SHORT GUT SYNDROME (SGS) :

A MANAGEMENT CHALLENGE!

Muhammad SaaiqDEPARTMENT OF SURGERY ,PIMS , ISLAMABAD.

Surgical Grand Round, Pakistan Institute of MedicalSciences (PIMS), Islamabad. September 23, 2005.

INTRODUCTION

Adults 90-120 cmChildren 30-60 cm

CAUSES OF SGS :

INTESTINAL ATRESIAMIDGUT VOLVULUSNEC. ENTEROCOLITIS

CROHN’SMESENTERIC VASCULAR DISEASECARCINOMA

RADIATION ENTERITIS/ REGIONAL ENTERITISTRAUMAILIOJEJUNAL BYPASS FOR OBESITY

FACTORS AFFECTING SEVERITY

1) EXTENT OF RESECTION / LENGTH OF RESIDUAL SMALL GUT .

2) SITE OF RESECTION .3) STATE OF THE RESIDUAL GUT .4) ILEOCAECAL VALVE .5) COLON .6) ADAPTIVE CAPACITY OF THE

REMNANT GUT.7) GENERAL FACTORS .

PATHOPHYSIOLOGY :

1) LOSS OF INTESTINAL ABSORPTIVE SURFACE .

2) MORE RAPID INTESTINAL TRANSIT .

3) PRIMARY ILLNESS

NORMAL LENGTH OF GUT PARTS

PART OF GUT LENGTH MOUTH - PYLORUS 65 cm

DUODENUM 25cm

JEJUNUM&ILEUM 400-600cm

COLON 110cm

GUT TRANSIT TIME :

PART OF GUT TR. TIMESTOMACH

* FLUIDSOTHERS

30 minFew hours

SMALL GUT 4-6 hoursLARGE GUT 6-12 hours

DAILY FLUID TURN-OVER IN GIT:

AMOUNT

EXOGENOUS INTAKE 2 LitresENDOGENOUS SECRETIONS :

SalivaryGastricBilePancreaticIntestinal

1.5 L2.5 L0.5 L1.5 L1 L9 L

CLINICAL FEATURES :

DIARRHOEA / STEATORRHOEA ELECTROLYTE IMBALANCEMALNUTRITIONVITAMIN DEFICIENCY esp. B 12GASTRIC ACID HYPERSECRETIONLIVER DYSFUNCTIONCHOLELITHIASISNEPHROLITHIASISBACTERIAL OVERGROWTH

ADAPTATION:

1) STRUCTURAL & FUNCTIONAL

CHANGES IN THE GUT .

2) ENTERAL NUTRIENTS ARE MUST .

3) ENTEROGLUCAGON HAS A ROLE

MANAGEMENT:THE COURSE OF ILLNESS IS DIVIDED INTO THREE PHASES:

1) IMMEDIATE POST-OP PHASE

2) TRANSITION PHASE

3) PHASE OF LONG- TERM COMPLICATIONS

Manag.Contd:

IMMEDIATE POST-OP PHASE :

Critical care

Sepsis control

Maintenance of Fluid/Elec. Balance

Gastric acid suppression

Total parenteral nutrition

General care

Manag.Contd:TRANSITION PHASE :

TPN-----EN / Home TPN

Role of Antimotility / Antisecretory agents

Dietary management:

Small frequent meals

Nutrients in simplest form

Separate solid nutrients from liquids

Avoid hyper-osmolar fluids

Restricted fat intake

Avoid high oxalate

MANAGEMENT OF LONG- TERM COMPLICATIONS :

1) Correction of nutritional derangements

2) Catheter related problems

3) Cholelithiasis

4) Nephrolithiasis

5) Liver dysfunction

6) Bacterial overgrowth

Manag.Contd:ROLE OF SURGERY :1) Restoration of intestinal continuity

2) Enteroplasty / Lengthening procedure

3) Slowing down rapid transit:

