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Unformatted text preview: SHORT BOWEL SYNDROME
A MANAGEMENT DILEMMA Vic Vernenkar, D.O.
Department of Surgery
St. Barnabas Hospital Definition Short Bowel Syndrome is defined as any of the
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,
steatorrhea, and diarrhea arising from decreased
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
thrombosis. 1970- Infarcted small bowel. Today- Crohn’s accounts for 50%, followed by
Todaymesenteric thrombosis, radiation enteritis,
volvulus, and trauma.
Pathophysiology The problem
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, 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
Protiens Total Parenteral Nutrition
Total Initial hydration and electrolyte support
Carbohydrate, protien, and fluid requirements
Glutamine Phase Specific Treatment
Acute Phase: Focus on fluid and electrolytes
TPN on day three to day four
Start enteral support early
Adaptation Phase: Steadily increasing enteral
support Correlation between remnant and nutritional
prognosis Maintenance Phase: Transition to oral diet Enteral Support
Enteral Start with water, clear soups, gradually increasing
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
Clonidine Preventing Complications
Preventing Catheter-related sepsis
TPN-induced liver disease
Bacterial overgrowth Adaptation
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
Intestinal Pacing Increase Absorption
Increase Intestinal tapering and lengthening Mucosal harvest Transplantation
The ideal candidate Summary
Summary Short Bowel Syndrome increasingly common Malnutrition is avoidable with early TPN/enteral
support Diet individualized Minimize complications, diagnose early Surgical management includes preserving length,
Improving Transplatation is evolving as a promising
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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.
- Fall '11