Dietetic Management of

Short Bowel Syndrome

Ali SingerGastroenterology Specialist Dietitian

Frenchay Hospital

Content

• Definition• Physiology• Management• Case Study

Definition

• The reduction of functioning gut mass to below the minimum necessary for the absorption of nutrients and/or water and electrolytes

Fleming & Remington,

1981

Variability in Intestinal Lengths• Small intestinal length at autopsy:

• 3-8.5m Bryant, 1924

• Shorter in women• SBS more common in women (67%)

• Small intestinal length at laparotomy:n mean (cm) range

(cm)Cook, 1974 6 421 320-521Backman, 1974 32 643 400-846Slater, 1991 38 500 302-782

Record of Intestinal Length

• Length removed often recorded

• Length remaining is more important:•Laparotomy•SB contrast studies (less accurate)

• Nutritional/fluid supplements needed if < 200cm SB

Causes of SBS

F istu la / obstruction

Ileus

C hem otherapy In fection

En te ritis

Sm all bowe l dysfunction

Acu te

Je junum -co lon Je junostom y

Short bow el G u t bypass

Irrad iation C rohns

En te ritis D ysm o tility

Sm all bowe l dysfunction

C hron ic

In testina l Failu re

Commonest causes: • Crohns • Superior mesenteric artery thrombosis• Irradiation

SBS: Anatomy• Mid-SB resection:

• Uncommon• Rarely problems

• Jejunocolic anastomosis:• Usually fluid balance maintained• Nutritional issues when SB <100cm

• Jejunostomy/high output enterocutaneous fistula:• Large stoma/fistula water and sodium losses• Dehydration• +/- nutritional problems

Types of Short Bowel

Pt Groups Jejunum

Ileum Colon Nutritional needs

Jejunum - ileum

Resected

Intact Intact Rarely need nutrition

Jejunum -colon

Resected

Intact Gradual undernutritionAdaption occurs<50cm may need TPN

Jejunostomy Intact Resected / Absent

Absent Fluid & electrolyte lossesNo adaption<100cm IV saline<75cm IV nutrition also

Normal GI PhysiologyJejunum

• Na+/H2O secretion 1st 100cm

• Leaky• Na+ absorption

• Small conc. gradient only• Dependent on H2O

movement• Coupled to gluc/AA

absorption

• Maximal Na+ absorption when [Na+] 120mmol/l

Ileum

Active Na+/H2O absorption

• Less leaky• Na+ absorption

• Large conc. gradient

• Not dependent on H2O movement

• Not coupled to gluc/AA absorption

• Increased by Aldosterone

Normal GI PhysiologyLiquid Vol secreted

(L)Vol absorbed(L)

External Food & drink 2

Salivary glands

Saliva 0.5-1

Stomach Gastric juice 2-3

Pancreas

Pancreatic juice 0.5-0.8

Liver Bile 0.5-0.9

Jejunum Passive proximal secretion & distal absorption

1-2 1-2

Ileum Active absorption 2-5, vit B12, bile salts

Colon Large capacity

External Faeces 400

Total 6.5-9.7 3-9

Gastrointestinal Motility

Jejunal-colon:NORMAL

Jejunostomy:FAST

Peptide YY and GLP-2 (glucagon-like peptide 2) are released when food passes the terminal ileum and caecum that act as ileal and colonic braking mechanisms; this is lost in jejunostomy

Physiological Consequences• Increased gastric emptying• Increased SB transit• Increased gastric secretions (first 2 wks)

• Resection of ileal & colonic braking mechanism

• Changes in GI hormones• Reduced peptide YY, glucagon like peptide 2• Increased gastrin

Critical Lengths

Critical SB length

Note

Jejunostomy

100cm More needed if diseased bowel

Jejunocolic anastomosis

~50cm Depends on amount of residual colon

Nutritional Support and Bowel Length

Jejunal length Jejunum-colon Jejunostomy

0 - 50 cm Parenteral nutrition Parenteral nutrition and saline +/- Mg

51 - 100cm Oral / Enteral nutrition

Parenteral nutrition and saline +/- Mg

85 - 100cm Parenteral saline

101 - 150cm None Oral / enteral nutrition and glucose / saline solution

151 - 200cm None Oral / enteral glucose / saline solution

• <200cm: restrict oral hypotonic fluids, sip glucose - saline supplement (100mmol/L Na, like jejunostomy fluid)

