Short Bowel Syndrome 2005

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Short Bowel SyndromeShort Bowel Syndrome

Anne Aspin 2005Anne Aspin 2005


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DefinitionDefinition

Rickham (1967)Rickham (1967) an extensive resection toan extensive resection tomaximum of 75cmmaximum of 75cm

Kuffer (1972)Kuffer (1972) 15cm with ileocaecal valve15cm with ileocaecal valve-- 38cm without ileocaecal valve38cm without ileocaecal valve

Dorney (1985)Dorney (1985) 11cm with I/C valve or 25cm11cm with I/C valve or 25cmwithout I/C valvewithout I/C valve


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IntroductionIntroduction

Most common cause of intestinal failure.Most common cause of intestinal failure.

NEC, Congenital atresia, Gastroschisis andNEC, Congenital atresia, Gastroschisis andvolvulus.volvulus.

Promote adaptive response throughPromote adaptive response throughenteral feeding and careful managemententeral feeding and careful managementof TPN.of TPN.


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The Digestive SystemThe Digestive System

Digestion starts in the mouthDigestion starts in the mouth

Moisten by saliva (contains Pytalin),Moisten by saliva (contains Pytalin),begins to turn starch to sugar.begins to turn starch to sugar.

In stomach food churned mixes withIn stomach food churned mixes withgastric juices.gastric juices.


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Gastric juicesGastric juices

Acid reactionAcid reaction

Kills bacteriaKills bacteria

Controls pylorusControls pylorus


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Gastric juices:Gastric juices:

-- Rennin coagulates milkRennin coagulates milk

-- Hydrochloric AcidHydrochloric Acid Converts Pepsinogen toConverts Pepsinogen to

Pepsin.Pepsin.

-- Pepsin turns protein to peptonePepsin turns protein to peptone


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Food is released in small amounts byFood is released in small amounts byrelaxation of the sphincter passing ontorelaxation of the sphincter passing onto

Duodenum.Duodenum.

Food further digested by Trypsin, AmylaseFood further digested by Trypsin, Amylase

and Lipase.and Lipase.

Digestion completed in small intestine.Digestion completed in small intestine.


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Intestinal juices.Intestinal juices.

EnterokinaseEnterokinase pancreatic trypsinogenpancreatic trypsinogen PeptidasePeptidase polypeptide to amino acidpolypeptide to amino acid MaltaseMaltase -- maltose}maltose} SucraseSucrase sucrose} to glucosesucrose} to glucose

LactaseLactase Lactose}Lactose}

LipaseLipase Fats to fatty acids and glycerolFats to fatty acids and glycerol


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Onto large intestine where fluids andOnto large intestine where fluids andnutrients are re absorbed.nutrients are re absorbed.

Waste fluids taken by blood stream toWaste fluids taken by blood stream tokidneys to be filteredkidneys to be filtered


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Small intestineSmall intestine

Convoluted tube from pyloric sphincter toConvoluted tube from pyloric sphincter tothe junction of ileothe junction of ileo caecal valvecaecal valve

Mucus membraneMucus membrane has circular folds tohas circular folds toincrease surface area for absorption.increase surface area for absorption.

Villi which contain blood and lymph vessel.Villi which contain blood and lymph vessel. Supplied with tubular glands secretingSupplied with tubular glands secretingintestinal juice.intestinal juice.


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AbsorptionAbsorption

Proteins, Carbohydrates and Fats throughProteins, Carbohydrates and Fats throughvilli in small intestine.villi in small intestine.

Fats in the form of fatty acids and glycerolFats in the form of fatty acids and glycerolare absorbed by cells covering villi. Passare absorbed by cells covering villi. Pass

into lymph within villi drained by lymphaticinto lymph within villi drained by lymphaticcapillaries.capillaries.


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What is SBSWhat is SBS

Reduced bowel surface area forReduced bowel surface area forabsorption of nutrients together with rapidabsorption of nutrients together with rapid

transit of intestinal contents.transit of intestinal contents.

TPN reduced as enteral feeds areTPN reduced as enteral feeds are

introduced.introduced.

Need to promote intestinal adaptation.Need to promote intestinal adaptation.


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MotilityMotility

The IC valve and colon is important toThe IC valve and colon is important toslow intestinal transit.slow intestinal transit.

Proteins, Fats and Carbohydrates areProteins, Fats and Carbohydrates areabsorbed almost completely within firstabsorbed almost completely within first

150cm of small bowel.150cm of small bowel.


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JejunumJejunum most of electrolyte absorptionmost of electrolyte absorption

Ileum is the only site for absorption of VitIleum is the only site for absorption of VitB12 and bile salts.B12 and bile salts.


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After resection.After resection.

Increase gastric emptying.Increase gastric emptying.

Ileal resection, increased transit timeIleal resection, increased transit time

An intact IC valve prolongs gut transit, loss ofAn intact IC valve prolongs gut transit, loss of

this causes an increase.this causes an increase.

