Management of short bowel syndrome
Short bowel syndrome is a reduction in the small bowel’s
capacity to adsorb and digest adequate amounts of nutrients, said WENDY
LLOYD, pharmacist, Royal United Hospital, Bath. In addition, the ability
of the gastrointestinal tract as a whole to reabsorb its secretions is
compromised. Short bowel syndrome can be caused by an anatomically short
bowel (as a result of surgery) or by a functional abnormality.
Problems caused by short bowel syndrome include
diarrhoea or a high output stoma resulting in dehydration and reduced
electrolyte, mineral and nutrient absorption, she explained. Replacing
electrolytes and fluids lost is an important part of treatment in short
bowel syndrome. Patients should be encouraged to drink as much oral rehydration
therapy solution as they can tolerate, aiming for at least one or two
litres a day, she said. The solution should be made up according to the
World Health Organization/St Marks formulation: 20g (six 5ml spoonfuls)
of glucose, 3.5g (one 5ml spoonful) of salt and 2.5g (one 2.5ml spoonful)
of sodium bicarbonate in one litre of water. Non-electrolyte drinks should
be restricted to one litre a day and fluid intake should be avoided for
30-60 minutes around meals, she said. Patients should be given 90mmol
sodium for each litre of fluid lost. Potassium supplements are not usually
needed. Deficiency of magnesium is common and supplementation is needed.
Loperamide should be given as capsules or as tablets
because the sorbitol in the liquid causes diarrhoea, she said. The dose
should be started at 4mg four times a day, increased every few days to
a maximum of 16mg four times a day. It acts locally on opioid receptors
in the gut and is not absorbed. Codeine can be used in combination with
loperamide at a maximum dose of 120mg four times a day (starting at 60mg
four times a day). Both drugs should be given 30–60 minutes before meals.
There are systemic problems with codeine such as drowsiness and addiction.
Co-pheotrope (Lomotil) should be avoided because of its atropine-like
side effects.
Octreotide is not licensed for use in small bowel
syndrome but it reduces gastric, biliary and pancreatic secretions and
slows gastrojejunal transit time, she said. A starting dose of 50–100µg
should be used. Ocreotide is expensive and few general practitioners would
pay for patients to have the drug. A similar drug, lanreotide, is a long
acting, depot formulation. Proton pump inhibitors reduce gastric acid
secretion which tends to be higher than normal in patients with short
bowel syndrome. It is used in large doses: maximum of omeprazole 40mg
twice a day or lansoprazole 30mg twice a day, although diarrhoea was more
likely to occur with lansoprazole.
In conclusion, Ms Lloyd said that patients with
short bowel syndrome were often in hospital for months. They represented
an interesting challenge with plenty of scope for pharmacists to input
into their management.
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