Short Bowel Syndrome Flashcards
What defines short bowel syndrome (SBS) in adults?
Malabsorption and malnutrition generally occurring when less than 180 cm of functional intestine remains.
What factors determine the severity of SBS?
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.
What are the main pathophysiologic changes seen in SBS?
Loss of intestinal absorptive surface and more rapid intestinal transit
What are common complications associated with SBS?
Malnutrition
weight loss
diarrhea
steatorrhea
vitamin deficiency
electrolyte imbalance
nephrolithiasis
cholelithiasis
transient gastric hypersecretion
and bacterial overgrowth.
Why is liver disease a concern in patients with SBS on parenteral nutrition (PN)?
It remains an important factor in mortality due to long-term PN dependence.
What type of adaptation occurs in the intestine after massive resection?
Functional and structural adaptation
improving nutrient absorption and decreasing diarrhea within the first few months post-resection.
What are the primary management goals for patients with SBS beyond the early critical phase?
Maintain adequate nutritional status
maximize absorptive capacity of the remaining intestine, and prevent complications related to SBS and nutritional therapy
What are the key elements of surgical approaches in managing SBS?
Preserving and maximizing the function of the intestinal remnant, and augmenting intestinal length via transplantation.
What is the most important therapeutic objective in managing short bowel syndrome (SBS)?
Maintaining the patient’s nutritional status
How is nutritional status initially maintained in SBS patients postoperatively?
Primarily through parenteral nutrition (PN) support
When can enteral nutrition support be started in SBS patients?
Early after the operation, once ileus has resolved
Why is early initiation of enteral nutrition important in SBS management?
It maximizes intestinal adaptation and helps prevent complications related to PN
What determines the likelihood of a patient requiring long-term PN in SBS?
The length of the remaining small intestine.
How does the length of the remaining intestine affect PN dependency?
180 cm: No PN generally needed.
90 cm (with colon present): PN required for less than 1 year.
<60 cm: Likely require permanent PN
What is a sign that increased enteral feeding is not tolerated in SBS patients?
A marked increase in gastrointestinal fluid loss
What are the primary objectives during the transition from PN to enteral nutrition in SBS?
Maintaining stable body weight and preventing large fluctuations in fluid balance.
What should be done as parenteral nutrition requirements decrease in SBS management?
Intermittent PN can be introduced, reducing therapy hours and eventually alternating days
What type of monitoring is essential during the transition to enteral nutrition in SBS patients?
Metabolic monitoring to detect and correct any metabolic abnormalities and micronutrient deficiencies
Why might some SBS patients require ongoing fluid supplementation?
To maintain hydration and support nutrient absorption as part of long-term management
What factors influence dietary management in patients with short bowel syndrome (SBS)?
Intestinal remnant length and location
underlying intestinal disease
status of remaining digestive organs
and the existence of a stoma
Why might patients with SBS develop hyperphagia?
To compensate for their inefficient nutrient absorption
What type of feeding may allow greater nutrient absorption in patients with less than 90 cm of intestinal remnant?
Continuous enteral feeding.
What type of diet is initially appropriate for SBS patients, especially if the colon is in continuity?
A high-carbohydrate, high-protein diet
How should fat intake be managed in SBS patients with colon in continuity?
Fat should be restricted to 20% to 30% of caloric intake to prevent steatorrhea and nephrolithiasis
Why are isotonic feedings important for patients with jejunal remnants?
Because the jejunal mucosa is relatively permeable and isotonic feedings optimize water and sodium absorption
What is the role of glucose-electrolyte oral rehydration solutions in SBS?
To optimize water and sodium absorption in the proximal jejunum and prevent secretion into the lumen
Which nutrient’s role remains controversial in SBS management, but may have trophic effects on the gut?
Glutamine.
What agents are used for their antisecretory and antimotility effects in SBS?
Codeine
diphenoxylate-atropine (Lomotil)
loperamide,
octreotide
Why should octreotide not be routinely used for chronic diarrhea in SBS?
It may cause deleterious effects, such as steatorrhea, inhibition of intestinal adaptation, and increased incidence of cholelithiasis.
Which medications are effective for controlling gastric hypersecretion in SBS?
H2 receptor antagonists and proton pump inhibitors.
What is cholestyramine used for in SBS?
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
What is teduglutide, and how is it used in SBS?
A GLP-2 analogue approved for promoting intestinal absorption and adaptation, reducing the need for supplemental fluids and nutrients
How are GLP-1 analogues like liraglutide used off-label in SBS?
To slow gastric emptying and intestinal motility.
Medical Treatment of Short Bowel
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Medical Treatment of Short Bowel
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What are common metabolic complications in patients with short bowel syndrome (SBS)?
Dehydration
renal dysfunction
hypocalcemia
hyperglycemia
hypoglycemia
metabolic acidosis/alkalosis
and nutrient deficiencies
Why is hypocalcemia a common issue in SBS?
