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Short bowel syndrome. Dr. Henrik Csaba Horvath. Bible class February 20, 2013. Definition of short-bowel syndrome. Loss of intestinal absorption from surgical resection , congenital defect or diseases characterized by the inability to maintain - PowerPoint PPT Presentation
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Short bowel syndromeDr. Henrik Csaba Horvath
Bible class February 20, 2013
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Definition of short-bowel syndrome
Loss of intestinal absorption from surgical resection,congenital defect or diseases characterized by the inability to maintainprotein-energy, fluid, electrolyte, or micronutrient balances when on aconventionally accepted, normal diet
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Which conditions can lead to a short-bowel syndrome?
Physical loss ofportions of intestine
Loss of function
cObstruction
Dysmotility
Surgicalresection(volvulus)
Congenitaldefect
Disease-associatedloss of absorption
(Crohn`s,postirradiation)
Loss of bowelor enterocyte mass(trauma, infarction)
SBS-associated intestinal failure
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Major causes of SBS in adults?
Postoperative complicationsIrradiaton/cancerMesenteric valvular disease (mesenteric ischemia)Crohn`s diseaseTrauma
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Which factors are associated with worse prognosis in patients with SBS?
Total parenteral nutrition< 50 cm intact bowelEnterostomyRadiation or ischemic enteritis
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Which factors have impact on the outcome of SBS?
Presence/abscence of ileocaecal valve
Outcome of SBS
Length of theremaining intestine
Segment of intact bowel(jejunum vs. ileum, colon continuity)
Absorptive quality ofthe remnant bowel
Presence of residualunderlying disease
(e.g.Crohn`s)
Age/BMI ofthe patient
State of other digestive organs
Efficacy ofnutrition support
Pharmacologic therapy
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How does affect the remnant length the risk of developing SBS?
Anastomosis PLUS length of residual small intestine
Duodenostomy or jejunoileal < 35 cm
Jejunocolic or ileocolic < 60 cm
End jejunostomy < 115 cm
Patients at highest risk of developing SBS are
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Which impact has on absorption the resection of…
Loss of the major intestinal absorption areaLoss of digestive enzymesLoss of GI feedback hormones (gastric emptying)
Jejunum:
Ileum:
Loss of the absorption of jejunal secretion Loss of absorption of vitamin B12
Loss of absorption of bile salts (fat malabsorption)
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Which impact has the loss of ileocaecal valve?
Dilatation of the small intestineSlower motility
Bacterial overgrowth of the small intestine
Competition for nutrients,inflammation, GI bleeding,bacterial translocation ± endotoxaemia,liver injury, D-lactic acidosis
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Which adaptive mechanisms occur in the residual intestine/ GI tract?
Mucosal hyperplasia (due to fat stimulated glucagon-like peptide receptor II)Increased mucosal blood flowImproved segmental absorption
Gastric hypersecretionIncreased pancreatobiliary secretions
Up to 70% can do without TPN due to these mechanisms
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Importance of colon in compensation for the lack of intestine?
Increase reabsorption of water, electrolytes, short-chain fatty acids and GI secretions
Slow down the intestinal transit and stimulate intestinal adaptation by hormonal regulation
Fermentation of malabsorbed carbohydrates by colonic bacteria
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Measurement of the functional capacity of the small intestine?
1. 48-hour nutritional balance test analysis of daily absorption rate (intake-output)
prediction of intestinal failure: <1,4 kg wet weight/day 1170 kcal/day of energy
(Difficulties with duplicate food portions and accurate stool collections)
2. Fasting plasma citrulline concentration (>5 μmol/L)(is synthetized by the small intestine, best practical measure of enterocyte function)
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Two major groups of complications of SBS?
