Short Bowel Syndrome - Guidelines for the Management of Adult Patients with

Publication: 01/12/2009  --
Last review: 24/07/2019  
Next review: 24/07/2022  
Clinical Guideline
CURRENT 
ID: 1999 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2019  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Guidelines for the management of patients with short bowel syndrome

Summary of Guideline/Protocol

Aims

  • To improve the diagnosis and management of short bowel syndrome, high output stomas and high output fistula.
  • To assist all members of the multidisciplinary team in the provision of care to adults with short bowel syndrome, during any treatment throughout hospital admissions or following discharge.

Objective

  • To provide evidence-based recommendations for appropriate diagnosis, investigation and management of those with short bowel syndrome leading to intestinal failure.

Background

Short bowel syndrome occurs after extensive small bowel resections.  Common causes are Crohn’s disease, mesenteric ischaemia, irradiation, small bowel volvulus and adhesions.  The severity of symptoms will vary with both the amount of small bowel remaining, and also whether or not the colon is in continuity (Nightingale et al. 2006).

Patients with a short bowel are not common but should be managed by a multidisciplinary team led by a clinician with expertise in this area.  Local guidelines with the Leeds Teaching Hospitals NHS Trust (LTHT) were produced in poster version by a multidisciplinary team in 2000.  National guidelines were developed by the British Society of Gastroenterology (BSG) (Nightingale et al. 2006). Their recommendations were graded on the category of supporting evidence. The grading system used, and replicated within these guidelines can be seen in Appendix 1.

Some LTHT staff may not be aware of the production of the BSG guidelines and it was therefore decided that LTHT guidelines should be reviewed, updated and disseminated based on the new evidence.  If these patients are managed appropriately there may be an improved quality of care and possibly cost savings as patients receive optimal management (Nightingale et al. 2006)

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Diagnosis

It is encouraged that any member of staff involved in caring for patients with short bowel syndrome seek further advice from the LTHT Nutrition team.  Although the guidelines help inform practice, this does not negate the need for staff to remain observant when exercising professional judgement, and seek advice from those with relevant expertise.
Patients should also be referred rapidly to those with relevant expertise to facilitate successful management.

Short bowel syndrome occurs after extensive small bowel resections. There is reduced intestinal absorption therefore supplements of nutrition, fluid and electrolytes are required to maintain health. If untreated, undernutrition and dehydration can occur.  Any patient with a small bowel length of less than 1.5 metres should be referred to the LTHT nutrition team for assessment.

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Investigation

Bowel length
From the duodenojejunal flexure to the ileocaecal valve, the length of bowel varies from 2.75 to 8.5 metres and tends to be shorter in females (thus females are more likely to develop short bowel syndrome).  It is therefore very important after a significant resection to measure the amount of small bowel remaining, rather than the amount excised.

The 3 possible types of patients following a major resection are:

  1. Those with a jejunoileal resection, resulting in a jejunocolic anastomosis (jejunumcolon) - these patients often do well initially, but may lose weight subsequently and become significantly malnourished.
  2. Those with a jejunal resection with >10 centimetres (cm) of terminal ileum and the colon remaining (jejunum-ileum) - these patients rarely need nutritional support.
  3. Those with a jejunoileal resection, colectomy and formation of a stoma (jejunostomy) - these patients often have major problems with fluid, electrolyte and calorie balance due to high output.

In addition, complex patients with small bowel fistulae will often mimic those with a jejunostomy, with fluid balance and electrolyte problems.

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Treatment / Management

Assessment of the patient should be individual and includes consideration of water, sodium, magnesium and nutritional status.

A guide to the type of nutritional support needed is shown in Table 1, although this varies with individual patients.  In addition, intestinal adaptation can take up to two years, and some patients will be able to reduce their nutritional support.  This is much less likely for patients with a jejunostomy, where there is little evidence of long-term adaptation.

