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Enteral Nutrition support in Short Bowel Syndrome

Enteral Nutrition support in Short Bowel Syndrome. 4C1 Ri 葉麗青 2006/05/29. Short Bowel Syndrome (SBS) . Short Bowel Syndrome (SBS) is defined as malabsorption resulting from loss of a significant length of the small intestine. Short Bowel Syndrome (SBS) .

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Enteral Nutrition support in Short Bowel Syndrome

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  1. Enteral Nutrition support in Short Bowel Syndrome 4C1 Ri 葉麗青 2006/05/29

  2. Short Bowel Syndrome (SBS) • Short Bowel Syndrome (SBS) is defined as malabsorptionresulting from loss of a significant length of the small intestine.

  3. Short Bowel Syndrome (SBS) • Typically, a 70%–75% loss of small bowel will result in SBS. • Patients of SBS can be divided into 2 distinct group: 1. with partial or intact colon in continuity 2. without colon in continuity • SBS has also been defined as a bowel length of 100–120 centimeters (cm) of small bowel (SB) without a colon, or 50 cm of SB with a colon.

  4. Etiology • Adults • SB ischaemia / mesenteric infarction requiring massive SB resection • Chron’s disease having undergone multiple and repeated SB resection • Radiation enteritis, trauma • Children • Intestinal atresia • Necrotizing enterocolitis • Midgut volvulus, gastroschisis

  5. Clinical Manifestation • Diarrhea • Dehydration • Electrolytes loss • Malabsorption and malnutrition • Weight loss

  6. ICU Care for SBS • Dietary Treatment • Fluid and Electrolytes Treatment • Vitamin Supplements • Medical Treatment • Trophic and Prokinetic Therapy

  7. Clinical Course of SBS • Phase 1 • Initial stage after resection • Poor absorption of nearly all nutrients • Characterised by fluid and electrolyte loss ► Aggressive fluid and electrolyte replacement ► Totally dependent on parenteral nutrition (TPN) • Phase 2 • Adaptation of the residual intestine ► PN weaning ► Oral intake with  TPN requirement • Phase 3 • Maximal intestinal adaptation reached • Months to years

  8. Factors affecting severity of SBS • The extent of resection • Prior or concomitant resection of colon • Resection of ileocecal valve • Disease in the remaining intestinal tract • Capacity of the remaining bowel to adapt

  9. Short Bowel Syndrome (SBS) • Enteral nutrition plays a significant role in the process of intestinal adaptation • Stimulation of mucosal hyperplasia by direct contact with the epithelial cells • Stimulation of trophic GI hormone secretion • Stimulation of production of trophic pancareaticobiliary secretions • Fasting and TPN leads to intestinal hypoplasia

  10. Nutrition support Phase I (TPN) Phase II (PN weaning & Early enteral nutrition) What is the best enteral food pattern?

  11. Enteral Formula • Elemental or monomeric formulas • Semi-elemental or oligomeric formulas • Polymeric formulas • Specialized formulas

  12. Elemental Formula • Individual amino acids • Glucose polymers • Low fat (only about 2~3% of calories derived from LCT)

  13. Semi-elemental Formula • Peptides of varying chain length • Simple sugars, glucose polymers or starch • Fat, primarily as MCT

  14. Polymeric Formula • Intact proteins • Complex carbohydrates • Fat mainly LCTs

  15. Specialized formula • Biologically active substances or nutrients such as glutamine, arginine, nucleotides or essential formulas

  16. Elemental Formula • Widely used for SBS • Better absorbed • Less allergic • Better tolerated in patients with malabsorptive states • Cause less exocrine pancreatic stimulation in patients with pancreatitis

  17. But….. • Expensive • Unpalatable • Hyperosmolar and may increase diarrhea

  18. Effects of specific nutrients on intestinal adaptation • Animal models of SBS • LCT were shown to enhance adaptation more than protein and polysaccharides • Free fatty acids > LCT(Grey VL et.al.Am J Clin Nutr. 1984 Dec;40(6):1235-42.) • Disaccharides>Monosaccharides(Weser E. et.al. Gastroenterology. 1986; 91: 1521-7) • Whole proteins > hydrolysates(Vanderhoof JA et. al. ) • polymeric diet can contribute to a better intestinal mucosa regeneration than a monomeric diet in the rats with massive intestinal resection.(Taiwan Yi Xue Hui Za Zhi. 1989 Oct;88(10):982-8.)

  19. From the aspect of caloric absorption • A liquid diet consisting of peptides, oligosaccharides, and medium-chain triglycerides is not more beneficial than a polymeric diet in patients with a high jejunostomy.(McIntyre PB et. al. Gastroenterology. 1986 Jul;91(1):25-33) • Intestinal permeability, energy, and nitrogen balance in short bowel syndrome were not influenced in the short term by hydrolysis of the enteral nitrogen source.(Ksiazyk J et. al. J Pediatr Gastroenterol Nutr. 2002 Nov;35(5):615-8.)

  20. Thank you very much for your attention

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