Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

jejunoileocolic anastomosis

1st line – oral diet and re-hydration

Back
ACUTE
|
jejunoileocolic anastomosis
1st line – 

oral diet and re-hydration

When thirsty, oral re-hydration solution (ORS) should be encouraged in all patients instead of water, juice, or sports drinks.[16][38][39]

Patients must be encouraged to eat 2 to 3 times more calories than they did prior to acquiring SBS.

Patients should be encouraged to eat a diet rich in complex carbohydrates, starch, and soluble fibre, and low in oxalate.[4][28] Foods containing lactose are a rich source of calcium and should be encouraged unless the patient is known to be lactose intolerant, or a massive jejunal resection has been performed.[40]

Patients with bile salt malabsorption may benefit from a diet rich in medium-chain triglycerides (MCT) or may use MCT supplements.

Plus – anti-diarrhoeal treatment

Back
ACUTE
|
jejunoileocolic anastomosis
Plus – 

anti-diarrhoeal treatment

Treatment recommended for ALL patients in selected patient group

Anti-diarrhoeal medicine is required to control fluid losses.[4]

Options include loperamide, diphenoxylate/atropine, codeine, tincture of opium, octreotide, or clonidine.

Clonidine produces side effects of hypotension and central effects such as drowsiness.

Octreotide slows intestinal transit and inhibits intestinal adaptation, and must be administered subcutaneously or intravenously. It should therefore be used only if other agents fail to control diarrhoea because of potential adverse effects on intestinal adaptation and gallbladder motility.

Primary options

loperamide: 2 mg orally four times daily initially, increase according to response, maximum 16 mg/day

OR

diphenoxylate/atropine: 2.5 mg orally four times daily initially, increase according to response, maximum 20 mg/day

More

Secondary options

codeine phosphate: 15-60 mg orally every 6-8 hours when required, maximum 240 mg/day

OR

opium tincture: 15 drops orally four times daily, increase gradually according to response, maximum 20 mL/day

Tertiary options

clonidine transdermal: 0.1 mg/24 hour patch once weekly

or

clonidine: 0.1 to 0.6 mg orally twice daily

OR

octreotide: 100-1500 micrograms/day subcutaneously given in 2-4 divided doses

Plus – calcium supplementation

Back
ACUTE
|
jejunoileocolic anastomosis
Plus – 

calcium supplementation

Treatment recommended for ALL patients in selected patient group

Indicated in all patients to maintain normal calcium status and protect against osteoporosis.

Primary options

calcium carbonate: 1-2 g/day orally given in 3-4 divided doses

Consider – parenteral nutrition (PN) support with subsequent weaning

Back
ACUTE
|
jejunoileocolic anastomosis
Consider – 

parenteral nutrition (PN) support with subsequent weaning

Additional treatment recommended for SOME patients in selected patient group

Patients require PN support if adequate nutrition is not achieved with oral diet alone. This is more common in patients with ≤100 cm residual bowel (or ≤150 cm if colon partially resected). Patients with a jejunoileocolic anastomosis have the greatest likelihood of weaning from PN.[4]

PN is initially administered over a 24-hour period and the feeding time is gradually condensed to a 10- to 12-hour night-time feeding schedule (usually by 2-hour increments whereby the infusion rate is increased and infusion duration is decreased).

Catheter safety instructions are critical for the prevention of complications such as catheter sepsis and venous thrombosis.

Weaning is achieved by gradually increasing oral intake in small, frequent feedings as tolerated. The aim is to consume 2 to 3 times the normal oral caloric intake. This is accompanied by: a corresponding adjustment to the frequency and content of PN; monitoring of fluid and nutrition status; diarrhoea control; and use of oral rehydration solutions.

Consider – proton-pump inhibitor

Back
ACUTE
|
jejunoileocolic anastomosis
Consider – 

proton-pump inhibitor

Additional treatment recommended for SOME patients in selected patient group

Required for 6 months after the initial surgery to control gastric hyper-secretion.[2][4][43][44][45][46][47]

Less-extensive surgery, such as small segmental resections for Crohn's disease, may not cause gastric hyper-secretion, and therapy may not be not required for these cases.

Can induce diarrhoea in some patients, therefore monitoring the volume of diarrhoea before and after the commencement of treatment may be useful.

Primary options

omeprazole: 40 mg orally twice daily

OR

lansoprazole: 15-30 mg orally once or twice daily

Consider – electrolyte, vitamin, and micro-nutrient replacement

Back
ACUTE
|
jejunoileocolic anastomosis
Consider – 

electrolyte, vitamin, and micro-nutrient replacement

Additional treatment recommended for SOME patients in selected patient group

Patients are tested regularly for electrolyte and vitamin deficiencies to guide supplementation, including vitamins A, pyridoxine (B6), B12, D, E, and K, and copper, zinc, and selenium.

Deficiencies of fat-soluble vitamins (A, D, E, K) are the most common vitamin deficiencies encountered; absorption of water-soluble vitamins is preserved.

Potassium, magnesium, bicarbonate, and phosphorus supplementation should also be provided as needed.

Caution must be used with oral magnesium supplements as they can induce diarrhoea and worsen absorption. Magnesium gluconate is preferred as it may result in less diarrhoea than other formulations.

Patients with greater than 60 cm terminal ileum resection usually develop vitamin B12 deficiency.

jejunoileal anastomosis with fully resected colon

1st line – parenteral nutrition (PN) with oral re-hydration

Back
ACUTE
|
jejunoileal anastomosis with fully resected colon
1st line – 

parenteral nutrition (PN) with oral re-hydration

PN is initially administered over a 24-hour period and the feeding time is gradually condensed to a 10- to 12-hour night-time feeding schedule (usually by 2-hour increments whereby the infusion rate is increased and infusion duration is decreased) to enable the patient to be pump free during the day.

Instruction in proper catheter care is essential to avoid complications such as catheter sepsis and venous thrombosis.

When thirsty, oral re-hydration solution should be encouraged in all patients instead of water, juice, or sports drinks.[16][38][39]

Plus – anti-diarrhoeal treatment

Back
ACUTE
|
jejunoileal anastomosis with fully resected colon
Plus – 

anti-diarrhoeal treatment

Treatment recommended for ALL patients in selected patient group

Anti-diarrhoeal medicine is required to control fluid losses.[4]

Options include loperamide, diphenoxylate/atropine, codeine, tincture of opium, or octreotide.

Clonidine produces side effects of hypotension and central effects such as drowsiness.

Octreotide slows intestinal transit and inhibits intestinal adaptation, and must be administered subcutaneously or intravenously. It should therefore be used only if other agents fail to control diarrhoea because of potential adverse effects on intestinal adaptation and gallbladder motility.

Primary options

loperamide: 2 mg orally four times daily initially, increase according to response, maximum 16 mg/day

OR

diphenoxylate/atropine: 2.5 mg orally four times daily initially, increase according to response, maximum 20 mg/day

More

Secondary options

codeine phosphate: 15-60 mg orally every 6-8 hours when required, maximum 240 mg/day

OR

opium tincture: 15 drops orally four times daily, increase gradually according to response, maximum 20 mL/day

Tertiary options

octreotide: 100-1500 micrograms/day administered subcutaneously in 2-4 divided doses

Plus – calcium supplementation

Back
ACUTE
|
jejunoileal anastomosis with fully resected colon
Plus – 

calcium supplementation

Treatment recommended for ALL patients in selected patient group

Indicated in all patients to maintain normal calcium status and protect against osteoporosis.

Primary options

calcium carbonate: 1-2 g/day orally given in 3-4 divided doses

Consider – proton-pump inhibitors

Back
ACUTE
|
jejunoileal anastomosis with fully resected colon
Consider – 

proton-pump inhibitors

Additional treatment recommended for SOME patients in selected patient group

Required for 6 months after the initial surgery to control gastric hypersecretion.[2][4][43][44][45][46][47]

Less-extensive surgery, such as small segmental resections for Crohn's disease, may not cause gastric hyper-secretion, and therapy is not required for these cases.