Jejunal length (cm)

Jejunum-colon

Jejunostomy

0-50

PN (grade B)

PN+PS

51-100

ON

PN+PS* (grade B)

101-150

None

ON+OGS

151-200

None

OGS (grade B)

Table 1. Guide to bowel length and long term fluid / nutritional support needed by patients with a short bowel.
PN=parenteral nutrition
ON=oral (or enteral) nutrition
PS=parenteral saline
OGS=oral (or enteral) glucose / saline solution
*At 85 -100 cm, may need PS only

Fluid therapy

Gastrointestinal Secretions
Normal daily gastrointestinal secretions consist of:

  • 500 mls of saliva
  • 2000 mls of gastric juice
  • 1500 mls of pancreaticobiliary secretions
  • Passive jejunal secretions to render the lumen isotonic during passage and digestion of ingested nutrients

The majority of fluid is reabsorbed in the proximal jejunum and colon.  Jejunum-colon patients can therefore reabsorb fluid in their colon, but this is not the case for jejunostomy patients who lose much salt and water from their stoma.  For jejunostomy patients, if less than 100 cm of jejunum remains, the patient may lose more fluid than is taken by mouth, a so called ‘net-secretor’.

In addition, if any solution with a sodium concentration of <90 mmol/l is drunk, there is a net transfer of sodium from the plasma into the bowel lumen, until a luminal sodium concentration of approximately 100 mmol/l is reached.

Key fluid management (grade B)
Fluid management involves:

  • Restriction of  oral hypotonic fluids to 500 mls per 24 hrs. These include water, tea, coffee, fruit juice, alcohol, fizzy drinks, and sugary drinks and may also include oral nutritional sip feeds.  It is possible that this can be relaxed at a later stage dependent on the individual patient’s progress.
  • Regular use of an electrolyte solution with a sodium concentration of approximately 100mmol/l.  Please discuss with Nutrition Team as to the most appropriate solution for an individual patient.
  • Examples of rehydration solutions are given below:

Name of Oral rehydration solution (ORS)

Amount of product made to 1000mls water

Sodium concentration (when made up to 1000mls)

Potassium concentration
(when made up to 1000mls)

Dioralyte®

8 sachets

96 mmols

32 mmol

Glucodrate®

1 sachet

120 mmol

0.88 mmol

St Mark’s Solution*

Homemade solution from base products*

90 mmol

0 mmol

*https://www.sps.nhs.uk/articles/what-is-st-markos-electrolyte-mix-solution/

St Mark’s Solution Recipe
Glucose powder 20g (6 x 5ml teaspoon)
Salt 3.5g ( 1 x level 5ml teaspoon)
Sodium bicarbonate 2.5g ( 1 x 2.5ml teaspoon or half a level 5ml teaspoon)

These can be sipped throughout the day.  ORS may be more palatable if either kept in the fridge, or concentrate added such as squash (this must be with no added sugar).  

Electrolyte status of the patient may determine which ORS is used, for example in hyperkalaemia or hypercalcaemia is present.

  • Regular measurement of urinary sodium to check effectiveness of rehydration therapy is necessary
    • Urinary Na <20 mmol/l implies sodium depletion; therefore management should be reviewed by the LTHT Nutrition team. In patients with SBS, this is usually associated with severe dehydration.
    • Aim for urinary Na >20 mmol/l.  This indicates fluid management is currently effective.

Drug therapy (grade B)

  • Gastric emptying and small bowel transit for liquids are fast in patients with a jejunostomy, as the ileal and colonic braking mechanisms have been resected. This is less of a problem if the colon is in continuity.
  • For net secretors, it is also important to reduce the volume of acid and other small bowel secretions.
  • Thus the key management involves the following drugs, measuring stoma output at each stage to gauge effectiveness.

Reduction of motility

  • Loperamide, starting at 2 milligrams QDS, typically 30 minutes pre-meal, and slowly titrating up to a maximum dose of 64 milligrams daily.  This is higher than the ‘BNF’ dose, but patients with short bowel syndrome may not experience full drug absorption, and have also usually lost their enterohepatic circulation.   
  • Initiate loperamide capsules first line. They can be opened, mixed with water or put on food if emerge unchanged in output. Dispersible tablets may be used at Consultant request only in individual patient circumstances. If used, on-going clinical response and benefit over capsules should be closely monitored and reviewed. Avoid loperamide liquid as the excipient sorbitol can exert an osmotic laxative effect.
  • Codeine 30 milligrams to 60 milligrams QDS.  Often patients find they become drowsy when they start codeine, but the drug can usually be increased slowly, with increasing tolerance.  
  • The combination of loperamide and codeine is usually more effective than one drug alone.

