short bowel syndrome

Question 1

pt with shortened bowel due to large surgical resection (with or without stoma formation) may require medical management to ensure…

Answer 1

adequate absorption of nutrients and fluid

Question 2

true or false - absorption of oral meds is often impaired

Answer 2

true

Question 3

deficiencies of the following can occur

Answer 3

A, B12, D, E, K
essential fatty acids, zinc, selenium

Question 4

this electrolyte disturbance is common

Answer 4

hypomagnesesmia

Question 4

hypomagnesiemia is common. it is treated with….

Answer 4

oral or IV magnesium supplementation
oral can cause diarrhoea

Question 5

is diarrhoea common in short bowel syndrome

Answer 5

yes

Question 6

what should you consider using in pt with diarrhoea

Answer 6

ORS to promote adequate hydration

Question 7

oral intake influences the volume of stool passed. therefore reducing food intake will lessen diarrhoea, however….

Answer 7

it will also exacerbate the problems of undernutrition

Question 8

if the extent of diarrhoea is unacceptable, a patient may require the following to allow them to eat less

Answer 8

parenteral nutrition

Question 9

2 drugs that can reduce intestinal motility and thus exert antidiarrhoeal actions

Answer 9

loperamide
codeine

Question 10

which drug is preferred for diarrhoea

Answer 10

loperamide as it is not sedative and does not cause dependence or fat malabsorption

Question 11

high doses of loperamide may be needed in short bowel syndrome due to disrupted enterohepatic circulation with rapid GI transit time. if the desires response is not obtained with loperamide, then the following drug can be added to therapy

Answer 11

codeine

Question 12

this drug has traditionally been used alone or in combo with other meds to help decrease faecal output. however it crosses BBB and can produce CNS SE which can limit its use. also has potential for dependence and anticholinergic effects.

Answer 12

co-phenotrope

Question 13

in patients with intact colon and <100cm of ileum resected, the following drug can be used to bind to unabsorbed bile salts and reduce diarrhoea

(hint: cholesterol)

Answer 13

colesyramine

Question 14

In patients with an intact colon and less than 100 cm of ileum resected, colestyramine can be used to bind the unabsorbed bile salts and reduce diarrhoea. When colestyramine is given to these patients, it is important to monitor for….

Answer 14

evidence of fat malabsorption (steatorrhoea) or fat-soluble vitamin deficiencies.

fat soluble vitamins A, D, E, and K

Question 15

what can be given as an antisecretory drug and why

hint commonly used for ac..

Answer 15

PPI
Drugs that reduce gastric acid secretion reduce jejunostomy output.

Question 16

Omeprazole can be used as an antisecretory drug because it reduces gastric acid and thus reduced jejunostomy output. it is readily absorbed in the duodenum and upper small bowel, but if less than 50 cm of jejunum remains…

Answer 16

then needs to be given IV

Question 17

does the use of a PPI alone eliminate the need for further intervention for fluid control ?

Answer 17

NO

Use of a proton pump inhibitor alone does not eliminate the need for further intervention for fluid control (such as antimotility agents, intravenous fluids, or oral rehydration salts).

Question 18

this drug reduces ileostomy diarrhoea and large volume jejunostomy output by inhibiting multiple pro-secretory substances. however, there is insufficient evidence to establish its role in the management of short bowel syndrome.

Answer 18

Octreotide [unlicensed indication]

Question 19

discuss use of growth factors

Answer 19

Growth factors can be used to facilitate intestinal adaptation after surgery in patients with short bowel syndrome, thus enhancing fluid, electrolyte, and micronutrient absorption.

Question 20

What is teduglutide and discuss its use

Answer 20

Teduglutide is an analogue of endogenous human glucagon-like peptide 2 (GLP-2) which is licensed for use in the management of short bowel syndrome.

It may be considered after a period of stabilisation following surgery, during which intravenous fluids and nutritional support should have been optimised.

Question 21

discuss drug absorption

Answer 21

Many drugs are incompletely absorbed by patients with a short bowel and may need to be prescribed in much higher doses than usual (such as levothyroxine, warfarin, oral contraceptives, and digoxin) or may need to be given intravenously.

Question 22

Several factors can alter the absorption of drugs taken by mouth in patients with a compromised gastrointestinal system.

Answer 22

• most important factors: length of intestine available for drug absorption, and which section has been removed
• small intestine (large SA and high blood flow) is the most important site of drug absorption
• the larger the amount of small intestine removed, higher the possibility that drug absorption will be affected
• other factors such as gastric emptying and gastric transit time, also affect drug handling.

Question 23

why are EC and MR preparations unsuitable for use in patients with short bowel syndrome, particularly in patients with an ileostomy

Answer 23

Enteric-coated and modified-release preparations are unsuitable for use in patients with short bowel syndrome, particularly in patients with an ileostomy, as there may not be sufficient release of the active ingredient.

Question 24

what types of dosage form should be used in pt with short bowel syndrome esp in pt with ileostomy

and what considerations to make before prescribing liquid forms

Answer 24

Dosage forms with quick dissolution (soluble tablets) should be used. Uncoated tablets and liquid formulations may also be suitable.

Before prescribing liquid formulations, prescribers should consider the osmolarity, excipient content and volume required. Hyperosmolar liquids and some excipients (such as sorbitol) can result in fluid loss. The calorie density of oral supplements should also be considered, as it will influence the volume to be taken.