Can induce diarrhoea in some patients, therefore monitoring the volume of diarrhoea before and after the commencement of treatment may be useful.

Primary options

omeprazole: 40 mg orally twice daily

OR

lansoprazole: 15-30 mg orally once or twice daily

Consider – electrolyte, vitamin, and micro-nutrient replacement

Back
ACUTE
|
jejunoileal anastomosis with fully resected colon
Consider – 

electrolyte, vitamin, and micro-nutrient replacement

Additional treatment recommended for SOME patients in selected patient group

Patients are tested regularly for electrolyte and vitamin deficiencies to guide supplementation, including vitamins A, pyridoxine (B6), B12, D, E, and K, and copper, zinc, and selenium.

Deficiencies of fat-soluble vitamins (A, D, E, K) are the most common vitamin deficiencies encountered in this patient group; absorption of water-soluble vitamins is preserved. The risk of vitamin K deficiency is further increased because the colonic bacterial flora, which can synthesise vitamin K, have been lost.

Potassium, magnesium, bicarbonate, and phosphorus supplementation should also be provided as needed.

Caution must be used with oral magnesium supplements as they can induce diarrhoea and worsen absorption. Magnesium gluconate is preferred as it may result in less diarrhoea than other formulations.

Patients with greater than 60 cm of terminal ileum resection usually develop vitamin B12 deficiency.

Consider – oral diet with weaning of parenteral nutrition (PN)

Back
ACUTE
|
jejunoileal anastomosis with fully resected colon
Consider – 

oral diet with weaning of parenteral nutrition (PN)

Additional treatment recommended for SOME patients in selected patient group

Weaning from PN may be possible in patients with >100 cm of residual small bowel, and is achieved by gradually increasing oral intake in small, frequent feedings as tolerated. The aim is to consume 2 to 3 times the normal, pre-resection oral caloric intake. This is accompanied by: a corresponding adjustment to the frequency and content of PN; monitoring of fluid and nutrition status; diarrhoea control; and use of oral rehydration solutions.

end jejunostomy or duodenostomy

1st line – re-anastomosis of colon

Back
ACUTE
|
end jejunostomy or duodenostomy
1st line – 

re-anastomosis of colon

Primary re-anastomosis of small bowel with colon must be performed in all patients to enable the intestine to take advantage of the colon's role in fluid and nutrient absorption. This greatly improves the patient's chances of weaning from parenteral nutrition (PN).

Patients will likely be dependent on PN if re-anastomosis of the colon is not possible.

Plus – parenteral nutrition (PN) support and oral re-hydration

Back
ACUTE
|
end jejunostomy or duodenostomy
Plus – 

parenteral nutrition (PN) support and oral re-hydration

Treatment recommended for ALL patients in selected patient group

Patients require total PN support for the first 7 to 10 days after surgery, after which partial PN support in combination with oral diet should be commenced. Patients with >100 cm residual small bowel (or >150 cm if the colon is partially resected) can be transitioned to oral diet relatively quickly, while those with ≤100 cm residual small bowel (or ≤150 cm if the colon is partially resected) may require PN for longer. Dietary intake may need to be decreased to control faecal losses.

Instruction in proper catheter care is essential to avoid complications such as catheter sepsis and venous thrombosis.

When thirsty, oral re-hydration solution (ORS) should be encouraged in all patients instead of water, juice, or sports drinks.[16][38][39]

Plus – anti-diarrhoeal treatment

Back
ACUTE
|
end jejunostomy or duodenostomy
Plus – 

anti-diarrhoeal treatment

Treatment recommended for ALL patients in selected patient group

Anti-diarrhoeal medicine is required to control fluid losses.[4]

Options include loperamide, diphenoxylate/atropine, codeine, tincture of opium, or octreotide.

Octreotide slows intestinal transit and inhibits intestinal adaptation, and must be administered subcutaneously or intravenously. It should therefore be used only if other agents fail to control diarrhoea because of potential adverse effects on intestinal adaptation and gallbladder motility.

