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Internal Medicine

Short bowel syndrome (SBS)

Congenital/acquired condition affecting the small intestine, hallmarked by loss of intestinal absorptive capacity with resultant malabsorption, dehydration, and malnutrition.

Introduction

Short bowel syndrome is a condition that occurs when either the small intestine and/or the large intestine become physically shorter when a portion is removed by surgery, or functionally shorter, when a portion is damaged in a way that makes it nonfunctional.

Congenital/acquired condition affecting the small intestine, hallmarked by loss of intestinal absorptive capacity with resultant malabsorption, dehydration, and malnutrition.

  • 15% of adult patients who undergo intestinal resection
  • 3/4th cases resulting from massive intestinal resection
  • 1/4th cases from multiple sequential resections.
  • 1-year survival: 75%

Aetiology

  1. Jejunum‐colon: Jejunoileal resection and a jejunocolic anastomosis
  2. Jejunum‐ileum: Predominantly jejunal resection, and have more than 10 cm of terminal ileum and the colon remaining
    • Uncommon cases and rarely have problems of undernutrition and therefore do not often need nutritional support
  3. Jejunostomy: Jejunoileal resection, colectomy, and formation of a stoma
Jejunum‐colonJejunostomy
Crohn’s diseaseCrohn’s disease
Mesenteric ischaemiaUlcerative colitis
IrradiationIrradiation
Small bowel volvulusMesenteric ischaemia
AdhesionsDesmoid

Pathophysiology

Manifestations of SBS are due to:

  1. Loss of absorptive surface area
  2. Loss of site-specific transport processes
  3. Loss of site-specific endocrine cells and gastrointestinal (GI) hormones
  4. Loss of ileocecal valve
The relative locations of digestion and absorption of nutrients in the healthy gastrointestinal tract. CHO = carbohydrate. Photo: Lianne Friesen and Nicholas Woolridge | Jeejeebhoy, K. N. (2002). Short bowel syndrome: a nutritional and medical approach. CMAJ : Canadian Medical Association Journal = Journal de l’Association Medicale Canadienne, 166(10), 1297–1302. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/12041848

Clinical presentation

  • Diarrhoea (life-threatening)
  • Weight loss
  • Dehydration
  • Malnutrition & malabsorption of macro- and micronutrients.

Management

Nutritional management:

Patient must achieve nutritional autonomy: independent of IV nutrition in the future. Enteral feeding of whole food should be encouraged to enhance intestinal adaptation even if TPN is required.
  • Total parenteral nutrition (TPN): Often needed on prolonged/permanent basis to support SBS patient while intestinal adaptation takes place and specific treatment is instituted.
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Severity of intestinal failure. Treatment aims to reduce the severity of intestinal failure. |
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Probability of achieving nutritional autonomy with “standard therapy” or treatment with growth hormone (GH), glutamine (GLN) and a modified diet based on patient weight and jejunalileal length. Figure is based on results from 45 short bowel patients with a portion of colon in continuity with small bowel. | Wilmore DW, Lacey JM, Soultanakis RP, Bosch RL, Byrne TA (1997) Factors predicting a successful outcome after pharmacologic bowel compensation. 226: 288–293

Pharmacological management:

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Commonly used drugs in short bowel syndrome | Seetharam, P., & Rodrigues, G. (2011). Short bowel syndrome: a review of management options. Saudi Journal of Gastroenterology : Official Journal of the Saudi Gastroenterology Association, 17(4), 229–235. https://doi.org/10.4103/1319-3767.82573

Surgical management:

  • Bowel lengthening procedures:
    • Bianchi longitudinal intestinal lengthening and tailoring (LILT) procedure
    • Serial transverse enteroplasty (STEP) procedure
  • Transit slowing procedures (largely abandoned)

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