Short bowel syndrome medical therapy

Short bowel syndrome Microchapters
Home
Patient Information
Overview
Historical Perspective
Classification
Pathophysiology
Causes
Differentiating Short bowel syndrome from other Diseases
Epidemiology and Demographics
Risk Factors
Screening
Natural History, Complications and Prognosis
Diagnosis
Diagnostic Study of Choice
History and Symptoms
Physical Examination
Laboratory Findings
Electrocardiogram
X-ray
Echocardiography and Ultrasound
CT scan
MRI
Other Imaging Findings
Other Diagnostic Studies
Treatment
Medical Therapy
Surgery
Primary Prevention
Secondary Prevention
Cost-Effectiveness of Therapy
Future or Investigational Therapies
Case Studies
Case #1
Short bowel syndrome medical therapy On the Web
Most recent articles
Most cited articles
Review articles
CME Programs
Powerpoint slides
Images
American Roentgen Ray Society Images of Short bowel syndrome medical therapy All Images X-rays Echo & Ultrasound CT Images MRI
Ongoing Trials at Clinical Trials.gov
US National Guidelines Clearinghouse
NICE Guidance
FDA on Short bowel syndrome medical therapy
CDC on Short bowel syndrome medical therapy
Short bowel syndrome medical therapy in the news
Blogs on Short bowel syndrome medical therapy
Directions to Hospitals Treating Short bowel syndrome
Risk calculators and risk factors for Short bowel syndrome medical therapy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sadaf Sharfaei M.D.[2]

Overview

Management of short bowel syndrome is complicated and requires close collaboration of all medical team members including the physician, nutritionist, and nurse with the patient and their families. Medical therapy consists of nutritional therapy and pharmacotherapy. Nutritional therapy is essential for short bowel syndrome and to restore the intestinal adaptation. It could be provided through oral, enteral and parenteral routes. The ultimate goal is to provide necessary nutrients via oral route other than parenteral or enteral routes. All patients require enough fluid, electrolytes, supplements and calories. Medications are used to control symptoms of short bowel syndrome include antimotility agents, antisecretory agents, and trophic agents. Lifelong follow-up is usually needed.

Medical Therapy

• Management of short bowel syndrome is complicated and requires close collaboration of all medical team members including the physician, nutritionist, and nurse with the patient and their families.
• Management of short bowel syndrome consists of medical therapy and surgical interventions.
• Medical therapy consists of nutritional therapy and pharmacotherapy.
• Lifelong follow-up is usually needed.

Nutritional therapy

• Nutritional therapy is essential for short bowel syndrome and to restore the intestinal adaptation. It could be provided through oral, enteral and parenteral routes.
• Parenteral nutrition should be started after bowel resection.
• The ultimate goal is to provide necessary nutrients via oral route other than parenteral or enteral routes.
• Required diet must be started as soon as possible after surgery. However the composition of their diet would be different depending upon the condition of the patient.
• All patients require enough fluid, electrolytes, supplements and calories.
  • 1 Fluids
    • 1.1 Acute phase
      • Preferred regimen (1): Normal saline
      • Preferred regimen (1): Ringer's lactate
    • 1.2 Maintenance phase
      • Oral rehydration solutions (ORS)
      • Water
      • Sports drinks
      • Sodas without caffeine
      • Salty broths

• Note (1): 300-500 ml must be added to fluid loss as an insensible loss.

