Title: Short Bowel Syndrome

Key words: Case history, jejunostomy, anastomosis, nutritional management, parenteral nutrition, enteral nutrition

Date: July 2000

Category: 13. Specific conditions

Type: Article

Author: Dr van rhijn

 

Short Bowel Syndrome

A Case History Approach

 

 

Introduction

IH and PM are two patients with short bowel syndrome after surgical resection for intestinal infarction. Both have 50cms of jejunum. IH has a jejunostomy. PM has a retained colon with an anastomosis between the jejunum and the ascending colon. The nutritional management of these patients and the expected differences in their nutritional needs are discussed below.

Consequences of short bowel syndrome (SBS = intestinal length < 200 cm) are intestinal failure (IF = gut unable to maintain normal nutritional and/or electrolyte status), which may lead to malnutrition and sepsis. The two types of SBS, end jejunostomy and colon in continuity, require different nutritional management by a multidisciplinary team1.

Initial Nutritional Management of IH & PM

Nutritional management of SBS depends on the site and the lengths of jejunum & ileum resected, the presence or absence of the ileocaecal valve and the amount of intact colon2. Both IH and PM have a duodenum and 50cm of jejunum intact, thereby preserving pancreatic enzymes, secretin and cholecystokinin. This reduces the risk of gall bladder stasis3 and cholelithiasis4. Vasoactive intestinal & gastric inhibitory peptides and serotonin inhibit gastrin release, preventing gastric hypersecretion. The absence of ileum and the ileocaecal valve poses problems by decreasing intestinal transit time (diarrhoea), deficiency in protein-energy, water-soluble vitamins, trace elements. Unabsorbed bile salts may cause malabsorption of fat & fat-soluble vitamins, but may be bound with cholestyramine5.

Parenteral nutrition (PN) is instigated6, complemented by early, safe7,8 enteral feeding when tolerable9 to encourage mucosal adaptation (mucosal hypertrophy increases absorptive surface, modulates metabolic response to surgical trauma10 and prevents sepsis11,12,13). Hypertonic solutions (glucose & lactose) should be avoided. Meals should be small and low-fat, amino acid based14 but given frequently, tailored to the individual patients’ needs. Nutritional status15,16 should be monitored to prevent disease morbidity, restricted growth and macro & micronutrient excess.

The diet should be supplemented with fat-soluble vitamins, Vit B12 and minerals (Fe & Zn). Immuno-enhancing nutrients17 (ornithine a -ketoglutarate18, anti-oxidants19, glutamine20,21, n-3 PUFA’s22,23, RNA24 and arginine25.26) such as Impact27 promote healing and reduce septic complications28, promote recovery29 and increase survival30. The beneficial effects of lipids on the immune system are extensively reviewed31,32,33 and cholecystokinin reduces cholestasis34.

Long-Term Nutritional Management of IH - Jejunostomy

PN is substituted with safe35 home parenteral nutrition (HPN), delivered through a central catheter or subcutaneous port36 (PEG - overnight infusion), to supplement oral diet (enteral tube feeding is ineffective). IH will require more nutrition and may have problems related to leakage from the jejunostomy and also major electrolyte imbalance (jejunum permeability). The risk of magnesium, sodium and water loss can be minimised37 by restricting oral fluid to isotonic rehydration solutions (sodium content 90 – 100 mmol/L). High-energy, iso-osmolar fat diets38,39 pose less risk of causing diarrhoea. HPN is expensive and associated with serious potential complications. Epidermal growth factor40 can exert trophic effects on the small intestine.

Long-term Nutritional Management of PM – Colon in Continuity

Complete enteral nutrition (EN)41,42 via nasal flow-care tube43 positioned in the upper jejunum44, precedes normal feeding, as PM will eventually adapt and be able to eat normally. As it is less permeable colon preservation reduces the risk of electrolyte and fluid imbalance. Energy should be supplied in the form of high unrefined carbohydrates and low fat45 for the former is a substrate for energy salvage (3-4 MJ/day)46 from bacterial fermentation of short chain fatty acids47 with a trophic effect on the colonic mucosa48. Fat, however, is associated with an increased risk of steatorrhoea, oxaluria & oxalate renal stones49 and offensive diarrhoea. Low oxalate diets may be beneficial in fat malabsorption. Lack of an ileoccecal valve encourages bacterial reflux, overgrowth and fermentation, causing D-lactic acidosis.

Conclusion

Most patients with short bowel syndrome can be adequately managed with current nutritional techniques. It should be possible for them to retain a normal body mass index and maintain a good quality of life.

