Documente Academic
Documente Profesional
Documente Cultură
ABSTRACT
Article history:
Short bowel syndrome (SBS) refers to the clinical consequences resulting from loss of
small bowel absorptive surface area due to surgical resection or bypass. The syndrome is
characterized by maldigestion, malabsorption, and malnutrition. Survival of patients
with SBS is dependent on adaptation in the remaining bowel and a combination of
pharmacologic and nutrition therapies. Individual plans of care are developed based on
the length and sites of remaining bowel, the degree of intestinal adaptation, and the
patients ability to adhere to the medication and dietary regimens. Antisecretory and
antidiarrheal medications are prescribed to slow intestinal transit times and optimize
uid and nutrient absorption. Based on postsurgical anatomy, enteral feedings, parenteral infusions, complex diet plans, and vitamin and mineral supplementation are used
in various combinations to nourish patients with SBS. In the acute care setting, registered dietitians (RDs) assist with infusion therapy, diet education, and discharge planning. Long-term, as the small intestine adapts, RDs revise the nutrition care plan and
monitor for nutrient deciencies, metabolic bone disease, and anemia. The frequent
monitoring and revision of care plans, plus the appreciable benets from proper
medical nutrition therapy, make this patient population extremely challenging and
rewarding for RDs to manage. This article provides a brief, case study-based overview of
the medical and nutrition management of SBS.
Keywords:
Pathophysiology of short bowel syndrome
Medical nutrition therapy
Clinical management of patients with short bowel
syndrome
Copyright 2013 by the Academy of Nutrition
and Dietetics.
2212-2672/$36.00
doi:10.1016/j.jand.2013.05.001
PATHOPHYSIOLOGY
Normal length of the small intestine varies from 300 to 600
cm; approximately half of the upper intestine (jejunum) can
be removed without signicant problems. Patients with <100
cm of small intestine will have severe malabsorption, which
will result in malnutrition if untreated. There are two clinically useful categories of patients with SBS: those with a
1200
RESEARCH
After surgical resection the remaining small bowel undergoes an adaptation process that involves morphologic and
functional changes.8 The small bowel dilates and the villi
height and crypt depth increase, expanding the absorptive
surface area of the small bowel without change in length.9
The mechanism of adaption is not fully understood. Important factors include hormonal growth factors, nutrients
(particularly complex macronutrients), bile and pancreatic
secretions, and local intestinal hormones such as glucagonlike peptide 2.10 Adaptation begins soon after intestinal
resection and may continue for 2 years.11 Because oral nutrients stimulate intestinal adaptation, it is important to
initiate an oral diet or enteral feedings as soon as possible
after surgery.12
MANAGEMENT OF SBS
The goal of therapy is to maximize small bowel absorption of
uids and nutrients to prevent deciencies and dehydration.12
This is accomplished by controlling the rate at which nutrients and uids move through the intestinal tract with the use
of medications and diet therapy. In some cases infusion
therapy (enteral and/or parenteral) with nutrients and uid
may be required either temporarily after surgery, or lifelong.1
Pharmacotherapy
The common categories of medications used to manage SBS
include antimotility agents, antisecretory agents, and parenteral infusion therapy (intravenous [IV] uids and/or PN).1
Antimotility medications (the most common are loperamide,
diphenoxylate and atropine, codeine, and deodorized tincture
of opium [DTO]) are used to slow peristalsis and improve absorption of uid, electrolytes, and nutrients.13 These medications are usually taken as needed after a loose bowel
movement, but for patients with SBS the dose is given
routinely 30 minutes before meals and at bedtime. Often patients with SBS have to adjust the timing and titrate the dose of
antimotility agents based on meal composition, daily activities,
and degree of bowel adaptation. Patients taking opiate-based
medications to control uid and electrolyte losses (codeine
and DTO) must be closely monitored for side effects, including
impaired mental or physical alertness as well as symptoms of
withdrawal if the medications are abruptly discontinued after
prolonged use.14 Clonidine, an a2-adrenergic agonist, has been
shown to increase intestinal transit time and decrease fecal
weight in patients with SBS.15-17 It can be administered by oral
medication or transdermal patch, which is an effective alternative for patients with reduced small bowel absorption.
