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Short bowel syndrome

Short bowel syndrome. Dr. Henrik Csaba Horvath. Bible class February 20, 2013. Definition of short-bowel syndrome. Loss of intestinal absorption from surgical resection , congenital defect or diseases characterized by the inability to maintain

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Short bowel syndrome

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  1. Short bowelsyndrome Dr. Henrik Csaba Horvath BibleclassFebruary 20, 2013

  2. Definition ofshort-bowelsyndrome Loss of intestinal absorptionfromsurgicalresection, congenitaldefectordiseasescharacterizedbytheinabilitytomaintain protein-energy, fluid, electrolyte, ormicronutrientbalanceswhen on a conventionallyaccepted, normal diet

  3. Whichconditionscanleadto a short-bowelsyndrome? c Physicallossof portionsofintestine Loss offunction Surgical resection (volvulus) Obstruction Disease-associated lossofabsorption (Crohn`s, postirradiation) Loss ofbowel orenterocyte mass (trauma, infarction) Dysmotility Congenital defect SBS-associated intestinal failure

  4. Major causesof SBS in adults? Postoperative complications Irradiaton/cancer Mesentericvalvulardisease (mesentericischemia) Crohn`sdisease Trauma

  5. Whichfactorsareassociatedwithworseprognosis in patientswithSBS? Total parenteral nutrition < 50 cm intactbowel Enterostomy Radiation orischemicenteritis

  6. Whichfactorshaveimpact on theoutcomeof SBS? Presence/abscenceofileocaecalvalve • Lengthofthe • remainingintestine • Segment ofintactbowel • (jejunum vs. ileum, coloncontinuity) • Absorptive qualityof • theremnantbowel Outcomeof SBS • Presence of residual • underlyingdisease • (e.g.Crohn`s) • State ofother digestive organs • Efficacyof • nutritionsupport • Pharmacologictherapy • Age/BMI of • thepatient

  7. Howdoesaffecttheremnantlengththeriskofdeveloping SBS? Patientsathighestriskofdeveloping SBS are

  8. Whichimpacthas on absorptiontheresectionof… Loss ofthemajor intestinal absorptionarea Loss of digestive enzymes Loss of GI feedbackhormones (gastricemptying) Jejunum: Ileum: Loss oftheabsorptionofjejunalsecretion Loss ofabsorptionofvitamin B12 Loss ofabsorptionofbilesalts (fatmalabsorption)

  9. Whichimpacthasthelossofileocaecalvalve? Dilatation ofthesmallintestine Slowermotility Bacterialovergrowthofthe small intestine Competitionfornutrients, inflammation, GI bleeding, bacterialtranslocation± endotoxaemia, liverinjury, D-lacticacidosis

  10. Which adaptive mechanismsoccur in the residual intestine/ GI tract? Mucosalhyperplasia (due tofatstimulatedglucagon-likepeptidereceptor II) Increasedmucosalbloodflow Improved segmental absorption Gastrichypersecretion Increasedpancreatobiliarysecretions • Upto 70% can do without TPN due tothesemechanisms

  11. Importanceofcolonin compensationforthe lack ofintestine? Increasereabsorptionofwater, electrolytes, short-chainfattyacidsand GI secretions Slow down the intestinal transitandstimulate intestinal adaptationby hormonal regulation Fermentation ofmalabsorbedcarbohydratesbycolonicbacteria

  12. Measurement ofthefunctionalcapacityofthesmallintestine? 1. 48-hour nutritional balancetest analysisofdailyabsorption rate (intake-output) predictionof intestinal failure: <1,4 kg wetweight/day 1170 kcal/dayofenergy (Difficultieswithduplicatefoodportionsandaccuratestoolcollections) 2. Fastingplasmacitrullineconcentration (>5 μmol/L) (issynthetizedbythesmallintestine, bestpracticalmeasureofenterocytefunction)

  13. Twomajorgroupsofcomplicationsof SBS? dehydration electrolytederangements (Mg, Ca, K) • Early complications: Diagnosis: • urinaryelectrolytelevels (plasmacanbe normal!) Treatment: • sustainedcorrection due toslowcellularuptake • Latecomplications: TPN-related bacterialovergrowth micronutrientdeficiency metabolic

