Short_Bowel - SHORT BOWEL SYNDROME SHORT A MANAGEMENT...

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Unformatted text preview: SHORT BOWEL SYNDROME SHORT A MANAGEMENT DILEMMA Vic Vernenkar, D.O. Department of Surgery St. Barnabas Hospital Definition Short Bowel Syndrome is defined as any of the Short malabsorptive conditions stemming from massive resection of the small bowel with or without an attendant resection of the colon. attendant Clinically manifested by malnutrition, weight loss, Clinically steatorrhea, and diarrhea arising from decreased absorptive capacity. absorptive Severity of Symptoms Severity Extent of resection Site of resection Underlying intestinal disease Presence or absence of ileocecal valve Functional status of remaining digestive organs Adaptive capacity of intestinal remnant History History 1880- First massive resection of SB by Koeberle, 1880with 205 cm removed. with 1888- Senn states that removal of 1/3 of SB can 1888be done without development of marasmus. be 1935- Flint demonstrated that 50% can be safely 1935removed with no metabolic conseq. removed 1950- 70% resection feasable with adequate 1950support, presence of ileocecal valve. support, Etiologies of Massive Resections Etiologies 1800- Early 1900- strangulated hernias. 1935- Volvulus, incarcerated hernia, mesenteric 1935thrombosis. thrombosis. 1970- Infarcted small bowel. Today- Crohn’s accounts for 50%, followed by Todaymesenteric thrombosis, radiation enteritis, volvulus, and trauma. volvulus, Pathophysiology Pathophysiology The problem Nutrition Bile acids, steatorrhea, fat malabsorption Presence or absence of colon Gallstones and renal stones Loss of regulatory function D-Lactic acidosis Postoperative Phases Postoperative Phase I (Acute): profuse diarrhea, massive fluid and electrolyte losses. Can last 1-3 mos as patient’s bowel undergoes hypertrophy, elongation, hyperplasia. elongation, Phase II (Adaptation): Period of gut adaptation. Lasts 1-2 years. Lasts Phase III (Maintenance): Maximal adaptation. Theraputic Goals Theraputic Maintenance of nutritional status Maximization of enteral nutrient absorption Prevention of complications Nutrient Absorbtion Nutrient Fats Carbohydrates Protiens Total Parenteral Nutrition Total Initial hydration and electrolyte support Vitamins Calories Carbohydrate, protien, and fluid requirements Glutamine Phase Specific Treatment Phase Acute Phase: Focus on fluid and electrolytes TPN on day three to day four Start enteral support early Adaptation Phase: Steadily increasing enteral Adaptation support support Correlation between remnant and nutritional Correlation prognosis prognosis Maintenance Phase: Transition to oral diet Enteral Support Enteral Start with water, clear soups, gradually increasing Start to diluted solution of defined diet with simple amino acids, short chain peptides. Use medium chain TGL. Avoid conc. sugars, caffeine, etoh. chain Elemental vs Polymeric diets Pectin Avoidance of oxalate Helpful Medications Helpful Loperamide, codeine and other opiates H-2 Blockers, proton pump inhibitors Somatostatin/Octreotide Cholestyramine Clonidine Preventing Complications Preventing Catheter-related sepsis TPN-induced liver disease Prophylactic cholecystectomy? Bacterial overgrowth Adaptation Adaptation Mechanisms Parenteral support Hormones Surgical Considerations Surgical Above all, preserve intestinal remnant. Methods to delay transit time. Methods to increase absorptive area. Transplantation Delay Transit Delay Valves and Sphincters Antiperistaltic Segments Antiperistaltic Small Intestine Colon Recirculating Loops Intestinal Pacing Increase Absorption Increase Intestinal tapering and lengthening Mucosal harvest Transplantation Transplantation Problem History Advances Studies The ideal candidate Summary Summary Short Bowel Syndrome increasingly common Malnutrition is avoidable with early TPN/enteral Malnutrition support support Diet individualized Minimize complications, diagnose early Surgical management includes preserving length, Surgical Improving function Improving Transplatation is evolving as a promising Transplatation alternative alternative ...
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This note was uploaded on 12/27/2011 for the course STEP 1 taught by Professor Dr.aslam during the Fall '11 term at Montgomery College.

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