Short Bowel Syndrome: Review of Treatment Options

Nina Oktafianti Marfu’ah, Herry Purbayu, Iswan Abbas Nusi, Poernomo Boedi Setiawan, Titong
Sugihartono, Ummi Maimunah, Ulfa Kholili, Budi Widodo, Muhammad Miftahussurur, Husin
Thamrin and Amie Vidyani
Department of Internal Disease, Faculty of Medicine, Universitas Airlangga, Dr. Soetomo General Hospital,
Surabaya, Indonesia
[email protected]

Keywords: Short Bowel Syndrome, Total Parenteral Nutrition, Bowel Resection, Malabsorption.

Abstract: Short bowel syndrome (SBS) is malabsorption due to intestinal surface area insufficiency. In Europe, the
incidence of home Total Parenteral Nutrition (TPN) is approximately three cases per million people per
year, and the prevalence is four cases per million per year, whereas most people who get home TPN are
patients with SBS at 35%. There are three types of SBS bowel resection types, namely ileocolonic,
jejunocolonic, and jejunostomy. The main causes of SBS in adults are bowel resection associated with
vascular disorders and Crohn's disease. Clinical manifestations of SBS are malabsorption of macronutrients,
fluids, and electrolytes, vitamin and mineral deficiencies, diarrhea, gastric hypersecretion, wound healing
and infection. SBS management includes nutrition management, pharmacological management, and surgical
management. SBS complications include gallstones, oxalate kidney stones, liver diseases, d-lactate acidosis,
peptic ulcers, and metabolic bone disease. This study is a literature review aiming to discuss treatment
options for short bowel syndrome.

1 INTRODUCTION Management of SBS patients is complex and

individualized. The ultimate goal of the management
Short bowel syndrome (SBS) is a malabsorption of SBS patients is to maintain adequate nutritional
condition due to a decrease in the intestinal and hydration status and to prevent occurrence of the
absorption area following a massive resection of the underlying pathophysiological complications.
intestine. Survey data in Europe in 1997 showed an Optimum management reduces morbidity and
incidence of home total parenteral nutrition (TPN) of mortality. Thus, this literature review discusses the
about three cases per million people per year, and pathophysiology and management of SBS.
the prevalence of four cases per million population
per year, with the majority of those who have home
TPN suffering from SBS (35%) (Buchman, 2010; 2 DEFINITION
Fedorak, 2009).
It is difficult to determine the exact incidence of SBS is defined as malabsorption due to insufficiency
SBS. Data collection from the TPN home typically of the intestinal surface area so that it cannot absorb
provides an incidence of the SBS heavy spectrum enough liquids, energy, or nutrients. SBS occurs
that requires TPN, making it less accurate because when the length of the small intestine is left less than
uncomplicated SBS patients who do not need a TPN 200 cm. Generally the length of the small intestine
home are not covered (Lamprecht, 2015). In of adults ranges from 450-500 cm (Buchman, 2010).
America, in 1992 there were about 40,000 patients Measurements of intestinal length were performed
requiring TPN per year, of which 26% were SBS from duodenojejunal flexure (Ligamentum Treitz),
(Buchman, 2010). A retrospective review of either directly measured at surgery, or evaluation of
pediatric referral centers estimating the incidence of contrast images following the long axis of the rest of
SBS in neonates found 22 cases per 1,000 neonates the intestine, or measurement at autopsy (Wall,
entering the ICU and 25 cases per 100,000 live 2013). Two fifths of proximal are jejunum, while
births (Fedorak, 2009). three fifths are ileum. Colon length is generally 150

