3. Short Bowel Syndrome

Short Bowel Syndrome (SBS): 

Overview

  • Short Bowel Syndrome (SBS): A condition resulting from extensive resection or congenital disease of the small intestine, leading to malabsorption, nutritional deficiencies, and potential intestinal failure.
  • Pathophysiology:
    • Intestinal resection → reduced absorptive surface → impaired nutrient, fluid, and electrolyte absorption.
    • The degree of malabsorption depends on the length and location of the remaining intestine.
    • The colon and ileocecal valve contribute to fluid and electrolyte conservation.

Clinical Types of SBS

  1. End-Jejunostomy: Jejunum ends at the abdominal wall; colon is absent.
  2. Jejunocolic Anastomosis: Jejunum connects to the colon; ileum and ileocecal valve are absent.
  3. Jejunoileal Anastomosis: Jejunum connects to the ileum; ileocecal valve and colon are intact.

Phases of Short Bowel Syndrome

  1. Acute Phase:
    • Occurs immediately post-resection (3–4 weeks).
    • Characterized by high fluid and electrolyte losses.
  2. Adaptation Phase:
    • Lasts up to 2 years.
    • Morphological and functional changes in the intestine to improve nutrient absorption.
    • Gradual reduction in nutritional support.
  3. Maintenance Phase:
    • Stable intestinal function is achieved.
    • Long-term dietary modifications and nutritional support are optimized.

Clinical Features

  • General symptoms: Diarrhea, dehydration, weight loss, fatigue.
  • Jejunostomy patients:
    • High-output stoma with significant fluid and electrolyte losses.
    • Risk of hypomagnesemia.
  • Colon-in-continuity patients:
    • Gradual undernutrition due to improved water and sodium absorption by the colon.

Management Guidelines (ESPEN, BSG)

1. Nutritional Support

  • Parenteral Nutrition (PN):
    • Indicated for patients with <50 cm of remaining small intestine.
    • May be lifelong in patients with jejunostomy <75 cm.
    • Reduce lipid content if there are concerns about intestinal failure-associated liver disease (IFALD).
  • Enteral Nutrition (EN):
    • Introduced gradually during adaptation.
    • Continuous tube feeding to enhance adaptation.
  • Oral Nutrition:
    • Tailored to bowel anatomy.
    • High-carbohydrate, low-oxalate diet (to prevent renal stones).
    • Avoid hypotonic fluids to reduce jejunal losses.

2. Pharmacological Therapy

  • Antidiarrheal agents: Loperamide to reduce output.
  • Proton Pump Inhibitors (PPIs): Reduce gastric acid secretion, particularly in patients with <100 cm of jejunum.
  • GLP-2 Analogues (e.g., Teduglutide): Enhance intestinal adaptation and nutrient absorption.

3. Fluid and Electrolyte Management

  • Jejunostomy patients require tailored sodium supplementation (~100 mmol/L).
  • Oral rehydration solutions with glucose-saline may reduce stomal sodium losses.
  • Treating hypomagnesemia:
    • Correct sodium depletion.
    • Administer oral/IV magnesium and vitamin D analogues (e.g., 1-alpha hydroxycholecalciferol).

4. Surgical Interventions

  • Intestinal lengthening procedures: Considered for patients with recurrent complications.
  • Intestinal Transplantation:
    • Failure of home parenteral nutrition (HPN).
    • Impending liver failure due to IFALD.
    • Central venous catheter thrombosis (>2 veins).
    • Recurrent infections or single episode of severe septicemia.
    • Ultrashort bowel (<20 cm residual small intestine).
    • Indications:

5. Preventing Catheter-Related Infections

  • Handwashing and aseptic techniques.
  • Use of 2% chlorhexidine for wiping hubs, stopcocks, and ports.
  • Single-lumen, tunneled catheters are preferred.

 

Table 1: Comparison of Clinical Features and Management Based on Remaining Bowel Anatomy

Bowel Anatomy

Clinical Features

Management

Jejunostomy (<75 cm)

High-output stoma, dehydration, hypomagnesemia

Long-term parenteral nutrition (PN), saline supplements, avoid hypotonic fluids, anti-diarrheal agents (e.g., loperamide)

Jejunocolic Anastomosis

Some fluid and sodium absorption via colon

High-carbohydrate, normal-fat diet, PN if <50 cm, sodium supplementation

Ileum and Colon Intact

Improved fluid absorption; rarely require long-term PN

Liberal oral intake, high-complex-carbohydrate diet, low oxalate to prevent renal stones

Ultrashort Bowel (<20 cm)

Severe malabsorption, dependence on HPN

Intestinal transplant consideration, strict nutritional and fluid monitoring

 

Special Considerations by Bowel Anatomy

Patients with Jejunostomy (<75 cm of jejunum):

  • Long-term PN and saline are essential.
  • Fluid losses dominate due to lack of colon.
  • Oral hypotonic fluids should be limited.

Patients with Jejunocolic Anastomosis:

  • Colon retains some absorptive capacity for water and electrolytes.
  • Require a high-carbohydrate, normal-fat diet.
  • May need PN if small intestine length is <50 cm.

Patients with Ileum and Colon:

  • Rarely require long-term PN.
  • Diet can be more liberal.

Complications and Long-Term Follow-Up

  • Intestinal Failure-Associated Liver Disease (IFALD):
    • Features: Cholestasis and steatosis.
    • Prevention: Minimize caloric load, use lipid-sparing PN.
  • Metabolic Bone Disease:
    • Monitor vitamin D and calcium levels.
  • Psychosocial Impact:
    • Consider quality-of-life measures, especially in younger patients dependent on HPN.

References

  1. ESPEN Guidelines on Chronic Intestinal Failure
  2. Gut Journal BSG Guidelines