Syndrome of the small intestine refers to the category of severely leaking conditions, which are fraught with the development of a lethal outcome in the event of removal of a significant part of the intestine.
Treatment of such patients should be comprehensive and requires the participation of a whole group of specialists: surgeons, gastroenterologists, nutritionists, psychologists and even social workers.
According to medical statistics( far from complete, since not every episode is registered), the frequency of this pathology is two cases per million inhabitants of European countries.
The concept of
The syndrome of the small intestine is a whole complex of chronic manifestations caused by pathologies of the small intestine, leading to its insufficiency or extensive( more than 25% of the length) resection of certain sections.
In the body of a healthy person, the length of the small intestine varies between 270-840 cm, and in men it is significantly longer than in women.
Thus, the total area of the mucous membranes of the small intestine, performing a number of secreting and absorbing functions, is about five hundred square meters, which is comparable to the area of the tennis court.
Syndrome of the small intestine is associated with a number of digestive disorders. Patients suffering from it are observed:
- Maldegestia - insufficiently complete digestion of food.
- Malabsorption is a violation of the absorption of nutrients by the structures of the small intestine.
- Trophological insufficiency is an imbalance between the amount of nutrients entering the patient's digestive tract and the body's need for them.
The severity of the clinical picture in the syndrome of the small intestine depends on many factors: the age of the patient, the extent of the remote department, the presence of concomitant diseases, etc.
In the international classification of diseases of the tenth version( ICD-10), the syndrome of the small intestine is classified as XI class,digestive organs, under the code K91.2.
Forms of
In the clinical course of the syndrome of the small intestine, the following periods are distinguished( some experts call them forms):
- Acute postoperative. Beginning immediately after performing a resection, this period can take from several weeks to several months. Throughout its extent, the patient's condition, caused by a significant loss of fluid and dehydration, is characterized as very severe. A typical manifestation of the clinical picture of the postoperative period is the presence of frequent and abundant fluid stools, aggravating the symptoms of dehydration. In the patient's body, a metabolic disorder occurs, development of mental and neurological abnormalities is observed.
- Subcompensation. During this period, which can take at least a year, there is a gradual restoration of impaired functions, normalization of stool and metabolic processes is noted. At the same time, the losing weight continues to suffer from anemia and a lack of vitamins, its skin remains dry, the hair falls out, and the nails are stratified.
- Adaptations of the body. This period, stretching for several years, in most patients is characterized by the complete restoration of all body systems, however, in some patients, complete adaptation is not observed. For the most part, this depends on which particular department of the small intestine is incapacitated. Not the least role in insufficiently effective restoration of an organism is played by presence of heavy accompanying pathologies.
Depending on the severity of the clinical symptoms, the pathology is classified as one of three degrees:
- In patients with mild degree of SCD , there is a slight decrease in body weight, recurrent diarrhea( the so-called frequent stool), flatulence( increased accumulation of gases in the intestine) and the presence of anemia( a significant decrease in hemoglobin and the number of red blood cells in the blood).
- The state of moderate severity of is characterized by the presence of daily diarrhea( its frequency can reach seven times during the day), a noticeable decrease in weight and a tendency towards its further decrease. Anemia becomes resistant, the patient is deficient in vitamins( hypovitaminosis).Already at this stage the patient can develop a number of complications represented by deep( with the appearance of ulcers) lesions of the walls of the intestine and stomach and the formation of stones in the kidneys and gall bladder.
- With severe of the syndrome of the small intestine frequent( up to fifteen times during the day) diarrhea acquires a debilitating character, weight loss becomes significant, a serious violation of all kinds of metabolism occurs. Skin covers of the patient become dry and scaly, a blood test indicates the presence of severe anemia. The patient develops a number of mental and neurological disorders.
Causes of
pathology Syndrome of the small intestine, diagnosed during the first days of life of a newborn baby, can be of an innate nature. Most often it becomes a consequence:
- of congenital shortening of the small intestine;
- of the turn of the middle gut;
- agangliosis( Hirschsprung disease) - congenital abnormalities of the large intestine, manifested by the appearance of persistent constipation;
- gastroschisis - congenital defect of the anterior wall of the abdomen, in which internal organs or intestinal loops may fall out of the cleft in the abdominal cavity;
- stenosis( atresia) of the intestine, consisting in a significant( sometimes reaching an absolute blockage) narrowing of the intestinal lumen, which makes it impossible to eat alone;
- necrotizing enterocolitis - a severe disease of the neonatal period, accompanied by the appearance of ulcers and necrosis of the intestinal walls.
The need for its implementation may occur in patients suffering from:
- Crohn's disease( in some medical sources it is called transmural ileitis, regional or granulomatous enteritis) - a chronic relapsing disease of unknown etiology leading to granulomatous inflammation affecting individual segments of all parts of the gastrointestinal tract: from the oral cavity to the rectum. The most severe cases may require several surgeries.
- Intestinal obstruction - a condition characterized by complete absence of movement of food and stool masses through the intestines due to blockage of its lumen, spasm, compression, nervousness or hemodynamic disorders.
