Short Bowel Syndrome (SBS), Short Gut Syndrome

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Text of Short Bowel Syndrome (SBS), Short Gut Syndrome

  • 1. Short Bowel Syndrome (SBS) Dr.Atul Kumar Mishra M.S. (Gen.Surgery)
  • 2. SBS Result of surgical resection, congenital defect, or disease-associated loss of absorption Characterized by inability to maintain protein- energy, fluid, electrolyte, or micronutrient balance when on a normal diet
  • 3. Definition Presence of
  • 4. EPIDEMIOLOGY True incidence of SBS in United States unknown Overall neonatal incidence 24.5 per 100,000 livebirth, with higher incidence in premature infants (Wales et al) 15% of adult who undergo intestinal resection suffer from SBS, 3/4th from massive resection, 1/4th from multiple sequential resections Case fatality rate 37.5% With emergence of intestinal rehablitation centers and advancement in surgical procedures 70% patient alive 1year Survival rates for pediatric SBS 52% - 95% at 5 years
  • 5. SBS can be classified into 3 anatomic subtypes Intestinal Anatomy TYPE 1 End jejunostomy TYPE 2 Jejunocolic anastomosis TYPE 3 Jejunoileocolic anastomosis
  • 6. Causes of Short Bowel Syndrome Adults : Postoperative Irradiation Cancer Mesentric vascular disease Crohn disease Trauma Desmoid tumours Childrens : Gastroschisis Necrotizing enterocolitis Midgut volvulus Intestinal atresia Shackelfords Surgery of the Alimentary Tract 7th edition
  • 7. Pathophysiologic Consequences of Massive Resection GENERAL Malnutrition and weight loss Diarrhea and steatorrhea Vitamin and mineral deficiencies Fluid and electrolyte abnormalities SPECIFIC Gastric hypersecretion Cholelithiasis Liver disease Nephrolithiasis
  • 8. Pathophysiology
  • 9. Manifestation related to site of resection Duodenal resection Jejunal resection Ileal resection Loss of ileocecal valve Colon
  • 10. Duodenal resection Protein , CHO, fat maldigestion Ca, mg, iron, folate malabsorption Fat soluble vit deficiency
  • 11. If significant portion or all of jejunum is resected, absorption of proteins, carbohydrates, most vitamins and minerals can be unaffected because of adaptation in ileum. BUT unfortunately, enzymatic digestion suffers because of irreplaceable loss of enteric hormones produced by jejunum. ALSO, gastrin levels rise, causing gastric hypersecretion. High acid output from stomach injure SI mucosa. JEJUNUM
  • 12. In addition, TI is site of absorption of bile salts and vitamin B-12 Continued loss of bile salts leads to fat malabsorption, steatorrhea, and loss of fat-soluble vitamins Ileal resection severely decreases the capacity to absorb water and electrolytes. ILEUM Peptide YY, released from L cells in distal ileum and colon, slows gastric emptying and intestinal transit. In event of distal ileal and colonic resection, this feedback inhibition is lost
  • 13. Retention of ileocecal valve plays pivotal role in massive small bowel resection If ileocecal valve is lost, transit time is faster, and loss of fluid and nutrients is greater Colonic bacteria can colonize the small bowel, worsening diarrhea and nutrient loss ILEOCECAL VALVE
  • 14. Preservation of the colon has positive and negative attributes. Increasing colonic water absorption as much as 5 times its normal capacity Resident bacteria capacity to metabolize undigested CHO into SCFA These are a preferred fuel source for coloncytes & body Increasing the incidence of urinary calcium oxalate stone formation Small intestinal bacterial overgrowth COLON NEGATIVE POSITIVE
  • 15. Phases Of SBS Acute Phase Immediately after bowel resection and lasts for 1-3 months Ostomy output greater than 5 liters per day Life threatning dehydration and electrolyte imbalances Extremely poor absorption of all nutrients Development of hypergastrenemia and hyperbilirubinemia
  • 16. Adaptation phase Begins 12 24 hours after resection and last up to 1-2 years 90% adaptation occurs during this phase Enterocyte, villus hyperplasia and increased crypt depth ocurrs resulting in increased absorptive area Luminal nutrition is essential for adaptation and should be initiated as early as possible Parenteral nutrition is essential through out this period
  • 17. Maintenance phase Absorptive capacity is maximum during this phase Nutritional metabolic homeostasis can be achieved with oral feeding
  • 18. Change in morphorogy Macroscopic Elongation and dilation Microscopic Villus: increase height and diameter Crypt: elongation Epithelial cell life cycle: increase proliferation Decrease apoptosis
  • 19. Change in functional capacity Increase absorption per unit length Upregulation of sodium glucose transporter
  • 20. Factors Influencing Intestinal Adoptation GASTROINTESTINAL REGULATORY PEPTIDES Luminal contents Nutrients Secretions SYSTEMIC FACTORS Growth factors Hormones Cytokines TISSUE FACTORS Immune system Mesenchymal factors Mesentric blood flow Neural influences
  • 21. Lab investigation Blood U&E, bone profile, & mg, PRN then biweekly CBC, triglycerides, cholesterol Weekly Folate, vit B12, copper, zinc, Monthly Blood gas and AG for suspected lactic acidosis.
  • 22. Microbiology If sepsis suspected; blood & urine c/s Cultures from both the central and peripheral sites. Consider opportunistic infections, so search for fungal infection.
  • 23. Imaging Studies To assess for potential complications, Infection Abdominal ultrasonography to look for fungal balls in the kidney Bowel obstruction Plain radiography. Barium imaging of the bowel Liver disease Abdominal US to study the liver, biliary tract, & presence of ascites.
  • 24. Clinical Features History of several intestinal resections as in Crohn disease or major vascular event like midgut volvulus or embulus to superior mesenteric vessel Diarrhea is almost constant finding (with or without steatorrhea) Significant weight loss, lethargy and fatigue Dehydration, protein calorie malnutrition, and loss of critical vitamins and minerals
  • 25. Physical examination Significant protein and calorie malnutrition present with temporal wasting, loss of digital muscle mass and edema. Skin dry and flaky In children poor growth occurs Signs of vitamin and mineral deficiency appear
  • 26. Management The goals of nutritional therapy 1.Maintain adequate nutrition 2.Promote intestinal adaptation 3.Avoid complications
  • 27. Management 1. Fluid and electrolyte balance 2. Nutrition Require TPN at least initially Enteral feeding gradually introduced once ileus has resolved 3. Macro and micronutrients 4. Drugs: PPI, Antimotilty agents
  • 28. HOME PN Unfortunately, some patients are extremely difficult/impossible to wean from parenteral nutritionand and maintained on home PN or HPN HOME PN Common characteristics of these patients: Very short remaining small bowel segments (100 cm) Insufficient evidence to recommend use of bile acid supplements to decrease steatorrhea; and they may worsen diarrhea Cholestyramine is not useful in patients with >100 cm of ileal resection, and it may actually worsen steatorrhea because of the binding of bile salts
  • 46. Gastric hypersecretion Massive small bowel resection is associated with hypergastrinemia during initial first 6 months after surgery High-dose H2 antagonists and proton pump inhibitors reduce gastric fluid secretion, and fluid losses during first 6 months post-enterectomy
  • 47. Renal stones Normally, oxalate in diet binds to dietary calcium and is excreted in stool In presence of significant fat malabsorption, dietary