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 (ASPEN) 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.
Dietary Suggestions
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 small, frequent feedings
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, rather than with 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.
Medication Alternatives
Besides dietary changes, some medications may help to control
diarrhea. For example, H2
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.
| Eating Guidelines Which May Help Control Diarrhea |
|
|
Copyright © 1995 The Oley Foundation