1. Clinical Case Study: Short Bowel Syndrome
Amy Lofley
Clinical Update

2. Objectives Overview of Short Bowel Syndrome Multidisciplinary team
Terminology
Physiology
Pathophysiology
Treatment
Medication
Recommendations
Multidisciplinary team
Case Study
Medical Hx
Nutrition Assessment
Nutrition Intervention
Prognosis
Conclusion

3. Short Bowel Syndrome
Clinical Update

4. Terminology[1,2]
Short bowel syndrome (SBS): “inadequate functional bowel to support nutrient and fluid requirements for that individual, regardless of the length of the GI tract in the setting of normal fluid and nutrient intake”[1].
Ileocecal valve: valve at the end of the ileum that allows transit of small intestine contents into the large intestine.
Intestinal adaptation: “a growth process of the remaining small bowel through morphological and functional changes, leading to improved absorption”[2].
Dumping syndrome: rapid emptying of the stomach into the small bowel especially when simple carbohydrates are consumed

5. Normal Physiology [4,5]
The small intestine is the site of nutrient absorption.
Normal length of a small intestine varies between 300 to 800 cm in an adult and 250 cm in a term baby.
On average it absorbs g monosaccharides, g fatty acids, g amino acids and peptides and g ions.
Most absorption occurs in the ileum.
The first cm of jejunum is where carbohydrates, nitrogen and fat are absorbed.
The large intestine is the site at which water and salts are absorbed.
It is approximately 1.5 m in length and absorbs 500 to 1000 ml a day.

6. Normal Physiology [2] Bowel Segment Main function Duodenum
Absorption of CHO, FAT, PRO
Micronutrient absorption (iron, calcium, phosphorus, magnesium, copper, folic acid)
Jejunum
Primary site of CHO & PRO absorption
Water-soluble vitamin absorption
Ileum
Primary site of vitamin B12 and bile salt absorption
Absorption of fat-soluble vitamins
Colon
Fluid absorption
Na, Cl, K, and fatty acid reabsorption

7. Pathophysiology [2,4] Decreased ability for bowel to absorb normally.
Signs and symptoms
Diarrhea
Weight loss
Dehydration
Nutritional deficiencies
Electrolyte imbalances
The health and amount of remaining small bowel will determine the type of nutrition support a patient will require both short term and long term.

8. Pathophysiology [3]
Other portions of the small intestine will adapt absorption abilities for the removed portions.
The jejunum and ileum are the most important for absorption. The jejunum is more adaptive to absorption problems than the ileum.
The length of ileum that is left will determine the absorption of vitamin B12 and fat malabsorption.
If no ileum is left a patient may be dependent on TPN.
The presence or absence of the ileocecal valve will affect transit time, ostomy, how fluid is managed, and if small bowel bacteria will grow.

9. Pathophysiology [2] Bowel Segment Complications of Resection Duodenum
Decreased macronutrient digestion
Acidosis, anemia, osteopenia
Jejunum
Macronutrient and water-soluble vitamin malabsorption
Fluid and electrolyte losses
Ileum
Unable to absorb B12
Loss of fat-soluble vitamins
Decreased absorption of trace elements
Increased risk of renal oxalate stones
Colon
Dehydration
Electrolyte abnormalities
Reduce ability to absorb bile salts

10. Pathophysiology [2,5]
Recovery from bowel surgery can vary in length of time depending on:
Age
Comorbidities
Preexisting malnutrition
Primary diagnosis
Loss of ileocecal valve
Length of remaining bowel
Adaptation can begin within 48 hours and continue months after surgery.
Adaptation occurs by the bowel lengthening and becoming thicker with a larger diameter.

