Nutritional Management of Short Bowel Syndrome PDF
Nutritional Management of Short Bowel Syndrome PDF
Nutritional Management of Short Bowel Syndrome PDF
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Fig. 1.
Anatomy of the portion of intestine left in SBS, from left to right: type 1 – with end-jejunostomy formed (SBS-J); type 2 –
jejuno-colonic anastomosis with part of the colon in continuity (SBS-JC); type 3 – jejuno-ileal anastomosis with ileo-cecal
valve and the entire colon in continuity (SBS-JIC)
Source: own compilation.
In the course of SBS, 3 phases are distinguished: of the intestine left [5]. Adaptation changes (villous
acute phase, adaptation phase, and stabilisation hyperplasia, deepening of the crypts, increase in the
phase. The acute phase lasts, on average, for 3-4 weeks enzymatic activity of the brush border) are related
after resection. An excessive secretion of gastric juice with an increase in the area and mass of the intestinal
and disorders in the secretion of gastrointestinal hor- mucosa, and consequently, an increase in the absorp-
mones and neuromodulators usually persist for up to tion of nutrients, minerals, water, and electrolytes
6 months [2]. In order to avoid serious complications [5,9]. The adaptation process takes place most inten-
in the acute phase, such as dehydration and acute re- sively during the first 2 years after resection; however,
nal failure, electrolyte deficiency or metabolic acido- an increase in the capability for absorption of nutri-
sis, it is necessary to monitor the state of the patient in ents, water and electrolytes by the intestine left is also
hospital conditions [2]. In the acute phase, oral nutri- possible during the later period [5,9]. Nutrients ad-
tion is contraindicated considering an increase in flu- ministered to the intestinal lumen, through trophic
id loss from the gastrointestinal tract, and therefore stimulation of the intestinal epithelium, increase in
an increased number of defecations. The demand for blood flow, regulation of secretion of the pancreatic
nutrients, minerals, fluids and electrolytes is entirely juice and intestinal hormones, exert an effect on the
covered via the parenteral route. activity of the intestinal neurons and intestinal motil-
In the adaptation phase, there occurs a gradual ity [5,9]. The volume of enteral nutrition should be
regaining of efficiency by the intestine. During this gradually increased, paying attention to the number
time, the patient requires HPN, compensating for of defecations [5]. Due to intestinal adaptation, in
water-electrolyte disorders and the deficiency of nu- a considerable number of patients with SBS it is pos-
trients [2]. In parallel, rehabilitation of the intestine is sible to limit the supply of nutrients and water ad-
also carried out, including dietary care and pharma- ministered via the parenteral route to the benefit of
cological treatment, mainly of disorders on the part enteral nutrition, including orally [9].
of the gastrointestinal tract [7]. Intestinal adaptation At the final stabilization phase the intestine left ob-
leads to structural and functional changes increasing tains the maximum degree of absorption capability.
the absorption of nutrients and fluids in the portion However, the achievement of nutritional autonomy is
not possible in all patients, and this depends, among of body composition using measurements of bioelec-
other things, on the length of the intestine left [7]. trical impedance, resistance and reactance. The BIVA
The goal of treatment of patients with SBS is the method allows an overall assessment of hydration
provision of a proper supply of nutrients, vitamins, and mass of soft tissues in any clinical condition [11].
electrolytes and water, indispensable for the mainte- P.G. Fassini et al. confirmed that in patients with SBS,
nance of the normal status of nutrition and hydration, BIVA was a more sensitive method in the detection
introduction of enteral nutrition, with a simultane- of changes in the state of hydration and muscle mass,
ous limitation of parenteral nutrition, decrease in the compared to the standard BIA [12]. It is emphasized
number of complications resulting from the primary that in the long-term assessment of the nutritional
disease, and the provision of an appropriate quality of status of patients with SBS, body water content and
life [1]. Properly managed nutritional therapy via the cell mass are important elements in the analysis of
parenteral route should minimize the feeling of hun- body composition [13].
