Short Bowel Syndrome
Nutritional support, pharmacological management and intestinal adaptation
Short bowel syndrome results from extensive surgical resection of the small intestine, leaving less than 200 cm of functioning bowel. This leads to chronic malabsorption, fluid and electrolyte imbalances, and nutritional deficiencies that require specialist multidisciplinary management. Common causes include Crohn's disease, mesenteric ischaemia, volvulus, radiation enteritis, and trauma. Treatment centres on nutritional support, antimotility drugs, and intestinal rehabilitation.
Presentation and Diagnosis
Patients with SBS present with persistent diarrhoea, high-output stoma or fistula (often exceeding 2 litres per day), dehydration, malnutrition, weight loss, and fatigue. Electrolyte imbalances are common — hyponatraemia, hypokalaemia, and hypomagnesaemia. Fat-soluble vitamin deficiencies (A, D, E, K) may cause night blindness, osteoporosis, and coagulopathy. Vitamin B12 deficiency occurs when the terminal ileum has been resected. Diagnosis involves measuring stool output, daily fluid balance, comprehensive blood tests including electrolytes, vitamins, and trace elements, and imaging to assess remaining bowel anatomy.
Nutritional Support and Fluid Management
Parenteral nutrition (TPN) is the mainstay in acute SBS and when enteral nutrition is impossible. Enteral nutrition via nasogastric tube or jejunostomy is preferred when tolerated, as it promotes intestinal adaptation. Oral diet should consist of small frequent meals — high in complex carbohydrate and low in fat for patients with a colon in continuity. Oral rehydration with St Mark's solution or glucose-saline ORS should be taken between meals rather than with them. Fluid restriction between meals can reduce stool output.
Pharmacological Management
Antimotility drugs are central to managing SBS. Loperamide at 2–4 mg four times daily reduces transit time and stool output, taken 30–60 minutes before meals. Codeine phosphate is an adjunct if loperamide is insufficient. Omeprazole 40 mg twice daily addresses gastric acid hypersecretion in early SBS. Octreotide may be used in specialist centres for high-output states. Teduglutide (NICE TA427) is a GLP-2 analogue that stimulates intestinal adaptation and is licensed for adults with SBS dependent on parenteral nutrition three or more times per week. All patients require vitamin B12 injections (if terminal ileum resected), fat-soluble vitamin supplements, magnesium, zinc, and calcium with vitamin D.