creating artificial valve

construction of anti-peristaltic segment

colonic interposition

construction of recirculatig loop

pacing with electrodes in retrograde fashion

4) Small gut / combined liver & small gut transplant

5) Management of complications

CONCLUSION

THANK YOU

CASE CASE PRESENTATIONPRESENTATION

NAME : ABCAGE : 14 YRSGENDER : MALE ADDRESS : PIND DAD KHAN DOA : 09/04/2004

PRESENTING COMPLAINTS :SEVER DIFFUSE ABDOMINAL PAIN : 1

DAY VOMITING : 1 DAYCONSTIPATION : 1 DAY

HISTORY OF PRESENT ILLNESS

PATIENT WAS IN USUAL STATE OF HEALTH DEVELOPS SEVERE GRIPPING DIFFUSE ABDOMINAL PAIN OF SUDDEN ONSET CONTINOUS IN NATURE AGGREVATED BY MOVEMENTNO RELIEVING FACTOR.

HE HAS 3 BOUTS OF VOMITING WITH IN TWO HOURS OF ONSET OF PAIN , GREENISH IN COLOUR WITH BLOOD TINGE IN IT .

ASSOCIATED SYMPTOM : ABSOLUTE CONSTIPATIONTWO MONTH BACK HE EXPERIENCED AN EPISODE OF MILD DULL ACHING PAIN IN UMBILICAL REGION LASTED FOR 4 HOURS , CONSULTED DOCTOR LOCALLY WHO ADVISED ANALGESIC THAT RELIEVED HIS SYMPTOM

PERSONAL HISTORY : 7th CLASS STUDENT

WITH GOOD APPETITE PREVIOUSLY , NORMAL SLEEP , NONSMOKERB , NON ADDICTEDPAST HISTORY:UNREMARKABLEFAMILY HISTORY : SOCIOECNOMIC HISTORY :MEDICATION HISTORY :

EXAMINATION :GPE :

BP 100/70 PULSE : 104/ MIN T : 100 * F R / RATE : 24 / MIN

ABDOMEN : MILD DISTENSIONTENDER ALL OVER ABDOMEN

BS NEGATIVE PR:UNREMARKABLE.

SYSTEMIC EXAMINATION

CVSCNSGUSRESPIRATORYMSS

ALL ARE UNREMARKABLE

INVESTIGATIONS

PLAIN X-RAY ABDOMEN : DILATED GUT LOOP , NO PNEUMOPERITONEUMU/S ABDOMEN : DILATED GUT LOOPS , MINIMAL AMOUNT OF FREE FLUID IN PERITONIAL CAVITYBCP : TLC :12500RFT , SE , LFTs , S.AMYLASE , PT/APTTALL WERE WITH IN NORMAL LIMITS

PLAN OF MANAGMENTPATIENT KEPT NPO PASSED NG TUBEI/V FLUID I/V ANTIBIOTICSEXPLORATORY LAPROTOMY

EXPLORATORY LAPROTOMY

INCISION : LOWER MID LINEFINDINGS :

PERITONIAL CAVITY FILLED WITH GANGRENOUS SMALL GUT . 80% OF JEJUNUM , ILEUM BEING TIGHTLY TWISTED TWICE AROUND LONG LOOSE MESENTERY THAT CONTAINED A BENIGN LOOKING LUMP (12 *10*6 cm ) ABOUT3cm FROM MESENTERICBORDER OF THE JUNCTION OF JEJUNUM &ILEUM

PROCEDURE:

THE GANGRENOUS SMALL GUT ( ABOUT 340 cm) WAS RESECTED LEAVING BEHIND HEALTHY 75cm JEJUNUM & 10cm ILEUM . THE REMNANT STUMPS WERE PARTIALLY ANASTOMOSED & BRING OUT AS COMBINED STOMA THROUGH RIGHT LOWER ABDOMEN

POST OPERATVE MANAGMENT

I/V ANTIBIOTC TPN ACID SUPPRESSANT

STOMA WAS REVERSED AFTER 8 WEEKS PATIENT STARTED ON ORAL FEED AFTER 1 WEEK .

HE IS NOW TOLERATING ENTERAL FEEDS & GAINING WEIGHT .

BIOPSY REPORT:HISTOPATHOLOGY REVEALED BENIGN LIPOMA

LIPOSITES

CAPSULE OF LIPOMA

FOUR LAYERS OF GUT ON LIPOMA

CONGESTION OF GUT WALL

CONGESTION

CONGESTED BLOOD VESSELS IN LIPOMA

THANK YOU