Nutritional absorption in short bowel syndrome

Eight patients with a short bowel resulting from intestinal resection and clinically stable for at least one year were studied for 10 days. The diet chosen was lactose-free with a low fiber content and contained 22% of total calories as protein, 32% as carbohydrate, and 46% as fat. Total fluid volume was kept constant, and all patients were in positive nitrogen balance. During the 10-day period, blood chemical concentrations, stool, and/or ostomy volume, urine volume, electrolyte excretion, and calorie and divalent cation absorption were measured. In addition it was determined that fluid restriction during meals did not affect these parameters. In these patients the absorptions of fat, carbohydrate, protein, and total calories were 54%, 61%, 81%, and 62%, respectively. Similarly the absorption of the divalent cations, calcium, magnesium, and zinc, were 32%, 34%, and 15%, respectively. We suggest that patients with short bowel syndrome, who have been stable for at least one year and who can tolerate oral diets, do not need to restrict fat or to separate fluids from solids during their meals. Furthermore, they should increase their oral intake to 35–40 kcal/kg ideal body weight in order to counteract their increased losses. The diet should contain 80–100 g protein/day in order to maintain a positive nitrogen balance and a large margin of safety. In addition, these patients may take oral supplementation of calcium, magnesium, and zinc to maintain divalent cation balance.This work was supported by a grant from the Ontario Ministry of Health PR. 228.     

Nutritional management of short bowel syndrome

Short-bowel syndrome refers to malabsorption, diarrhea, and weight loss following an extensive resection of small bowel. A main consequence is malabsorption of macro- and micronutrients. Nutritional outcome after intestinal resection depends on the extent and location of resection, presence of ileocecal valve and a colon, functional status of the residual intestine, and adaptation. Intraluminal nutrients and trophic factors are critical for intestinal adaptation. The dietary management is focused on the enhancement of intestinal adaptation and optimal caloric intake. Patients with short-bowel syndrome require an individualized diet, and some may require total parenteral nutrition indefinitely. Growth hormone, glutamine, and GLP-2 are reviewed with emphasis on their current use in clinical practice. The nutritional aspect of short-bowel syndrome is complex, with the ultimate goal of weaning the patients from parenteral nutrition. Intestinal transplant is a treatment option for select patients.     

Nutritional management of short bowel syndrome in adults

Short bowel syndrome (SBS) comprises the sequelae of nutrient, fluid, and weight loss that occurs subsequent to greatly reduced functional surface area of the small intestine. Signs and symptoms of SBS include electrolyte disturbances; deficiencies of calcium, magnesium, zinc, iron, vitamin B12, or fat-soluble vitamin deficiency; malabsorption of carbohydrates, lactose, and protein; metabolic acidosis, gastric acid hypersecretion; formation of cholesterol biliary calculi and renal oxalate calculi; and dehydration, steatorrhea, diarrhea, and weight loss. Thorough nutritional management is the key factor in achieving an optimal outcome in SBS. Total parenteral nutrition is necessary in the early stages, as is replacement of excess fluid and electrolyte losses. Nutritional management of SBS has traditionally been divided into three phases: an acute phase when total parenteral nutrition is usually begun, an adaptation phase, and a maintenance phase. Recommendations regarding the need for parenteral nutrition vary depending on the presence or absence of certain factors: the ileocecal valve, jejunum, and functional colon. Patients with residual small bowel length of 100 cm or less usually require the administration of parenteral nutrition at home with good results. The total parenteral nutrition diet should consist of a majority of calories from fat, followed by protein, and the remaining as carbohydrates. Vitamins, minerals, and trace elements should also be added accordingly. Although total parenteral nutrition is initially necessary, treatment goals should focus on early transition to enteral nutrition followed by oral feeds. Other recent advances in the medical management of SBS include pharmacologic treatment and the use of specific nutrients and growth factors to stimulate intestinal absorption and adaptation. Both animal studies and clinical trials in humans have shown much promise in supplementation with growth factors and hormones. This strategy is likely to play a greater role in the treatment of SBS in the future.     

