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A1-G Surg Note Small Bowel > Short Bowel Syndrome > Flashcards

Short Bowel Syndrome Flashcards

1
Q

What defines short bowel syndrome (SBS) in adults?

A

Malabsorption and malnutrition generally occurring when less than 180 cm of functional intestine remains.

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2
Q

What factors determine the severity of SBS?

A

Extent and site of resection
underlying intestinal disease
presence of the terminal ileum and ileocecal valve, functional status of remaining organs
and adaptive capacity of the intestinal remnant.

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3
Q

What are the main pathophysiologic changes seen in SBS?

A

Loss of intestinal absorptive surface and more rapid intestinal transit

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4
Q

What are common complications associated with SBS?

A

Malnutrition
weight loss
diarrhea
steatorrhea
vitamin deficiency
electrolyte imbalance
nephrolithiasis
cholelithiasis
transient gastric hypersecretion
and bacterial overgrowth.

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5
Q

Why is liver disease a concern in patients with SBS on parenteral nutrition (PN)?

A

It remains an important factor in mortality due to long-term PN dependence.

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6
Q

What type of adaptation occurs in the intestine after massive resection?

A

Functional and structural adaptation
improving nutrient absorption and decreasing diarrhea within the first few months post-resection.

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7
Q

What are the primary management goals for patients with SBS beyond the early critical phase?

A

Maintain adequate nutritional status
maximize absorptive capacity of the remaining intestine, and prevent complications related to SBS and nutritional therapy

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8
Q

What are the key elements of surgical approaches in managing SBS?

A

Preserving and maximizing the function of the intestinal remnant, and augmenting intestinal length via transplantation.

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9
Q

What is the most important therapeutic objective in managing short bowel syndrome (SBS)?

A

Maintaining the patient’s nutritional status

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10
Q

How is nutritional status initially maintained in SBS patients postoperatively?

A

Primarily through parenteral nutrition (PN) support

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11
Q

When can enteral nutrition support be started in SBS patients?

A

Early after the operation, once ileus has resolved

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12
Q

Why is early initiation of enteral nutrition important in SBS management?

A

It maximizes intestinal adaptation and helps prevent complications related to PN

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13
Q

What determines the likelihood of a patient requiring long-term PN in SBS?

A

The length of the remaining small intestine.

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14
Q

How does the length of the remaining intestine affect PN dependency?

A

180 cm: No PN generally needed.

90 cm (with colon present): PN required for less than 1 year.

<60 cm: Likely require permanent PN

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15
Q

What is a sign that increased enteral feeding is not tolerated in SBS patients?

A

A marked increase in gastrointestinal fluid loss

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16
Q

What are the primary objectives during the transition from PN to enteral nutrition in SBS?

A

Maintaining stable body weight and preventing large fluctuations in fluid balance.

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17
Q

What should be done as parenteral nutrition requirements decrease in SBS management?

A

Intermittent PN can be introduced, reducing therapy hours and eventually alternating days

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18
Q

What type of monitoring is essential during the transition to enteral nutrition in SBS patients?

A

Metabolic monitoring to detect and correct any metabolic abnormalities and micronutrient deficiencies

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19
Q

Why might some SBS patients require ongoing fluid supplementation?

A

To maintain hydration and support nutrient absorption as part of long-term management

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20
Q

What factors influence dietary management in patients with short bowel syndrome (SBS)?

A

Intestinal remnant length and location
underlying intestinal disease
status of remaining digestive organs
and the existence of a stoma

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21
Q

Why might patients with SBS develop hyperphagia?

A

To compensate for their inefficient nutrient absorption

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22
Q

What type of feeding may allow greater nutrient absorption in patients with less than 90 cm of intestinal remnant?

A

Continuous enteral feeding.

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23
Q

What type of diet is initially appropriate for SBS patients, especially if the colon is in continuity?

A

A high-carbohydrate, high-protein diet

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24
Q

How should fat intake be managed in SBS patients with colon in continuity?

A

Fat should be restricted to 20% to 30% of caloric intake to prevent steatorrhea and nephrolithiasis

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25
Q

Why are isotonic feedings important for patients with jejunal remnants?

A

Because the jejunal mucosa is relatively permeable and isotonic feedings optimize water and sodium absorption

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26
Q

What is the role of glucose-electrolyte oral rehydration solutions in SBS?

