Clinical problems of a short bowel and their treatment

Abstract

Sir David Cutherbertson was a chemist before qualifying in medicine. During his first job as a clinical biochemist at the Royal Infirmary in Glasgow, a clinician asked him if he could help solve the problem of the non-union of fractures of the lower third of the tibia. He accepted this challenge and set up a six-bedded metabolic ward. There he performed careful balance studies on patients who had experienced trauma. It was from this work that he described an initial period of reduced metabolism and hyperglycaemia following injury (ebb period); this was followed by a period of increased metabolism and increased protein catabolism (flow phase). His work did not stop there. He went on to show that the magnitude of the N loss during the flow period could be reduced by giving protein and nutrient supplements (Widdowson, 1991).The work presented here follows his example. I shall describe the clinical problems experienced by patients with a short bowel. With the use of balance studies the problems of water, electrolyte and energy absorption are demonstrated and appropriate treatments are evaluated. WHAT I S A SHORT B O W E L ? Small-bowel length in normal subjectsSmall-intestinal length has been measured surgically, radiologically and at autopsy. Bryant (1924) very carefully measured the small-intestinal length from the duodenojejunal flexure to the ileo-caecal valve at 160 autopsies. The mean small-bowel length was 6.2 m, with the mean for women being shorter than that for men. He showed a wide variation in normal human small-intestinal length from 3.0 to 8.5 m. The results he obtained are similar to those obtained at surgery (Backman & Hallberg, 1974;Slater & Aufses, 1991), but slightly longer than those obtained radiologically (Hirsch et al. 1956;Fanucci et al. 1984).In a patient with a total small-intestinal length of 8.5 m a resection of 2.0 m will make little difference, but if the starting length is 3-0 m the same resection may cause major problems. Thus, it is important to refer to the residual length of small intestine rather than to the amount resected.

Clinical outcome of long-term home parenteral nutrition in non-oncological patients: a report from two specialised centres

“…Weaning off HPN after intestinal adaptation and/or rehabilitative surgery is expected in about half of the HPN patients with non-malignant diseases [11,18]. In particular, recovery to full oral nutrition at 1 year has been foreseen in 70% of Crohn's disease patients but only in 26% of oncologic patients [6][7][8][9][10][11][12].…”

Guidelines for management of patients with a short bowel

“…[111][112][113][114][115][116][117][118][119] The greatest reductions in intestinal output are in those with a net secretory output, and the volume of parenteral supplements needed may be reduced. [115][116][117][118][119] The reduction in sodium output parallels that of intestinal output 111-119 while magnesium balance is unchanged. 112 117 Total energy 115 118 119 and nitrogen 111 113 117-119 absorption are not significantly changed while fat absorption may be unchanged [117][118][119] or reduced.…”

Causes and management of a high-output stoma

“…Management of a HOS includes the identification and treatment of any cause for the high output, reduction and replacement of water and electrolyte losses [initially via the intravenous (iv) route], oral hypotonic fluid restriction with the use of glucose ⁄ electrolyte solution [9,11,12], anti diarrhoeal [13][14][15] and anti secretory medication [9,[16][17][18][19][20][21][22][23], nutritional support, wound care and psychological support.…”