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  • • Intestinal stasis and bacterial overgrowth related to disruption of propulsive forces or other factors that limit bacterial growth

    • Proliferating bacteria deconjugate bile acids, making micellar formation inadequate resulting in increased colonic fatty acids and steatorrhea

    • Megaloblastic anemia results from malabsorption of vitamin B12 .

    • Treatment should be geared toward correcting the anatomic defect predisposing to bacterial overgrowth, or decreasing bacterial concentration through antibiotic treatment

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Epidemiology

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  • • Caused by the disruption of the mechanisms that limit bacterial growth

    • -Peristalsis

      -Interdigestive migrating motor complex

      -Gastric acidity

      -Immunoglobulins

      -Prevention of reflux of colonic contents by the ileocecal valve

    • Strictures, diverticula, fistulas, or poorly emptying segments of intestine cause stagnation and permit bacterial proliferation

    • Stasis of intestinal contents may also result from a functional abnormality of motility (eg, scleroderma)

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Symptoms and Signs

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  • • Steatorrhea

    • Diarrhea

    • Malnutrition

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Laboratory Findings

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  • • Megaloblastic anemia

    • Hypocalcemia

    • Impaired absorption of orally administered vitamin B12

    • Quantitative culture of upper intestinal aspirates (> 105/mL are abnormal)

    14C-d-xylose breath test: Anaerobic bacteria in the small bowel metabolize xylose, releasing 14CO2, which is detected in the breath

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Imaging Findings

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  • Upper GI contrast radiographic study or CT scan: May reveal blind intestinal loop, intestinal stricture, or fistula

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  • • Steatorrhea is the consequence of bacterial deconjugation and dehydroxylation of bile salts in the proximal small bowel, resulting in micelle formation that is inadequate to solubilize ingested fat

    • Hypocalcemia occurs because calcium is bound to unabsorbed fatty acids in the intestinal lumen

    • Macrocytic anemia is due to malabsorption of vitamin B12 , largely because of binding of the vitamin by anaerobic bacteria

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Rule Out

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  • • Other causes of malabsorption (short bowel syndrome, small intestinal lymphoma, pancreatic exocrine insufficiency, inflammatory bowel disease)

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  • • CBC

    • Peripheral blood smear

    • Serum calcium

    • Upper GI aspirate with culture

    14C-d-xylose breath test

    • GI contrast radiography or CT scan for defining anatomic defects

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When to Admit

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  • • Severe malnutrition

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  • • Surgical treatment of underlying fistula, blind loop, diverticula, or other lesion

    • In others, treatment consists of broad-spectrum antibiotics and drugs to control diarrhea

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Surgery

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Indications

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  • Anatomic defects amenable to treatment: Fistula, diverticulum, blind loop

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Medications

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  • • Antibiotics

    • Antidiarrheal agents

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Treatment Monitoring

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  • • CBC count

    • Symptomatic control (diarrhea, steatorrhea, malnutrition)

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Prognosis

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  • • Good if anatomic defect can be identified and corrected

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References

Goulet O, Ruemmele F: Causes and management of intestinal failure in children. Gastroenterology 2006;130(2 suppl 1):S16. ...

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