A

To optimize water and sodium absorption in the proximal jejunum and prevent secretion into the lumen

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27
Q

Which nutrient’s role remains controversial in SBS management, but may have trophic effects on the gut?

A

Glutamine.

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28
Q

What agents are used for their antisecretory and antimotility effects in SBS?

A

Codeine
diphenoxylate-atropine (Lomotil)
loperamide,
octreotide

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29
Q

Why should octreotide not be routinely used for chronic diarrhea in SBS?

A

It may cause deleterious effects, such as steatorrhea, inhibition of intestinal adaptation, and increased incidence of cholelithiasis.

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30
Q

Which medications are effective for controlling gastric hypersecretion in SBS?

A

H2 receptor antagonists and proton pump inhibitors.

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31
Q

What is cholestyramine used for in SBS?

A

It is beneficial when diarrhea is related to unabsorbed bile salts in the colon, especially if less than 100 cm of ileum has been resected

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32
Q

What is teduglutide, and how is it used in SBS?

A

A GLP-2 analogue approved for promoting intestinal absorption and adaptation, reducing the need for supplemental fluids and nutrients

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33
Q

How are GLP-1 analogues like liraglutide used off-label in SBS?

A

To slow gastric emptying and intestinal motility.

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34
Q

Medical Treatment of Short Bowel

A

1

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35
Q

Medical Treatment of Short Bowel

A

2

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36
Q

What are common metabolic complications in patients with short bowel syndrome (SBS)?

A

Dehydration
renal dysfunction
hypocalcemia
hyperglycemia
hypoglycemia
metabolic acidosis/alkalosis
and nutrient deficiencies

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37
Q

Why is hypocalcemia a common issue in SBS?

A

Due to poor calcium absorption and binding by intraluminal fat.

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38
Q

What supplementation is important to minimize bone disease in SBS patients?

A

Adequate calcium, magnesium, and vitamin D

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39
Q

What are common causes of hyperglycemia and hypoglycemia in SBS patients?

A

Receiving a significant portion of their calories parenterally

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40
Q

Which micronutrient deficiencies need to be monitored in SBS patients?

A

Iron, selenium, zinc, and copper

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41
Q

Why are SBS patients at risk for fatty acid deficiency

A

Due to poor fat absorption

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42
Q

What is an important preventative measure against catheter-related sepsis in SBS patients?

A

Meticulous technique and patient education
Ethanol and antibiotic lock therapy

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43
Q

How can catheter thrombosis impact SBS patients requiring permanent PN?

A

It can become a critical factor affecting patient survival due to limited vascular access

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44
Q

What long-term complication is associated with parenteral nutrition (PN) in SBS patients?

A

liver disease, potentially leading to steatosis, cholestasis, or cirrhosis

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45
Q

What measures can help prevent PN-induced liver disease?

A

Providing as much enteral nutrition as possible
avoiding overfeeding
and minimizing lipid intake, especially soy-based

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46
Q

What complication may indicate bacterial overgrowth in SBS patients?

A

Changes in absorptive capacity and stool habits, especially if sudden.

47
Q

What is a potential therapy for bacterial overgrowth in SBS patients?

A

Antibiotics and possibly probiotics

48
Q

What is the incidence of cholelithiasis in SBS patients, and what factors increase the risk?

A

Occurs in 30% to 40% of patients
higher risk if less than 120 cm of intestine remains, terminal ileum resected, and PN is required.

49
Q

How can cholelithiasis be prevented in SBS patients?

A

By providing nutrients enterally, using therapies to stimulate gallbladder emptying, and considering prophylactic cholecystectomy during other surgeries

50
Q

What dietary management can help prevent nephrolithiasis in SBS patients?

A

A low-oxalate diet
minimizing intraluminal fat
calcium supplementation
maintaining high urinary volume

51
Q

What medication can be used to bind oxalic acid in the colon to prevent nephrolithiasis?

A

Cholestyramine

52
Q

What causes gastric hypersecretion in SBS patients?

A

Massive intestinal resection leading to
parietal cell hyperplasia and hypergastrinemia
due to loss of an inhibitor from the resected intestine

53
Q

Why is gastric hypersecretion a problem in SBS patients?

A

It exacerbates malabsorption, diarrhea, and increases the risk of peptic ulcer disease.

54
Q

What treatments are recommended for controlling gastric acid secretion in SBS patients?