ger and thirst experienced by the patient. The treat-
ment of patients with SBS frequently lasts until the
end of their life, from more than a dozen months to Basic assumptions of oral
several dozen years. The quality of treatment, its out- diet in patients with SBS
comes and the frequency of complications consider-
ably affect the quality of life of patients [7]. Nutritional therapy via the parenteral route and
a proper intravenous supply of fluids and electrolytes
play the most important role in the treatment of pa-
tients with SBS [5,6]. Appropriately adjusted oral diet
Assessment of nutritional in patients with SBS with an aligned nutritional and
and hydration status hydration status may result in an increase in absorp-
of patients with SBS tion of nutrients, vitamins and fluids from the gas-
trointestinal tract, and therefore reduce the number
Due to the reduction in the functional length of the of defecations [14]. The assumptions of an oral diet
intestine, patients with SBS are exposed to malnutri- should consider general principles referring to all pa-
tion and an excessive loss of fluids. The objective of tients with SBS, individual nutritional preferences of
the study by K.U. Jang et al. was assessment of the patients, and their experiences related with the intake
clinical factors related with the nutritional status of of specified types of products and meals [8,15]. In or-
patients who had undergone bowel resection due der to increase the probability of observance of nu-
to Crohn’s disease. The study included 394 patients. tritional recommendations by patients with SBS and
Nutritional status was assessed using the body mass increase the effectiveness of dietary management, it
index (BMI) and modified nutritional risk index is important to explain to patients the rationale of the
(mNRI). Aggravation of the primary disease, pos- applied diet modifications, imparting of information
session of ileostomy and length of the intestine left concerning the type of the recommended products
≤ 230 cm are the factors which may exert an effect and meals, and methods of their preparation [14,16].
on deterioration of the nutritional status of patients Patients with SBS should consume 6-8 low volume
after small bowel resection. However, no correlation meals during the day, slowly, exactly biting and chew-
was observed between time which had elapsed from ing every mouthful [8,15]. In association with dis-
the last surgery and the nutritional status of patients. turbed absorption related with SBS, as much as 50%
According to K.U. Jang et al., while evaluating the nu- or more of nutrients from oral diet may not be nor-
tritional status of patients after small bowel resection, mally absorbed [1]. Allowed fluids should be drunk
the results of bioelectrical impedance vector analy- between meals, instead of during meals [8].
sis (BIVA) should be taken into consideration [10]. As a result of an increase in the intestinal absorp-
BIVA is a non-invasive technique for the estimation tive surface in the process of its adaptation, changes
in nutritional status and levels of microelements in development of urolithiasis, especially when as a re-
serum, the dietary recommendations for patients sult of dehydration the amount of excreted urine
with SBS will be subject to modifications [16]. Di- decreases to less than 1 litre/daily [15]. It is possible
etary counselling in patients with SBS should be to reduce the absorption of oxalates by reduction of
managed by a qualified dietician [15]. the content in oral diet. Then, the consumption of
products which are the source of oxalates should be
limited, including, among others: beetroot, spinach,
Protein rhubarb, strawberries, chocolate, tea, wheat bran and
pulses (except for green beans) [14]. A low-fat diet
In patients with SBS, protein in the oral diet should in patients with SBS may result in an increased risk
supply from 20 – 30% of energy, most of which should of deficiency of indispensable polyunsaturated fatty
be protein with a high nutritional value, originating acids, including fatty acids of the n-3 family and fat-
from products such as meat, poultry, fish, eggs, and soluble vitamins [15].
dairy products [14,16]. In patients with SBS, a high
amount of protein is lost with intestinal contents, and
additionally, the presence of an inflammatory pro- Carbohydrates
cess increases the demand for this nutrient [8]. Dairy
products which are simultaneously the source of A high amount of simple carbohydrates in the diet
lactose should not be routinely eliminated from the contributes to an increase in its osmolarity, retention
diet when their consumption does not result in an of water in the intestinal lumen, and may be the cause
increased number of defecation in patients with SBS of osmotic diarrhea [5]. Therefore, patients with SBS
[15]. A reduced intestinal surface area, to a slight de- should avoid products with a high content of simple
gree, disturbs the absorption of nitrogen, therefore, carbohydrates: sweets, carbonated beverages, fruit
usually it is not necessary to apply diets containing juices and drinks [5]. Some simple carbohydrates, e.g.
