Chapters Transcript Video Short Bowel Syndrome: Symptoms to look for, How to Diagnose and How to Manage Dr. DiBaise describes management challenges, treatments, and background of SBS. we are fortunate to have dr jOHN D. Base, a professor of medicine in the division of gastroenterology at Mayo Clinic in Arizona, he is going to be talking to us about short bowel syndrome. How do we identify it? How do we diagnose and manage it the quick and dirty of this in 15 minutes holier questions we'll have at the end of it will have a panel discussion so feel free to send us questions along the way. Thank you and john please take over. Thank you doctor saying I'd also like to thank the all of course planners for the opportunity to be here with you today. It is a pleasure and a privilege and I'm going to dive right into this just because we only have 15 minutes. This is a big topic because it is a large topic. I'm really just going to focus on some select challenges or complications that occur in the management of shortfall patients that I think will be relevant to your IBD practice and hopefully be useful in your clinical practice. So in the process I'll also briefly discuss conventional management of short bowel syndrome. But I'm gonna start with talking about some definitions causes of short bowel types of short bowel and other complications that can occur. So here you have a disclosure slide and then a definition. So why am I talking about with short bowel syndrome. This is a matter absorptive syndrome related to reduce reduce gut length that results in the inability to maintain nutrition hydration, electrolyte or micronutrients while consuming a normal diet. This implies the need of some form of parental support, whether the F. B. I. V. Fluids or ivy nutrition TPN. However, it's important to keep in mind that because of the wide range in normal small bottle length, particularly adults as well as the tremendous functional reserve of the small bowels such that it's only one about maybe three quarters of the small bottles removed that severe malabsorption complications occur. We really can't put a specific um length on the definition. Nevertheless, as is commonly done, if you do read some literature and short bowel clinical trials in particular, they do often have a specific length and that is usually less than 200 centimeters because when there's less than 200 centimeters of small bowel remaining generally, people start developing problems with the need of parental support, Interestingly, Medicare coverage states that short balls should be considered when the length is 150 cm or less. So what are some causes of short ballots can occur both in Children and adults, as would expected to be expected in in Children or infants there congenital anomalies that generally occur as well as some catastrophic neonatal events in adults. There also Certainrophic events that can occur resulting and oftentimes we're seeing particularly over the last 10, 15 years, more postoperative catastrophic events that are obstructive or vascular and ideology. But the key point here is particularly with respect to inflammatory bowel disease. Crohn's disease is usually in the top three uh prevalence to in terms of causes of short bowel and adults. So what can I say about short battle in uh inflammatory bowel disease and test summary section general occurring up to 60% of those with chrome disease and 30% with all sorts of colitis at some point And up to a third of the patients with chronic disease will require multiple receptions. However, short bowel syndrome, particularly those with short bowel who require parental support or have intestinal failure, remains relatively rare in inflammatory bowel disease, such as about 1% in five years, 4%, 10 years and about 8% in 20 years. There have been several studies that looked at risk factors for the development of short bowel syndrome and both those sort of colitis. And put a couple of them on here. We're not gonna go into specifics. And then mainly because there's really not a whole lot of consistency with these risk factors. And so I'm not, I won't put a whole lot of uh credence in in anyone in particular. So, what about the use of biologics, has this changed intestinal resection or the development of short bowel syndrome? Well, it seems to have reduced the uh need for intestinal receptions. And here I've shown a couple of large database studies and in this one, on top You can see in Crohn's disease. About 9% of those on biologics versus 12% on no biologics required resection And an ulcer of colitis. Similarly, 7% on biologics for quite a collective 11% of the biologics, how does that translate into short bowel? Well, short of it is we just don't know yet. At this point it appears to be that there really hasn't been a whole a lot of impact in the prevalence of short battle on biologics. But time will tell. So there are three main bowel anatomy types and short bowel syndrome is demonstrated here. The engagement asked me the Juno colonic and the Juno elio colonic. The Juno Kalanick is the most common. They're here, we have a portion of june um with a portion of colon. Key point here is that the prognosis for the need of permanent parental nutrition increases as the amount of june um decreases. And in particular when there's less than 65 centimeters of the genome with at least half of the call in the risk of requiring permanent printer nutrition is a high the engage in Ostuni anatomy has the worst prognosis