Page 40 of 73 SYNDROME of the SHORT small bowel
Inborn short small bowel. The inborn short small bowel, apparently, is a consequence of disturbance of its pre-natal development. This defect is combined with the wrong turn of intestines and sometimes with its atresia. In hard cases diarrhea and insufficient absorption begin at once after the birth. Radiological the wrong turn of a large intestine and considerable shortening thin comes to light, however the structure of fibers of the last is kept. If the newborn survives, then in the next years functioning of intestines gradually improves.
Extensive enterectomy. To resect big pieces of a small bowel happens it is necessary for patients of any age, but at newborns such operation is fraught with especially serious consequences. Already at chest age the organism possesses sufficient reserves to transfer removal of all large intestine or short segments thin, but after a resection of 25% from 200 — 300 cm of a small bowel continuous correction of a water salt metabolism is necessary. Now, when parenteral administration of full-fledged nutrients is widely applied, children survive even if after operation there are only 20 cm of a gut. In 2 years after an enterectomy at the newborn it is possible to expect spontaneous improvement of digestive and vsasyvatelny function.
Removal of distal part of a gut conducts to more serious effects. The jejunum cannot compensate completely absence ileal as the last is the only place where salts of bile acids and B12 vitamin are soaked up. Even at an extensive resection it is important to keep an ileocecal sphincter as it interferes with retrograde distribution of indestinal flora and increases time of contact of intestinal contents with a mucous membrane of the remained small bowel.
After an extensive resection various complications are possible. Influence of an acid gastric juice and settling by bacteria of a small bowel is often observed after a resection of its proximal part and leads to absorption disturbance. Increase of acidity of a gastric juice in such cases usually has tranzitorny character. Lack of a terminal piece of an ileal gut leads to considerable loss of bilious salts and, therefore, to malabsorption of food fats and fat-soluble vitamins. Not soaked up salts of bile acids, getting into a large intestine, provoke hypersecretion of water and electrolytes. The resection of average and distal department of a jejunum, and also an ileal gut can lead to permanent disturbance of a water balance. Removal of distal department of a small bowel at preservation thick often conducts to a hyperoxaluria, but the nephrolithiasis at children of younger age arises seldom. Cellular immunity does not suffer though after an extensive resection the content of immunoglobulins can fall in blood.
Often within several weeks after operation food eaten inside is not acquired. The patient needs to enter nutrients into this period parenterally.
The diet in each case should be selected according to age of the patient and degree of functional insufficiency. At first liquids and liquid mixes have to be izotonichna, they should be entered in the small frequent portions. It is not recommended to give a lot of liquid, especially right after dense food. At a heavy steatorrhea it is necessary to limit reception of fats with a long chain and to replace them with triglycerides with an average chain. Food glucose is acquired better, than disaccharides, but concentration it should not exceed 50 g/l as it maintains relative isotonicity of food. Usually it is required to enter in addition vitamins, and also calcium, magnesium, potassium and phosphorus (according to their concentration in serum). During removal of considerable part of an ileal gut it is necessary to do for life vitamin B injections [2 (on 100 mg monthly), however it is necessary to consider that a hypovitaminosis. B12 usually arises not earlier than in 2 years after operation. For prevention.
rickets introduction of high doses of vitamin D can be required. Vitamin K is entered according to a prothrombin time. Anti-diarrheal drugs are usually ineffective after an extensive enterectomy. Connecting bile acids in a small bowel, holestiramin reduces loss of water and sodium after a resection of rather short segment, but at an extensive resection and the expressed steatorrhea this drug, apparently, only aggravates weight of a condition of the patient. Theoretically antacids have to work positively at a hyperoxemia of a gastric juice, but their efficiency is in this situation not proved. At dysbacteriosis and a syndrome of a congestive loop it is possible to reach temporary improvement by means of oral administration of antibiotics, but this method of treatment sometimes causes the necessity in additional surgical intervention.
Treatment of the child who transferred an extensive resection demands the combined efforts of doctors of different specialties. Along with obligatory actions for recovery of balance of nutrients it is necessary to pay special attention to maintenance of psychological communication of mother with the child and stimulation of his development. Such measures provide intellectual development of the patient even in cases of heavy and long insufficiency of food.