By Amnah Azim

Learning Objectives To know what is Short bowel syndrome

To know about changes in small bowel after resection

Learn how to manage with different medical n surgical strategies.

Short Bowel Syndrome Short bowel syndrome is a spectrum of

pathophysiological disorder that occurs as a consequences of insufficient absorptive and digestive small intestinal mucosal surface area. [1]

OR Parental nutrition dependence for greater than

3 months.[2]

Ref : 1. Warner BW ,Small bowel syndrome, text book of pediatric surgery 6th edition 2 Jaksic T , ,Small bowel syndrome, text book of pediatric surgery 7th edition

EtiologySmall Gut Length

Mid gut volvulus

Intestinal atresia

NEC

Gastroschiasis

Functional Disorders

Aganglionosis

Idiopathic intestinal obstruction

Crohn’s disease

Gut Resection Rickham (1967) – an extensive resection to maximum of

75cm

Kuffer (1972) – 15cm with ileocaecal valve

- 38cm without ileocaecal valve

Dorney (1985) – 11cm with I/C valve or 25cm without I/C valve

what happens when gut resected?

Acute phase : starts immediately and upto 3-4 months

Adaptation phase : starts immediately and last upto 12-24 months

Maintenance phase : absorptive capacity will be maximize.

How does the bowel adapt? Cellular hypertrophy and

hyperplasia

Villi become taller

Crypts become deeper

Intestinal dilatation

Altered motility

Hormonal changes

Medical management Fluid and electrolyte balance:

Fluid loss in ostomy, diarrhea + Normal fluid requirement +300~500ml for insensible loss

Enteral feeding can be initiated at 5-1o post op day if not surical complication occur.

Breast milk feeding is appropriate in infants due to abundance in epidermal growth factor

Lactose intolerance is not uncommon; glucose polymer is better.

Initiat TPN in high output ostomies and if not tolerating enteral feed .

Fluid Management

Parrish. Pract Gastroenterol. 2005

Or 800ml urine with sodium 20mmol/L

Pharmacologic Agents

High-dose loperamide

Codeine phosphate

H2 blocker (i.e. ranitidine)

Proton pump inhibitor (i.e. omeprazole)

Somatostatin analogue (octreotide)

Cholestyramine

Cholecystokinin

Antibiotics

Surgical therapies Procedures that

Delay intestinal transit time

Construction of various valves and sphincters

Construction of anti-peristaltic (reversed) segments

Recirculating loops

Colonic interposition

Increase absorptive area

Intestinal tapering and lengthening

Small bowel transplantation

Isolated small intestinal graft

Combined liver/small intestinal grafts

Townsend et al. Sabiston Textbook of Surgery 17th Edition. 2004

Tapering

Bowel lengthening Cutting bowel longitudinally, preserve blood supply to

both sides and create a segment of bowel twice length, half diameter without loss of mucosal surface area.

Bowel lengthening

Antiperistaltic small intestine segment

Colonic interposition

Any Query??

Thank you