• <100cm: parenteral saline

• <50cm: parenteral nutrition and saline

GI Secretions

Jejunum – colon• Reabsorb unabsorbed fluid in colon

Jejunostomy• Salt and water loss from stoma• <100cm jejunum: losses > oral intake• Rapid sodium fluxes occur in jejunum

• If water/solutions of <90mmol/L sodium are drunk a net efflux of sodium into the bowel lumen occurs until 100mmol/L is reached

Absorptive Functions

B12 and fat malabsorption occur if >60-100cm terminal ileum resected

• Increased hepatic synthesis of bile salts cannot compensate; unabsorbed bile salts contribute to colonic secretion

Magnesium deficiency • Chelation of unabsorbed fatty acids

reduces absorption• Increased renal excretion; secondary

hypoaldosteronism

Hypomagnesaemia

R e du ced a bso rp tion

M a g ne s iu m ch e la tion w ith u n ab sorb ed fa tty ac ids

R e d uce d se cre tiona n d fu n ctio n P TH

D e c rea se d je ju n a lm a gn e siu m a bso rp tion

R e du ced m a nu fa ctu reo f 1 ,25 h yd ro xy-v itam in D

D ire c t inc re a se in re n a lm a gn e s ium losses

H yp oa ld ers te ro n ism d ueto hyp o na tre m ia

Clinical PictureWater Na Mg Nutrition

• Thirst• Low BP/ postural hypotension• Urea/ Creatinine/ Potassium• Daily body weight• Fluid balance/ stoma output• Low urine volume• Urine Na 1-2/7, then weekly, as OP 2-3 monthly• Depletion if urine Na <10mmol

Serum magnesiumHigh stoma outputSx in Mg < 0.6mmol/L

BMI <18.5kg/m2

Mid-arm muscle circumference <19cm: <22cm men

Adaptive Processes

• Hyperphagia; increased food intake

• Structural adaption:• increasing absorptive area

• Functional adaption;• slowing gastrointestinal transit (gastric emptying

and small bowel transit)• Occurs in jejunum-colon patients due to high

peptide YY and GLP-2, leads to increased jejunal absorption of macronutrients (glucose, water, Na, Ca) and overtime may no longer need TPN

Jejunum-Colon Pts

Post resection:• Parenteral fluids and nutrition (helps

surgical repair, ileus recovery and avoids deficiencies)

• 6/12 PPI• Multivitamin

Long term:• Undernutrition• Diarrhoea due to malabsorption• Vitamin/mineral deficiency

Undernutrition

• >50% of energy from diet malabsorbed• High energy foods, sip feeds +/- NG/PEG

feed; if fails TPN. Improves over time.• Long term TPN:

• Absorption of <33% oral energy intake• Absorption 30-60%, high energy requirements• Large volume stomal output / diarrhoea

• High carbohydrate, normal fat, low oxalate diet

• Topical sunflower oil for essential fatty acids

The Fat Dilemma

R e du cetra n s it t im es

R e d uce wa ter a ndso d ium ab so rp tion

R e d u ce b ac te ria lca rbo h yd ra te fe rm e n ta tion

In c rea sed s too l losses

B in d ca lc iuma n d m ag n es ium

R e na l s to n es

In c rea se o xa la tea b so rp tion

In c rea sedD la c tic a c id o s is

U n ab so rb e d lo n g ch a in fa tty ac id s in co lon

H ig h fa t d ie t

But high carbohydrate without fat is unpalatable and fat yields twice as much energy as carbohydrate; also a low fat diet risks essential fatty acid deficiency.

