DR SIKANDAR PGR GASTROENTEROLOGY

SHORT
BOWEL
SYNDROME
 Presentation overview

 Introduction
 Epidemiology
 Etiology
 Pathophysiology
 Clinical features
 Management
 Prognosis
 Introduction

 Short-bowel syndrome is a disorder clinically defined by
 Malabsorption
 Diarrhea
 Steatorrhea
 Fluid and electrolyte disturbances
 Malnutrition
 Due to functional or anatomical loss of extensive
segments of small intestine so that absorptive capacity is
severely compromised
 Extensive segment

 No defined length of remaining bowel is identified
although various literature mentioned controversial
lengths.
 Less than 200 cm of viable small bowel or loss of
50% or more of the small intestine places the patient
at risk for developing short-bowel syndrome.

 The average length of the adult human small intestine is approximately 600 cm
and the range extends from 260 to 800 cm –
 Definition

 Intestinal failure associated with the inability to maintain
protein, energy, fluid, electrolytes or micronutrient balances
while on conventionally accepted normal diet.

Short bowel syndrome and intestinal failure: consensus definitions and

overview.
 Etiology

 Depends on age groups
 In adults
 Crohn’s disease
 Mesenteric ischemia - thrombosis and embolism of
superior mesenteric vessels
 Radiation enteritis
 Iatrogenic – jejuno ileal bypass, now abandoned
 Neoplastic
 Motility disorders
 Trauma
 Pediatric and neonatal age groups

 Necrotizing enterocolitis
 Multilevel small-bowel atresia
 Midgut volvulus with ischemic bowel infarction
 Pathophysiology

 About 90% of digestion and absorption of significant
macronutrients and micronutrients are accomplished
in the proximal 100-150 cm of the jejunum
 Symptoms occurs due to
 Loss of intestinal absorptive capacity
 Rapid intestinal transit
 Gastric hypersecretion and inactivation of digestive
enzymes
 Loss of bile salts
 
 Functional or anatomical loss of small bowel surface
area will reduce the absorption of intestinal contents
leading to symptoms of SBS
 Loss of small bowel reduce pancreatic and biliary
secretion and increase gastric secretion lowering the
PH in small intestine which further impairs the
action of digestive hormones
 
 Impaired absorption will accumulate osmotically active
particles in small bowel retaining more water results in
diarrhea.
 Loss of ileum will results in reduced absorption of fats
leading to steatorrhoea (reduction of bile salts)

 Role of ileocecal valve

 Increase transit time allowing more absorption
 Prevent colonization of small bowel from large bowel
which will aggravate the diarrhea
 Other factors which affect outcome

 Premorbid length of small bowel
 The segment of intestine that is lost
 The age of the patient at the time of bowel loss
 The remaining length of small bowel and colon,
 The presence or absence of the ileocecal valve.
 Place of colon

 Increases it water absorption capacity up to 5 times
 Colonized bacteria metabolize undigested
carbohydrates to short chain fatty acids which can be
absorb to utilize as somatic fuel.

 Increase absorption of oxalates and increase risk of

urinary calculi formation
 Increases colonization of small bowel in the
absence of ileocecal valve
 Adaptations to live without small bowel


 The physiologic changes and adaptation of
patients with short-bowel syndrome can be viewed
in three phases.
1. Acute phase
2. Adaptation phase
3. Maintenance phase
 Acute phase

 The acute phase occurs immediately after massive
bowel resection and may last up to 3-4 months.
 It is associated with malnutrition and fluid and
electrolyte loss through the GI tract.
 Enteral feedings may also be initiated, but it should
be relatively slow. Patients with less than 100 cm of
small intestine will require TPN.
 Adaptation phase


 The adaptation phase generally begins 2-4 days after
bowel resection and may last up to 12-18 months.
 During this second phase, up to 90% of the bowel
adaptation may occur.
 Villous hyperplasia
 Increased crypt depth
 Intestinal dilatation occur.
 Early continuous feedings with a high viscosity
elemental diet may reduce the duration of TPN.
 Maintenance phase

 The absorptive capacity of the GI tract is at its
maximum.
 Some patients may still require TPN.
 In other patients, nutritional and metabolic
homeostasis can be achieved by small meals and
supplemental nutritional support for life.
 Clinical features

