Short Bowel Syndrome

• • Extensive small bowel resection

  • Diarrhea

  • Steatorrhea

  • Malnutrition

Epidemiology

• • 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

Symptoms and Signs

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

Laboratory Findings

• • Hemoconcentration

  • Metabolic acidosis

  • Hypokalemia

  • Hypocalcemia

Imaging Findings

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

• • 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

Rule Out

• • Other causes of steatorrhea and diarrhea

  • -Blind loop syndrome

    -Small intestinal lymphoma

    -Pancreatic exocrine insufficiency

    -Inflammatory bowel disease

• • Quantification and electrolyte analysis of diarrheal fluid

  • Serum electrolytes

  • GI contrast radiography

  • Nutritional assessment

When to Admit

• • Severe malnutrition

• • 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

Medications

• • Vitamin B12

  • H2 blockers

  • Antidiarrheal agents

  • Supplemental electrolytes as indicated

Complications

• • Oxalate urinary calculi

  • Cholelithiasis

  • Catheter sepsis

Prognosis

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

References