- All possible( both benign and malignant) intestinal tumors.
- Radiation enteritis - inflammation of the small intestine, characterized by a significant disruption of its work and dystrophic lesions of the mucous membranes, resulting from radiation exposure.
- Ischemia of the intestine - a disease accompanied by a violation of blood circulation in the walls of the small intestine.
- From the effects of trauma to the stomach, which led to extensive damage to the intestine.
- Necrotizing enterocolitis of newborns is a nonspecific inflammatory disease that occurs in premature babies in the first days of their life under the influence of infectious microflora as a result of damage to the mucous membranes of the small intestine or their functional immaturity. As a result of this acute inflammatory process, the infarction of the walls of the thick or small intestine can develop.
- Involvement of the intestine - mechanical( strangulation) intestinal obstruction, caused by the rotation of the intestinal loop around the mesentery axis, causing a violation of blood supply and nutrition of the intestinal wall. Untimely rendering of medical assistance is fraught with the emergence of extensive necrosis of the intestine.
- Various pathologies of the development of the organs of the gastrointestinal tract.
The clinical manifestations and severity of the syndrome of the small intestine in a particular patient largely depend on the type of resection of the small intestine that has been performed.
In the conditions of modern surgical clinics it is possible:
- to completely remove the large or small intestine;
- remove only part of the intestine, retaining the ileocecal valve dividing the thick and small intestine;
- perform extensive extirpation of the ileum and the initial section of the large intestine.
Symptoms of the syndrome of the small intestine
The severity of the clinical symptoms is determined by the scale of the lesion: the greater the volume of the remote site of the intestine, the more complex the disease progresses.
During the acute postoperative period, the patient observes the presence of:
- abundant( up to nine liters per day) liquid stool;
- dehydration( severe dehydration);
- a significant metabolic disorder;
- a whole complex of neurological and psychiatric disorders requiring the help of a professional psychologist.
Symptomatic of the disease that entered the compensated stage is:
- anemia( anemia);
- increased fatigue;
- significant( ten to twenty kilograms) weight loss;
- hypovitaminosis( acute shortage of vitamins);
- dry skin;
- fragility of nail plates and hair.
- The clinical picture of the CCM during the adaptation period has no pronounced manifestations. With the most favorable option, a complete restoration of the patient's body takes place, as a result of which, with independent eating, there will subsequently be no problems. Quite a different picture arises in the period of adaptation of patients who underwent resection of the distal part of the small intestine, performed by the method of terminal ejinostomy. During this complicated operation, the colon, iliac and part of the jejunum are removed. The remaining part of the small intestine is brought to the stoma - an artificially formed opening in the anterior wall of the abdomen, intended for the exit of stool. In this category of patients and during the adaptation period, there will be clinical symptoms characteristic of the compensated CCM stage. As a rule, such patients can only eat food with a special probe.
Diagnosis
The complex of diagnostic measures for the syndrome of the small intestine begins with a thorough survey( the gastroenterologist will find out when and for what reasons the operation was performed) and physical examination of the patient, during which the doctor discovers: a significant soreness of the abdominal cavity( this is found out by palpation);
The complex of laboratory tests provides for mandatory implementation:
- of a general blood test. With CCM, its results will indicate a decreased level of hemoglobin and a decrease in the number of red blood cells, the presence of leukocytosis and an increased rate of erythrocyte sedimentation( ESR).
- Biochemical blood test. The data from this study will help to establish the presence of signs of renal insufficiency, as well as provide information on the concentration of calcium, sodium and potassium in the blood serum( as a rule, the content of minerals, proteins and vitamins in it is lowered).
- Coprograms - the analysis of stools, revealing in them the presence of fats and particles of poorly digested food.
- Bacteriological culture of blood. This analysis is performed if there is a suspicion of septic damage to the blood.
- pH-metry of gastric secretion, revealing an increased content of hydrochloric acid in it.
The group of instrumental methods for diagnostic examination of patients with CCM includes:
- Ultrasound examination of the abdominal cavity organs - diagnostic technique, during which the specialist scans the echostructure of vessels, retroperitoneal space and parenchymal organs. Reflected ultrasonic waves are registered on the monitor, so a clear picture arises that allows to examine the internal structure, contours, topography of the organs under study, to reveal the accumulation of fluid and the presence of any pathologies( inflammatory processes, lesions, neoplasms) in them.
- Radiographs of the passage of barium in the small intestine. This procedure allows you to visualize the progress of the radiopaque substance - barium sulfate suspension, taken by the patient inside before the beginning of the study. As the barium suspension moves through the small intestine, the radiologist performs a series of aiming X-rays( the interval between the shots is no more than half an hour).The procedure is completed only after all sections of the small intestine have been procontrasted, and barium sulfate has appeared in the rectum.
- Fibroesophagogastroduodenoscopy( FEGS) - instrumental examination of the upper sections of the gastrointestinal tract( esophageal tube, stomach and duodenum), performed with a fibroendoscope - an optical flexible probe. To eliminate the gag reflex, the procedure is performed on an empty stomach, under general anesthesia or under local anesthesia.
