1. Short Bowel Syndrome
(SBS)
Dr.Atul Kumar Mishra
M.S. (Gen.Surgery)

2. SBS
 Result of surgical resection, congenital defect,
or disease-associated loss of absorption
 Characterized by inability to maintain protein-
energy, fluid, electrolyte, or micronutrient
balance when on a normal diet

3. Definition
 Presence of <one-third (approximately200
cm) of remaining small intestine
 Clinically defined by malabsorption, diarrhea,
steatorrhea, fluid and electrolyte disturbances
and malnutrition
 Functional or anatomic loss of extensive
segments of small intestine that result in loss
of absorptive surface area and increase in
intestinal transit

4. EPIDEMIOLOGY
 True incidence of SBS in United States unknown
 Overall neonatal incidence 24.5 per 100,000 livebirth, with higher incidence in
premature infants (Wales et al)
 15% of adult who undergo intestinal resection suffer from SBS, 3/4th
from
massive resection, 1/4th
from multiple sequential resections
 Case fatality rate 37.5%
 With emergence of intestinal rehablitation centers and advancement in surgical
procedures 70% patient alive 1year
 Survival rates for pediatric SBS 52% - 95% at 5 years

5. SBS can be classified into 3 anatomic subtypes
Intestinal Anatomy
TYPE 1 – End jejunostomy
TYPE 2 – Jejunocolic anastomosis
TYPE 3 – Jejunoileocolic anastomosis

6. Causes of Short Bowel Syndrome
Adults :
 Postoperative
 Irradiation
 Cancer
 Mesentric vascular
disease
 Crohn disease
 Trauma
 Desmoid tumours
Childrens :
 Gastroschisis
 Necrotizing enterocolitis
 Midgut volvulus
 Intestinal atresia
Shackelford’s Surgery of the Alimentary Tract 7th
edition

7. Pathophysiologic Consequences of
Massive Resection
GENERAL
 Malnutrition and weight loss
 Diarrhea and steatorrhea
 Vitamin and mineral
deficiencies
 Fluid and electrolyte
abnormalities
SPECIFIC
 Gastric hypersecretion
 Cholelithiasis
 Liver disease
 Nephrolithiasis

8. Pathophysiology

9. Manifestation related to site of
resection
 Duodenal resection
 Jejunal resection
 Ileal resection
 Loss of ileocecal valve
 Colon

10. Duodenal resection
 Protein , CHO, fat maldigestion
 Ca, mg, iron, folate malabsorption
 Fat soluble vit deficiency

11. If significant portion or all of jejunum is resected, absorption of proteins,
carbohydrates, most vitamins and minerals can be unaffected because of adaptation in
ileum.
BUT unfortunately, enzymatic digestion suffers
because of irreplaceable loss of enteric hormones
produced by jejunum.
ALSO, gastrin levels rise, causing gastric
hypersecretion. High acid output from stomach
injure SI mucosa.
JEJUNUM

12. In addition, TI is site of absorption of bile salts and
vitamin B-12
Continued loss of bile salts leads to fat malabsorption,
steatorrhea, and loss of fat-soluble vitamins
Ileal resection severely decreases the capacity to
absorb water and electrolytes.
ILEUM
Peptide YY, released from L cells in distal ileum and colon, slows gastric emptying and
intestinal transit. In event of distal ileal and colonic resection, this feedback inhibition
is lost

13. Retention of ileocecal valve plays pivotal role in
massive small bowel resection
If ileocecal valve is lost, transit time is
faster, and loss of fluid and nutrients is
greater
Colonic bacteria can colonize the small bowel, worsening diarrhea and nutrient loss
ILEOCECAL VALVE

14. Preservation of the colon has positive
and negative attributes.
Increasing colonic water absorption
as much as 5 times its normal
capacity
Resident bacteria capacity to
metabolize undigested CHO into SCFA
These are a preferred fuel source for
coloncytes & body
Increasing the incidence of urinary
calcium oxalate stone formation
Small intestinal bacterial
overgrowth
COLON
NEGATIVE
POSITIVE

15. Phases Of SBS
 Acute Phase
 Immediately after bowel resection and lasts for 1-3 months
 Ostomy output greater than 5 liters per day
 Life threatning dehydration and electrolyte imbalances
 Extremely poor absorption of all nutrients
 Development of hypergastrenemia and hyperbilirubinemia