11. Types of resections

12. Etiology of SBS [1,] Children Adults Necrotizing enterocolitis (NEC)
Intestinal atresia (volvulus, hernia, intussusception)
Congenital short bowel syndrome
Trauma
Gastroschisis
Apple peal anomaly
Crohn’s disease
Abdominal tumors
Radiation enteritis
Hirschsprung’s disease
Adults
Massive surgical resection
Crohn’s
Malignancy
Radiation enteritis
Trauma
Vascular catastrophies (embolism/thrombus)
Volvulus
Stangulated hernias
SB fistulas
Surgical bypass
Surgical error or obesity treatment
Chronic intestinal pseudo-obstruction

13. Medical Treatment [7,4]
Two treatment therapies: Pharmocotherapy and Medical Nutrition Therapy
Pharmocotherapy includes antimotility agents, antisecretory agents, H2 Blockers, and IVs
MNT includes TPN, EN, and oral feeds, as well as educating patient on how to eat and care for nutrition support.
SNAPP is an acronym to help remember how SBS is treated
S=sepsis – treated with antibiotics and CT scan
N=nutrition – hydration is the fist concern, enteral nutrition is the preferred feeding. First line of feeding is TPN and then weaned to tube feeding and then oral feedings if feasible
A=anatomy – knowing the anatomy helps to determine treatment and side effects
P=protect the skin – if a stoma is created wound care needs to be taught
P=planned surgery – additional surgeries for further resection, stoma care, and fistulas.

14. Medication uses

15. Medical Treatment [8]
TPN is needed immediately after surgery to maintain fluid and electrolytes until bowel function returns.
Should begin within the first 24 hours and is usually required for the first 7-10 days.
TPN energy requirements: kcal/kg/day with g/kg/ day protein
EN feedings are started within 2-3 days after surgery or fluid and electrolyte losses are reduced and patient is stable. Start with trickle feeds and advanced as tolerated about every 3-7 days.
Lactose free formulas are usually suggested to decrease lactose malabsorption and symptoms.
“Management includes meticulous nutritional support, with emphasis on early advancement of enteral feeds, weaning from parenteral nutrition, monitoring for complications, and addressing possible associated liver dysfunction”

16. Practice Recommendations [1,4]
The ability to return to a normal diet is determined by the amount of remaining bowel, presence of a colon, and an intact ileocecal valve.
Oral rehydration solutions may be required if less than 100 cm of jejunum remains to help absorb sodium.

17. Practice Recommendations [7]
Nutrient
Small Bowel Ostomy
Colonic continuity
Carbohydrates
50% of total energy complex carbohydrates including soluble fiber, limit simple sugars
50-60% of total energy complex carbohydrates, including soluble fiber
Proteins
20-30% of total energy
Fats
<40% of total energy
Fluids
ORS important; minimize fluids with meals, sipping of fluids between meals
Minimize fluids with meals, sipping of fluids between meals
Vitamins
Daily multivitamin with minerals; monthly B-12; possibly vitamins A, D, and E supplements
Daily multivitamins with minerals; possibly B-12; possibly vitamins A, D, and E supplements
Minerals
Generous use of sodium chloride on food; calcium 1,000-1,500 mg daily, possibly iron, magnesium and zinc supplements
mg calcium with meals; possibly iron, magnesium, and zinc supplements; reduced oxalate
Meals
4-6 small meals
3 small meals plus 2-3 snacks

18. Evidence-Based Practice

19. Practice Recommendations [7,1]
“The goal of therapy is to maximize small bowel absorption of fluids and nutrients to prevent deficiencies and dehydration”(7).
The optimal diet for individuals with jejunostomies includes:
50% CHO
20-30% protein
≤40% fat.
Including foods high in fiber to help slow gastric emptying, transit time, and thicken ostomy effluent.
The optimal diet for individuals with intact colon includes:
A diet high in complex CHO, and lower in fat with a distribution
50-60% CHO
20-30% fat.
It is best to avoid foods and drinks that are high in simple sugars to prevent dumping syndrome

20. Dietary advice [1] Proper eating techniques Oral diets Eating slowly
Resting after eating
Minimal fluid with meals
Proper preparation of ORS if required
Avoid sweets
Liberal use of salt – encourage salty foods and the salt shaker
Fiber is needed for patients with a colon
Lactose should be no more than 20 g/day
Oral diets
Patients may need % more than their needs to take into account malabsorption
A higher carbohydrate diet is recommended for those with a colon whereas a higher fat, low carbohydrate diet is needed in patients with jejunostomies.