A

H2 receptor antagonists or proton pump inhibitors, especially in the perioperative period and until hyperacidity resolves

55
Q

What percentage of SBS patients require abdominal reoperation after discharge?

A

Approximately 50%

56
Q

What is the most frequent indication for reoperation in SBS patients?

A

Intestinal problems

57
Q

What surgical techniques can be used to avoid resection in SBS patients?

A

Intestinal tapering
strictureplasty for benign strictures
and serosal patching for certain strictures and chronic perforations

58
Q

What can occasionally be recruited into continuity during reoperation in SBS patients?

A

Intestinal segments from previous surgeries

59
Q

What are potential benefits of restoring intestinal continuity in patients with a colonic remnant?

A

Improved intestinal absorption
increased surface area
energy from short-chain fatty acids
prolonged transit time, and improved quality of life.

60
Q

What are potential drawbacks of restoring intestinal continuity in SBS patients?

A

Secretory diarrhea from bile acids
disabling perianal problems
and increased risk of calcium oxalate stone formation

61
Q

Why does the colon increase the risk of calcium oxalate stone formation in SBS patients?

A

oxalate is primarily absorbed in the colon.

62
Q

What is the minimum length of small intestine generally required to prevent severe diarrhea and perianal complications?

A

At least 60 cm.

63
Q

What are some surgical goals for managing short bowel syndrome (SBS)?

A

Slowing intestinal transit
improving function of existing intestine
and increasing intestinal surface area

64
Q

What innovative surgical approaches have been used to slow intestinal transit in SBS patients?

A

Reversing intestinal segments and interposing colonic segments into the small intestine.

65
Q

How are stenotic segments in the intestine managed in SBS patients?

A

By relieving the obstruction, often through strictureplasty

66
Q

What surgical treatment is used for dilated dysfunctional segments in SBS?

A

Tapering enteroplasty

67
Q

What is the best surgical option for patients with particularly short intestinal remnants to improve nutrient absorption?

A

Increasing intestinal surface area through intestinal lengthening procedures.

68
Q

What is considered the final surgical solution for severe SBS?

A

Intestinal transplantation

69
Q

What factors determine the surgical approach in SBS patients?

A

Nature of nutritional support
patient stability
malabsorption status
risk of requiring PN
complications related to PN

70
Q

When should surgery be considered in SBS patients who are stable on enteral nutrition?

A

Only if they demonstrate worsening malabsorption or have other significant symptoms related to malabsorption.

71
Q

What is the main surgical goal for SBS patients who are stable on long-term PN?

A

To wean the patient off PN

72
Q

What are common indications for intestinal transplantation in SBS patients?

A

Significant complications related to PN, such as liver disease, difficult vascular access, and recurrent sepsis

73
Q

How do patient age and underlying disease influence the surgical approach for SBS?

A

Children are more likely to adapt to enteral nutrition and be surgical candidates

whereas adults with mesenteric vascular disease and malignancy undergo operations less frequently

74
Q

What factors influence the choice of operation in SBS patients?

A

Intestinal remnant length, function, and caliber

75
Q

Surgical management of short bowel syndrome.

A

see

76
Q

What length of intestinal remnant allows adult patients to likely be sustained on enteral nutrition alone?

A

Greater than 120 cm, especially if the ileocolonic junction is intact

77
Q

What common complication can develop in adult SBS patients with sufficient intestinal length?

A

Dilated bowel secondary to obstruction, often at the site of a previous anastomosis

78
Q

What surgical procedure is often used to relieve intestinal obstruction in adult SBS patients?

A

Strictureplasty, though other procedures may sometimes be necessary.

79
Q

What length of intestinal remnant allows children to usually be sustained on enteral nutrition alone?

A

Greater than 60 cm

80
Q

How does dilation of the intestinal remnant in children with SBS differ from adults?

A

It appears to have a different pathophysiologic basis and may resemble a variant of intestinal pseudo-obstruction.

81
Q

What common complication do children with dilated bowel and SBS routinely experience?

A

Bacterial overgrowth.

82
Q

What surgical procedure is often appropriate for children with dilated bowel in SBS?

A

Tapering enteroplasty.

83
Q

What are two methods for performing tapering enteroplasty in children with SBS?

A

Excising the redundant bowel along the antimesenteric border or imbricating it (the preferred approach).