dehydrationelectrolyte derangements (Mg, Ca, K)
Diagnosis: urinary electrolyte levels (plasma can be normal!)Treatment: sustained correction due to slow cellular uptake
TPN-relatedbacterial overgrowthmicronutrient deficiencymetabolic
Early complications:
Late complications:
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TPN-related late complications of SBS are…
gallstones, cirrhosis (IFALD)
end-stage liver cirrhosis in 15% of pts after one year TPN100% mortality rate within 2 yrs
infection: one-third of deaths in 50% 5-yr-mortality rate in SBSthrombosis (v. cava superior): 0.2/1000 catheter days
1. Due to bypass first pass liver metabolism:
2. Catheter-associated complications:
steatosis cholestasis
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Bacterial overgrowth-related late complications of SBS are…
1. carbohydrate malabsorption 2. sepsis due to bacterial localisation
3. decreased absorption of fatty acids due to interference with chilomicron formation
4. loss of absorptive capacity due to inflammatory response
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Which are the most common micronutritient deficiencies as late complications of SBS?
2. fat-soluble vitamins (A,D,E,K)
3. vitamin B12
4. folate
(if >60 cm of terminal ileum resected)
(if proximal jejunum resected)
1. Mg, Ca, Zn, Se
Micronutrients Recommended dose /day
Vitamin A 10.000-50.000 units
Vitamin B12 300 μg/month
Vitamin C 200-500mg
Vitamin D 1600 U
Vitamin E 30 IU
Vitamin K 10 mg/week
Calcium 800-1200 mg
Magnesium As needed
Iron As needed
Selenium 60-100 μg
Zinc 220-440 mg
Bicarbonate As needed
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The most common metabolic complications of small-bowel syndrome?
gram-positive colonic bacteriaferment carbohydrate to D-lactic acid
Acidic environment
short-chain fatty acids
proliferation of the flora
Metabolic acidosis (encephalopathy, headaches, ataxia, dysarthria)
1. Metabolic acidosis2. Hyperoxaliuria (nephrolithiasis, chronic renal failure)3. Hyperammoniaemia4. Metabolic bone disease (osteoporosis, osteomalacia)
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3 key points of management?1. Nutrition / Supplementation of micronutrients2. Maintaining fluid, electrolytes and acid/base balance3. Avoid complications
Calories to be supplied: 25-30 kcal/kg/day
Proteins to be supplied: 1.0-1.5 g/kg/day
40-50% carbohydrates20-30% proteins20-40% lipids
Continous PN
Cyclic/discontinous PN
Continous enteral
Bolus enteral
Intravenous fluid Oral rehidration fluid(glucose-polymer based with sodium)
ORS ±oral electrolyte suppl.
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Pharmacologic adjuncts in the management?
2. loperamid, diphenoxylate, codein: anti-motility agents
3. octreotid: increasing the small bowel transit time (but also inhibits pancreatic secretions) only if > 3 L of iv. fluid intake is required
4. cholestyramine: binding bile salts in steatorrhea secondary to bile acid malabsorption
1. glucagon-like peptide-2 (teglutide): promotion of adaption
Cheng TT et al :Clinical and Experimental Gastroenterology 2011:4 189–196
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Two categories of surgical treatment options?
2. transplant1. non- transplant
1. Preserve intestinal remnantminimize resrection, restore intestinal continuity, recruit additional intestine
2. Slow intestinal transit (segmental reversal of intestine, colonic interposition)
3. Increase intestinal surface (LILT = longitudinal intestinal lengthening and tailoring with longitudinal devision of intestine and blood supply at the mesenteric border) STEP = serial transverse enteroplasty)
Aims of non-transplant surgical treatments?
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Surgical treatment of short bowel syndrome
Indications for intestinal transplants?
1. Impending or overt liver failure (ESLD)2. Thrombosis of major central venous channels3. Frequent central line-related sepsis (>2 episodes/year)4. Frequent severe dehydration5. Diffuse mesenteric venous thrombosis with complications
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Intestinal transplantation for SBS
Which effect has the combined transplanton the rejection rate of intestinal transplants?
Major complications and cause of death after intestinal transplantation?
Acute and chronic rejection rate is lower in combined transplants(liver+intestine, multivisceral)
Sepsis, MOF, rejection