 Weight loss, fatigue, malaise, and lethargy
 Vitamin A - night blindness and xerophthalmia
 Vitamin D - paresthesias and tetany
 Vitamin E - paresthesias, ataxic gait, and retinopathy
 Vitamin K depletion - easy bruisability or prolonged
bleeding
 Vitamin B12, folic acid - Anemia
 Calcium and magnesium - paresthesias and tetany
 Low zinc levels - anorexia and diarrhea
 Physical signs

 Temporal wasting
 Loss of digital muscle mass
 Peripheral edema
 Dry and flaky skin
 Prominent ridges in nail
 Lingual papillae are blunted or atrophic
 Management

 Management of SBS is progressed through
several phases
 Management goals varies depending on phases

 Initial phase
 To stabilize critically ill patient
 Controlling sepsis
 Fluid and electrolyte balance
 Initiation of nutrtional support
 
 As patient is recovered from acute stage primary
goal of management is to maintain nutritional status
 To maximize the absorptive capacity
 Prevent complications of PN and short bowel
syndrome
 Management options

 Preserving the intestinal remnant
 Improve the function of remnant bowel
 Augmenting the intestinal length
 Intestinal transplantation
 Medical rehabilitation

 Goal is to return patients to as normal lifestyle as possible
with as little dependence on parenteral nutrition as can be
achieved.
 Intestinal rehabilitation is the process of enhancing
intestinal absorption and function through the use of
modified diet, enteral nutrition, oral rehydration solution,
antimotility and antisecretory agents, antibiotics and growth
factors.
 Maintain nutritional status

 PN support in the early post operative period
 Provision of energy substrate, protein, fluid,
electrolytes, minerals, vitamins and micronutrients
 25-30 kcal/kg per day
 1 to 1.5 g of proteins per day
 Enteral feeding following surgery

 Should started as early as possible when ileus is
settled
 Help to maximize absorptive capacity and to reduce
the complications related to PN
 Patients with small bowel more than 180 cm will
not require PN
 Patients with small bowel more than 90 cm with
colon require PN less than 1 year duration
 Less than 60cm of small bowel might require
permanent PN depending on colon length
 CONTINUOUS ENTERAL
FEEDING MAY PERMIT
GREATER ABSORPTION
OF NUTRIENTS THAN
 ENTERAL
INTERMITTENT
FEEDING

Continuous enteral nutrition during the early adaptive stage of the short
bowel syndrome.
 Maximize absorptive capacity

 Hyposmolar diets are started initially to reduce the
intestinal fluid loss
 High protein high carbohydrate diets are recommended
for maximum absorption
 Providing nutrient as their simplest form improves
absorption
 Di and tri peptide sugars
 Medium chain tri glycerides
 Addition of pectin increase transit time and reduce
water loss
 Maximize adaptive capacity

 Early enteral nutrition
 Provision of long chain fatty acid and fiber
 Glutamin – trophic to the gut as well as act as fuel
for enterocytes
 Meal itself act as endocrine stimulation for
adaptation via various hormones and growth factors
Antimotility and antisecretory drugs

 To minimize diarrhoea and GI secretion
 Narcotics – codeine, diphenoxylate and loperamide
 Diminished action over time
 Progressive dosage
 Drug holidays
 PPI AND H2 RECEPTOR
BLOCKERS REDUCE
GASTROINTESTINAL
SECRETION 

 Clonidine also reduce fluid loss (alpha 2 receptor agonist)

 Pre biotics and pro biotics also proven to improve
absorption
 Newer therapies
 GLP – 2

 Increase intestinal absorption and adaptation
 Produce by enteroendocrine cells in small intestine
 Shown to increase absorption and increase villous
height and crypt depth
 Still undergoing further studies
 Prevent complications

 Complications of short bowel syndrome
 Therapy related
 Diarrhea and steatorrhea
 Metabolic abnormalities
 Nutritional deficiencies
 Infectious complications
 Liver disease
 Physiologic
 Cholelithaisis
 Nephrolithiasis
 Gastric hypersectretion
 Bacterial overgrowth
Measures to prevent complications

 Supplementation of vitamin D calcium and magnesium
 Treat bacterial over growth in small bowel which can
cause metabolic acidosis
 Prevent catheter related sepsis
 PN related liver disease – multifactorial
 Maximizing enteral calories
 Avoid over feeding
 Prevent specific nutrient deficiencies
Small bowel bacterial overgrowth

 Due to stasis, obstruction and absence of iliocecal valve
 Reduce absorption by villous blunting
 Duodenal aspiration and culture is diagnostic
 Poorly absorbed antibiotics are preferable for
treatment
 Obstruction can be surgically corrected.
 Cholelithiasis