Deficiencies

Common:• B12 deficiency;

replace• Selenium deficiency;

replace• Magnesium

deficiency; replace if occurs

• Vitamins D, E, A, K and essential fatty acids; replace

Rare:• Potassium deficiency• Zinc deficiency; rare

unless large stool volumes

• Water and sodium; rare as absorbed well in colon, if occurs sips of glucose saline drink

Other complications

Diarrhoea• Limit food intake• Consider loperamide 2-8mg 30mins pre meals,

codeine 30-60mg 30mins pre meals• If >100cm terminal ileum resected cholestyramine

for bile salt malabsorption and reduced oxalate absorption

Confusion• Hypomagnesaemia, thiamine deficiency, lactic

acidosis (restrict mono / oligo saccharides) and hyperammonaemia (inadequate citrulline manufacture, Tx is arginine)

Drug absorption • warfarin, digoxin, thyroxine, loperamide and if <50cm jejunum

omeprazole may not be absorbed

Gallstones (calcium bilirubinate stones)• Bilary stasis. Therefore occurs in 45%, especially men• Tx IV amino acids, enteral feed, cholecystokinin injections,

NSAIDS, ursodeoxycholicacid, metronidazole, cholecystectomy

Renal stones (calcium oxalate stones/nephrocalcinosis/CRF)

• Occurs in 25% largely due to increased colonic absorption of oxalate

Social

Ca Oxalate Renal Stones

S ym pto m atic ren a l sto n es

L o w o xa la te d ie tA v o id d eh yd ra tion

In c rea se d ie ta ry C a

In c rea sed c o lo n ica b so rp tio n o f o xa la te

L o w fa t d ie tR e p la ce fa t w ith m e d ium

ch a in trig lyc e rid es

F a tm a lab so rp tion

O ra l cho le s tyra m ine

B ile sa lt ind u cedin c re ase d co lo n ic

p e rm e a b ility to o xa la te

R e d uce d b a cte ria ld e gra da tio n o f o xa la te

R e p la ce m e nt

P yrid ox in e o rth ia m in e d e ficie n cy

H yp o c itra tu ria

C a lc iu m ox a la tep re c ip ita tion in re n a l tra ct

N e p h ro ca lc in o s is+ /- re n a l fa ilu re

Jejunostomy Patient Issues• Salt and water depletion

• May be large volume of stomal output• Greater volume lost after food or fluids• GI secretion 4L/day, majority absorbed in jejunum

therefore more fluid losses via stoma if short jejunum• Jejunostomy fluid contains 100mmol/L Na,

15mmol/L K• If given hypotonic fluids 100mmol/L the mucosa

allows leaking of fluid and electrolytes into the lumen • Low sodium levels are NOT SIADH but sodium

depletion, this is resolved when urine Na 30mmol

• Hypokalemia• Rare, occurs when <50cm jejunum• Usually due to secondary hypoaldersteronism from Na

depletion

• Can be due to hypomagnesaemia causing potassium channel dysfunction and increased renal potassium secretion which responds to Mg not K supplements

• Hypomagnesaemia• B12 deficiency, confusion, drug absorption,

and gall stones• Nutritional

Jejunostomy Patient Issues

High Output Jejunostomy

• Exclude other causes of a high output

• Stage1: Establish stability

• Stage 2: Establish oral intake• Introduce enteral food/fluid/feed

• Stage 3: Rehabilitation•Stoma care, HPN training, social issues

• Stage 4: Long term care

Other Causes

• Intra-abdominal sepsis• Partial/intermittent bowel obstruction• Enteritis (clostridium, salmonella)• Recurrent disease in remaining bowel

(Crohn’s, irradiation)• Bacterial overgrowth• Suddenly stopping drugs (steroids, opiates)• Giving prokinetics (metoclopramide)• Coeliac• Hyperthyroidism

Stage 1: Establish Stability

• Severe dehydration & Na+ depletion•Keep patient NBM• IV normal saline (2-6L/day)

Treat the Cause

• Intraabdominal sepsis / abscess • Partial / intermittent bowel obstruction• Strictures; placement / muscle tunnel / adhesions /

crohns / ischaemic fibrosis / radiotherapy

• Enteritis; clostridium / salmonella / rota virus

• Recurrent disease; Crohns / irradiation

• Sudden stopping of drugs; steroids / opiates

• Drugs; prokinetics / metoclopramide / metformin / PPI / statin

• Diet; lactose intolerant / coeliac

Stage 2: Establish Oral Intake

• Restrict oral fluids to <500ml/day•Hypotonic (water, tea, coffee, squash,

alcohol)•Hypertonic (fruit juices, coca cola, sip

feeds)