84
Q

What is a potential postoperative concern after tapering enteroplasty in children?

A

Recurrent dilation

85
Q

Is repeat tapering feasible in children with SBS who experience recurrent dilation?

A

Yes, repeat tapering may be possible

86
Q

What length of intestinal remnant defines a challenging group of SBS patients?

A

90–120 cm in adults

87
Q

Why is slowing rapid intestinal transit important in certain SBS patients?

A

It may allow these patients to be sustained on enteral nutrition alone

88
Q

What is one surgical approach to slow rapid intestinal transit in SBS patients?

A

Reversing 10- to 15-cm intestinal segments

89
Q

What issue is associated with longer reversed intestinal segments?

A

Increased risk of chronic obstruction.

90
Q

How effective are shorter reversed intestinal segments in influencing intestinal transit?

A

They have less influence on intestinal transit and function but can still provide some benefit.

91
Q

What has been reported about the outcomes of reversing intestinal segments in SBS patients?

A

Clinical improvement has been reported in at least half of the patients in literature, though long-term function raises concerns.

92
Q

What are isoperistaltic and antiperistaltic colon interpositions?

A

Surgical techniques attempted to prolong intestinal transit time by interposing colon segments into the small intestine

93
Q

What has been the challenge with using colon interposition to slow intestinal transit?

A

Despite intrinsic motility differences, actual benefit has been difficult to demonstrate

94
Q

What surgical procedure has been attempted to replace the ileocecal valve?

A

Creating artificial valves, such as a sphincter similar to the continent ileostomy but shorter (2 cm).

95
Q

What is considered a short remnant length in SBS patients?

A

Less than 90 cm in adults and less than 30 cm in children

96
Q

What surgical technique is considered optimal for lengthening the intestine in patients with very short remnants?

A

Intestinal lengthening procedures

97
Q

What is the Bianchi procedure?

A

A technique involving longitudinal intestinal tapering and lengthening by dividing the bowel into two parallel limbs and anastomosing them to increase length.

98
Q

How is the bowel divided in the Bianchi procedure?

A

By dissecting along the mesenteric edge and using a stapling device for longitudinal transection.

99
Q

What are the reported outcomes of the Bianchi procedure?

A

Improved nutrition in approximately 90% of patients, with segments lengthened up to 55 cm

100
Q

What are common complications associated with the Bianchi procedure?

A

Ischemia, anastomotic leaks, and recurrent dilation, with complications reported in 20% of procedures.

101
Q

How is the STEP procedure performed?

A

By applying a linear stapler transversely from opposite directions to divide the bowel, creating a lengthened segment

102
Q

What advantage does STEP have over the Bianchi procedure?

A

It avoids difficult dissection along the mesenteric border and end-to-end anastomosis, leading to fewer complications.

103
Q

Can the STEP procedure be repeated if recurrent dilation occurs?

A

Yes, the STEP procedure can be repeated

104
Q

What is a limitation of intestinal lengthening procedures like the STEP and Bianchi?

A

They can only be applied to patients with an intestinal diameter greater than 3 to 4 cm

105
Q

What approach is used to make intestinal lengthening feasible for more patients?

A

Sequential operations, starting with an artificial valve to induce intestinal dilation, followed by lengthening

106
Q

What is the ideal treatment for SBS patients with very short intestinal remnants (< 60 cm in adults and < 30 cm in children) who develop complications related to PN?

A

Intestinal transplantation.

107
Q

Who are candidates for combined liver and small intestine transplantation?

A

Patients with SBS and liver failure

108
Q

Which patients are candidates for solitary intestinal transplantation?

A

Patients with reversible liver dysfunction or adequate liver function but complications such as difficult vascular access and recurrent infection.

109
Q

What type of transplant has been advocated for patients with irreversible liver failure and rehabilitable SBS?

A

Isolated liver transplantation

110
Q

Which group represents the majority of intestinal transplant recipients?

A

Children

111
Q

What percentage of patients who survive long-term after intestinal transplantation are able to discontinue PN and return to more normal function?

A

80%

112
Q

What are the reported survival rates for intestinal transplantation recipients?

A

76% at 1 year
56% at 5 years
43% at 10 years.

113
Q

When is intestinal transplantation particularly appropriate for SBS patients?

A

For individuals with an anticipated survival of less than 12 months due to PN-induced complications

A1-G Surg Note Small Bowel (10 decks)

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