BRIEF R E P O R T

SHORT BOWEL SYNDROME: A CASE REPORT AND LITERATURE REVIEW

O. Shell, J. J. Murphy and D. P. O'Donoghue

Departments of Surgery and Gastroenterology, St. Vincent's Hospital, Elm Park, Dublin 4.

Summary This report suggests that 90 cms of heal;.hy

small bowel is compatible with life on a normal diet with minimal supplements.

Case Report C. H. a 64 year old female was admitted com-

plaining of severe generalised abdominal pain and vomiting for 12 hours. She gave a six month history of symptoms compatible with mesenteric angina: On examination she was in acute dis- tress with central cyanosis and dehydration. She was ayprexial with a regular heart rate of 90 beats per minute and blood pressure of 110/60 mmHg. There was generalised abdominal tender- ness and distension. Bowel sounds were absent.

Investigations on admission showed dehydra- toin (Haemoglobin 18.2 g/dl, P.C.V. 0.55), white cell count 15 x 109/I and severe metabolic aci- dosis (pH 7.2 and HCO,, 9.3 mmol/I). Serum Amylase was normal. Abdominal x-rays showed multiple fluid levels and colonic dilatation.

A clinical diagnosis of intestinal infarction was made and laparotomy was performed following appropriate resuscitation. There was mesenteric infarction from a point 90 cms from the duodenal -jejunal flexure to the lower sigmoid colon. The necrotic bowel was excised and an end jejunos- tomy fashioned with the upper end of the trans- sected sigmoid colon brought out as a mucous fistula. Post-operatively the patient's clinical and metabolic state improved greatly. However, on the fourth day necrosis of the sigmoid colon occurred. The patient was again submitted to laparotomy where the necrotic sigmoid colon was removed and the rectum closed as a modified Hartman's procedure. The remaining jejunum looked healthy. Total parenteral nutrition was commenced via an intra-atrial Hickman catheter.

The early post-operative problems were: Sepsis : This included respiratory tract, urinary

tract and wound infections: a subheoatic abscess requiring aspiration under ultrasound control; septicaemia which led to premature removal of the central feeding line in the fourth week.

Address for correspondence: Dr. D. P. O'Donoghue, Department of Gastroen. terology, St. Vincent's Hospital, Elm Park, Dublin 4.

Jeiunostomy care : Skin excoriation proved a major problem once enteral nutrition was com- menced. Abdominal adiposity compounded the problem of the short jejunostomy. This problem eventually resolved as the patient's general con- dition improved.

Mental state: Understandably the patient be. came severely depressed following two major operations and the acquisition of a jejunostomy with its attendant problems. A short period of psychosis occurred and may have been caused by metabolic disturbances.

Electrolyte imbMance: This was the most persistent and difficult problem. Severe hypo- natraemia developed. Figure 1 shows this prob- lem continued for many weeks requiring both parenteral and enteral replacement. There was evidence of compensatory aldosteronism with low urinary sodium and high urinary potassium (ratio <1) . Serum aldosterone levels were greatly elevated (1675 pg/I). Hypomagnesaemia also developed requiring regular parenteral sup- plements. Interestingly no other electrolyte prob- lems were encountered.

Progress : Four weeks post-operatively enteral nutrition with an elemental diet (NUTRANEL) was commenced. During the next four weeks a normal diet was gradually reintroduced and by the twelfth week the elemental diet was success- fully discontinued. Daily sodium supplements re- duced from 460 mmol/day at six weeks to 112 mmol/day at 24 weeks with return of serum sodium levels to normal. However the hyperaldos- teronism persisted and the jejunal loss of sodium remained high. The magnesium requirements also fell from 12 mmol MgS04/day to 4 mmol MgSO,/week. 'The patient remained well and maintained weight. She was discharged four months after admission and now twelve months post resection she remains in excellent health on a normal diet with no fluid restriction. Thirst is her only remaining symptom. She requires sodium, magnesium and vitamin B,= supplements and takes Ranitidine prophylactically. She is fit to return to her employment.

Discussion The length of normal small intestine is contro~

versial. Figures from 3-9 metres have been given.