Reduction of secretions

  • Initiate treatment with omeprazole capsules 40 milligrams OD or lansoprazole capsules 30 milligrams OD.
  • The dose should be titrated to reach a stoma pH of > 5.5. (grade A).
  • If there is a lack of effect or capsules emerge unchanged in output consider a dispersible formulation. Use lansoprazole as the first line dispersible tablet choice. Use omeprazole dispersible tablets as the second line choice only if there is a lack of effect with with lansoprazole dispersible tablets. If used, ongoing clinical response and benefit should be closely monitored and reviewed.
  • If <50cm of jejunum remains, an intravenous proton pump inhibitor should be considered
  • Please recheck stoma pH regularly as unnecessary continued use of PPI can increased diarrhoea/stomal output.
  • Octreotide is only recommended if patients have a stomal output of > 3 litres per 24hrs (Grade A).  If used, start at 50 micrograms subcutaneously TDS, increasing every 2 to 3 days to a maximum of 200 micrograms TDS, according to output.  It is important to use it as a trial only, and stop if there is no response after 2 weeks of the maximum dose.

Low Magnesium

  • This is one of the most common electrolyte disorders and is particularly troublesome in patients with relative fat malabsorption due to chelation of magnesium.  Treatment should be approached in three ways (grade B):
  • Treat underlying dehydration. In dehydrated patients, sodium will be retained in preference to magnesium due to hyperaldosteronism.  Assess this by measuring urinary sodium.
  • Give oral magnesium replacement, although all these products are unlicensed.
  • Preparations to consider are magnesium sachets, capsules or liquid.
  • Please note some of these may be poorly absorbed orally in patients with short bowel syndrome. Discuss with a pharmacist or Nutrition Team about an appropriate supplement and suitable dose to use.
  • Levels of 1,25 hydroxy-vitamin D are reduced in the presence of low magnesium due to low parathyroid hormone levels.  Refer to the Guidelines for Vitamin D Deficiency in adults to assist management of low vitamin D status:
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  • Ensure patients do not remain on high dose proton pump inhibitors unnecessarily as inadvertent hypomagnesaemia could result.

Nutrition support
All patients require referral to the dietitian for formal assessment and monitoring of nutritional status.

Jejunostomy or high output ileostomy
A summary is demonstrated in table 2.

Parenteral
Early post operative feeding is required to prevent malnutrition. This may be needed longer term if less than 40% of dietary energy is absorbed.  It also may be needed to provide adequate vitamins and minerals.

Oral
Patients may benefit from taking liquids and solids at different times (grade C).
They should be advised to reduce or avoid excess lipid in diet if hypomagnesaemia occurs (grade C).

Oral/Enteral

  • High energy intake required
  • No need for elemental diet
  • A constant amount of energy and protein is usually absorbed despite varying intake

Dietary Content

Amount required

Energy

High

Long chain triglyceride

Normal

Medium chain triglyceride

Normal

Carbohydrate

Normal

Oxalate

Normal

Sodium chloride

Extra needed (use salt capsules or OGS) (Grade B)

Magnesium

IV supplementation then oral may be required (grade C)

Vit B12

Additional injection

Selenium

Normal. However may need supplementation if low levels or poor nutritional status

Fat soluble vitamins and essential fatty acids

Normal. However may need treatment with bile salt binder

Table 2.  Nutritional support needed for patients with a jejunostomy or high output ileostomy

Jejunoileal and jejunocolic anastomosis
A summary is demonstrated in Table 3.

Parenteral
Early post-operative parenteral nutrition is required to:

  • Prevent malnutrition secondary to malabsorption
  • Promote surgical healing
  • Prevent vitamin and mineral deficiencies
  • The aim is to wean off the parenteral nutrition post operatively to oral / enteral nutrition.
  • This may not be possible if less than 30% of oral / enteral nutrition is absorbed, or if bowel losses are unmanageable.

Oral / Enteral

  • High energy intake to approximately 150% of requirements
  • Include oral nutritional sip feeds
  • May need additional high energy enteral feeds

Dietary Content

Amount

Energy

High

Long chain triglyceride

Low

Medium chain triglyceride

High

Carbohydrate

High (polysaccharide) (grade A)

Oxalate

Low (grade A)

Sodium chloride

Normal

Magnesium

May need additional supplementation

Vit B12

Additional injection

Selenium

May need additional supplementation

Fat soluble vitamins and essential fatty acids

May need additional supplementation

Table 3.  Nutritional support needed for patients with a jejunoileal or jejunocolic anastomosis

Monitoring of patients
These patients are metabolically very unstable, and need close monitoring as follows, whatever nutritional support they are receiving:

  • Daily weight
  • Accurate 24 hour fluid balance
  • Urinary sodium
    • Initially daily
    • Then twice weekly
    • If long term every 2 months until stable
  • Serum sodium, potassium, calcium, magnesium, phosphate, creatinine
    • Initially daily
    • Then twice weekly
  • Liver function tests twice weekly
  • Vitamins (A, D, E) and trace elements should be checked at initial assessment, then weekly and at least 6 monthly once stable.
  • If dehydration is suspected, particularly if there is an unexpected fall in weight, this can be assessed using sitting and standing blood pressure measurements.
  • There will be ongoing assessment of nutritional status by the dietitian including:
    • BMI
    • % weight loss / gain
    • Mid-arm muscle circumference
    • Hand grip strength

Nursing management
Good nursing of these patients is critical, particularly with regards to stoma care.  The following principles should be followed:

  • Refer the patient to the Colorectal Nursing Department ext 65535
  • If the patient has a stoma, use appropriate stoma appliance and, if needed, a high output system with or without an overnight drainage system
  • Record and document volume, consistency and colour of the stoma output accurately on the fluid balance chart
  • Check pH of the stoma output.  If less than 5.5 increase proton pump inhibitor (PPI). Record pH value in nursing or medical documentation
  • Observe and maintain peristomal skin integrity; if deteriorating check the template size and use appropriate accessory products if needed
  • If patient does not have a stoma, maintain perianal skin integrity with optimal hygiene and appropriate use of barrier creams as required
  • Promote individual’s independence with their care
  • Provide patients with accurate information regarding SBS, to aid understanding and compliance
  • Refer all patients with inflammatory bowel disease (IBD) to the IBD Clinical Nurse Specialists ext 68679

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List of Abbreviations

Abbreviation

Definition

BD

Twice daily

BMI

Body Mass Index

BSG

British Society of Gastroenterology

cm

Centimetres

Dept

Department

EN

Enteral nutrition

Ext

Extension

Hrs

Hours

IBD

Inflammatory bowel disease

IV

Intravenous

l

Litre

LTHT

Leeds Teaching Hospitals NHS Trust

m

Metres

mls

Millilitres

mmol

Millimoles

Na

Sodium

OD

Once daily

OGS

Oral glucose/saline solution

ON

Oral nutrition

PN

Parenteral  Nutrition

PS

Parenteral saline

QDS

4 times daily

SBS

Short bowel syndrome

TDS

3 times daily

Vit

Vitamin

Less than

Greater than

%

Percent

Provenance

Record: 1999
Objective: To provide evidence-based recommendations for appropriate diagnosis, investigation and management of those with short bowel syndrome leading to intestinal failure.
Clinical condition:

Short Bowel Syndrome secondary to disease and/or surgery of the gastrointestinal tract

Target patient group: Intestinal failure
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Pharmacists
Allied Health Professionals
Adapted from:

Evidence base

Evidence Base:   

References  and Evidence levels:
A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. Leeds consensus. (where no national guidance exists or there is wide disagreement with a level C recommendation or where national guidance documents contradict each other)

References

Nightingale et al. (2006).  Guidelines for management of patients with a short bowel.  Gut 55 (Suppl IV):iv1-iv12

Staun et al. (2009).   ESPEN Guidelines on Parenteral Nutrition: Home Parenteral Nutrition (HPN) in adult patients.  Clinical Nutrition 28: 467-479

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 2.0

Related information

List of Abbreviations

Abbreviation

Definition

BD

Twice daily

BMI

Body Mass Index

BSG

British Society of Gastroenterology

cm

Centimetres

Dept

Department

EN

Enteral nutrition

Ext

Extension

Hrs

Hours

IBD

Inflammatory bowel disease

IV

Intravenous

l

Litre

LTHT

Leeds Teaching Hospitals NHS Trust

m

Metres

mls

Millilitres

mmol

Millimoles

Na

Sodium

OD

Once daily

OGS

Oral glucose/saline solution

ON

Oral nutrition

PN

Parenteral  Nutrition

PS

Parenteral saline

QDS

4 times daily

SBS

Short bowel syndrome

TDS

3 times daily

Vit

Vitamin

Less than

Greater than

%

Percent

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Equity and Diversity

The Leeds Teaching Hospitals NHS Trust is committed to ensuring that the way that we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group.