16. Adaptation phase
 Begins 12 – 24 hours after resection and last up to 1-2
years
 90% adaptation occurs during this phase
 Enterocyte, villus hyperplasia and increased crypt depth
ocurrs resulting in increased absorptive area
 Luminal nutrition is essential for adaptation and should
be initiated as early as possible
 Parenteral nutrition is essential through out this period

17. Maintenance phase
 Absorptive capacity is maximum during this phase
 Nutritional metabolic homeostasis can be achieved
with oral feeding

18. Change in morphorogy
 Macroscopic
 Elongation and dilation
 Microscopic
 Villus: increase height and diameter
 Crypt: elongation
 Epithelial cell life cycle: increase proliferation
 Decrease apoptosis

19. Change in functional capacity
 Increase absorption per unit length
 Upregulation of sodium glucose
transporter

20. Factors Influencing Intestinal Adoptation
 GASTROINTESTINAL REGULATORY PEPTIDES
Luminal contents
Nutrients
Secretions
 SYSTEMIC FACTORS
Growth factors
Hormones
Cytokines
 TISSUE FACTORS
Immune system
Mesenchymal factors
Mesentric blood flow
Neural influences

21. Lab investigation
 Blood
 U&E, bone profile, & mg, PRN then biweekly
 CBC, triglycerides, cholesterol Weekly
 Folate, vit B12, copper, zinc, Monthly
 Blood gas and AG for suspected lactic
acidosis.

22. Microbiology
 If sepsis suspected; blood & urine c/s
 Cultures from both the central and
peripheral sites.
 Consider opportunistic infections, so search
for fungal infection.

23. Imaging Studies
To assess for potential complications,
 Infection
 Abdominal ultrasonography to look for fungal balls in
the kidney
 Bowel obstruction
 Plain radiography.
 Barium imaging of the bowel
 Liver disease
 Abdominal US to study the liver, biliary tract, &
presence of ascites.

24. Clinical Features
 History of several intestinal resections as in Crohn
disease or major vascular event like midgut volvulus
or embulus to superior mesenteric vessel
 Diarrhea is almost constant finding (with or without
steatorrhea)
 Significant weight loss, lethargy and fatigue
 Dehydration, protein calorie malnutrition, and loss of
critical vitamins and minerals

25. Physical examination
 Significant protein and calorie malnutrition
present with temporal wasting, loss of digital
muscle mass and edema. Skin dry and flaky
 In children poor growth occurs
 Signs of vitamin and mineral deficiency appear

26. Management
The goals of nutritional therapy
1.Maintain adequate nutrition
2.Promote intestinal adaptation
3.Avoid complications

27. Management
1. Fluid and electrolyte balance
2. Nutrition
Require TPN at least initially
Enteral feeding gradually introduced once
ileus has resolved
3. Macro and micronutrients
4. Drugs: PPI, Antimotilty agents

28. HOME PN
Unfortunately, some patients are extremely
difficult/impossible to wean from parenteral
nutritionand and maintained on “home PN
or HPN”
HOME PN
Common characteristics of these patients:
 Very short remaining small bowel segments (<60 cm)
 Loss of colon
 Loss of ileocecal valve or
 Small bowel strictures with stasis and bacterial overgrowth

30. Managements for SBS
 Nutritional support
 Fluid & electrolyte replacement
 Medication for possible complications
 Trophic therapy
Randomized, controlled trials have not shown glutamine and/or growth hormone
to improve intestinal absorption

31. PARENTERAL NUTRITION
 Typically, patients who have undergone
massive enterectomy require TPN, once
hemodynamic stability has been achieved,
for the first 7 to 10 days after surgery
 25 to 30 kcal/kg per day based on ideal body
weight for adults

32.  Indications for continued parental
nutrition
 Poor weight gain or loss of maintenance weight
 Extensive stomal fluid and electrolyte losses
which cannot be replaced orally

33. TPN
 Dextrose is providing 3.4 kcal/mL. Maximum
dextrose infusion rate should be 5 to 7 mg/kg/min
 Blood glucose should be monitored at least daily,
optimally QID, and should be <180 to 200 mg/dL,
Addition of regular insulin toTPN may be required. If
insulin is required, it should be added toTPN bag
with initial dose of 0.1 U/g dextrose
 Intravenous lipids used to provide 20 to 30 percent
of infused calories
 Protein supplied in form of amino acids and should
be supplied at 1.0 to 1.5 gm/kg/day

