Case Report: Nutritional Management in Short bowel syndrome
Shraddha Bhatt
Dietetic Intern
ARAMARK Healthcare
Distance Learning Dietetic Internship
Virginia Hospital Center
December 21, 2014
Abstract
Short Bowel Syndrome (SBS) is a malabsorptive syndrome caused due to functional and / or
anatomical loss of extensive small bowel. It’s a heterogeneous disorder with a wide range of
variation in disease severity arising from different types of intestinal resection. The spectrum of
malabsorption varies from intestinal insufficiency to intestinal failure. The chief goal in
managing SBS is to regain as much gut function as possible. Thus, during this process parenteral
nutrition (PN) and / or enteral nutrition (EN) will be essential to maintain adequate nutrients,
water and electrolytes to maximize health and quality of life. Therefore, to treat this condition,
modifications in dietary macro and micronutrients, fluid and pharmacologic options are required
for maximizing health and quality of life and to reduce the complications and SBS associated
mortality. This case study illustrates the use of the nutrition care process (NCP), outlining the
components of the assessment, determination of nutrition diagnoses, and the application of
evidence-based recommendations for nutritional interventions in form of nutrition support.
Disease description
SBS is defined as inadequate absorptive capacity due to decrease in bowel length or bowel
function. SBS is defined as small bowel length of less than 200cm without a colon or 50cm of
SB with a colon (1).The incidence and prevalence of this disorder is unclear but based on Oley
Foundation home Parenteral nutrition (PN) registry for US, approximately 26% of 40,000 home
TPN patients had SBS in 1992 (2). SBS can be congenital or acquired i.e. SBS can result from
surgical resection of bowel. This is generally due to multiple resections for conditions like
recurrent Crohn’s disease, massive enterectomy, venous thrombosis, volvulus, trauma, tumor
resection, radiation enteritis, mesenteric vascular accidents and recurrent intestinal obstruction(2).
The clinical presentation of SBS patients includes diarrhea, dehydration, electrolyte
abnormalities, Vitamin and mineral deficiencies, malnutrition. SBS can also lead to certain
complications such as osteoporosis, Nephrolithiasis, Peptic ulcer disease (PUD), small bacterial
overgrowth. Adaptation to remaining bowel depends on various factors such as length of
remaining bowel, section of bowel resected, overall health of the remaining bowel, length of
time elapsed since the initial surgery , stimulation by intra-luminal nutrients, stimulation by bile
and pancreatic secretions, trophic effects of gut hormones, altered intestinal blood flow and
altered bowel innervations (12). There are 3 types of intestinal resections in patients with SBS and
it is associated with different range and severity of SBS symptoms (Figure 1) (3, 4, 5).
Evidence-Based Nutrition Recommendations
According to American society for parenteral and enteral nutrition (ASPEN) guidelines, nutrition
strategies to manage SBS should aim to prevent malnutrition and dehydration, and maintain the
best possible nutrition status. The general guideline for managing SBS include consumption of
small frequent meals consisting of complex foods according to GI anatomy, 20-30% energy from
fats, 20% energy from protein; use of anti-diarrheals and antisecretory agent, oral rehydration
solutions, enteral nutrition when oral eating is not possible and parenteral nutrition
The long term treatment of SBS and its recovery depends on what sections of small intestine
were removed, how much is left and how well the remaining small intestine adapts over time (6).
The primary physiologic consequence of SBS is malabsorption which leads to decrease in
availability of vitamins due to decreased oral intake of fruits/vegetables and/or decreased
intestinal absorption. To support this, a prospective analysis of serum carotenoids, vitamin A and
tocopherols was carried out by Luo M. et al (7) . In this study, 21 PN dependent adult SBS
patients similar in age, gender, body mass index (BMI), diseases leading to SBS, length of
residual small bowel, presence of colon and PN regimen at study entry were enrolled in a 12week intestinal rehabilitation program which included individualized dietary modification,
multivitamin supplementation and randomization to receive either s.c. placebo or human growth
hormone (GH). PN was weaned after week 4 and advanced as tolerated. This study showed that
serum α-tocopherol concentration was negatively correlated with PN lipid dose (r=-0.34,
p<0.008). Also significant % of subjects were depleted in diet-derived carotenoids despite oral
and intravenous multivitamin supplementation and dietary adjustment during intestinal
rehabilitation and PN weaning. The limitations of this study was small sample size, the lack of
quantitative information on dietary intake of specific fruit, vegetable, or dietary fiber items in
individual patients, lack of absorption studies for the specific nutrient compounds in response to
test meals, and the relatively short 12-week timeframe.
