physiological consequences of a short bowel - · pdf filelancet 1966; ii: 146-7 * gouttebel mc...
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ESPEN Congress Brussels 2005
Physiological Consequences of a Short Bowel
Jeremy Nightingale
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Physiological Consequences of a Short Bowel
Jeremy NightingaleLeicester Royal Infirmary
United Kingdom
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• Definition and types of short bowel
• Problems of a short bowel
• Physiology - normal or altered
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Short Bowel - DefinitionsLength• Less than 200 cm small bowel remaining.
Function• Fasting plasma citrulline.
Consequences• Reduced absorption that without treatment results in undernutrition,
dehydration and / or reduced growth.
Needs• Reduced absorption so that macronutrient and / or water and
electrolyte supplements are needed to maintain health and / orgrowth.
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CitrullineCrenn P et al. Gastroenterology 2000; 119: 1496-1505
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Types of Patient with a Short BowelJejunostomy Jejunum-colon
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Major Problems of Jejunostomy• High output stoma
Water, sodium and magnesium depletion
• MalabsorptionUndernutritionB12 deficiency
• No improvement with time
• Gallstones
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Major Problems of Jejunum-colon
• MalabsorptionDiarrhoea (steatorrhoea)UndernutritionB12 deficiencyRenal Stones
• Gallstones
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Reasons for Jejunostomy Output
• Loss of normal daily secretions
• Iso-osmolar contents
• Gastric acid hypersecretion
• Increased gut transit
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Jejunostomy Output in Patient with 30 cm JejunumNightingale JMD et al. Lancet 1990; 336: 765-8
1.5Weight
(kg)
1.0
Oral IntakeJejunostomy output
0.5
0.0
8 10 12 14 16 18 20 22 24 2 4 6 8
Time (hours)
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Net Intestinal Output and Jejunal LengthNightingale JMD et al. Lancet 1990; 336: 765-8
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Jejunostomy ClassificationNightingale JMD et al. Lancet 1990; 336: 765-8
SECRETORSintestinal output > oral intakenegative water and sodium balanceless than 100 cm jejunum
ABSORBERSintestinal output < oral intakepositive water and sodium balance100 - 200 cm jejunum
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Iso-osmolar Contents - Jejunum
“Leaky” intercellular junctionsWater / Na+
Na+ / glucose pump
Stomal outputOsmolality 300 mOsm/kgNa+ 100 mmol/L
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Iso-osmolar Contents - JejunumElemental Diet
Hyper-osmolarLow sodium
PLASMAOsmolality 290 mOsmol / kgWaterNa+ 140 mmol / l
WaterNa+
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Denervated Gastric Pouch and Gastric Acid Hypersecretion
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Gastric Acid Hypersecretion in Manwith a Short Bowel and a Colon
Year n Gastric aspirate L/24hrsFrederick PL et al 1965 2 2.2 - 4.6
N Engl J Med;272:509-514
Aber GM et al 1967 1 3.0 – 4.0Am J Dig Dis; 12: 785-93
Windsor CWO et al 1969 8/19* > 1.5Gut; 10:779-86
Fielding JF et al 1971 8# Basal and pentagastrinLancet; i:1106-7 induced acid secretion
increased
*: > 300 cm small bowel resected#: Crohn’s and > 60 cm ileum resected
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Gastric Acid Secretion in Jejunostomy Patients
O’Keefe SJD. Gastroenterology 1994; 107: 379-388
9 jejunostomy patients more than 1 year after surgeryv
9 healthy controls
“Baseline measurements of pentagastrin-stimulated acid secretion were no different
between patients and healthy controls”
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Increased Gut Transit
Stoma bag
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Gastric Emptying of Liquid7 Jejunostomy Patients
Nightingale JMD et al. Gut 1993; 34: 1171-1176
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15 MINUTES
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Distal Gut Hormones to Slow Transit in Patients with a Short Bowel
PYYPYYGLPGLP--22
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Peptide YY in Patients with a Short BowelNightingale JMD et al. Gut 1996; 39: 267-72
0
20
40
60
80
100
120
140
160
180
0 30 60 90 120 150 180
Jejunostomy
Jejunum-colon
Normal subjects
***
*
****** **
****
**
**
pmol
/ l
* : p<0.05** : p<0.005
Time (minutes)
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Hypomagnesaemia in patients with less than 200 cm jejunum
Nightingale JMD et al. Gut 1992; 33: 1493-7
Receiving magnesium or low serum magnesium
n %Jejunostomy 31 / 40 78
Jejunum-colon 15 / 31 48
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Fatty acidsResection of Ileum / colon
Dehydration(hyperaldosteronism)
Low Mg2+
Parathormone Secretion / function
Renal Mg2+ reabsorption 1α hydroxylase activity
Gut magnesium absorption
1, 25 - hydroxycholecalciferol
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Colonic FermentationNordgaard I et al. Lancet 1994; 343: 373-376
Starch / soluble non-starch polysaccharides
Anaerobic bacteria
Short chain fatty acidsbutyrate
proprionateacetate
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Renal Stones
25 % Jejunum – colon patients develop symptomatic renal stonesNightingale JMD et al. Gut 1992; 33: 1493-7
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Formation of Calcium Oxalate Renal Stones
Ca-oxalate
FFA’s
Ca-FFA
Oxalate
Bile acids
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Intestinal Adaptation
The process that attempts to restore the total gut absorption of macronutrients, macrominerals and water to that of before a resection.
