Enteral and Parenteral Nutrition in Patients with Short-Bowel Syndrome

Abstract

Short-bowel syndrome is functionally defined as a state of malabsorption following loss of small bowel. Most cases occur in the neonatal period after extensive resection for necrotizing enterocolitis, or due to congenital anomalies of the gastrointestinal tract. A smaller percentage originate later in life from surgical treatment of Crohn's disease, neoplastic disorders, or vascular events. The physiological, morphological and functional intestinal gradient determines the clinical picture leading to better tolerance of jejunal than ileal resections. The subsequent adaptation process requires enteral feeding with a different impact of specific nutrients, and is also influenced by a number of humoral mediators such as enteroglucagon, gastrin, growth factors, prostaglandins and polyamines. Nutritional management starts parenterally via a central venous line covering basic demands, substituting current losses and restoring pre-existing deficiencies. Continuous enteral tube feeding is added as soon as postoperative ileus resolves, beginning with an elemental diet, which is gradually increased first in concentration, then in quantity, and supplemented by small oral meals. Cycling of parenteral nutrition is the next step. As soon as sufficient stability is reached, the child should be discharged home under continued outpatient care. Main long-term problems comprise bacterial overgrowth, fluid and electrolyte disequilibration, nutritional deficiencies, parenteral nutrition-related liver disease, and central venous line complications such as sepsis and thrombosis.

Parenteral arginine impairs intestinal adaptation following massive small bowel resection in a rat model

“…4) compared with sham animals (group A). The reported changes are consistent with results of our previous studies [23][24][25] and with data presented by other investigators [9][10][11]. Following parenteral arginine administration (group C), SBS rats demonstrated a significant decrease in ileal overall bowel (43±4 vs. 51±2, p<0.05) and mucosal weight (14±2 vs. 18±1, p<0.05), mucosal DNA content in jejunum (55±7 vs. 92±12 lg/cm/100 g, p<0.05) and protein content in ileum (30±6 vs. 51±6 lg/cm/100 g, p<0.05), villus height in jejunum (712±128 vs. 1009±64 lm, p<0.05) and ileum (493±58 vs. 622±65 lm, p<0.05), and crypt depth in jejunum (167±2 vs. 235±25 lm, p<0.05) and ileum (159±13 vs. 201±14 lm, p<0.05) compared with SBS-untreated animals (group B).…”

“…A large number of nutrients, hormones, and peptide growth factors are known to stimulate intestinal adaptation. Luminal nutrients appear to be particularly important [24]. It has been reported that prolonged ''bowel rest'' together with total parenteral nutrition may impair intestinal adaptation and the ability of such patients to achieve nutritional autonomy.…”

Dietary fat for infants with enterostomies

“…Amino acid-based complete enteral formulations have been shown to improve tolerance in infants with short gut, decreasing the need for parenteral nutrition [13]. Maternal breast milk has also been suggested as being beneficial in improving tolerance of enteral feeds [14]. Mucous fistula refeeding has been shown to be an alternative method to improve absorption and prevent disuse atrophy of the distal bowel, although skin breakdown, bag leakage, and difficulties in performing in the home environment may make this a less desirable method [15,16].…”

Effects of bowel rehabilitation and combined trophic therapy on intestinal adaptation in short bowel patients

“…So, oral diet is encouraged, if there is any absorptive capacity of the remaining bowel, bowel adaptation should be promoted. An enteral tube feeding might be used to supplement the diet in an effort to wean patients from TPN [16] . At first, diluted solutions of chemically defined diets containing simple amino acids and short-chain peptides were offered.…”