 Occur in 1/3rd of patients
 Due to increase bile stasis, and reduction of bile
salt absorption which leads to cholesterol stones

 Early enteral feeding reduce the stasis and

occurrence of bile stones
 Intermittent CCK injections prevent stasis
 Consider prophylactic cholecystectomy when
laparotomy is being performed for other reasons.
 Nephrolithiasis

 Increase risk in colon preserved patients
 Binding of non absorbed FFA with calcium releases free
oxalate which are soluble and absorbed in colon
 Free oxalate bind with calcium and form stones in
urine
 To prevent
 Low oxalate diet
 Reduce intraluminal fat
 Oral calcium supplement
 Cholestyramine binds with oxalic acid in colon
 Gastric hyper secretion

 Due to loss of inhibiting factors from the small
bowel
 Exacerbate malabsorption and diarrhea
 Causes peptic ulcer disease

 Prevention by PPI and H2 receptor blockers,

which continue up to 1 year postop
 Surgical therapy

 Re operation surgery is required in half of the patients
 Aim is to preserve the intestinal remnant length
 Avoid resection much as possible
 Surgical options available
 Intestinal tapering for dilated segments
 Strictureplasty
 Serosal patching
 Recruitment of isolated or bypassed bowel segment
When to consider surgical treatment

 Half of the patients can maintain nutrition only on
enteral nutrition and doesn’t require surgery
 But surgery should be consider if they are having
following
 worsening malabsorption
 Increased requirement for parenteral nutrition
 Disabling symptoms related to malabsorption
 Other half who is stable on TPN can undergo
surgery in the aim of weaning off from PN
 INTESTINAL TRANSPLANT SHOULD BE
CONSIDER IN PATIENTS WHO ARE HAVING
PERSISTING AND RECURRENT COMPLICATIONS
WHILE TOTALLY DEPEND ON PN.
 WILL DIE
 MANY SUCH PATIENTS
PREMATURELY
 Type of surgery depend on

 Intestinal remnant length
 Intestinal function
 Diameter of the intestinal remnant
 ADULTS WITH REMNANT MORE THAN
120CM

 Initial conservative management
 But when dilatation occurs – due to obstruction caused by
adhesions of stricture at anastomotic site, surgery is done for
adhesiolysis and strictureplasty
 If necessary non functional short segment resection
 PATIENTS WITH MARGINAL REMNANT, 60
-120CM
 THEY HAVE RAPID 
TRANSIT

 Reversing 10 – 15 cm segment yielded good results

 Other options
 Creation of artificial valves – not successful
 Retrograde intestinal pacing with electrodes
 PATIENTS WITH SHORT
REMNANT LENGTH < 60
CM WITH DILATED
BOWEL 
 Goal is to preserve the functional length and luminal
diameter
 When the dilatation is progressive in the absence of
obstruction – adaptive dilation and attempted medical
management are unsuccessful surgical intervention is
indicated.
 Intestinal lengthening surgeries

 Longitudinal lengthening – Bianchi procedure
 Allocate terminal blood vessels anatomically to the either
side of the bowel wall
 Longitudinal transection of the bowel
 Anastomosis of two limbs
 More than 100 cases reported
 Improvement is see in 80% of patients
 20% complications – anastomotic leak, ischemia
 Long term benefit in 50% of patients
 10% underwent intestinal transplant
Serial transverse enteroplasty(STEP)

 Repeated applications of linear stapling device from
opposite directions in zig sag fashion
 Requires diameter at least 4 cm
 Recurrent dilatation can managed in similar fashion
 80% of patients improve clinically
 5% undergone subsequent intestinal transplant
 STEP is preferable than Bianchi procedure
 Intestinal transplant

 Indicate in patients with SBS with life threatening
complications
 Recurrent central venous catheter infections
 Progressive liver failure
 Progressive loss of central venous access
 2000 OF TRANSPLANTS DONE IN US
BY 2012

 75% of patients are younger than 18 years
 1 year graft survival is 89% in adults
 But children less than 1 year of age it is 69%
 Patients survival rates are similar at 1 and 5 year
after transplant
 After one year of surgery 90 % of patients are independent
from PN
Yang feng suffering SBS following resection of small
bowel due to diverticulosis, 1st Chinese to survive
successfully following Small bowel transplantation

