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Short Bowel Syndrome
New Developments in the Management of Short Bowel Syndrome
a report by
John K DiBaise, MD, FACG
Associate Professor of Medicine, Mayo Clinic College of Medicine, Rochester, and
Senior Associate Consultant, Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale
Short bowel syndrome (SBS) is a malabsorption syndrome resulting from resection rather than the length of small bowel removed. When an operative
extensive intestinal resection.
1
Although the diagnosis of SBS relies less on report is unavailable or incomplete, a barium contrast small bowel series may
an anatomical definition and more on a functional definition, for practical provide an estimate of bowel length and is useful to delineate other structural
purposes in adults SBS can be defined as the presence of <200cm of features, such as the presence of bowel dilatation.
7
remaining small intestine. In infants, necrotizing enterocolitis and
congenital intestinal anomalies are frequently responsible. In older The region of the remaining small intestine and the presence of the colon also
children and adults, multiple resections for Crohn’s disease and massive affect the outcome of the SBS patient. In general, an SBS patient will have one
resections due to catastrophic mesenteric vascular events, radiation of the following bowel anatomies: jejuno-colic anastomosis, end-jejunostomy,
enteritis, adhesive obstruction, and trauma represent the more common or jejuno-ileocolonic anastomosis. Patients with a jejuno-ileal anastomosis
causes of SBS.
2
These patients frequently experience chronic diarrhea, have the best prognosis; however, this anatomy is the least common. Patients
dehydration, and macro- and micronutrient deficiencies often requiring with an end-jejunostomy are the most difficult to manage and are the most
enteral or parenteral nutrition support at home. likely to require permanent parenteral support.
6
A jejunal resection is generally
better tolerated than an ileal resection because the ileum is capable of both
While SBS is uncommon, it remains an important clinical problem due to its structural and functional adaptation, while the jejunum mainly adapts
effect on the quality and duration of life of these patients, the high rate of functionally.
6
Intestinal adaptation refers to a process following intestinal
associated complications, and the subsequent high costs involved in their resection in which the remaining bowel undergoes a variety of macroscopic
care.
3
Survival studies from France and the US have demonstrated two-year and microscopic changes in response to a number of stimuli in order to
and five-year survival rates for SBS at over 80 and 70%, respectively.
4,5
increase its ability to absorb fluid and nutrients.
8,9
This stage may last for up
Furthermore, the study from France reported parenteral nutrition (PN) to two years and it is during this time that most PN weaning occurs. The
dependency at two years of 49%, and 45% at five years.
5
Survival rates were presence of the colon is beneficial in SBS patients given its ability to absorb
lowest in the end-jejunostomy and ultra-short small bowel groups. Other water, electrolytes, and short-chain fatty acids (as an additional energy
factors affecting survival include the patient’s age, primary disease process, source), slow intestinal transit, and stimulate intestinal adaptation.
10
It has
comorbid diseases, presence of chronic intestinal obstruction, and the been suggested that, in terms of need for PN, the presence of at least half of
experience of the team managing the patient.
6
Knowledge of the small bowel the colon is equivalent to about 50cm of small bowel.
11
length can be useful for predicting the clinical outcome in SBS patients. The
large range of small bowel length in humans (300–800cm) underscores the Intestinal Rehabilitation
importance of being aware of the small bowel length remaining following a The relatively recent concept of intestinal rehabilitation emphasizes strategies
to reduce or eliminate the need for PN and small bowel transplantation and
can be applied to both adult and pediatric populations.
12
A major component
John K DiBaise, MD, FACG, is an Associate Professor of
of intestinal rehabilitation consists of medication and dietary and fluid
Medicine at Mayo Clinic College of Medicine in Rochester,
and a Senior Associate Consultant in the Division of
manipulation and, as such, lifestyle changes and increased out-of-pocket
Gastroenterology and Hepatology at Mayo Clinic in Scottsdale.
expenses are required on the part of the patient. The provision of patient
Between 1998 and 2005, he was on faculty at the University of
education relative to the underlying disease process and the treatments being
Nebraska Medical Center in Omaha, where he was an Associate
Professor in the Department of Internal Medicine. Dr DiBaise
prescribed is important to enhance compliance with the care plan. SBS patients
has published over 150 articles, reviews, chapters, abstracts,
differ in their response to dietary and fluid manipulation depending on their
and editorials. In addition, he is an active clinical investigator
bowel anatomy—specifically, the presence or absence of a colon. A high-
and educator focusing on gastrointestinal motility and nutrition-related disorders. He is a Fellow
of the American College of Gastroenterology (ACG) and a member of the American Society of
carbohydrate (60%), low-fat (20%) diet has been shown to reduce fecal
Gastrointestinal Endoscopy (ASGE), the American Gastroenterological Association (AGA), and the
calorie loss, increase overall energy absorption, and result in improved wet
American Society of Parenteral and Enteral Nutrition (ASPEN). He completed his gastroenterology
weight absorption in SBS patients with colon-in-continuity.
13,14
In contrast, end-
and hepatology fellowship at the University of Nebraska Medical Center and his post-graduate
training in internal medicine at the University of Iowa Hospitals and Clinics in Iowa City.
jejunostomy patients do not seem to benefit from dietary modifications.
15
Dr DiBaise received his medical degree from the University of Nebraska College of Medicine in
Owing to regional differences in water and sodium handling, those SBS
Omaha, and his undergraduate degree from Northwestern University in Evanston, Illinois.
patients without a colon generally require the use of a glucose–electrolyte oral
E: dibaise.john@mayo.edu
rehydration solution (ORS) to enhance absorption and reduce secretion. The
ingestion of an ORS with a sodium concentration of 90–120mEq/l has been
56 © TOUCH BRIEFINGS 2008
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