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Short Bowel Syndrome. Anne Aspin 2010. Definition. Rickham (1967) – an extensive resection to maximum of 75cm Kuffer (1972) – 15cm with ileocaecal valve - 38cm without ileocaecal valve Dorney (1985) – 11cm with I/C valve or 25cm without I/C valve .

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Short Bowel Syndrome

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short bowel syndrome

Short Bowel Syndrome

Anne Aspin 2010

  • Rickham (1967) – an extensive resection to maximum of 75cm
  • Kuffer (1972) – 15cm with ileocaecal valve

- 38cm without ileocaecal valve

  • Dorney (1985) – 11cm with I/C valve or 25cm without I/C valve
  • Most common cause of intestinal failure.
  • NEC, Congenital atresia, Gastroschisis and volvulus.
  • Promote adaptive response through enteral feeding and careful management of TPN.
the digestive system
The Digestive System
  • Digestion starts in the mouth
  • Moisten by saliva (contains Pytalin), begins to turn starch to sugar.
  • In stomach food churned mixes with gastric juices.
gastric juices
Gastric juices
  • Acid reaction
  • Kills bacteria
  • Controls pylorus
Gastric juices:

- Rennin coagulates milk

- Hydrochloric Acid – Converts Pepsinogen to Pepsin.

- Pepsin turns protein to peptone

Food is released in small amounts by relaxation of the sphincter passing onto Duodenum.
  • Food further digested by Trypsin, Amylase and Lipase.
  • Digestion completed in small intestine.
intestinal juices
Intestinal juices.
  • Enterokinase – pancreatic trypsinogen
  • Peptidase – polypeptide to amino acid
  • Maltase - maltose}
  • Sucrase – sucrose} to glucose
  • Lactase – Lactose}
  • Lipase – Fats to fatty acids and glycerol
Onto large intestine where fluids and nutrients are re absorbed.
  • Waste fluids taken by blood stream to kidneys to be filtered
small intestine
Small intestine
  • Convoluted tube from pyloric sphincter to the junction of ileo – caecal valve
  • Mucus membrane –has circular folds to increase surface area for absorption.
  • Villi which contain blood and lymph vessel.
  • Supplied with tubular glands secreting intestinal juice.
  • Proteins, Carbohydrates and Fats through villi in small intestine.
  • Fats in the form of fatty acids and glycerol are absorbed by cells covering villi. Pass into lymph within villi drained by lymphatic capillaries.
ileo caecal valve
Ileo Caecal valve.
  • The Caecum lies in the right ileac fossa.
  • The Ileum opens into the Caecum through the Ileo-Caecal valve.
  • This is a sphincter which prevents the IC contents passing back into the Ileum.
what is sbs
What is SBS
  • Reduced bowel surface area for absorption of nutrients together with rapid transit of intestinal contents.
  • TPN reduced as enteral feeds are introduced.
  • Need to promote intestinal adaptation.
  • The IC valve and colon is important to slow intestinal transit.
  • Proteins, Fats and Carbohydrates are absorbed almost completely within first 150cm of small bowel.
Jejunum – most of electrolyte absorption
  • Ileum is the only site for absorption of Vit B12 and bile salts.
after resection
After resection.
  • Increase gastric emptying.
  • Ileal resection, increased transit time
  • An intact IC valve prolongs gut transit, loss of this causes an increase.
  • If colon resected transit increases.
Duodenal resection – malabsorption of Iron, Calcium and Folic Acid.
  • Jejunal resection – If extensive resection, lactose intolerence
  • Ileal resection – Some diarrhoea due to bile salts being incompletely absorbed.
gastric hypersecretion
Gastric Hypersecretion
  • After abdominal surgery, gastric hyper-secretion occurs in 50% cases.
  • This impairs digestion of lipids by lowering intraluminal PH and inactivating the pancreatic enzymes.
  • Also stimulates peristalsis.
how does the bowel adapt
How does the bowel adapt?
  • Cellular hyperplasia
  • Villous hypertrophy
  • Intestinal lengthening
  • Altered motility
  • Hormonal changes
  • Takes approx 2 years to reach max effect.
management of sbs
Management of SBS.
  • Total TPN
  • Gradual introduction of enteral feeding.
  • Fluid and electrolyte balance
  • Fluid replacement if stool, gastric aspirate or ostomy losses are high
  • Reducing substances above1% contra indicate increasing enteral feeds.
weaning off tpn
Weaning off TPN
  • Cycling – one hour off, line lock with Gentamycin. Build up to off all day.
  • Bacterial overgrowth
  • Anaemia
  • Bile salt depletion
  • Bone disease
  • Cholestasis
  • Diarrhoea
  • Hypocalcaemia
complications cont
Complications (cont)
  • Hypomagnesaemia
  • Liver fibrosis
  • Renal stones
  • Protein malnutrition
  • Trace mineral deficiency
  • Vitamin deficiency, A, D, E, K, B12
central line complications
Central line complications
  • Infection
  • Thrombosis
  • Break in catheter
  • Air embolus
  • Tissue necrosis
  • Malposition
  • Cardiac tamponade
bacterial overgrowth
Bacterial Overgrowth
  • Bloating, cramps, diarrhoea, gastrointestinal blood loss.
  • Treat with sugar free Metronidazole and Trimethoprim
watery diarrhoea
Watery diarrhoea
  • Loperamide
  • Malabsorption of bile acids.
  • Pectin
  • Further resection might be avoided by tapering, strictureplasty or serosal patching.
  • Patients with dilated segments proximal to tight anastomosis – resect and taper improves bacterial overgrowth by improving flow.
bowel lengthening
Bowel lengthening
  • Cutting bowel longitudinally, preserve blood supply to both sides and create a segment of bowel twice length, half diameter without loss of mucosal surface area.
medical management
Medical management
  • Pectin (water sol, non cellulose dietary fibre which promotes intestinal adaptation)
  • Ranitidine (PH > 4)
  • Loperamide (slow gut transit time)
  • Cholestyramine (binds bile salts)
  • Bentley D, Lifschitz C, Lawson M (2001). Necrotising Entercolitis
  • And Short Bowel Syndrome.
  • Koglmeier J, Day C, Puntis J (2008). Clinical outcome in patients from a single region who were dependent on parenteral nutrition for 28 days or more. Archives of Disease in Childhood. 93 (4) : 300 - 302
  • Martin G, Wallace L and Sigalet D (2004). Glucagon – like Peptide -2 Induces Intestinal Adaptation in Parenterally Fed Rats with Short Bowel Syndrome. American Journal of Physiology. Gastro-intestinal and Liver Physiology. 286: G964-G972
  • McMahon M, Leviller J and Chescheir N (1996). Prenatal Ultrasonographic Findings Associated with Short Bowel Syndrome in Two Fetuses with Gastroschisis. Obstetrics and Gynaecology. 88: 676-678
  • Seidner D and Matarese L (2003). Selected topics in
  • Gastrotherapy. Case 2: Short Bowel Syndrome : Etiology,
  • Pathophysiology and Management. The Cleveland Clinic Center for Continuing Education
  • Sinden A, Sutphen S (2003) Nutritional Management of Paediatric Short Bowel Syndrome. Nutrition Issues in Gastroenterology. Series #12 p28-48
  • Warner B, Vanderhoof J and Rayes J (2000). What’s New In The Management of Short Gut Syndrome in Children. Division of Paediatric Surgery. Department of Surgery. American College of Surgeons. p725-736