protein in a hydrolized form [17]. fructose, are classified into fermentable oligosaccha-
rides, disaccharides, monosaccharides and polyols
(FODMAP). FODMAP pass through the gastrointes-
Fats tinal tract in an unchanged form, undergo bacterial
fermentation taking course with an enhanced pro-
Fats are the best source of calories; however, at the duction of carbon dioxide and hydrogen, and as a re-
same time, they are the nutrient which is most dif- sult of further transformations - hydrogen sulphide
ficult to digest and absorb. In some patients with SBS, and methane. They cause an accumulation of fluids
an excess of fat may result in the occurrence of fatty and gases in the lumen of the intestine result in the
stools and intensification of loss of nutrients, fat- acceleration of its motility, and for this reason may be
soluble vitamins, water and electrolytes [15,16]. The responsible for intensification of complaints on the
total content of fats in the diet of patients without part of the gastrointestinal tract, e.g. pain, diarrhea,
a colon (SBS-J), in the case of their normal tolerance, constipation, or bloating [17]. In a randomized pro-
should not exceed 40% of the energy value of oral spective study of patients with inflammatory bowel
diet [15,16]. diseases, which are among causes of bowel resection,
In patients with SBS with a preserved colon (SBS- N. Pedersen et al. confirmed the effectiveness of diet
JC, SBS-JIC), fat in the diet should constitute 20-30% with a low content of FODMAP in the reduction of
of energy value of the oral diet [1,17]. An excessive symptoms on the part of the gastrointestinal tract,
amount of fat in the diet is related with calcium and the improvement of the quality of life of patients
and magnesium and may intensify the absorption during the phase of clinical remission, compared to
of oxalates in the colon [1,17]. Therefore, patients ordinary diet [18]. Nevertheless, further studies are
with SBS-JC, SBS-JIC are especially exposed to the necessary, which would confirm the effectiveness
of a diet with a limited content of FODMAP in the reduce the number of defecations, patients with SBS
elimination of complaints on the part of the gastroin- are recommended to replace ordinary drinks by oral
testinal tract, including in patients with SBS. rehydration solutions (ORS) [19]. The absorption of
Irrespective of the anatomy of the intestine left, the sodium and water in the small intestine takes place
basic source of energy in patients with SBS should be at the concentration of sodium of at least 90 mmol/l,
complex carbohydrates with a low content of dietary in the upper part of the small intestine. In the ORS
fibre from wheat, wheat-rye, corn bread, fine cereals, preparations, in order to stimulate absorption of so-
and white rice. The addition of soluble fibre (e.g. pec- dium and water, the system of coupled transport of
tin) to the diet in order to increase intestinal absorp- sodium and glucose is used, acting mainly in the jeju-
tion is not recommended [15]. In patients with SBS, num. An optimum concentration of sodium in ORS
a moderate intake of soluble fiber is often encouraged is from 90–120 mEq Na+/l, with n optimum carbohy-
[8]. As a result of bacterial fermentation of undigested drates/sodium ratio 1: 1 [8]. Home ORS recipes are
soluble dietary fibre, in the colon are produced short- also available (Tab. 1). In order to improve the taste,
chain fatty acids (SCFA), the absorption of which may ORS may be administered in a chilled form.
be an additional source of energy [2,5]. A high amount Patients with SBS lose large amounts of sodium,
of dietary fibre in the diet of patients with SBS is not magnesium, potasium and calcium with the excret-
recommended. Fibre delays emptying of the stomach, ed intestinal content. In patients with SBS-J or ileos-
accelerates intestinal passage, and increases the num- tomy, the daily loss of sodium may reach even 105
ber of defecations [8,15]. Vegetables and fruits should mEq (2430 mg) per 1 litre of stool [8]. Therefore,
be subjected to mechanical and thermal processing in patients with SBS are recommended to additionally
order to increase their digestibility. Seeds of legume salt meals and consume salty snacks, e.g. crackers,
plants (peas, beans, lentils, soy beans), similar to gas- salty sticks, etc.
producing vegetables (onions, leaks, cabbage, cauli- In patients with SBS there often occur disturbanc-
flowers, broccoli) are usually not recommended in the es in the absorption of fat-soluble vitamins, including
diet of patients with SBS. vitamin D [5]. Among the causes of vitamin D defi-
ciency are, among others, an insufficient exposure to
sunshine, insufficient amount of products which are
Fluids and electrolytes the source of this vitamin in the diet, limited toler-
ance of products with a high-fat content in patients
In patients with SBS, the supplementation of electro- with SBS, concomitant diseases, and administered
lytes and fluids should be carried out mainly via the drugs. S. Fan et al., in the prospective study includ-
parenteral route. Thirst caused by dehydration in un- ing 60 adult patients with SBS, determined the level
balanced patients with SBS is frequently related with of vitamin D in blood serum (25-OHD) and bone
the consumption of larger amounts of water. Then, mineral density. In all patients, vitamin D deficiency
the volume of fluids secreted into the intestinal lu- was observed, despite routine oral supplementation.