Clonidine is commonly used to treat hypertension so blood
pressure should be monitored closely when starting this
medication. Patients with severe coronary heart disease,
chronic renal insufciency, and hemodynamic instability may
not be good candidates for clonidine therapy.14
Hypersecretion of gastrin and gastric acid occurs in patients after extensive small bowel resection.18 Histamine H2
antagonists (ie, H2 blockers) and the more potent proton
pump inhibitors (PPIs) are used in SBS to decrease gastric acid
secretion, diarrheal losses, and risk for peptic ulcer disease
and its complications. The H2 blockers inhibit histamine at
the histamine H2 receptors of gastric parietal cells thus
reducing gastric acid secretion whereas PPIs directly inhibit
hydrogen potassium ATPase pump of parietal cells effectively
September 2013 Volume 113 Number 9
1201
RESEARCH
Small bowel
ostomy
Colonic
continuity
Carbohydrates
50% of total
energy; complex
carbohydrates
including soluble
ber, limit simple
sugars
50%-60% of total
energy; complex
carbohydrates,
including soluble
ber
Proteins
20%-30% of total
energy
20%-30% of total
energy
Fats
40% of total
energy
20%-30% of total
energy
Fluids
ORSb important;
minimize uids
with meals,
sipping of uids
between meals
Minimize uids
with meals,
sipping of uids
between meals
Vitamins
Daily multiple
vitamin with
minerals; monthly
B-12; possibly
vitamins A, Dc,
and E
supplements
Daily multiple
vitamin with
minerals; possibly
B-12 ; possibly
vitamins A, D, and
E supplements
Minerals
Generous use of
sodium chloride
on food; calcium
1,000-1,500 mg
daily; possibly
iron, magnesium,
and zinc
supplements
400-600 mg
calcium with
meals; possibly
iron, magnesium,
and zinc
supplements;
reduced oxalate
Meals
Nutrient
PATIENT PROFILE
The patient is a 72-year-old woman with a past medical
history of colon cancer that was treated by partial colectomy
and chemotherapy. Recurrent colon cancer was diagnosed 11
years later requiring a complete colectomy with end ileostomy. Postoperative Day 3, she developed severe abdominal
pain and blood-tinged ostomy efuent; re-exploration surgery demonstrated extensive distal small bowel necrosis. The
necrotic bowel was resected leaving an estimated 105 cm of
proximal small bowel to an end jejunostomy. The patients
recovery was uneventful; she was discharged from the hospital on a regular diet.
During the rst month after discharge from the hospital,
the patient had multiple admissions for dehydration and
weight loss. During one such hospitalization, a double-lumen
peripherally inserted central catheter (PICC) was placed and
PN initiated. Soon after the start of therapy, she developed an
September 2013 Volume 113 Number 9
RESEARCH
upper extremity deep vein thrombosis originating at the PICC
insertion site; anticoagulation therapy was started. During
the same hospitalization, she developed fevers due to a
catheter-related blood infection, hypotension, hypokalemia,
and increased liver function tests. On Hospital Day 17, the
patient was transferred to a tertiary care hospital for management of SBS.
AT HOME
At home, the patients oral intake increased with subsequent
increase in jejunostomy output, necessitating adjustment of
the PN volume to 1.5 L infused over 12 hours and titration of
the DTO dose to 1 mL four times a day. Six months after
discharge PN, she had stable serum chemistry values,
adequate hydration, and she was slowly losing weight; the
PN infusion was changed to every other day and the anticoagulation therapy was discontinued. Subsequent serum
chemistry results suggested negative uid balance, and the
patient complained of extreme thirst and fatigue. A 24-hour
urine collection during an off day from PN resulted in only
400 mL urine. The PN volume was increased to 2.4L over 12
hours every other day, and the patient was instructed to
strictly adhere to the diet and ORS therapy. The patient had
improved hydration on noninfusion days and the repeat 24hour urine collection yielded 850 mL.