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Volume 154 Short bowel syndrome 81 Number 2

During life its average length in the adult is 5 metres (Gray, 1980). The rain=mum length of small bowel necessary to sustain life with oral nutrition is unknown. Up to 50% may be lost without significant problems in sustaining normal nutrition (Weser et al, 1979). Jee~eebhoy (1983) reported that when resection exceeds 75% nutri- tional status cannot be maintained without special help including parenteral support. Our patient however, has had a resection of at least 8 0 % of small intestine together with a total colectomy and is being sustained on a normal diet.

(1983) has also described the "end jejunostomy syndrome" of dehydration, hypokalaemia, hypo- notraemia and hypomagnesaemia as a result ef the isotonic jejunal salt and water loss. In these patients it has been well shown that glucose electrolyte compounds can promote adequate sodium absorption to correct the sodium deficit and can obviate frequent parenteral saline re- placement (Griffin et al, 1982). As shown in Fig. 1 our patient developed severe hyponatraemia which persisted despite both parenteral and enteral replacement. The use of a glucose eIec- trolyte compound (DIORALYTE) together with

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The optimal diet for patients with the short bowel syndrome is also controverslal. A restricted diet has been necessary for many patients (Weser, 1979 Griffin, 1982; Woolf, 1983; Lade- foged, 1979, 1982), whereas Simko (1980) and Woolf (1983) have described the beneficial effects of a high fat diet in some patients.

There have been many reports of the fluid and electrolyte problems in the short bowel syn- drome (Weser, 1979; Griffin, 1982; Jeejeebhoy, 1983; Kennedy, 1983; Woolf, 1983). Jeejeebhoy

sodium chloride tablets brought serum sodium levels to normal but total body sodium remained low as shown by the low urinary sodium potas- sium ratio. This persists despite the addition of further glucose (CALOREEN) in the regime used by Griffin et ~ (1982).

Our patient is therefore unusual in that firstly she has survived an extensive mesenteric infarc- tion, the mortality of which is between 85% and 100% (Ottinger, 1967, 1978). Secondly she enjoys a normal diet and requires small oral

82 She# et al. I.J.M.S. February. 1985

sodium supplements to maintain normal serum sodium. Perhaps this can be explained by the fact that the remaining bowel is healthy.

This report would suggest that 90 cms of healthy small bowel is compatible with life on a normal diet with minimal supplements.

References

Gray. 1980. Gray's Anatomy. 36th Edition. Churchill & Livingstone. p. 1342.

Griffin, G. E., Fagan, E. F., Hodgson, H. J. and Chadwick, V. S. 1982. Enteral therapy in the management of massive gut resection compli- cated by chronic fluid and electrolyte deple- ticn. Dig. Dis. Sci. 27, 10, 902-908.

Jeejeebhoy, K. N. 1983. Therapy of the Short Gut Syndrome. Lancet. June 25, 1427-1430.

Kennedy, H. J., AI-Dujaili, E. A. S., Edwards, C. R. W. and Truelove, S. C. 1983. Water and electrolyte balance in subjects with a perman- ent ileostomy. GUT. 24, 702-705.

Lade~oged K. and Olgaard, K. 1979. Fluid and

electrolyte absorption and renin-angiotensin- aldosterone axis in patients with severe short

bowel syndrome. Scand. J. Gastroent. 1979, 14, 720-735.

Ladefoged, K. 1982. Intestinal and renal loss of infused minerals in patients with severe short bowel syndrome. Am. J. Clin. Nutr. 36, 59-67.

Ottinger, L. W. and Austen, W. G. 1967. A study of 136 patients with Mesenteric Infarction. Surg. Gynaecol. Obstet. 124, 251-263.

Ottinger, L. W. 1978. The Surgical "Management of Acute Occlusion of the Superior Mesenteric Artery. Ann. Surg. 188, 721-731.

Simko, V., McCarroll, A. M., Goodman, S., Wees- ner, R. E. and Kelley, R. E. 1980. High Fat Diet in a Short Bowel Syndrome - - Intestinal absorption and gastroenteropancreatic hor- mone responses. Dig. Dis. Sci. 25, 5, 333-339.

Weser, E., Fletcher. J. T. and Urban E. 1979. Short Bowel Syndrome. Gastroenterology 77, 572-599.

Woolf, G. M., Miller, C., Kurian, R. and Jeejeeb- hoy, K. N. 1983. Diet for patients with a short bowel: High fat or high carbohydra~.e. Gastro- enterology. 84, 823-8.