men and the number of defecations increase, and the Only in 2 patients the normal bone mineral density
symptoms of dehydration aggravate [5]. In patients was noted. It was found that a low 25-OHD level was
with SBS-J, the daily consumption of liquids should related with decreased bone mass [23]. The concen-
not exceed 500 ml/daily [4]. trations of vitamins, trace elements and mineral salts
The capability for maintaining the proper hydra- in blood serum of patients with SBS should be strict-
tion status by hypotonic fluids depends on the pres- ly monitored [5]. In practice, in patients chronically
ence of the colon. In the majority of patients with SBS receiving nutritional therapy, the determination of
with the colon preserved, it is possible to maintain their levels is performed every 3 months.
proper hydration by means of hypotonic fluids [19]. General assumptions of the diet for patients with
In order to increase the intestinal absorption and SBS are summarized in Tab. 2.
Table 1.
Selected home ORS recipes – own compilation based on [20,21,22]
WHO Formula St Mark’s Elec- Home Made Basic Homema- Cranberry juice
trolyte Mix Cereal-Based de Recipe
• ½ teaspoon • 20 g glucose • ½ glass • 1 litre of • ½– ¾ glass
of salt of dry, or water of cranberry
• 2,5 g sodium
preliminarily juice
• ½ teaspoon bicarbonate • 1 glass of
cooked rice
of potassium (baking soda) orange juice • 3 and ¼ glass
flakes
chloride of water
• 3,5 g sodium • 8 teaspoons
• 2 glasses of
• 8 teaspoon of chloride of sugar • ¾ tablespoon
water
sugar (table salt) of salt
• ½ teaspoon
• ½ teaspoon
• ½ teaspoon of baking
of salt
of baking soda
Mix all
soda
ingredients • ½ teaspoon
Mix all
• 1 litre of thoroughly Combine all of salt
ingredients
water ingredients. Keep
thoroughly
refrigerated. The
Mix all
solution should
Mix all ingredients
be dense.
ingredients thoroughly
thoroughly
Table 2.
General assumptions of the diet for patients with SBS
Quality of life of patients how much and what type of food they can eat without
inducing specified symptoms on the part of the gas-
with short bowel syndrome trointestinal tract (pain, diarrhea). All participants of
the study felt safe in the knowledge that HPN covers
Symptoms related with SBS, including diarrhea or their demand for energy, nutrients, and liquids, and
a large number of defecations, stool incontinence, ab- enables regaining the original body mass from before
dominal pain, need for constant eating, and depen- the disease [28].
dence on parenteral nutrition and its potential com-
plications (e.g. septic complications, thrombosis),
exert a negative effect on the quality of life of patients Conclusions
[24,25]. The care of patients chronically receiving nu-
tritional therapy should focus not only on the prolon- 1. HPN conducted by the Clinical Nutrition
gation of survival time, but also cover an improvment Unit, is a basic strategy for the treatment of
in the quality of life (QoL) [26]. Patients dependent patients with SBS.
on HPN require regular intravenous infusions, which 2. After aligning the nutritional and hydration
usually last for 12–14 hours, 1–7 days a week. One status of the patient, intestinal rehabilitation
of the main assumptions of the study by S.T. Burden should be conducted in parallel, consisting
et al. was determination of the conditioning of QoL of proper dietary management and
in patients fed HPN, with consideration of the effect pharmacological treatment, mainly of
of the clinical situation, method of treatment, includ- disorders on the part of the gastrointestinal
ing the number of weekly performed infusions, and tract.
personal characteristics of patients. It was found that 3. Patients with SBS, in association with multi-
gender, time elapsed from the onset of HPN, educa- factor etiology, are a very diverse group of
tion and marital status, had no effect on the QoL, patients.
whereas a larger number of night HPN infusions was 4. SBS is related with a high risk of complications;
related with a decreased QoL of patients [27]. therefore, it is important to provide treatment
The possibility of consumption of meals together by a multi-specialist therapeutic team,
with loved ones and deriving pleasure from this sig- including physicians, nurses, pharmacists,
nificantly affects the QoL of patients with intestinal clinical dieticians, who are medically
failure (IF). The goal of the study by M.F. Winkler et prepared, as well as psychologists and other
al. was an attempt to provide an answer to the question specialists according to the needs.
in what way the problems related with consumption
of meals affect the quality of life of patients receiv-
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