21. Multidisciplinary team
Physician
Hospitalist
Infectious Disease
Surgeon
Registered Dietitian
Metabolic Nurse
Nurses
Pharmacist

22. Case Study

23. Mrs. E Age: 66 YOF Presents to hospital with nausea and vomiting
Medical Diagnosis
Colitis

24. Past Medical/Surgical/social History
Past Medical History
COPD
Perforated diverticulitis w/colostomy (now reversed)
HTN
GERD
Breast Cancer
Past Surgical History
Exploratory lap and resection
Hysterectomy
Mastectomy
Social History
Smoke one pack/day
Occasional alcohol use

25. Initial Nutrition Assessment (9/2/13)
Labs
Albumin 2.4 L
Phosphorus 8.6 H
Ammonia 149 H
Glucose 220 H
Energy and protein needs (based on facility guidelines)
Calorie needs: kcals (11-14 kcals/ kg)
Protein needs: 118 g (2 g/kg IBW)
Carbohydrate needs: 147 g (50%)
Fluid Needs: 1500 mL
Assessment
Abdominal pain
Constipation
Vomiting
Diet order: NPO
Colitis that may need surgery
Patient is intubated
fragile skin
Anthropometrics
Height: 66 inches
Height: kg
BMI = 33.4
IBW = 59 kg
%IBW = 159%

26. Nutrition diagnosis
Inadequate protein-energy intake RT GI/oral complaints, alteration in GI tract structure and/or function, sedated on ventilator, distention, no bowel sounds, constipation AEB 0% meal, NPO diet restriction, inadequate protein possible d/t surgery pending.

27. Nutrition Intervention/monitor/evaluate
TF – continuous; Osmolite with start rate of 10 mL/hour (goal rate 10 mL/hour).
Provides kcals, 8 g protein
Goal: Tube feeding will meet 50% of estimated needs within 2-3 days
Monitor/Evaluate
Monitor rate for start
GI function/tolerance
Labs (sodium, glucose, phosphorus, potassium, magnesium, intake, output)
Status
weight

28. medications Medication Use Nutrition Interaction Propofol Sedative
Provides 1.1 kcals/ml
Levophed
Used for hypotension or removing blood flow to the GI tract
Don’t feed while one this medication
Cipro
Antibiotic
Vancomycin
Zosyn

29. 9/3/13 Nutrition follow up Diet order: NPO
Nutrition Dx: Inadequate protein energy intake
Meds: 12.3 mL/hour = 325 kcal
mcg/kg/min
Cipro, vancomycin, flagyl, zosyn
Wt: 216 lbs. 9# weight gain in 1 day
Labs
Potassium 3.2; Ammonium 43; Fasting Glucose 173; intake 8729; output 1485 (og=300, stool-50)
Total colectomy, ileostomy, w/jejunostomy (gangrene bowel)
Goal: Tube feeding will meet 50% of estimated needs within 2-3 days
Monitor: GI function/tolerance, labs, weight
Follow up daily

30. 9/4/13 Nutrition follow up Diet order: NPO
Nutrition Dx: Inadequate protein-energy intake
Meds: 14 mL/hour = 370 kcals
Labs
Potassium 3; phosphorus 1.7; Ammonium 38; Fasting Glucose 196; intake 7209; output 3450 (og =800; ileo=150)
Patient remains intubated, s/p colectomy secondary to ischemia, viable ileostomy (95 cmsm bowel from ligament of treitz)
Goal: trickle feeding vs. PN start over next 2 days
Coordination of care: surgery notes may start PN in next 24 hours.

