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  • • Extensive small bowel resection

    • Diarrhea

    • Steatorrhea

    • Malnutrition

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Epidemiology

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  • • May develop after extensive resection of the small intestine

    • When 3 m or less of the small intestine remain, serious nutritional abnormalities develop; with 2 m or less remaining, function is clinically impaired in most patients, and many patients with 1 m or less of normal bowel require parenteral nutrition at home indefinitely

    • If the jejunum is resected, the ileum is able to take over most of its absorptive function

    • Because transport of bile salts, vitamin B12 , and cholesterol is localized to the ileum, resection of this region is poorly tolerated

    • -Bile salt malabsorption causes diarrhea, and steatorrhea occurs if 100 cm or more of distal ileum is resected

    • Steatorrhea and diarrhea are more pronounced if the ileocecal valve is removed

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Symptoms and Signs

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  • • Diarrhea (> 2 L of daily fluid and electrolyte losses)

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Laboratory Findings

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  • • Hemoconcentration

    • Metabolic acidosis

    • Hypokalemia

    • Hypocalcemia

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Imaging Findings

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  • GI contrast radiographic studies: Show decreased intestinal length and decreased transit time

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  • • The progression from strict dependence on IV feeding to oral intake is possible because of intestinal adaptation, a compensatory increase of absorptive capacity in the intestinal remnant; food in the lumen of the intestine is required for full adaptation, which may require up to 2 years

    • Calcium oxalate urinary tract calculi form in 7-10% of patients who have extensive ileal resection (or disease) and an intact colon; this results from excessive absorption of oxalate from the colon

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Rule Out

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  • • Other causes of steatorrhea and diarrhea

    • -Blind loop syndrome

      -Small intestinal lymphoma

      -Pancreatic exocrine insufficiency

      -Inflammatory bowel disease

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  • • Quantification and electrolyte analysis of diarrheal fluid

    • Serum electrolytes

    • GI contrast radiography

    • Nutritional assessment

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When to Admit

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  • • Severe malnutrition

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  • • Initially, no enteral intake and total parenteral nutrition (TPN)

    • Oral feedings should be initiated when diarrhea subsides to < 2.5 L/d while continuing IV nutrition

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Medications

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  • • Vitamin B12

    • H2 blockers

    • Antidiarrheal agents

    • Supplemental electrolytes as indicated

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Complications

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  • • Oxalate urinary calculi

    • Cholelithiasis

    • Catheter sepsis

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Prognosis

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  • • In most patients, intestinal adaptation and oral intake can be achieved

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References

Buchman AL, Scolapio J, Fryer J: AGA technical review on short bowel syndrome and intestinal transplantation. Gastroenterology 2003;124:1111.  [PubMed: 12671904]
Jeppesen PB: Glucagon-like peptide 2 improves nutrient absorption and nutritional status in short-bowel patients with no colon. Gastroenterology 2001;120:806.  [PubMed: 11231933]
Kim HB et al: Serial transverse enteroplasty (STEP): a novel bowel lengthening procedure. J Pediatr Surg 2003;38:425....

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