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Marfu’ah, N., Purbayu, H., Nusi, I., Setiawan, P., Sugihartono, T., Maimunah, U., Kholili, U., Widodo, B., Miftahussurur, M., Thamrin, H. and Vidyani, A.
Short Bowel Syndrome: Review of Treatment Options.
In Proceedings of Surabaya International Physiology Seminar (SIPS 2017), pages 453-461
ISBN: 978-989-758-340-7
Copyright © 2018 by SCITEPRESS – Science and Technology Publications, Lda. All rights reserved
SIPS 2017 - Surabaya International Physiology Seminar

cm (Fedorak, 2009). In wider terms, intestinal malabsorption/SBS. Resection of more than 75%
failure, caused by obstructive conditions, (450 cm) often leads to malabsorption requiring
dysmotility, surgical resection, congenital defects, or enteral and parenteral replacement therapy (Fedorak,
loss of disease-related absorption, is characterized as 2009).
an inability to maintain protein, energy, fluid,
electrolyte, and micronutrient balance (Fedorak, Table 1: Causes of Short bowel syndrome.
2009; Tappenden, 2014; Lamprecht, 2015). In infant children In adults
There are three main types of bowel resection Prenatal Vascular disorders
(Figure 1), namely Jejunoileal/ileocolonic, which is
Vascular disorders Thrombosis or embolism
a limited ileal resection, usually accompanied by a
of the superior
cecostomy or right hemicolectomy. Jejunocolonic is mesenteric artery
a wide ileal resection with or without partial Intestinal atresia Thrombosis of superior
colectomy and Jejunostomy which is a widespread mesenteric veins
intestinal resection. Volvulus (malrotation) Volvulus
Abdominal wall defects Strangulation
Gastroschisis Post-surgery
Postnatal Jejunoileal bypass in
obesity
Arterial Thrombosis Abdominal trauma
embolism requiring intestinal
resection
Venous thrombosis Careless Anastomosis
gastrocolic ileal
Necrotizing enterocolitis (inadvertent)
Figure 1: Three main types of bowel resection in SBS Trauma Others
(Buchman, 2010). Crohn’s Disease Crohn’s disease, with or
without surgical
resection
Volvulus Fistula intestinal
3 ETIOLOGY Hirschsprung Diseases Enteropathy of radiation
Enteropathy of radiation Primary neoplasm or
The incidence of prenatal vascular disorders that secondary
gastrointestinal tract
cause bowel atresia or volvulus is a major cause of
Complicated
SBS in children. The main causes of SBS in adults intussusception
are bowel resection associated with vascular
disorders and Crohn's disease, as shown in Table 1 2. Specific intestinal location taken
(Fedorak, 2009). a. Jejunum
Jejunum absorbs significant nutrients and
liquids, but single jejunal resection usually causes
4 PATHOPHYSIOLOGY little interference with absorption. This is due to
two factors. The first factor: a tight junction
The consequence of massive bowel resection is the jejunum is relatively leaky compared to the ileum
loss of absorption surface area causing or colon, resulting in significant back diffusion of
malabsorption. The degree of malabsorption is the material transported into the intestinal lumen,
determined by the length of residual intestine, the causing fluid and electrolyte absorption in the
specific location of the resected intestine, and the jejunum to be less efficient (40% efficiency) than
residual intestinal adaptive adaptation process in the ileum (75 % efficiency). The second factor:
(Buchman, 2010; Fedorak, 2009). the ileum is the gut section with the largest
1. The length of the remaining intestines adaptation capacity, so it can compensate for
The length of residual intestine after resection almost all the absorption function of the jejunum.
determines the available surface area for absorption Therefore, jejunal resection is usually tolerated
and determines the intestinal transit time. SBS may well (Fedorak, 2009). In contrast, the jejunum
occur from massive single resection or recurrent cannot compensate for the absorption of bile salts
short resection. About 50% (300 cm) of the small and vitamin B12 in the ileum. The location of
intestine can usually be resected without causing

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 Short Bowel Syndrome: Review of Treatment Options

nutrient absorption in the gastrointestinal tract can Although the presence of the colon improves
be seen in Figure 2. fluid and electrolyte absorption, it can also lead to
maladaptive consequences. In addition, a
combination of massive intestinal resection, fat
malabsorption, and the presence of intact colon
cause calcium oxalate kidney formation because
free fatty acids in the colon are more likely to bind
calcium, resulting in free oxalates absorbed by the
colonic mucosa into the systemic circulation.
d. Availability of the ileocecal valve
The ileocecal valve separates the contents of
the ileum and colon, providing a barrier that
prevents migration of colonic microorganisms into
the distal intestine. In addition it serves as a brake
to prolong the intestinal transit time so as to
increase absorption (Buchman, 2010; Fedorak,
2009). The removal of the ileocecal valve may
cause bacterial overgrowth in the small intestine.
This bacteria deconjugates the bile salts in the
small intestine lumen, disrupting micelle
formation, so the absorption of fat and fat-soluble
vitamins decreases. Furthermore, this deconjugated
bile salt spills into the colon and directly
stimulates the secretion of fluid and colonic
electrolytes and causes SBS. Intraluminal bacteria
also use vitamin B12 for their metabolic processes,
Figure 2: Absorption location of the normal thus decreasing the availability of vitamin B12 for
gastrointestinal tract (Jeejeebhoy, 2002). host absorption and exacerbating vitamin B12
deficiency. SBS patients who still have a colon and
b. Ileum ileocecal valve have a good prognosis. If the
The ileum is the main site of active absorption of ileocecal valve is taken, the tendency for SBS
bile acids and vitamin B12. Malabsorption of increases and is usually quite severe (Fedorak,
vitamin B12 occurs after resection of more than 60 2009; Buchman, 2010; Seetharam and Rodrigues;
cm of the ileum. Resection of more than 100 cm of 2011).
the ileum usually decreases the active absorption 3. Intestinal Adaptation
of bile acids, so bile acids are retained in the lumen The results of all these adaptive changes are
and overflow into the colon. This deconjugated increased surface area of intestinal absorption,
bile acid directly stimulates the colon to secrete increased microvillus enzyme activity and
fluid and electrolytes, causing secretory diarrhea absorption capacity per unit of intestinal length. This
and SBS. During intestinal adaptation, the body adaptive process is more visible in residual ileum
compensates for the loss of bile acids by increasing than residual jejunum. The adaptation process takes
bile acid stores through an eightfold increase in one to two years, and is highly dependent on
hepatic bile acid synthesis. More loss of ileum intraluminal nutrients to maintain bowel structure
causes severe malabsorption of bile acids, where and function. In inducing an adaptive process, SBS
the loss exceeds the synthesis. patients are encouraged to initiate oral intake as soon
c. Colon as possible in the postoperative phase (Fedorak,
The main function of the colon is to absorb 1-2 2009; Buchman, 2010).
liters of fluid received daily from the ileum Intraluminal nutrients stimulate intestinal
(Fedorak, 2009). In total there are 8-9 liters of adaptation through three mechanisms: 1)
fluid reaching the small intestine, derived from Intraluminal nutrients stimulate morphological and
oral intake and endogenous secretion; about 98% functional adaptations of the intestine. Mucosal
of these fluids are re-absorbed, including 80% by atrophy occurs when all the nutrients are
the small intestine and 18% by the colon administered parenterally because without exposure
(Tappenden, 2014). to intraluminal nutrients the adaptation does not

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occur, resulting in hypoplasia. In addition, non- absorbed both through the entire small intestine and
nutritional ingredients do not stimulate mucosal are generally available sufficiently. Steatorrhea is
growth; thus, the absorption or metabolism of related to the decrease of fat-soluble vitamins,
luminal nutrients is important for intestinal particularly vitamin D, A, K and (rarely) E. Most
adaptation processes; 2) Intraluminal nutrients human vitamin K is obtained from synthesis by
stimulate the secretion of some trophic colonic bacteria (60%), so patients with colon have a
gastrointestinal hormones that function in intestinal low risk of deficiency (Buchman, 2010). Mineral
growth and adaptation processes, such as: gastrin, deficiency includes calcium and magnesium
cholecystokinin, secretin, glucagon-like peptide 1 commonly occurring, secondary to malabsorption of
and 2, peptide YY, vasoactive intestinal peptide; 3) fatty acids, thus forming a complex with this
Stimulation of pancreatic and biliary secretions divalent cation. Calcium deficiency can also be
(Fedorak, 2009). triggered by vitamin D malabsorption.
3. Diarrhea
Several factors make diarrhea inevitable from
5 CLINICAL MANIFESTATION patients with large bowel resection due to reduction
of absorption surface area; decreased intestinal
AND COMPLICATIONS transit time; gastric hypersecretion, small intestine,
and colon; increased osmolality of the contents of
Clinical features of SBS patients result from the the colon with osmotic diarrhea, secondary to
intestinal adaptation process through three stages. carbohydrate and fat malabsorption.
The first stage (acute stage), lasts 1-2 weeks, 4. Gastric Hypersecretion
characterized by excessive diarrhea. During this Gastric hypersecretion occurs during 6-12
stage, water, electrolytes, and nutrients are provided months after resection, secondary to
via the parenteral route. The second stage (the period hypergastrinemia, which occurs due to loss of
of intestinal adaptation), lasts 2-24 months, when the hormone inhibitors produced in the proximal
oral intake begins and is increased gradually. intestine. Gastric hypersecretion causes loss of fluid
Enteral/parenteral, full or partial supplementation, and excessive electrolytes, and decreases intestinal
usually necessary to maintain optimal nutrition. At absorption, and peptic esophagitis/ulcers arise.
the third stage (long-term management stage), 5. Calcium oxalate kidney stones
maximal intestinal adaptation is reached, and normal Fat malabsorption, secondary to bile acid
oral intake may occur. Some patients who cannot deficiency in patients with extensive ileal resection
reach the full oral nutrition stage, can continue with and the presence of intact colon, is associated with
a combination of enteral or parenteral nutrition at an increased risk of oxalate kidney stones. Oxalates
home (Fedorak, 2009). in food usually settle as calcium oxalate in the
The following are the clinical manifestations and intestinal lumen, and exit through the stools.
complications of SBS patients: Malabsorption of fat in SBS patients causes
1. Malabsorption of macronutrients, liquids, and unabsorbed LCFA to compete between oxalate
electrolytes towards calcium present in the intestinal lumen. As a
After intestinal resection, the carbohydrates from result, large amounts of free oxalate are present in
the small intestine go to the colon, where they are the colon, and are absorbed and then excreted
metabolized by bacteria to SCFA (short-chain fatty through the kidneys, manifesting as hyperoxaluria or
acids). SCFA causes diarrhea through two form calcium oxalate stones, as shown in Figure 3.
mechanisms that cause osmotic diarrhea, and Management of hyperoxaluria is limiting foods
directly stimulate the colon to secrete fluid and intake containing oxalate. Oral calcium citrate may
electrolytes. Liquids and electrolytes can disappear a be administered because extra calcium precipitate
lot and often occur during the first few weeks after the oxalate and citrate diet to prevent the formation
bowel resection. of stones in the urine.
2. Deficiency of vitamins and minerals 6. Gallstones
(micronutrients) The incidence of gallstones increases three-fold
Vitamin B12 deficiency often occurs after ileal after ileal resection. Disorders of bile enterohepatic
resection because the intrinsic receptor of vitamin circulation and bile salts malabsorption result due to
B12 is limited to the ileum, but bacteria in the small ileal resection, disrupting the composition of the bile
intestine and colon can metabolize vitamin B12, thus organic component of hepatic bile acids, cholesterol,
increasing deficiency. Water-soluble vitamins are and phospholipids, leading to an increase in

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 Short Bowel Syndrome: Review of Treatment Options