31. 9/5/13 Nutrition follow up Diet order: NPO
Nutrition Dx: Inadequate protein-energy intake
Meds: 16.8 mL/hour 443 kcals
Labs
Phosphorus 1.9; Magnesium 1.5; Fasting Glucose 180; intake 6087; output 4590
Energy: kcals, 118 g protein
Goal: tolerate at least 50% of needs as PN over next 2 days
Initiate PN: plan PN goal of 119 g protein (33.5%), 160 g CHO (39%), 39 g fat (27.5%) to provide ~ 1400 kcal
Tkcals provided plus meds=1255 kcals, 0 g lipids, 118 g protein, 100 g CHO
Coordination of care: noted surgery plans to start PN, discussion of low rate EN but not yet ordered
Monitor progression of diet vs. alternative nutrition
Follow up daily

32. 9/6/13 Nutrition follow up Diet Order: NPO
Nutrition Dx: Inadequate protein-energy intake
Meds: 16.8 mL/hour 443 kcals
Enteral kcals = 443 from propofol
PN not started
Wt kg
Labs
Potassium 2.6; Magnesium 1.7; Fasting glucose 102; intake 2605; output 3751; lactic acid 1.5 (ileo 605, g 250)
PN not started secondary to only a femoral line and plans for PICC placement
Energy kcals 118 g protein

33. 9/6/13 Nutrition follow up
Goal: tolerate at least 50% PN/EN over 2 days
Initiate EN osmolite at 10 mL/hour; 0 mL flush
Patient with short gut syndrome start trickle feed via g-tube and monitor
Initiate PN at goal except CHO at reduced rate, hold lipids secondary to med rate
Provides 118 g protein, 120 CHO, 1400 kcals
Coordination of care: discussed start of trickle feeding with intensivist; plan to start PN after PICC
Monitor progression of diet vs. alternative nutrition
Follow up 3-4 times/week

34. 9/7/13 Nutrition follow up Diet order: NPO
New PES: Altered GI tract RT alteration in GI tract structure and function AEB short gut syndrome, malabsorption
Goal: Moving forward with PN to provide at least 75% of needs w/meds over the next 1-2 days.
Meds: 19 ml/hr = 501 kcals
PN: 120 g CHO (75%), 118 g pro (100%), 0 g lipids, 1440 volume
Wt.: 108 kg, wt decreased 2 kg over 1 day (lasix is noted in meds)
Labs: alb 2.8, phos 3, mag 2.4, FSBS 171, intake 1439, output 2835, ileo out 1100
Increase EN to today with no flush
Total kcals with meds is 508, total protein 18 g
PN: decrease CHO to 50%, increase in TF and elevated BG, will also decrease pro d/t increase in TF
Total kcals with meds is 1173, 0 g lipids, 100 g protein, 80 g CHO
Collaborated with physician: discussed TF advancement, per MD will increase TF to 20 ml/hr at 2000 (24 hr after initial start)
Monitor GI function/tolerance and labs daily
Total: 1424 kcals (100%), 118 g pro (100%), meets 72 of CHO needs

35. 9/8/13 Nutrition follow up EN: osmolite @ 20 ml/hr w/o flush
Total kcals with meds: 508 and 18 g protein
PN: propofol 19ml/hr = 501 kcals total kcals= 1173
80 g CHO (50%), 100 g pro (85%), 0 g lipids
Wt.: kg,
Labs: alb 2.7, pot 3.9, FSBS 178, phos 5.2, alk phos wdl
Tolerating nutrition regimen ileo out 815, residue 100 ml
Goal: PN + TF to provide % estimated needs of 1317 kcal, 118 g protein
Collaborate with other disciplines: discussed poc with MD, once osmolite bag empty change to “a more calorie dense formula” per MD request
Monitor GI function/tolerance and labs daily

36. 9/9/13 Nutrition follow up Meds: pepcid, lasix, prednisone, zosyn
Wt. 228# weight loss of 6# in 1 day
Labs: prealb 17.7, BUN 42, Na 146, FSBS 208, intake 2580, output 5131 (stool=435, g-tube=100), CVP 14
Tolerating GI
Goal: PN+TF to provide % estimated needs and protein within 24 hrs
EN: change formula to 30 ml/hr w/o flush
936 kcals, 48 g prot, MD was more calorie dense formula
PN: change tkcals 871, 70 g protein
Total for TF+PN +meds = 1807 kcals, 118 g pro, 59 g lipids, 130 g CHO
Monitor GI, labs, skin and weight daily

