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|Controlling Diarrhea in Patients With Short Bowel Syndrome|
Sue Morrisson, MS, RD, RN, CNSD, CNSN
Diarrhea is a difficult problem to address, especially for the person with short bowel syndrome (SBS). The reasons for diarrhea vary widely with the type of resection or the degree of lost bowel function. Recognizing that a strategy which works for one SBS patient may not work for another, this article reviews some of the most recent dietary management ideas found in professional literature. Also included is information from the 1995 American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Clinical Congress.
How SBS Leads to Diarrhea
The gastrointestinal (GI) tract consists of two main parts - the small intestine and the large intestine (also called the colon and rectum). In adults, the small intestine measures approximately 20 feet and the large intestine approximately 7 feet. Short bowel syndrome (SBS) is defined in many ways, but often it refers to a small intestine that has been resected or shortened by 50 percent, or more. Loss of the small intestine is especially problematic if it involves the loss of the lower ileal region and the ilio-cecal valve.
The GI tract is the major transport system for nutrients to enter and be used by the body. Food and fluids that are taken by mouth must be digested or changed chemically so the nutrients can be absorbed and used for energy, growth and maintenance of life. Specifically, the small intestine digests and absorbs food, and the large intestine absorbs leftover salt, minerals and water. In the short bowel patient, the colon also conserves calories. The remaining indigestible waste products are fermented by bacteria, lubricated and stored until they are expelled as feces through the rectum. Any significant change in the GI tract, such as a loss of any portion of the tract, can cause a breakdown of this very efficient process. These changes may result in the rapid transit of nutrients through the GI tract or diarrhea.
Anyone who has lost most of their colon will have loose or diarrheal stools since this is where most water reabsorption takes place. The intestine normally absorbs two to three liters of ingested food and water, plus seven to nine liters of secreted fluid daily. Patients without the distill small bowel, ilio-cecal valve and colon may lose three to five liters of fluid per day that cannot be absorbed. Even with no food intake there will be fluid lost. Sometimes oral intake will actually exacerbate the problem, increasing the net loss of fluid in these patients.
William D. Heizer, M.D., from the University of North Carolina, Chapel Hill, discussed several treatment strategies at a recent ASPEN Clinical Congress. (Note,these suggestions are not for the immediate post operative diet but are used later, once some adaptation has occurred and regular foods can be tolerated.) To help control diarrhea, he suggested persons with SBS nourish themselves with of high nutrient, dense foods such as breads, cereals, meat, poultry, fish and eggs. Six to eight feedings per day are recommended. Ultimately, the SBS person may have to eat as much as three times the normal calorie requirements in order for the body to absorb enough nutrients.
Beyond this, the diet must be individualized to the tolerance of the person. The eating guidelines given in the chart may help you weed out problematic foods. For example, many short bowel patients should avoid foods containing lactose, such as milk and milk products.
Another dietary change that may help to reduce diarrhea in short bowel patients is to drink liquids at room temperature between meals, SBS patients may also want to try a bulking agent such as Metamucil, or to increase their consumption of foods high in soluble fibers (pectins/gums) such as oatmeal, pears, and potatoes. If necessary, the diet can be supplemented with liquid or chewable vitamins and minerals. Many patients have found standard liquid nutritional supplements to be convenient, nutrient-dense snacks; however, the formula must be of low osmolarity and lactose free. The more expensive elemental or oligomeric products may not offer more benefit because of their higher osmolarity.
The Fat Controversy
For years the standard therapy for SBS patients in Western countries has been a high protein diet with limited fat intake (30 to 40 grams per day) which is partially supplemented with medium chain triglycerides (MCT) oil. Most of the calories in this diet come from complex carbohydrates.
Unlike their Western counterparts, many Russian short bowel patients have been managed with high fat diets. Several studies looking at this issue have concluded that a higher fat diet is well tolerated if the patient is missing the ileal region of the small intestine and the colon (where unabsorbed fat causes active salt and water secretion). These studies also point out that a higher fat diet is often more palatable.
Besides dietary changes, some medications may help to control diarrhea. For example, blockers can reduce 50 percent of short bowel losses in the early stages. Drugs which slow bowel motility may also reduce diarrhea, such as Imodium, Lomotil, deodorized tincture of opium and liquid codeine. In addition, if the colon is present, a low-dose of cholestyramine may help bind some of the non-absorbed bowel salts and thus decrease output.
The optimal diet for a person with SBS will vary depending on the degree of lost bowel function. Often the best way to determine a successful diet is by trial and error. Remember, anything entering the mouth has the potential to provide nutrients and/or result in diarrhea. For this reason, it is necessary to monitor the diet carefully and pay close attention to the response of extra fluid output in order to eliminate problem foods. Careful attention should also be given to the medical regime prescribed by the physician. If problems become severe, the SBS patient should work with the physician or registered dietitian to control symptoms. The ultimate goal for dietary therapy is to decrease the frequency and volume of diarrhea while providing for the nutritional needs of the person.