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Extreme short bowel syndrome can be successfully weaned from parenteral nutrition by an oral transition diet

Introduction
Massive intestinal resection due to mesenteric vascular occlusion represents one of the most common causes of short bowel syndrome (SBS) in adults (1). The severity and prognosis of SBS primarily depend on the length of the intestinal remnant (2). The patients with a small bowel remnant longer than 100 cm generally tolerate oral feeding within a short period of time. On the other hand, patients who have a very short small bowel
Case Report
A 65-year-old man presented with acute abdomen and underwent laparatomy. Exploration revealed extensive small bowel necrosis and right colon necrosis up to the middle of the transverse colon, due to superior mesenteric artery embolism. A near total small bowel resection and right hemicolectomy were performed. An end-to-side jejuno-colostomy between the remaining 15 cm proximal jejunum and transverse colon was constructed. Following regulation of fluid and electrolyte balance, nutritional support was initiated with TPN two days after the operation. The nutritional intake was calculated according to the Harris-Benedict formula and proteins were given at 2.0 g/kg per day. Vitamins, minerals and trace elements were added to the TPN according to the recommended daily doses. The patient stabilized and a specific OTD (Table 1) was commenced on five days after the operation. The patient tolerated OTD well during the first 10 days, and thereafter continued with SAD with recommended precautions (Table 2). Parenteral nutrition was discontinued at day 15 following the surgery. Vitamins, minerals and trace elements were prescribed through parenteral and oral routes. The patient has been followed-up every month. Weight loss stopped after an initial 15% loss of body weight during the first 2 months after the operation. Now, 9 months later, the patient is healthy, able to attend his daily activities, not losing weight and he does not need artificial enteral nutritional support. He has not diarrhea and has 3 to 5 daily bowel discharges. Blood chemistry; protein and vitamin levels are within normal limits.

Discussion
Most adult patients who have less than 50 cm of jejunum require permanent TPN or intestinal transplantation (IT) (1-4, 6). Long-term TPN has well-known septic, metabolic and catheter-related complications. The definitive treatment option for patients with extreme SBS is IT. However, IT has not been a widely performed operation and the indications for IT have not been standardized yet (2).

Intestinal adaptation plays a significant role in the management of patients with SBS. Adaptation is related with both structural and functional changes by which the remaining bowel increases the absorptive capacity. Hyperplasia of the intestinal epithelium is the primary event in intestinal adaptation (7, 8). Following massive intestinal resection, first few weeks represents a stage of fluid and electrolyte unequilibrium. This stage is followed by a period of adaptation that lasts between 3 months to 1 year, during which enterocyte hyperplasia occurs (10). There are several factors which affect intestinal adaptation (Table 3).

The presence of the colon is one of the most important factors to stimulate intestinal adaptation besides its beneficial effects such as absorption of the water, electrolytes and fatty acids; and slow intestinal transit in SBS patients (1, 6-10). Even patients with very short segments of remaining jejunum may survive without TPN in the presence of a jejunocolic anastomosis without a proximal diverting jejunostomy (2, 11).

Presence of luminal nutrients and early enteral feeding is another factor in the process of intestinal adaptation. Early initiation of diet manipulation appears most useful in SBS patients with remaining colon (2, 12-13). Transition from TPN to an oral diet in a short time is important and it is a safe way to allow intestinal adaptation.

General suggestions for dietary and fluid management have been presented for patients with SBS (14,15). These suggestions involve the use of oral rehydration solutions, avoidance of the hyperosmolar fluids such as fruit juices, addition of soluble fiber, provisions of complex carbohydrates since they reduce the osmotic load and exert a positive effect on the adaptation process, and oxalate restriction to reduce the risk of oxalate nephropathy. Dietary fat is recommended to be restricted to 20-30% of the daily caloric intake in SBS patients with a colon. This results in reduction in steatorrhea, magnesium and calcium loss, and oxalate absorption.

The SAD is a diet for SBS patients, and it has special features, rules and restrictions. Foods are given frequently (10 meals a day) in small quantities. Patients consume 2 L of water, and drinking fluids is avoided during meals. Oral feeding is initiated as soon as possible after the operation as an OTD, and increased in composition and quantity step by step during the first 10 days (Table 1). Unrestricted foodstuff (Table 2) is gradually commenced on depending on the tolerance and desire of the patient after 10 days.

The SAD which has been described in detail in this paper was successfully used before in SBS patients with less than 50 cm of remnant small bowel, who underwent jejunocolic anastomosis (2,5). The present case represents an extreme SBS case with only 15 cm of proximal small bowel, who was successfully weaned from TPN by the same dietary strategy.

In conclusion, regardless of the length of the remaining bowel, especially in the presence of the colon, an aggressive, appropriate and early prescription of enteral nutrition after massive intestinal resection is a key factor in successful weaning from TPN and avoidance from IT. The presented strategy, including the 10-day oral transition diet followed by the specific adaptation diet, should be in the clinician’s armamentarium in the nutritional management of SBS patients.