Due to poor calcium absorption and binding by intraluminal fat.
What supplementation is important to minimize bone disease in SBS patients?
Adequate calcium, magnesium, and vitamin D
What are common causes of hyperglycemia and hypoglycemia in SBS patients?
Receiving a significant portion of their calories parenterally
Which micronutrient deficiencies need to be monitored in SBS patients?
Iron, selenium, zinc, and copper
Why are SBS patients at risk for fatty acid deficiency
Due to poor fat absorption
What is an important preventative measure against catheter-related sepsis in SBS patients?
Meticulous technique and patient education
Ethanol and antibiotic lock therapy
How can catheter thrombosis impact SBS patients requiring permanent PN?
It can become a critical factor affecting patient survival due to limited vascular access
What long-term complication is associated with parenteral nutrition (PN) in SBS patients?
liver disease, potentially leading to steatosis, cholestasis, or cirrhosis
What measures can help prevent PN-induced liver disease?
Providing as much enteral nutrition as possible
avoiding overfeeding
and minimizing lipid intake, especially soy-based
What complication may indicate bacterial overgrowth in SBS patients?
Changes in absorptive capacity and stool habits, especially if sudden.
What is a potential therapy for bacterial overgrowth in SBS patients?
Antibiotics and possibly probiotics
What is the incidence of cholelithiasis in SBS patients, and what factors increase the risk?
Occurs in 30% to 40% of patients
higher risk if less than 120 cm of intestine remains, terminal ileum resected, and PN is required.
How can cholelithiasis be prevented in SBS patients?
By providing nutrients enterally, using therapies to stimulate gallbladder emptying, and considering prophylactic cholecystectomy during other surgeries
What dietary management can help prevent nephrolithiasis in SBS patients?
A low-oxalate diet
minimizing intraluminal fat
calcium supplementation
maintaining high urinary volume
What medication can be used to bind oxalic acid in the colon to prevent nephrolithiasis?
Cholestyramine
What causes gastric hypersecretion in SBS patients?
Massive intestinal resection leading to
parietal cell hyperplasia and hypergastrinemia
due to loss of an inhibitor from the resected intestine
Why is gastric hypersecretion a problem in SBS patients?
It exacerbates malabsorption, diarrhea, and increases the risk of peptic ulcer disease.
What treatments are recommended for controlling gastric acid secretion in SBS patients?
H2 receptor antagonists or proton pump inhibitors, especially in the perioperative period and until hyperacidity resolves
What percentage of SBS patients require abdominal reoperation after discharge?
Approximately 50%
What is the most frequent indication for reoperation in SBS patients?
Intestinal problems
What surgical techniques can be used to avoid resection in SBS patients?
Intestinal tapering
strictureplasty for benign strictures
and serosal patching for certain strictures and chronic perforations
What can occasionally be recruited into continuity during reoperation in SBS patients?
Intestinal segments from previous surgeries
What are potential benefits of restoring intestinal continuity in patients with a colonic remnant?
Improved intestinal absorption
increased surface area
energy from short-chain fatty acids
prolonged transit time, and improved quality of life.
What are potential drawbacks of restoring intestinal continuity in SBS patients?
Secretory diarrhea from bile acids
disabling perianal problems
and increased risk of calcium oxalate stone formation
Why does the colon increase the risk of calcium oxalate stone formation in SBS patients?
oxalate is primarily absorbed in the colon.
What is the minimum length of small intestine generally required to prevent severe diarrhea and perianal complications?
At least 60 cm.
What are some surgical goals for managing short bowel syndrome (SBS)?
Slowing intestinal transit
improving function of existing intestine
and increasing intestinal surface area
What innovative surgical approaches have been used to slow intestinal transit in SBS patients?
Reversing intestinal segments and interposing colonic segments into the small intestine.
How are stenotic segments in the intestine managed in SBS patients?
By relieving the obstruction, often through strictureplasty
What surgical treatment is used for dilated dysfunctional segments in SBS?
Tapering enteroplasty
What is the best surgical option for patients with particularly short intestinal remnants to improve nutrient absorption?
Increasing intestinal surface area through intestinal lengthening procedures.
What is considered the final surgical solution for severe SBS?
Intestinal transplantation
What factors determine the surgical approach in SBS patients?
Nature of nutritional support
patient stability
malabsorption status
risk of requiring PN
complications related to PN
When should surgery be considered in SBS patients who are stable on enteral nutrition?
Only if they demonstrate worsening malabsorption or have other significant symptoms related to malabsorption.
What is the main surgical goal for SBS patients who are stable on long-term PN?
To wean the patient off PN
What are common indications for intestinal transplantation in SBS patients?
Significant complications related to PN, such as liver disease, difficult vascular access, and recurrent sepsis
How do patient age and underlying disease influence the surgical approach for SBS?
