Remnant Small Bowel Research Articles

Predictive Potential of Biomarkers of Intestinal Barrier Function for Therapeutic Management with Teduglutide in Patients with Short Bowel Syndrome.

The human intestinal tract reacts to extensive resection with spontaneous intestinal adaptation. We analyzed whether gene expression analyses or intestinal permeability (IP) testing could provide biomarkers to describe regulation mechanisms in the intestinal barrier in short bowel syndrome (SBS) patients during adaptive response or treatment with the glucagon-like peptide-2 analog teduglutide. Relevant regions of the GLP-2 receptor gene were sequenced. Gene expression analyses and immunohistochemistry were performed from mucosal biopsies. IP was assessed using a carbohydrate oral ingestion test. The study includes 59 SBS patients and 19 controls. Increases in gene expression with teduglutide were received for sucrase-isomaltase, sodium/glucose cotransporter 1, and calcium/calmodulin serine protein kinase. Mannitol recovery was decreased in SBS but elevated with teduglutide (Δ 40%), showed a positive correlation with remnant small bowel and an inverse correlation with parenteral support. Biomarkers predicting clinical and functional features in human SBS are very limited. Altered specific gene expression was shown for genes involved in nutrient transport but not for genes controlling tight junctions. However, mannitol recovery proved useful in describing the absorptive capacity of the gut during adaptation and treatment with teduglutide.

213.7: A Data-driven Predictive Analytics Framework for the Analysis of Prognostic Factors and Health Outcomes in Paediatric Intestinal Failure Patients

Introduction: Machine learning (ML) involves computational methods and learning mechanisms that can help generate new knowledge from large databases. These techniques are uniquely suited to analyses of paediatric intestinal failure (IF) where classification, prognostication, identification of risk factors, and knowledge extraction can be challenging. Heterogeneous patient populations, small sample sizes, and variations in treatments may complicate our ability to manually identify trends in data. Factors that predict enteral autonomy (EA) and patient management (optimal intravenous lipid emulsion [ILE] solutions; central venous catheter [CVC] complications) have been described, yet a systematic approach that may be prospectively applied to large datasets has never been performed in this patient population. Our study aims to identify predictors of EA through machine learning (ML) and assess their impact on TPN duration. For patients on TPN, assessments of lipid emulsion (ILE) and central venous catheter (CVC) type were also performed. Methods: Demographics, procedures, and outcomes for patients (N=17) from McMaster Children’s Hospital’s (MCH) Intestinal Rehabilitation Program (1999-2021) were collected for a retrospective chart review. Predictors of EA status were obtained using a decision tree ML model. Performance was evaluated as area under the receiver operator characteristics (AUC) and precision-recall (PR) curves. These predictors were assessed for ability to impact TPN duration with Kaplan-Meier (KM) estimates and Cox proportional-hazards (CPH) models. ILE treatments were compared using the Mann-Whitney U test, and CVC types were compared with KM, CPH, and analysis of variance (ANOVA). Results: The model retrieved 10 predictors of EA status. AUC and PR curves were 91% and 71% respectively. Of these 10 predictors: sex, serial transverse enteroplasty (STEP) procedure, ileocecal valve (ICV) presence, and remnant small bowel length were significant for predicting EA status under KM, but not CPH. For ILE treatment, patients on SMOF Lipid® had lower total bilirubin values compared to Intralipid® at six months (4.0 versus 10.0 uMol/L). Longevity of peripherally inserted central catheters (PICC) was 847 days versus 268 days for tunnelled CVCs, and 181 days for ports (95% CI: 0-2044, 93-443, 144-218). Types of complications were not significantly different across CVC. Conclusions: Our study supports the role for ML frameworks in advanced pattern recognition, and promoting adaptive clinical management. Validation of this model using our single-centre dataset supports similar conclusions derived from larger, multi-center registries. Ongoing use of our ML framework offers a novel contribution to intestinal failure analyses by helping identify unique risk factors and protective factors for EA, and approaches to clinical management in the paediatric IF population.

Intestinal failure-associated liver disease in patients with short bowel syndrome: Evaluation by transient elastography.

Patients with short bowel syndrome (SBS) receiving long-term parenteral nutrition (PN) are at risk for intestinal failure-associated liver disease (IFALD). The aim of the present study was to evaluate dynamic changes of liver fibrosis and steatosis within 12 mo by transient elastography (TE), including controlled attenuation parameter (CAP) in a cohort of patients with SBS receiving long-term PN. Twenty-five adult patients with SBS and PN requirement for ≥3 mo consecutively were included and prospectively followed. Liver stiffness by FibroScan (Echosens, Paris, France) and CAP measurement were done at study entry and after 12 mo. Clinical parameters, as well as data on underlying bowel disease and nutrition composition, were collected. Bioelectrical impedance analysis was performed in all patients. FibroScan and CAP did not show any significant differences after 12 mo (5.2 kPa [2.8-16.2 kPa]; 223dB/m [101-366 dB/m]) compared with study entry (5.3 kPa [2.7-12.3 kPa]; 237dB/m [100-344 dB/m]). There was no significant correlation between FibroScan and CAP and elevated transaminase levels. CAP significantly correlated with triacylglyceride levels (r = 0.411; P = 0.042) and body mass index (r = 0.468; P = 0.016). Patients with a remnant small bowel <100cm showed a significantly higher stiffness value by FibroScan than those having a remnant length ≥100cm (6.1 versus 4.7 kPa; P = 0.028). In the present study cohort, prevalence of advanced fibrosis or cirrhosis was low (<10%) without significant dynamic within the 12-mo follow-up. Short intestinal remnant length <100cm appeared to be a risk factor for development of fibrosis.

The evolution of the serial transverse enteroplasty for pediatric short bowel syndrome at a single institution

PurposeThe serial transverse enteroplasty (STEP) tapers and lengthens the gut to improve adaptation. Mortality has decreased with multidisciplinary intestinal rehabilitation programs (IRP) allowing more time to reach adaptive potential. We reviewed our STEP experience to compare surgical outcomes between early and late eras of our IRP. MethodsA retrospective cohort study of all STEP patients managed by our IRP (Jan 2003–Dec 2016; era 1 2003–2005, era 2 2006–2016) was completed. Patient demographics, operative data, complications, and outcome data were collected. Univariate analysis between eras with nonparametric statistics was performed. ResultsThirty-six patients received STEP (Era 1 = 12; Era 2 = 24) [median age 5mo; males 22/36 (61.1%)]. In Era 2 a higher proportion had gastroschisis (8.3% vs 58.3%); p = 0.004) and shorter pre-STEP small bowel remnant (48 vs 111 cm, p = 0.001). The median increase in bowel length post-STEP was 52.9%. Overall, 42% of patients reached enteral autonomy (Era 1 7/12 (58%) vs Era 2 8/24 (33%); p = 0.15). Median time to PN discontinuation was shorter in Era 1 (259 vs 968 days, p = .208). Staple line complications were higher in Era 1 (16.7% vs 0%; p = 0.040). ConclusionPresently, STEP is reserved for a specific subset of IRP patients, allowing 42% to wean off PN. STEP's use should be under the umbrella of a multidisciplinary IRP. Type of studyRetrospective cohort study. Level of evidenceIII

Serum Citrulline Levels Exhibit Circadian Variation and Fluctuations in Relation to Food Intake in Mice.