The patient remains on every-other-day IV infusions for
uid, vitamins, minerals, and electrolytes; her weight has
stabilized at 86 kg (body mass index 30.7). Four years after
discharge on PN her insurance provider mandated a switched
to noneamino acid-containing IV uid (Table). She continues
to strictly adhere to the diet regimen, but has ceased using
ORS because she no longer appreciates hydration benets
from the therapy. Repeat chemistry data, including normal
vitamin levels and triene to tetraene ratio (an indication of
adequate absorption of essential fatty acids), plus stable body
mass index, suggest adequate hydration and nutrient uptake
with the current management.
DISCUSSION
Historically, loss of a signicant portion of the intestine was
physically devastating and often a death sentence. During the
past 50 years, with the advent of PN and a better understanding of small bowel physiology, most patients with SBS
recover and live without signicant reduction in quality of
life.41-44 The case of the patient provided is an excellent
example of the metabolic consequences of massive small
bowel resection and the complications of infusion therapy.
September 2013 Volume 113 Number 9
PRACTICE APPLICATIONS
Management of patients with SBS requires a thorough understanding of intestinal physiology, knowledge of pharmaconutrition therapy (ie, the use of nutrients for therapeutic
benet), close attention to detail, and patience. Each SBS
patient presents with unique nutrient requirements based on
the length, site, and health of their remaining intestine.
When caring for a patient with SBS, a registered dietitian
(RD) must know the exact intestinal anatomy so that a plan of
care is developed to optimize bowel function and nourish the
patient. If the operative report is unavailable or there is
question as to the length or health of the remaining bowel, an
upper gastrointestinal with small bowel follow-through
barium study provides vital information on the length and
condition of intestine remaining as well as transit time.45 In
addition, RDs must have accurate intake and output data to
assess uid balance; awareness of all prescribed medications
and supplements; knowledge of IV access, including catheter
tip location; weight history; and laboratory data.
Before hospital discharge, there are many details RDs
must ensure are in place for patients with SBS (Figure 2).
First, the patient must understand the proper diet and oral
hydration guidelines as well as the dosage and timing of
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
1203
RESEARCH
Table. Data for a 72-year-old female patient from hospital admission to 4 y after massive small bowel resection
Transfer to
tertiary
care center
Patient data
Body mass index
35.3
5.5 mo
6 mo
6.5 mo
7.5 mo
32.5
32.5
31.5
30.7
4y
30.7
Laboratory dataa
Glucose (65-110 mg/dL)b
169
148
115
122
100
119
89
138
137
138
144
140
140
141
3.3
4.4
4.2
4.2
4.2
3.8
4.2
95
103
105
102
103
105
105
35
26
26
29
33
30
29
22
37
28
22
26
22
21
1.0
0.8
1.0
1.3
1.2
1.0
0.96
7.7
9.3
8.9
9.5
9.2
8.7
9.5
3.8
3.9
4.0
3.8
4.2
3.6
3.5
1.9
2.2
2.2
2.1
2.2
2.2
2.3
6.0
7.8
7.9
7.6
6.7
7.6
2.9
3.3
4.5
4.0
3.9
4.0
1.6
0.95
0.9
1.29
0.97
0.8
Albumin (g/dL)
239
204
320
217
400
850
163
95
1,794
0.69
Medications
Warfarin (mg)
Proton pump inhibitor (mg/d)
Deoderized tincture of opium (mL/day)
40
40
40
40
40
40
30
1.2
4
l
1l
Oral multivitamin
1,000
500
1.5
1.5
490
490
490
80
60
60
2.4
410
60m
410
60m
2.4
410
60m
2.4m
170m
0
1204
RESEARCH
Checklist item
Diet education
Laboratory data
Daily weight
Daily I/O data
Weekly weight
Once weekly I/O data until stable, then monthly
(more frequently if change in medical
management or status)
Medications
Antimotility agent
PPId or H2 blockere
Multivitamin and mineral supplements
Antimotility agent
PPI or H2 blocker
Multivitamin and mineral supplements
Possibly pancreatic enzyme replacement or bile
acid sequestrant
Nutrition support
Monitoring frequency
Daily
Other
Figure 2. Checklist for registered dietitian management of patients with short bowel syndrome.a
antimotility and acid-blocking medications.46 In addition,
the patient should be aware that the dosage of the medications may change once he or she is home and eating
more food. Emphasis should be placed on proper eating
techniques; for example, eating slowly, resting after eating,
minimal uid intake with the meal, and sipping of uids
between meals.47 If an ORS is required, recipes to prepare
the solution or information on where to purchase ORS
must be given to the patient. The RD may have to reinforce
this information repeatedly before and after discharge.