To identify possible complications that can occur against the background of the syndrome of the small intestine, the patient may be assigned a number of additional instrumental examinations:
- Computed tomography.
- Obstetric radiography of the abdominal cavity is an X-ray procedure performed without the use of a contrast agent, with the help of an overview radiographs that provides information on the accumulation of free gases and fluid in the abdominal cavity, perforation and rupture of the walls of hollow organs, and the presence of intestinal obstruction.
- MSCT is a multispiral computed tomography of the abdominal cavity, which represents an improved technique for X-ray computer scanning with a constantly rotating tube and a continuously moving tomograph table. The use of modern equipment, which provides for a large number of detectors, can significantly reduce the time of investigation and the level of radiation exposure.
Treatment of the syndrome of the small intestine
The main goal of the treatment of the syndrome of the small intestine is to ensure the uninterrupted intake of a sufficient amount of water, nutrients, vitamins, macro- and microelements in the patient's body, provided that parenteral( intravenous) nutrition is minimized.
The content of treatment activities in the management of patients with short bowel syndrome, primarily depends on the stage of the pathological process, the degree of its severity and localization.
If the digestive tube has been shortened to such an extent that the length of its remaining area is from 60 to 180 cm, the patient's nutrition for 4-8 weeks will be periodically performed by intravenous( parenteral) administration of a complex of nutrients.
All patients with CCM are required to follow a strict diet, including:
- Frequent intake of small portions of food cooked on steam( without the use of spices and any flavor enhancers).
- Complete refusal to eat salty, fried and spicy dishes.
- Inclusion in the diet of low-fat cheeses, sour-milk and dairy products, capable of replenishing an acute shortage of calcium. Since whole milk can provoke an increase in diarrhea, special care is needed in the use of this product.
- Use of natural juices and low-fat broth to replenish body fluids.
Drug therapy is performed by taking:
- Antacids - drugs designed to treat acid-dependent gastrointestinal diseases by neutralizing hydrochloric acid, which is the main component of digestive juice.
- Antidiarrhoeal preparations.
- Antibiotics to prevent infection.
- Medications that help to reduce the symptoms of dehydration.
- Proton pump inhibitors - drugs that prevent excessive secretion of hydrochloric acid.
- Complex multivitamins.
- Drugs that stimulate the functioning of the intestines by improving the absorption of bile acids.
Surgical treatment is used only in case of too long and severe course of the CCM, as well as with insufficient effectiveness of conservative treatment.
Interventions can be performed to:
- restoring the remaining patch of the small intestine;
- transplantation( transplant) part of the resected bowel;
- forming in the small intestine new artificial valves designed to restore a normal passage of food over it.
Despite the rather high efficiency of the above operations, the consequences of their implementation are sometimes unpredictable( in operated patients, gut flaps may occur or strictures may be formed).
That's why the operation is appointed only after the attending specialists are convinced that the patient has no adaptive mechanisms.
Complications of
The syndrome of the small intestine can lead to a number of severe complications, represented by:
- Gipovitaminosis. With a lack of vitamin A, patients develop "night blindness";their mucous membranes and skin are characterized by increased dryness. Acute deficiency of vitamin D is fraught with the development of osteoporosis and fractures of bones. A lack of vitamin K leads to a danger of extensive internal bleeding. With a deficiency of vitamin E, the reproductive function of the female body is diminishing, manifested in the inability to have offspring.
- Dysbacteriosis - a violation of the balance between a useful and pathogenic microflora, leading to active microbial colonization of the intestine( the degree of dysbiosis can be different).
- The formation of stones in the kidney and gallbladder. A high( three times higher than normal) risk of their occurrence is due to a lower concentration of bile salts in the bile. This is a consequence of resection of the ileum, which causes a violation of absorption of bile salts. The use of parenteral nutrition reduces the contractile activity of the gallbladder, which only increases the possibility of stagnation of bile.
- Metabolic acidosis - an increase in the concentration of lactic acid in the body of the patient, which provokes an increase in diarrhea and the occurrence of various neurological disorders.
- Ulceration of the stomach and intestines.
- Cholestasis( congestion of bile) is a pathological process characterized by impaired bile production and problems with its admission into the duodenum.
- The reduced response of the human body to the action of certain tableted medicines( the effectiveness of injecting drugs and sublingual tablets remains the same).
Forecast
Despite the large number of complications that occur in patients with CCMs and significantly worsen their overall condition, adequate therapy, the use of special nutrition, regular dynamic observation by a gastroenterologist, can achieve good results, accelerate the recovery of the body, reduce the risk of negative consequencesand death.
There are no preventive measures that can prevent this dangerous pathology from occurring today. To minimize the harm to the patient's body, when performing a resection of the small intestine, surgeons choose the most gentle methods of surgical intervention.
Video on the effectiveness of conservative therapy in the treatment of patients with small bowel syndrome: