Short bowel syndrome pathophysiology: Difference between revisions
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==Overview== | ==Overview== | ||
==Pathophysiology== | ==Pathophysiology== | ||
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*The [[jejunum]], second portion of [[small intestine]], is responsible to absorb [[Nutrient|nutrients]]. The inner surface of the [[jejunum]] is covered in [[villus|villi]], which increase the surface area of [[Tissue (biology)|tissue]] available to absorb [[Nutrient|nutrients]] from the [[Gastrointestinal tract|gut]] contents. The [[Villus|villi]] in the [[jejunum]] are much longer than in the [[duodenum]] or [[ileum]]. It has many large [[circular folds]] in its [[submucosa]] called [[Circular folds|plicae circulares]], which increase the surface area for [[nutrient]] [[absorption]]. | *The [[jejunum]], second portion of [[small intestine]], is responsible to absorb [[Nutrient|nutrients]]. The inner surface of the [[jejunum]] is covered in [[villus|villi]], which increase the surface area of [[Tissue (biology)|tissue]] available to absorb [[Nutrient|nutrients]] from the [[Gastrointestinal tract|gut]] contents. The [[Villus|villi]] in the [[jejunum]] are much longer than in the [[duodenum]] or [[ileum]]. It has many large [[circular folds]] in its [[submucosa]] called [[Circular folds|plicae circulares]], which increase the surface area for [[nutrient]] [[absorption]]. | ||
*The [[ileum]], third portion of [[small intestine]], is responsible to absorb [[vitamin B12]] and [[bile salts]] and whatever products of [[digestion]] that were not absorbed by the [[jejunum]]. Its surface is made up of folds, mainly [[villi]] and [[microvilli]]. Therefore the [[ileum]] has an extremely large surface area both for the [[adsorption]] of [[enzymes]] and for the [[absorption]] of products of [[digestion]]. The diffuse neuroendocrine system (DNES) [[Cell (biology)|cells]] that line the [[ileum]] contain the [[protease]] and [[carbohydrase]] [[enzymes]] ([[gastrin]], [[secretin]], [[cholecystokinin]]) responsible for the final stages of [[protein]] and [[carbohydrate]] [[digestion]]. | *The [[ileum]], third portion of [[small intestine]], is responsible to absorb [[vitamin B12]] and [[bile salts]] and whatever products of [[digestion]] that were not absorbed by the [[jejunum]]. Its surface is made up of folds, mainly [[villi]] and [[microvilli]]. Therefore the [[ileum]] has an extremely large surface area both for the [[adsorption]] of [[enzymes]] and for the [[absorption]] of products of [[digestion]]. The diffuse neuroendocrine system (DNES) [[Cell (biology)|cells]] that line the [[ileum]] contain the [[protease]] and [[carbohydrase]] [[enzymes]] ([[gastrin]], [[secretin]], [[cholecystokinin]]) responsible for the final stages of [[protein]] and [[carbohydrate]] [[digestion]]. | ||
===Pathogenesis=== | ===Pathogenesis=== | ||
*Short bowel syndrome is the result of [[bowel resection]] following various causes including [[Crohn's disease]], [[Cancer|malignancies]], [[ischemia]], and [[Physical trauma|trauma]].<ref name="pmid11873098">{{cite journal |vauthors=Sundaram A, Koutkia P, Apovian CM |title=Nutritional management of short bowel syndrome in adults |journal=J. Clin. Gastroenterol. |volume=34 |issue=3 |pages=207–20 |year=2002 |pmid=11873098 |doi= |url=}}</ref> | *Short bowel syndrome is the result of [[bowel resection]] following various causes including [[Crohn's disease]], [[Cancer|malignancies]], [[ischemia]], and [[Physical trauma|trauma]].<ref name="pmid11873098">{{cite journal |vauthors=Sundaram A, Koutkia P, Apovian CM |title=Nutritional management of short bowel syndrome in adults |journal=J. Clin. Gastroenterol. |volume=34 |issue=3 |pages=207–20 |year=2002 |pmid=11873098 |doi= |url=}}</ref> | ||
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sadaf Sharfaei M.D.[2]
Overview
Pathophysiology
Physiology
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The small intestine has an average length of 5.5-6 meter and is responsible for digestion and absorption of food and nutrients. Three portions of small intestine are duodenum, jejunum, and ileum. There is an anatomic gradient for absorption throughout the gastrointestinal tract.[2][3]
- The duodenum, first portion of small intestine, is responsible for the breakdown of food in the small intestine. Brunner's glands, which secrete mucus, are found in the duodenum.
- The jejunum, second portion of small intestine, is responsible to absorb nutrients. The inner surface of the jejunum is covered in villi, which increase the surface area of tissue available to absorb nutrients from the gut contents. The villi in the jejunum are much longer than in the duodenum or ileum. It has many large circular folds in its submucosa called plicae circulares, which increase the surface area for nutrient absorption.
- The ileum, third portion of small intestine, is responsible to absorb vitamin B12 and bile salts and whatever products of digestion that were not absorbed by the jejunum. Its surface is made up of folds, mainly villi and microvilli. Therefore the ileum has an extremely large surface area both for the adsorption of enzymes and for the absorption of products of digestion. The diffuse neuroendocrine system (DNES) cells that line the ileum contain the protease and carbohydrase enzymes (gastrin, secretin, cholecystokinin) responsible for the final stages of protein and carbohydrate digestion.