If colon resected transit increases.If colon resected transit increases.


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Duodenal resectionDuodenal resection malabsorption ofmalabsorption ofIron, Calcium and Folic Acid.Iron, Calcium and Folic Acid.

Jejunal resectionJejunal resection If extensive resection,If extensive resection,lactose intolerencelactose intolerence

Ileal resectionIleal resection Some diarrhoea due toSome diarrhoea due tobile salts being incompletely absorbed.bile salts being incompletely absorbed.


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Gastric HypersecretionGastric Hypersecretion

After abdominal surgery, gastric hyperAfter abdominal surgery, gastric hyper--secretion occurs in 50% cases.secretion occurs in 50% cases.

This impairs digestion of lipids by loweringThis impairs digestion of lipids by loweringintraluminal PH and inactivating theintraluminal PH and inactivating the

pancreatic enzymes.pancreatic enzymes.

Also stimulates peristalsis.Also stimulates peristalsis.


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How does the bowel adapt?How does the bowel adapt?

Cellular hyperplasiaCellular hyperplasia Villous hypertrophyVillous hypertrophy

Intestinal lengtheningIntestinal lengthening Altered motilityAltered motility Hormonal changesHormonal changes

Takes approx 2 yearsTakes approx 2 yearsto reach max effect.to reach max effect.


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Management of SBS.Management of SBS.

Total TPNTotal TPN Gradual introduction of enteral feeding.Gradual introduction of enteral feeding. Fluid and electrolyte balanceFluid and electrolyte balance Fluid replacement if stool, gastric aspirateFluid replacement if stool, gastric aspirate

or ostomy losses are highor ostomy losses are high

Reducing substances above1% contraReducing substances above1% contraindicate increasing enteral feeds.indicate increasing enteral feeds.


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Weaning off TPNWeaning off TPN

CyclingCycling one hour off, line lock withone hour off, line lock withGentamycin. Build up to off all day.Gentamycin. Build up to off all day.


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Complications.Complications.

Bacterial overgrowthBacterial overgrowthAnaemiaAnaemia Bile salt depletionBile salt depletion Bone diseaseBone disease CholestasisCholestasis DiarrhoeaDiarrhoea HypocalcaemiaHypocalcaemia


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Complications (cont)Complications (cont)

HypomagnesaemiaHypomagnesaemia Liver fibrosisLiver fibrosis Renal stonesRenal stones Protein malnutritionProtein malnutrition Trace mineral deficiencyTrace mineral deficiencyVitamin deficiency, A, D, E, K, B12Vitamin deficiency, A, D, E, K, B12


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Central line complicationsCentral line complications

InfectionInfection ThrombosisThrombosis Break in catheterBreak in catheterAir embolusAir embolus Tissue necrosisTissue necrosis MalpositionMalposition Cardiac tamponadeCardiac tamponade


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Bacterial OvergrowthBacterial Overgrowth

Bloating, cramps, diarrhoea,Bloating, cramps, diarrhoea,gastrointestinal blood loss.gastrointestinal blood loss.

Treat with sugar free Metronidazole andTreat with sugar free Metronidazole andTrimethoprimTrimethoprim


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Watery diarrhoeaWatery diarrhoea

LoperamideLoperamide

Malabsorption of bile acids.Malabsorption of bile acids.

PectinPectin


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SurgerySurgery

Further resection might be avoided byFurther resection might be avoided bytapering, strictureplasty or serosaltapering, strictureplasty or serosal

patching.patching.

Patients with dilated segments proximal toPatients with dilated segments proximal to

tight anastomosistight anastomosis resect and taperresect and taperimproves bacterial overgrowth byimproves bacterial overgrowth byimproving flow.improving flow.


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TaperingTapering


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Bowel lengtheningBowel lengthening

Cutting bowel longitudinally, preserveCutting bowel longitudinally, preserveblood supply to both sides and create ablood supply to both sides and create a

segment of bowel twice length, halfsegment of bowel twice length, halfdiameter without loss of mucosal surfacediameter without loss of mucosal surfacearea.area.


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Bowel lengtheningBowel lengthening


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Antiperistaltic small intestineAntiperistaltic small intestine

segmentsegment


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Colonic interpositionColonic interposition


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Medical managementMedical management

Pectin (water sol, non cellulose dietaryPectin (water sol, non cellulose dietaryfibre which promotes intestinalfibre which promotes intestinal

adaptation)adaptation)

Ranitidine (PH > 4)Ranitidine (PH > 4)

Loperamide (slow gut transit time)Loperamide (slow gut transit time)

Cholestyramine (binds bile salts)Cholestyramine (binds bile salts)


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It takes approximately two years toIt takes approximately two years to

achieve some normal dietachieve some normal diet


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Thank youThank you

Short Bowel Syndrome 2005

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