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
What factors influence the choice of operation in SBS patients?
Intestinal remnant length, function, and caliber
Surgical management of short bowel syndrome.
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What length of intestinal remnant allows adult patients to likely be sustained on enteral nutrition alone?
Greater than 120 cm, especially if the ileocolonic junction is intact
What common complication can develop in adult SBS patients with sufficient intestinal length?
Dilated bowel secondary to obstruction, often at the site of a previous anastomosis
What surgical procedure is often used to relieve intestinal obstruction in adult SBS patients?
Strictureplasty, though other procedures may sometimes be necessary.
What length of intestinal remnant allows children to usually be sustained on enteral nutrition alone?
Greater than 60 cm
How does dilation of the intestinal remnant in children with SBS differ from adults?
It appears to have a different pathophysiologic basis and may resemble a variant of intestinal pseudo-obstruction.
What common complication do children with dilated bowel and SBS routinely experience?
Bacterial overgrowth.
What surgical procedure is often appropriate for children with dilated bowel in SBS?
Tapering enteroplasty.
What are two methods for performing tapering enteroplasty in children with SBS?
Excising the redundant bowel along the antimesenteric border or imbricating it (the preferred approach).
What is a potential postoperative concern after tapering enteroplasty in children?
Recurrent dilation
Is repeat tapering feasible in children with SBS who experience recurrent dilation?
Yes, repeat tapering may be possible
What length of intestinal remnant defines a challenging group of SBS patients?
90–120 cm in adults
Why is slowing rapid intestinal transit important in certain SBS patients?
It may allow these patients to be sustained on enteral nutrition alone
What is one surgical approach to slow rapid intestinal transit in SBS patients?
Reversing 10- to 15-cm intestinal segments
What issue is associated with longer reversed intestinal segments?
Increased risk of chronic obstruction.
How effective are shorter reversed intestinal segments in influencing intestinal transit?
They have less influence on intestinal transit and function but can still provide some benefit.
What has been reported about the outcomes of reversing intestinal segments in SBS patients?
Clinical improvement has been reported in at least half of the patients in literature, though long-term function raises concerns.
What are isoperistaltic and antiperistaltic colon interpositions?
Surgical techniques attempted to prolong intestinal transit time by interposing colon segments into the small intestine
What has been the challenge with using colon interposition to slow intestinal transit?
Despite intrinsic motility differences, actual benefit has been difficult to demonstrate
What surgical procedure has been attempted to replace the ileocecal valve?
Creating artificial valves, such as a sphincter similar to the continent ileostomy but shorter (2 cm).
What is considered a short remnant length in SBS patients?
Less than 90 cm in adults and less than 30 cm in children
What surgical technique is considered optimal for lengthening the intestine in patients with very short remnants?
Intestinal lengthening procedures
What is the Bianchi procedure?
A technique involving longitudinal intestinal tapering and lengthening by dividing the bowel into two parallel limbs and anastomosing them to increase length.
How is the bowel divided in the Bianchi procedure?
By dissecting along the mesenteric edge and using a stapling device for longitudinal transection.
What are the reported outcomes of the Bianchi procedure?
Improved nutrition in approximately 90% of patients, with segments lengthened up to 55 cm
What are common complications associated with the Bianchi procedure?
Ischemia, anastomotic leaks, and recurrent dilation, with complications reported in 20% of procedures.
How is the STEP procedure performed?
By applying a linear stapler transversely from opposite directions to divide the bowel, creating a lengthened segment
What advantage does STEP have over the Bianchi procedure?
It avoids difficult dissection along the mesenteric border and end-to-end anastomosis, leading to fewer complications.
Can the STEP procedure be repeated if recurrent dilation occurs?
Yes, the STEP procedure can be repeated
What is a limitation of intestinal lengthening procedures like the STEP and Bianchi?
They can only be applied to patients with an intestinal diameter greater than 3 to 4 cm
What approach is used to make intestinal lengthening feasible for more patients?
Sequential operations, starting with an artificial valve to induce intestinal dilation, followed by lengthening
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?
Intestinal transplantation.
Who are candidates for combined liver and small intestine transplantation?
Patients with SBS and liver failure
Which patients are candidates for solitary intestinal transplantation?
Patients with reversible liver dysfunction or adequate liver function but complications such as difficult vascular access and recurrent infection.
What type of transplant has been advocated for patients with irreversible liver failure and rehabilitable SBS?
Isolated liver transplantation
Which group represents the majority of intestinal transplant recipients?
Children
What percentage of patients who survive long-term after intestinal transplantation are able to discontinue PN and return to more normal function?
80%
What are the reported survival rates for intestinal transplantation recipients?
76% at 1 year
56% at 5 years
43% at 10 years.
When is intestinal transplantation particularly appropriate for SBS patients?
For individuals with an anticipated survival of less than 12 months due to PN-induced complications
