About Short Bowel Syndrome

Symptoms of SBS

Symptoms

Adults with SBS often experience weight loss and low energy, resulting in fatigue. Infants and children fail to grow and develop. Signs and symptoms are related to the malnutrition resulting from inability to absorb nutrients, vitamins and minerals.

In general the following symptoms may occur at any time but exacerbations indicate lack of adequate nutritional management:

Pale, greasy stools
Particularly foul-smelling stools
Diarrhea-worsening
Edema
Weight loss
Fatigue
Confusion/lethargy(associated with overgrowth)
Blood in stools
Increasing abdominal distention

Physical Findings may include

Muscle wasting
Abdominal distention
Succession splash-denoting fluid filled loops of bowel.(With child standing there will be a noticeable, palpable fluid shift noted from one lateral side of abdomen to the other.)
Scars from previous surgery

Patients who are severely protein and energy malnourished may present with temporal wasting, loss of digital muscle mass, and peripheral edema.
The skin may be dry and flaky. The nails can feature prominent ridges, and the lingual papillae are blunted or atrophic.
Patients with essential fatty acid deficiency of linoleic and linolenic acid experience growth retardation, dermatitis, and alopecia.
Vitamin A deficiency includes corneal ulcerations & loss of night vision.
Low levels of the B complex vitamins in general can present with stomatitis, cheilosis, and glossitis. Vitamin B-1 deficiency is associated with edema, tachycardia, ophthalmoplegia, and depressed deep tendon reflexes. Vitamin B-6 deficiency can cause peripheral neuropathies and seizures. Peripheral neuropathy can be a feature of B-12 deficiency also.
Vitamin D depletion is associated with rickets/osteoporosis features.
Severe vitamin E deficiencies can result in ataxia, edema, and depressed deep tendon reflexes.
The physical hallmarks of vitamin K deficiency are related to derangements in hemostasis. These include petechiae, ecchymoses, purpura, or outright bleeding diatheses.
Physical clues to the presence of iron deficiency include pallor, spooned nails, and glossitis.
Zinc deficiency causes angular stomatitis, poor wound healing, and alopecia. Also, a scaly erythematous rash can erupt around the mouth, eyes, nose, and perineum. Of note: decreased serum zinc concentration in association with decreased serum alkaline phosphatase suggests zinc deficiency severe enough to cause poor growth and impaired intestinal adaptation.
Magnesium manifest by symptoms of fatigue, depression, muscle weakness, and excitability

Causes of SBS

Digestive anatomy

The Basics of Digestive Anatomy

To figure out the condition Short Bowel Syndrome (SBS) first you need to understand the purpose of your digestive tract and how it operates. Your small intestine is responsible for absorption of nutrients into your body.

When a large amount of the small intestine is either Resected (removed) in surgery due to a congenital condition, trauma, radiation sickness, or intestinal volvulus, there is a chance that you can develop SBS. Lack of sufficient bowel length a/o appropriately functioning remaining bowel tissue may make it difficult to absorb the correct amount of nutrients from food to maintain a healthy lifestyle.

Absorption

Knowing how food is digested and absorbed by the body will help your understanding of SBS. If you have SBS, information that you find on this site may help aide you discover what treatment options are available.

The Small Intestine (Small Bowel) is the organ that breaks down your nutrients and absorbs them into your body. The liver processes many of the nutrients and the cells of the body use the individual carbohydrate, proteins and fats to create the energy we need and maintain the functions of the rest of the body. The liver also helps detoxify and the kidneys filter and eliminate nutrient waste. The Large Intestine (Colon) primarily functions to absorb water from the nutrition we consume but under certain circumstances can adapt to perform nutrient absorption. It also acts as a storage organ for the food substrates we cannot digest (such as insoluble fiber) and the normal bacteria we carry in our intestines.

Stomach

When you swallow food, it travels down your Esophagus: a tube connecting the mouth to the stomach. The food stimulates a release of substances that aid in the digestion and the acid kills any harmful micro-organisms once in the stomach. These 2 substances digested food or partially digest food, otherwise known as Chyme, as it then passes into the small intestine.

