Das Kurzdarmsyndrom: Eine interdisziplinäre Herausforderung

Zusammenfassung

Die Behandlung und Betreuung von Patienten mit Kurzdarmsyndrom (KDS) stellt eine große Herausforderung für die betreuenden Ärzte, Ernährungsberaterinnen und Pflegefachpersonal dar. Die optimale ernährungsmedizinische, medikamentöse und chirurgische Behandlung setzt ein grundlegendes Verständnis der pathophysiologischen Konsequenzen der geänderten Länge und Struktur des Intestinaltraktes voraus. Die Behandlung erfordert eine koordinierte Zusammenarbeit von verschiedenen Spezialisten. In dieser Übersichtsarbeit werden Ursachen, anatomische und pathophysiologische Aspekte beim KDS beschrieben. Die Ernähungstherapie während den verschiedenen Phasen des Krankheitsverlaufes, die Diagnostik und neuere medikamentöse Therapieformen werden besprochen. Die zu Beginn eingeleitete parenterale Ernährung soll frühzeitig durch eine enterale Ernährung ergänzt werden, um die intestinale Adaptation zu begünstigen, den Flüssigkeitsverlust zu reduzieren und die Nährstoffresorption zu verbessern. Die langfristige Ernährungstherapie hängt von der Anatomie des Restdarms ab (Vorhandensein oder Fehlen von Dickdarm und Ileum). Im weiteren wird auf besondere Aspekte beim KDS eingegangen, welche unbedingt beachtet werden müssen. Ziele der Behandlung sind die Gewichtsstabilisierung und ggf. die Gewichtszunahme, der Ausgleich von Mikronährstoffdefiziten, bedarfgerechte Energie- und Nährstoffversorgung, weitgehende Symptomfreiheit und Steigerung des Wohlbefindens.

Abstract

The treatment and care of patients with Short Bowel Syndrome (SBS) is a challenge for physicians, dieticians and nursing staff. The optimal nutrition, drug and surgical management are based on the specific knowledge of the pathophysiologic consequences of the changed length and structure of the involved intestine. The optimal management require an multidisciplinary teamwork of all specialists involved. The content of this present review are etiological factors, functional and anatomic aspects, and treatment strategies of the SBS. In the postoperative period it is essential that parenteral nutrition is followed by an enteral diet to stimulate bowel adaptation, reduce fluid loss and increase nutrient absorption. The final nutritional support is based on the anatomy of the remaining bowel (presence or absence of a colon and ileum). In addition we give advice about the optimal nutritional support and new drug medication in the different phases of the disease are discussed. Furthermore we report about particular features of the SBS where we call attention to. The aim of the treatment is to stabilize or increase the bodyweight, the compensation of the micronutrients deficits, the adequate provision of energy and nutrient requirements, the reduction of symptoms and increased well-being.

Schlüsselwörter

Kurzdarmsyndrom - Ernährungstherapie - Mangelernährung - Malabsorption - Maldigestion

Key words

Short bowel syndrome - nutritional therapy - malnutrition - malabsorption - maldigestion

