SHORT BOWEL SYNDROME
Mohamed Ibrahim Abada;
Abstract
The Short Bowel Syndrome (SBS) is a significant devastating problem in clinical medicine (Wilmore and Robinson, 2000).
It has emerged at the beginning of the last century, when the first resections of the gastrointestinal tract have started to be carried out (Wilmore and Robinson, 2000).
The history of the first intestinal resection dates back to 1880, when Koeberle performed a resection of 2 meters of the intestine in a patient who managed to survive. A few decades later (1935), Haymond reported a large series of patients having undergone bowel resection; he concluded that an almost normal bowel function could be expected after resection of one-third of the small bowel length, but loss of 50% of the small bowel was considered as the upper limit of safety (Wilmore and Robinson, 2000).
SBS is defined as the malabsorptive state, which follows massive small bowel resection. This syndrome occurs when there is less than 200 cm of residual bowel. This significant diminution in small bowel length is usually the result of extensive surgical resections and causes significant reduction in the bowel absorptive surface; thus, the usual intake of enteral nutrients cannot support the body mass and the patient gets malnourished. The patients gradually develop symptoms and signs of chronic dehydration, selective nutrient, and vitamin deficiencies (Buchman et al., 2003).
The incidence of severe SBS in the population is estimated to be approximately 2 per million per year. (Buchman, et al, 2003)
There is a substantial difference between the causes of SBS in adults and children. In adults the most common cause of SBS is mesenteric vascular occlusion. Occasionally SBS may be developed by volvulus or strangulation or obstruction of the bowel owing to congenital malrotation of the gastrointestinal tract. Additionally, a blunt or penetrating trauma may be accused (Dabney et al, 2004)
In infants, necrotizing enterocolitis, a common acquired condition, and intestinal atresia (jejunal or ileal), a congenital disease, seems to be the leading causes of SBS. (Misiakos et al, 2000)
The clinical symptomatology varies with the type and extent of intestinal resection. Patients with jejunocolonic anastomosis often seem in good condition after surgical resection except for diarrhea/steatorrhea, but in the following months may lose weight and become severely undernourished. The jejunostomy patients have problems of dehydration immediately after surgery because of large stomal water and electrolyte loss (Nightingale, 2001)
Diagnosis of SBS is rarely in doubt, because these patients have undergone resection of various length of bowel. The clinical assessment of a patient with a SBS includes a measurement of residual small bowel length and an assessment of water, electrolyte, and nutritional status (Jianfeng et al., 2005).
Treatment starting medically as the patient pass by acute phase and late phase. The acute phase lasting for a period of not more than 4 weeks. At first hospitalization central venous catheter is used for nutrient administration. Most of these patients require TPN with meticulous monitoring of weight, water, and electrolyte balance(WilmoreandRobinson, 2000).
The late phase lasting for 1 to 2 years the patient should be placed in oral/enteral nutrition with gradually increasing nutrient loads. Feeding should contain free fatty acids, small amounts of medium chain triglycerides (Keller et al., 2004).
Finally, most patients with SBS will have to cope with an average malabsorption of 30% of nutrients ingested. This requires for a target absorption rate of 30 to 40 kcal/ kg.d (Keller et al., 2004).
Surgical treatment, the primary goal of nontransplant therapy in SBS is to increase nutrient and water absorption by slowing intestinal transit or increasing intestinal surface area. The goal is to reduce the need for TPN, and is used when medical approach alone has failed. Various surgical methods have been applied to small groups of patient (Wales,2004).
Surgical procedures that delay intestinal transit time as construction of various valves and sphincters, construction of antiperistaltic segments or increase absorptive area. Intestinal tapering and lengthening can be achieved by other longitudinal excision or imbrications (Townsend et al., 2004).
Small Bowel Transplantation (SBT) has developed as a means to manage end-stage intestinal failure, which has failed conventional management(Kocoshis et al., 2004).
A recent scientific registry of transplant recipients’ annual report shows a 1-year patient survival rate of 76.9% and a graft survival rate of 66.1%. To date, 5-year patient survival is 52.5%. More than 80% of all current survivors worldwide have stopped TPN and resumed normal daily activities (Grant et al., 2005).
Intestinal and multivisceral transplantation offers a comparable or even better survival rates, less costs and better quality of life than long-term TPN (Di Benedetto et al., 2005).
During the last 20 years, the field of tissue engineering has been developed as a means to overcome this problem.The idea was to create living structures by designing and constructing them. In the following years, a new field termed ‘‘regenerative medicine’’ has been developed (Vacanti, 2003).
Tissue-Engineered Small Intestine (TESI) implantation in rat after massive small bowel resection has helped improving postoperative weight and vitamin B12 absorption (Grikscheit et al., 2004).