in general. If there's less than 100 centimeters of Juno from the ligament of rights, generally, they will require permanent parental nutrition. On the other hand, Gino Elio Kalanick is the best has the best prognosis. This has segment of both genome and terminal ilium as well as the entire colon. If there's less than 30 cm generally of of small bowel and this ballot anatomy type generally, they'll require parental nutrition support. Unfortunately though while it's has the best prognosis, it's also the least common, at least in the United States. So what about some conventional shortfall treatments? I've kind of just kind of summarized them here. Key point with regards to the management of inflammation, inflammatory bowel disease. There's really no difference from the management of in this respect from the non IBD patients. The of course the main difference is going to be the use of the anti inflammatory agents in the IBD patients. So the main conventional treatment approaches are dietary modifications, fluid modifications and then medications. The diet and fluids are generally going to be based on the ballot anatomy type and particularly whether there's a colon and continuity or not. I'm not going to go through them because of time. But you can, you know, I've got a good list of both diet and fluid modifications here. Main medications are going to be anti secretary proton pump inhibitors in particular, particularly during the first 6 to 12 months when there's a hyper secretary State and then anti motility or anti diarrheal drugs. And I'll kind of mention these again in other sections here. So what are some challenges of short bowel management? There's lots of them and you can divide them into those related to the bowel anatomy, those related to the printer nutrition support involved and those related to the central venous catheter required to infuse the printer nutrition. And here I'm going to focus just on top because of time. Just on these three that are in the orange box the nets a critter, the hippo magna xenia and those who have been unable to win completely from printer nutrition support. So we'll start with the nets creator. What is this? This is when the patient who has a stool output that exceeds their oral intake. This is most common in those who have the engage in Ostuni. And it's kind of defined as greater than two leaders of output per day. In essence, you can kind of think if you prefer to think of the net secreta is just a high output Stomach or high output Ostuni. That's just another way to think of it. And just as a comparison from those with a mature Elias. To me once that's been, you know, after a few months generally they'll have a median of about 500 ml of output a day. Other could be considerably more initially. So what's the problem with this high output situation can cause large fluid electrolyte losses in the stool. This can result in significant volume depletion result in nephrology, dialysis and cute and chronic kidney injury and is a major cause of morbidity and hospitalization. So in this little slide about that looks at passive permeability. I think this is useful to recall some basic intestinal physiology regarding regarding fluid handling and in order to kind of get a better sense of how to best manage these from oral fluid. And take standpoint. Now you'll recall that uh the june um has the leakiest uh because so to speak compared to the ilium and colon unfortunately was short battle. Oftentimes we just have a section of june um with a portion of colon. And so what we have to try to manage the fluid intake to try to best improve the ability to the genome to absorb. And this will come back to this in a bit. But this requires just take um to take advantage of the sodium glucose transport system and the use of oral rehydration solutions or glucose electrolyte solutions. So how do you treat these? And this can can go into three different stages. The first stages exclude other causes of high output, small bottle of structure, inter abdominal sepsis, certain medications and Terek infection. And then when you've excluded those, you initiated an anti dumping diet, separate the fluids from the solid component of the meals. Avoid simple sugars during meals restrict oral fluids. This can be very helpful particularly for the very high output. In those cases you may actually need to hospitals a hospitalist them in order to start them on I. V. Fluids while you're restricting their oral fluids trying to determine how best to manage their fluid there. Ostuni output Start with non specific anti diarrheal too low paramount for example four times per day it might be a reasonable place to start well monitoring their fluid balance including have certain goals for urine outputs, electrolytes and body weight and so on. After a few days reassess and make changes. Stage two I actually can combine. Stage one. Stage two. Stage two would be uh you know, starting them on anti Secretary agent like a proton pump inhibitor, beginning an oral rehydration solution and this glucose electrolyte solution. And the key from previous Studies have demonstrated that a solution containing 90 mil equivalents per liter of sodium works best to optimize journal absorption. You know. And then I've I've listed some pearls to try to enhance the palatability of these all rehydration solutions which can be a big problem for these patients to maintain adherence. And finally the last stages you might want to use something in