Outlines
                                                                                                                  Outlines
                   Short Bowel Syndrome                                                                  „ Anatomy
                   Short Bowel Syndrome
                                                                                                         „ Function of bowel segment
                                                                                                         „ Short bowel syndrome
                                                  นพ.วีระชาติ  ลิ้มจิตสมบูรณ                                   „Etiology 
                                                  พญ.พิพาพร  คงเจริญสมบัติ                                      „Clinical manifestation
                                                  พญ.สรินนา  อรุณเจริญ                                          „Bowel adaptation
                                                  พญ.วิยดา    บุญเลื่อง                                         „Management 
                                                  รศ.พญ.บุษบา วิวัฒนเวคิน                                      „Complication
                      Gastrointestinal System                                                     Gastrointestinal System
                      Gastrointestinal System                                                     Gastrointestinal System
                   „ Oral cavity                                                              „ Oral cavity
                   „ Major glands                                                             „ Major glands
                      „ Salivary gland                                                            „ Salivary gland
                      „ Pancrease                                                                 „ Pancrease
                      „ Liver                                                                     „ Liver 
                      „ Gall bladder                                                              „ Gall bladder
                   „ Alimentary canal                                                         „ Alimentary canal
                      „ Esophagus                                                                 „ Esophagus 
                      „ Stomach                                                                   „ Stomach 
                      „ Small intestine :                                                         „ Small intestine : 
                        Duodenum, jejunum, ileum                                                    Duodenum, jejunum, ileum
                      „ Large intestine : colon,                                                  „ Large intestine : colon, 
                        caecum, rectum, anal canal                                                  caecum, rectum, anal canal
                                                : 
                    Small Intestine                Gross Anatomy
                    Small Intestine : 
                                       2.5 m.(8 ft.)                                                                                     Duodenum
                                      3.5 m.(12 ft.)
                                         25cm.
              „ From pyloric sphincter 
                         pthaigastro.org
                 to the ileocecal valve
              „ Neonate ~ 250 cm.
              „ Adulthood : grows to 750 cm.
                                                                                                                                                                    1
                     Small Intestine : Microscopic Anatomy                                             Large Intestine : Gross Anatomy
                     Small Intestine :                                                                 Large Intestine : 
                                                                                                   „ 1.5 m. (5ft.)
                                                                                                   „ cecum
                                                                                                   „ appendix
                                                                                                   „ colon
                                                                                                      „ ascending
                                                                                                      „ transverse
                                                                                                      „ descending 
                                                                                                      „ sigmoid 
                  „ Plicae                                                                         „ rectum
                    circulares                                                                     „ anal canal
                  „ Villi
                  „ Microvilli
                     Large Intestine : Microscopic Anatomy
                     Large Intestine :                                                               Function of the ileocecal valve
                                                                                                     Function of the ileocecal valve
                                                                                                                                              To prevent
                                                                                                                                              To prevent
                                                                                                                                           backflow of fecal
                                                                                                                                           backflow of fecal
                                                                                                                                           contents from the
                                                                                                                                           contents from the
                                                                                                                                           colon → small
                                                                                                                                           colon → small
                                                                                                                                           intestine
                                                                                                                                           intestine
                   Function of the bowel segment                                                                           Motility
                                                                                                                           Motility
                 4 basic digestive processes                                                         Segmentation                             Peristalsis
                                „ Motility
                                „ Secretion
                                „ Digestion
                          pthaigastro.org
                                „ Absorption
                                                                                                                                         Pylorus → ICV 3-5 hr.
                                                                                                                                         ICV  → T.colon 8-15 hr.
                                                                                                                                         T.Colon → sigmoid 2-3/day
                                                                                                                                                                                2
                                        Secretion                                                                         Digestion
                                        Secretion                                                                         Digestion                       Lipid
                                                                                                      Carbohydrate
                    Crypts of Lieberkuhn
                     Crypts of Lieberkuhn
                       1.  Water , Na , Cl , HCO
                       1.  Water , Na , Cl , HCO
                                                   3
                                                   3
                       2.  Enzyme : 1800 mL/day , pH7.5-8.0                                                                        Protein
                       2.  Enzyme : 1800 mL/day , pH7.5-8.0
                       X
                                „ Peptidase
                                „ Peptidase
                                „ Sucrease , maltase , isomaltase , lactase
                                „ Sucrease , maltase , isomaltase , lactase
                                „ Intestinal lipase
                                „ Intestinal lipase
                    Brunner’s gland :  mucous
                     Brunner’s gland :  mucous
                                                   Large intestine
                         Digestion : Large intestine                                                                    Absorption
                          Digestion :                                                                                   Absorption
                                                                                                    Site           Nutrients
                         „much mucus , no enzymes are secreted                                      Site           Nutrients
                         „some digestion of chyme by bacteria in                                             Calcium , magnesium , 
                         „some digestion of chyme by bacteria in                                  Duodenum  iron , zinc
                           colon 
                           colon 
                               bacteria produce some vitB complex                                            „Mono , disaccharide
                             „
                             „bacteria produce some vitB complex                                             „Protein
                               and K                                                                         „Fat-soluble vitamin A 
                               and K                                                              Jejunum     and D
                                                                                                             „Water-soluble vitamin 
                                                                                                              : B1,B2,B6,C,folic acid
                                                                                                  Ileum      Fat , B12 , bile salts
                                                                                                  Colon      Fluid , electrolyte 
                                                                                                                                             Water 
                                       Absorption                                                               Absorption : Water 