References

  1. Jones, J.S. Nutritional support of the hospitalized patient: a team approach. J. Miss. State. Med. Assoc. 1995; 36:4, 91 – 99.
  2. Culpepper Morgan, J.A. et al. Using enteral nutrition formulas. Gastroenterologist. 1993; 1:2, 143 – 157.
  3. Booth, I.W. & Lander, A.D. Short bowel syndrome. Baillieres Clin. Gastroenterol. 1998; 12:4, 739 – 773.
  4. Nightingale, J.M. Management of patients with a short bowel. Nutrition. 1999; 15:7-8, 633 – 637.
  5. Muir, L. et al. Gastrointestinal Disease. In: Ziegler E. & Filer L. Present knowledge in Nutrition. Seventh Edition. ILSI Press. Washington. 1996; Chapter 49. pp 488 – 497.
  6. Elia, M. Nutritional support in sepsis, trauma and other clinical conditions. In: Clinical Nutrition. 1999; pp: 483 - 499.
  7. Reissman, P. et al. Is early oral feeding safe after colorectal surgery? Ann. Surg. 1995; 222: 73 – 77.
  8.  

  9. Carr, C.S. et al. Randomised trial on safety and efficacy of immediate postoperative enteral feeding in patients undergoing gastrointestinal resection. BMJ. 1996; 312: 869 – 871.
  10. Lara, T.M. Effect of critical illness and nutritional support on mucosal mass and function. Clin. Nutr. 1998; 17: 99 – 105.
  11. Senkal, M. et al. Early postoperative enteral nutrition: clinical outcome and cost-comparison analysis in surgical patients. Crit. Care Med. 1997; 25(9): 1489 – 1496.
  12. Moore, F.A. et al. Early enteral feeding compared with parenteral, reduces postoperative septic complications: the result of a meta-analysis. Ann. Surg. 1991; 216:172 – 183.
  13. Kudsk, K.A. Early enteral nutrition in surgical patients. Nutrition. 1998; 14:6, 541 – 544.
  14. Kudsk, K.A. et al. Enteral versus parenteral feeding: effects on septic morbidity after blunt and penetrating abdominal trauma. Ann. Surg. 1992; 215: 503 – 513.
  15. Bines, J. et al. Reducing parenteral requirement in children with short bowel syndrome: impact of an amino acid-based complete infant formula. J. Pediatr. Gastroenterol. Nutr. 1998; 26:2, 123 – 128.
  16. Baxter, J.P. Problems of nutritional assessment in the acute setting. Proc. Nutr. Soc. 1999; 58: 39 – 46.
  17. Collier, S. & Lo, C. Advances in parenteral nutrition. Curr. Opin. Pediatr. 1996; 8:5, 476 – 482.
  18. Bower, R.H. et al. Early enteral administration of a formula (Impact) supplemented with arginine, nucleotides, and fish oil in intensive care unit patients: results of a multicenter, prospective, randomized, clinical trial. Crit. Care Med. 1995; 23:3, 436 – 449.
  19. Le Bricon, T. et al. Ornithine a -ketoglutarate metabolism after enteral administration in burn patients: bolus compared with continuous infusion. Am. J. Clin. Nutr. 1997; 65: 512 – 518.
  20. Dhur, A. et al. Relationship between selenium, immunity and resistance against infection Comp. Biochem. Physiol. C. 1990; 96:2, 271 - 280.
  21. Morlion, B.J. et al. Total Parenteral Nutrition with Glutamine Dipeptide after major abdominal surgery: a randomised, double-blind controlled study. Ann. Surg. 1998; 2: 302 – 308.
  22. Cukier, C. et al. Clinical use of growth hormone and glutamine in short bowel syndrome. Rev. Hosp. Clin. Fac. Med. Sao Paulo 1999; 54:1, 29 – 34.
  23. Swails, W.S. et al. Effect on a fish oil structured lipid-based diet on prostaglandin release from mononuclear cells in cancer patients after surgery. JPEN. 1997; 21: 266.
  24. Bower, R.H. et al. Early enteral administration of a formula (Impact) supplemented with arginine, nucleotides and fish oil in intensive care unit patients: results of a multicenter, prospective, randomised clinical trial. Crit. Care Med. 1995; 23: 436 – 449.
  25. Kemen, M. et al. early postoperative enteral nutrition with arginine, w -3 fatty acids and ribonucleic acid-supplemented diet versus placebo in cancer patients: an immunologic evaluation of Impact. Crit Care Med. 1995; 23: 652 – 659.
  26. Kirk, S.J. et al. Arginine stimulates woung healing and immune function in elderly human beings. Surgery. 1993; 114(2): 155 – 159.
  27. Braga, M. et al. Artificial nutrition after major abdominal surgery: impact route of administration and composition of diet. Crit. Care Med. 1998; 26: 24 – 30.
  28. Braga, et al. Perioperative immunonutrition in patients undergoing cancer surgery. Results of a randomised double-blind phase 3 trial. Arch. Surg. 1999; 134: 428 – 433.
  29. Donnell, S.C. et al. Nutritional implications of gut overgrowth and selective decontamination of the digestive tract. Symposium on ‘Nutrition and gut barrier function’. Proc. Nutr. Soc. 1998; 57: 381 – 387.
  30. Kudsk, K.A. et al. A randomised trial of isonitrogenous enteral diets after severe trauma: an immune-enhancing diet reduces septic complications. Ann. Surg. 1996; 224: 531 – 542.
  31. Jones, C. et al. Randomized clinical outcome study of critically ill patients given glutamine-supplemented enteral nutrition. Nutrition. 1999; 15: 108 - 115.
  32. Bozetti, F. Lessons learned from studies on immune-nutrition in postoperative patients. Clin. Nutr. 1999; 18(4): 193 – 196.
  33. Mayer, K. et al. Clinical use of lipids to control inflammatory disease. In: Current Opinion in Clinical Nutrition and Metabolic care. Rapid Science Ltd. 1998; 1: 179 – 184.
  34. Yacoob, P. Lipids and the immune response. In: Current Opinion in Clinical Nutrition and Metabolic care. Rapid Science Ltd. 1998; 1: 153 – 161.
  35. Rintala, R.J. et al. 1995. Total parenteral nutrition-associated cholestasis in surgical neonates may be reversed by intravenous cholecystokinin: a preliminary report. J. Pediat. Surg. 30: 827 – 830.
  36. Huang, F.C. et al. Home parenteral nutrition in children. J. Formos. Med Assoc. 1996; 95:1, 45 – 50.
  37. Kirby, D.F. et al. Percutaneous endoscopic gastrostomies: a prospective evaluation and review of the literature. J. Parenter. Enteral Nutr. 1986; 10:2, 155 – 159.
  38. Pennington, C.R. Intestinal Failure and Artificial Nutritional Support.Proc. R. Coll. Physicians. Edin. 1997; 27: 418 - 431.
  39. Lennard-Jones, J.E. & Wood, S. Coping with the short bowel. Hosp. Update. 1991; 17: 797 – 807.
  40. Nightingale, J.M. 1995. The short-bowel syndrome. Eur. J. Gastroenterol. Hepatol. 7:6, 514 – 520.
  41. Fürst, P & Rombeau, J.L. growth factors and the intestine in critical illness. In: Rombeau, J.L. & Takala, J. Gut Dysfunction in Critical Illness. Berlin: Springer Verlag. 1996; pp. 375 – 393.
  42. Bengmark, S. Progress in perioperative enteral tube feeding. Review. Clin. Nutr. 1998; 17: 145 – 152.
  43. Vanderhoof, J.A. & Matya, S.M. Enteral and parenteral nutrition in patients with short-bowel syndrome. Eur. J. Pediatr. Surg. 1999; 9:4, 214 - 219 .
  44.  