References
1. DiBaise JK, Young RJ, Vanderhoof JA. Intestinal rehabilitation and the short bowel syndrome: part 1. Am J Gastroenterol. 2004;99:1386-95
2. Atalay F, Ozcay N, Gundogdu H, Orug T, Gungor A, Akoglu M. Evaluation of the outcomes of short bowel syndrome and indications for intestinal transplantation. Transplant Proc. 2003;35:3054-6
3. Carbonnel F, Cosnes J, Chevret S, Beaugerie L, Ngo Y, Malafosse M, Parc R, Le Quintrec Y, Gendre JP. The role of anatomic factors in nutritional autonomy after extensive small bowel resection. JPEN 1996;20:275-80
4. Gouttebel MC, Saint-Aubert B, Astre C, Joyeux H. Total parenteral nutrition needs in different types of short bowel syndrome. Dig Dis Sci. 1986;31:718-23
5. Ozcay N, Gundogdu H, Orug T, Atalay F, Akoglu M. Two cases of short bowel syndrome taking restricted oral diet: still candidates for intestinal transplantation? Transplant Proc. 2002;34:872-3
6. Nightingale JM, Lennard-Jones JE, Gertner DJ, et al. Colonic preservation reduces need for parenteral therapy, increases incidence of renal stones, but does not change high prevalence of gall stones in patients with a short bowel. Gut 1992;33:1493-7
7. Hanson WR, Osborne JW, Sharp JG. Compensation by the residual intestine after intestinal resection in the rat. II. Influence of postoperative time interval. Gastroenterology. 1977;72(4 Pt 1):701-5.
8. Hanson WR, Osborne JW, Sharp JG. Compensation by the residual intestine after intestinal resection in the rat. I. Influence of amount of tissue removed. Gastroenterology. 1977;72(4 Pt 1):692-700
9. Iacono G, Carroccio A, Montalto G, Cavataio F, Lo Cascio M, Notarbatolo A. Extreme short bowel syndrome: a case for reviewing the guidelines for predicting survival. J Pediatr Gastroenterol Nutr. 1993;16:216-9
10. Norgaard I, Hansen BS, Mortensen PB. Colon as a digestive organ in patients with short bowel. Lancet 1994;343:373-6
11. Jordan PH, Stuart JR, Briggs JD. Radical small bowel resection. Report of two cases. Am J Dig Dis 1958;3:823-43
12. DiBaise JK, Young RJ, Vanderhoof JA. Intestinal rehabilitation and the short bowel syndrome: part 2. Am J Gastroenterol. 2004;99:1823-32
13. Fishbein TM, Schiano T, LeLeiko N, Facciuto M, Ben-Haim M, Emre S, Sheiner PA, Schwartz ME, Miller CM. An integrated approach to intestinal failure: results of a new program with total parenteral nutrition, bowel rehabilitation, and transplantation. J Gastrointest Surg. 2002;6:554-62
14. AGA technical review on short bowel syndrome and intestinal transplantation. Gastroenterology 2003;124:1111-34
15. Matarese LE, Seidner DL, Steiger E. Growth hormone, glutamine, and modified diet for intestinal adaptation. J Am Diet Assoc. 2004;104:1265-72


Table 1: Short Bowel Syndrome Oral Transition Diet
Breakfast Lunch and dinner Snacks
1-2nd days Linden tea (unsugared) Apple or peach juice (unsugared)
3-4th days Linden tea (unsugared)
Low-fat cheese (30 g)
One slice of bread Apple or peach juice (unsugared)
Mashed potato soup (free of fat)
Apple or peach juice (unsugared) at 10:00–15:00–20:00–22:00
5-6th days Linden tea (unsugared)
Low-fat cheese (60 g)
One slice of bread Rice mush (with salt)
Boiled potato (with salt)
One apple or banana Apple or peach juice at
10:00–15:00–20:00–22:00
7-10th days Linden tea (unsugared)
Low-fat cheese (30 g)
One slice of bread
Honey (one dessert spoon) Spaghetti with cheese (boiled with one dessert spoon of olive oil)
Boiled potato (with salt)
Chicken meat (a small piece, boiled, free of fat)
Yogurt
One apple, peach or banana 10:00 Fruit juice
15:00 Mashed potato soup (with salt and butter)
20:00 Mashed potato soup (with salt and butter)
22:00 one apple or banana

After 10 days
Specific adaptation diet, divided in to ten meals a day, is gradually commenced on depending on the tolerance and desire of the patient.


Table 2: Short Bowel Syndrome Specific Adaptation Diet List

Foodstuff Unrestricted Prohibited
Meat Boiled, grilled or baked veal, cattle, mutton, chicken, turkey, fish, liver Fried or roasted meat, salami, sausage
Cereals Phyllo, spaghetti, rice, macaroni, vermicelli Whole-wheat bread, wheats, lentil, chickpea, beans, corn
Soups Vegetable, vermicelli, rice soups Lentil and tomato soups
Vegetables Carrot, potato, pumpkin, eggplant, bamia, spinach All other vegetables
Fruits Banana, apple, peach, apricot, water melon, honeydew melon, greypfrut, mandarine, orange, pomegranate, lemon, grape, cherry, sour cherry, All other fruits
Desserts Fruit compost, milk pudding (if patient has not diarrhea) Chocolate, molasses, cream-cake
Oils Olive oil All other oils
Drinks Soft tea, linden tea, sage tea Caffee, coke, hard tea

Specific precautions:
• Unrestricted vegetables must be consumed well-cooked in less than 2 meals a day.
• Artificial sweeteners are prohibited.
• White meats to be preferred to red ones.
• Fluids and water must be consumed between meals, rather than during meals.
• At least 2 liters of water must be consumed daily.
• Unrestricted green vegetables must be limited to 1 meal per week.


Table 3: Factors Affecting Intestinal Adaptation

Remnant bowel length and anatomy
Presence of colon
Presence of ileum
Luminal factors
Nutrients
Pancreaticobiliary secretions
Hormones
Growth factors


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