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Short Bowel Syndrome

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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  1. Short Bowel Syndrome Anne Aspin 2010

  2. 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

  3. Introduction • Most common cause of intestinal failure. • NEC, Congenital atresia, Gastroschisis and volvulus. • Promote adaptive response through enteral feeding and careful management of TPN.

  4. 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.

  5. Gastric juices • Acid reaction • Kills bacteria • Controls pylorus

  6. Gastric juices: - Rennin coagulates milk - Hydrochloric Acid – Converts Pepsinogen to Pepsin. - Pepsin turns protein to peptone

  7. 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.

  8. 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

  9. Onto large intestine where fluids and nutrients are re absorbed. • Waste fluids taken by blood stream to kidneys to be filtered

  10. 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.

  11. Absorption • 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.

  12. 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.

  13. 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.

  14. Motility • 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.

  15. Jejunum – most of electrolyte absorption • Ileum is the only site for absorption of Vit B12 and bile salts.

  16. 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.

  17. 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.

  18. 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.

  19. How does the bowel adapt? • Cellular hyperplasia • Villous hypertrophy • Intestinal lengthening • Altered motility • Hormonal changes • Takes approx 2 years to reach max effect.

  20. 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.

  21. Weaning off TPN • Cycling – one hour off, line lock with Gentamycin. Build up to off all day.

  22. Complications. • Bacterial overgrowth • Anaemia • Bile salt depletion • Bone disease • Cholestasis • Diarrhoea • Hypocalcaemia

  23. Complications (cont) • Hypomagnesaemia • Liver fibrosis • Renal stones • Protein malnutrition • Trace mineral deficiency • Vitamin deficiency, A, D, E, K, B12

  24. Central line complications • Infection • Thrombosis • Break in catheter • Air embolus • Tissue necrosis • Malposition • Cardiac tamponade

  25. Bacterial Overgrowth • Bloating, cramps, diarrhoea, gastrointestinal blood loss. • Treat with sugar free Metronidazole and Trimethoprim

  26. Watery diarrhoea • Loperamide • Malabsorption of bile acids. • Pectin

  27. Surgery • 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.

  28. Tapering

  29. 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.

  30. Bowel lengthening

  31. Antiperistaltic small intestine segment

  32. Colonic interposition

  33. 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)

  34. It takes approximately two years to achieve some normal diet

  35. Thank you

  36. References • Bentley D, Lifschitz C, Lawson M (2001). Necrotising Entercolitis • And Short Bowel Syndrome. http://www.naspghan.org/wmspage.cfm?porm1=130 • 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

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