Short bowel syndrome medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

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.
• Patients should eat more than usual to overcome the malabsorption.
  • 1 Fluid
    • 1.1 Acute phase
      • Preferred regimen (1): Normal saline
      • Preferred regimen (1): Ringer lactate
  • 1.2 Maintenance phase
    • 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 Parenteral infusion
    • 2.1 Acute phase
      • 2.1.1 Diet
        • Preferred regimen (1): 30-40 kcal/kg/day diet consists of carbohydrate 55-60%, fat 20-25%, and protein 20%
      • 2.1.2 Electrolytes
        • 2.1.2.1 Sodium
        • 2.1.2.2 Potassium
        • 2.1.2.3 Magnesium
    • 2.2 Maintenance phase
      • 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):
  • 3 Enteral nutrition
    • 1.2.1 Adult
      • Preferred regimen (1): drug name 500 mg PO q8h
    • 1.2.2 Pediatric
      • Preferred regimen (1): drug name 50 mg/kg/day PO q8h (maximum, 500 mg per dose)
  • 4 Supplement
    • 4.1 Vitamins
      • 4.1.1 Vitamin A
      • 4.1.2 Vitamin B12
      • 4.1.3 Vitamin D
      • 4.1.4 Vitamin E
    • 4.2 Minerals
      • 4.2.1 Calcium
        • Preferred regimen (1): Calcium 1000-1500 mg PO qd
      • 4.2.2 Iron
      • 4.2.3 Zinc
    • 4.3 Exogenous enzyme replacement 
      • 4.3.1 Pancreatic enzyme
      • 4.3.2 Lactase
    • 4.4 Bile acid sequestrants
    • 4.5 Probiotics

Pharmacotherapy

• Medications are used to control symptoms of short bowel syndrome. They include:
  • 1 Antimotility agents
    • Preferred regimen (1): Loperamide 
    • 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):
    • 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)
    • 3.2 Glutamine
    • 3.3 Glucagon-like peptide-2 analogue
      • Preferred regimen (1): Teduglutide 0.1–0.2 mg PO q12h
  • 4 Antibiotics
    • Preferred regimen (1):

Note (1): Antibiotic is used to prevent and treat small bowel bacterial overgrowth.