34. Dietary Treatment
 When fluid and electrolyte balance has stabilized,
bowel sounds have returned, and there is < 2L/day
of diarrhea, elemental diet may be initiated
 Goal is to provide patients with approximately 25 to
30 kcal/kg/day and 1.0 to 1.5 g/kg per day of
protein
 Micronutrients, including water-soluble vitamins(B1,
B2, B3, B6, B12, biotin, folate, C) and fat-soluble
vitamins (A, D, E, K), and trace elements (Zn, Se)
often require supplementation
 Water-soluble vitamin deficiency is rare

35. Diet and Fluid Suggestion
COLON PRESENT COLON ABSENT
Carbohydrate 50%-60% of caloric
intakeComplex
carbohydrate
40%-50%
Fat 20%-30% caloric intake 30%-40%
Ensure adequate essential
fats MCT/LCT
LCT
Protein 20%-30% caloric intake
High biologic values
same
Fiber Soluble soluble
Fluids ORS and/or hypotonic ORS
Oxalate Restrict _______

36.  Lipid
 Medium-chain triglycerides
 Better absorbed in presence of bile acid or
pancreatic insufficiency
 Long-chain triglycerides : more effective
in stimulating intestinal adaptation
 Mix MCT + LCT

37. Oral rehydration solutions (ORS)
 To decrease dehydration and to decrease TPN fluid
requirements in patients with residual jejunum ending in a
jejunostomy
 WHO: formulated by dissolving following in 1 L tap water:
NaCl (2.5 g), KCl (1.5 g), Na2CO2 (2.5 g), and glucose (table
sugar, 20 g)
 Optimal Na concentration : at least 90 mmol/L, which is usual
concentration of small bowel effluent
 NTHU: Babyate oral electrolyte maintenance sol.

38. ORS
 With residual colon in continuity, ORS may of value, but, provided
sufficient Na present in diet, amount of Na in ORS may not be as
critical since colon readily absorbs Na and water against a steep
electrochemical gradient
 For patients with no jejunum, but have residual ileum, presence of
glucose in ORS is not critical because ileal water absorption is not
affected by presence of glucose
 Patients with SBS should be cautioned against consumption of plain
water and should be encouraged to drink ORS whenever they are thirsty

39. Factors affecting TPN dependence
In addition to residual small bowel length other
factors are:
 Presence of colon because it can absorb
large amount of fluid and electrolytes and
absorption of short chain fatty acids
 Intact ileocecal valve, it delays transit of
chyme from small intestine to colon Increasing
the time of contact of nutrient with absorptive
small bowel mucosa

40. Contd
.
 Healthy small bowel has more absorptive
capacity than diseased small bowel
 Resection of jejunum is better tolerated than
ileum because ileum is associated with bile
salt and vitamin B12 absorption

41.  Factors that influence length of time
until independent of TPN
 Extent/ location of resection
 Presence or absence of colon
 Presence /Absence of ICV
 Degree of adaptation in remaining bowel
 Extent of residual bowel disease or
complications e.g. adhesions, strictures

42. Contd
 Anatomically TPN dependence persists when
100 cm of residual small bowl without
functioning colon
 And 60cm with functioning colon
 Among infants weaning from TPN has been
achieved even with 10cm of residual small gut

43. Pharmacologic therapy
 Decrease stomal secretory losses
 H2 blockers, PPI & octreotide
 ??Loperamide
 Ursodeoxycholic acid: Improves bile acid–dependent bile
flow
 Antibiotics used to prevent small-bowel overgrowth
 Insufficient data regarding -glutamine
 GH some benefit

44. Complications of SBS
 Diarrhea
 Cholerheic diarrhea / Steatorrhea
 Gastric Hypersecretion
 Nephrolithiasis
 D-Lactic acidosis

45. Diarrhea
 Anti-motility agents, such as loperamide hydrochloride
 Octreotide (100 mcg SC, tid, 30 minutes before meals) Used
only if fluid intravenous requirements are >3 L daily (High output
jejunostomy)
 Octreotide useful to slow intestinal transit and increase water and
sodium absorption
 Octreotide may impair post resectional intestinal adaptation.
There is also an increased risk for cholelithiasis in a patient
group already predisposed to this problem

46. Steatorrhea
 Luminal digestion of lipid may be impaired because
of impaired bile salt reabsorption related to resected
ileum (>100 cm)
 Insufficient evidence to recommend use of bile acid
supplements to decrease steatorrhea; and they may
worsen diarrhea
 Cholestyramine is not useful in patients with >100
cm of ileal resection, and it may actually worsen
steatorrhea because of the binding of bile salts

