sbs handout

Download SBS HandOut

Post on 03-Feb-2017

249 views

Category:

Documents

8 download

Embed Size (px)

TRANSCRIPT

  • !(Short Bowel Syndrome)!!

    ! !

    ! (Definition)!! The National Institute of Diabetes and Digestive and Kidney Diseases 1 anorexia 2 (disease-associated loss of absorption) (subset of intestinal failure) 1,3,4!! (short bowel syndrome) 30-50% 180-200 75 /4-7 iIeocecal valve !! (intestinal failure) Figure 1!!!!!!!!!!!!!!!!!!!

    Figure 1: intestinal failure8

  • (Prevalence, Incidence and Etiologies) !! (Home Total Parenteral Nutrition Registry) 1997 35% 3 4 1 1992 Oley Foundation Home TPN Registry 26% 40,000 9!! Acquire disease Crohn s disease 10 ( Uchino Crohn s disease 24 Crohns disease 721 1974-2010) mesenteric vascular disease, trauma, radiation enteritis recurrent intestinal obstruction (67%) 8 atresias abdominal wall defect necrotizing enterocolitis (NEC) volvulus malignancies 11!

    Figure 2: 11!!! 2005-2014 22 Table 1!!

    Table 1: !12

    C AT E G O R Y N U M B E R L E N G T H ( C M ) M E A N L E N G T H ( C M )

    A G A N G L I O N S I S 7 5 - 1 6 5 4 0

    AT R E S I A 4 1 5 - 4 5 3 7A B D O M I N A L W A L L D E F E C T 4 5 - 2 3 1 7E N T E R O E N T E R I C F I S T U L A 1 7 2 7 2

    T U M O U R 2 1 5 1 5

    V O LV U L U S 4 5 - 4 0 1 5

  • (Normal Intestinal Physiology)!! 275850 Term infant 200-250 2 11 pepsin (chymes) pylorus (pyloric sphincter) (duodenum) (iron) folate (jejunum) cholecystokinin (CCK) delayed gastric emptying time (ileum) bile salt B12 intrinsic factor peptide YY (PYY) glucagon-like peptide 1 (GLP-1) L (slow gastric emptying and intestinal motility) ileal brake8,13 glucogon-like peptide 2 (GLP-2) ileocaecal valve (IC) folate IC !! carbohydrates amylase amylase complex carbohydrates (short-chain fatty acids: SCFAs) 4.2 mJ 13!! denature) parietal cell fundus pepsin chief cell trypsin peptidase PepT1 (jejunal and ileal epithelial cells) !! lipase bile acid (duodenum) lipase long-chain fatty acids monoglycerides micelles mucosal brush border medium short chain fatty acids micelles!! 8-9 80% 18% 2% !

  • !!!!!!!!!!!!!!!!!! !Figure 3: 13!!!

    (Pathophysiology and Prognosis)!! 3 13!1. Jejunoileal anastomosis!2. Jejunocolic anastomosis!3. End-Jejunostomy!!Jejunoileal anastomosis !! (ileum) tight junction (less permeable) (jejunum) luminal diffuse 1.9 5 !! (post jejunal resection) (CCK and secretin) gastrin transient hypergastrinemia 2 6 gastric acid hypersecretion peptic ulcer (duodenum) proton pump inhibitors (PPI) H2 antagonists !!Jejunocolic anastomosis!! (Jejunum) diarrhea !

  • ! (distal ileum) B12 (post ileal resection > 100 cm)14 B12 (vitamin B12 supplement) !! bile acid Bile acid (fat malabsorption) (vitamin A, D, E and K) (fat-soluble vitamins deficiencies) bile acid diarrhea (steatorrhea choleretic diarrhea bile acid ) !! bile acid diarrhea loss of ileal brake effect gastric emptying time diarrhea peptide YY, GLP-1 GLP-2 ileal break diarrhea !!End-Jejunostomy!! (duodenum and jejunum) 100 ostomy net secretors (long term parenteral nutrition)!! B12 loss of ileal brake jejunocolic anastomosis (magnesium deficiencies) (magnesium supplements)!! !! 60-90 (jejunocolic anastomosis) 150 (end-jejunostomy) 2 (life long TPN)15!! (Intestinal Adaptation After Massive Intestinal Resection)!! 24 !2 -3 3 11,16-18!1. (Initial stage) 1-3 !2. (Stage 2 or Early adaptation phase) 1-3 1 !3. (Stage 3 or Long term adaptation phase) 1 2-3

  • !! !! !! (macroscopic changes): dilatation, thickening and increase in length!! (microscopic changes): villus crypt (increase in proliferation and decrease apoptosis of epithelial cell via bcl-2 gene overexpression)!! (protein content): RNA DNA!! upregulation Na-glucose transporter!! !! (distal ileum) 180-200 6 !! (Factors stimulation of adaptation) 3 !1. Pancreato-biliary secretions hyperphagia hyperplastic response)!!2. (Nutritive factors)!2.1 (Presence of food in the gut lumen) hyperphagia !2.2 (Diet complexity) !!!