Pathogenesis
- Short bowel syndrome is the result of bowel resection following various causes including Crohn's disease, malignancies, ischemia, and trauma.[4]
- The small intestine has a very good adaptation following bowel resection of up to half of the small bowel length. However, the small intestine less than 2 meters is considered as short bowel syndrome and requires nutritional therapy to prevent malnutrition.[5]
Post bowel resection adaptation
- Adaptation is the specific ability of the intestine to increase its capacity to absorb nutrients following loss of its surface and length.[6][7]
- There will be structural, motility and functional changes in the remaining intestine to compensate its loss.[2][5]
- Changes usually starts in the first 24 hours following bowel resection.[8]
| Change | Main features |
|---|---|
| Structural changes |
|
| Motility changes | |
| Functional changes |
|
- Adaptation depends on multiple factors including individual, intestinal and therapeutic measurements.[6]
- Adaptation is usually occurred during the first two years after the bowel resection.
- Successful adaptation depends on the length of remaining intestine, portion of the resected intestine, early introduction of nutrition therapy. Total intestinal adaptation defines as when patient is weaned from parenteral nutrition.[9]
- Following the bowel resection, adaptation occurs in three phases including acute, adaptive, and maintenance phases.[10]
| Intestinal adaptation | ||
|---|---|---|
| Phase | Duration | Main feature |
| Acute phase | 1 to 3 months |
|
| Adaptive phase | 1 to 2 years |
|
| Maintenance phase | Following adaptive phase |
|
- There are factors which stimulate the intestinal adaptation, including:[11]
- Oral nutrients
- Soluble fibres such as polysaccharides present in pectin and soy
- Hydrolysed or whole protein formula
- Polyamines
- Long-chain triglycerides and short-chain fatty acids
- Glucagon-like peptide 2 (GLP-2)
- Secretin
- Cholecystokinin
- Neurotensin
- Insulin-like growth factor I
- Glutamine
- There are factors which decrease the intestinal adaptation, including:
- Starvation
- Absence of luminal nutrients
- Absence of pancreato-biliary secretions
- Monosaccharides
Malabsorption
- The main reasons for malabsorption following bowel resection include:
- Reduced absorption capacity of the small intestine due to loss of surface area, leading to:
- Loss of fluid and dehydration
- Electrolyte imbalance
- Loss of Macronutrients including carbohydrates, lipids and proteins
- Disturbance in production of enzymes and hormones, leading to:
- Diarrhea
- Steatorrhea
- Loss of vitamins
- Resection of specific sites, leading to:
- Loss of absorption of vitamin B12 and bile salts
- Reduced capacity of fluid retention
- Loss of ileocecal valve, leading to:
- Small bowel bacterial overgrowth
- Increased gastric and intestinal transit
- Compromised production of gastrointestinal regulators including cholecystokinin, secretin, gastric inhibitory polypeptide and peptide YY, leading to:
- Increased gastric and intestinal transit
- Hypergastrinemia
- Reduced absorption capacity of the small intestine due to loss of surface area, leading to:
Associated Conditions
Short bowel syndrome might be associated with following pathologies:
- Mesenteric vascular events including thrombosis or occlusion of the superior mesenteric artery or vein
- Crohn's disease
- Malignancy
- Radiation enteritis
- Volvulus
- Adhesions
- Jejunoileal bypass surgery to treat obesity
- Trauma to the small intestine
- Internal hernia
Gross Pathology
- On gross pathology, the resected bowel may show the underlying causes including Crohn's disease, malignancies or ischemia.
 |
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Microscopic Pathology
- On microscopic histopathological analysis, the resected bowel may show the underlying causes including Crohn's disease, malignancies or ischemia.
References
- ↑ "File:Diagram of the small bowel 01 CRUK 045.svg - Wikimedia Commons".
- ↑ 2.0 2.1 Tappenden KA (2014). "Pathophysiology of short bowel syndrome: considerations of resected and residual anatomy". JPEN J Parenter Enteral Nutr. 38 (1 Suppl): 14S–22S. doi:10.1177/0148607113520005. PMID 24500909.
- ↑ Thomson, Alan B.R.; Drozdowski, Laurie; Iordache, Claudiu; Thomson, Ben K.A.; Vermeire, Severine; Clandinin, M. Tom; Wild, Gary (2003). Digestive Diseases and Sciences. 48 (8): 1546–1564. doi:10.1023/A:1024719925058. ISSN 0163-2116. Missing or empty
|title=(help) - ↑ Sundaram A, Koutkia P, Apovian CM (2002). "Nutritional management of short bowel syndrome in adults". J. Clin. Gastroenterol. 34 (3): 207–20. PMID 11873098.
- ↑ 5.0 5.1 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.
- ↑ 6.0 6.1 Warner, Brad W. (2013). "Adaptation: Paradigm for the gut and an academic career". Journal of Pediatric Surgery. 48 (1): 20–26. doi:10.1016/j.jpedsurg.2012.10.014. ISSN 0022-3468.
- ↑ Rowland, Kathryn J.; McMellen, Mark E.; Wakeman, Derek; Wandu, Wambul S.; Erwin, Christopher R.; Warner, Brad W. (2012). "Enterocyte expression of epidermal growth factor receptor is not required for intestinal adaptation in response to massive small bowel resection". Journal of Pediatric Surgery. 47 (9): 1748–1753. doi:10.1016/j.jpedsurg.2012.03.089. ISSN 0022-3468.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ "File:ResectedIleum.jpg - Wikimedia Commons". External link in
|title=(help) - ↑ "File:Crohn Jejunum.PNG - Wikimedia Commons".