Short Bowel Syndrome and Malnutrition: Nutrition Strategies, TPN, and Long-Term Management

What Is Short Bowel Syndrome?

Short bowel syndrome (also called short gut syndrome) is a rare but serious malabsorption disorder. It occurs when the small intestine is too short or cannot absorb enough nutrients from food. 

In most cases, short bowel syndrome occurs when a portion of the small intestine is surgically removed to treat another medical condition. It can also occur in infants born with a shorter-than-typical small intestine. 

According to the American Gastroenterological Association (AGA), short bowel syndrome commonly occurs when less than about 200 cm of small intestine remains. However, the amount of intestine needed to maintain adequate nutrition varies depending on which sections remain and whether the colon is intact [1]. For reference, the average length of the adult small intestine is about 600 cm [2]. 

Treatment for short bowel syndrome aims to control diarrhea and fluid losses, improve intestinal absorption, and maintain adequate nutrition and hydration. The treatment can include [3]:

• Certain medications 
• Hormonal therapy
• Dietary changes
• Enteral nutrition 
• Total parenteral nutrition (TPN)
• Surgery 

Short Bowel Syndrome and Malnutrition: What to Know

In short bowel syndrome, malnutrition can occur when the body cannot absorb enough calories, protein, vitamins, minerals, or other nutrients to meet its needs. This can lead to weight loss, vitamin and mineral deficiencies, dehydration, and other health complications.  

Malnutrition is a common complication of short bowel syndrome. Because much of the absorption of nutrients and fluids occurs in the small intestine, having short bowel syndrome can lead to malabsorption, dehydration, nutritional deficiencies, and other metabolic complications. 

Signs and symptoms can include: 

• Diarrhea with or without foul-smelling stools
• Excessive tiredness
• Poor appetite
• Weight loss
• Dehydration 
• Slowed growth in infants and children 

Specific symptoms may occur due to vitamin and mineral deficiencies, such as:

• Night blindness and dry eyes due to vitamin A deficiency
• Muscle weakness or bone pain due to vitamin D deficiency
• Anemia due to iron, folate, or vitamin B12 deficiency
• Loss of appetite and impaired wound healing due to zinc deficiency
• Muscle cramps or weakness due to calcium or magnesium deficiency
• Easy bruising or bleeding due to vitamin K deficiency

Understanding the Nutrition Strategy

Each case of short bowel syndrome is different, and so is the treatment. 

A team of healthcare professionals works together to determine which treatment or combination of treatments is best for you. The healthcare team can include dietitians, pharmacists, nurses, surgeons, gastroenterologists, and social workers. 

Treatment typically starts with a comprehensive nutrition assessment by a dietitian experienced in short bowel syndrome. They may review your medical history, medications, usual diet, fluid intake and losses, weight changes, and a food diary, if available. 

They may also assess you for:

• Other medical conditions that may affect nutrient absorption, food intake, or fluid loss
• Signs and symptoms of malnutrition and dehydration
• Vitamin and mineral deficiencies that can occur with short bowel syndrome

You will also need regular tests for liver and kidney function, micronutrient levels, bone density, fluid balance, and weight changes. 

Then, they will recommend a diet tailored to your needs, along with appropriate dietary counseling. 

Dietary recommendations for short bowel syndrome vary considerably depending on how much and which portions of the intestine remain, whether the colon is intact, and the amount of fluid lost through diarrhea or an ostomy. The following strategies may be recommended for some patients, but your healthcare provider or an SBS-experienced dietitian can help determine which are appropriate for you [4]:

• Eat smaller meals more frequently, such as 5 to 6 meals throughout the day.
• Limit foods and beverages high in added sugars, which may worsen diarrhea in some people.
• Take small bites and chew food thoroughly.
• Follow your healthcare provider’s recommendations about when and how much to drink with meals.
• Limit or avoid alcohol and excessive caffeine if they worsen fluid losses or symptoms.
• If recommended by your healthcare team, use an oral rehydration solution (ORS) to help replace fluids and electrolytes.

Short Bowel Syndrome and Malnutrition: When Do You Need TPN?

Total parenteral nutrition (TPN) is a life-saving treatment for patients with short bowel syndrome. It is essential for nearly all patients with short bowel syndrome during the initial period after surgery. TPN helps prevent malnutrition. 

