Below are recommendations and tips in the management of patients with symptoms related to relatively short small intestinal length (short bowel syndrome, short gut). Management should include multidisciplinary care and may require referral to a specialty center. Many thanks to Dr. Abigail Martin, UK Pediatric Surgery, for sharing this document.
Short Gut Syndrome
Overview:
-
Patients with short gut have improved outcomes
when being followed by an interdisciplinary, consistent team at an intestinal
rehabilitation center
-
Patients with chronic/irreversible short gut
syndrome will be dependent on parenteral nutrition for the remainder of their
lives
-
Long term comorbidities include:
o Parenteral
nutrition associated liver disease (PNALD)
o Intestinal
failure associated liver disease (IFLAD)
o Complications
from need for long term central venous access (mainly infectious, thrombotic)
-
Teduglutide may be used to treat short gut
syndrome and possibly reduce dependence on parenteral nutrition by promoting
mucosal growth and possibly restoring gastric emptying and secretion. This is
easier to obtain when working with an intestinal rehabilitation center
-
Indications for intestinal transplant:
o Presence
of liver failure from parenteral nutrition
o Significant
line complications including frequent CLABSIs or loss of central access due to
thrombosis of veins
o Frequent
hospitalizations to control the sequela of short gut syndrome (such as
dehydration or electrolyte imbalances)
-
Early involvement of Palliative Care will help
with long term decision making and to discuss the long term issues that pertain
to short gut syndrome
Care Team Planning
for Newly Diagnosed Short Gut:
-
Recommend GI consult while inpatient
-
Identify which team will manage home
parenteral/enteral nutrition
-
Ensure case management and social work is
notified to prepare for home health nursing and home parenteral nutrition
Anatomy:
-
Undergo UGI/SBFT study in one year from
diagnosis to establish baseline anatomy
-
If concerned for IFALD/PNALD or if patient is
having any other abdominal surgery in the future, perform needle biopsy using
18 Ga needle of the liver
Parenteral
Nutrition:
-
Cycle parenteral nutrition as soon as possible
to decrease risk of PNALD, better QOL
o Goal
of 12-16 hour cycling schedule before discharge home (most patients end up
discharging on 16 hour cycling schedule)
o Goal
over time of 10-12 hour cycling schedule
-
Consider Omegaven in Peds and SMOF in Adults if
developing evidence of IF associated cholestasis (Dbili >2 for 2+ weeks)
-
In newly diagnosed patients, all estimated
nutritional needs should be provided via parenteral nutrition until weight
maintenance is demonstrated
Gastric Feeds:
-
Benefits of tube feeds (especially continuous
low volume feeds):
o Stimulation
of intestinal mucosa to improve growth/absorption
o Allows
for more total enteral calories and less parenteral calories
o Sometimes
better tolerated for stool volume or potential dumping
-
Discuss NGT vs gastrostomy tube with patient
Oral Feeds:
-
Volume limited by titration to goal of 4-6 soft,
formed stools daily
-
Do not continue a clear liquid diet other than
water and no-sugar drinks
-
Consult with dietician about education for short
gut syndrome diet
-
Plan on 6-8 small meals per day
-
Limit fluids to <4 ounces per meal
-
Take soluble fiber preferentially, avoid
insoluble fiber
-
Avoid sugary and sugar-substitute containing
foods as this may worsen diarrhea
Nutritional
Supplementation:
-
Will need life long monitoring for
micronutrients, vitamins, minerals
-
Evaluated at 6 month mark by home infusion plan
and TPN modified accordingly
-
Consider starting Juven BID once PO is allowed,
unless it contributes to dumping syndrome
Stooling:
-
Goal of 4-6 soft but formed stools daily
-
Daily fluids should be adjusted to meet stooling
goals
-
Add pectin and/or fiber to help bulk up stools
and prevent diarrhea
-
Start Imodium to help thicken stools, many
patients require high doses daily
-
Consider cholestyramine of pectin, fiber, and
Imodium do not help solidify stools
o Cholestyramine
will benefit patients without a terminal ileum or intact colon most
Bacterial
Overgrowth:
-
Primary IF care providers should monitor for
need of cycling oral antibiotics
-
Probiotics should be used with caution as may
cause CLABSI/bacteremia
o Administer
probiotics separately from parenteral nutrition
o Ideally
a different person that does not care for and hang the parenteral nutrition
should be administering the probiotics
-
Consider famotidine 80mg in parenteral nutrition
to help decrease level of gastric acid secretion, as this can sometimes make
stooling worse. IV PPI is not compatible in the TPN, and PPI tablets may not be
absorbed as well.