37. 9/10/13 Nutrition follow up Labs: intake 3454, output 5380 (stool=590)
Tolerating GI, no change to needs
Goal: meet % estimated kcal and protein needs via tube feeds next hrs.
EN: change to 40 ml/hr (increased by MD) no flush 1248 kcals, 64 g prot, 173 g CHO
PN: change secondary to change in TF rate, meds: 287 kcals 54 g prot, 21 g CHO (per discussion w/Rph- needs small amount for compounder)
Monitor GI, labs, skin and weight daily

38. 9/11/13 Nutrition follow up Diet order: Clear liquids
Pt took 100% jello and juice this a.m.
Meds: lasix, prednisone, zosyn
Wt. 204#, 24# weight loss in 2 days (diuresing)
Labs: FSBS 144, intake 2949, output 6125, ileo=900
Tolerating GI
Energy needs reassessed: (18-20), 118 g pro (2g/kg IBW), 220 g CHO (50%), fluid 1ml/kcal
New goal: Meet 100% estimated calories and protein needs via TF +po diet within next hrs.
EN: 40 ml/hr with 3 prostat 1548 kcals (93%), 109 g prot (92%)
Collaborated with MD, MD wants to add prostat to tube feeds today, but continue TPN for 2 days and begin clear liquids
PN: continue PN w/protein reduced to 50% from yesterday: 35 g protein=140kcals and 21 g CHO=71 kcals
Coordination of care: pt will get 1759 kcals (100%) and 144 g protein (122%)
Monitor GI, labs, PO, skin and weight daily

39. 9/12/13 Nutrition follow up Diet order: Regular
Labs: Na 139, K 4.3, FSBS 141, output 3150, ileo 1700
Tolerating GI
Goal: TF + po to meet at least 100% needs: not met (however 100% kcal pro needs met with TPN+TF)
TPN to discontinue today, diet advanced to regular today, anticipate goal met in next 1-2 days.
Supplement: Ensure BID = provides 700 kcal, 27 g pro
EN: continue at current rate: 40 ml/hr with 3 prostat : 1548 kcals (93%), 108 g prot (92%)
PN: Stop
Monitor GI function/tolerance, PO adequacy dily
Anticipate oral intake to slowly increase over the next 1-2 days, for now will keep TF at current goal
Pt discharged prior to F/U

40. Expected Outcomes Prognosis is good with a full recovery.
Pt left with TF and oral diet

41. Lessons Learned
SBS management is very complicated and needs careful management by a team including: physician, dietitian, surgeon.
The amount of bowel resected affects when and how a patient can be fed
It is very important to know the exact amount of bowel left and what sections they are.
Things I would have done differently
When doing this assessment I would probably explain more the amount of bowel left.
Educate the patient on how they are supposed to eat.
Recommend using a standard formula such as Isosource that has a higher calorie instead of perative.

42. References
Parrish CR. The clinician’s guide to short bowel syndrome. Nutrition Issues in Gastroeneterology 2005;(31):
Nutrition Care Manual. Short Bowel Syndrome.
Nutrition Care Manual. Bowel Resection.
Peck J, Soo L, Boland L, Windsor A, Engledow A. Short bowel syndrome: the pathophysiology and treatment. Gastrointestinal Nursing. 2012;10(2):32-38.
Krause
Rahhal RM. Short Bowel Syndrome. Chapter
Wall EA. An overview of short bowel syndrome management: adherence, adaptation, and practical recommendations. Journal of the Academy of Nutrition and Dietetics
Donohoe CL, Reynolds JV. Short Bowel Syndrome. The Surgeon. 2010:
Seetharam P, Rodrigues G. Short bowel syndrome: a review of management options. Saudi J Gastroenterol. 2011;17: