Short bowel syndrome medical therapy: Difference between revisions
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** 3 '''Trophic agents'''<ref name="pmid25052938">{{cite journal |vauthors=Bechtold ML, McClave SA, Palmer LB, Nguyen DL, Urben LM, Martindale RG, Hurt RT |title=The pharmacologic treatment of short bowel syndrome: new tricks and novel agents |journal=Curr Gastroenterol Rep |volume=16 |issue=7 |pages=392 |year=2014 |pmid=25052938 |doi=10.1007/s11894-014-0392-2 |url=}}</ref> | ** 3 '''Trophic agents'''<ref name="pmid25052938">{{cite journal |vauthors=Bechtold ML, McClave SA, Palmer LB, Nguyen DL, Urben LM, Martindale RG, Hurt RT |title=The pharmacologic treatment of short bowel syndrome: new tricks and novel agents |journal=Curr Gastroenterol Rep |volume=16 |issue=7 |pages=392 |year=2014 |pmid=25052938 |doi=10.1007/s11894-014-0392-2 |url=}}</ref> | ||
*** 3.1 Growth hormone<ref name="pmid16770169">{{cite journal |vauthors=Steiger E, DiBaise JK, Messing B, Matarese LE, Blethen S |title=Indications and recommendations for the use of recombinant human growth hormone in adult short bowel syndrome patients dependent on parenteral nutrition |journal=J. Clin. Gastroenterol. |volume=40 Suppl 2 |issue= |pages=S99–106 |year=2006 |pmid=16770169 |doi=10.1097/01.mcg.0000212680.52290.02 |url=}}</ref> | *** 3.1 Growth hormone<ref name="pmid16770169">{{cite journal |vauthors=Steiger E, DiBaise JK, Messing B, Matarese LE, Blethen S |title=Indications and recommendations for the use of recombinant human growth hormone in adult short bowel syndrome patients dependent on parenteral nutrition |journal=J. Clin. Gastroenterol. |volume=40 Suppl 2 |issue= |pages=S99–106 |year=2006 |pmid=16770169 |doi=10.1097/01.mcg.0000212680.52290.02 |url=}}</ref> | ||
**** Preferred regimen (1): Somatropin 0.03-0.14 mg/kg SC qd for up to 4 weeks (not to exceed 8 mg/day) | **** Preferred regimen (1): Somatropin 0.03-0.14 mg/kg SC qd for up to 4 weeks (not to exceed 8 mg/day) '''(Contraindicated in malignancy, or with acute critical illness in intensive care units)''' | ||
*** 3.2 Glutamine | *** 3.2 Glutamine | ||
**** Preferred regimen (1): Glutamine 0.16 g/kg IV qd | **** Preferred regimen (1): Glutamine 0.16 g/kg IV qd |
Revision as of 15:06, 5 December 2017
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Medical Therapy
- Management of short bowel syndrome is complicated and requires close collaboration of all medical team members including the physician, nutritionist, and nurse with the patient and their families.[1][2]
- Management of short bowel syndrome consists of medical therapy and surgical interventions.[3][4][5][6][7][8][9][10][11][12]
- Medical therapy consists of nutritional therapy and pharmacotherapy.
- Lifelong follow-up is usually needed.
Nutritional therapy
- Nutritional therapy is essential for short bowel syndrome and to restore the intestinal adaptation. It could be provided through oral, enteral and parenteral routes.
- Parenteral nutrition should be started after intestinal resection.
- The ultimate goal is to provide necessary nutrients via oral route other than parenteral or enteral routes.
- Required diet must be started as soon as possible after surgery. However the composition of their diet would be different depends on their situation.
- All patients require enough fluid, electrolytes, supplements and calories.
- 1 Fluid
- 1.1 Acute phase
- Preferred regimen (1): Normal saline
- Preferred regimen (1): Ringer lactate
- 1.2 Maintenance phase
- Oral rehydration solutions (ORS)
- Water
- Sports drinks
- Sodas without caffeine
- Salty broths
- 1.1 Acute phase
- 1 Fluid
- Note (1): 300-500 ml must be added to fluid loss as an insensible loss.
- Note (2): Urine output should be at least 1 L per day.
- 2 Diet
- Preferred regimen (1): 30-40 kcal/kg/day diet consists of carbohydrate 55-60%, fat 20-25%, and protein 20%
- 2 Diet
- Note (1): Small and frequent diet is recommended.
- Note (2): Foods high in sugar, protein, fat, and fiber must be avoided.
- Note (3): Patients with preservation of the colon require diet rich in carbohydrates but low fat.
- Note (4): Patients with ileal resection more than 100cm, require low oxalate and high calcium diet.
- Note (5): Patients who have diarrhea more than 3L per day, must avoid high levels of fiber in their diet.
- Note (6): Medium-chain triglycerides should be avoided in patients with a jejunostomy or ileostomy.
- Note (7):
- Note (8):
- 3 Supplement
- 3.1 Electrolytes
- 3.1.1 Sodium
- 3.1.2 Potassium
- 3.1.3 Magnesium
- 3.2 Vitamins
- 3.2.1 Vitamin A
- Preferred regimen (1): Vitamin A 10,000–50,000 U PO qd
- 3.2.2 Vitamin B12
- Preferred regimen (1): Vitamin B12 300 mcg SC qm (following terminal ileum resection)
- 3.2.3 Vitamin C
- Preferred regimen (1): Vitamin C 200–500 mg PO qd
- 3.2.4 Vitamin D
- Preferred regimen (1): Vitamin D 1600 U PO qd
- 3.2.5 Vitamin E
- Preferred regimen (1): Vitamin E 30 IU PO qd
- 3.2.6 Vitamin K
- Preferred regimen (1): Vitamin K 10 mg PO qw
- 3.2.1 Vitamin A
- 3.3 Minerals
- 3.3.1 Calcium
- Preferred regimen (1): Calcium 1000-1500 mg PO qd
- 3.3.2 Iron
- 3.3.3 Zinc
- Preferred regimen (1): Zinc 220–440 mg PO qd
- 3.3.4 Selenium
- Preferred regimen (1): Selenium 60–100 mg PO qd
- 3.3.1 Calcium
- 3.4 Exogenous enzyme replacement
- 3.4.1 Pancreatic enzyme
- Preferred regimen (1): Pancreatin 25,000-40,000 U PO per meal
- 3.4.2 Lactase
- 3.4.1 Pancreatic enzyme
- 3.5 Bile acid sequestrants
- 3.6 Probiotics
- 3.7 Essential amino acids
- Preferred regimen (1): Essential amino acids 186 mg/kg PO qd
- 3.1 Electrolytes
- 3 Supplement
Pharmacotherapy
- Medications are used to control symptoms of short bowel syndrome. They include:
- 1 Antimotility agents
- Preferred regimen (1): Loperamide 4-16 mg PO qd
- Preferred regimen (2): Codeine phosphate 30-60 mg PO q6h as needed
- Preferred regimen (3): Lomotil (diphenoxylate and atropine) 2.5-7.5 mg q6h (maximum 30 mg per day)
- Alternative regimen (1): Cholestyramine 24 g PO qd (recommended for patients with an intact colon and partial ileal resection of <100 cm)
- Alternative regimen (2): Codeine 60 mg IM q4h
- Alternative regimen (3): Tincture of opium 5-10 mL PO q4h
- 1 Antimotility agents
- Note (1): Antimotility agents reduce peristalsis and increase transit time which improve nutrient absorption.
- Note (2): Antimotility agents must be used 30 minutes before meal and at bedtime.
- Note (3): Patients who receive opiates to control their diarrhea must be closely monitored.
- 2 Antisecretory agents
- 2.1 Histamine H2 antagonists
- Preferred regimen (1): Ranitidine 300-600 mg PO qd
- Preferred regimen (2): Famotidine 40-80 mg PO qd
- 2.2 Proton pump inhibitors
- Preferred regimen (1): Omeprazole 40 mg PO BID or TID
- 2.3 Somatostatin analogue
- Preferred regimen (1): Octreotide 100 mcg SC q8h (maximum 1,500 mcg per day)
- 2.4 Clonidine 0.1–0.2 mg PO q12h
- 2.1 Histamine H2 antagonists
- 3 Trophic agents[3]
- 3.1 Growth hormone[13]
- Preferred regimen (1): Somatropin 0.03-0.14 mg/kg SC qd for up to 4 weeks (not to exceed 8 mg/day) (Contraindicated in malignancy, or with acute critical illness in intensive care units)
- 3.2 Glutamine
- Preferred regimen (1): Glutamine 0.16 g/kg IV qd
- Preferred regimen (2): Glutamine 30 g PO qd
- 3.3 Glucagon-like peptide-2 analogue
- Preferred regimen (1): Teduglutide 0.1–0.2 mg PO q12h (Contraindicated in patients with current or a past malignancy, except for basal cell carcinoma)
- 3.1 Growth hormone[13]
- 2 Antisecretory agents
Follow-up
- Close long-term follow-up is needed.
- Monitoring and measuring blood levels of nutrients are required.[14]
Table below summarizes the tests and imaging studies which are required in patients with short bowel syndrome when discharge from the hospital.
