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SHORT BOWEL SYNDROME Abdulwahab Telmesani Associate Professor Of Pediatrics

SHORT BOWEL SYNDROME Abdulwahab Telmesani Associate Professor Of Pediatrics Umm Al-Qura University. Definition. Malabsorption + Shortened Bowel. Etiology. Primary: (Abnormal anatomically) Born with short bowel

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SHORT BOWEL SYNDROME Abdulwahab Telmesani Associate Professor Of Pediatrics

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  1. SHORT BOWEL SYNDROME Abdulwahab Telmesani Associate Professor Of Pediatrics Umm Al-Qura University

  2. Definition Malabsorption + Shortened Bowel

  3. Etiology • Primary: (Abnormal anatomically) Born with short bowel Congenital anomalies e.g. Multiple Artesia's, Gastroschisis • Secondary: NEC Hirschsprung disease Ischemia Radiation Tumors Crohns’s

  4. Jejunum • Long villi →Large absorptive surface area • High concentration of enzymes and transport carrier • Large tight junction →Porous to large molecule

  5. Ileum • Short villi →Less absorptive capacity • Small tight junction →Less porous and increased absorption for fluid & electrolyte • Specific function of absorption of B12 and bile salts (specific receptors) • Synthesis of hormones e.g.Enteroglucagon & negative gastrin feedback

  6. Ileocecal valve • Stops reflux of bacteria • Regulate fluid and nutrient exit

  7. Adaptation Ileum > Jejunum

  8. Adaptation • Hyperplasia, Increased crypts and villi • Dilatation • Increased Absorption capacity

  9. Adaptive factors • Entral feed: Direct stimulation Upper GI secretion Trophic GI hormone • Hormonal regulation: Enteroglucagon, Neurotensin, Secretin Cholicystokinin,Epidermal growth factors(EGF) IGF-I + GH

  10. Adaptive factors(Contd.) • Prostaglandin • Polyamines • Intracellular regulation (Genetic)

  11. Nutrients stimulate adaptation better • Long chain fatty acid • 3-Omega fatty acids (fish oil) • Fibers • Glutamine

  12. Management

  13. Management • TPN • Replace losses (Electrolyte & fluid) • Introduction of Enteral feed

  14. TPN Gradual introduction with monitoring of blood chemistry,LFT &lipids

  15. Replace losses • Losses from : NG, gastrostomy, diarrhea, Ostomy • Appropriate fluid (based on lost electrolyte) • Replace losses through separate infusion pump

  16. Enteral feeding • Continuous enteral infusion (can use portable) • Breast Milk/Predigested formulas as a start • Progress to solids • Wean TPN as enteral feeding increases

  17. Guide to advancing enteral feeding • Diarrhea not getting worse > 50% or 40ml/kg/day • Stool reducing substances (pH < 5.5)

  18. Complications • Bacterial overgrowth • Diarrhea • Nutritional deficiency • TPN related liver disease • Catheter related

  19. Bacterial overgrowth • More that 105 bacterial growth in upper intestine(facultative bacteria & anaerobes) • Causes: stagnation, dilatation, lost ileocaecal valve

  20. Bacterial overgrowth cont. • Manifestations: Deconjugation of bile → Malabsorption Lactose intolerance → Diarrhea, bloating, cramps Lactic acidosis →CNS symptoms Inflammation →Ileitis, colitis

  21. Bacterial overgrowth(Contd.) • Diagnosis: Aspiration of intestine for C&S Breath hydrogen test • Treatment: Antibiotics:CommonlyTMP-SMX + Metronidazole Frequent defecation Surgical

  22. Diarrhea • Causes: Osmotic load Elevated gastrin • Treatment: Revise enteral feeds Cholestyramine H2 blockers

  23. Nutritional deficiency • Fat soluble vitamin A,D,E,K • Zinc (low serum alkaline phosphatase) • Trace elements • B12 • Micronutrients e.g. carnitine, choline, taurine

  24. TPN liver disease • Hepatocellular damage • Cholestasis,Cholelethiasis • Sepsis

  25. Catheter related complication • Sepsis Improper catheter care bacterial overgrowth →bacteremia • Thrombosis

  26. Surgical management • Treat anastomosis strictures: Tapering enteroplasty, stricturoplasty • Increased length: Intestinal transection (Bianchi procedure)

  27. Surgical management cont. • Increased intestinal transit: -Colon interposition -Creation of valve • Transplantation

  28. Transplantation • Getting better survival • Not yet a standard procedure • Problem with rejection • Post-immunosuppressant lymphoproliferativedisorders

  29. Transplantation cont. • Indicated when You are against the wall -Major liver disease secondary to TPN -Intolerance to feeding -Catheter sepsis, thrombosis and no site for insertion

  30. SBS In the Neonates

  31. Correlates of good outcome • Use of breast milk • Use of Amino acid based formulas • Percentage of enteral calories at 6 WKs • Residual small bowel length at Sx • The year of Sx Androsky et al 2001

  32. Correlates with low Peak Bilirubin Level • Early Closure of Ostomy • Enteral Calories at 6 WKs • Less Gm +ve Infections • Use of Casein hydrolysate formulas Androsky et al 2001

  33. Correlations Between:Early enteral feeding and the subsequent weaning of TPNSondheimer et al 1998 Length of the small bowel at Sx and discontiuation of TPN

  34. A correlation between amino acid based formula and weaning from TPN was observed Bines et al 1999

  35. Conclusions • Early introduction of enteral feeding • Use of BREAST MILK / Hydrolysate formulas • Early closure of the OSTOMIES • Use of improved types of TPN solutions • Stringent care of the TPN catheters • Watch and treat bacterial over growth

  36. DONE

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