1. TOM THOMAS MATHEW 2002 BATCH
SHORT BOWEL SYNDROME
TOM THOMAS MATHEW
2002 BATCH

2. DEFINITION
A GROUP OF SIGNS AND SYMPTOMS THAT RESULT FROM A SMALL BOWEL LENGTH THAT IS INADEQUATE TO SUPPORT NUTRITION.

3. AETIOLOGY ADULTS 1.CROHNS DISEASE 2.MESENTERIC ISHEMIA 3.MALIGNANCY
4.RADIATION ENTERITIS
5.TUBERCULOSIS
6.MULTIPLE FISTULAS
TB INTESTINE

4. - Acute mesenteric ischemia.
CROHNS DISEASE
75%
- Single operation
- Acute mesenteric ischemia.
25%
-Multiple operations
-Crohns disease
ISCHEMIC BOWEL

5. 1) Necrotising enterocolitis
INFANTS
1) Necrotising enterocolitis
2)Volvulus
3)Intestinal atresia
4)Meconium ileus
5)Aganglionosis
6)Intussusception.
INTUSSUSCEPTION

6. PATHOPHYSIOLOGY Resection of less than 50%- tolerated
Length of bowel and site –important
Intact colon,iliocaecalvalve,terminal illeum-70% resected

7. Colon-
-absorb large amount of fluid and
electrolyte.
illeocecal valve –
- delay transit time.
- colonization by colonic bacteria.
Terminal illeum-
- bile salt and vitaminB12-specific

8. Divided into three clinical stages
1.Acute phase
2.Adaptive phase
3.Chronic phase

9. ACUTE PHASE From recovery of postoperative ileus to 4 weeks
Profuse watery diarrhoea(5 to 10 L)
- Acute loss of surface area
- Rapid intestinal transit

10. Severe - illeocaecal value or colon is resected.
Hypergastrinemia-- Diarrhoea
1.Hypersecretion.
2.Steatorrhea - pancreatic lipase
3.Acid enteritis

11. Delayed gastric emptying –Vomiting and nasogastric aspiration.
Acute peptic ulceration may develop
Adequate fluid and electrolyte should be given
With proper nutrition the patient will survive to enter the adaptive stage

12. ADAPTIVE PHASE It takes upto 2 years
More effective in illeum than jejunum
Attempt to increase the surface area.
Increase in the circumference of intestine.
Only minimal increase in length
Villous height

13. depth of crypts.
number of crypts.
total mucosal turnover rate.
migration of epithelial cell from crypt
bases to tip of villi
Age of individual cell is unaffected.

14. FACTORS RESPONSIBLE FOR ADAPTATION
Luminal nutrients.
Trophic gut hormones
1. Gastrin
2.CCK and secretin
3. Neurotensin – Most potent
4.Peptide y
5.Bombesin.
GASTRIN
NEUROTENSIN

15. Pancreatic and biliary secretions Gut derived peptides- GLP-2
Dietary fibre
-Increase stool acidity
-increase colonic absorption
Other hormones
- Growth hormone
- Insulin like growth factor.
GROWTH HORMONE

16. CHRONIC PHASE Begins after the adaptive changes occur Unstable
Easily disturbed by minor illness
Acute disturbances may develop
Deficiencies should be recognised and should be treated.

17. Factors Affecting Severity of Malabsorption, Number of Complications, and Dependence on Parenteral Nutrition
Loss of ileum, especially distal one third
Length of remaining small intestine
Loss of ileocecal valve

18. Loss of colon
Disease in remaining segments of gastrointestinal tract
Coexisting malnutrition

19. SBS Induced Malnutrition
Fat soluble nutrients and vitamins -poorly absorbed
Water soluble vitamin deficiencies - rare.

20. Hyperoxaluria- Oxalate stones(60%).
Terminal ileum- vit B12.
Proximal resection-
1)Calcium
2)Magnesium.
3)Iron
4)Folic acid

21. CLINICAL FEATURES Diarrhea Steatorrhoea Weight loss
Fluid and Electrolyte deficiency
Nutritional Deficiency

22. COMPLICATIONS Gastric hypersecretion - Proximal resection(common)
- Basal acid secretion.
- Clearance of gastrin.
Cholesterol and Pigment stones
-Due to reduced bile salt pool

23. Impaired renal function and stone formation
Hepatic disease.
-Fatty infitration.
Impaired renal function and stone formation
-Reduced GFR due to diarrhoea.
Metabolic bone disease-
-Hypocalcemia.
Fatty change
Oxalate stones O

24. DIAGNOSIS
Clinical features and knowledge of extent of bowel resection

25. TEST OF MALABSORPTION Assessment of severity
1) Estimation of faecal fat
>6g per day – abnormal
2) Breath test for carbohydrate malabsorption
-Oral administration of 14C-lactose
-Breath is analysed for 14CO2

26. 3) Bile absorption test.
-ability of terminal illeum to absorb bile acid.
STEPS
- A dose of 17Se labelled synthetic bile is administered orally or iv
- A gamma counter measures absorption .

