Leading article 1061

Short bowel syndrome: searching for the proper diet

Herbert Tilg
K Normal length of the small bowel varies
considerably from 320800 cm; a small bowel
length of less than 200cm predisposes to the
development of intestinal failure.
K Prevalence of short bowel syndrome (SBS) is
not known; 30% may depend on parenteral
nutrition.
K Patients with SBS should always be early
assessed for resuming an oral diet.
K Underlying disease and type of surgical procedure
have to be taken into consideration for the best
care of SBS patients.
Short bowel syndrome occurs subsequent to anatomical
and/or functional loss of mainly small bowel. This
often-devastating disease leads to weight loss and
immune dysfunction. Proper medical management
involves adequate substitution and maintenance of
fluid, electrolytes, and nutrients. Although several
pharmacological therapies such as clonidine, growth
hormone, or octreotide have shown promising results
in short bowel syndrome, optimal nutritional management
is the most important factor in these patients. If enteral
nutrition is possible, diet should consist mainly of fat,
followed by protein, and less intake of carbohydrates.
Supplementary nonprocessed cereals may be beneficial
in a certain subgroup of patients. With the recent
developments in medical therapy, a balanced diet
may allow many patients to become nutritionally
autonomous. Eur J Gastroenterol Hepatol 20:10611063
c
2008 Wolters Kluwer Health | Lippincott Williams &
Wilkins.
European Journal of Gastroenterology & Hepatology 2008, 20:10611063
Keywords: bowel adaptation, cereals, diet, inflammatory bowel disease
Christian Doppler Research Laboratory for Gut Inflammation, Clinical Division
of Gastroenterology and Hepatology, Medical University Innsbruck,
Innsbruck, Austria
Correspondence to Herbert Tilg, MD, Christian Doppler Research Laboratory for
Gut Inflammation, Clinical Division of Gastroenterology and Hepatology, Medical
University Innsbruck, Anichstrasse 35, Innsbruck 6020, Austria
Tel: +43 512 504 23374; e-mail: Herbert.Tilg@i-med.ac.at
Received 6 April 2008 Accepted 8 April 2008
Resection of small bowel leads to malabsorption of fluid,
electrolytes, minerals, and other key nutrients, finally
resulting in malnutrition and dehydration. Short bowel
syndrome (SBS) may occur when less than 200 cm of
functional small intestine are left [1]. Although milder
forms can be managed less aggressively, the most severe
forms need parenteral nutrition (PN) or even intestinal
transplantation [2]. In adults, SBS commonly results
from surgical resection for Crohns disease, vascular
insufficiency, or after radiation injury. In case of SBS,
the remaining colon could become an important digestive
organ. Therefore, the simple length of remaining small
bowel is often of little value in clinical practice as
outcome depends on various prognostic factors including
the quality of the remaining bowel. Loss of bowel in
patients with Crohns disease or after radiation therapy is
more serious than loss of a bowel after traumatic injury.
Definitions of SBS and its complications are often
influenced and limited by the fact that some definitions
are anatomically based, whereas others define this
syndrome through functional aspects. At the end,
patients with SBS do not care about our definitions as
their complaints and miseries define their individual
disease. Owing to those limitations, recently a new
definition has been proposed: Short-bowel-syndrome-
intestinal failure results from surgical resection, congeni-
tal defect, or disease-associated loss of absorption and
is characterized by the inability to maintain protein-
energy, fluid, electrolyte, or micronutrient balances when
on a conventionally accepted, normal diet [1]. Proper
management of patients with SBS should not only involve
their primary specialists (surgeons and gastroenterolo-
gists), but also a balanced team with profound expertize
in clinical nutrition.
Bowel adaptation
Clinical symptoms of SBS depend on how intestinal
adaptation takes place after extensive surgical resection
[3]. An ileocecal valve in place significantly influences
the situation as it slows down small intestinal transit and
prevents small bowel bacterial overgrowth. The process of
intestinal adaptation is generally associated by lengthen-
ing of intestinal villi, which is accompanied by enhanced
absorptive capacity. Therefore, the overall absorptive area
increases, whereas specific active transporters are not
affected. Not surprisingly, this process develops over
0954-691X c 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins DOI: 10.1097/MEG.0b013e3283040cc9
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years and remains in most cases an insufficient adapta-
tion. Moreover, enteral nutrition with associated func-
tional, hormonal, biliary, and pancreatic secretions drives
this process and increases mucosal adaptation suggesting
that adaptation is a highly active process requiring enteral
nutrition. Some evidence exists that certain biochemical
parameters such as the antisecretory factor, a 41 kDa
protein present in many human tissues, or citrulline
might be correlated with the bowel length after surgical
resection is found [4,5].
Clinical management: general strategies
Several key clinical advices have to be considered by
physicians taking care of patients with SBS. Patients
should avoid drinking water without adding any food,
disseminate fluid intake over the day and try to sip
liquids. Furthermore, hypotonic fluids should not be
used and patients should rather drink oral rehydration
solutions containing salts and carbohydrates.
With the recent development of various hormone and
gut peptide therapies such as growth hormone, octreotide,
and glucagon-like peptide-2 management even of pa-
tients highly dependent on PN could be improved
considerably [6,7]. Management of SBS requires appro-
priate vitamin and mineral substitution (K
+
, Cl

