S2900 Tincture of Opium in a Refractory Case of Short Bowel Syndrome

Abstract

INTRODUCTION: Short bowel syndrome is a complication of extensive bowel resection with length of the remaining small intestine and presence of colon in continuity the most important predictors of patient’s outcome. While there is extensive literature regarding the management of short bowel syndrome, still no single agent is universally effective. Refractory cases with intestinal failure can lead to life-threatening complications requiring small bowel transplant, yet this is not a widely available option. Tincture of opium is an agent with promising results in refractory cases. We present a challenging case of a short bowel syndrome with high output ostomy unresponsive to first-line therapy requiring long length of hospital stay, ICU admission, and significant use of resources which ultimately showed optimal response to tincture of opium. CASE DESCRIPTION/METHODS: A 74-year-old female with diabetes, chronic kidney disease, and sigmoid colon intussusception status post diverting ostomy presented with abdominal pain and increased ostomy output. EGD with gastric and duodenal biopsy was non-revealing, and infectious work up was negative. Increased ostomy output of 5500 mL lead to hypovolemic shock, critical hyperkalemia requiring urgent hemodialysis and ICU admission. Careful review of previous operative report and CT showed 60 cm of small intestine and small portion of ascending colon remaining with end jejunostomy. High output ostomy with short bowel syndrome was treated with serial addition of psyllium, loperamide, cholestyramine, octreotide, protonix all titrated up to maximum dose, a trial of rifaximine for possible SIBO allowing 2-3 days in between each escalation therapy to monitor for response. Clonidine was not used due to hypotension. Finally, tincture of opium was added which decreased ostomy output to 400 cc daily, the remaining agents were successfully removed and ostomy output was well-controlled on a daily dose of loperamide and tincture of opium. DISCUSSION: Short bowel syndrome is a challenging condition requiring a large amount of resources and adds tremendous cost to the health care system. In our case, the patient was unresponsive to the first-line antimotility agents due to limiting length of remaining intestine. The optimal effect of tincture of opium we observed in our case offers an effective solution and suggests that early use of this agent in refractory cases of short bowel syndrome may help to avoid unnecessary hospitalization and long length of stay.