no longer need TPN

21. Jejunum-Colon Pts Post resection:
Parenteral fluids and nutrition (helps surgical repair, ileus recovery and avoids deficiencies)
6/12 PPI
Multivitamin
Long term:
Undernutrition
Diarrhoea due to malabsorption
Vitamin/mineral deficiency

22. Undernutrition >50% of energy from diet malabsorbed
High energy foods, sip feeds +/- NG/PEG feed; if fails TPN. Improves over time.
Long term TPN:
Absorption of <33% oral energy intake
Absorption 30-60%, high energy requirements
Large volume stomal output / diarrhoea
High carbohydrate, normal fat, low oxalate diet
Topical sunflower oil for essential fatty acids

23. The Fat Dilemma
But high carbohydrate without fat is unpalatable and fat yields twice as much energy as carbohydrate; also a low fat diet risks essential fatty acid deficiency.

24. Deficiencies Common: Rare: B12 deficiency; replace
Selenium deficiency; replace
Magnesium deficiency; replace if occurs
Vitamins D, E, A, K and essential fatty acids; replace
Rare:
Potassium deficiency
Zinc deficiency; rare unless large stool volumes
Water and sodium; rare as absorbed well in colon, if occurs sips of glucose saline drink

25. Other complications Diarrhoea Confusion Limit food intake
Consider loperamide 2-8mg 30mins pre meals, codeine 30-60mg 30mins pre meals
If >100cm terminal ileum resected cholestyramine for bile salt malabsorption and reduced oxalate absorption
Confusion
Hypomagnesaemia, thiamine deficiency, lactic acidosis (restrict mono / oligo saccharides) and hyperammonaemia (inadequate citrulline manufacture, Tx is arginine)

26. Gallstones (calcium bilirubinate stones)
Drug absorption
warfarin, digoxin, thyroxine, loperamide and if <50cm jejunum omeprazole may not be absorbed
Gallstones (calcium bilirubinate stones)
Bilary stasis. Therefore occurs in 45%, especially men
Tx IV amino acids, enteral feed, cholecystokinin injections, NSAIDS, ursodeoxycholicacid, metronidazole, cholecystectomy
Renal stones (calcium oxalate stones/nephrocalcinosis/CRF)
Occurs in 25% largely due to increased colonic absorption of oxalate
Social

27. Ca Oxalate Renal Stones

28. Jejunostomy Patient Issues
Salt and water depletion
May be large volume of stomal output
Greater volume lost after food or fluids
GI secretion  4L/day, majority absorbed in jejunum therefore more fluid losses via stoma if short jejunum
Jejunostomy fluid contains 100mmol/L Na, 15mmol/L K
If given hypotonic fluids  100mmol/L the mucosa allows leaking of fluid and electrolytes into the lumen
Low sodium levels are NOT SIADH but sodium depletion, this is resolved when urine Na  30mmol

29. Jejunostomy Patient Issues
Hypokalemia
Rare, occurs when <50cm jejunum
Usually due to secondary hypoaldersteronism from Na depletion
Can be due to hypomagnesaemia causing potassium channel dysfunction and increased renal potassium secretion which responds to Mg not K supplements
Hypomagnesaemia
B12 deficiency, confusion, drug absorption, and gall stones
Nutritional

30. High Output Jejunostomy
Exclude other causes of a high output
Stage1: Establish stability
Stage 2: Establish oral intake
Introduce enteral food/fluid/feed
Stage 3: Rehabilitation
Stoma care, HPN training, social issues
Stage 4: Long term care

31. Other Causes Intra-abdominal sepsis
Partial/intermittent bowel obstruction
Enteritis (clostridium, salmonella)
Recurrent disease in remaining bowel (Crohn’s, irradiation)
Bacterial overgrowth
Suddenly stopping drugs (steroids, opiates)
Giving prokinetics (metoclopramide)
Coeliac
Hyperthyroidism

32. Stage 1: Establish Stability
Severe dehydration & Na+ depletion
Keep patient NBM
IV normal saline (2-6L/day)

33. Treat the Cause Intraabdominal sepsis / abscess
Partial / intermittent bowel obstruction
Strictures; placement / muscle tunnel / adhesions / crohns / ischaemic fibrosis / radiotherapy
Enteritis; clostridium / salmonella / rota virus
Recurrent disease; Crohns / irradiation
Sudden stopping of drugs; steroids / opiates
Drugs; prokinetics / metoclopramide / metformin / PPI / statin
Diet; lactose intolerant / coeliac