BackgroundPlasma citrulline is a nonessential amino acid synthesized almost exclusively by enterocytes of the small intestine. Correlation between post-operative plasma citrulline levels and remnant small bowel mass and function has led to its use as a simple biomarker of functional intestinal mass in adults and children, with a proposed prognostic value for achieving enteral autonomy in the setting of intestinal failure. While it is standard to measure fasting levels in humans, the optimal timing of blood draws in relation to food intake and time of day has not been standardized and is poorly studied in animal models. We hypothesize that serum citrulline levels vary both throughout the day and with relation to food intake in mice.MethodsSerum citrulline levels were measured from 12 C57BL/6 mice (6 - 9 weeks old) in the mornings and evenings, either after ad libitum food intake or after 8 - 12 h of access to water only. Blood draws for each experimental set-up were performed 1 week apart according to our Institutional Animal Care and Use Committee (IACUC) guidelines for acceptable blood collection volumes for survival procedures. At the end of the experiment, mice were euthanized and small intestine was harvested for morphometric measurements. Group means were compared using Student’s t-test with significance assumed for P < 0.05.ResultsAfter withholding chow for 8 - 12 h, serum citrulline levels were significantly greater in the morning compared to levels drawn in the evening. When mice were allowed ad libitum chow, there was no significant difference in serum citrulline levels drawn in the morning compared to the evening. There was no difference detected in villus height across the different experimental conditions.ConclusionsSerum citrulline levels exhibit circadian variation and fluctuations in relation to food intake in mice, without apparent concurrent changes in enterocyte mass. There was no diurnal variation of serum citrulline levels in fed mice whereas fasted mice had significantly higher levels of serum citrulline in the morning compared to the evening. These findings underscore the paramount importance of consistent sample collection strategies in the setting of translational research.

Remnant Small Bowel Length in Pediatric Short Bowel Syndrome and the Correlation with Intestinal Dysbiosis and Linear Growth

Pediatric short bowel syndrome (SBS) is a malabsorptive state placing patients at risk for malnutrition, dehydration, and bacterial overgrowth. These patients are often dependent on parenteral nutrition (PN) while intestinal adaptation is underway. The aim of this study was to characterize the effect of remnant small bowel length on the gut microbiome. Further, we sought to examine the contribution of clinical and nutritional variables to the gut microbiota and anthropometric growth. Clinical data, anthropometrics, and fecal samples were collected from 14 SBS patients and 10 age- and sex-matched controls. Fecal bacterial DNA composition was analyzed using 16s ribosomal RNA gene sequencing. Statistical analysis was completed using the Mann-Whitney or Fisher's exact tests when applicable and linear mixed effect modeling. Distinct microbiota changes were found among those with the least remaining small bowel (<35 cm) compared with those with longer remaining bowel and controls. Those with <35 cm small bowel displayed an increased relative abundance of Proteobacteria, while those with longer remaining small bowel had a higher proportion of Firmicutes. Further, patients with less remaining bowel required more PN (p < 0.01), with a tendency to be shorter in height (p= 0.05) and with a higher BMI (p= 0.05). Remnant small bowel length appears to be a predictor of stunting with diminished linear growth, parenteral nutrition dependency, and a greater relative abundance of Proteobacteria in the gut. These findings suggest an integrated adaptive response predicted by remnant intestinal length. Further research is necessary to examine the effects of intestinal dysbiosis on clinical outcomes.

Surgical revascularization of the celiac artery for persistent intestinal ischemia in short bowel syndrome

Background and objectivesWithout prompt superior mesenteric artery (SMA) revascularization, acute mesenteric ischemia (AMI) frequently leads to death or short bowel syndrome (SBS). In SBS patients, persistent or chronic intestinal ischemia (PII) of the remnant bowel can lead to recurrences of AMI. Since SMA revascularization is sometimes unfeasible, celiac artery (CA) revascularization may improve blood supply to the remnant bowel. The aim of this study was to describe and to assess our experience of the CA revascularization in case of SMA occlusion unsuitable for revascularization in the setting of PII in SBS patients. MethodsAll consecutive patients with i) SBS consecutive to AMI, ii) persistent intestinal ischemia (PII), iii) irreversible SMA occlusion, i.e unsuitable for radiological or surgical revascularization and iv) occlusion or severe stenosis of the CA were included. ResultsThirteen patients (7 males/6 females, mean age = 47.2 ± 12.1 years) were included. The mean length of remnant small bowel was 47 ± 39 cm and 77% of patients had a stoma. The types of revascularization included anterograde aorto-hepatic bypass n = 11 (84%), ilio-hepatic bypass n = 1 (8%) and endarterectomy n = 1 (8%). Major adverse events were observed in 5 cases: bypass graft infection (n = 2), hemorrhagic pericarditis (n = 2), hemorrhagic shock (n = 2) and aortic false aneurysm (n = 1). After a mean follow-up of 27.0 ± 25.2 months, symptoms of PII relieved in 12 cases (92%) allowing for digestive surgical rehabilitation with continuity restoration in 7 patients (54%). PN was weaned for 2 patients. One-year and 3-year survival rates were 73.8% and 73.8% respectively. No recurrence of AMI or further need for bowel resection was noticed. ConclusionFor patients with SBS suffering from PII with CA occlusion or stenosis without possibility of SMA revascularization, the surgical revascularization of the CA allowed digestive rehabilitation with acceptable morbidity and mortality rates.

