Short Bowel Syndrome

Podcast Transcript

Dr. Scott Steele: Butts & Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end to end. Hi again everyone and welcome to another episode of Butts & Guts. I'm your host, Dr. Scott Steele, the Chair of Colorectal Surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio. And today, we're very pleased to have Dr. Shirley Paski, who is a Gastroenterologist in the Department of Gastroenterology, Hepatology and Nutrition here at the Cleveland Clinic. We’re going to talk a little bit about short bowel syndrome. Dr. Paski, thanks so much for joining us on Butts & Guts.

Dr. Shirley Paski: Thank you for having me. I really appreciate it.

Dr. Scott Steele: Before we jump in, if you can tell us a little bit about yourself, where you're from, where'd you train, and how did it come to the point that you're here in the Cleveland Clinic?

Dr. Shirley Paski: I grew up in Vancouver Canada. Did my medical education mostly in Canada, and then came to the U.S. for fellowship. And then after fellowship in GI, I worked in the area of intestinal failure, small bowel diseases, and then landed at the Cleveland Clinic in order to work with a team of like-minded individuals and provide excellent care for my patients.

Dr. Scott Steele: Well we're super excited to have you here. And today we're going to talk about short bowel syndrome. So to start, can you touch exactly what is short bowel syndrome to our listeners?

Dr. Shirley Paski: Yes. So short bowel syndrome is a condition that occurs after an individual has had multiple surgeries, or one surgery that involves resection of a very large amount of their small intestine, sometimes other parts of their GI tract as well. But the real principle of short bowel syndrome is when an individual has less than 200 centimeters of small intestine left in their body.

Dr. Scott Steele: So, you mentioned a little bit about surgery. So how common is short bowel syndrome? And are there any other conditions outside of surgery that can lead to short bowel?

Dr. Shirley Paski: It's not a common condition. Short bowel syndrome would be considered a rare disease overall. We see it in individuals coming from a variety of conditions, and that's where each individual with short bowel syndrome is unique. But as a whole, the condition is rare. And then when you get down to each individual person with short bowel syndrome, there's certainly nuances and uniqueness about each one of them.

Dr. Scott Steele: You mentioned a little bit about the definition of being less than 200 centimeters of small bowel. So, what are some of the complications that occur as a result of short bowel syndrome?

Dr. Shirley Paski: I like to think of complications as being the short-term things that you experience in the now, and then also chronic, more longer-term complications that result from the abnormal changes that go in the body with the short bowel syndrome. So in the short term, individuals will experience higher output of stool, because there's less time to process all of that. They may experience deficiencies in electrolytes, in fluids, and also in nutrients that can lead to dehydration, or weight loss, as well as deficiencies in vitamins and minerals. In the longer term, short bowel syndrome can actually have an effect on all different body parts. The chronic dehydration can lead to difficulty with kidney function and kidney stones. The effect on nutrition and some of the other additives that we need to do in order for the treatments of short bowel syndrome can sometimes lead to problems with the liver. And we call that intestinal failure-related liver disease.

And we can also see even changes in bone health, and then emotional health too, just because having a disease like short bowel syndrome is something that people don't necessarily see on the outside, can weigh a lot on patients.

Dr. Scott Steele: So truth or myth, truth or myth, short bowel syndrome can first present at any age.

Dr. Shirley Paski: It can. We see infants, not in my practice, because I see only adults, but one of the most common conditions leading to short bowel syndrome in children is something called necrotizing enterocolitis that occurs in neonates. And people can become short gut in infancy in fact. Then we can see it through all ages. I think the oldest patient that I had with short bowel syndrome was 90 years old for de novo short bowel syndrome after an operation.

Dr. Scott Steele: You mentioned this a little bit before about some of the signs and symptoms of it in terms of diarrhea, or if somebody's got a stoma, they have high output stoma, but are there any other common signs and symptoms for short bowel syndrome?

Dr. Shirley Paski: Those are the main symptoms. Some of the other symptoms people will experience, especially if they have electrolyte abnormalities. So that's changes in things like sodium, potassium, magnesium. They may experience symptoms of fatigue or weakness, especially when they're active trying to do things. With the dehydration, you may experience dizziness when standing up, and changes in heart rate with those changes, or just lower urine output, not sweating as much, and just really more difficulty doing some things.

Dr. Scott Steele: So, as a surgeon, I could go into somebody's belly and measure their bowel, and see if they got less than 200 centimeters, but outside of that, how is short bowel syndrome diagnosed?

Dr. Shirley Paski: If we have the measurements, then we have a fairly good idea of what's going on. And I want to differentiate short bowel syndrome from intestinal malabsorption here. So some of the symptoms of intestinal malabsorption where the body has sufficient length of small intestine, but the actual intestine is not healthy enough to do its job will manifest with very similar symptoms. And by definition, that's not technically short bowel syndrome, whereas with short bowel syndrome when you have it, the symptoms that people have are going to be as we describe. And we may reinforce measurements to know how well that intestine is functioning. And we test for it with measures of the stool or ostomy output to see how well the body is absorbing things like fat, carbohydrates or protein. We may also measure vitamin and mineral levels usually in blood work. And then we may also look at other factors like 24 hour urine output as well.