Adults in particular have difculty changing their eating
habits and may nd it challenging to adhere to the new
guidelines until they begin to see reduction in stool output
and improved overall sense of well-being. Also, the patient
September 2013 Volume 113 Number 9
1205
RESEARCH
After hospital discharge, patients with SBS are best served
by frequent follow-up appointments with all members of the
nutrition support team, in particular the managing physician
and RD. The primary goals of these appointments are to
assess adherence to the prescribed therapies; monitor uid,
electrolyte, hydration, and nutritional status; reinforce the
principles of nutrition therapy; and adjust the therapies as
necessary.50 Periodic weights and blood chemistry levels
(including liver function tests) will help to determine the
extent of bowel adaptation, liver-related complications of PN,
and the possibility of weaning from EN or PN.48 If a patient
develops PN-related liver disease, the workup should assess
for small bowel bacterial overgrowth, blood infection, and reevaluate IV fat emulsion deliveryall of which can alter liver
function.51 Treatment may include a reduction in the amount
and frequency of IV fat emulsion infusions (<1 g/kg/day as
infrequently as once a week) with periodic monitoring for
essential fatty acid deciency.52
Baseline vitamin (eg, folate; B-12; and vitamins A, D, E);
mineral (eg, iron, calcium, and magnesium); and trace mineral
(eg, zinc, copper, and selenium and chromium and manganese
for PN patients) levels and dual-energy x-ray absorptiometry
scan are required for comparison purposes in long-term follow
up.53 The standard parenteral multivitamin and trace mineral
additives may not meet a patients exact requirements and can
cause deciency or toxicity states over time.54 For example,
daily trace mineral infusions of 0.3 mg manganese over time can
lead to deposits in the brain,55 and chronic standard multivitamin dosing of 200 IU vitamin D can cause insufciency or
deciency states.56 Further complicating the issue of monitoring micronutrient levels of patients dependent on PN are the
ongoing product shortages. These shortages have led to omission or rationing of certain nutrients that can cause lifethreatening deciency states.50,57,58 These levels should be
checked no less than every 6 to 12 months, or more frequently if
abnormal levels are identied.58,59 With time, as a patient stabilizes and thrives at home, the length of time between clinic
visits can be extended. For patients with stable, chronic SBS the
minimum follow-up should occur every 6 to 12 months. As with
the patient prole provided, bowel adaptation can occur slowly.
It can take more than 2 years before adaptation has fully
occurred to change the treatment plan and wean articial
nutrition support.11
CONCLUSIONS
Management of SBS is complex and requires a concert of
medical, nutrition, and pharmaceutical therapies to optimize
uid and nutrient absorption for survival. Each patients
unique care plan depends on the amount and site of
remaining intestine and the patients ability to adhere to the
medical and nutrition therapies. Some patients will be able to
survive with antisecretory and anti-motility agents along
with strict diet adherence alone, whereas other patients will
require lifelong infusion therapy. In either case, patients with
SBS must have close follow-up with a specialized medical
team to monitor for nutrient deciencies and potential
complications of SBS. The most common long-term complications include metabolic bone disease, PN-related liver disease, nephrolithiasis, anemia, central line infection, central
access problems (thrombosis and superior vena cava syndrome due to vein stenosis), and vitamin and trace mineral
1206
References
1.
Semrad CE. Approach to the patient with diarrhea and malabsorption. In: Goldmans Cecil Medicine. 24th ed. Philadelphia, PA: Elsevier
Saunders; 2012:895-913.
2.
OKeefe SJD, Buchman AL, Fishbein TM, Jeejeebhoy KN, Jeppesen PB,
Shaffer J. Short bowel syndrome and intestinal failure: Consensus definitions and overview. Clin Gastroenterol Hepatol. 2006;4(1):6-10.
3.
4.
5.
6.
7.
8.
9.