Nutritional therapy of irritable bowel syndrome

Nutritional factors relative to IBS include diagnostic and therapeutic considerations. Etiologically, foods do not cause IBS. A small percentage of patients with childhood allergic diatheses, usually in association with atopic dermatitis and asthma, may be intolerant to one or more of wheat, corn, dairy products, coffee, tea, or citrus fruits. Diagnostically, many patients labeled as IBS subjects are in fact intolerant to the ingestion of lactose-containing foods, sorbitol, fructose, or combinations of fructose and sorbitol. A precise dietary history will characterize this group. Taken in its broadest context, IBS involves the entire hollow tract inclusive of esophagus, stomach, small bowel, and colon. The symptomatic presentation relative to the hollow organ involved allows the selection of dietary manipulations that may help to reduce symptoms. Gastroesophageal reflux, a consequence of low LES pressure in some IBS patients, may be treated with the elimination of fatty foods, alcohol, chocolate, and peppermint. Delayed gastric emptying may be helped by the elimination of fatty foods and reduction of soluble fiber. Aberrant small bowel motor function may be ameliorated by reduction of lactose, sorbitol, and fructose and the addition of soluble fiber. Gas syndromes may be improved by reduced intake of beans, cabbage, lentils, legumes, apples, grapes, and raisins. Colonic motor dysfunction may be overcome by the gradual addition of combinations of soluble and insoluble fiber-containing foods and supplements. The selective use of activated charcoal and simethicone may be helpful.     

Surgical therapy of the short bowel syndrome

Patients with the short bowel syndrome should be managed initially by giving total parenteral nutrition and by maximizing the function of the remaining intestine. Enteral feedings should be instituted as soon as the patient stabilizes, usually after 2 to 4 weeks. The gastric hypersecretion that accompanies the syndrome can usually be controlled with an H2-receptor blocker. In those patients who fail to recover adequate digestion and absorption after 6 months to 1 year, operations to improve absorption should be considered. The reversed intestinal segment and the intestinal lengthening procedures are most often employed, but neither type of operation can be recommended without reservation. Newer procedures, such as growing new intestinal mucosa on serosal patches, intestinal pacing, and intestinal transplantation may play a role in future therapies. At present, long-term parenteral nutrition remains the cornerstone of therapy.     

Enhancing bowel adaptation in short bowel syndrome

Malabsorption of both nonessential and essential nutrients, fluid, and electrolytes will, if not compensated for by increased intake, lead to diminished body stores and to subclinical and eventually clinical deficiencies. By definition, intestinal failure prevails when parenteral support is necessary to maintain nutritional equilibrium. After intestinal resection, adaptation, a progressive recovery from the malabsorptive disorder, may be seen. Research has focused on optimizing remnant intestinal function through dietary or pharmacologic interventions. In this review, factors responsible for the morphologic and functional changes in the adaptive processes are described. Results of clinical trials employing either growth hormone and glutamine or glucagon-like peptide-2 in short bowel patients are presented.     

The short bowel syndrome

The authors demonstrate on case-histories their experience with short-loop syndrome which develops after extensive resections of the small intestine. The clinical picture of the syndrome is characterized by diarrhoea, steatorrhoea, maldigestion and malabsorption with loss of body weight. Non-surgical treatment of the syndrome copies its different stages. The objective of conservative therapy is above all to preserve the nutritional integrity of the organism and gradual adaptation of the gut which will make eventually a change to oral intake possible. This adaptation takes 1 to 2 years. Last not least, treatment should eliminate the diarrhoea. The authors demonstrate on examples that properly conducted treatment prevented the development of malnutrition, contrary to another case where the sequelae of surgery were underestimated and the patient developed cachexia and pernicious anaemia.     

Nutritional therapy in inflammatory bowel disease

Protein-energy malnutrition and specific nutrient deficiencies are common in inflammatory bowel diseases (IBD), more particularly in Crohn's disease. In adults, the use of artificial nutrition is indicated in the event of malnutrition, short bowel syndrome, or IBD refractory to all other treatments. In children, enteral nutrition has a place as first-line treatment to avoid side effects of corticosteroids on growth. The use, as a therapeutic tool, of specific nutrients (n-3 fatty acids, glutamine, antioxydant vitamins and minerals, TGF-beta, probiotics...) seems interesting at the pathophysiological level. Nevertheless, these nutrients are still under evaluation and there are not enough available studies to recommend them in clinical routine. A very promising solution is the use of probiotics for the treatment of refractory pouchitis.     

