management of patients with short bowel syndrome

Management of Patients with Short Bowel Syndrome : 

Management of Patients with Short Bowel Syndrome By: Rachel Jessop

Short Bowel Syndrome (SBS) : 

Short Bowel Syndrome (SBS) “Short gut syndrome” or “Short Gut” Defined as mal-absorption resulting from anatomical or functional loss of a significant length of the small intestines Main causes in infants and newborns are removal of half or more of the small intestines, injuries, or defects present at birth Necrotizing entrocolitis, Intussusception, congenital defects, Crohn’s disease Main symptom of SBS is diarrhea Weakness and fatigue is another sign.

Management of SBS : 

Management of SBS Nutritional supplementation depends upon the degree and portion of the small intestines removed Iron is absorbed in the duodenum Carbohydrates, proteins, vitamins, and some fats are absorbed in the jejunum Most fats, bile acids and Vitamin B12 are absorbed in the ileum Removal of the ileocecal valve results in ↓ fluid and nutrient absorption and ↑ bacterial growth in the small bowel TPN is required initially after surgery, and can be long term for some, depending on the severity of SBS. A central line is required for administration The patient should be given as much enteral/oral nutrition as possible to facilitate bowel growth (adaption) and decrease TPN effects on the liver Prevention of and observing for sign and symptoms of infection and/or bacterial overgrowth of the intestines Teaching parents about nutritional requirements to meet extra needs of the infant and caring for their child at home.

Nutritional Support : 

Nutritional Support In infants with massive small-bowel resection, enteral nutrition is initiated very quickly Providing small frequent feedings can help manage problems with excessive stool and abdominal distention in the setting of significant malabsorption Enteral feedings can facilitate intestinal adaption and can prevent liver and gallbladder complications Parenteral nutrition should be start as soon as possible for patients with massive small-bowel resection Enteral calcium supplementation is required B12 - parenteral or as needed to prevent pernicious anemia Zinc supplementation is often needed secondary to ↑ fecal loss – cannot be measured accurately if C-reactive protein is greater than 5.0 Fat-soluble vitamins supplements Vitamin K supplementation is usually not needed but can be monitored with prothrombin time (PT)

Medication Management : 

Medication Management Antibiotics are used sparingly to prevent bacterial overgrowth in the small intestines – they are change often to prevent bacterial resistance H2 blockers, such as Zantac, are used to prevent gastric hyper-secretion and ulcers – when giving Zantac with TPN, stomach pH needs to be maintained between 4-6 Proton Pump Inhibitors, such as Prilosec, are used to ↓ gastric acid secretion Choleretic Agents, Ursodiol/Phenobarbital, used to improve biliary flow and prevent TPN-induced liver disease Bile Salt Binders, Cholestyramine, decrease choleretic diarrhea Antisecretin Agents, octreotide, decrease intestinal secretion Hypomotility Agents, Loperamide, ↑ intestinal transit time, acts on intestinal muscles to inhibit peristalsis and slow intestinal motility Watch for closely for any adverse effect. CHILDREN WITH SBS HAVE AN INCREASED RISK FOR SENSIVITY

TPN Therapy : 

TPN Therapy Individualized depending on the patients needs. Lipids are light sensitive and should be protected to prevent cellular damage. Sterile technique is required for administration Central line dressing should be kept sterile and are usually changed Q 48 hrs. TPN tubing should be changed Q72 hrs. for continuous infusions and Q24 hrs. for intermittent infusions to help prevent occlusion of the central line and decrease the risk of infection. Monitor anthropometric measurements, CBC, electrolytes, BUN, glucose, LFTs, plasma proteins, serum vitamin and mineral levels, PT, and plasma and urine osmolality Serum zinc and copper levels will read false with C-reactive protein (CRP) levels greater than 5.0 Carnitine can be added to TPN if the infant/newborn weighs less than 1.5 kg or is a spinal muscular atrophy patient

Complications of TPN : 

Complications of TPN The nurse needs to monitor and teach parents to monitor for signs and symptoms of complications Glucose abnormalities are common with TPN, and TPN should be adjusted to stabilized glucose levels Liver dysfunction, painful hepatomegaly, and hyperammonemia are especially common in infants Volume overload Metabolic bone disease can develop in patients on long term TPN. Temporarily or permanently stopping of TPN is the only treatment Adverse reactions to lipid emulsion – may be minimized or prevented by slowing or stopping infusions of lipids – temporary hyperlipidemia may occur after initation of therapy Cholelithiasis and cholecystitis – oral or enteral feeding can help ↓ risk Leading cause of death in infant with SBS who are treated with TPN is central line sepsis and complications of liver and biliary tract with prolonged use.

Parent Teaching : 

Parent Teaching Parents need to know how to provide nutritional support for their infant Central line care and prevention of infection Medication administration The importance of following up with the physician to prevent bacterial resistance with antibiotics S/S of infection and S/S of bacterial overgrowth or other complications – when to contact the physician Home health care is essential to help in the management of home care and central line infection control

References : 

References Aerde, J. E. V. (2004). http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2724168/ Brizee, L. S. (2007). Short Bowel Syndrome. Gaining and Growing Assuring Nutritional Care of Preterm Infants. http://depts.washington.edu/growing/Assess/SBS.htm Cuffari, C. (2009). Short Bowel Syndrome. eMedicine. http://emedicine.medscape.com/article/931855-print Short Bowel Syndrome (2009). National Digestive Diseases Information Clearing House. http://digestive.niddk.nih.gov/ddiseases/pubs/shortbowel/ Spencer, A. U., & et al. (2005). Pediatric Short Bowel Syndrome; Redefining Predictors of Success. Annals of Surgery, 242(3). 403-412. doi: 10.1097/01.sla.0000179647.24046.03. Thomas, D. R. (2009). Total Parenteral Nutrition (TPN). Merck Manual Online Medical Library. http://www.merckmanuals.com/professional/sec01/ch003/ch003c.html