During the initial phase of short bowel syndrome, your healthcare provider may use TPN with another feeding method called enteral or tube feeding. 

TPN may also be administered at home in the subsequent periods. Also called home PN, it offers long-term care in the comfort of your home. However, you will need regular monitoring and supplementation to reduce the risk of micronutrient deficiencies. 

Will You Need TPN Forever?

Whether you will need TPN forever depends primarily on the length of the remaining small intestine. You will likely need TPN for a lifetime if your remaining small intestine is less than 100 cm and you have excessive fluid losses. 

The risk of having to use lifetime TPN may also be higher in people who have:

• Lost the large intestine (colon)
• Lost the valve between the end of the small intestine and the colon 
• Narrowing of a portion of the small intestine 

Conversely, you may be able to wean off TPN if the remaining small intestine adapts to changing demands after surgery. Certain medications and supplemented diets may help intestinal adaptation. 

According to the American Gastroenterological Association (AGA), more than half of adults with short bowel syndrome will be able to live without TPN within 5 years of diagnosis [1]. 

What Are the Risks of TPN for Short Bowel Syndrome?

While TPN can be life-saving, it is not free of risks. Some of them can include:

• Central venous catheter infections, which can sometimes lead to bloodstream infection or sepsis
• Blood clots associated with the central venous catheter
• Loss of usable central venous access after repeated catheter complications
• Fluid, electrolyte, or blood glucose abnormalities
• Metabolic bone disease
• Liver and gallbladder complications

Additionally, long-term TPN use can increase the risk of complications called parenteral nutrition-associated liver disease (PNALD). Liver complications are one of the most common causes of death in people with short bowel syndrome. 

Moreover, early evidence suggests that patients who need to be on TPN for survival are at a greater risk of developing complications requiring intestinal transplant. 

Long-Term Management of Short Bowel Syndrome-Associated Malnutrition

Long-term management of short bowel syndrome focuses on appropriate medications, individualized nutrition, fluid management, and other supportive measures to maintain adequate nutrition and hydration and, when possible, reduce dependence on parenteral nutrition. 

Your healthcare team may also consider surgery to help increase the intestine’s ability to absorb nutrients. Surgery is usually reserved for cases where other treatment options have failed or when life-threatening complications occur. 

Living with short bowel syndrome can be challenging. Dietary changes, frequent bowel movements, fatigue, and ongoing medical care can affect everyday life. In addition to medical and nutritional treatment, several strategies may help you manage these challenges. 

• Consider joining a support group where you can connect with others living with short bowel syndrome and share experiences and practical strategies. 
• Stay active. It can be challenging, but small efforts add up. Start slow and gradually increase the duration or intensity of the activity. Ask your healthcare provider about the activities appropriate to your condition. 
• If you need to use a restroom frequently, find out if there are local facilities when you are traveling or are out and about. Plan ahead!

Frequently Asked Questions

What is the life expectancy of a child with short bowel syndrome?

Life expectancy varies considerably among children with short bowel syndrome. Outcomes depend on factors such as the amount and type of intestine remaining, the underlying cause of SBS, the child’s ability to achieve intestinal adaptation, dependence on parenteral nutrition, and whether serious complications develop. Advances in nutrition support, intestinal rehabilitation, and medical and surgical treatment have substantially improved outcomes for children with short bowel syndrome. 

What causes short bowel syndrome in adults? 

Short bowel syndrome in adults usually develops after extensive surgical removal of the small intestine. Conditions that may lead to this surgery include: 

• Crohn’s disease
• Trauma 
• Recurrent intestinal obstruction 
• Damage to the small intestine by radiation therapy 
• Loss of blood flow to the intestine (mesenteric ischemia) 

What is the best diet for short bowel syndrome and malnutrition?

There is no single diet that is best for everyone with short bowel syndrome. Your nutritional needs depend on factors such as which portions of your intestine remain, whether your colon is intact, your stool or ostomy output, and your ability to absorb fluids and nutrients.

Depending on your individual needs, your healthcare team may recommend eating smaller, more frequent meals; getting adequate protein and calories; limiting concentrated sugars; and using an oral rehydration solution when appropriate. Some people may also need specific adjustments to fat, fiber, oxalate, or fluid intake.

Because dietary recommendations can vary substantially, work with a dietitian experienced in short bowel syndrome to develop an individualized nutrition plan.