Nutritional therapy in inflammatory bowel diseas

Opinion statement Nutritional intervention is an important adjunctive therapy for patients with inflammatory bowel disease (IBD). The correction and maintenance of nutritional status, achieved by careful nutritional monitoring and intervention, should be an integral part of the multidisciplinary management of IBD throughout all stages of the disease. In acute Crohn’s disease, enteral nutrition (polymeric and elemental) is an effective and safe primary therapy for many patients. Enteral diets should be considered as primary therapy in pediatric Crohn’s disease patients, especially in children with poor nutritional status or growth impairment and in patients with severe drug-induced side effects. Total parenteral nutrition does not have a primary therapeutic role in IBD.     

Hypomagnesemia and chondrocalcinosis in short bowel syndrome

Chondrocalcinosis is a result of deposition of calcium pyrophosphate dihydrate (CPPD) crystals in cartilage and fibrocartilage. Chondrocalcinosis is usually sporadic but has also been associated with a variety of metabolic diseases including hypomagnesemia. Reported cases of hypomagnesemia associated chondrocalcinosis were mostly due to renal genetic disorders such as Bartter's or Gitelman's syndrome. We describe 3 patients with chronic hypomagnesemia induced by short bowel syndrome who developed symptomatic chondrocalcinosis. CPPD crystals were identified by polarizing light microscopy in one patient. The underlying intestinal pathology was radiation enteritis in 2 patients and mesenteric arterial thrombosis in the third. Our observations strengthen the hypothesis of a role for magnesium in CPPD crystal deposition disease.     

Mortality and economics in short bowel syndrome

The incidence of patients with short-bowel syndrome (SBS) has increased over the years due to progress of intensive care medicine and parenteral nutrition techniques. These techniques have significantly improved the prognosis of neonates, children and adults who have lost major parts of their intestinal tract. Long-term survival is possible and does not depend primarily on the length of the remaining bowel but on complications such as parenteral nutrition-associated cholestasis, recurrent septicaemia, central venous catheter infections, and the motility of the remaining intestine. Thus, the overall related mortality in infants with SBS ranges from 15 to 25%, and in adults from 15 to 47%, depending on the age of the patients, the underlying disease, and the duration on total parenteral nutrition. Home parenteral nutrition (HPN) significantly decreases the complication rate and improves the psychological situation of the patient. Additionally, HPN reduces in-hospital cost significantly. Nevertheless, the annual costs/patient are between $100000 and $150000. The mortality rate of SBS patients on HPN is about 30% after 5 years, which is still lower than the 5-year survival rate of intestinal grafts, and it is about equal to patients' survival after intestinal transplantation. However, the overall costs of a successful intestinal transplantation are already lower after 2 years when compared with the cost of a prolonged HPN programme.     

Fecal lactate and short bowel syndrome

In patients with short bowel syndrome (SBS), the carbohydrate overload to the colon may disturb the normal pattern of colonic fermentation with production ofd-lactic acid and subsequent development of a metabolicd-lactic acidosis. We measuredd-lactic acid in blood, urine, and feces, as well as the composition of fecal water and fecal reducing substances from 11 patients with SBS, comparing the results with those from normal subjects. The fecal water from patients with SBS was characterized by low pH, potassium, and volatile fatty acids, high osmotic gap, and high concentration ofl- andd-lactic acid. Five of 11 had abnormal amounts of fecal reducing substances. Fecald-lactic acid was increased in nine of 11 patients. However, none of these patients showedd-lactic acid in urine, and only one had a very low concentration in plasma. These results show thatd-lactic acid was overproduced in the colon of most of the patients with SBS. However, other factors such as absorption or impairedd-lactic acid metabolism may be necessary for a plasmatic increase ofd-lactic acid.Unidad de Terapia Nutricional, Hospital de Niños Sor Maria Ludovica, La Plata, Provincia de Buenos Aires, Argentina.Part of this work was presented at the International Symposium on Short Chain Fatty Acids, Strasbourg, France, September 1993.     

Intestinal microbiota in short bowel syndrome

Short bowel syndrome (SBS) is the main cause of intestinal failure especially in children. The colon is a crucial partner for small intestine adaptation and function in patients who have undergone extensive small bowel resection. However, SBS predisposes the patient to small intestine bacterial overgrowth (SIBO), explaining its high prevalence in patients with this disorder. SIBO may significantly compromise digestive and absorptive functions and may delay or prevent weaning from total parenteral nutrition (TPN). Moreover, SIBO may be one of the causes of intestinal failure-associated liver disease, requiring liver transplantation in some cases. Traditional tests for assessing SIBO may be unreliable in SBS patients. Management of SIBO with antibiotic therapy as a first-line approach remains a matter of debate, while other approaches, including probiotics, offer potential based on experimental evidence, though only few data from human studies are available.     

