Real-World Management of High Stool Output in Patients with Short Bowel Syndrome: An International Multicenter Survey

Chronic Intestinal Failure and Short Bowel Syndrome in Adults: The State of the Art

Background

Short bowel syndrome (SBS) is a devastating malabsorptive condition and the most common cause of chronic intestinal failure (CIF). During the intestinal rehabilitation process, patients may need parenteral support for months or years, parenteral nutrition (PN), or hydration/electrolyte supplementation, as a bridge for the desired enteral autonomy.

Summary

Several classification criteria have been highlighted to reflect different perspectives in CIF. The management of CIF-SBS in adults is a multidisciplinary process that aims to reduce gastrointestinal secretions, slow transit, correct/prevent malnutrition, dehydration, and specific nutrient deficiencies, and prevent refeeding syndrome. The nutritional support team should have the expertise to take care of these complex patients: fluid support; oral, enteral, and PN; disease/PN-related complications; pharmacologic treatment; and surgical prevention/treatment.

Key Messages

CIF-SBS is a complex disease with undesired consequences, if not adequately identified and managed. A comprehensive approach performed by a multidisciplinary team is essential to reduce PN dependence, promote enteral independence, and improve quality of life.

Real-world experience with glucagon-like peptide 2 analogues in patients with short bowel syndrome and chronic intestinal failure: Results from an international survey in expert intestinal failure centers

BACKGROUND AND AIMS

Glucagon-like peptide 2 (GLP-2) analogues are the first available disease-modifying treatments for patients with intestinal failure (IF) due to short bowel syndrome (SBS). Efficacy in terms of reduction of parenteral support (PS) has been demonstrated in multiple studies and real-world reports. However, it remains unclear how many patients are eligible to receive the treatment, when treatment is started after intestinal resection, how treatment efficacy is assessed outside of clinical trials, and how the treatment is modified in case of non-response or adverse events. The aim of this study was to investigate the real-world management of patients treated with GLP-2 analogues in expert centers around the world.

METHODS

A survey questionnaire was developed by a multidisciplinary working group consisting of 52 questions related to various aspects of multidisciplinary care of SBS-IF patients. The 17 questions related to the use of GLP-2 analogues in clinical practice were analyzed for this study. The online survey was sent to 33 participating centers in a phase 3 study of a long-acting GLP-2 analogue. Only responses from countries with access to commercially available GLP-2 analogues were included in the study. A descriptive analysis was performed for each question. Results are presented as median (interquartile range).

RESULTS

The responses from the 19 expert IF centers with access to GLP-2 analogues indicated that 10 (10-20) % of patients with SBS-IF were treated with a GLP-2 analogue, which was less than the number of eligible patients (30 (25-40) %). In most centers (10 centers, 53 %), GLP-2 therapy was started 6-12 months after the last intestinal resection, with 5 centers (26 %) starting later (12-24 months). Multiple parameters were used in combination to determine the response to GLP-2 analogues of which the three most common were >20 % decrease in PS (95 %), at least 1 day of PS reduction per week (84 %) and increased urinary output (68 %). In non-responders GLP-2 therapy was stopped within the first year by 67 % of the centers. Finally, strategies in case of significant adverse events include stopping the GLP-2 analogue (used by 79 % of experts), dose reduction (67 %) and temporary treatment interruption (62 %).

CONCLUSION

The results of this survey completed by expert IF centers show the real-life use of GLP-2 analogues in clinical practice. Key learning points identified include the accounting for a period of intestinal adaptation before starting GLP-2 analogues and not stopping the treatment too early in case of non-response. The best strategy in case of adverse effects should be studied further.

Successful weaning from parenteral nutrition in a short bowel syndrome patient with high-output stoma through restricted oral diet: a case report

A restricted oral diet plays a significant role in the nutritional management of patients with Short Bowel Syndrome (SBS). SBS patients often experience increased intestinal output, especially if they are classified as net "secretors" (typically having less than 100 cm of residual jejunum). This means they lose more water and sodium from their stoma than they take in by mouth. In this report, we present the case of an SBS patient with 80 cm of remaining bowel, no colon in continuity, and a high-output stoma. The patient was managed with a restrictive oral diet in combination with parenteral nutrition, pharmacological treatment, and high patient compliance. Following this regimen, the patient's condition improved significantly, leading to a reduction in stoma output and an improvement in nutritional status, including stabilization and weight gain. Upon discharge from the hospital, the patient was maintaining an oral diet with specific nutritional recommendations and receiving parenteral saline. This case report suggests that the combined use of restricted oral intake and parenteral nutrition (PN), alongside appropriate pharmacological management and high patient compliance, can effectively manage high-output stomas and improve nutritional status, even in cases where the small bowel is less than 100 cm in length.

Current Status of Chronic Intestinal Failure Management in Adults

BACKGROUND

Chronic intestinal failure (CIF) is a heterogeneous disease that affects pediatric and adult populations worldwide and requires complex multidisciplinary management. In recent years, many advances in intravenous supplementation support, surgical techniques, pharmacological management, and intestinal transplants have been published. Based on these advances, international societies have published multiple recommendations and guidelines for the management of these patients. The purpose of this paper is to show the differences that currently exist between the recommendations (ideal life) and the experiences published by different programs around the world.

METHODS

A review of the literature in PubMed from 1980 to 2024 was carried out using the following terms: intestinal failure, CIF, home parenteral nutrition, short bowel syndrome, chronic intestinal pseudo-obstruction, intestinal transplant, enterohormones, and glucagon-like peptide-2.

CONCLUSIONS

There is a difference between what is recommended in the guidelines and consensus and what is applied in real life. Most of the world's countries are not able to offer all of the steps needed to treat this pathology. The development of cooperative networks between countries is necessary to ensure access to comprehensive treatment for most patients on all continents, but especially in low-income countries.

Fat malabsorption in pancreatic cancer: Pathophysiology and management

Exocrine pancreatic insufficiency (EPI) is common in pancreatic ductal adenocarcinoma (PDAC) and may lead to significant nutrition compromise. In the setting of cancer cachexia and gastrointestinal toxicities of cancer treatments, untreated (or undertreated) EPI exacerbates weight loss, sarcopenia, micronutrient deficiencies, and malnutrition. Together, these complications contribute to poor tolerance of oncologic therapies and negatively impact survival. Treatment of EPI in PDAC involves the addition of pancreatic enzyme replacement therapy, with titration to improve gastrointestinal symptoms. Medical nutrition therapies may also be applicable and may include fat-soluble vitamin replacement, medium-chain triglycerides, and, in some cases, enteral nutrition. Optimizing nutrition status is an important adjunct treatment approach to improve quality of life and may also improve overall survival.