Not prescribing an adequate short bowel regimen
As already mentioned, short bowel is characterised by a high stomal output. To reduce the loss of water, electrolytes, minerals and nutrition, a short bowel regimen can be effective. This regimen comprises restricting oral hypotonic fluids to <1 L per day, drinking ≥1 L of a glucose/saline solution per day, taking antimotility agents before food, taking antisecretory medications, involving a dietitian to give tailored dietary advice, and separating food and fluid at mealtimes.
In terms of antimotility agents, loperamide is an opioid receptor agonist 23,24 that is not readily absorbed from the bowel and, thereby, has no addictive or sedative side effects, and in this regard should be considered the first-line treatment.16 Higher than standard dosages of loperamide are often required as transit through the small bowel in patients with short bowel is often very rapid. These dosages are up to 24 mg four times a day.15,16,24,25 Loperamide capsules can be opened if they are found to pass into the effluent unchanged. Of note, there has been a safety warning regarding ECG abnormalities and mortality with very-high-dose loperamide in patients taking it for nonlicenced usages.26,27 We therefore suggest that it would be prudent to check an ECG and measure the QT interval in all patients who require regular loperamide. Codeine (30–60 mg four times a day) can be used for a similar effect to loperamide,15,25 but should be considered as a second-line treatment, ideally in combination with loperamide. This preference is due to the systemic side effects of codeine, which include drowsiness and dependence.
For the antisecretory medications, PPIs (e.g. omeprazole) and H2 antagonists (e.g. ranitidine) reduce gastric secretions and are effective at reducing stomal output with no effect on energy or micronutrient absorption.28 Ranitidine should be given at a dosage of 300 mg orally twice a day, whereas omeprazole should be given at a doseage of 40 mg orally once or twice a day, or 40mg intravenously twice a day (if small bowel length is less than 50 cm).15 The side effects of these classes of drugs include hypomagnesaemia in patients on a PPI and CNS side effects for H2 antagonists, in particular in elderly patients.15
Somatostatin analogues are also antisecretory medications that can reduce intestinal output while maintaining micronutrient and energy absorption.29 In practice they should only be tried in patients who have a resistant high output, starting at a dose of 50 µg of octreotide twice a day, administered subcutaneously, and titrated up to a dose of 100 µg three times a day. There are several disadvantages to octreotide: the clinical response is unpredictable; it is suggested that it affects postresectional intestinal adaptation; it predisposes patients to cholelithiasis;30 it is expensive, and injections are uncomfortable for patients. For these reasons, octreotide is best reserved for patients in whom other attempts to reduce stoma output have been unsuccessful. In patients for whom octreotide is effective, long-acting depot preparations of octreotide can be used. Note that PPIs and somatostatin analogues have only been shown to reduce secretion in patients who are net ‘secretors’.15
Other management options such as intestinal lengthening, transplantation and growth factors (e.g. Teduglutide®) may be considered in patients who are atable, in a tertiary setting, but the focus is always ensuring that patients are on an optimal short bowel regimen.
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