Dr. Scott Steele: Let’s talk a little bit about treatment for short bowel syndrome. So, is there an initial treatment that you approach? Is it multifactorial, or how do you approach these patients?

Dr. Shirley Paski: At Cleveland Clinic, we're fortunate to have a multidisciplinary care team that includes physicians, dieticians, gastroenterologists, surgeons, nurses as well. And we approach patients with short bowel syndrome from a multidisciplinary approach. The approach that we have always starts with dietary modifications and lifestyle modifications to help reduce symptoms. So, we do a thorough review of what people are drinking as far as their fluids, as well as what they're eating for nutrients. And then we can sometimes make modifications to diet, as well as the types of fluids that they drink, and the way that they drink them. And then in addition to that, we sometimes we usually have to add on some other medications, particularly to manage diarrhea, and that may be anything as simple as antidiarrheals to more stronger medications.

And then we sometimes use other anti-secretory medications or hormonal medications to slow down the bowel as well. And all of that's done in a basic sense. For individuals who still have problems meeting their nutrition or their fluid needs, that's when we start to talk about something called nutrition support. And in some cases, we can use tube beads or nutritional supplements. In other cases, we even need to use intravenous either total parenteral nutrition, or IV fluids in order for patients to meet their full needs.

Dr. Scott Steele: So what's the prognosis for someone experiencing short bowel syndrome?

Dr. Shirley Paski: It depends. I think the biggest principle is what is the remaining health of the small bowel, and is there a potential to improve that? So, when an individual develops short bowel syndrome, it's usually after an operation. Then there's an adaptation period. And that adaptation period is the greatest in the first six months. That actually extends to two and five years beyond that. And if somebody has relatively healthy bowel, and is very adherent to diet, medications, lifestyle modifications and everything, then they can get significant recovery from their short bowel syndrome. And sometimes, they may start out on IV nutrition, but be able to wean off of that with time if the remaining bowel health is pretty good. Other times, we really try to wean them down to the lowest possible.

If the bowel is still unhealthy, and that can happen in diseases for example, like inflammatory bowel disease where there's still medical issues and problems with the remaining bowel. Or if the bowel is just incredibly short, we call that ultrashort bowel syndrome, then that usually ends up being dependent on IV support. But we try to make their lifestyle as reasonable and easy as possible in that setting.

Dr. Scott Steele: Can short bowel syndrome be prevented?

Dr. Shirley Paski: It depends. I think we've seen prevention with much better treatment of Crohn's Disease over time. And we have much better medications for Crohn's Disease. And patients who previously had to have numerous bowel resections to treat their disease are no longer getting those. So that would be a preventative approach, but otherwise, when most of the operations that lead to short bowel syndrome were necessary operations.

Dr. Scott Steele: Are there any advancements on the horizon when it comes to either the diagnosis or the treatment of short bowel syndrome?

Dr. Shirley Paski: Diagnosis I think not so much as far as advances in that area, but certainly the treatments I think we're getting better at. We do have hormonal therapies, and growth factors, and then we have other clinical trials here for other medications that slow down the GI track, and also change the amount of fluid that the small bowel secretes. There are also surgical strategies that we have here at Cleveland Clinic, intestinal rehabilitation, as well as even intestinal transplant in extreme cases for patients who would either benefit from that, or who have experienced complications related to TPN IV nutrition.

Dr. Scott Steele: That's fantastic. And now it's time for our quick hitters, when we get a chance to know you a little bit better. So first of all, what is your favorite meal?

Dr. Shirley Paski: Sushi.

Dr. Scott Steele: What was your first car?

Dr. Shirley Paski: Toyota Tercel. It was periwinkle blue.

Dr. Scott Steele: Nice. Nice. Nice. Nice. What's the favorite place that you've traveled to?

Dr. Shirley Paski: Probably Belgium.

Dr. Scott Steele: And finally, tell us a little something about why you like living here in Northeast, Ohio.

Dr. Shirley Paski: I love the four seasons. I like the environment. The people here are super friendly, super nice. I have family that's not too far away driving distance, which is great. I can spend more time with them, and just really enjoy Cleveland as a city actually.

Dr. Scott Steele: Well that's great. And we're lucky to have you here. So, give us a final take-home message regarding short bowel for our listeners.

Dr. Shirley Paski: If you have had previous surgery and are concerned that you have short bowel syndrome as a result of having your small intestine removed in a large quantity, then there is help to create a better quality of life. If you have had previous surgery and are concerned that you have short bowel syndrome as a result of having your small intestine removed in a large quantity, then there is help to create a better quality of life. While we don't have all the answers right now, and we're certainly doing research to hope that we get them, we want to help our patients live as best a possible life as they can in spite of their limitations.

Dr. Scott Steele: Well, that's great. And to learn more or schedule an appointment for short bowel syndrome treatment here at the Cleveland Clinic, call the Digestive Disease Institute at 216.444.7000. That's 216.444.7000. You can also visit our website at clevelandclinic.org/digestive. That's clevelandclinic.org/digestive. Dr. Paski, thanks so much again for joining us on Butts & Guts.

Dr. Shirley Paski: Thank you very much. Thanks for having me.

Dr. Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts & Guts.