Recently, pharmacological hormonal therapy has been introduced to stimulate intestinal
adaptation after intestinal resections. There are various studies involving growth hormone,
glutamine, and glucagon-like peptide 2 growth hormone (GLP-2). To substantiate this, a
systematic review and meta-analysis of randomized controlled trials was conducted by Guo M et
al (8). They performed a search to identify all publications regarding randomized controlled trials
(RCT) on the use of growth hormone (GH) with or without glutamine for the treatment of
patients with SBS and its effect on body weight, lean body mass and intestinal absorption
function. A meta-analysis of 4 trials involving 70 patients showed that GH had a positive but
short term effect in terms of increased weight (p <0.0001), energy absorption (p=0.04), lean
body mass (p<0.001), nitrogen absorption (p=0.04) and fat absorption (p=0.04).
As seen from the evidence based recommendations, it can be concluded that the aim of dietary
management in SBS patients should be to treat the symptoms associated with severe
malabsorption while optimizing nutrient absorption which can minimize or eliminate the reliance
on specialized non-volitional nutrition support. Also, a multidisciplinary approach is required to
manage SBS such as use of oral rehydration therapy, medications and hormonal therapy however
large-scale, long-term follow-up RCTs are needed to confirm the efficacy and safety of GH
treatment in patients with SBS in future.
Case Presentation
A 67 year old African American female was brought to the hospital from her workplace where
she was found supine, in a mute condition. The patient underwent a stroke code at the hospital.
As per the patient’s past medical history, she had type 2 diabetes mellitus, recent treatment for
pneumonia approximately 3weeks ago, uncontrolled hypertension with baseline pressures
usually between 150s to 160s systolic, congestive heart failure (CHF), diastolic dysfunction
hypothyroidism, DM2 retinopathy under treatment at National Institute of Health (NIH). The
patient was found to have dilated small bowel likely due to small bowel obstruction (SBO) per
the CT of abdomen. GI and nutrition consultations were requested by the admitting physician.
The patient was intubated/on vent with NG put to low suction. The patient was then operated for
small bowel resection due to necrosis of majority of small bowel with 65cm total small bowel
left in place but not anastomosed. After 3 days, end-to end anastomosis was done with colon
being intact. Pt had worsening renal status.
Nutrition Care Process: Assessment



Client History: The patient was a 67 year old working female. Her past medical history
includes type 2 Diabetes mellitus, recent treatment for pneumonia, approximately 3
weeks ago, uncontrolled hypertension with baseline blood pressure usually between 150s
to 160s systolic, vague history of having CHF, diastolic dysfunction, no precious
histories of myocardial infarctions, hypothyroidism. DM2 retinopathy under treatment at
NIH. The patient was a non-smoker, had no family history for early strokes or heat
attack. She was prescribed aspirin, labetalol, lantus, Pepcid, nicardipine, fentanyl and
vancomycin. The purpose and side-effects of these medications related to the patient’s
condition are detailed in Table 1 (9).
Food/Nutrition-Related History: Prior to admission patient used to take following
medications: Simvastatin, clonidine, Lasix, Lisinopril, Coreg, Levothyroxine, Aspirin and
Glipizide. Unable to obtain any information regarding food/nutrition related history since
patient was intubated.
Nutrition-Focused Physical Findings: On admission, she had right sided hemiplegia
and was extremely drowsy, had BP of 189/127 and had altered mental status. She was
brought from her workplace where she found supine, unable to stand up. Per the patient’s
son and daughter, patient used to complain about right sided numbness in the upper
extremities 2-3 weeks before hospitalization. These physical findings are consistent with
classic symptoms of Cerebrovascular accident (CVA), hypertension and AFib.