• Note (2): Urine output should be at least 1 L per day.
  • 2 Diet
    • Preferred regimen (1): 30-40 kcal/kg/day diet consists of carbohydrate 55-60%, fat 20-25%, and protein 20%
• Note (1): Small and frequent diet is recommended.
• Note (2): Foods high in sugar, protein, fat, and fiber must be avoided.
• Note (3): Patients with preservation of the colon require diet rich in carbohydrates but low fat.
• Note (4): Patients with ileal resection more than 100cm, require low oxalate and high calcium diet.
• Note (5): Patients who have diarrhea more than 3L per day, must avoid high levels of fiber in their diet. 
• Note (6): Medium-chain triglycerides should be avoided in patients with a jejunostomy or ileostomy.
  • 3 Supplement
    • 3.1 Electrolytes
      • 3.1.1 Sodium
      • 3.1.2 Potassium
      • 3.1.3 Magnesium
    • 3.2 Vitamins
      • 3.2.1 Vitamin A
        • Preferred regimen (1): Vitamin A 10,000–50,000 U PO qd 
      • 3.2.2 Vitamin B12
        • Preferred regimen (1): Vitamin B12 300 mcg SC qm (following terminal ileum resection)
      • 3.2.3 Vitamin C
        • Preferred regimen (1): Vitamin C 200–500 mg PO qd  
      • 3.2.4 Vitamin D
        • Preferred regimen (1): Vitamin D 1600 U PO qd  
      • 3.2.5 Vitamin E
        • Preferred regimen (1): Vitamin E 30 IU PO qd  
      • 3.2.6 Vitamin K
        • Preferred regimen (1): Vitamin K 10 mg PO qw  
    • 3.3 Minerals
      • 3.3.1 Calcium
        • Preferred regimen (1): Calcium 1000-1500 mg PO qd
      • 3.3.2 Iron
        • Preferred regimen (1): Ferrous sulfate 30-90 mg PO qd (Elemental iron 6-18 mg per day)
      • 3.3.3 Zinc
        • Preferred regimen (1): Zinc 220–440 mg PO qd  
      • 3.3.4 Selenium
        • Preferred regimen (1): Selenium 60–100 mg PO qd  
    • 3.4 Exogenous enzyme replacement 
      • 3.4.1 Pancreatic enzyme
        • Preferred regimen (1): Pancreatin 25,000-40,000 U PO per meal
      • 3.4.2 Lactase
        • Preferred regimen (1): Lactase 3,000-9,000 units PO with meals or dairy
    • 3.5 Bile acid sequestrants
      • Preferred regimen (1): Cholestyramine 4 to 8 gr PO qd or q12h (maximum 24 gr per day)
      • Preferred regimen (2): Colestipol 2-16 gr PO qd or q12h
      • Preferred regimen (3): Colesevelam 3.75 gr PO qd
    • 3.6 Probiotics
    • 3.7 Essential amino acids
      • Preferred regimen (1): Essential amino acids 186 mg/kg PO qd

Pharmacotherapy

Medications are used to control symptoms of short bowel syndrome. They include:

• 1 Antimotility agents
  • Preferred regimen (1): Loperamide 4-16 mg PO qd
  • Preferred regimen (2): Codeine phosphate 30-60 mg PO q6h as needed
  • Preferred regimen (3): Lomotil (diphenoxylate and atropine) 2.5-7.5 mg q6h (maximum 30 mg per day)
  • Alternative regimen (1): Cholestyramine 24 g PO qd (recommended for patients with an intact colon and partial ileal resection of <100 cm)
  • Alternative regimen (2): Codeine 60 mg IM q4h
  • Alternative regimen (3): Tincture of opium 5-10 mL PO q4h

• Note (1): Antimotility agents reduce peristalsis and increase transit time which improve nutrient absorption.
• Note (2): Antimotility agents must be used 30 minutes before meal and at bedtime.
• Note (3): Patients who receive opiates to control their diarrhea must be closely monitored.
  • 2 Antisecretory agents
    • 2.1 Histamine H2 antagonists
      • Preferred regimen (1): Ranitidine 300-600 mg PO qd
      • Preferred regimen (2): Famotidine 40-80 mg PO qd
    • 2.2 Proton pump inhibitors
      • Preferred regimen (1): Omeprazole 40 mg PO BID or TID
    • 2.3 Somatostatin analogue
      • Preferred regimen (1): Octreotide 100 mcg SC q8h (maximum 1,500 mcg per day)
    • 2.4 Clonidine 0.1–0.2 mg PO q12h
  • 3 Trophic agents
    • 3.1 Growth hormone
      • Preferred regimen (1): Somatropin 0.03-0.14 mg/kg SC qd for up to 4 weeks (not to exceed 8 mg/day) (Contraindicated in malignancy, or with acute critical illness in intensive care units)
    • 3.2 Glutamine
      • Preferred regimen (1): Glutamine 0.16 g/kg IV qd
      • Preferred regimen (2): Glutamine 30 g PO qd
    • 3.3 Glucagon-like peptide-2 analogue
      • Preferred regimen (1): Teduglutide 0.1–0.2 mg PO q12h (Contraindicated in patients with current or a past malignancy, except for basal cell carcinoma)

Follow-up

• Close long-term follow-up is needed.
• Monitoring and measuring blood levels of nutrients are required.

Table below summarizes the tests and imaging studies which are required in patients with short bowel syndrome when discharge from the hospital.

Measurement	Frequency
Clinic visit	Every 6 to 12 months
Weight	Every week to check for malnutrition and dehydration
Intake and output	Every 1 to 4 weeks to check for malnutrition and dehydration
Comprehensive metabolic panel including magnesium	Every 4 weeks to check for malnutrition and dehydration
Essential fatty acids	Every 6 to 12 months to check for malnutrition
Vitamin levels	Every 6 to 12 months to check for malnutrition
Minerals	Every 6 to 12 months to check for malnutrition
Liver function tests	Every 6 months to check for liver disease
Dual-energy x-ray absorptiometry scan	Every 2 years to check for osteoporosis

References

​