Bines JE, Taylor RG, Justice F, et al. Diet following small bowel
resection: Inuence of diet complexity on intestinal adaptation
following massive small bowel resection in a preclinical model.
J Gastroenterol Hepatol. 2002;17(11):1170-1179.
10.
11.
12.
Buchman AL. Etiology and initial management of short bowel syndrome. Gastroenterology. 2006;130(suppl):S5-S15.
13.
14.
Lacy CF, Armstrong LL, Goldman MP, Lance LL. Drug Information
Handbook: A Comprehensive Resource for All Clinicians and Healthcare
Professionals. 19th ed. Hudson, OH: Lexi-Comp; 2010.
15.
Rubinoff MJ, Piccione PR, Holt PR. Clonidine prolongs human intestine transit time: Use of the lactulose-breath hydrogen test. Am J
Gastroenterol. 1989;84(4):372-374.
16.
17.
18.
19.
20.
21.
22.
RESEARCH
23.
24.
42.
Baxter JP, Fayers PM, McKinlay AW. A review of the quality of life of
adult patients treated with long-term parenteral nutrition. Clin Nutr.
2006;25:543-553.
43.
Byrne T, Veglia L, Camelio M, et al. Beyond the prescription: Optimizing the diet of patients with short bowel syndrome. Nutr Clin
Pract. 2000;15(6):306-311.
44.
45.
25.
26.
46.
47.
Woolf GM, Miller C, Kurian R, Jeejeebhoy KN. Diet for patients with a
short bowel: High fat or high carbohydrate? Gastroenterology.
1983;84(4):823-828.
Matarese LE, OKeefe SJ, Kandie HM, et al. Short bowel syndrome:
Clinical guidelines for nutrition management. Nutr Clin Pract.
2005;20(5):493-502.
48.
49.
50.
51.
52.
53.
Dreesen M, Foulon V, Vanhaecht K, et al. Guidelines recommendations on care of adult patients receiving home parenteral nutrition:
A systematic review of global practices. Clin Nutr. 2012;31:602-608.
27.
28.
29.
30.
Tilg H. Short bowel syndrome: Searching for the proper diet. European J Gastroenterol Hepatol. 2008;20(11):1061-1063.
31.
Shatnawei A, Parekh NR, Rhoda KM, et al. Intestinal failure management at the Cleveland Clinic. Arch Surg. 2010;145(6):521-527.
32.
33.
34.
Banks MR, Farthing MJG. Fluid and electrolyte transport in the small
intestine. Curr Opin Gastroenterol. 2002;18(2):176-181.
54.
35.
Howard L, Ashley C, Lyon D, Shenkin A. Autopsy tissue trace elements in 8 long-term parenteral nutrition patients who receive the
current U.S. Food and Drug Administration formulation. JPEN J
Parenter Enteral Nutr. 2007;31(5):388-396.
55.
36.
56.
57.
37.
38.
Mziray-Andrew CH, Sentongo TA. Nutritional deciencies in intestinal failure. Pediatr Clin North Am. 2009;56(5):1185-1200.
39.
58.
Mirtallo JM, Holcombe B, Kochevar M, Guenter P. Parenteral nutrition product shortages: The A.S.P.E.N. strategy. Nutr Clin Pract.
2012;27(3):385-391.
40.
Green R. Indicators for assessing folate and vitamin B12 status and for
monitoring the efcacy of intervention strategies. Food Nutr Bull.
2008;29(2 suppl):S52-S63.
59.
41.
60.
1207
RESEARCH
AUTHOR INFORMATION
E. A. Wall is a nutrition support dietitian, The University of Chicago Medicine, Chicago, IL.
Address correspondence to: Elizabeth A. Wall, MS, RD, LDN, The University of Chicago Medicine, 5841 S. Maryland Ave, MC 4080, Chicago,
IL 60637. E-mail: elizabeth.wall@uchospitals.edu
ACKNOWLEDGEMENTS
The author thanks Patricia Sheean, PhD, RD, for the invitation to write this article and for her guidance with respect to the content. The author
also thanks Carol E. Semrad, MD, for her expert review of this articles content as well as Linda Trumbore, MS, RD, and Scott Lozano, PharmD, for
providing editorial assistance.
1208