Anthropometric Measurements: The patient was unable to state her usual body
weight. Body mass index and desirable body weight calculations are based on Ht: 157cm
and current weight of 81.6kg indicating that the patient was obese per BMI. Table (2)

Biochemical Data, Medical Tests, and Procedures: Laboratory data and its relevance
to the patient’s condition upon admission are summarized in Table 3. All lab values
evaluated were nutritionally relevant to the patient’s condition.
Abdominal CT suggested no significant bowel wall thickening, pneumatosis or portal
venous gas identified to suggest secondary signs of intestinal ischemia, dilated small
bowel likely due to small bowel obstruction.

Nutrient Needs: Macronutrient requirements were estimated to be 58-69g protein and
1029-1327kcal / day. Nutrient requirements, based on adjusted body weight, are
summarized in Table 2 (11).

ARAMARK Nutrition Status Classification: Utilizing ARAMARK’s Nutrition Status
Classification Worksheet, the patient was classified as moderately compromised (status
3), with 10 total nutrition care priority points. Points were based on: nutrition history
(unable to assess), 4 points for feeding modality (NPO), 0 points for stable weight, 2
points for serum albumin (3.2 g/dl) and 4 points for diagnosis (SBO). Based on the
patient’s status, the plan for follow-up and re-assessment occurred every 3-5days.
The above information obtained upon admission was utilized to perform the initial
nutritional assessment and the following problems and interventions were identified.

Malnutrition Identification: The patient had no signs of malnutrition: she was eating
fair amount of food, no recent weight loss, no signs of loss of muscle mass, had slight
fluid accumulation, had fair amount of functional status.
 Nutrition Care Process: Nutrition Diagnoses
The following PES statement (10) was based on the patient’s status upon admission.
PES: (Clinical): Altered GI function related to likely SBO as evidence by NG output of 1.2L
overnight and 875ml since 7AM.
Nutrition Care Process: Intervention(s)
I: Enteral nutrition: Rate
Goal: EN vs PN depending on bowel improvement
Nutrition Care Process: Monitoring and Evaluation
DAY 1 of assessment: The initial plans for monitoring and evaluation included:
-
Plan to continue to keep patient NPO , NG to LCWS for monitoring NG output
Initiate tube feeding: With NG output improved and less abdominal distention, trickle
feeds to be started: Osmolite 1.5
Repeat abdomen CT to evaluate SBO vs Ischemia
Initiate parenteral nutrition if patient with true SBO and no improvement by day 4 after
this assessment.
Due to the patient’s status, follow-up assessments were scheduled every 1 to 4 days.
DAY 3 of assessment: The patient was operated after 2 days of assessment, Ex-lap and
resection of small bowel was done due to necrosis of majority of small bowel, 65cm total
small bowel was left in place but not anastomosed with pending 2nd e-lap and anastomose
if viable.
PES: Altered GI function related to extensive SB resection with SBS as evidence by
65cm SB left.
Intervention(I): Parenteral nutrition: composition
Goal: Meet needs with TPN
Monitoring and evaluation plans: Get PICC placed and start TPN: 30g protein, 140g D,
15g lipids at 65ml (1st bag at 50ml) = 1164kcal, 47g protein, 1560ml volume. Adjust
protein load with change in renal status or on HD. Provide 100mg thiamine, 1mg folic
acid in TPN to avoid refeeding risk.
DAY 7 of assessment: PICC was still not place, end to end anastomosis was done with
duodenum intact, 30cm from Ligament of Treitz and 30cm from ileo-ceacal valve was
anastomosed and colon intact. Patient was still intubated/vent, NG to LCWS, renal status
was worsening.
PES: Altered GI function related to s/p surgery for bowel ischemia as evidence by SBS
syndrome, in need of TPN.
I: Parenteral nutrition: composition
Goal: Meet needs with TPN.
Monitoring and evaluation: Initiate parenteral nutrition. Check labs: blood glucose.
Triglyceride, BUN/Cr for protein adjustment.
Day 9 of assessment: Tube feeds Osmolite 1 was infusing at 10ml and also TPN.