  • 2.3 (Diet composition) !! complex carbohydrate high fiber butyrate DNA RNA D-lactic acidosis fiber transit time !! arginine arginine (post massive small bowel resection) (stabilized intestinal permeability) glutamine conditionally essential fatty acid glutamine 19!! long chain fatty acids long chain fatty acids bile acid long chain fatty acid long chain fatty acid long chain fatty acid long chain fatty acid !3. (Non-Nutritive Factors)!! GLP-2 teduglutide (The U.S. Food and Drug Administration The European Medicines Agency) 2012 GLP-2 long-acting synthetic human GLP-2 analogue, teduglutide (ALX-0600) teduglutide teduglutide 20 GLP-2 GLP-2 gastric emptying time villus crypt 19 randomized control trial (RCT) teduglutide 0.05 mg/kg/day (subcutanous injection) (Figure 4) citrulline teduglutide (baseline mean SD teduglutide VS placebo groups 18.4 9.5 mol/L VS 17.5 9.0 mol/L, at 24 weeks overbaseline 20.6 17.5 mol/L VS 0.7 6.3 mol/L, P 0.0001)21! !!! Glucagon nephroglucagonoma villus hypertrophy Slow transit time 22 bowel adaptation 23!

  • ! Growth Hormone intestinal hyperplasia growth Hormone glutamine !! !

    Figure 4: Mean (SE) absolute reduction in PN support ! teduglutide 21!!!

    ! IGF-1 (Insulin Growth Factor-1) des-IGF-1 cell proliferation (human duodenal mucosa)24 !! Epidermal Growth Factor (EGF) Brunner EGF 25 !! Melatonin (5-methoxy-N-acetyltryptamine) (pineal gland) melatonin villus height, crypt depth number of mitotic figures DNA/protein ratio melatonin 26!!!!!! !!!!

  • (Management)!! !-Acute phase or post operative phase 1-2 (acute renal failure) normal saline solution balaned electrolyte solution ringer solution 1-2 800-1000 ml / day random urine sodium > 20 mmol/L27 24 27 !!-Adaptation phase hyperphagia (enteral feeding adjustment) enteral feeding intestinal adaptation ostomy content high ostomy content transit time catheter access ! !! serum citrulline concentration (citrulline marker of absorptive enterocyte mass )28,29 serum citrulline < 15 micromol/L permanent intestinal failure sensitivity 89% specificity 78%30!! end-jejunostomy high stromal output !! (dehydration) (sodium balance) (hypokalemia) stoma (intake/output balance) creatinine 1-2 volume status 10 mmol/l !! (hypomagnesium) aldersterone

  • high stomal output 0.6 mmol/l (rehydration) secondary hyperaldosteronism stromal output magnesium oxide 4 mmol 12-24 mmol 1-alpha hydroxy-cholecalciferol 0.25-9.00 g hyperalderstonism 3!! gastric acid hypersecretion transient hypergastrinemia Proton pump inhibitor (PPI) H2 antagonists 6 !! ( body mass index (BMI) (
  • ! jejunostomy content (management high stomal output) ! small bowel ostomy ileostomy jejunostomy high output ostomy 2 contents high output high output ostomy partial small bowel obstruction, abdominal sepsis, active disease Crohn ulcerative colitis (UC), steriods opiates, prokinetic drugs enteritis content < 1200 ml/day 8-14 31!! high output 2-3 (oral hypotonic drinks hypertonic solutions sorbitol glucose diarrhea ) intravenous normal saline 2-4 litre/day 800 ml/day urine Na > 20 mmol/l !! 2-3 content glucose-saline replacement solutions 90 mmol/l Table 3 1-2 !!!

    Table 3: high stromal output27

  • ! (500 mg ) 100 mmol/l osmolality 300 mosmol/kg !! (simple sugar) high stromal content 30 !! ostomy content ostomy content secretors ostomy contents 2 !! 1. (Antimotility or antidiarrheal drugs) 2 loperamide codeine phosphate ileostomy 20-30% loperamide codeine fat malabsorption loperamide bowel dilatation bacterial proliferation diarrhea !! Oral loperamide 4 mg 30 (4 ) loperamide enterohepatic circulation ileum ileum 16 mg 4 !! Codeine phosphate 30, 60 mg 30 (2-4 )!! loperamide 2 3 ostomy !! 2. (Antisecretory drugs) !! - (H2 antagonists or proton pump inhibitors)!! Cimetidine 400 mg oral or intravenous (IV) 4 !! Ranitidine 300 mg oral !! Omeprazole 40 mg oral 40 mg IV q 12 duodenum upper small bowel 50 IV!! - !! Octreotide 20 g SC q 12 stomal output intestinal adaptation splanchnic protein synthesis villus growth !! long acting octreotide/somatostatin sandostatin LAR Depot 20 mg IM 2 small bowel transit time intestinal adaptation

  • 32!!-Maintenance or Stabilization phase!! (multidisciplinary team care) intestinal rehabilitation (IR)19 Home Nocturnal Total Parenteral Nutrition (TPN) !!! (Complication) !-Small bowel bacterial overgrowth (SBBO) colon - present bile acid monoglycerides fatty acid !! - IC valve !! - small bowel dilatation slower transit time !! - !! poor weight gain, new onset of diarrhea (rosacea) enterocolitis D-lactic acidosis D-lactic D-lactic carbohydrate carbohydrate carbohydrate bacterial overgrowth carbohydrate confusion, cerebellar ataxia slurred speech !! gold standard investigation nasojejunal tube (NJ tube) small bowel aspiration >105 cfu/ml invasive (definition location is beyond ligament of Treitz) 33 cirrhosis Billroth II 105 cfu/ml ( 0-103 cfu/ml) small bowel aspiration

  • invasive small bowel aspiration 34!! breath test Carbohydrate 34 !! Glucose breath test sensitivity 20-93% specificity 30-86%!! Lactulose breath test sensitivity 31-68% specificity 44-100%!! 14xylose breath test sensitivity 14.3-95% specificity 40-94%!! Xylose breath test sensitivity 33-42% specificity 33-81%!! Rice