Short Bowel Syndrome

Objectives and Study: Intestinal failure (IF) is a state of severe intestinal malabsorption requiring parenteral nutrition (PN) for survival. The leading cause of IF is short bowel syndrome (SBS). This study aims to show whether the presence of the colon makes a difference in children with SBS, and to find correlations between intestinal absorption rate, citrulline level, anatomy of the remnant bowel and parenteral nutrition dependency. Methods: Twenty-three SBS children were included in this study and divided into two groups according to the presence or absence of the colon. Bowel length, citrulline plasma levels, intestinal absorption rate [by using three days stool balance analysis] and PN dependency index [by using the index Non Protein Energy Intake (NPEI)/Resting Energy Expenditure (REE) by Schofield formula], were assessed. Regression analysis and student t tests comparing variables were performed. Results: Patients with colon (n=14) had significantly shorter remnant small bowel as compared with those without colon (n=9) (29.25 ± 25.64 vs. 60.88 ± 22.54 cm; P < 0.003) and lower fecal sodium losses (48.5 ± 28.07 vs. 85.88 ± 18.98 mmol/l; P < 0.002). No difference was found between the groups for the percentage energy absorption (63.4 ± 19.0 vs 66.4 ± 15.4% respectively), while citrulline plasma levels showed only a tendency to be higher in SBS without colon (19.1 ± 12.17 vs. 14.4 ± 9.72 μmol/l; P = 0.17). PN dependency was not significantly different between neither groups, nor the total energy intake from oral or enteral nutrition. No correlation was found between the different parameters, although the citrulline level correlates with the small bowel length in the group with colon (r2 = 0.57). Conclusion: By using three days’ stool balance analysis, this study demonstrates for the first time in SBS children, the role of the colon in energy salvage in addition to water- electrolytes absorption. It emphasizes the importance of early restoration of intestinal continuity and preservation of intestinal microbiota.

Ultrashort Bowel Syndrome Outcome in Children Treated in a Multidisciplinary Intestinal Rehabilitation Unit.

Aim Short bowel syndrome (SBS) is the leading cause of intestinal failure (IF) in the pediatric population. Our aim was to review long-term outcome of ultrashort bowel syndrome (USBS) in an Intestinal Rehabilitation Unit (IRU). Patients and Methods Retrospective study of patients with USBS (defined as < 10 cm of remnant small bowel) treated between 2000 and 2015. Demographic data, clinical, and treatment variables including parenteral nutrition (PN), surgical techniques, and intestinal transplantation (IT) were analyzed. Results Out of 250 children, 30 referred to the IRU met inclusion criteria. Upon first assessment, patients had a median age of 3 (1-217) months and had undergone 3 (1-6) previous laparotomies that left 5 (0-9) cm of remnant small bowel. The main cause of USBS was neonatal midgut volvulus (50%). Follow-up was 28 (4-175) months. Advanced IF-associated liver disease (IFALD) was documented in 63%. None of the patients achieved digestive autonomy and was consequently considered for IT. One patient was excluded, five died before IT, and three are still on the waiting list. Six patients received an isolated IT, 6 a combined liver IT, and 18 a multivisceral graft. Digestive autonomy was achieved in 71% after 31 (14-715) days after IT and currently 62% are alive and off total PN. A significant drop in IFALD progression prior to IT was observed with the introduction of new lipid emulsions in 2010 (SMOF or Soy oil MCT (mid-chain triglycerides) Olive oil Fish oil). Conclusion A multidisciplinary IRU including an IT program offers a comprehensive approach for patients with IF and is crucial to improve survival rate of USBS. New PN lipid emulsions had an impact on IFALD progression and may eventually reduce overall mortality.

