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Short Bowel Syndrome

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Published in: Medicine
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This presentation explains in detail about Short Bowel Syndrome, including a real patient case presentation. We talk about causes, pathophysiology and management.

Noor U / Dubai

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  1. Overgrowth in Short Bowel Syndrome Noor ul Huda Zeeshan Visiting Medical Student
  2. Objectives Case presentation Define Short Bowel Syndrome and Intestinal Failure Define Small Intestine Bacterial Overgrowth Explore risk factors Review symptoms and differential diagnosis Review diagnostic options Review management options
  3. Case •12 y/o female •Presenting to the Gl service to establish care for her known diagnosis of Short Bowel Syndrome (SBS) (Previously had intestinal care at Nebraska Omaha) •SBS due to gastroschisis repair in infancy, 32 weeker •S/p multiple surgeries for bowel resection, resulting in short bowel syndrome with only 26 cm left and hemi colon •Underwent primary repair for her gastroschisis on day 1 of life, is s/p enterectomy, jejunotomy, stomal revision, G tube placement, Boviac line placement and central line •She is on full oral enteral nutrition since > 10+ years and doing well with it
  4. Subjectively Abdominal pain (3+ years) Located in RLQ, intermittent, described as a cramping sensation, non radiating No specific time of day but has noticed association with empty stomach and reports 9/10 severity at its peak occasionally Bloating, diarrhea onset with consumption of gluten recently and has not tried elimination Does not take any medication for the pain or other symptoms Stooling 3 times daily on average, stool is bristol 6-7 No complains of constipation in between or blood per rectum She has a good appetite and denies any dietary restrictions. She denies other food triggers, known food allergies, steatorrhea, reflux symptoms, weight loss, fatigue, recent infections, constitutional symptoms Had recent hospital admission over a month back for worsening abdominal pain + distension Pain has significantly improved since this episode
  5. Recent ED visit and hospital admission On 09/09/23 she had an ED visit for abdominal pain and distension. Prior to this she had no admissions for her pain post op. Abdominal pain began spontaneously at night. Described pain as sharp in left upper and lower quadrants and noticeable distension which bothered her more. She had one bowel movement that day. Had nausea, but no vomiting. Labs done on this visit were within range. CT on this visit in ER: BOWEL: The stomach is mildly to moderately distended with fluid. Most of the colon is moderately dilated, containing gas and fluid. There is an apparent 4 cm long segment Of relatively decompressed distal sigmoid colon in the pelvis that may be a site Of transition from dilated colon to a relatively nondistended more distal rectosigmoid colon. There is also a long segment of markedly dilated distal fluid-filled small bowel leading up to the colon. The course of the small and large bowel are difficult to follow due to the distended bowel and the paucity Of intra-abdominal fat. A normal-appearing ileocecal valve is not visualized.
  6. Past Surgical History SURGICAL HX: • COLECTOMY 4/17/2011 • CYST REMOVAL 04/17/2011 Urachal cyst. • GASTROSTOMY TUBE PLACEMENT 06/01/2011 For drip feedings • ILEOSTOMY OR JEJUNOSTOMY 06/01/2011 BX from jejunostomy. • LAPAROTOMY 04/17/2011 Exploratory laparotomy with extensive enterectomy, creation of Hartmann pouch, and creation of end jejunostomy. • OTHER SURGICAL HISTORY 04/17/2011 Gastroschisis abdominal wall repair • REVISION COLOSTOMY 5/6/2011 Stoma revision due to retraction. • TUNNELED VENOUS CATHETER PLACEMENT 04/17/2011 Placement of 4.2-French Broviac catheter via right jugular vein.