Advances in the management of short bowel syndrome

Short bowel syndrome (SBS) is the predominant cause of intestinal failure and is thus associated with a high degree of morbidity and mortality. One of the reasons this occurs is the dramatic reduction in nutrient absorptive capacity. Of the many causes of SBS, the most common cause is extensive surgical resection. The impressive ability of the bowel to adapt functionally and morphologically is critical for decreasing morbidity and mortality in these patients. The degree of adaptation is vital in decreasing the dependence on parenteral nutrition (PN) and for improving patient quality of life and long-term outcome. Provision of appropriate and sufficient nutritional and fluid support is essential for the management of these patients. The primary goal is to prevent or eliminate the need for PN. Recent developments have promoted a greater understanding of the process of intestinal adaptation. Various intestinal trophic factors have been recognized. These efforts have led to the early development of hormonal therapy to stimulate intestinal adaptation and enhance intestinal absorption. Intestinal transplantation remains an option for those who have developed life-threatening complications from PN and cannot be managed using more conservative techniques.     

High-fat diet in a short bowel syndrome

A patient with only 137 cm of jejunum suffereing from excessive jejunostomy losses was studied on three isocaloric liquid formula diets (3850 kcal/24 hr) differing only in carbohydrate and fat content. An increase in dietary fat from 64 g to 200 g per 24 hr and a reciprocal decrease in dietary carbohydrates resulted in a linear increase in the amount of fat absorbed, from 44 g to 133 g and in a 2.5-fold decrease in ostomy fluid bile acids. No undesirable side effects were noted on the 200-g fat diet: the ostomy fluid dry weight was lower than on 64 g of fat and the ostomy fluid output was lowest of all diets. Compared to healthy adults, the patient had higher fasting blood insulin and pancreatic glucagon. Meal-stimulated insulin, glucagon, gastrin, and GIP were also more than two standard errors above mean responses observed in healthy subjects. Smallest meal-stimulated increase in insulin, gastrin and GIP was noted on the 200-g fat diet. This diet induced the highest levels of glucagon. In a hormonally hyperactive individual after massive resection of the distal intestine favorable effects of a high-fat diet consist of increased absorption of dietary fat and bile acids and reduced release of gastroenteropancreatic hormones with the exception of glucagon.     

Nutritional status and nutritional therapy in inflammatory bowel diseases

Underweight and specific nutrient deficiencies are frequent in adult patients with inflammatory bowel disease （IBD）. In addition, a significant number of children with IBD, especially Crohn＇s disease （CD） have impaired linear growth. Nutrition has an important role in the management of IBD. In adults with CD, enteral nutrition （EN） is effective in inducing clinical remission of IBD, although it is less efficient than corticosteroids. Exclusive EN is an established primary therapy for pediatric CD. Limited data suggests that EN is as efficient as corticosteroids for induction of remission. Additional advantages of nutritional therapy are control of inflammation, mucosal healing, positive benefits to growth and overall nutritional status with minimal adverse effects. The available evidence suggests that supplementary EN may be effective also for maintenance of remission in CD. More studies are needed to confirm these findings. However, EN supplementation could be considered as an alternative or as an adjunct to maintenance drug therapy in CD. EN does not have a primary therapeutic role in ulcerative colitis. Specific compositions of enteral diets-elemental diets or diets containing specific components-were not shown to have any advantage over standard polymeric diets and their place in the treatment of CD or UC need further evaluation. Recent theories suggest that diet may be implicated in the etiology of IBD, however there are no proven dietary approaches to reduce the risk of developing IBD.     

Streptococcus bovis catheter infection and the short bowel syndrome

Streptococcus bovis bacteremia has been associated with several gastrointestinal disorders, most notably carcinoma of the colon. This report describes a 57-year-old woman with short bowel syndrome in whom S. bovis bacteremia and an infection of an indwelling parenteral nutrition catheter developed. A barium enema revealed diverticula and a foreshortened small intestine. This case implicates the short bowel syndrome in the pathogenesis of S. bovis bacteremia and supports empiric antibiotic coverage for both skin flora and enteric pathogens in patients with Hickman catheter sepsis and known gastrointestinal pathologic conditions.