  45. Jeppsson, B. et al. Technical developments, A new self-propelling nasogastric feeding tube. Clin. Nutr. 1992; 11: 373 – 375.
  46. Prichard, C. & Jeejeebhoy, K.N. Nutritional management of clinical undernutrition. In: Garrow, J.S & James, W.P. Human nutrition and Dietetics. Ninth Edition. Churchill Livingstone. 1996; Ch. 29. pp. 421 – 437.
  47. Ladefoged, K. et al. Nutrition in short-bowel syndrome. Scand. J. Gastroenterol. 1996; (Suppl): 216:, 122 – 131.
  48. Jeppesen, P.B. & Mortensen, P.B. Significance of a preserved colon for parenteral energy requirements in patients receiving home parenteral nutrition. Scand. J. Gastroenterol. 1998; 33:11, 1175 – 1179.
  49. Jeppesen, P.B. & Mortensen, P.B. Colonic digestion and absorption of energy from carbohydrates and medium-chain fat in small bowel failure. J. Parenter. Enteral Nutr. 1999; 23:5 (Suppl): S101 – S105.
  50. Jolliet, P. et al. Enteral nutrition in intensive care patients: a practical approach. Clin. Nutr. 1999; 18, 1: 47 – 56.
  51. Cummings, J.H. Nutritional management of diseases of the stomach and bowel. In: Garrow, J.S & James, W.P. Human nutrition and Dietetics. Ninth Edition. Churchill Livingstone. 1996; Ch. 33. pp. 480 – 506.