  7. Current Medications Her medications include multi vitamins Calcium carbonate (TUMS) 500 MG chewable tablet Give 3 tabs every morning, 2 in afternoon and bedtime. Chew thoroughly. Cyanocobalamin (VITAMIN B 12) 100 MCG Lozenge Give one every Mon-wed-Fri Multiple Vitamin (MULTI VITAMIN OR) Take 1 Tab by mouth one time a day. probiotic product (PROBIOTIC-IO OR) Take 1 Tab by mouth one time a day. Vitamins A D C (HEALTHY KIDS COD LIVER/VIT D) Chew Tab Take 3 Tabs by mouth one time a day
  8. Family History GERD (father) Pancreatic cancer (grandfather) Social History Good relation with parents and peers at school 7th grader Doing well at school, As and Bs Plays on the volleyball team
  9. Objective She was vitally stable. 34 percentile for weight, 24 percentile for height On physical exam (positive findings) Abdomen was mildly distended Surgical scar present in RLQ
  10. Assessment and Plan 12 year old with Short Gut Syndrome who is doing well. She is thriving and has not needed TPN or G tube feeds in 10+ years. Appeared well in clinic. Had mild abdominal distention and her most recent CT shows a possible "transition" vs "stricture". Recommend Upper GI/SBFT to further assess this. She was advised to see our intestinal rehabilitation team as well. 2. 3. Establish care with intestinal rehab team Over-read CT here UGI/SBFT to further evaluate the poorly distended segment seen in her CT scan, possible stricture and further understand her anatomy 4. 5. She may need endoscopic assessment in the future (she is doing well now, would hold off any acute interventions) Consider lab evaluation with CBC, BMP, Hepatic function panel, GCT, INR, vitamin D, Iron studies, thyroid and celiac studies
  11. PEDIATRIC INTESTINAL FAILURE AND SHORT BOWEL SYNDROME Intestinal failure is a clinical disorder resulting from intestinal obstruction, dysmotility, surgical resection, congenital defect, or disease-associated loss of absorption Characterized by the inability to maintain protein, energy, fluid, electrolyte or micronutrient balance. IF is an umbrella term for conditions requiring parenteral support either in the form of parenteral nutrition (PN) or intravenous hydration. SBS being the most common cause of IF. An important distinction between IF and SBS in that SBS is associated with significant loss of absorptive surface area. whereas IF is a lack of satisfactorv absorption.
  12. Incidence of SBS is approximately 24.5 per 100,000 live births per year The prevalence has increased over the past several decades with improved survival of affected children Most common etiologies are necrotizing enterocolitis (NEC), gastroschisis, volvulus, intestinal atresia, complicated meconium ileus, and aganglionosis
  13. Causes of Abdominal Pain in Short Bowel Syndrome Patients Causes to rule out are linked with complications of short bowel syndrome: Gastrointestinal- gastric hypersecretion, small bowel bacterial overgrowth Surgical- bowel strictures, adhesions, intestinal ischemia Hepatobiliary- intestinal failure associated liver disease, cholelithiasis Metabolic - fluid and electrolyte abnormalities, D-Lactic acidosis, micronutrient deficiencies Renal- nephrolithiasis, chronic renal failure
  14. Small Intestinal Bacterial Overgrowth in Short Bowel Syndrome Small intestinal bacterial overgrowth (SIBO) is defined as excessive numbers of bacteria within the small bowel causing gastrointestinal symptoms (colonization of small bowel with colon derived bacteria usually in the order of > 105 cfu/ml of aspirate)
  15. Risk factors • Dysmotility (The migrating motor complex, in particular, phase Ill of the MMC clears the small bowel of debri) Anatomical disturbances in the bowel, such as- resection of Ileo-cecal valve - fistulas - diverticula and blind loops created after surgery Gastroenteritis induced alterations to the small intestine Lack of enteral nutrition - due to absence of lumenal sweep, alteration of pH Use of certain medications: - proton pump inhibitors, H2 blockers, antibiotics, probiotics.
  16. Pathogenesis Figure I Factors that protect against the development Of SIBO in health and that may be susceptible to disruption in disease.
  17. Epidemiology • Very common in patients with risk factors: 50% of these cases are children with short bowel syndrome from NEC Diagnosis of SBBO not related to bowel length or degree of enteral tolerance in these children The colon was in continuity with the residual small bowel at the time of the diagnosis. Ileocecal valve was absent in 60% > J Epub Feb The rate of bloodstream infection is high in infants with short bowel syndrome: relationship with small bowel bacterial overgrowth, enteral feeding, and inflammatory and immune responses R Cole C 2. Brian I a. g Mddings s.