Surgery for post-operative entero-cutaneous fistulas: is bowel resection plus primary anastomosis without stoma a safe option to avoid early recurrence? Report on 20 cases by a single center and systematic review of the literature.

A review was performed on entero-cutaneous fistula (ECF) repair and early recurrence, adding our twenty adult patients (65% had multiple fistulas). The search yielded 4.098 articles but only 15 were relevant: 1.217 patients underwent surgery. The interval time between fistula's diagnosis and operative repair was between 3 months and 1 year. A bowel resection with primary anastomosis was performed in 1.048 patients, 192 (18.3%) underwent a covering stoma: 856 patients (81.7%) had a fistula takedown in one procedure. The patients had 14.3% recurrence and 13.1% mortality rate. In our experience 75% were surgically treated after a period equal or above one year from fistula occurrence: surgery was very demolitive (in 40% remnant small bowel was less than 100 cm). We performed a bowel resection with a hand-sewn anastomosis (95%) without temporary stoma. In-hospital mortality was 0% and at discharge all were back to oral intake with 0% early re-fistulisation. Literature supports our experience: ECF takedown could be safely performed after an adequate period of recovery from 3 months to one year from fistula occurrence. In our series primary repair (bowel resection plus reconnection surgery without temporary stoma) avoided an early recurrence without mortality.

Establishing Short Bowel Syndrome in Nigerian Dogs

Determining the relationship between percentage resection and development of short bowel syndrome is important as it provides information on the expected outcome of the resection carried out which will enable the surgeon to prepare adequately to manage such patients. Ten adult Nigerian indigenous dogs with mean body weight 11.2 kg were used in this study. The animals were premedicated with atropine (0.04mg/kg) and xylazine (1mg/kg) intramuscularly. Anaesthesia was induced with thiopentone sodium (10mg/kg) intravenously. The abdominal cavity was entered through the ventral midline incision. Three animals each were subjected to 50% and 60% small intestinal resection while four animals were subjected to 70% small intestinal resection. The animals subjected to 50% and 60% intestinal resection did not manifest signs of short bowel syndrome. However, the animals subjected to 70% small intestinal resection manifested clinical signs attributable to short bowel syndrome. The animals subjected to 50% and 60% small intestinal resection had remnant small intestinal tract of up to 100cm while dogs that underwent 70% resection had remnant small intestinal bowel length of less than 100 cm. It is therefore, concluded that 70% small intestinal length resection is the minimum that can produce short bowel syndrome in Nigerian dogs and animals with remnant small bowel length of less than 100 cm after undergoing resection will come down with short bowel syndrome.

Early Intestinal Rehabilitation Therapy Ameliorates Intestinal Adaptation in Children with Short Bowel Syndrome: The Long-Term Outcome

In the management of short bowel syndrome (SBS), the benefits of treatment with growth hormone (GH), glutamine, and enteral nutrition (EN) on intestinal adaptation among children patients is still controversial. The aim of present study is to determine whether GH, glutamine, and EN have positive effect on intestinal adaptation in children with SBS. Sixteen children with SBS (small bowel remnant length, 56.75 ± 8.09 cm; mean ± SE) were treated with GH (0.05 mg/kg/d), glutamine (0.45 mg/kg/d), plus EN-enriched fiber diet for four weeks. After four weeks of treatment, patients were discharged home; GH was discontinued, but the EN with glutamine was continued. Repeated treatment was performed if there were lose weight, dysplasia, or severe diarrhea. All patients completed the treatment. Body weight, intestinal absorptive capacity, and plasma levels of proteins were significantly improved after complete treatment, without any major adverse effects. On follow-up, no death was reported. Treatment with GH, glutamine, and EN in early stage significantly improved intestinal adaptation in pediatric patients with SBS. Furthermore, the positive effect of the treatment does not seem to be sustained once GH discontinued until the residual intestinal adaptation reaches its maximum.