Small Intestine (Small Bowel)

The small intestine or small bowel is where digestion and absorption occur. Ninety percent of nutrient absorption takes place in the small bowel. The Small Intestine is coiled and around 3 meters in length. It is covered with numerous finger-like projections called villi which greatly increase the surface area such that if laid out flat would cover the surface of a football field. The small intestine is composed of three main sections:

Duodenum: Using enzymes, the main purpose of the duodenum is to do the primary break down of food particles as they pass from the stomach. By using hormonal pathways it can regulate the rate at which the stomach contents empty into the small intestine. The duodenum receives arterial blood from the gastroduodenal artery and its branch the superior pancreaticoduodenal artery. Most of the iron we consume is absorbed in this part of the intestine.
Jejunum: Known as the “mid-gut” of the small intestine, it lies between the duodenum and the ileum. In adults, the small intestine is usually between 5.5 and 6meters long, 2.5meters of which is the jejunum. Its main purpose is to absorb nutrients from the contents of the duodenum. The jejunum and the ileum are suspended by the mesentery which gives the bowel great movement within the abdomen. It also contains rounded and longitudinal smooth muscle which helps to move food along by a process known as peristalsis. A large portion of the jejunum may be removed with the remaining tissue able to compensate for the functions of the lost tissue with appropriate rehabilitation. The jejunum is characterized by long villi, a large absorptive surface area, a high concentration of enzymes and transport carrier proteins, and a surface in which the junctions between the cells are relatively large, rendering the area more porous. Consequently, the jejunum is the site for the greatest nutrient absorption in the small intestine. It is also relatively leaky, allowing free and rapid flux of water and electrolytes to and from the blood vessels.
Ileum: The “final section” of the small intestine. The ileum trails the duodenum and jejunum and is separated from the cecum by the ileocecal valve (ICV). The ileum functions primarily to absorb Vitamin B12, bile salts, and products of digestion that were not processed by the jejunum. The ileum also has a large surface area for the absorption of the remaining products of digestion. The ileum is characterized by shorter villi, more lymphoid tissue, less absorptive capacity, and a tighter surface. The junctions are smaller, permitting less flux of fluid and nutrients but functions efficiently for the absorption of fluid and electrolytes. Nutrients are absorbed less rapidly than in the jejunum. The ileum also has certain capabilities that are not present in the jejunum, namely, the absorption of vitamin B12 and bile salts .

Simply put the loss of a large part of the ileum makes one more prone to dehydration and electrolyte losses but loss of most of the jejunum leads to more nutrient losses than fluid. The ileum is also known to be able to compensate over time (adaptation) for the jejunal functions but the jejunum seems to have less ability to compensate for a major loss of the ileum. When a large amount of the small or large intestine is either Resected (removed) in surgery due to a congenital condition, trauma, radiation sickness, or intestinal volvulus, there is a chance that you may develop SBS. It may be difficult to absorb the correct amount or type of nutrients from food to maintain a healthy lifestyle.

Large Intestine (Colon)

The Large Intestine or Colon is the last part of the digestive system, serving as a connector from the small intestine to the rectum. Once the small intestine has absorbed nutrients from food and liquids, the colon removes the water from the chyme and prepares it for fecal elimination. There are three sections of the colon, the ascending, transverse, and descending colon, followed by the separated from the small intestine by the Ileocecal Valve or ICV.

Resection of the ileocecal valve may have a major impact following small bowel resection. The ileocecal valve appears to have two functions. It serves as a barrier for preventing colonic bacteria from the colon from getting into the small intestine and may also play a role in regulating the exit of fluid and nutrients from the small intestine. Consequently, resection of the ileocecal valve may result in bacterial overgrowth. In addition, following resection of the ileocecal valve, rapid transit of nutrients from the small intestine into the colon may exacerbate malabsorption. The importance of the ileocecal valve has been questioned, and its perceived importance may actually be related to the value of the adjacent ileum.

Ascending Colon: The first segment of the colon. The muscles of the ascending colon push chyme upwards, absorbing water in the process; it is an estimated eight hour process.
Transverse Colon: Connects the ascending colon to the descending colon, hanging across the abdomen. In normal stiuations chyme goes through this segment for an estimated six to eight hours.

3. Descending Colon: The last segment of the large intestine. Chyme takes an estimated four hours to move down the descending colon where it becomes solid and prepares for fecal elimination through the rectum.

Diagnosis, Tests, and Procedures

Diagnosis

The diagnosis of short bowel diseases is based on a combination of a physical exam, laboratory tests and imaging exams.

Medical History and Physical Examination

The first step in diagnosing and properly treating short bowel syndrome is an in-depth interview with the patient and a physical exam. During the interview, the gastroenterologist gathers details about the patient’s conditions and surgical history. It is essential that patients bring all previous surgical reports for the physician to review during the evaluation.