PES: No new diagnosis
Intervention: No acute intervention required at this time. Tube feeds as tolerated and
continue TPN
Plans: Advance TF as tolerated to 45ml; with output >1L, give lomotil and monitor; if
feeds tolerated with <1L output ,wean and d/c TPN.
DAY 14 of assessment: TPN was adjusted due to increase in blood sugar levels and TF
were running at 45ml
DAY 16 of assessment: Pt was operated for repair of anastomotic leak of SB
anastomosis. TF were stopped due to vomiting after suction, TPN was infusing at 50ml.
PES: Inadequate intake from enteral/ parenteral nutrition related to feeds
off/surgery/anastomatic leak as evidenced by meeting ~70% of needs with TPN.
I: Parenteral nutrition: Composition; goal: to meet 100% needs with TPN
Plans: TPN: 55g protein, 165gD, 22g lipids at 50ml (845kccal, 54g protein, 1200ml
volume); increase lomotil, monitor stool output, blood glucose, renal profile
Day 21 of assessment: No change
DAY 24 of assessment: Pt was with trach/CPAP, NG to LCWS, two dehisced wounds at
abdominal surgical incision.
PES: Increased nutrient needs (protein) related to wound healing as evidenced by 2
dehisced sites at the abdominal surgical incision.
I: Parenteral nutrition: Composition
Goal: Increase protein
Plans: Protein was increased in TPN (140g D, 55g protein, 19g fat at 65ml (1382kcal,
86g protein)), to check healing status of wound, Check labs:BG, renal, consider
readjusting energy needs in next assessment to provide more calories.
Day 28 of assessment: Pt with trach/CPAP, NG to LCWS , JP drain placed, draining
milky white fluid.
PES: Increased nutrient needs (protein) related to wound healing as evidenced by 2
dehisced sites at the abdominal surgical incision.
I: Parenteral nutrition: Composition
Goal: Increase protein
Plan: TPN: 63g protein, 150g D, 22g fat at 65ml (1532kcal, 98g protein, 1560ml), Initiate
TF :Osmolite 1.0 at 10 to test tolerance If can tolerate ~500ml volume’s worth (20ml X
24hr), should get PEG.
Day 30 of assessment: Pt with trach/CPAP, NG to LCWS, TF not initiated due to fluid
collection/viscus leak found in CT, JP drain in place, Increase in edema noted, anasarcic
PES: No new nutrition diagnosis; continue TPN to meet needs
Plans: Continue TPN, Try cyclic TPN in next assessment.
Day 35 of assessment: Pt on trach collar, on Hemodialysis (HD), JP in left lower
quadrant (LLQ) remains unchanged with small amount of drainage. New JP placed in
Left upper quadrant (LUQ), Abdominal wound vac placed and rectal tube placed.
PES: Increased nutrient needs related to increased energy needs for breathing as evidence
by patient’s status on trach collar.
I: Parenteral nutrition: Composition
Goal: Increase calories, cyclic to allow break from TPN
Plan: Change parenteral formula: 22hr cyclic: 65gm protein, 170g D, 22g fat at 40ml first
hour, 80ml X 20hr, 40ml last hour (1777kcal, 109g protein, 1680ml volume, GIR:3.7).
Osmolite 1.0 at 10 to test tolerance. If can tolerate ~500ml volume’s worth (20ml X
24hr), should get PEG.
Day 38 of assessment: Pt not tolerating trach collar, placed on vent, corpak in place, 2 JPs
still in place, TPN infusing at 80ml
PES: Altered nutrition related lab values related to infusion of cyclic TPN as evidence by
blood glucose (BG) of 244.
I: Nutrition related medication: Prescription medication
Goal: Increase insulin dosage to control high BG level related to cyclic TPN.
Plan: Continue TPN at 80ml, check BG and start Osmolite 1.0 at 30ml to test tolerance.
Day 42 of assessment: Pt on CPAP, corpak in place, incision area healing well, abdomen
slightly distended, stool output of 400ml.