Literatur

• 1 Szczygiel B. Nutritional support in extensive gut resections. In: Espen (ed) Basics in Clinical Nutrition. 3. ed. 2004: 345-357
• 2 Bakker H, Bozzetti F, Staun M. et al . Home parenteral nutrition in adults: a european multicentre survey in 1997. ESPEN-Home Artificial Nutrition Working Group.  Clin Nutr. 1999;  18 135-140
• 3 Nightingale J M, Lennard-Jones J E. The short bowel syndrome: what's new and old?.  Dig Dis. 1993;  11 12-31
• 4 Ladefoged K, Hessov I, Jarnum S. Nutrition in short-bowel syndrome.  Scand J Gastroenterol Suppl. 1996;  216 122-131
• 5 Suter P. Checkliste Ernährung. Stuttgart; Thieme 2002
• 6 Nightingale J M. Management of patients with a short bowel.  World J Gastroenterol. 2001;  7 741-751
• 7 Thompson W G, Wrathell E. The relation between ileal resection and vitamin B12 absorption.  Can J Surg. 1977;  20 461-464
• 8 Carbonnel F, Cosnes J, Chevret S. et al . The role of anatomic factors in nutritional autonomy after extensive small bowel resection.  J Parenter Enteral Nutr. 1996;  20 275-280
• 9 Nightingale J M, Lennard-Jones J E, Walker E R. et al . Jejunal efflux in short bowel syndrome.  Lancet. 1990;  336 765-768
• 10 Gouttebel M C, Saint-Aubert B, Astre C. et al . Total parenteral nutrition needs in different types of short bowel syndrome.  Dig Dis Sci. 1986;  31 718-723
• 11 Kasper H. Ernährungsmedizin und Diätetik. 9. Auflage ed. München; Urban & Fischer Verlag 2000
• 12 AKE .Österreichische Arbeitsgemeinschaft für Klinische Ernährung. 2. ed. Wien; Ernährung ÖAfK 2001
• 13 Lübke H, Meier R, Lochs H. et al . DGEM-Leitlinie Enterale Ernährung: Gastroenterologie.  Aktuel Ernaehr Med. 2003;  28 S69-S86
• 14 Götz M L, Rabast U. Diättherapie, Lehrbuch mit Anwendungskonzepten. 2. Auflage. Stuttgart, New York; Thieme Verlag 1999
• 15 Jeppesen P B, Mortensen P B. Intestinal failure defined by measurements of intestinal energy and wet weight absorption.  Gut. 2000;  46 701-706
• 16 Woolf G M, Miller C, Kurian R. et al . Nutritional absorption in short bowel syndrome. Evaluation of fluid, calorie, and divalent cation requirements.  Dig Dis Sci. 1987;  32 8-15
• 17 Jeppesen P, Mortensen P. The influence oa a preserved colon on the absorption of medium chain fat in patients with small bowel resection.  Gut. 1998;  43 478-483
• 18 Scolapio J S, McGreevy K, Tennyson G S. et al . Effect of glutamine in short-bowel syndrome.  Clin Nutr. 2001;  20 319-323
• 19 Scolapio J S. Current update of short-bowel syndrome.  Curr Opin Gastroenterol. 2004;  20 143-145
• 20 Jeppesen P B, Sanguinetti E L, Buchman A. et al . Teduglutide (ALX-0600), a dipeptidyl peptidase IV resistant glucagon-like peptide 2 analogue, improves intestinal function in short bowel syndrome patients.  Gut. 2005;  54 1224-1231
• 21 Ferrone M, Scolapio J S. Teduglutide for the Treatment of Short Bowel Syndrome. Ann Pharmacother 2006, May 16 Epub
• 22 Dudrick S J, Latifi R, Fosnocht D E. Management of the short-bowel syndrome.  Surg Clin North Am. 1991;  71 625-643
• 23 Lennard-Jones J E. Review article - practical management of the short bowel.  Aliment Pharmacol Ther. 1994;  8 563-577
• 24 Weale A R, Edwards A G, Bailey M. et al . Intestinal adaptation after massive intestinal resection.  Postgrad Med J. 2005;  81 178-184
• 25 Edler J, Eisenberger A, Hammer H. et al . Das Kurzdarmsyndrom - Teil 3: Ernährungsmedizinische und medikamentöse Therapie.  Journal für Gastroenterologische und Hepatologische Erkrankungen. 2004;  2 27-35
• 26 Arrigoni E, Marteau P, Briet F. et al . Tolerance and absorption of lactose from milk and yogurt during short-bowel syndrome in humans.  Am J Clin Nutr. 1994;  60 926-929
• 27 Martinez-Riquelme A, Rawlings J, Morley S. et al . Self-administered subcutaneous fluid infusion at home in the management of fluid depletion and hypomagnesaemia in gastro-intestinal disease.  Clin Nutr. 2005;  24 158-163
• 28 Jeppesen P B, Szkudlarek J, Hoy C E. et al . Effect of high-dose growth hormone and glutamine on body composition, urine creatinine excretion, fatty acid absorption, and essential fatty acids status in short bowel patients: a randomized, double-blind, crossover, placebo-controlled study.  Scand J Gastroenterol. 2001;  36 48-54
• 29 Buchman A L, Scolapio J, Fryer J. AGA technical review on short bowel syndrome and intestinal transplantation.  Gastroenterology. 2003;  124 1111-1134
• 30 Nightingale J M. Management of patients with a short bowel.  Nutrition. 1999;  15 633-637
• 31 Woolf G M, Miller C, Kurian R. et al . Diet for patients with a short bowel: high fat or high carbohydrate?.  Gastroenterology. 1983;  84 823-828
• 32 Lemann G. Effect of octreotide on fluid and electrolyte losses, nutrient absorption and transit in short-bowel syndrome.  European Journal of Gastroenterology and Hepatology. 1993;  5 817-822