Laboratory Tests – Complete blood count (CBC)

Doctors typically use a CBC to detect anemia in patients who are being evaluated for short bowel syndrome. The test measures the levels of white, red and hemoglobin cells in the blood.

Blood chemistry tests-Comprehensive Metabolic Profile

These tests are performed on the portion of blood called serum. The tests evaluate electrolyte levels, and chemicals related to metabolism and other digestive functions.

Other specific laboratory tests include:

Pre-albumin to assess acute nutritional status
Liver enzymes: AST, ALT, GGTP
Protein/PTT/INR

Mineral levels including:

Iron/TIBC
Zinc
Magnesium
Phosphorus
Chromium
Vitmain Levels including
Vitamin A
Vitamin E
25 OH-Vitamin D
B12/Folate

Monitoring for bacterial overgrowth with:

D-lactate
Urine indicants
Glucose breath hydrogen test
Sedimentation rate
Stool calprotectin

Fecal fat test

This test measures the amount of fat released in a patient’s feces, which indicates whether a patient is absorbing the amounts of dietary fat necessary for proper nutrition.

Imaging Studies

The following imaging studies may be used to determine details about a patient’s condition.

X-rays generate a two-dimensional view of the abdomen that helps physicians locate abnormalities in the small bowel, such as obstruction.

Barium upper GI X-rays. Patients drink liquid containing barium, which coats the intestines and helps show abnormal structures or obstructions in the small bowel. Patients must abstain from food and beverages prior to the test.

CT scans generate two-dimensional images of the abdomen that may reveal problems in the small intestine.

Bone Densitometry

Endoscopy or Colonoscopy

Specialists can examine the interior of the duodenum, the upper part of the jejunum (proximal jejunum), and the lowest parts of the small intestine (terminal ileum) using an endoscope or colonoscope. For these procedures, physicians give patients a mild sedative before passing a thin tube containing a light source and camera down the throat and through the stomach (endoscopy), or up through the rectum (colonoscopy). Unfortunately, neither test reaches the entire small bowel.

Complications

Complications of Short Bowel Syndrome

Due to lack of absorption of nutrients can create problems in the patients overall health if they have SBS. Monitoring to prevent complications is important & includes:

TPN liver disease:

Prevent with aggressive use of enteral feedings, avoidance of septic episodes, and treatment of small bowel bacterial overgrowth.
Ursodeoxycholic acid may be helpful to increase bile flow.

Biliary Tract disease:

Gallstones-most common in TPN-dependent patients who are intolerant of enteral feedings.

Small Bowel Bacterial Overgrowth: Bloating, gas, and flatulence occur when to many bacteria grows in the small bowel tract. Loss of the ICV can lead to this condition; one of the functions of the ICV is to prevent bad bacteria from the large intestine to move into the small intestine. Bacteria Overgrowth often results in Acidosis or Acidotic Spells

Common if motility is slow or the bowel is dilated
Diagnosis based on increased urine indicans (by-product of bacterial metabolism), elevated breath hydrogen after glucose administration, increased serum d-lactate level, xray findings of bowel dilatation with or without area of narrowing.
Presence is common but a problem requiring treatment only if S/S result
May respond to antibiotics & anti-inflammatory therapy.

Acidosis:

The abnormal level of lactic acid in the bloodstream. Undigested carbohydrates in the colon produce lactic acid, which can be absorbed into the body. Acidosis causes impaired vision, disorientation, confusion, and slurred speech. It mimics the effects of acting drunk.

Anastomotic Ulceration:

May result in severe blood loss and anemia and requires endoscopic diagnosis

Osteoporosis:

Lack of absorbing Vitamin D and Calcium, which leads to the reduction of bone mass. The weakening of the bones is referred to as Osteomalacia.

Kidney Stones:

Because of the reduced absorption of calcium, fats and bile salts produce hard like crystal-like stones, called Kidney Stones. They an block the flow of urine out of the kidneys and lead to reduced kidney function. Some stones will pass through on their own through the urinary tract, and other stones will need to be removed by a common procedure named a Lithotripsy.

Transplant info - Financing a Transplant

30 days Pre-transplant	$ 48,400
Procurement	$ 77,200
Hospital Transplant Admission	$ 743,800
Physician during Transplant	$ 100,600
180 days Post Transplant Admin	$ 124,300 (dependent upon patient’s health at time of transplant).
Immuno-suppressants	$ 27,500
Total:	$ 1,121,800