Short Bowel Syndrome Flashcards by Sydney Perry

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

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SBS is characterized by …

Severe, chronic _____________
__________ of macro- & micronutrients

_______
_________ Imbalances

Progressive ______ and ________

diarrhea & steatorrhea
Malabsorption

Dehydration
Electrolyte

weight loss & malnutrition

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SBS diarrhea is due to ____, _____, and _____

malabsorption, altered motility, & increased secretions

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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

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Etiology of SBS - Adults

Crohn’s disease (main)
Mesenteric infarct
Small bowel volvulus
Radiation enteritis
Cancer
Trauma
Small bowel fistulas

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Etiology of SBS - Children

Necrotizing enterocolitis (NEC)
Small bowel volvulus
Intestinal atresia
Crohn’s disease

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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

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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

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Location of Bowel Resection

Consider ________ and ________ of the segment removed

nutrients absorbed and functions

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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

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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

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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

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_________ 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

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Factors which influence adaptation

Oral/enteral nutrition
Complex luminal nutrients vs. simple
Glutamine
Short-chain fatty acids (SCFA)
Hormones

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hormones important in influencing intestinal adaptation

Intestinal hormones: enteroglucagon, glucagon-like peptide 1, peptide YY

Growth Hormone

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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

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Malabsorption of …

Fluid & electrolytes
Bile salts=>_________
Fat=>________
Fat soluble vitamins
Vitamin ____
Minerals: ____________
Lactose

cholerrheic diarrhea
steatorrhea
B12
Ca, Zn, Mg, Mn, Cu, selenium & chromium

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____________ Can occur after significant SB resections

gastric hypersecretion

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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

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what causes small bowel bacteria overgrowth

Removal of the ICV
Blind loops
Antimotility meds
Acid-suppression meds

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small bowel bacterial overgrowth results in ?

Deconjugated bile salts

Inflammatory mucosal damage

Gas, abdominal bloating & pain, steatorrhea, fat-soluble vitamin & vitamin B12 deficiency

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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

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what anemias can occur with SBS

vit B12 or folate deficiencies

these are macrocytic

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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

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