  18. SIBO is usually associated with abnormally high counts of multiple organisms in the small intestine. Most common organisms are Escherichia coli and Klebsiella. Inflammation is caused by invasive strains of bacteria. Facultative anaerobes can injure the intestinal surface by direct adherence and production of enterotoxins. Aerobic bacteria produce enzymes and metabolic products that can induce epithelial cell injury MALABSORPTION
  19. Consequences.... • Carbohydrate and protein deprivation • Diarrhea from carbohydrate malabsoprtion • Deconjugation of bile acids by luminal bacteria leads to - Fat malabsorption including deficiencies in fat-soluble vitamins: Steatorrhea • Megaloblastic, macrocytic anemia - Utilization of vitamin B12 by luminal bacteria Ramotar K et al. J. Infect Dis 1984; 150:213-8 Brandt LJ et al. Ann Intern Med 1977;87:546-51
  20. Symptoms of SIBO • • • Abdominal pain or distention Foul flatulence Intolerance to previously acceptable foods Hematochezia Altered mental status Unexplained metabolic acidosis Unexplained worsening of liver injury tests
  21. Diagnosis There are invasive and non-invasive methods Non invasive such include breath tests while invasive methods comprise culture-dependant and culture-independent approaches. • Elevated numbers of bacteria in duodenojejunal aspirate or bacteria densely adherent to the mucosal surface of duodenojejunal biopsy specimens obtained during upper endoscopy > 10 5 bacteria/ml used for diagnosis • Breath tests are considered abnormal (positive) - if there was an increasing curve of hydrogen or methane by >15-20 parts per million (ppm) above baseline within 90 minutes Diagnosis is usually established with a positive carbohydrate breath test (most practical option) as culture has several limitations (due to contamination and invasive nature).
  22. Management Antibiotic therapy is generally initiated on an empiric basis. A systematic review and meta-analysis of antibiotic use in the context of SIBO found that rifaximin was by far the most commonly applied. Alternative approaches that may have application but the efficacy of which remains uncertain FODMAP (Fermentable Oligosaccharides, Disaccharides, Monosaccharides, and Polyols) diets in decreasing fermentable substrates in the context of SIBO. O Probiotics can also be considered as potential agents in the management of SIBO.
  23. O Currently, there are no set guidelines regarding diagnosis or treatment of SIBO in Short Bowel Syndrome children. O Given the heterogenous and non-specific nature of the disease, it is sometimes challenging to decide in whom to initiate SIBO diagnostic work-up. O It is important to first rule out signs and symptoms (i.e., red flags) that may indicate diseases other than SIBO.
  24. 2022 May; 3(2): e185. Published online 2022 Mar 17. dot 10 1097/pcgg 0000000000000185 PMCID: PMC10158461 PMID 37168915 Small Intestinal Bacterial Overgrowth in Children: Clinical Features and Treatment Response MD, MS,x• Rebecca_m-Gardner, MS,t Mahe2!lA-Hassan, MD,t KustQQbgc_Kapphann, MS,t and Ann-Ming-Yeb, MD: Author information Article notes Copyright and License information RMC Dvsclaimer
  25. Objectives: To characterize the population of children diagnosed with small intestinal bacterial overgrowth (SIBO) based on breath test (BT), correlate symptomatology, and describe SIBO treatments and treatment efficacy. Methods: A retrospective cohort study of pediatric patients seen at Stanford Children's Health Gastroenterology Clinics from 2012 to 2018 who had a positive BT, defined by a rise in hydrogen by 220 ppm, a baseline hydrogen level 220 ppm, or a methane value 210 ppm. The main outcome was symptom resolution, defined as complete or partial improvement after a course of treatment. Absolute standardized differences and Chi-square tests were used to assess associations. Treatment modality- antibiotics, probiotics with or without—--- antibiotics studied: rifaximin, metronidazole, cephalexin, amoxicillin-clavulanic acid, neomycin, ciprofloxacin, trimethoprim-sulfamethoxazole
  26. Results: Complete or partial resolution of symptoms was achieved in 13 of 16 (81.2%) patients who ecceived probiotics with or without antibiotics versus 21 of 31 (67.7%) patients treated with antibioti alone (P = 0.524). Metronidazole versus rifaximin versus other antibiotics showed no significant difference in symptom resolution (12 (63.2%), 13 (76.5%), 7 (77.8%), respectively, P = 0.601). Conclusion: Seventy-two percent of patients experienced at least partial symptom relief after treatment. We did not find a strong correlation between specific symptoms and analyte elevation. There was no difference in effectiveness between metronidazole and rifaximin to treat SIBO symptoms. Further research needs to be done to determine effective treatments for SIBO in pediatrics.
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