Title: Short Bowel Syndrome

Key words: Case history, jejunostomy, anastomosis, nutritional management, parenteral nutrition, enteral nutrition

Date: July 2000

Category: 13. Specific conditions

Type: Article

Author: Dr van rhijn

 

Short Bowel Syndrome

A Case History Approach

 

 

Introduction

IH and PM are two patients with short bowel syndrome after surgical resection for intestinal infarction. Both have 50cms of jejunum. IH has a jejunostomy. PM has a retained colon with an anastomosis between the jejunum and the ascending colon. The nutritional management of these patients and the expected differences in their nutritional needs are discussed below.

Consequences of short bowel syndrome (SBS = intestinal length < 200 cm) are intestinal failure (IF = gut unable to maintain normal nutritional and/or electrolyte status), which may lead to malnutrition and sepsis. The two types of SBS, end jejunostomy and colon in continuity, require different nutritional management by a multidisciplinary team1.

Initial Nutritional Management of IH & PM

Nutritional management of SBS depends on the site and the lengths of jejunum & ileum resected, the presence or absence of the ileocaecal valve and the amount of intact colon2. Both IH and PM have a duodenum and 50cm of jejunum intact, thereby preserving pancreatic enzymes, secretin and cholecystokinin. This reduces the risk of gall bladder stasis3 and cholelithiasis4. Vasoactive intestinal & gastric inhibitory peptides and serotonin inhibit gastrin release, preventing gastric hypersecretion. The absence of ileum and the ileocaecal valve poses problems by decreasing intestinal transit time (diarrhoea), deficiency in protein-energy, water-soluble vitamins, trace elements. Unabsorbed bile salts may cause malabsorption of fat & fat-soluble vitamins, but may be bound with cholestyramine5.

Parenteral nutrition (PN) is instigated6, complemented by early, safe7,8 enteral feeding when tolerable9 to encourage mucosal adaptation (mucosal hypertrophy increases absorptive surface, modulates metabolic response to surgical trauma10 and prevents sepsis11,12,13). Hypertonic solutions (glucose & lactose) should be avoided. Meals should be small and low-fat, amino acid based14 but given frequently, tailored to the individual patients’ needs. Nutritional status15,16 should be monitored to prevent disease morbidity, restricted growth and macro & micronutrient excess.

The diet should be supplemented with fat-soluble vitamins, Vit B12 and minerals (Fe & Zn). Immuno-enhancing nutrients17 (ornithine a -ketoglutarate18, anti-oxidants19, glutamine20,21, n-3 PUFA’s22,23, RNA24 and arginine25.26) such as Impact27 promote healing and reduce septic complications28, promote recovery29 and increase survival30. The beneficial effects of lipids on the immune system are extensively reviewed31,32,33 and cholecystokinin reduces cholestasis34.

Long-Term Nutritional Management of IH - Jejunostomy

PN is substituted with safe35 home parenteral nutrition (HPN), delivered through a central catheter or subcutaneous port36 (PEG - overnight infusion), to supplement oral diet (enteral tube feeding is ineffective). IH will require more nutrition and may have problems related to leakage from the jejunostomy and also major electrolyte imbalance (jejunum permeability). The risk of magnesium, sodium and water loss can be minimised37 by restricting oral fluid to isotonic rehydration solutions (sodium content 90 – 100 mmol/L). High-energy, iso-osmolar fat diets38,39 pose less risk of causing diarrhoea. HPN is expensive and associated with serious potential complications. Epidermal growth factor40 can exert trophic effects on the small intestine.

Long-term Nutritional Management of PM – Colon in Continuity

Complete enteral nutrition (EN)41,42 via nasal flow-care tube43 positioned in the upper jejunum44, precedes normal feeding, as PM will eventually adapt and be able to eat normally. As it is less permeable colon preservation reduces the risk of electrolyte and fluid imbalance. Energy should be supplied in the form of high unrefined carbohydrates and low fat45 for the former is a substrate for energy salvage (3-4 MJ/day)46 from bacterial fermentation of short chain fatty acids47 with a trophic effect on the colonic mucosa48. Fat, however, is associated with an increased risk of steatorrhoea, oxaluria & oxalate renal stones49 and offensive diarrhoea. Low oxalate diets may be beneficial in fat malabsorption. Lack of an ileoccecal valve encourages bacterial reflux, overgrowth and fermentation, causing D-lactic acidosis.

Conclusion

Most patients with short bowel syndrome can be adequately managed with current nutritional techniques. It should be possible for them to retain a normal body mass index and maintain a good quality of life.

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