Intestinal failure due to short bowel syndrome: impact of a multidisciplinary intestinal rehabilitation program

In patients suffering intestinal failure due to short bowel, the goal of an Intestinal Rehabilitation Program is to optimize and tailor all aspects of clinical management, and eventually, wean patients off lifelong parenteral nutrition. To report the results of our program in patients suffering intestinal failure. A registry of all patients referred to the Intestinal Failure unit between January 2009 and December 2015 was constructed. Initial work up included prior intestinal surgery, blood tests, endoscopic and imaging studies. Also demographic data, medical and surgical management as well as clinical follow-up, were registered. Data from 14 consecutive patients aged 26 to 84 years (13 women) was reviewed. Mean length of remnant small bowel was 100 cm and they were on parenteral nutrition for a median of eight months. Seven of 14 patients had short bowel secondary to mesenteric vascular events (embolism/thrombosis). Medical management and autologous reconstruction of the bowel included jejuno-colic anastomosis in six, enterorraphies in three, entero-rectal anastomosis in two, lengthening procedures in two, ileo-colic anastomosis in one and reversal Roux-Y gastric bypass in one. Thirteen of 14 patients were weaned off parenteral nutrition. Our Multidisciplinary Intestinal Rehabilitation Program, allowed weaning most of the studied patients off parenteral nutrition.

Wernickeʼs Encephalopathy Following Roux-en-Y Gastric Bypass Complicated by Gastrojejunal Stenosis and Small Bowel Obstruction: 2016 ACG Presidential Poster Award

A 28 year-old woman was admitted to our hospital with 3 weeks of abdominal pain, nausea, and vomiting. At another facility, she had undergone Roux-en-Y gastric bypass 3 months prior for morbid obesity, followed by laparoscopic cholecystectomy one week prior for presumed chronic cholecystitis. The patient suffered from multiple daily episodes of nausea and vomiting, resulting in a 95 pound weight loss since her bariatric surgery. The cholecystectomy did not improve her symptoms. Neurologic examination was remarkable for horizontal rotary nystagmus, patellar and ankle areflexia, impaired pin-prick and temperature sensation of anterior aspects of the chest and abdomen, as well as distal legs and feet, impaired vibration sense in both feet, and wide-based ataxic gait. Empiric high dose intravenous thiamine repletion was immediately begun; whole blood thiamine level was later confirmed to be low. An upper GI series/small bowel follow-through did not reveal an obstruction initially, though CT scan showed a distended and fluid-filled gastric remnant and proximal small bowel, with possible transition point near the jejunojejunal anastomosis. EGD, however, demonstrated a normal appearing jejunojejunal anastomosis, but a mild gastrojejunal stenosis, which was successfully dilated. The patient rapidly improved following the dilation and with aggressive thiamine repletion. However, she was re-admitted three weeks later with recurrence of pain, nausea, and vomiting. CT now showed an evolving small bowel obstruction, prompting exploratory laparotomy with lysis of an adhesive band causing obstruction of the common channel. A feeding gastrostomy tube was also placed. Her neurological signs and symptoms have since improved and she is no longer requiring tube feeds. This case illustrates the importance of prompt attention to the development of any central or peripheral neurologic manifestations following bariatric surgery. This is especially important for thiamine deficiency, as Wernicke's encephalopathy only rarely presents with the classical triad of altered mental status, ocular motility abnormalities, and ataxia. If Wernicke's encephalopathy is suspected, it should be treated urgently, as confirmatory laboratory results would result in delays during which neurologic damage may progress. Additionally, although gastric bypass itself can predispose to thiamine deficiency, an underlying etiology, such as complications of surgery, should be sought and addressed.Figure 1Figure 2Figure 3

Apo AIV and Citrulline Plasma Concentrations in Short Bowel Syndrome Patients: The Influence of Short Bowel Anatomy.

