Short Bowel Syndrome Flashcards
Short bowel syndrome is the metabolic & nutritional consequences which result from inadequate _______________
Unable to support the individual’s ______ and _____ requirements
Deficiency in bowel length due to extensive surgical resection
bowel mucosal absorptive surface area
nutritional & fluid
SBS is characterized by …
Severe, chronic _____________
__________ of macro- & micronutrients
_______
_________ Imbalances
Progressive ______ and ________
diarrhea & steatorrhea
Malabsorption
Dehydration
Electrolyte
weight loss & malnutrition
SBS diarrhea is due to ____, _____, and _____
malabsorption, altered motility, & increased secretions
SBS is Difficult to diagnose on _____ alone–need to consider symptoms
A loss of _______% of small bowel
<______ of remaining small bowel length
If >_____% of bowel removed/less than ______ remaining=> will have severe malabsorption and will likely need ____ for survival
length
70-75%
200 cm
75%
100 cm
PN
Etiology of SBS - Adults
Crohn’s disease (main)
Mesenteric infarct
Small bowel volvulus
Radiation enteritis
Cancer
Trauma
Small bowel fistulas
Etiology of SBS - Children
Necrotizing enterocolitis (NEC)
Small bowel volvulus
Intestinal atresia
Crohn’s disease
Factors that Influence the Severity of SBS
Remaining ___________
Health of remaining __________
__________ of resection
Presence of the ____________
Presence of the ________
Degree of __________ of the remaining bowel
Remaining bowel length
Health of remaining intestinal mucosa
Location of resection
Presence of the ileocecal valve
Presence of the colon
Degree of adaptation of the remaining bowel
Malabsorption increases with increased amount of small bowel removed or non-functional
Minimal small intestine length necessary for adequate absorption of oral/enteral is:
~______ of small bowel if no colon
~______ of small bowel with an intact colon
150 cm
60-90 cm
Location of Bowel Resection
Consider ________ and ________ of the segment removed
nutrients absorbed and functions
With Duodenal resection:
_____________ may occur
With Jejunal resection:
_________ can occur
Adequate absorption unless >_____% removed
______ can assume absorptive functions of the jejunum
Dumping syndrome
Lactose intolerance
75
Ileum
Ileal Resection
Only site for _____ and _____ absorption
Resections of > _____ results in a net loss of ______ causing _______ and ________
Large resections can result in severe malabsorption of _____, _______, ____, ____, _____, _____, and ____
Loss of the ileal _____
____________ =>dehydration & electrolyte deficiencies
Loss of the ICV can result in=> ___________
bile salt & vitamin B12
100 cm
bile salts
steatorrhea & cholerrheic diarrhea
fat, fat soluble vitamins, Ca, Mg, Zn, selenium, & B12
brake
End-jejunostomies
bacterial overgrowth
Partial or Total Resection
Increased risk of _______ and ______ losses
Intestinal transit time will be _______ with presence of a colon
____________=> slows gastric emptying
Intact colon=>metabolism of _____=> source of ____
dehydration and electrolyte
prolonged
Colonic brake
SCFA
kcal
_________ is when Remaining small bowel undergoes structural & functional changes to increase nutrient absorption
what can occur? (4)
Begins_________ after surgery and occurs over a _______ period
Intestinal Adaptation
Hyperplasia
elongation
increase height of the villi
increases in brush border enzymes
immediately
2-3 year
Factors which influence adaptation
Oral/enteral nutrition
Complex luminal nutrients vs. simple
Glutamine
Short-chain fatty acids (SCFA)
Hormones
hormones important in influencing intestinal adaptation
Intestinal hormones: enteroglucagon, glucagon-like peptide 1, peptide YY
Growth Hormone
Increased rate of gastric emptying Caused by loss of intestinal ________ & _________, loss of the ________
________=>rapid transit in remaining bowel
hormones
feedback control
pyloric sphincter
Ileal resection
Malabsorption of …
Fluid & electrolytes
Bile salts=>_________
Fat=>________
Fat soluble vitamins
Vitamin ____
Minerals: ____________
Lactose
cholerrheic diarrhea
steatorrhea
B12
Ca, Zn, Mg, Mn, Cu, selenium & chromium
____________ Can occur after significant SB resections
gastric hypersecretion
gastric hypersecretion results in…
Decreased ____ and _____ secretion=> increased serum _____levels=> increased ______ secretion
_____ volume of secretions entering the SB and promotes ____
______ damage to intestinal mucosa
Denatures __________
Precipitates _______ – disrupts _______ formation
Stimulates _______
CCK & secretin
gastrin
gastric acid
Increases
diarrhea
Acid
pancreatic enzymes
bile salts
micelle
peristalsis
what causes small bowel bacteria overgrowth
Removal of the ICV
Blind loops
Antimotility meds
Acid-suppression meds
small bowel bacterial overgrowth results in ?