47. Gastric hypersecretion
 Massive small bowel resection is associated with
hypergastrinemia during initial first 6 months
after surgery
 High-dose H2 antagonists and proton pump
inhibitors reduce gastric fluid secretion, and fluid
losses during first 6 months post-enterectomy

48. Renal stones
 Normally, oxalate in diet binds to dietary calcium and is excreted
in stool
 In presence of significant fat malabsorption, dietary calcium
preferentially binds to free fatty acids, rendering the oxalate free
to pass into colon
 Once absorbed into colon, oxalate renally filtered, where it binds
to calcium, resulting in hyperoxaluria and calcium oxalate
nephrocalcinosis and nephrolithiasis
 In patients with colon in continuity, oxalate should be restricted in
diet
 Oral Ca supplements may be for prevention of Ca-oxalate
nephrolithiasis

49. Bacterial overgrowth
 Resection of ileocecal valve may allow colonic
bacteria to populate the small intestine, resulting
bacterial overgrowth
 Bacteria compete for nutrients with the enterocytes
 Treatment with antibiotics

50. D-lactic acidosis
 diagnosis : serum level of D-lactic acid is >3 mmol/L
 Standard treatment consists of minimizing oral carbohydrates,
correction of metabolic acidosis, and long-term suppression of
pathogenic floras with antibiotics

51. SICU protocol for SBS
Outcome prediction:
 <100 cm small bowel TPN
 >100 cm small bowel,
<100 cm small bowel + colon,
100~150 cm small bowel + partial colon
 Partial TPN
 >100 cm small bowel + colon
 TPN generally not required

52. Phamacological bowel compensation
For enhancing bowel adaptation
 Growth hormone at 0.03-0.13 s/c for
4weeks
 Parenteral or enteral Glutamine

53. Surgery for SBS
• AUTOLOGOUS INTESTINAL RECONSTRUCTION SURGERY (AIRS)
Improve Intestinal Function and Motility/Maximize Remnant
1.Avoid resection
2.Restore continuity
3.Recruit bypassed intestinal segments
4.Relieve obstruction due to adhesions and strictures
5.Slow intestinal transit
6.Taper dilated bowel segments
Increase Absorptive Area
1.Intestinal lengthing procedures
2.Longitudinal intestinal lengthening and tailoring (LILT/Bianchi)
3.STEP
4.Isolated bowel segment (Kimura/IOWA procedure)
• INTESTINAL TRANSPLANTATION

54. Nontransplantation procedures
 To improve surface area or to slow transit time
 Bianchi procedure (intestinal tapering or
lengthening)
 Indicated in small bowel with bacterial
overgrowth, dilated bowel and continued
malabsorption
 Cutting bowel longitudinally, and create a segment
of bowel twice length, half diameter without loss
of mucosal surface area

55. Contd
 Goal of these operations is to slow intestinal transit time
and increasing intestinal length
 Operations for slow transit time include:
 Segmental reversal of small bowel Interposition segment
of colon between segments of small intestine
 Construction of small intestinal valves

56. Bowl Lengthening procedures
 Longitudinal intestinal lengthening and tailoring
procedure especially in pediatric patients with
dilated small bowel

57. Tapering/PlicationTapering/Plication Bowel lengtheningBowel lengthening

58. Serial Transverse Enteroplasty
(STEP)
SURGERY can both lengthen and
taper the small intestine in some patients
During procedure, a short segment of intestine is carefully cut and reshaped into a
longer, thinner segment. Longer, thinner intestine is thought to function more
efficiently and lead to better absorption of food

59.  Indications
 Impending or overt liver failure
 IV access loss
 Frequent central line related sepsis
 Intestinal failure
Small bowel transplantation

60. Intestinal Transplantation
Combined intestine-liver
transplantation
Isolated intestinal
transplantation
Is only alternative for patients who
have developed end-stage liver
disease related to SBS or long-term
TPN therapy
Considered for patients with significant
liver disease that has not yet progressed
to cirrhosis
Also, for those with significant fluid losses
and who have episodes of frequent, severe
dehydration despite appropriate medical
management.

61. Prognosis
 Ultimately patient with SBS may be
successfully wean from TPN although
entire process may take several years
 Intestinal transplantation should be
consider as a last resort

62. Conclusion
 Early management of SBS replacement of fluid and
electrolytes
 Enteral feeding should begin once patient stabilizes
 Continuous enteral feeding preferred
 Several pharmacological approaches have been tested
to enhance intestinal adaptation and improve feeding
tolerance. None are proven helpful, but studies are
ongoing

63. THANKS FOR YOUR
ATTENTION!