IntroductionParenteral nutrition (PN) dependence in short bowel syndrome (SBS) patients is linked to the functionality of the remnant small bowel (RSB). Patients may wean off PN following a period of intestinal adaptation that restores this functionality. Currently, plasma citrulline is the standard biomarker for monitoring intestinal functionality and adaptation. However, available studies reveal that the relationship the biomarker with the length and function of the RSB is arguable. Thus, having additional biomarkers would improve pointing out PN weaning.AimBy measuring concomitant changes in citrulline and the novel biomarker apolipoprotein AIV (Apo AIV), as well as taking into account the anatomy of the RSB, this exploratory study aims to a better understanding of the intestinal adaptation process and characterization of the SBS patients under PN.MethodsThirty four adult SBS patients were selected and assigned to adapted (aSBS) and non-adapted (nSBS) groups after reconstructive surgeries. Remaining jejunum and ileum lengths were recorded. The aSBS patients were either on an oral diet (ORAL group), those with intestinal insufficiency, or on oral and home parenteral nutrition (HPN group), those with chronic intestinal failure. Apo AIV and citrulline were analyzed in plasma samples after overnight fasting. An exploratory ROC analysis using citrulline as gold standard was performed.ResultsBiomarkers, Apo AIV and citrulline showed a significant correlation with RSBL in aSBS patients. In jejuno-ileocolic patients, only Apo AIV correlated with RSBL (rb = 0.54) and with ileum length (rb = 0.84). In patients without ileum neither biomarker showed any correlation with RSBL. ROC analysis indicated the Apo AIV cut-off value to be 4.6 mg /100 mL for differentiating between the aSBS HPN and ORAL groups.ConclusionsTherefore, in addition to citrulline, Apo AIV can be set as a biomarker to monitor intestinal adaptation in SBS patients. As short bowel anatomy is shown to influence citrulline and Apo AIV plasma values, both biomarkers complement each other furnishing a new insight to manage PN dependence.

Factors affecting poor nutritional status after small bowel resection in patients with Crohn disease.

In Crohn disease, bowel-preserving surgery is necessary to prevent short bowel syndrome due to repeated operations. This study aimed to determine the remnant small bowel length cut-off and to evaluate the clinical factors related to nutritional status after small bowel resection in Crohn disease.We included 394 patients (69.3% male) who underwent small bowel resection for Crohn disease between 1991 and 2012. Patients who were classified as underweight (body mass index < 17.5) or at high risk of nutrition-related problems (modified nutritional risk index < 83.5) were regarded as having a poor nutritional status. Preliminary remnant small bowel length cut-offs were determined using receiver operating characteristic curves. Variables associated with poor nutritional status were assessed retrospectively using Student t tests, chi-squared tests, Fisher exact tests, and logistic regression analyses.The mean follow-up period was 52.9 months and the mean patient ages at the time of the last bowel surgery and last follow-up were 31.2 and 35.7 years, respectively. The mean remnant small bowel length was 331.8 cm. Forty-three patients (10.9%) underwent ileostomy, 309 (78.4%) underwent combined small bowel and colon resection, 111 (28.2%) had currently active disease, and 105 (26.6%) underwent at least 2 operations for recurrent disease. The mean body mass index and modified nutritional risk index were 20.6 and 100.8, respectively. The independent factors affecting underweight status were remnant small bowel length ≤240 cm (odds ratio: 4.84, P < 0.001), ileostomy (odds ratio: 4.70, P < 0.001), and currently active disease (odds ratio: 4.16, P < 0.001). The independent factors affecting high nutritional risk were remnant small bowel length ≤230 cm (odds ratio: 2.84, P = 0.012), presence of ileostomy (odds ratio: 3.36, P = 0.025), and currently active disease (odds ratio: 4.90, P < 0.001).Currently active disease, ileostomy, and remnant small bowel length ≤230 cm are risk factors affecting the poor nutritional status of patients with Crohn disease after small bowel resection.

Spectrum of Short Bowel Syndrome in Adults

Short bowel syndrome (SBS) refers to the malabsorptive state caused by physical or functional loss of portions of the small intestine, most commonly following extensive intestinal resection. Such resections hinder absorption of adequate amounts of macronutrients, micronutrients, electrolytes, and water, resulting in malnutrition, diarrhea, and dehydration. Clinical features of SBS vary along a continuum, depending on the extent and anatomy of intestine lost and the ability of the patient and the remaining intestine to compensate for the loss. The impact of SBS can be extensive, leading to diminished health-related quality of life because of its many physical and psychological effects on patients. SBS is associated with decreased survival; risk factors for SBS-related mortality include very short remnant small bowel, end-jejunal remnant anatomy, and arterial mesenteric infarction as primary cause. Although parenteral nutrition and/or intravenous fluid (PN/IV) is a life-saving measure for many patients with SBS, patients with the most severe malabsorption (ie, dependent on PN/IV) are at risk for severe, chronic complications and death. Patients' treatment needs vary depending on disease severity and resection type; thus, each patient should be individually managed. This review discusses the spectrum of disease in patients with SBS and presents common complications encountered by these patients to highlight the importance of individualized management and treatment.

