THE SHORT BOWEL SYNDROME - WHATS NEW AND OLD

Conditions which resulted in colonic preservation such as strangulated hernia, intestinal volvulus, and mesenteric infarction were once the main reasons for a major intestinal resection leading to the short bowel syndrome. Now Crohn's disease is the most common underlying diagnosis; such patients often have a jejunostomy. A measurement of the residual jejunal length from the duodenojejunal flexure makes possible predictions of patient outcome. Patients with a jejunostomy and less than 100 cm jejunum usually need long-term parenteral support, whereas 50 cm or more of jejunum usually suffices for adequate oral nutrition if the colon is preserved. While patients with and without a colon have problems with nutrient absorption, those with a jejunostomy also have problems of water, sodium and magnesium losses. Stomal losses may exceed oral intake and all such patients ('secretors') need parenteral supplements. Fluid and sodium losses can be reduced by octreotide, omeprazole or H-2 blockers but not sufficiently to avoid the need for intravenous supplements. Colonic preservation increases the incidence of calcium oxalate renal stones (20%). Patients with and without a colon have a high prevalence of gallstones (40%). Clinically important intestinal adaptation occurs in those with a colon but not in those with a jejunostomy. Many surgical techniques, including small bowel transplantation, have been suggested to improve absorption, but as the quality of life of most patients with a short bowel is good with current treatments, they are not at present recommended.