Short bowel syndrome
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.
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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
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2017, Clinical NutritionCitation 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].
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2017, Clinical Gastroenterology and HepatologyCitation 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