Short bowel syndrome in infants: the critical role of luminal nutrients in a management program.

Short bowel syndrome develops when the remnant mass of functioning enterocytes following massive resections cannot support growth or maintain fluid-electrolyte balance and requires parenteral nutrition. Resection itself stimulates the intestine's inherent ability to adapt morphologically and functionally. The capacity to change is very much related to the high turnover rate of enterocytes and is mediated by several signals; these signals are mediated in large part by enteral nutrition. Early initiation of enteral feeding, close clinical monitoring, and ongoing assessment of intestinal adaptation are key to the prevention of irreversible intestinal failure. The length of the functional small bowel remnant is the most important variable affecting outcome. The major objective of intestinal rehabilitation programs is to achieve early oral nutritional autonomy while maintaining normal growth and nutrition status and minimizing total parenteral nutrition related comorbidities such as chronic progressive liver disease. Remarkable progress has been made in terms of survivability and quality of life, especially in the context of coordinated multidisciplinary programs, but much work remains to be done.

Effect of growth hormone, glutamine, and enteral nutrition on intestinal adaptation in patients with short bowel syndrome

In the management of short bowel syndrome, the benefits of treatment with growth hormone, glutamine, and enteral nutrition for intestinal adaptation is still controversial. The aim of the current study was to determine whether growth hormone, glutamine, and enteral nutrition had positive effect on intestinal adaptation. Twelve patients with short bowel syndrome (small-bowel remnant length, 59±9 cm; mean±SEM) received growth hormone (0.05 mg/kg/day), oral glutamine (30 g/day), plus enteral nutrition for 4 weeks. Intestinal absorptive capacity and biochemical parameters were investigated before treatment and after treatment. Body composition was determined by bioelectric impedance analysis. All patients completed the treatment. Intestinal absorptive capacity and plasma levels of proteins were significantly improved after treatment. Body weight, lean body mass, total body water, and body cell mass also increased without any major adverse effects. At the 3-month follow-up, the nutritional status of patients was also well maintained, and there was no death during this period. Four weeks of intestinal rehabilitation therapy significantly improved intestinal absorption if appropriate patient with short bowel syndrome was selected.

Long-term incidence and characteristics of intestinal failure in Crohn’s disease: a multicenter study

The aim of this study was to clarify the risk and characteristics of intestinal failure (IF) in patients with Crohn's disease (CD). The present study was a retrospective study in 12 hospitals. CD patients who underwent initial surgery at any of the 12 hospitals between 1970 and 2009 were collected (n=1,703). Those who developed IF were reviewed (n=68), and the cumulative risk of IF was analyzed by the Kaplan-Meier method. In addition, IF patients who underwent initial surgery at other hospitals and were then treated at any of the 12 hospitals were also reviewed (n=33). Thus, a total of 101 IF patients were collected, and the cumulative risk of IF-related death was analyzed. The cumulative risk of IF after the initial surgery was 0.8% (5years), 3.6% (10years), 6.1% (15years), and 8.5% (20years). In CD patients with IF, mean age at initial surgery, IF occurrence, and present age at the time of the study were 28.2, 38.2, and 46.1years, respectively. The mean number of surgeries per patient was 3.3. The mean length of the remnant small bowel was 163cm. Twelve IF patients (12%) had died and the cumulative risk of IF-related death by the time from the occurrence of IF was 1.1% (3years), 3.7% (5years), 6.5% (7years), and 8.9% (10years). The occurrence of IF and IF-related death in CD patients is not rare over the long term. There is a pressing need to develop strategies for the prevention and management of IF.