cholesterol synthesis so bile becomes supersaturated processes). D-lactate is absorbed from the colon and
with cholesterol, and gallstones form. Most patients is metabolized by humans due to lack of D-lactate
with ileostomy have biliary stones containing dehydrogenase enzyme. The main excretion of D-
calcium compared to gallstones of radiolucent lactate is by the kidneys. D-lactate absorption leads
cholesterol. to an increase in metabolic acidosis. The
management consists of correcting acidosis with
sodium bicarbonate and reducing oral intake of
carbohydrates.
9. Wound and infection healing
As a result of macro and micronutrient
malabsorption, wound healing becomes impaired in
SBS. In experimental animals, mice with extensive
resection of the intestine exhibited poor collagen
synthesis and a decrease in the strength of
anastomosis resulting in dehiscence or stenosis. The
loss of integrity of the epithelial barrier and bacterial
translocation is positively correlated with the loss of
the ileocecal valve. In animal experiments with SBS,
the bacterial translocation rate increased with an
Figure 3: The mechanism of oxalate hyper absorption in
87% incidence as a result of excess bacterial growth
SBS patients with steatorrhea (Buchman, 2010)
in the rest of the intestine (Fedorak, 2009).
10. Metabolic bone disease
7. Liver disease
Patients with SBS have an increased risk of
Incidence of liver disease increases up to 65% in
osteomalacia, osteoporosis, and secondary
SBS patients requiring long-term TPN, manifesting
hyperparathyroidism. Specific risk factors are the
as cholestasis, steatosis or steatohepatitis, and
effects of parenteral nutrition, macro malabsorption
hepatic dysfunction. After 5 years of TPN use, more
and micronutrients (e.g. vitamin D, hypocalcemia,
than 50% of SBS patients have severe liver disease.
hypomagnesemia), and chronic metabolic acidosis.
Liver failure occurs in 15% of SBS patients who
Management includes correction of calcium,
depend on TPN. This may be due to a lack of enteral
magnesium and vitamin D deficiency, and correction
intake and decreased gastrointestinal or
of metabolic acidosis (Buchman, 2010).
gastrointestinal secretion due to episodes of sepsis,
11. Complications related to catheters
including bacterial translocation through the
The majority of patients receiving long-term
permeable bowel epithelium. Vascular factors may
TPN face complications related to central venous
also play a role in hepatic dysfunction, where portal
catheters, i.e. infections, and mechanical problems
blood flow disruption is a factor. Hepatic steatosis is
such as occlusion and catheter damage (Buchman,
associated with excess lipid content in TPN and
2010).
deficiency of essential fatty acids. Cholestasis
correlates with the extent of gut that is resected in
adulthood, prematurity and low birth weight in
infants. Liver disease may be an indication for bowel 6 MANAGEMENT
transplantation, with or without a liver transplant.
8. D-Lactic Acidosis 7.1 Management of nutrients, fluids,
This is a rare complication of SBS and is only and electrolytes
observed in patients with intact colon. The incidence
of acidosis is usually triggered by increased oral Nutritional management for SBS patients is a
intake of excess carbohydrates. Unabsorbable dynamic process that follows the evolution of the
carbohydrates are metabolized by colonic bacteria to clinical stage of bowel adaptation. In the immediate
SCFA and lactate, which decreases intracolonic PH. postoperative period, all patients undergoing
The low pH inhibits especially the growth of temporary fasting bowel resection require TPN
Bacteroides species and promotes the growth of support. If the intestinal residual is more than 25%,
acid-resistant bacteria, anaerobic gram-positive parenteral nutrition may be subsequently
(Bifidobacterium, Lactobacillus, and Eubacterium), discontinued (Fedorak, 2009). The patient remains
which have the ability to produce D-lactate (in fasting for 5-10 days, for healing of enteric
contrast to L-lactate produced in normal metabolic anastomosis, and for assessing basal loss of fluids

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SIPS 2017 - Surabaya International Physiology Seminar

