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Short Bowel Syndrome MCQs

QUESTION:  True or false. Short gut syndrome is a diagnosis which is made on symptoms, not on length of bowel.  

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ANSWER:  True.

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QUESTION:  What are the symptoms of short gut syndrome?

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ANSWER: Symptoms: diarrhea, steatorrhea, weight loss

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QUESTION: What deficiencies do people with short gut syndrome develop 

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ANSWER:  

– nutritional deficiency

– lose fat

– B12

– electrolytes

– water

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QUESTION:  What stain can you use to check for fecal fat?

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ANSWER: Sudan red stain – checks for fecal fat

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QUESTION: In a patient with shurt gut syndrome, what test could you use to check for B12 absorption? 

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ANSWER: Schilling test- checks for B12 absorption (radiolableed B12 in urine)

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QUESTION: How many cm of bowel do you need to survive off TPN, if you have a competent ileocecal valve? 

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ANSWER: Need 50cm with competent ileocecal valve to survive off TPN

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QUESTION: How many cm of bowel do you need to survive off TPN, if you have a incompetent ileocecal valve? 

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ANSWER:  Need at least 75cm to survive off TPN with incompetent ileocecal valve

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QUESTION:   Concerning short gut syndrome, all of the following are true except:

a. This is a clinical diagnosis of inability to absorb enough water and nutritional elements to be off TPN

b. The length of bowel in general needs to be at least 75cm if there is no ileocecal valve

c. The length of bowle in general needs to be at least 50cm if the ileocecal valve is present

d. The length of bowel needs to be at least 150cm if there is no ileocecal valve

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ANSWER:   

The answer is d: Short gut syndrome is a clinical diagnosis of iniability to maintain appropriate hydration and nutrition without the use of TPN.

– In general though, the length of bowel needs to be at least 50cm with the ileocecal valve and at least 75cm without the ileocecal valve to avoid TPN.

THE SMALL BOWEL: SHORT BOWEL SYNDROME [SURGICAL REVIEW, P.135]

– Short bowel syndrome is caused by massive surgical resection of the small bowel.

– Common reasons for such resections include midgut volvulus, traumatic injury, and vascular occlusion.

– Clinical manifestations include diarrhea, malnutrition, and fluid and electrolyte abnormalities.

– Symptoms depend on the amount of small bowel resected, the state of the ileocecal, and whether the proximal or distal bowel is lost.

– If the ileocecal valve is intact, resection of approximately 70% of the small bowel may be well tolerated.

– Resection of the proximal small bowel is better tolerated than resection of distal small bowel, as distal bowel can undergo adaptation, thereby increasing absorptive capacity.

– This adaptation is characterized by hyperplasia of the remaining enterocytes, lengthening of the villi, wall hypertrophy, and increased caliber.

– Stimuli for bowel adaptation may include enteral feeding and gut hormones (eg. insulinlike growth factor 1, glucagon-like peptide 2, growth hormone, and neurotensin.)

TREATMENT

– Patients with short bowel syndrome may benefit from special enteral diets (eg. elemental or polymeric) as well as vitamins and medium-chain fatty acids

– Medications that slow bowel motility should be used sparingly

– Surgical treatments are of limited utility, and few clinical studies support the use of surgical techniques such as reversed intestinal segment interposition, colonic interposition, or construction of an intestinal valve to slow intestinal transit time.

– Long-term outcomes following small bowel transplantation specifically for this disease process have yet to be determined.

SHORT BOWEL SYNDROME

Signs/symptoms:
– weight loss, diarrhea, steatorrhea, malabsorption, malnutrition.  Symptoms generally start with <120cm (50in) of SB.

Generally speaking, the amount of bowel needed to stay off TPN is:

  colon / ileocecal valve absent: 110-150cm. 

  colon / ileocecal valve present: 70cm

Causes:

  Adults: malignancy, radiation, vascular insufficiency

  Children: NEC, atresias, volvulus, gastrochisis.

Avoidance: minimize length of resection, preserve ileocecal valve.  Jejunal resection better tolerated than ileal resection.  Generally, 90cm needed to prevent chronic diarrhea and perianal problems.  After major resection, manage fluid/electrolyte shifts, sepsis.  TPN+early enteral feeds, including trace elements and MVI.

Treatment / Prognosis:

 if >180cm (70in) no deficit will occur.  In healthy adults, most protein, carbohydrate, and fat absorbed in first 150cm of jejunum.

 if 60<x<180cm, adaptation will occur over one year: hypertrophy, hyperplasia, elongation, dilatation.  Also, some degree of colonic adaptation occurs, allowing for colonic absorption of short chain fatty acids.

Optimal diet unknown, but generally thought that isotonic, elemental, continuous feeds are best. Some data show no benefit to elemental feeds.

if colon in continuity:

  protein 20-30% of caloric need

  fat 20-30%

  carbo 50-60% (allows colon to ferment and absorb energy)

  restrict oxalate

  isotonic fluid

  5-10g/d of soluble fiber

if colon not in continuity:

  protein 20-30%

  fat 30-40%

  carbo 30-40%

  isotonic, high sodium oral rehydration solution

  no restrictions on oxalate

Complications

LINE SEPSIS: minimize with tunneled lines, strict hygiene.

DIARRHEA: increase fiber intake, imodium or lomotil, ranitidine to reduce gastric output volume.  if no ileum, add cholestyramine.  Avoid octreotide.

METABOLIC/NUTRITIONAL DEFICIENCY: monitor alb, prealb, Ca, CBC, B12, folate, Fe, trace elements.

KIDNEY STONES: maintain high UO, Ca supplementation, minimize intraluminal fat, reduce dietary oxalate.

GALLSTONES: consider prophylactic cholecystectomy.  Risk of symptomatic cholelithiasis 1/3.

TPN CHOLESTASIS: maximize enteral intake, cycle TPN. occaisonally ursodiol.

PEPTIC ULCERS: caused from hypergastrin state.  H2 blocker to reduce gastric output and increase pH

BACTERIAL OVERGROWTH: from poor peristalsis / colon reflux.  Trial of metronidazole.

SOURCES
ABSITE KILLER Q&A

                

            

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