PES: No new nutrition diagnosis
I: Parenteral nutrition: Composition
Goal: Change to 20hr cycle and tolerate
Plans: Change TPN: 20hr cycle:68g protein, 170g D,25g fat at 45ml, 85ml X 18hr,45ml
last hr (1782kcal, 110g, 1620ml volume, GIR 3.9). Discussed with patient’s daughter
about outpatient source to reach outpatient GI clinical at University of Virginia (UVA),
provided contact number. Swallowing evaluation when patient alert for po intake
DAY 45 of assessment: Pt on CPAP, TPN infusing at 85ml, JP drain from LLQ removed,
patient no longer on wound vac. Plan to discharge patient once JP drain is removed.
Tolerating 20hr cycle, will cycle down to 18hr.
PES: No new nutrition diagnosis
I: Parenteral nutrition: Composition
Goal: Change to 18hr cycle and tolerate
Plans: Change TPN formula: 18hr cycle: 68g protein, 150g D, 25g fat at 50ml first hour,
95ml X 16hr, 50ml last hour (1672kcal, 110g protein, 1620ml volume, GIR:3.8). Check
BG and triglycerides.
Conclusion
Patients undergoing massive small-bowel resections often experience fluid shifts and difficulties
with volume and electrolyte homeostasis in the early postoperative period and malabsorption of
vitamins and minerals. The immediate treatment focuses on resuscitation, stabilization, diagnosis
and treatment of complications. Nutrition intervention with TPN is often required on a prolonged
or permanent basis in the management of SBS patients. In addition to nutrition intervention,
pharmacological treatment with the use of antimotility agents such as Imodium is also essential
to slow the intestinal transit time and to allow increased absorption of nutrients and fluid.
The case subject was discharged after 2 days of last assessment (45th day) to a specialty hospital,
with a JP drain in place with minimal drainage. She will be on HD, doing well. Plan to
discontinue JP drain after CT scan of abdomen and pelvis to look at size of the fluid collection
on next week of discharge. She was discharged on corpak for medications and TPN at 85ml/hr
for 30hrs, then 45ml for 1hr and then stop TPN for 2 hours and then restart at 45ml/hr for 1 hr.
The patient was provided with contact details of Dr. Parrish for GI nutrition consultancy. She
was prescribed following medications on discharge: Aspirin, Metoprolol, Amlodipine, Catapres,
Procit, Fentanyl Patch, Lasix, Simvastatin, Gentamicin, Heparin, Lantus (18uts), Levothyroxine,
Vancomycin, Coumadin
APPENDIX:
Figure 1. Types of intestinal resection: (A) jejunoileal anastomosis (B) Jejunocolic anastomosis
(C) Jejunostomy and (D) outcomes associated with each type of resection.
Table 1: Medications
Medication
Aspirin
Rationale
Platelet aggregation inhibitor
Labetelol
Anti-hypertensive
Side-effects
Gastric bleeding, decreases iron,
potassium
Fatigue, dizziness
Lantus
Long acting insulin, anti-diabetic
Decrease Mg, K, Phosphorus
Pepcid
Antacid
Decrease Vitamin
absorption
Nicardipine
Fentanyl
Treat high blood pressure
Narcotic
Vancomycin
Antibiotic, to treat/prevent MRSA
B12 and Fe
Dry
mouth,
dyspepsia,
nausea/vomiting,
drowsiness,
abdominal pain, constipation
Increase BUN, Cr
Table 2. Selected Anthropometric Data and Macronutrient Requirements
Anthropometrics
Height
Weight
157
81.6
Macronutrient Needs
Calories
18-23kcal/kg due to intubation=
1039-1327kcal
DBW
165%
BMI
33.10
Protein
1-1.2 / kg =58-69kg
Table 3. Nutrition related Lab parameters
Measurement
Chloride
Value
114
Normal
96-106 MEQ / L
Rationale
Metabolic acidosis, impaired renal
function
Blood Urea Nitrogen
45 (H)
6-20 mg / dl
Impaired kidney function
Creatinine
2.4 (H)
0.9-1.3 mg / dl
Impaired kidney function
CO2
Blood glucose
16 (L)
182(H)
23-29MEQ/L
<70- 110mg/dl
Metabolic acidosis
Diabetes
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