Short Bowel Syndrome

Question 1

Why do patients with short bowel syndrome require medical management? What should you consider with the route of administration?

Answer 1

To ensure adequate absorption of nutrients and fluid.

Absorption of oral medication is also often impaired.

Question 2

Nutritional deficiencies associated with short bowel syndrome

Answer 2

Vit A, B12, D, 3 and K, essential fatty acids, zinc and selenium
Hypomagensaemia

Question 3

Treatment of the nutritional deficiencies

Answer 3

Supplementation e.g., alfacalcidol
PO/IV Magnesium

Question 4

Side effect of oral magensium

Answer 4

Diarrhoea

Question 5

Treatment of diarrhoea / high output stomas associated with short bowel syndrome

Answer 5

Oral rehydration salts to promote adequate hydration

Reducing food intake = reduces diarrhoea but may be undernourished

Loperamide and codeine to reduce intestinal motility

Co-phenotrope has been used alone or in combination to help decrease faecal output

Colestyramine - Used in patients with intact colon and less than 100cm of ileum resected

Question 6

Why is loperamide preferred over codeine to treat diarrhoea?

Answer 6

As it is not sedative and does not cause dependence or fat malabsorption

Question 7

Why would high doses of loperamide be required in short bowel syndrome?

Answer 7

High doses may be required due to disrupted enterohepatic circulation and rapid gastrointestinal transit time

Question 8

Side effect of Co-phenotrope

Answer 8

Crosses BBB and can produce CNS side effects and dependence and anticholinergic effects

Question 9

How does colestyramine treat diarrhoea? What must be monitored during treatment?

Answer 9

Bind the unabsorbed bile salts and reduce diarrhoea

Monitor evidence of fat malabsorption (steatorrhea) or fat-soluble vitamin deficiencies

Question 10

Which medications can also reduce stoma/jejunostomy output?

Answer 10

Antisecretory drugs - omeprazole

Question 11

When would omeprazole be required to be administered IV in the management short bowel syndrome?

Answer 11

If less than 50cm of jejunum remains as it is readily absorbed in the duodenum and upper small bowel

Question 12

Role of growth factors in the management of short bowel syndrome. Give an example of one.

Answer 12

Can be used to facilitate intestinal adaptation after surgery in patients with short bowel syndrome and enhance fluid, electrolyte, and micronutrient absorption

Teduglutide (analogue of human glucagon-like peptide 2 (GLP-2) )

Question 13

Which drugs may not be completely absorbed by patients with a short bowel and therefore may require higher doses than usual or IV administration?

Answer 13

Levothyroxine, warfarin, oral contraceptives, digoxin

Question 14

Which site of the GI tract is most important for absorption?

Answer 14

The small intestine due to its large surface area and high blood flow

Question 15

Factors which will impact drug absorption in patients with short bowel syndrome

Answer 15

The site which has been removed e.g., small intestine
Altered gastric emptying
Altered gastric transit time

Question 16

Which formulations are unsuitable for use in patients with short bowel syndrome?

Answer 16

Enteric-coated and MR as there may not be sufficient release of the active ingredient

Question 17

Which formulations should be used in patients with short bowel syndrome?

Answer 17

Soluble tablets, uncoated tablets, liquids

Question 18

What should be considered when prescribing liquids for patients with short bowel syndrome?

Answer 18

Osmolarity, excipient content and volume required.

Hyperosmolar liquids and sorbitol can result in fluid loss