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Adaptation
• HyperphagiaCrenn P et al. Gut 2004; 53: 1279-86
• Structural adaptation
• Functional adaptation
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Structural Jejunal Adaptation in Man
Jejunostomy• None (n=9)
O’keefe SJD. Gastroenterology 1994; 107: 379-388
Jejunum-colon• Epithelial hyperplasia (n=4)
Porus RL. Gastroenterology 1965; 48: 753-59Weinstein D et al. Arch Surg 1969; 99: 560-2
• Epithelial atrophy (n=7)De Francesco A et al. Transplant Proc 1994; 26: 1455-6
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Functional Adaptation in ManJejunostomy (or ileal resection)• None
Hill GL et al. Gut 1974; 15: 982-7Nightingale JMD et al. Gut 1992; 33: 1493-7
Jejunum-colon• Increased absorption of macronutrients (glucose),
water, sodium and calcium *• Ability to stop parenteral nutrition
Althausen TL et al. Gastroenterology 1950; 16: 126-34 *Dowling RH & Booth CC. Lancet 1966; ii: 146-7 *Gouttebel MC et al. Dig Dis Sci 1986; 31: 718-23Gouttebel MC et al. Dig Dis Sci 1989; 34: 709-15 *Nightingale JMD et al. Gut 1992; 33: 1493-7Cosnes J. Eur J Gastrenterol Hepatol 1994; 6: 197-202 *Carbonnel F et al. J Parenter Enteral Nutr 1996; 20: 275-80Messing B et al. Gastroenterology 1999; 117: 1043-50
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Enzyme Changes with Adaptation
AnimalsNa+ / glucose co-transporterNa+ / H+ co-transporter
ManColonic di and tripeptide transporter(Pep T1) (5 x activity)Ziegler TR et al. Am J Clin Nutr 2002; 75: 922-30
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Gallstones in 84 Patients with a Short BowelNightingale JMD et al; Gut 1992; 33: 1493-97
%Jejunostomy 43Jejunum-colon 44
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Pathogenesis of Gallstones in Patients with a Short Bowel
Ileal disease/resection
Surgery
Calcium bilirubinategallstones
stasis sludgeWeight loss
TPN
Drugs
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Summary - Physiological Consequences of a Short Bowel
Jejunostomy• Water / Na+ losses - normal secretions
- hyperosmolar / low Na+ diet- rapid liquid gastric emptying
• Hypomagnesaemia - secondary hyperaldosteronism
• Malabsorption - undernutrition (B12)
• No structural or functional adaptation
• Pigment gallstones
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Summary - Physiological Consequences of a Short Bowel
Jejunum-colon• Malabsorption
- diarrhoea (?gastric acid hypersecretion)- undernutrition (B12)- calcium oxalate renal stones
• Colonic fermentation
• Functional adaptation
• Pigment gallstones
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Advantages of Preserving the Colon
• Water, sodium and magnesium absorption.
• Carbohydrate fermentation.
• Slows gastric emptying.
• Aids small bowel adaptation.
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References
Greenwich Medical Media Limited 2001ISBN 1 900 151 936
Nightingale JMD. Management of patients with a short bowel.World J Gastroenterol 2001; 7: 741-751
American Gastroenterological Association. Short Bowel and Intestinal Transplantation. Gastroenterology 2003;124:1105-1134
British Society of Gastroenterology. Management of Patients with a Short Bowel. Gut (in press)
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Key WordsShort Bowel
Intestinal failureIleostomy diarrhoea
Gastric acidHypomagnesaemia
GallstonesRenal Stones
Intestinal Adaptation