Short bowel syndrome
The short bowel syndrome (English short bowel syndrome ) refers to a condition that is by surgical removal (resection ) or the congenital absence of large parts of the small intestine occurs.
Disease causes ( etiology )
Great small bowel surgery may be unavoidable in some diseases, despite their known adverse effects, such as in acute vascular occlusion of the intestine ( mesenteric infarction ), chronic inflammatory bowel disease Crohn's disease, in cancer in the abdomen, after radiation therapy of the abdominal region ( radiation enteritis ) or after injury with intestinal damage. In children intricacies of the bowel ( volvulus ), severe complications of prematurity ( necrotizing enterocolitis ) or congenital malformations ( Dünndarmatresie ) can make Dünndarmresektionen necessary.
Disease development ( pathogenesis )
Since the portions of the small intestine (duodenum, jejunum and ileum with ileocecal valve ) have different functions in digestion and nutrient absorption ( absorption ), it comes with removal of part of the small intestine at very different failures. It is not possible to specify exactly how much of the healthy adults, approximately four meters long small intestine have to be present to ensure a complaint-free nutrient absorption. Are more than 75 percent of the small intestine removed, but it is in any case to limitations in absorption of nutrients. The degree of discomfort depends on:
- The length and location of the removed portion of the small intestine
- The presence or absence of the more valve-like flap between the small and large intestine ( ileocecal valve ), which serves as reflux protection and bacterial barrier
- The functioning of the remaining small intestine, and the rest of the digestive tract: stomach, pancreas (pancreas) and liver
- Adaptation processes in the remaining small intestine
Complaints (symptoms )
Patients with short bowel syndrome suffer from frequent, massive diarrhea, fatty stools, lack of supply of water, macro-and micro - nutrients ( protein, fat, electrolytes, calcium, magnesium, water-and fat-soluble vitamins, especially vitamin B12) with the associated deficiency diseases and weight loss.
The diarrhea and fatty stools it comes to a fact that in the remaining small intestine reduces water and fat added ( absorbed ) are, on the other hand by the fact that upon removal of the ileum the bile salts from the bile no longer be adequately rücksorbiert. In the large intestine to stimulate the secretion of water and electrolytes, which increases the diarrhea.
Removal of the colon flap usually reinforced the complaints, as this shortens the transit time of the bolus, bacterial overgrowth of the small intestine is favored by colonic flora and the absorptive capacity of the small intestine for water and electrolytes reduced approximately by half.
Complications
In addition to the complaints directly affecting the digestive system may lead to further problems in the short bowel syndrome. These include:
- Overproduction ( hypersecretion ) of gastric acid, which arises because normally formed in the jejunum -inflammatory hormones disappear (gastric inhibitory polypeptide - GIP, Vasoactive intestinal polypeptide - VIP). The increased gastric acid diarrhea and fatty stools are exacerbated.
- Milk sugar ( lactose) intolerance by elimination of the intestinal mucosa in certain sections seated enzyme lactase. The lactose will take then degraded by the lactase by intestinal bacteria to D- lactate, which on the one hand increases the diarrhea and can lead to the other to acidosis of the body ( metabolic acidosis ).
- Gallstone formation by decreasing bile acid concentration in bile, which thus comes about that in ileal resection less bile acids are absorbed from the digested food. Since bile acids normally keep cholesterol in solution, the bile tends with decreasing bile acid concentration in the precipitation of cholesterol stones.
- Kidney stone formation: Usually oxalate is bound from food in the intestine to calcium, so is water insoluble and is excreted in the stool. However, in short- bowel syndrome, the calcium binds to not absorbed by the small intestine, fat, thereby increasing free oxalate is present, which is received in the still functioning colon and to an increase of the oxalate levels in the blood ( Hyperoxalatämie ) and in the urine ( Hyperoxalaturie ) leads. Together with the equally frequent draining the solubility threshold is exceeded slightly for oxalate, and it comes in the precipitation of oxalate stones in the urinary tract.
Treatment (therapy )
Treatment ideally starts even before bowel surgery by a possible miscarriage or pre-existing malnutrition through drinking or tube feeding is balanced.
Within the first year after the intestinal surgery, the remaining intestine adapts structurally and functionally to the new circumstances. To use the remaining maximum absorption capacity, needs the intestine continuous food contact. Therefore, it should be begun immediately following surgery with an enteral diet.
At the latest when the formation of a short bowel syndrome, the patient is tailored to their disease nutritional therapy. Case of severe malnutrition must artificially, possibly even completely through the bloodstream ( parenteral), are malnourished.
For the prevention of deficiency diseases of the blood levels of electrolytes, calcium, magnesium, phosphate, zinc, folic acid and vitamin B12 is to monitor and possibly compensate by increasing dose. Vitamin B12 is to be administered intramuscularly, when the last section of the ileum ( terminal ileum ) is missing, in which the vitamin is normally absorbed.
In case of overproduction of stomach acid should be treated with a proton pump inhibitor such as omeprazole. This usually improves the diarrhea.
In severe steatorrhea a high-carbohydrate diet is displayed. The proportion of medium-chain triglycerides (MCT) in the triglycerides should be increased to 50 to 75 percent.
To prolong the transit time of the bolus, it may help not to drink during meals.
Overall, the treatment should be as far as possible adapted to the individual situation of the patient in spite of the severity of the condition to allow him a maximum quality of life.
View
In the future, a small-bowel transplantation the treatment options for short bowel syndrome may include more frequent. By early 2003, approximately 800 patients have been operated worldwide in this way survived of which 50 percent in the longer term. Of these, 80 percent were no longer dependent on parenteral nutrition and had a good quality of life.