• Drink a glucose-saline solution <500ml/day

Hypotonic Fluids

0 mmol Na+

High Output

100 mmol/L Na

Na+ and H2O

•Leaky

•Small conc. gradient only

•Dependent on H2O movement

Na 140 mmol/L

Unable to maintain Na gradient

jejunum

Electrolyte Mix

90 mmol Na+/L

Smaller volume

100mmol/L Na+

Na+ 140 mmol/L

Oral Rehydration Therapy

Na(mmol/L)

K (mmol/L)

Glucose(mmol/L)

Volume(ml)

WHO 90 20 111 1000

Electrolyte mix

90 0 111 1000

Dioralyte 60 20 90 200

Recipe: ORS

• 20g (6 teaspoons) glucose• 3.5g (1 level 5ml teaspoon) salt• 2.5g (1 heaped 2.5ml spoon) sodium

bicarbonate• 1L water • Add cordial, chill and drink through a

straw

Drug Therapy

Antisecretory:

• Omeprazole; decreases gastric acid secretion

• Ranitidine/cimetidine

• Octreotide; decreases

intestinal secretions

Antimotility:

• Loperamide upto 64mg PO o.d as decreased enterohepatic circulation

• Codeine• Lomotil

Vit/min supplements:

• B12, selenium, Mg2+, vit A, D, E, K

Parenteral Therapy

• 0.5–1L saline sc +/- 4mmol MgSO4

1-3/week

• 1L saline IV +/- 4-12 mmol MgSO4

> 3/ week

• IVN

Outcome Aims

• Clinical:• No thirst or signs of dehydration• Acceptable strength, energy and appearance

• Measures:• Gut loss <2L/day• Urine volume >800ml/day• Urinary Na+ >20 mmol/L• Normal serum Na+, Mg2+ and K+

• Body weight within 10% of normal

Stage 3: Rehabilitation

• Transfer to IF unit•Wound healing•Stoma care•HPN training

•1st patient 1978•Longest 27 years•Mean age 50.2 years (19.9 – 76.9)•~27 new patients per year per unit

•Social issues

Stage 4: Long-Term Care

• 3 monthly multidisciplinary clinics• IF unit•Shared care with local hospital

Outcome 1 year after starting HPN (467 patients)

74.2

15.1

8.1

0.9

1.1

0.6

0 20 40 60 80

C ontinuing on HP N

R eturned to oral

Died

In hospital

Withdrawn

R efused

% patients

100% mortalityP ancreatic malignancy (1)C O AD (1)MND (1)3.7% mortalityC rohn’s (188)

BANS 1996-2000

Mr J: background information•72 male UC (1961)

•Pan-protocolectomy (1962)

•Refashioned/Re-sited Ileostomy (1993)

•s/b Dr Kaskey, Renal Physician 2º renal impairment and kidney stones

•Referred from renal dietetic clinic (pt initially attempted to resist a referral!)

IssuesHigh output

ileostomy output (estimated up to

2.5L per day)

Renal impairment &

stone formation

Dehydration ( UO, urine Na)

Assessment: Concerns• Renal impairment:

* stage 4 CKD

• Poor seal on stoma bags

• Not leaving house when stoma active

Biochem Result

Na 134

K 3.5

Ur 20.0

Creat 233

eGFR* 25

Uric Acid 0.64

InterventionIntervention Rationale

1. Add salt to meals Increase Na intake (& serum Na)

2. Low fibre diet Insoluble fibre & residue through bowel

3. Restrict hypotonic fluids to 1L/d

Avoid drawing H20 (& Na) into the bowel

4. St Marks Fluid 1L/d Promote H20/ Na absorption

5. Loperamide 4m.g qds

Anti-motility agent

6. Forceval o.d

7. Check Mg and if deplete, convert Mg-glycerophosphate to Mg-oxide

On Mg supplements but levels not checkedMg oxide has less diarrhoeal effect

8. Refer to MXL Specialist f/u

Outcomes• Outcome measures

•Biochemistry:

Biochem 09.08.07 03.04.08

Na 134 142

K 3.5 4.7

Ur 20.0 12.9

Creat 233 202

eGFR 25 29

Uric Acid 0.64 0.41

Outcomes

• Reduction in stoma output from ~ 2.5 L to < 1L /d• Thickened output (watery porridge-like

consistency)

• Pt satisfaction• Practicalities in day-to-day management of

stoma

• Follow-up• Sole Dietetic f/u• Renal physician’s happy with progress

Thank-you

Any Questions?