Short Bowel Syndrome

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Short Bowel Syndrome

• Anne Aspin 2005

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Definition

• Rickham (1967) an extensive resection to
  maximum of 75cm
• Kuffer (1972) 15cm with ileocaecal valve
• - 38cm without ileocaecal
  valve
• Dorney (1985) 11cm with I/C valve or 25cm
  without I/C valve

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Introduction

• Most common cause of intestinal failure.
• NEC, Congenital atresia, Gastroschisis and
  volvulus.
• Promote adaptive response through enteral feeding
  and careful management of TPN.

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The Digestive System

• Digestion starts in the mouth
• Moisten by saliva (contains Pytalin), begins to
  turn starch to sugar.
• In stomach food churned mixes with gastric juices.

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Gastric juices

• Acid reaction
• Kills bacteria
• Controls pylorus

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• Gastric juices
• - Rennin coagulates milk
• - Hydrochloric Acid Converts Pepsinogen to
  Pepsin.
• - Pepsin turns protein to peptone

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• Food is released in small amounts by relaxation
  of the sphincter passing onto Duodenum.
• Food further digested by Trypsin, Amylase and
  Lipase.
• Digestion completed in small intestine.

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Intestinal juices.

• Enterokinase pancreatic trypsinogen
• Peptidase polypeptide to amino acid
• Maltase - maltose
• Sucrase sucrose to glucose
• Lactase Lactose
• Lipase Fats to fatty acids and glycerol

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• Onto large intestine where fluids and nutrients
  are re absorbed.
• Waste fluids taken by blood stream to kidneys to
  be filtered

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Small intestine

• Convoluted tube from pyloric sphincter to the
  junction of ileo caecal valve
• Mucus membrane has circular folds to increase
  surface area for absorption.
• Villi which contain blood and lymph vessel.
• Supplied with tubular glands secreting intestinal
  juice.

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Absorption

• Proteins, Carbohydrates and Fats through villi in
  small intestine.
• Fats in the form of fatty acids and glycerol are
  absorbed by cells covering villi. Pass into lymph
  within villi drained by lymphatic capillaries.

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Ileo Caecal valve.

• The Caecum lies in the right ileac fossa.
• The Ileum opens into the Caecum through the
  Ileo-Caecal valve.
• This is a sphincter which prevents the IC
  contents passing back into the Ileum.

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What is SBS

• Reduced bowel surface area for absorption of
  nutrients together with rapid transit of
  intestinal contents.
• TPN reduced as enteral feeds are introduced.
• Need to promote intestinal adaptation.

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Motility

• The IC valve and colon is important to slow
  intestinal transit.
• Proteins, Fats and Carbohydrates are absorbed
  almost completely within first 150cm of small
  bowel.

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• Jejunum most of electrolyte absorption
• Ileum is the only site for absorption of Vit B12
  and bile salts.

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After resection.

• Increase gastric emptying.
• Ileal resection, increased transit time
• An intact IC valve prolongs gut transit, loss of
  this causes an increase.
• If colon resected transit increases.

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• Duodenal resection malabsorption of Iron,
  Calcium and Folic Acid.
• Jejunal resection If extensive resection,
  lactose intolerence
• Ileal resection Some diarrhoea due to bile
  salts being incompletely absorbed.

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Gastric Hypersecretion

• After abdominal surgery, gastric hyper-secretion
  occurs in 50 cases.
• This impairs digestion of lipids by lowering
  intraluminal PH and inactivating the pancreatic
  enzymes.
• Also stimulates peristalsis.

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How does the bowel adapt?

• Cellular hyperplasia
• Villous hypertrophy
• Intestinal lengthening
• Altered motility
• Hormonal changes
• Takes approx 2 years to reach max effect.

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Management of SBS.

• Total TPN
• Gradual introduction of enteral feeding.
• Fluid and electrolyte balance
• Fluid replacement if stool, gastric aspirate or
  ostomy losses are high
• Reducing substances above1 contra indicate
  increasing enteral feeds.

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Weaning off TPN

• Cycling one hour off, line lock with
  Gentamycin. Build up to off all day.

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Complications.

• Bacterial overgrowth
• Anaemia
• Bile salt depletion
• Bone disease
• Cholestasis
• Diarrhoea
• Hypocalcaemia

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Complications (cont)

• Hypomagnesaemia
• Liver fibrosis
• Renal stones
• Protein malnutrition
• Trace mineral deficiency
• Vitamin deficiency, A, D, E, K, B12

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Central line complications

• Infection
• Thrombosis
• Break in catheter
• Air embolus
• Tissue necrosis
• Malposition
• Cardiac tamponade

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Bacterial Overgrowth

• Bloating, cramps, diarrhoea, gastrointestinal
  blood loss.
• Treat with sugar free Metronidazole and
  Trimethoprim

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Watery diarrhoea

• Loperamide
• Malabsorption of bile acids.
• Pectin

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Surgery

• Further resection might be avoided by tapering,
  strictureplasty or serosal patching.
• Patients with dilated segments proximal to tight
  anastomosis resect and taper improves bacterial
  overgrowth by improving flow.

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Tapering
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Bowel lengthening

• Cutting bowel longitudinally, preserve blood
  supply to both sides and create a segment of
  bowel twice length, half diameter without loss of
  mucosal surface area.

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Bowel lengthening
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Antiperistaltic small intestine segment
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Colonic interposition
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Medical management

• Pectin (water sol, non cellulose dietary fibre
  which promotes intestinal adaptation)
• Ranitidine (PH gt 4)
• Loperamide (slow gut transit time)
• Cholestyramine (binds bile salts)

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It takes approximately two years to achieve some
normal diet
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Thank you