Vitamin D status after resection of ileum in childhood

Limited ileal resection in infancy: the long-term consequences

BACKGROUND/PURPOSE

The longer-term sequelae of short bowel syndrome in infancy are reasonably well documented, but little is known about the long-term nutritional and metabolic effects of limited (less than 50 cm) ileal resection. This makes it difficult to formulate a rational follow-up policy in such children.

METHODS

All children who underwent limited ileal resection for either necrotizing enterocolitis (NEC) or intussusception at our institution between 1984 and 1992 were invited to attend a detailed clinical, anthropometric, hematologic, and biochemical assessment, together with a biliary and renal ultrasound scan and measurement of bone mineral density.

RESULTS

Twenty-four children (NEC, 17; intussusception, 7) of median age 7.4 years (range, 5.5 to 13.7 years) agreed to participate. Nine previously had undergone an isolated ileal resection, and 15 also had had variable lengths of colon removed. The length of resected ileum ranged from 3 to 44 cm, with a median of 10 cm. Seven control subjects in whom neonatal NEC developed but recovered without surgery were also evaluated. Median height, weight, and body mass index after ileal resection were between the 25th and 50th percentiles; no child was stunted or wasted. After ileal resection, one boy was found to have asymptomatic vitamin B12 deficiency, and three children had low plasma concentrations of vitamin A. Hematologic and biochemical parameters were otherwise normal apart from a few marginally low trace element levels in both subjects and controls. No renal calculi were detected, and bone mineral density measurements were normal in all except one child. Four children had cholelithiasis, all of whom had previously undergone limited ileal resection for NEC (two isolated, two ileocolic). Thus, the prevalence of cholelithasis after limited ileal resection for NEC was 24% at a median age of 7.0 years.

CONCLUSIONS

Growth and nutritional status are well preserved after limited ileal resection in infancy. Limited ileal resection for NEC is associated with a subsequent high prevalence of cholelithiasis and a risk of vitamin B12 deficiency. These findings are important when planning strategies for long-term follow-up.

Studio delle alterazioni metaboliche dei pazienti sottoposti a neovescica ortotopica di sostituzione e reservoir urinario

Urine exposed to intestinal mucosa changes its composition, as some substances are absorbed and others are secreted. Metabolic effects in 57 patients who underwent bladder substitution, augmentation cystoplasty or continent reservoir, were reviewed in our institute. Hyperchloraemic metabolic acidosis was the most common effect. Even if the consequences are often limited by the body's compensatory response, the risk of long-term complications is always present and a close metabolic follow-up is mandatory.

Problems with intestinal lengthening

The surgical problems encountered in treating three infants with short-bowel syndrome are reported. The two survivors demonstrate many of the problems associated with the very short-bowel syndrome and both are dependent on parenteral nutrition despite undergoing intestinal lengthening.

Treatment and metabolic findings in extreme short-bowel syndrome with 11 cm jejunal remnant

A full term girl survived nonresected, subtotal small-bowel gangrene. The length of the small-bowel remnant (only jejunum) measured 11 cm. Anastomosis was performed with insertion of a 3-cm-long antiperistaltic segment. The ileocecal valve remained intact. The jejunal remnant showed an increase in length of at least 1 m. The resorptive functions of the bowel residue recovered incompletely, particularly the ileal functions. Disturbances of calcium and phosphorus metabolism are now in the foreground; nevertheless, the child now manages to live without parenteral feeding.

Vitamin D deficiency rickets as a late complication of the short gut syndrome during infancy

Four infants with less than 35 cm of jejunum and ileum remaining following neonatal operations and after being weaned from long-term total parenteral nutrition onto an "elemental" formula, developed the syndrome of vitamin D deficiency rickets at 9-15 mo of age. The diagnosis of rickets was confirmed by biochemical and radiographic findings. Serum 25 hydroxy vitamin D (25 OHD) values were significantly lower than normal and oral 25 OHD absorption studies indicated severe vitamin D malabsorption. This report emphasizes the importance of prospective assessment of all neonates having distal ileal resection to detect the early stages of vitamin D deficiency rickets.

Growth and fat absorption after resection of ileum in childhood

Twelve children who have survived resection of more than 45 cm of ileum (eight during the neonatal period and four later in childhood) have been reassessed at periods ranging from 3 to 16 years. No child had persistent diarrhea for longer than one year after a resection, and only two children had a restricted fat intake for more than two years. These two children showed no advantage in growth compared with the ten who had normal diet within two years of the resection. The weights of individual children are appropriate for their heights. Their heights tend to be less than those of their siblings, but only two are less than the third percentile compared to height expected in relation to that of parents. The older children still have marked steatorrhea but no diarrhea, and serum levels of vitamins A, D, and E are normal. These observations suggest that two years after extensive resection ileum some children may tolerate a normal diet and grow well despite persisting defects in absorption. Infants with more extensive resections are now surviving and may require special diets and vitamin supplements for longer periods of time.