and electrolytes. Enteral feeding, followed by oral as possible to avoid additional manipulation of
feeding, begins in the later postoperative phase when central venous catheters. A liquid or sublingual drug
the hemodynamic patient is stable, the return of formula will give the best results of pharmacokinetic
intestinal blood flow is adequate, and the absorption compared to pills (Fedorak, 2009).
postoperative ileus is reduced. Early oral feeding is a. Biliary supplementation
important for intestinal adaptation. The calorie When more than 100 cm of ileum is resected, fat
intake is improved slowly until the target is reached malabsorption may occur (fat-soluble vitamin
(Fedorak, 2009). The clinical assessment of SBS deficiency also occurs), because bile salt
patients includes measurement of fluid adequacy, malabsorption decreases micelle formation, leading
electrolytes, and nutritional status. Macronutrient to poor lipid solubilization. Bile salt replacement
needs can be seen Table 2. therapy is performed with ox bile or synthetic
conjugated bile acid (cholylsarcosine), dose of 2
Table 2: Macronutrient recommendations in short bowel g/meals, increased fat absorption in the small
syndrome (Buchman, 2010) intestine proximal, decreased urinary oxalate
With colon Without colon excretion, and decreased oxalate nephrolithiasis in
Carbohy Complex Varied intestinal resection patients with intravenous colon.
drate carbohydrate Thus, it can be a therapy option for patients with an
30-35 kcal/kg/day 30-35 kcal/kg/day oxalate stone formation history. The bile acid-
Soluble fiber sequestering agent, cholestyramine, is useful for
Fat MCT/LCT LCT reducing bile salt-related diarrhea in patients with
20%-30% of 20%-30% of calorie ileal terminal resection of less than 100 cm
calorie intake intake (Buchman, 2010).
± low fat/high fat ± low fat/high fat
Protein Protein intact Protein intact
Table 3: Recommendation regarding vitamin and minerals
1.0-1.5 g/kg/day 1.0-1.5 g/kg/day
in short bowel syndrome.
± formula ± formula peptide-
peptide-based based Micronutrient Requirements
Vitamin A 10,000-50,000 units/day
SBS patients with the availability of colon, Vitamin B12 1,000 µg subcutaneous/month (for
should be given a diet high in complex patients with ileal terminal
carbohydrates, such as starch, nonstarch resection/disease)
polysaccharides, and soluble fiber. The material is Vitamin C 200 mg/day
Vitamin D 50,000 unit of 1.25 (OH2)-D3 twice
usually not absorbed in the small intestine, but when
a week to twice a day
in the colon, colon bacteria ferment it into SCFA Vitamin E 30 IU/day
such as butyrate, acetate, and propionate. About 75 Vitamin K 10 mg/week
mmol SCFA is produced from 10 g of unabsorbed Calcium 1,000-1,500 mg/day
carbohydrate. Patients with intact colon can absorb Magnesium 30 ml twice a day (magnesium
up to 310-740 kcal (1.3-31 MJ) daily when fed a diet glucoheptonate liquid)
of 60% carbohydrates. Ferum (Fe) 300 mg twice a day (ferrous sulfate
Home TPN is used by patients requiring long- liquid)
term TPN after hospitalization. TPN fluid is usually Selenium 60-150 µg/day
Zinc 220-440 mg/day (in sulfate or
hypertonic, so it should be administered through a
gluconate form)
central vein, to reduce the risk of infection and If needed
thrombosis. Patients need to be informed of TPN Bicarbonate
indications, proper catheter care, dressing mode,
pump use, TPN solution preparation, as well as b. Management of gastric hypersecretion
acute TPN complications including air embolism, The use of a proton pump inhibitor or histamine
hypoglycemia, and catheter-related infections H2 receptor blocker is needed to suppress
(Buchman, 2010). hypersensitivity of gastric acid induced by
hypergastrinemia (Buchman, 2010; Lamprecht,
7.2 Pharmacological Management 2015).
c. Diarrhea management
Drug absorption is usually impaired in SBS. Most Opiates are an antimotility drug used for SBS-
drugs are absorbed in the proximal jejunum. Oral related diarrheal therapy. Opiate preparations
and enteral delivery routes should be used as much include natural preparations (e.g. paregoric and

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 Short Bowel Syndrome: Review of Treatment Options