Deconjugated bile salts
Inflammatory mucosal damage
Gas, abdominal bloating & pain, steatorrhea, fat-soluble vitamin & vitamin B12 deficiency
what is hyperoxaluria ?
when does it occur?
when steatorrhea, calcium bound to unabsorbed FA instead of oxalate, which increases absorption on free oxalate resulting in nephrolithiasis
occurs only if colon present
what anemias can occur with SBS
vit B12 or folate deficiencies
these are macrocytic
metabolic bone disease can occur with SBS due to malabsorption of _______ and _______. Also from ________ and _______.
vit D and calcium
metabolic acidosis
chronic inflammation
metabolic acidosis is caused by ?
bicarb loss from diarrhea and
…excess lactic acid production from SIBO
chronic inflammation occurs when patient has ____
IBD
Diet history: analysis of home diet/nutrition support, supplement use, foods that trigger ____________ or bowel movements
increased ostomy output
Nutrition assessment includes …
Detailed _______ records
Lab assessment: _______, ________, AND ________
I & O
electrolytes
malabsorption work-up
vitamin & mineral levels
ENERGY SBS
Individualize
______ kcal/kg; may need up to ____ kcal/kg
For those on PN: ___ kcal/kg
35-45
60
32
SBS PROTEIN
_____ g/kg
If on PN: _______ g/kg
Increased needs for …
Malnutrition
Recent ______
Presence of other diseases or conditions
Malabsorption
1.5-2.0
1.0-1.5
surgery
SBS FLUID
Increased fluid needs due to ______ or ______
diarrhea or ostomy output
For those with an ostomy, oral consumption of fluid should be _______ than ostomy output
Monitor closely and replace losses
Can be given ______________ to be Sipped slowly over the day
If >____/day ostomy output=> ________
greater
Oral Rehydration Solution (ORS)
2L
IVF with electrolytes
there are ____ post op phases of SBS
3
PHASE 1
Duration: ________
Severe _________
__________ of ________
Massive _____________
Rigorous ________ of fluid & electrolyte losses
Nutrition Support: __________
Initial 1-3 weeks
malabsorption
Hypersecretion of gastric secretions
diarrhea/ostomy output
IV repletion
NPO with TPN
PHASE 2
Duration: ________
______ malabsorption occurs with deficiencies in __________
Period of greatest ___________
Nutrition Support: ______________
1-3 months
Fat
fat-soluble vitamins, Ca, Mg, Zn
intestinal adaptation
TPN and initiation of enteral nutrition when/if diarrhea/ostomy output decreases to <2 L/d
PHASE 3
Duration: _____________
Goal is _____________
__________ controlled
Nutrition Therapy: ____________
Not all patients attain this phase=> _______
3-12 months or longer
adaptation and transition to oral diet
Diarrhea
discontinue TPN & increase to full enteral or oral feedings
home TPN
ENTERAL NUTRITION types ?