  14. TPN-relatedlatecomplicationsof SBS are… gallstones, cirrhosis(IFALD) 1. Due tobypassfirst pass livermetabolism: steatosis cholestasis end-stagelivercirrhosis in 15% ofpts after oneyear TPN 100% mortality rate within 2 yrs • 2. Catheter-associatedcomplications: infection: one-thirdofdeaths in 50% 5-yr-mortality rate in SBSthrombosis (v. cavasuperior): 0.2/1000 catheterdays

  15. Bacterialovergrowth-relatedlatecomplicationsof SBS are… 1. carbohydratemalabsorption 2. sepsis due tobacteriallocalisation 3. decreasedabsorptionoffattyacids due tointerferencewithchilomicronformation 4. lossof absorptive capacity due toinflammatoryresponse

  16. Whicharethemostcommonmicronutritientdeficienciesaslatecomplicationsof SBS? 1. Mg, Ca, Zn, Se 2. fat-soluble vitamins (A,D,E,K) 3.vitamin B12 (if >60 cm of terminalileumresected) 4. folate (if proximal jejunumresected)

  17. The mostcommonmetaboliccomplicationsofsmall-bowelsyndrome? Metabolicacidosis Hyperoxaliuria (nephrolithiasis, chronicrenalfailure) Hyperammoniaemia Metabolicbonedisease (osteoporosis, osteomalacia) gram-positive colonicbacteria fermentcarbohydrateto D-lacticacid proliferationoftheflora Acidicenvironment short-chainfattyacids Metabolicacidosis(encephalopathy, headaches, ataxia, dysarthria)

  18. 3 keypointsofmanagement? • Nutrition / Supplementation ofmicronutrients • Maintaining fluid, electrolytesandacid/basebalance • Avoidcomplications Caloriestobesupplied: Proteins tobesupplied: 1.0-1.5 g/kg/day 25-30 kcal/kg/day 40-50% carbohydrates 20-30% proteins 20-40% lipids Bolus enteral Continous enteral Cyclic/discontinous PN Oral rehidrationfluid (glucose-polymer basedwithsodium) ORS ± oral electrolytesuppl. Intravenous fluid Continous PN

  19. Pharmacologicadjuncts in themanagement? 1. glucagon-like peptide-2 (teglutide): promotionofadaption 2. loperamid, diphenoxylate, codein: anti-motilityagents • 3.octreotid: increasingthesmallboweltransittime (but also inhibitspancreaticsecretions) onlyif > 3 L ofiv. fluid intakeisrequired • 4. cholestyramine: bindingbilesaltsin steatorrheasecondarytobileacidmalabsorption Cheng TT et al :Clinical and Experimental Gastroenterology 2011:4 189–196

  20. Twocategoriesofsurgicaltreatmentoptions? 2. transplant 1. non- transplant Aimsof non-transplant surgicaltreatments? Preserve intestinal remnant minimizeresrection, restore intestinal continuity, recruit additional intestine 2. Slow intestinal transit (segmental reversalofintestine, colonicinterposition) 3. Increase intestinal surface (LILT = longitudinal intestinal lengtheningandtailoring withlongitudinal devisionofintestineandbloodsupplyatthemesentericborder) STEP = serialtransverseenteroplasty)

  21. Surgicaltreatmentofshortbowelsyndrome Indicationsfor intestinal transplants? Impendingorovertliverfailure (ESLD) Thrombosisofmajorcentralvenouschannels Frequentcentralline-relatedsepsis (>2 episodes/year) Frequentseveredehydration Diffuse mesentericvenousthrombosiswithcomplications

  22. Intestinal transplantationfor SBS Whicheffecthasthecombined transplant on therejection rate of intestinal transplants? Acuteandchronicrejection rate islower in combinedtransplants (liver+intestine, multivisceral) Major complicationsandcauseofdeath after intestinal transplantation? Sepsis, MOF, rejection

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