, Mg
2 +
,
Ca
2 +
, Zn
2 +
, Fe
2 +
, selenium, B12) and pharmaco-
therapy. Oral calcium supplements also may be of
relevance for the prevention of calcium-oxalate nephro-
lithiasis. Besides the already mentioned trophic factors/
hormones antidiarrheals, proton pump inhibitors, pancreatic
enzymes, bile salt-sequestering agents, and antimicrobials/
probiotics are of clinical value. Various other agents might
also positively affect bowel transit time. Buchman and
colleagues [8] recently presented evidence that cloni-
dine is able to improve diarrhea and sodium loss in
patients with a proximal jejunostomy. In this study, they
investigated the use of clonidine in eight PN-dependent
patients with an average residual small bowel length
of 72 cm. Transdermal administration decreased signifi-
cantly daily fecal volume and weight [8].
Dietary approaches
The likelihood of success of enteral nutrition in patients
with SBS depends on several factors such as length of
the remaining small bowel and/or small bowel segments,
presence of colon, and how intestinal adaptation devel-
oped. Attempts should be made to wean patients from
PN to an oral diet as soon as possible for already men-
tioned reasons. Dietary management is complex and
needs to be individualized for each patient dependent on
underlying disease, degree of resection, and lifestyle.
The immediate goal is to provide patients with approxi-
mately 2530 kcal/kg per day and 1.01.5 g/kg per day
protein. Nitrogen utilization is usually not affected and
therefore the use of peptide-based diets in these patients
is not beneficial. A small study supporting this notion has
recently been published [9]. The investigators evaluated
the role of a hydrolyzed versus nonhydrolyzed protein
diet in infants with SBS. They demonstrated in this
prospective, randomized, cross-over, double-blind study
that neither energy, intestinal permeability nor nitrogen
balance were affected. In patients with preserved colon,
soluble fiber can be used as an additional energy source.
Fiber supplementation might also positively affect the
adaptation process as it increases short-chain fatty acid
production. In addition, fiber addition might decrease
stool volume by enhancing water absorption.
No definite answer yet, whether to prefer a high-fat
low-carbohydrate versus low-fat high-carbohydrate diet, is
found. There are, however, certain arguments for a lower
carbohydrate, higher fat diet in these patients [10]. A
high-carbohydrate low-fat diet modifies the disturbed
microflora in SBS toward a flora dominated by lactobacilli
thereby producing massive amounts of D-lactic acid
and gaseous CO
2
. As a consequence, patients are faced
with increased flatulence, abdominal pain, and diarrhea
and low uptake of fat and lipophilic vitamins. Another
disadvantage of a high-carbohydrate content is the fact
that it creates a much higher osmotic load in the intestine
than fat or protein. The negative effects of carbohydrates
though might be less pronounced, especially in adults
with a preserved colon where malabsorbed carbohydrates
are metabolized to short-chain fatty acids and serve as
an additional energy source. Furthermore, randomized
controlled trials have not shown that glutamine or
growth hormone might improve intestinal absorption
[11]. Enteral formulations that contain a relatively high-
fat content and fiber are therefore preferred and generally
better tolerated.
Nonprocessed cereals in short bowel
syndrome: an advance in a subgroup
of patients
Specially processed cereals are derived from cereals
manufactured by a controlled hydrothermal process.
During this process, the cereals increase the percentage
of certain carbohydrates as well as amino acids. Pagoldh
and colleagues [12] present in this issue of the journal
an important study in a rather neglected field of
gastroenterology where they investigated the effects of
a supplementary diet comparing specially processed
versus nonprocessed cereals in patients with SBS. The
authors demonstrate that nonprocessed cereals might
decrease fecal volume at least in certain patient groups
and therefore could reflect an attractive supplementary
for some of those patients. It has to be mentioned that
23 of the 26 study patients had inflammatory bowel
disease including an unusual large number of patients
with ulcerative colitis. One might wonder whether
despite normal laboratory values (including C-reactive
1062 European Journal of Gastroenterology & Hepatology 2008, Vol 20 No 11
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protein) definition of SBS has been somewhat influ-
enced by activity of their underlying inflammatory bowel
disease, although patients did not receive any anti-
inflammatory therapy. Unfortunately data on endoscopy
are not provided for included patients and therefore
subclinical inflammation cannot be ruled out. Despite
these shortcomings the authors have to be congratulated
providing us with a simple and potentially important
message that the addition of nonprocessed cereals might
be beneficial in patients with SBS. Before recommending
such a diet, validation of the underlying disease, as well as
information about performed surgical procedures, is
needed. Patients with SBS are often neglected by clinical
research and as discussed by Pagoldh and colleagues [12],
only large international study efforts will allow in the
future to make the desperately needed clinical progress
for those often heavily compromised patients.
Acknowledgements
This study was supported by the Christian Doppler
Research Society.
Conflict of interest: none declared.
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