Fosters intestinal adaptation
Continuous infusion
ENTERAL NUTRITION FOSTERS INTESTINAL ADAPTATION
usually can be implemented within _______ after surgery
make sure it is infused into __________ in order to maximize the absorptive surface area
1 month
most proximal area
ENTERAL NUTRITION CONTINUOUS INFUSION
may need this for __________ if unable to meet needs with oral diet
home tube feeding
Research supports using ___________ formulas due to increased ____________ and decreased _________
If colon is intact, use a ____________ formula=> _____
If unsuccessful=> try a ______________
________ formulas=> no longer recommended
isotonic, polymeric
stimulation of intestinal adaptation
osmotic load
soluble fiber-containing
SCFA
semi-elemental/peptide-based formula with MCT
Elemental
Must consider anatomy for macronutrient distribution
Colon in continuity=>
______ CHO, ______ fat
______% of kcal from CHO
______% from fat
_____% from protein
_______ CHO; _______ fiber=>______
Absence of colon=> Moderate in CHO & fat
40-50% of kcal from CHO, 30-40% kcal from fat, 20% from protein
Complex CHO; soluble fiber
Higher
lower
50-60
20-30
20
Complex
soluble
SCFA
Macronutrients…
Absence of colon=>
_______ in CHO and ______ fat
______% of kcal from CHO
______% kcal from fat
______% from protein
_______ CHO; ______ fiber
Moderate
Moderate
40-50
30-40
20
complex
soluble
FOR ORAL NUTRITION…
Consume ___ _______ meals
Mimimize intake of __________
Emphasize ________ CHO
Chew food thoroughly
when do u drink fluid ??????
Drink _______ beverages - ____
Liberal use of salt (if _____)
Avoid caffeine & alcohol
5-6 small
concentrated sweets
complex
not during meals
isotonic
ORS
no colon
Individualize restrictions
If colon intact=>Restrict _________
________—if needed
Provide diet education with sample menus
oxalate intake
Low lactose
Sources of oxalate ?
berries
nuts
chocolate
green beans
celery
spinach
beets
beer
sweet potatoes
soy
Micronutrients (for those on oral &/or enteral nutrition)
___________ for all patients
Assess individually for additional supplementation
If steatorrhea=>_______________
In the absence of the ileum/large resection =>___________
MVI with minerals
fat-soluble vitamin supplement in water-soluble form
1000 mcg vit B12 IM injection monthly
other possible micronutrients you might give
calcium citrate
Mg
Zinc
K+, Na, Cl, bicarbonate
Calcium citrate supplementation=>________
Magnesium is _________ or ___________
500-600 mg tablet, 1-2 tablets TID
Mg lactate: 84 mg tablet 1-2 tablets TID
Mg gluconate: 1000 mg tablet or liquid, 1-3 tablets TID
Zinc=>lose _____ mg zinc/L of output
Rx _____ of _______ tablet, _____ tablets daily
K+, Na, Cl, Bicarbonate=> ____
12
220 mg zinc sulfate
1-3
ORS
Pharmacologic Management of SBS
Antimotility/antidiarrheals
Proton pump inhibitors & H2-receptor antagonists
Bile acid sequestrants
somatostatin analogue
Antimotility/antidiarrheals example
loperamide
Bile acid sequestrants example
cholestyramine
Food-drug interaction with bile acid sequestrants
Decreased absorption of fat-soluble vitamins, Ca, Fe, Zn, Mg, & folate
somatostatin analogue ?
octreotide
octedtride effects ?
FDI?
Antisecretory action
Antimotility
Reduces ostomy output and diarrhea
Food-drug interactions: N/V
FDA-Approved Proadaptive Therapy for Management of SBS ?
example ?
what does it do?
Glucagon-like peptide 2 (GLP-2) analogues
e.g., teduglutide (GATTEX)
Found to increase improve structural integrity of intestinal mucosa, increase intestinal absorption, and reduce PN requirements
Surgical Management of SBS
Longitudinal intestinal lengthening & tapering (LILT)
Serial transverse enteroplasty procedure (STEP)
Small bowel transplantation
*look these up to see what they are