34. Stage 2: Establish Oral Intake
Restrict oral fluids to <500ml/day
Hypotonic (water, tea, coffee, squash, alcohol)
Hypertonic (fruit juices, coca cola, sip feeds)
Drink a glucose-saline solution <500ml/day

35. Hypotonic Fluids 0 mmol Na+ High Output 100 mmol/L Na jejunum
Leaky
Small conc. gradient only
Dependent on H2O movement
Na 140 mmol/L
jejunum
Unable to maintain Na gradient
Electrolyte Mix
90 mmol Na+/L
Smaller volume
100mmol/L Na+
Na+ and H2O
Na+ 140 mmol/L

36. Oral Rehydration TherapyNa
(mmol/L) K
Glucose
Volume
(ml)
WHO 90 20
111
1000
Electrolyte mix
Dioralyte 60
200

37. Recipe: ORS 20g (6 teaspoons) glucose 3.5g (1 level 5ml teaspoon) salt
2.5g (1 heaped 2.5ml spoon) sodium bicarbonate
1L water
Add cordial, chill and drink through a straw

38. Drug Therapy Antimotility:
Loperamide upto 64mg PO o.d as decreased enterohepatic circulation
Codeine
Lomotil
Antisecretory:
Omeprazole; decreases gastric acid secretion
Ranitidine/cimetidine
Octreotide; decreases intestinal secretions
Vit/min supplements:
B12, selenium, Mg2+, vit A, D, E, K

39. Parenteral Therapy 0.5–1L saline sc +/- 4mmol MgSO4 1-3/week
1L saline IV +/ mmol MgSO4
> 3/ week
IVN

40. Outcome Aims Clinical: Measures: No thirst or signs of dehydration
Acceptable strength, energy and appearance
Measures:
Gut loss <2L/day
Urine volume >800ml/day
Urinary Na+ >20 mmol/L
Normal serum Na+, Mg2+ and K+
Body weight within 10% of normal

41. Stage 3: Rehabilitation
Transfer to IF unit
Wound healing
Stoma care
HPN training
1st patient 1978
Longest 27 years
Mean age 50.2 years (19.9 – 76.9)
~27 new patients per year per unit
Social issues

42. Stage 4: Long-Term Care 3 monthly multidisciplinary clinics IF unit
Shared care with local hospital

43. Outcome 1 year after starting HPN (467 patients)
BANS

44. Mr J: background information
72 male  UC (1961)
Pan-protocolectomy (1962)
Refashioned/Re-sited Ileostomy (1993)
s/b Dr Kaskey, Renal Physician 2º renal impairment and kidney stones
Referred from renal dietetic clinic (pt initially attempted to resist a referral!)

45. Issues High output ileostomy output (estimated up to 2.5L per day)
Dehydration ( UO,  urine Na)
Renal impairment & stone formation

46. Assessment: Concerns Renal impairment: * stage 4 CKD
Poor seal on stoma bags
Not leaving house when stoma active
Biochem
Result Na
134 K
3.5 Ur
20.0 
Creat
233 
eGFR*
25 
Uric Acid
0.64

47. Intervention Intervention Rationale 1. Add salt to meals
Increase Na intake (& serum Na)
2. Low fibre diet
 Insoluble fibre & residue through bowel
3. Restrict hypotonic fluids to 1L/d
Avoid drawing H20 (& Na) into the bowel
4. St Marks Fluid 1L/d
Promote H20/ Na absorption

48. 5. Loperamide 4m.g qds
Anti-motility agent
6. Forceval o.d
7. Check Mg and if deplete, convert Mg-glycerophosphate to Mg-oxide
On Mg supplements but levels not checked
Mg oxide has less diarrhoeal effect
8. Refer to MXL
Specialist f/u

49. Outcomes Outcome measures Biochemistry: Biochem 09.08.07 03.04.08 Na
134
142 K
3.5
4.7 Ur
20.0
12.9
Creat
233
202
eGFR 25 29
Uric Acid
0.64
0.41

50. Outcomes Reduction in stoma output Pt satisfaction Follow-up
 from ~ 2.5 L to < 1L /d
Thickened output (watery  porridge-like consistency)
Pt satisfaction
Practicalities in day-to-day management of stoma
Follow-up
Sole Dietetic f/u
Renal physician’s happy with progress

51. Thank-you
Any Questions?