27. 4)Hydrogen breath test
-Measure small bowel transit time
-Repeated measurements of the hydrogen in the end expiratory air are taken every few minutes after ingestion of meal.

28. -To assess the absorption of vitB12
Schilling test
-To assess the absorption of vitB12
STEPS
Parenteral injection of unlabelled vitaminB12
Radiolabelled VitB12(0.1microgram)orally.
Normal-excretion of 10% or more in urine.

29. TREATMENT Important principle is prevention.
Intestinal viability doutful
- smallest possible resection.
- second look operation(24h)

30. Early phase Crohn,s disease – limited resections.
Treatment divided into
1) Early phase
2) Late phase
Early phase
AIM-
1)Control of diarrhea
2)Replacement of fluid and electrolyte
3)Prompt institution of TPN
TPN

31. Output and input measurement.
Adequate replacement.
Control of diarrhea
1) Codeine,Diphenoxylate
2) H2receptor antagonists.
3) Cholestyramine
4) Octreotide

32. Late phase
Enteral nutrition should be started as soon as patient recovers from acute phase
Enteral nutrition -adaptation begin early.
Enteral diet are elemental(vivonex) or polymeric(isocal)
Milk products- avoided.

33. Diet should begin at isoosmolar concentration and in small volume
As gut adapts osmolality,volume and caloric content should be increased.
Combination of Glutamine,GH and modified oral diet is efficious.
Typical diet –High carbohydrate,high protein and low fat.
Fat in the form of medium chain fattyacid.

34. Antacids avoided
Vitamins especially fat soluble and calcium.magnesium and zinc should be supplemented.

35. SURGICAL METHODS AIM - Increase the length - Delay transit
1)REVERSED INTESTINAL SEGMENT
- Optimum length- 10 cm
-Delay transit and increase absorption

36. LONGITUDINAL INTESTINAL LENGTHENING AND TAILORING (LILT)
First described by Bianchi in 1980
Dilatation and ineffective peristalsis corrected.
Double the intestinal length.
Ideal in paediatric patients.

37. STEPS Separation of the dual vasculature of the small intestine.
Longitudinal division of the bowel.
Isoperistaltic end to end anastomosis.

38. SERIAL TRANSVERSE ENTEROPLASY PROCEDURE(STEP)
Lengthening of dilated small bowel.
Dual vasculature not separated.
Serial Transverse Enteroplasty (STEP) can lengthen the bowel in some patients. The surgeons make multiple incisions into a short, dilated segment to create a longer, thinner segment of intestine. Although the new segment is initially a zig zag in shape, it becomes straight as it heals.

39. INTESTINAL TRANSPLANTATION
INDICATION-
Presence of life threatening complications attributable to intestinal failure or long term TPN therapy.
TYPES
Isolated intestinal transplantation
Combined intestine/Liver transplantation.
Multivisceral transplantation.

40. COMPLICATIONS-
1)REJECTION
2)CMV INFECTION
3)Lympho proliferative d/s

41. OTHER SURGICAL METHODS
Interposition of colon between small segments of small bowel.
Construction of valves.
Electrical pacing of small intestine

42. NEWER TECHNIQUES
GLP-2
GLUTAMINE,GH WITH MODIFIED HIGH CARBOHYDRATE DIET.
STEM CELL TRANSPLANTATION.
GH AND GLUTAMINE

43. OUTCOME
LIFE LONG TPN(ADULTS)
Intact colon absent-<100cm
Intact colon <60cm
50% TO 70% patients achieve independence from TPN.
Prognosis is better among paediatric patients.

44. SUMMARY
Total small bowel length that is in adequate to support nutrition
Cause include crohn’s disease,acute mesenteric ischaemia in adults and necrotizing enterocolitis in infants

45. Diagnosis on the basis on symptoms and on the extent of resection.
TREATMENT
TPN,replacement of fluids and electrolytes,control of diarrhoea in the initial stage
Parenteral nutrition and gradually increasing enteral feed in the later stage.

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