Elsevier

The Surgeon

Volume 8, Issue 5, October 2010, Pages 270-279
The Surgeon

Short bowel syndrome

https://doi.org/10.1016/j.surge.2010.06.004Get rights and content

Abstract

The short bowel syndrome (SBS) is a state of malabsorption following intestinal resection where there is less than 200 cm of intestinal length. The management of short bowel syndrome can be challenging and is best managed by a specialised multidisciplinary team. A good understanding of the pathophysiological consequences of resection of different portions of the small intestine is necessary to anticipate and prevent, where possible, consequences of SBS. Nutrient absorption and fluid and electrolyte management in the initial stages are critical to stabilisation of the patient and to facilitate the process of adaptation. Pharmacological adjuncts to promote adaptation are in the early stages of development. Primary restoration of bowel continuity, if possible, is the principle mode of surgical treatment. Surgical procedures to increase the surface area of the small intestine or improve its function may be of benefit in experienced hands, particularly in the paediatric population. Intestinal transplant is indicated at present for patients who have failed to tolerate long-term parenteral nutrition but with increasing experience, there may be a potentially expanded role for its use in the future.

Introduction

The short bowel syndrome is a malabsorptive state usually following massive resection of the small intestine.1 It generally occurs when there is less than 200 cm of bowel in situ.2 Intestinal failure may be defined as a condition where faecal energy loss occurs and the patient is unable to increase oral intake or absorptive capacity sufficiently to maintain their nutritional status by the enteral route alone. These patients may become dependent on parenteral nutrition support to maintain their energy balance. Malabsorption of macronutrients and micronutrients may predominate as a clinical manifestation, whereas other patients may struggle to maintain fluid and electrolytes homeostasis.

Newer definitions of the syndrome have been proposed in order to better define and diagnose patients according to their likely requirement for surgical intervention and to evaluate new therapies.1 These definitions are included in Table 1.

Section snippets

Epidemiology

The exact population prevalence of the syndrome is unknown. However, this may be estimated from numbers of patients on home total parenteral nutrition–of whom approximately one quarter to one-third have short bowel syndrome. Thus the estimated population prevalence is approximately 1 per million.3 SBS is more likely to occur in women (2:1), most likely due to the shorter length of the small intestine in women.4

Short bowel syndrome (SBS) results from resection of unviable intestine secondary to

Pathophysiology

Consequences of the SBS arise from an inability to absorb adequate macro- and/or micronutrients. There may be an inability to maintain nutritional intake and this may include vitamin and mineral deficiencies or could result in fluid and electrolyte imbalances. Additionally, loss of gastrointestinal hormonal production may alter bowel motility, transit and gastroduodenal emptying. The degree of functional impairment is dependent on a number of factors: length of intestine, segments of intact

Adaptation

Following resection of large amounts of small intestine, the gastrointestinal tract undergoes a process of adaption whereby the ileum can increase slightly in length and diameter and adapts functionally to absorb macronutrients. This evolves over a one to two year period. Experimental models show epithelial hyperplasia 24–48 h after resection.16, 17, 18 The length of villi and thus the absorptive area increases. Animal models show that this process is stimulated by enteral nutrition by

Prognosis

The likelihood of being able to resume a normal oral diet after resection of large amounts of the small bowel can be predicted by certain parameters. Factors favouring the ability to resume oral nutrition include adequate length of the remaining bowel; the presence of colon and intact ileocaecal valve, and co-morbidities. The prognosis may be good where there is an intact duodenum, a jejunal length of greater than 200 cm, and an intact colon. The likelihood of requiring long-term parenteral

A: Early

Early complications include dehydration and electrolyte derangements. Intra-venous fluid supplementation (to either enteral or parenteral nutrition) may be required to maintain the patient’s hydration status. In particular, magnesium, calcium and potassium may be difficult to control in patients with SBS.

Electrolytes are secreted in high concentrations by the jejunum and ileum and if there is inadequate intestinal length, there may be net electrolyte losses. Knowledge of electrolyte physiology

Management strategy

The goal of management of patients with short bowel syndrome is to allow them resume a normal lifestyle. To that end the provision of adequate macro- and micronutrients and sufficient fluid to prevent dehydration are basic pre-requisites. It is important to correct and prevent acid-base disturbances. Steps in the management of SBS are summarised in Fig. 1.

Surgical treatment options

Broadly speaking there are two categories of surgical management in short bowel syndrome: transplant and non-transplant. Non-transplant options aim to increase nutrient and fluid absorption by wither restoring intestinal continuity or by slowing intestinal transit or increasing intestinal surface area.60 In a series of 160 patients with SBS from one centre, 28% underwent surgical treatment.60 Patients selected are usually those dependent on parenteral nutrition.61 In general terms the patient

References (85)

  • E.J. Feldman

    Effects of oral versus intravenous nutrition on intestinal adaptation after small bowel resection in the dog

    Gastroenterology

    (1976)
  • P.B. Jeppesen

    Glucagon-like peptide 2 improves nutrient absorption and nutritional status in short-bowel patients with no colon

    Gastroenterology

    (2001)
  • C.D. Liu

    Epidermal growth factor improves intestinal adaptation during somatostatin administration in vivo

    J Surg Res

    (1996)
  • J.A. Vanderhoof

    Effects of dietary menhaden oil on mucosal adaptation after small bowel resection in rats

    Gastroenterology

    (1994)
  • I. Vantini

    Survival rate and prognostic factors in patients with intestinal failure

    Dig Liver Dis

    (2004)
  • B. Messing

    Long-term survival and parenteral nutrition dependence in adult patients with the short bowel syndrome

    Gastroenterology

    (1999)
  • P. Crenn

    Postabsorptive plasma citrulline concentration is a marker of absorptive enterocyte mass and intestinal failure in humans

    Gastroenterology

    (2000)
  • P. Crenn et al.