• 33 Thompson J S, Nguyen B L, Harty R F. Somatostatin analogue inhibits intestinal regeneration.  Arch Surg. 1993;  128 385-389
• 34 Pietsch M. Kurzdarmsyndrom. In: Siewert R, Harder F (Hrsg) Chirurgische Gastroenterologie. 2. ed. Berlin, Heidelberg; Springer-Verlag 1990
• 35 Malik A, Westergaard H. Short bowel syndrome. In: Feldman M, Friedman L, Sleisenger M (eds) Gastrointestinal and Liver Disease - Pathophysiology/Diagnosis/Management. 7. ed. Vol. 92. Philadelphia, London, New York; W. B. Saunders Company 2002: 1807-1816
• 36 Szczygiel B. Nutritional support in extensive gut resections (short bowel). In: Sobotka L (ed) Basics in clinical nutrition. 2. ed. Prag; Galen 2000
• 37 Bosaeus I. Fibre effects on intestinal functions (diarrhoea, constipation and irritable bowel syndrome).  Clin Nutr. 2004;  Suppl 1 33-38
• 38 Hudson M, Pocknee R, Mowat N A. D-lactic acidosis in short bowel syndrome - an examination of possible mechanisms.  Q J Med. 1990;  74 157-163
• 39 Sela B A, Zlotnik J, Masos T. et al . D-lactic acidosis in short bowel syndrome.  Harefuah. 1999;  136 347-349
• 40 Nightingale J M, Lennard-Jones J E, Gertner D J. et al . Colonic preservation reduces need for parenteral therapy, increases incidence of renal stones, but does not change high prevalence of gall stones in patients with a short bowel.  Gut. 1992;  33 1493-1497
• 41 Marangella M, Vitale C, Petrarulo M. et al . Pathogenesis of severe hyperoxalaemia in Crohn's disease-related renal failure on maintenance haemodialysis: successful management with pyridoxine.  Nephrol Dial Transplant. 1992;  7 960-964
• 42 Farooqui S, Nath R, Thind S K. et al . Effect of pyridoxine deficiency on intestinal absorption of calcium and oxalate: chemical composition of brush border membranes in rats.  Biochem Med. 1984;  32 34-42
• 43 Schiller L. Diarrhea following small bowel resection. In: Bayless T, Hanauer S (eds) Advanced Therapy of Inflammatory Bowel Disease. Hamilton, London; B. C. Decker Inc 2001
• 44 Hatch M, Freel R W. Alterations in intestinal transport of oxalate in disease states.  Scanning Microsc. 1995;  9 1121-1126
• 45 Earnest D L, Williams H E, Admirand W H. A physicochemical basis for treatment of enteric hyperoxaluria.  Trans Assoc Am Physicians. 1975;  88 224-234
• 46 Domrongkitchaiporn S, Sopassathit W, Stitchantrakul W. et al . Schedule of taking calcium supplement and the risk of nephrolithiasis.  Kidney Int. 2004;  65 1835-1841
• 47 Tomson C. Nephrocalcinosis and nephrolithiasis. In: Nightingale J (ed) Intestinal Failure. Greenwich; Medical Media Limited 2001: 227-242
• 48 Harper J, Mansell M A. Treatment of enteric hyperoxaluria.  Postgrad Med J. 1991;  67 219-222
• 49 Nightingale J M. Hepatobiliary, renal and bone complications of intestinal failure.  Best Pract Res Clin Gastroenterol. 2003;  17 907-929
• 50 Sheldon G F, Peterson S R, Sanders R. Hepatic dysfunction during hyperalimentation.  Arch Surg. 1978;  113 504-508
• 51 Cavicchi M, Beau P, Crenn P. et al . Prevalence of liver disease and contributing factors in patients receiving home parenteral nutrition for permanent intestinal failure.  Ann Intern Med. 2000;  132 525-532
• 52 Allardyce D B. Cholestasis caused by lipid emulsions.  Surg Gynecol Obstet. 1982;  154 641-647
• 53 Epstein S, Traberg H, Levine G. et al . Bone and mineral status of patients beginning total parenteral nutrition.  J Parenter Enteral Nutr. 1986;  10 263-264
• 54 Vallee B L, Wacker W E, Ulmer D D. The magnesium-deficiency tetany syndrome in man.  N Engl J Med. 1960;  262 155-161
• 55 Hanna S, Harrison M, Macintyre I. et al . The syndrome of magnesium deficiency in man.  Lancet. 1960;  2 172-176
• 56 Hessov I, Andersson H, Isaksson B. Effects of a low-fat diet on mineral absorption in small-bowel disease.  Scand J Gastroenterol. 1983;  18 551-554
• 57 Ovesen L, Chu R, Howard L. The influence of dietary fat on jejunostomy output in patients with severe short bowel syndrome.  Am J Clin Nutr. 1983;  38 270-277
• 58 Selby P L, Peacock M, Bambach C P. Hypomagnesaemia after small bowel resection: treatment with 1 alpha-hydroxylated vitamin D metabolites.  Br J Surg. 1984;  71 334-337
• 59 Durlach J. Magnesium in clinical practice. London, Paris; John Libbey 1988
• 60 Buchman A L. The clinical management of short bowel syndrome: steps to avoid parenteral nutrition.  Nutrition. 1997;  13 907-913
• 61 WHO .Trace elements in human nutrition and health. Geneva; WHO 1996
• 62 Kondrup J, Rasmussen H H, Hamberg O, Stanga Z. Nutritional risk screening (NRS 2002): a new method based on an analysis of controlled clinical trials.  Clin Nutr. 2003;  22 321-336