Instructions
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Study 3 Citation: Sundaram A, Koutkia P, Apovian CM. Nutritional
management of short bowel syndrome in adults. |
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Abstract:
Short bowel syndrome (SBS) poses some significant medical problems, this article focuses on those related to feeding. SBS comprises the reduction of surface area of the small intestine. Signs and symptoms of SBS include vitamin and mineral deficiencies, electrolyte imbalances, malabsorption of carbohydrates, protein (including lactose), metabolic acidosis, gastric acid hypersecretion, dehydration, steatorrhea, diarrhea and resulting weight loss. The key to achieving a desirable outcome in SBS is nutritional management.
The authors note that nutritional management of SBS has traditionally been divided into three stages. The first is an acute phase when total parenteral nutrition (TPN) is instituted, along with fluid and electrolyte replenishment. The second phase is an adaptation phase where enteral feeds are introduced along with TPN. The final stage is maintenance where a full oral diet is desired. Obviously, the need for TPN may vary depending on the condition of the patient’s gut, namely the presence or absence of a functioning ileocecal valve, jejunem, and colon. Those patients that have had a gut resection and have less than 100cm of small bowel left are usually given TPN at home, where the authors say they have had very good experience. The TPN diet in this case should consist mainly of calories from fat, then protein, then carbohydrates. Especially important suffering from malabsorption, vitamins, minerals and electrolytes should be added accordingly. And while TPN is necessary at first, transitioning to enteral feeds followed by oral feeds should be the treatment goal.
Recent advances have brought various pharmacologic agents and specific nutrients and growth factors to use that can both stimulate intestinal absorption and help the adaptation phase. Growth factor and hormones have shown promise in human clinical trials and will likely play a role in the future treatment of SBS.
Key words:
Short bowel, Total Parenteral Nutrition (TPN), Colon
While this study looks specifically at short bowel syndrome, the role of TPN and enteral nutrition is well defined. As the author notes, patients with recently resected bowels require adjunctive nutritional support in order to survive, dependent upon the length of remaining bowel. The author clearly defines the role of TPN as clinically necessary immediately post-op (the acute phase of recovery). Later in the recovery phase the author states the objective is to transition the patient to enteral nutrition.
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This study is included in this grouping because it clearly puts into practice what the first two articles demonstrate. Short bowel syndrome requires parenteral as well as enteral support, carefully timed to the physical recovery of the patient and certain other factors such as whether or not the patient still has an ileocecal valve, jejunum or functional colon. Despite popular misconceptions surrounding TPN and it’s supposed role in bacterial translocation, gut motility, etc., Sundaram et al., clearly define TPN’s role with short bowel patients as not only preferred but necessary. In point of fact, notes the author, before the discovery of TPN in 1968 by Dudrick, et al., patients with short bowel often died as a result… (1,2). During the past three decades advances have made it possible to administer parenteral nutrition in the home environment with good results (3,4,5). |
References:
1. Dudrick SJ, Wilmore DW, Vars HM, et al. Long-term total parenteral nutrition with growth development and positive nitrogen balance. Surgery 1968; 64:134-42.
2. Dudrick SJ, Wilmore DW, Vars HM, et al. Can intravenous feeding as the sole means of nutritional support growth in the child and restore weight loss in the adult? An affirmative answer. Ann Surg 1969; 169:974-84.
3. Scolapio JS, Fleming CR, Kelly DG, et al. Survival of home parenteral nutrition-treated patients: 20 years of experience at Mayo Clinic. Mayo Clin Proc 1999; 74:217-22.
4. Jeppensen PB, Langholz E, Mortensen PB. Quality of life in patients receiving home parenteral nutrition. Gut 1999; 44; 844-52.
5. Thompson JS, Langas AN, Surgical approaches to improving intestinal function in short bowel syndrome. Arch Surg 1999; 134:706-11.