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Dear Dr. Keti, " ... In July of this year blood clots infarcted one of my kidneys, and everything but 11 inches of my small bowel. I do receive TPN. My doctor will try to re-connect the small bowel with the colon and transform everything into a colostomy. Will that make really a difference? I am afraid that down the road my only kidney will start troubles, what are my options? ... "

Dr. Keti:
18 October, 2002

Short Bowel Syndrome (SBS) and Total Parenteral Nutrition (TPN)

Deciding which type of treatment is best for you isn't easy. Your decision depends on your medical condition, lifestyle, and personal likes and dislikes.
The key is to learn as much as you can about your choices first. With that knowledge, you and your doctor will choose the treatment that suits you best.

TPN stands for Total Parenteral Nutrition. This is a complete form of nutrition, containing protein, sugar, fat and added vitamins and minerals as needed for each individual. It is administered through an intravenous infusion, usually using a central line.
Parenteral nutrition is an important therapy in the care of the patient with short-bowel syndrome. Parenteral nutrition provides adequate protein, calories, other macro and micronutrients until the bowel has had time to adapt.
From the literature surveyed, patients with acute renal failure given parenteral calories and amino acids have fewer infectious complications than similar patients given only calories.
Data from animal studies conducted by Wilmore and colleagues (1971) suggest that

supplementing enteral intake with parenteral nutrition early in the postoperative course results in better overall bowel adaptation.

Before the advent of parenteral nutrition, patients with acute short bowel syndrome from mesenteric vascular infarction or massive small bowel surgical resection seldom survived. Parenteral nutrition has allowed many patients to survive indefinitely with only a foot or two of small intestine. In some, the remaining bowel eventually adapts and allows the absorption of adequate calories and protein. This is especially true of patients who retain their iliocecal valve and colon. (2)

A gradual switch to overnight tube enteral (by mouth) hydration or constant sipping of an electrolyte solution may allow discontinuation of all parenteral support. Click here for more info on EATING GUIDELINES WHICH MAY HELP CONTROL DIARRHEA

Management of Short Bowel Syndrome

A key step in the Management of Short Bowel Syndrome is the Replacement of the fluid losses and Control of the diarrhea. In addition one has to take care to avoid production of Renal stones because of Hyperoxaluria, which occurs both in patients with an ileal resection and in patients with a short bowel who have had a distal small bowel resection. (10)
Treatment involves having a low-oxalate diet and taking medicine (e.g. cholestyramine) to bind bile salts and citrate to prevent stone formation.
Low-oxalate diets typically exclude cocoa, peanut products, tea, coffee, wheat germ, rhubarb, beets, collards, spinach, tofu and soybeans and restrict citrus drinks, tomatoes and fruit. (Reference: Short bowel syndrome: a nutritional and medical approach, Khursheed N. Jeejeebhoy; 2002 Canadian Medical Association or its licensors). (5)

  • TPN
    According to Buchman, A.L.; Sellin, J. in the article in: Bayless, T.M. and Hanauer, S.B. Advanced Therapy of Inflammatory Bowel Disease. Hamilton, Ontario: B.C. Decker Inc. 2001. p. 479-484: "Those patients with significant malabsorption requiring long-term TPN are at additional risk for hepatic steatosis (fatty liver) and cholestasis (an interruption of the flow of bile) with potential progression to cirrhosis (liver scarring), either acalculous (no stones) or calculous cholecystitis (inflammed gallbladder), metabolic bone disease, nephropathy (kidney disease), and central venous catheter-related problems, including infection and occlusion (thrombotic and nonthrombotic; clotting or nonclotting)." (5)

  • Despite bowel adaptation and meticulous nutritional therapy, some patients are unable to be freed from parenteral nutrition. These patients usually are those with less than 60 cm of small bowel remaining, loss of the ileum and ileocecal valve, and loss of the colon.

  • Specific Drug Therapies in short-bowel syndrome are mainly aimed at decreasing gastric hypersecretion or decreasing diarrhea. Gastric hypersecretion may be treated by proton pump inhibitors or histamine-2 (H2) blockers.
    Diarrhea, again, is a more lingering problem. Cases involving patients who have lost all of their colon and ileum, with less than 100 cm of jejunum (part of the intestines) and an end jejunostomy, are the most difficult to manage.
    In these patients, some enterologysts suggest the somatostatin analogue octreotide to be administered in doses of 100 mcg subcutaneously 3 times a day. This can reduce stool output by as much as 50% according to Farthing (1993).

  • Operative Therapies for short-bowel syndrome can be divided into 2 broad categories: (1) intestinal or combined liver-intestinal transplantation, and (2) nontransplant operations.
    • Nontransplant components for the treatment of short-bowel syndrome include intestinal lengthening (Bianchi) procedures, intestinal tapering for dilated(enlarged) dysfunctional bowel segments, stricturoplasty, and creation of intestinal valves or reversed bowel segments for patients with rapid intestinal movement.(2)
    • Organ Transplantation is a recent addition to the surgical approach to Short Bowel Syndrome, but continues to be burdened with problems.(4) The first successful combined transplantation of small intestine and liver in a human was performed in 1990.

    A Colostomy is performed when the lower large intestine, rectum, or anus is unable to function normally or needs rest from normal functions, or when infection or contamination from stool within the resected colon would prevent healing if the ends of the colon were to be reconnected. In most cases, depending on the disease process being treated, colostomies are temporary, and can be closed with another operation at a later date. If a large portion of the bowel is removed, or the distal end of the colon is so diseased that cannot be reconnect to the proximal intestine, the colostomy may be permanent.
    There are many risks assiciated with colostomy, some are related to general surgical procedures and anesthesia, such as:
    • Reactions to medications
    • Problems with breathing
    • Excessive bleeding
    • Surgical wound infection
    • Thrombophlebitis (inflammation and blood clot to veins in the legs)
    • Pneumonia
    • Pulmonary embolism (blood clot or air bubble in the lungs blood vessels)

    One study, reported in the Journal of WOCN, Journal of Wound, Ostomy and Continence Nurses. 28(2): 96-105. March 2001, conducted in Sweden, explored the practical aspects and the impact on daily life of short bowel syndrome (SBS) and an ostomy in people with SBS. In short, the most significant observation from the study was "the limited ability to act spontaneously, because all daily activities involved considerable planning."
    The authors of the study recommend a professional "team approach towards care" of the people involved, in order to help those with SBS and colostomy be able to coordinate everyday activities and limit those that interfere with their social life.

    Patients with short-bowel syndrome require lifetime follow-up. Those on parenteral nutrition require frequent monitoring of serum chemistries and in addition patients should be weighed regularly to assure that they are not losing weight on the nutritional regimen they are receiving. (7)

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