Higgins- SBS

PAY ATTENTION TO OBJECTIVES!!!!

What is Short Bowel Syndrome (SBS)?

malabsorptive state after extensive surgical resection of the small intestine

What are the indications for Short Bowel Syndrome (SBS)?

• re-surgery performed due to complications from a previous abdominal surgery

• massive small intestine surgical resection

• others: vascular complications, intra-abdominal trauma/neoplasm, radiation injury, small bowel obstruction

Symptoms of SBS:

• abdominal pain

• diarrhea/steatorrhea

• dehydration/electrolyte imbalance

• weight loss

What are the 2 classifications of SBS and their corresponding categories?

1. Anatomical

   • Type I: End-jejunostomy

   • Type II: Jejunocolonic anastomosis

   • Type III: Jejuno-ileal anastomosis

2. Pathophysiologic

   • SBS without colon

   • SBS with colon in continuity

What are the 4 Phases of SBS Development? What is the duration of each phase if applicable?

1. Acute: 3-4 weeks

2. Adaptation: 1-2 years

3. Chronic intestinal failure

4. Maintenace

Describe the acute phase of SBS.

• HOSPITALIZATION IS REQUIRED!!!!!!!!!!!!

• metabolic derangement/ intestinal losses + increased gastric secretions (due to loss of hormonal neg feedback)

Describe the adaptation phase of SBS.

structural AND functional adaptative changes of the remaining small bowel

The chronic intestinal failure phase of SBS occurs when…

adaptation phase fails

Describe the early management of SBS? (before the acute and adaptation phase etc.)

• early parenteral nutrition

• enteral nutrition when ileus resolved/harder stooler

• replace fluids/electrolytes IV (separate from TPN)

• avoid hypo- and hypervolemia

How is the acute phase of SBS managed? (aka describe how fluids, TPN, and EN are managed from right after surgery to weeks after.)

• RIGHT AFTER SURGERY: Give lots of fluids/electrolytes and little TPN.

• As weeks go by, start decreasing fluid/electrolyte amounts and increasing nutrition!!!

How is the adaptation phase of SBS managed? (aka describe how PN, EN, and Nutrition by mouth are managed from surgery to 1-2 years after)

• right after surgery during acute phase, pt. is on parenteral nutrition only

• as time passes, slowly decrease PN and start introducing EN and eventually nutrition by mouth (aka increase EN, decrease PN)

• nutrition by mouth is OUR GOAL!!!!! (promotes adaptation and stimulates intestinal adaptation)

• Nutrition wise—> try to eat at least 5 or more small meals/day, avoid sugars, supplement vitamins/minerals, and use oral rehydration to correct fluid balances

How is the chronic intestinal failure stage of SBS managed? (aka what are the 2 types, and what can we do to address symptoms)

• can be irreversible or reversible

  • irreversible: lifelong TPN

  • reversible: TPN over months—> years, wean off of it

• ADDRESS SYMPTOMS WITH MEDICATIONS!!!!! (prior to this, in the acute/adaptation phases the focus was fluids and nutrition, but now we want to initiate more)

What meds can be used during the late phases of SBS?

• antidiarrheals

• pancreatic enzyme replacement

• bile-acid resions

• H2RAs, PPIs

• abx

• lactase supplements

What meds can be used to reduce parenteral nutrition? Describe each.

• oral glutamine- anti-inflammatory

• recombinant growth hormone w/ glutamine (somatropin)- early dumping—> GI hormones, late dumping—> pancreas (insulin)

• glucagon-like peptide-2 analogues (GLP-2 analogues) like Teduglutide- SQ injection that reduces IV TPN, reduces stool weight, and increases villus height, crypt depth, and mitotic index

What are the complications of SBS?

• diarrhea

• intestinal failure-associated liver disease

• cholelithiasis (gallstones)

• oxalate nephropathy

• acidosis

What are the VITAMIN/MINERAL DEFICIENCES in SBS?

Deficiency	Disease
Vitamin C
Calcium
Vitamin A
Vitamin E
Vitamin K
Iron
Zinc

Deficiency	Disease
Vitamin C	scurvy
Calcium	osteoporosis
Vitamin A	night blindness, corneal ulcerations
Vitamin E	paresthesia (tingling/numb), ataxia (trouble coordinating muscles)
Vitamin K	bleeding
Iron	anemia, glossitis (tongue inflammation)
Zinc	stomatitis (mouth inflammation), alopecia

WHAT ARE THE COMPLICATIONS OF LONG-TERM PARENTERAL NUTRITION?

• IV catheter infections

• thrombosis

• metabolic bone disease

• iron deficiency anemia

What is an ostomy? What is a stoma? Are ostomies permanent or temporary?

• ostomy- opening or outlet through abdominal wall for eliminating waste

• the “opening” is called a stoma

• can be temporary or permanent

What are the 2 types of ostomies, where are they located, and what stools come out the hole?

1. ILLEOSTOMY—> right side/ liquid, mushy stool

2. COLOSTOMY—> left side/ semi-formed stool

What are some things to think about if you have an ostomy? (i don’t think that important)

• types of pouching systems (1 piece, 2 piece, drainable, closed end)

• fit and application

• wear time

• use of skin barrier rings, powder, paste

• avoid moisturizers

• food choices

What are complications of ostomies?

• psychological

• fluid/electrolyte imbalances

• vitamin/mineral deficiencies

• constipation/diarrhea

• intestinal gas

• skin irritation

• stoma complications

What are the medication considerations with ostomies?

• avoid SR, XR, and enteric coated meds

• check pouch for undissolved tablets

• medications can change the color of stool

• review meds for ADRs

WHAT ARE COMMON ostomy medication side effects?

(focus on indentifying the interacting drugs first then the side effects)

• antibiotics- diarrhea

• sulfa drugs- risk of crystallization in kidneys

• diuretics- increase fluid/electrolyte loss

• laxatives- use under close supervision

• antacids- diarrhea w/ Mg based products OR constipation w/ Al based

• opioids- constipation

SBS might end in needing a…

intestinal transplant