combination to the low pyramid or the diphenyl oxalate, something that might have a synergistic effect like Cody, possibly tincture of opium. But I tend to avoid that. What about a tree? A tide. This is kind of a step where you might try something like subcutaneous, solectria tied short acting, 200 micrograms three times a day for 3- five days. Um If no benefit, it's higher doses long acting. Not going to be a much benefit. Might as well stop it at that point. And sometimes these patients just need to be on sent home on I. V fluids for some period of time until some some compensation or adaptation occurs next or challenge would be hypo magazine you and this is something that kind of goes hand in hand with the high output state. This magnesium absorption is your recall occurs throughout the gut but is mainly in the distal ilium and colon. And of course this is the section that's most commonly removed from the shortfall patients. So this occurs in about 45% of patients with the outputs toma At about 69% of the patients with less than 200 cm of small bowel require long term supplementation usually orally. So there are lots of symptoms that can occur with hip magazine you but most commonly they're vague, non specific, including such things as fatigue and cramping. Key point to remember though is hippo calcium and hippo colina that are difficult to correct until the hippo magazine is corrected. Can oftentimes complicate the course of prolonged and severe hippo magazine mia. How do you how do you go about treating this? Of course. Magnesium supplementation is going to be important. Consider ivy supplementation if the magnesium consistently less than one. But I've also listed a variety of other um approaches that can be used to try to reduce urinary wasting magnesium and uh reduced kind of malabsorption and and improve absorption intestinal absorption of magnesium and for time purposes, I'll just let you read through those at your leisure and I'll move on to the last challenge, which is how do you get people off TPN when you've tried, you've already optimized those conventional treatment approaches and uh well one approach would be just to continue to have them on their parental nutrition. Say you've gotten them to four or five nights a week of printer nutrition and they're doing just well well. You may just continue that if on the other hand there intolerant for some reason of the home printer nutrition, they developed a complication, liver disease, recurrent severe sepsis uh losing their central venous access testicle, transplant referral might need to be considered. Other options are some surgical options. Autologous G. I. Reconstruct action, intestinal lengthening for example. Or the use of intestinal intestinal trophic factors or growth factors. And that's what I'm going to uh finish up with today. These are growth factors uh that kind of enhance the spontaneous intestinal adaptation that occurs. I'm gonna skip over a couple of slides just because time is running out. But I want to say that there are two intestinal trophic factors that are currently available. They're FDA approved. One is recombinant human growth hormone goes by an absorptive and uh it's not commonly used that much in an adult's anymore variety of reasons that we can discuss in A. Q. And A. If you like to do the tide also goes by the name. Got text. This is more commonly used even though it's still fairly rarely used. This is a longer acting GLP two analog and it's been shown in a couple of pivotal trials that led to its FDA approval that it was better than placebo in this particular slide it shows the responders rate. The responders were the percent of patients responding with greater than 20% reduction in PM volume at weeks 20 and 24 63% versus 30% placebo and a secondary endpoint was reduction in total volume and at six weeks you can see but 4.5 liters compared to 2.5 liters for placebo. What about being able to eliminate their need for printer of nutrition altogether? Well, greater than one additional day per week off was seen in those on 54% of those on to Google Italian compared to about 20% of those on placebo. And then in subsequent extension studies they showed that this improvement continued and even more patients were able to be to be gotten off of printer nutrition more days and some we completely So just a couple more sides precautions with to do go tied you. So if you're considering this there is a risk for acceleration of G. I need a plastic growth, particularly coal and it is a an intestinal growth factor. And so colonoscopy before treatment and a year later and then subsequently it's more standard surveillance intervals thereafter intestinal obstruction, particularly sites of anastomosis and stillness, pancreatic and biliary diseases as a potential complication. So lab monitoring before in every six months while on this medication is necessary fluid overload can occur because of increased fluid absorption and because of increased concomitant drug absorption. Those patients on medications with narrow therapeutic windows need to be monitored more closely, and, finally, reduced dose in moderate to severe chronic kidney disease is necessary. So in conclusion, I'll leave you with these. Take home points. Published Created by Related Presenters John DiBaise, MD Professor of MedicineDepartment of Gastroenterology and HepatologyMayo Clinic Dr. DiBaise is a Professor of Medicine at the Mayo Clinic in Phoenix, Arizona. View full profile