                                       Absorption                                                               Absorption : 
                                                  Small intestine                                                             •passive 
                       Absorption of              Small intestine           Colon                                             absorption 
                       Absorption of        upper       mid       lower     Colon
                                             pper
                                            u           mid       lower                                                       •osmosis
                  Carbohydrate                ++         +++        ++        0
                  Carbohydrate                ++         +++        ++        0
                  Amino acids                 ++         +++        ++        0
                  Amino acids                 ++         +++        ++        0
                  Fatty acids                +++         ++         +         0
                  Fatty acids                 +++        ++         +         0
                  Bile salts                   +          +        +++        0
                  Bile salts                   +          +        +++        0
                           pthaigastro.org
                  Water soluble vitamins      +++        ++         0         0
                  Water soluble vitamins      +++        ++         0         0
                  Vitamin B12                 0           +        +++        0
                  Vitamin B12                 0           +        +++        0
                  Na                          +++        ++        +++       +++
                  Na                          +++        ++        +++       +++
                  K                            +          +         +
                  K                            +          +         +
                  Ca                          +++        ++         +
                  Ca                          +++        ++         +
                  Fe                          +++        ++         +
                  Fe                          +++        ++         +
                  Cl                          +++        ++         +
                  Cl                          +++        ++         +
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                      Electrolyte composition of enteral fluids
                      Electrolyte composition of enteral fluids                                                              Short Bowel syndrome
                                                                                                                             Short Bowel syndrome
                                       +           -            +                          +
                                    Na+           Cl-          K+          HCO            H+
                                    Na            Cl           K           HCO            H
                                                                               3
                      Fluid                                                    3
                      Fluid        mEq/L        mEq/L        mEq/L         mEq/L        mEq/L
                                   mEq/L        mEq/L         mEq/L        mEq/L        mEq/L
                      Saliva       30-60        15-40          20          15-50         N/A
                      Saliva                                                                                      „ Etiology
                                                                                                                  „ Etiology
                     Gastric       20-80       100-150        5-20          N/A         30-100
                     Gastric                                                                                      „ Clinical related to site of resection
                                                                                                                  „ Clinical related to site of resection
                    Duodenal      100-140       90-130        5-15           50          N/A
                    Duodenal                                                                                         Intestinal adaptation
                                                                                                                  „
                                                                                                                  „ Intestinal adaptation
                       Bile       120-140       80-120        5-15         40-50         N/A
                       Bile                                                                                          Application of adaptive process
                                                                                                                  „
                                                                                                                  „ Application of adaptive process
                    Pancreatic    120-140       90-120        5-15           90          N/A
                    Pancreatic
                     Jejunal        100          100          5-10         10-20         N/A
                     Jejunal
                      Ileal         140         20-110        3-15           30          N/A
                      Ileal
                     Colonic         60           40           30            20          N/A
                     Colonic
                                                                                                                                         Background
                                             Background                                                                                  Background
                                             Background
                                                                                                                 „ Degree and extent of malaborption and 
                       The short bowel syndrome is a                                                             „ Degree and extent of malaborption and 
                    „
                    „ The short bowel syndrome is a                                                                 metabolic complications depend on the 
                       malabsorptive state that may follow                                                           metabolic complications depend on the 
                       malabsorptive state that may follow                                                          site of resection.
                       massive resection of the small intestine.                                                     site of resection.
                       massive resection of the small intestine.                                                 „ Factor that influence the length  of 
                       The small intestine of the neonate is                                                     „ Factor that influence the length  of 
                    „
                    „ The small intestine of the neonate is                                                         time until child independent of TPN
                       about 250 cm in length ,750 cm in adult.                                                      time until child independent of TPN
                       about 250 cm in length ,750 cm in adult.                                                      „ Remaining small bowel>40 cm
                                                                                                                      „ Remaining small bowel>40 cm
                    „ Loss of at less 50% of small bowel cause 
                    „ Loss of at less 50% of small bowel cause                                                       „ Absence of an ileocecal valve double time 
                                                                                                                      „ Absence of an ileocecal valve double time 
                                                                                                                        to complete adaptation.
                       short bowel syndrome.                                                                            to complete adaptation.
                       short bowel syndrome.
                                           Background                                                                                         Etiology
                                            Background                                                                                        Etiology
                                                                                                                 „ Normal GI anatomy :
                    „ Better outcome association with                                                            „ Normal GI anatomy :
                    „ Better outcome association with
                                                                                                                     „Resection of bowel from NEC ,Crohn’s
                        „ Breast milk                                                                                 „Resection of bowel from NEC ,Crohn’s
                        „ Breast milk                                                                                   dz ,volulus,tumor ,radiation enteritis, 
                        „ Aminoacid base formula                                                                        dz ,volulus,tumor ,radiation enteritis, 
                        „ Aminoacid base formula                                                                        Hirschsprung’s dz, ischemic injury
                        „ Percentage of kilocalories taken enterally                                                    Hirschsprung’s dz, ischemic injury
                        „ Percentage of kilocalories taken enterally                                                Congenital anomalies :
                                                                                                                 „
                           by 6wk of life                                                                        „ Congenital anomalies :
                           by 6wk of life
                              pthaigastro.org
                                                                                                                     „Atresia in anywhere of the intestine.
                        „ Residual  small bowel length at the time of                                                 „Atresia in anywhere of the intestine.
                        „ Residual  small bowel length at the time of 
                           surgery.
                           surgery.                                                                                  „Multiple atresia due to anomalies in 
                                                                                                                      „Multiple atresia due to anomalies in 
                                                                                                                        the superior mesemteric atery.
                                                                                                                        the superior mesemteric atery.
                                                                                                                     „gastroschisis
                                                                                                                      „gastroschisis
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