It has emerged at the beginning of the last century, when the first resections of the gastrointestinal tract have started to be carried out (Wilmore and Robinson, 2000).
The history of the first intestinal resection dates back to 1880, when Koeberle performed a resection of 2 meters of the intestine in a patient who managed to survive. A few decades later (1935), Haymond reported a large series of patients having undergone bowel resection; he concluded that an almost normal bowel function could be expected after resection of one-third of the small bowel length, but loss of 50% of the small bowel was considered as the upper limit of safety (Wilmore and Robinson, 2000).
SBS is defined as the malabsorptive state, which follows massive small bowel resection. This syndrome occurs when there is less than 200 cm of residual bowel. This significant diminution in small bowel length is usually the result of extensive surgical resections and causes significant reduction in the bowel absorptive surface; thus, the usual intake of enteral nutrients cannot support the body mass and the patient gets malnourished. The patients gradually develop symptoms and signs of chronic dehydration, selective nutrient, and vitamin deficiencies (Buchman et al., 2003).
The incidence of severe SBS in the population is estimated to be approximately 2 per million per year. (Buchman, et al, 2003)
There is a substantial difference between the causes of SBS in adults and children. In adults the most common cause of SBS is mesenteric vascular occlusion. Occasionally SBS may be developed by volvulus or strangulation or obstruction of the bowel owing to congenital malrotation of the gastrointestinal tract. Additionally, a blunt or penetrating trauma may be accused (Dabney et al, 2004)
In infants, necrotizing enterocolitis, a common acquired condition, and intestinal atresia (jejunal or ileal), a congenital disease, seems to be the leading causes of SBS. (Misiakos et al, 2000)
The clinical symptomatology varies with the type and extent of intestinal resection. Patients with jejunocolonic anastomosis often seem in good condition after surgical resection except for diarrhea/steatorrhea, but in the following months may lose weight and become severely undernourished. The jejunostomy patients have problems of dehydration immediately after surgery because of large stomal water and electrolyte loss (Nightingale, 2001)
Diagnosis of SBS is rarely in doubt, because these patients have undergone resection of various length of bowel. The clinical assessment of a patient with a SBS includes a measurement of residual small bowel length and an assessment of water, electrolyte, and nutritional status (Jianfeng et al., 2005).
Treatment starting medically as the patient pass by acute phase and late phase. The acute phase lasting for a period of not more than 4 weeks. At first hospitalization central venous catheter is used for nutrient administration. Most of these patients require TPN with meticulous monitoring of weight, water, and electrolyte balance(WilmoreandRobinson, 2000).
The late phase lasting for 1 to 2 years the patient should be placed in oral/enteral nutrition with gradually increasing nutrient loads. Feeding should contain free fatty acids, small amounts of medium chain triglycerides (Keller et al., 2004).
Finally, most patients with SBS will have to cope with an average malabsorption of 30% of nutrients ingested. This requires for a target absorption rate of 30 to 40 kcal/ kg.d (Keller et al., 2004).
Surgical treatment, the primary goal of nontransplant therapy in SBS is to increase nutrient and water absorption by slowing intestinal transit or increasing intestinal surface area. The goal is to reduce the need for TPN, and is used when medical approach alone has failed. Various surgical methods have been applied to small groups of patient (Wales,2004).
Surgical procedures that delay intestinal transit time as construction of various valves and sphincters, construction of antiperistaltic segments or increase absorptive area. Intestinal tapering and lengthening can be achieved by other longitudinal excision or imbrications (Townsend et al., 2004).
Small Bowel Transplantation (SBT) has developed as a means to manage end-stage intestinal failure, which has failed conventional management(Kocoshis et al., 2004).
A recent scientific registry of transplant recipients’ annual report shows a 1-year patient survival rate of 76.9% and a graft survival rate of 66.1%. To date, 5-year patient survival is 52.5%. More than 80% of all current survivors worldwide have stopped TPN and resumed normal daily activities (Grant et al., 2005).
Intestinal and multivisceral transplantation offers a comparable or even better survival rates, less costs and better quality of life than long-term TPN (Di Benedetto et al., 2005).
During the last 20 years, the field of tissue engineering has been developed as a means to overcome this problem.The idea was to create living structures by designing and constructing them. In the following years, a new field termed ‘‘regenerative medicine’’ has been developed (Vacanti, 2003).
Tissue-Engineered Small Intestine (TESI) implantation in rat after massive small bowel resection has helped improving postoperative weight and vitamin B12 absorption (Grikscheit et al., 2004).
Other data
| Title | SHORT BOWEL SYNDROME | Other Titles | مـتـــلازمــــــــة قصـــــــر الأمـعــــــــاء | Authors | Mohamed Ibrahim Abada | Issue Date | 2015 |
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