opium alkaloids), and synthetic preparations

(including codeine, diphenoxylate, and loperamide).
Antidiarrheal drugs should be taken 1 hour before 7.3 Surgical Management
meals. Octreotide, a long-acting somatostatin
analog, may slow the intestinal transit and increase 7.3.1 Procedure to extend the gut
absorption, but it can also decrease splanchnic
protein synthesis inhibiting post resection gastric The most important surgical procedure is the
adaptation, and also increase the risk of gallstones residual colon reanastomosis of residual colon
by the inhibitory effect on gallbladder contractions because it has a low rate of mortality and morbidity.
(Fedorak, 2009; Buchman, 2010; Seetharam and Other procedures, such as tapering enteroplasty,
Rodrigues, 2011). The α 2-adrenergic agonist intestinal valve manufacture, recirculating loops,
(Clonidine) is a potent intestinal absorption reversal of intestinal segment or colonic
stimulator, and decreases intestinal motility, but due interposition, are intended to prolong transit time but
to the effects of central and sedative hypotension, its the procedure is still experimental and its use is
use is limited as an antidiarrheal drug. If diarrhea is limited, and outcomes are usually not optimal.
caused by bile acid malabsorption, treatment with Bianchi procedure (longitudinal intestinal
bile acid-binding resins, such as cholestyramine (2-4 lengthening and tailoring), may be useful for
g at mealtime) or colestipol (1-2 g at mealtime) will patients with segmental dilatation and nonfunctional
reduce diarrhea (Buchman, 2010). Some bowel due to dysmotility and bacterial overgrowth.
medications to reduce diarrhea can be seen in Table Another procedure that is serial transverse
4. enteroplasty is more useful than Bianchi because the
technique is simpler, and there is no transection of
Table 4: Treatment used to reduce diarrhea (Fedorak, the intestine, making it easier to supply blood supply
2009) to the intestine (Buchman, 2010; Seetharam and
Drug Dose Rodrigues, 2011).
Loperamide 4-6 mg, 4x/day
Diphenoxylate- 7.3.2 Bowel transplantation
atropine 2.5-5 mg, 4x/day
Codeine Intestinal transplantation is a life-saving procedure
phosphate 15-30 mg, 2-4x/day that needs to be considered in patients with
Tincture opium 0.6 ml (2.5 mg), 2-4x/day irreversible intestinal failure with parenteral
Ranitidine 300 mg, 2x/day nutrition. In adult recipients, 21% need a
Omeprazole 40 mg, 2x/day combination of intestinal and liver transplants, 55%
Octreotide 50-100 µg subcutaneous, intestine, and 24% multivisceral transplantation. In
2x/day 2003 from the international small intestinal
Clonidine 0.3 mg transcutaneous patch,
1x/week
transplant registry, the 1-year graft/patient survival
rate was 67%/77% for small bowel transplants,
59%/60% for intestinal and liver combinations, and
d. Trophic therapy to improve bowel adaptation
61%/66% for multivisceral transplants. The results
This is the latest trophic therapy to strengthen the
are the same for child and adult transplants. About
endogenous process of intestinal adaptation. A study
80% of transplant survivors may quit parenteral
was conducted on phase III of two available
nutrition and use oral nutrition, 10% have partial or
pharmacologic therapies for PN-dependent SBS
non-functional transplant function, and 10% of
patients, Teduglutide (glucagon-like peptide 2
transplants are stabilized (Fedorak, 2009).
analog/GLP-2) and Somatropin (recombinant human
growth hormone). In these studies, both therapies
were reported to increase the capacity of intestinal
absorption and to decrease PN volume requirements 7 PROGNOSIS
(Storch, 2014). Data on the effects of both drugs are
limited, so their use is not recommended for routine Prognostic factors in SBS include residual intestinal
use (Van Gossum et al., 2009; Seetharam and length, presence of residual underlying disease,
Rodrigues, 2011; Jeppesen, 2014; Storch, 2014). presence or absence of colon and an ileocecal valve,
The SBS management algorithm can be seen in patient age, dependency on an enteral diet, and
Figure 4. nature of the underlying disease (Lamprecht, 2015).
In children, survival without enteral or TPN

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SIPS 2017 - Surabaya International Physiology Seminar

supplements can usually occur when the length of 75%. Survival is negatively correlated with end-
the small intestine is more than 40 cm (at least 20% enterostomy, ileocecal valve retrieval, colon
of normal length), while in adults survival is resection, small bowel length less than 50 cm (adult)
possible if the length of the remaining small and 15 cm (child), advanced persistent cholestatic
intestine is more than 150 cm (at least 25% of jaundice, and arterial infarction that causes SBS.
normal length), measured from the Treitz ligament. Dependence on parenteral nutrition is positively
In adults, the 5-year survival rate is 55% and correlated with a small bowel length of less than 100
dependence on parenteral nutrition is about 45%, cm, absence of ileum, ileocecal valve, or colon
while in children the 5-year survival rate is 73% and (Fedorak, 2009).

Figure 4: Pump management algorithm of short bowel syndrome.

types, namely ileocolonic, jejunocolonic, and

jejunostomy. The main causes of SBS in adults are
8 CONCLUSION intestinal resection associated with vascular
disorders and Crohn's disease. SBS management
Short bowel syndrome is malabsorption due to includes nutrition management, pharmacological
intestinal surface area insufficiency, occurring management and surgical management.
when the remaining small intestine is less than 200
cm. There are three types of SBS bowel resection

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