US Gastroenterology & Hepatology Review, 2008;4(1):56-8
Short bowel syndrome (SBS) is a malabsorption syndrome resulting from extensive intestinal resection.1 Although the diagnosis of SBS relies less on an anatomical definition and more on a functional definition, for practical purposes in adults SBS can be defined as the presence of <200cm of remaining small intestine. In infants, necrotizing enterocolitis and congenital intestinal anomalies are frequently responsible. In older children and adults, multiple resections for Crohn’s disease and massive resections due to catastrophic mesenteric vascular events, radiation enteritis, adhesive obstruction, and trauma represent the more common causes of SBS.2 These patients frequently experience chronic diarrhea, dehydration, and macro- and micronutrient deficiencies often requiring enteral or parenteral nutrition support at home.
While SBS is uncommon, it remains an important clinical problem due to its effect on the quality and duration of life of these patients, the high rate of associated complications, and the subsequent high costs involved in their care.3 Survival studies from France and the US have demonstrated two-year and five-year survival rates for SBS at over 80 and 70%, respectively.4,5 Furthermore, the study from France reported parenteral nutrition (PN) dependency at two years of 49%, and 45% at five years.5 Survival rates were lowest in the end-jejunostomy and ultra-short small bowel groups. Other factors affecting survival include the patient’s age, primary disease process, comorbid diseases, presence of chronic intestinal obstruction, and the experience of the team managing the patient.6 Knowledge of the small bowel length can be useful for predicting the clinical outcome in SBS patients. The large range of small bowel length in humans (300–800cm) underscores the importance of being aware of the small bowel length remaining following a resection rather than the length of small bowel removed. When an operative report is unavailable or incomplete, a barium contrast small bowel series may provide an estimate of bowel length and is useful to delineate other structural features, such as the presence of bowel dilatation.7
The region of the remaining small intestine and the presence of the colon also affect the outcome of the SBS patient. In general, an SBS patient will have one of the following bowel anatomies: jejuno-colic anastomosis, end-jejunostomy, or jejuno-ileocolonic anastomosis. Patients with a jejuno-ileal anastomosis have the best prognosis; however, this anatomy is the least common. Patients with an end-jejunostomy are the most difficult to manage and are the most likely to require permanent parenteral support.6 A jejunal resection is generally better tolerated than an ileal resection because the ileum is capable of both structural and functional adaptation, while the jejunum mainly adapts functionally.6 Intestinal adaptation refers to a process following intestinal resection in which the remaining bowel undergoes a variety of macroscopic and microscopic changes in response to a number of stimuli in order to increase its ability to absorb fluid and nutrients.8,9 This stage may last for up to two years and it is during this time that most PN weaning occurs. The presence of the colon is beneficial in SBS patients given its ability to absorb water, electrolytes, and short-chain fatty acids (as an additional energy source), slow intestinal transit, and stimulate intestinal adaptation.10 It has been suggested that, in terms of need for PN, the presence of at least half of the colon is equivalent to about 50cm of small bowel.11
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