    Citrulline as a biomarker of intestinal failure due to enterocyte mass reduction

    Clin Nutr

    (2008)
  • C. Chung et al.

    Postoperative jaundice and total parenteral nutrition-associated hepatic dysfunction

    Clin Liver Dis

    (2002)
  • S. Chan

    Incidence, prognosis, and etiology of end-stage liver disease in patients receiving home total parenteral nutrition

    Surgery

    (1999)
  • M. Gracey

    The contaminated small bowel syndrome: pathogenesis, diagnosis, and treatment

    Am J Clin Nutr

    (1979)
  • S.F. Taylor

    Noninfectious colitis associated with short gut syndrome in infants

    J Pediatr

    (1991)
  • M.L. Halperin et al.

    D-lactic acidosis: turning sugar into acids in the gastrointestinal tract

    Kidney Int

    (1996)
  • C.I. Obialo

    Pathogenesis of nephrolithiasis post-partial ileal bypass surgery: case-control study. The POSCH Group

    Kidney Int

    (1991)
  • J.S. Scolapio et al.

    Short bowel syndrome

    Gastroenterol Clin North Am

    (1998)
  • G.P. Bongaerts et al.

    Arguments for a lower carbohydrate-higher fat diet in patients with a short small bowel

    Med Hypotheses

    (2006)
  • F. Joly

    Tube feeding improves intestinal absorption in short bowel syndrome patients

    Gastroenterology

    (2009)
  • M.I. Spagnuolo

    Ursodeoxycholic acid for treatment of cholestasis in children on long-term total parenteral nutrition: a pilot study

    Gastroenterology

    (1996)
  • D. Seguy

    Low-dose growth hormone in adult home parenteral nutrition-dependent short bowel syndrome patients: a positive study

    Gastroenterology

    (2003)
  • J.S. Scolapio

    Effect of growth hormone, glutamine, and diet on adaptation in short-bowel syndrome: a randomized, controlled study

    Gastroenterology

    (1997)
  • J.S. Scolapio

    Effect of glutamine in short-bowel syndrome

    Clin Nutr

    (2001)
  • S.J. O’Keefe

    Long-acting somatostatin analogue therapy and protein metabolism in patients with jejunostomies

    Gastroenterology

    (1994)
  • J. Thompson et al.

    Intestinal lengthening for short bowel syndrome

    Adv Surg

    (2008)
  • A. Bianchi

    From the cradle to enteral autonomy: the role of autologous gastrointestinal reconstruction

    Gastroenterology

    (2006)
  • V.F. Garcia

    Colon interposition for the short bowel syndrome

    J Pediatr Surg

    (1981)
  • P.L. Glick

    Colon interposition: an adjuvant operation for short-gut syndrome

    J Pediatr Surg

    (1984)
  • B.A. Jones

    Autologous intestinal reconstruction surgery

    Semin Pediatr Surg

    (2010)
  • R.M. Devine et al.

    Surgical therapy of the short bowel syndrome

    Gastroenterol Clin North Am

    (1989)
  • B.P. Modi

    First report of the international serial transverse enteroplasty data registry: indications, efficacy, and complications

    J Am Coll Surg

    (2007)
  • T. Kaji

    Nutritional effects of the serial transverse enteroplasty procedure in experimental short bowel syndrome

    J Pediatr Surg

    (2009)
  • E.A. Pomfret

    Liver and intestine transplantation in the United States, 1996-2005

    Am J Transpl

    (2007)
  • H. Bakker

    Home parenteral nutrition in adults: a european multicentre survey in 1997. ESPEN-Home Artificial Nutrition Working Group

    Clin Nutr

    (1999)
  • Cited by (50)

    • Short Bowel Syndrome

      2019, Shackelford's Surgery of the Alimentary Tract: 2 Volume Set
    • Bioelectrical impedance vector analysis as a useful predictor of nutritional status in patients with short bowel syndrome

      2017, Clinical Nutrition
      Citation Excerpt :

      However, BIVA analysis identified that most SBS patients does not have adequate hydration (body water) and amount of soft tissue (fat free mass). Short bowel syndrome culminates in extensive loss of the absorptive area which may lead to nutrient, electrolyte and fluid malabsorption [19,20], and consequently to disturbances in the fluid homeostasis, diarrhea and weight loss [21]. In this context, malnutrition is present after major intestinal resections and the assessment of the nutritional status of these patients is of utmost importance [22].

    • Chronic Diarrhea: Diagnosis and Management

      2017, Clinical Gastroenterology and Hepatology
      Citation Excerpt :

      SBS occurs after resection of a large proportion of the small intestine. SBS is not likely if >200 cm of small intestine remains,44 although longer lengths will not protect against SBS if the remaining bowel is abnormal (eg, Crohn’s disease or radiation enteritis). In SBS, the remaining absorptive surface is insufficient to preserve nutrient, fluid, and/or electrolyte homeostasis.44

    View all citing articles on Scopus
    View full text