Measurement | Frequency |
---|---|
Clinic visit | Every 6 to 12 months |
Weight | Every week to check for malnutrition and dehydration |
Intake and output | Every 1 to 4 weeks to check for malnutrition and dehydration |
Comprehensive metabolic panel including magnesium | Every 4 weeks to check for malnutrition and dehydration |
Essential fatty acids | Every 6 to 12 months to check for malnutrition |
Vitamin levels | Every 6 to 12 months to check for malnutrition |
Minerals | Every 6 to 12 months to check for malnutrition |
Liver function tests | Every 6 months to check for liver disease |
Dual-energy x-ray absorptiometry scan | Every 2 years to check for osteoporosis |
References
- ↑ Matarese LE, Steiger E (2006). "Dietary and medical management of short bowel syndrome in adult patients". J. Clin. Gastroenterol. 40 Suppl 2: S85–93. doi:10.1097/01.mcg.0000212678.14172.7a. PMID 16770167.
- ↑ Kelly DG, Tappenden KA, Winkler MF (2014). "Short bowel syndrome: highlights of patient management, quality of life, and survival". JPEN J Parenter Enteral Nutr. 38 (4): 427–37. doi:10.1177/0148607113512678. PMID 24247092.
- ↑ 3.0 3.1 Bechtold ML, McClave SA, Palmer LB, Nguyen DL, Urben LM, Martindale RG, Hurt RT (2014). "The pharmacologic treatment of short bowel syndrome: new tricks and novel agents". Curr Gastroenterol Rep. 16 (7): 392. doi:10.1007/s11894-014-0392-2. PMID 25052938.
- ↑ Rodrigues, Gabriel; Seetharam, Prasad (2011). "Short bowel syndrome: A review of management options". Saudi Journal of Gastroenterology. 17 (4): 229. doi:10.4103/1319-3767.82573. ISSN 1319-3767.
- ↑ Wall, Elizabeth A. (2013). "An Overview of Short Bowel Syndrome Management: Adherence, Adaptation, and Practical Recommendations". Journal of the Academy of Nutrition and Dietetics. 113 (9): 1200–1208. doi:10.1016/j.jand.2013.05.001. ISSN 2212-2672.
- ↑ Thompson, Jon S.; Weseman, Rebecca; Rochling, Fedja A.; Mercer, David F. (2011). "Current Management of the Short Bowel Syndrome". Surgical Clinics of North America. 91 (3): 493–510. doi:10.1016/j.suc.2011.02.006. ISSN 0039-6109.
- ↑ Eça, Rosário; Barbosa, Elisabete (2016). "Short bowel syndrome: treatment options". Journal of Coloproctology. 36 (4): 262–272. doi:10.1016/j.jcol.2016.07.002. ISSN 2237-9363.
- ↑ Keller J, Panter H, Layer P (2004). "Management of the short bowel syndrome after extensive small bowel resection". Best Pract Res Clin Gastroenterol. 18 (5): 977–92. doi:10.1016/j.bpg.2004.05.002. PMID 15494290.
- ↑ Misiakos EP, Macheras A, Kapetanakis T, Liakakos T (2007). "Short bowel syndrome: current medical and surgical trends". J. Clin. Gastroenterol. 41 (1): 5–18. doi:10.1097/01.mcg.0000212617.74337.e9. PMID 17198059.
- ↑ Matarese LE, O'Keefe SJ, Kandil HM, Bond G, Costa G, Abu-Elmagd K (2005). "Short bowel syndrome: clinical guidelines for nutrition management". Nutr Clin Pract. 20 (5): 493–502. doi:10.1177/0115426505020005493. PMID 16207689.
- ↑ Sundaram A, Koutkia P, Apovian CM (2002). "Nutritional management of short bowel syndrome in adults". J. Clin. Gastroenterol. 34 (3): 207–20. PMID 11873098.
- ↑ Vanderhoof JA, Young RJ (2003). "Enteral and parenteral nutrition in the care of patients with short-bowel syndrome". Best Pract Res Clin Gastroenterol. 17 (6): 997–1015. PMID 14642862.
- ↑ Steiger E, DiBaise JK, Messing B, Matarese LE, Blethen S (2006). "Indications and recommendations for the use of recombinant human growth hormone in adult short bowel syndrome patients dependent on parenteral nutrition". J. Clin. Gastroenterol. 40 Suppl 2: S99–106. doi:10.1097/01.mcg.0000212680.52290.02. PMID 16770169.
- ↑ Wilmore, Douglas W.; Robinson, Malcolm K. (2014). "Short Bowel Syndrome". World Journal of Surgery. 24 (12): 1486–1492. doi:10.1007/s002680010266. ISSN 0364-2313.