Primary options

loperamide: 4 mg orally four times daily

OR

diphenoxylate/atropine: 5 mg orally four times daily

More

Secondary options

codeine phosphate: 15-60 mg orally every 6-8 hours when required, maximum 240 mg/day

OR

opium tincture: 15 drops orally four times daily; increase gradually according to response, maximum 20 mL/day

Tertiary options

octreotide: 100-1500 micrograms/day subcutaneously given in 2-4 divided doses

Plus – calcium supplementation

Back
ACUTE
|
end jejunostomy or duodenostomy
Plus – 

calcium supplementation

Treatment recommended for ALL patients in selected patient group

Indicated in all patients to maintain normal calcium status and protect against osteoporosis.

Primary options

calcium carbonate: 1-2 g/day orally given in 3-4 divided doses

Consider – proton-pump inhibitors

Back
ACUTE
|
end jejunostomy or duodenostomy
Consider – 

proton-pump inhibitors

Additional treatment recommended for SOME patients in selected patient group

Required for 6 months after the initial surgery to control gastric hyper-secretion.[2][4][43][44][45][46][47]

Can induce diarrhoea in some patients, therefore monitoring the volume of diarrhoea before and after the commencement of treatment may be useful.

Primary options

omeprazole: 40 mg orally twice daily

OR

lansoprazole: 15-30 mg orally once or twice daily

Consider – electrolyte, vitamin, and micro-nutrient replacement

Back
ACUTE
|
end jejunostomy or duodenostomy
Consider – 

electrolyte, vitamin, and micro-nutrient replacement

Additional treatment recommended for SOME patients in selected patient group

Patients are tested regularly for electrolyte and vitamin deficiencies to guide supplementation, including vitamins A, thiamine (B1), pyridoxine (B6), folate (B9), B12, C, D, E, and K, and copper, zinc, and selenium.

This patient group can develop deficiencies of both fat- and water-soluble vitamins.

Iron, potassium, magnesium, bicarbonate, and phosphorus supplementation should also be provided as needed.

Caution must be used with oral magnesium supplements as they can induce diarrhoea and worsen absorption. Magnesium gluconate is preferred as it may result in less diarrhoea than other formulations.

Patients with >60 cm terminal ileum resection usually develop vitamin B12 deficiency.

ONGOING

all patients

1st line – electrolyte, vitamin, and micro-nutrient replacement

Back
ONGOING
|
all patients
1st line – 

electrolyte, vitamin, and micro-nutrient replacement

Patients are tested regularly for electrolyte and vitamin deficiencies to guide supplementation, including vitamins A, thiamine (B1), pyridoxine (B6), folate (B9), B12, C, D, E, and K, and copper, zinc, and selenium.

Calcium supplementation is often indicated in all patients to protect against osteoporosis.

Primary options

calcium carbonate: 1-2 g/day orally given in 3-4 divided doses

Plus – long-term PN

Back
ONGOING
|
all patients
|
parenteral nutrition (PN)-dependent
Plus – 

long-term PN

Treatment recommended for ALL patients in selected patient group

Patients who cannot be weaned will require long-term PN. They should be carefully monitored for complications such as liver failure.

Patients with a jejunoileocolic anastomosis have the greatest likelihood of weaning from PN. Patients with a jejunoileal anastomosis with a fully resected colon with ≤100 cm of residual bowel will almost certainly be PN-dependent, as will be patients in whom a primary re-anastomosis with the colon is not performed. Instruction in proper catheter care is essential to avoid complications such as catheter sepsis and venous thrombosis.

Consider – teduglutide

Back
ONGOING
|
all patients
|
parenteral nutrition (PN)-dependent
Consider – 

teduglutide

Additional treatment recommended for SOME patients in selected patient group

A human glucagon-like peptide-2 (GLP-2) analogue that has been shown to improve intestinal absorption and reduce parenteral nutrition (PN) requirement in PN-dependent patients with SBS.[29][30] 

Weaning may be attempted after 4 weeks of treatment with teduglutide, and lifelong continuous treatment is required if weaning is successful. However, there is uncertainty regarding optimal maintenance dosing.

There is a risk of acceleration of neoplastic growth with teduglutide. Small bowel neoplasia has been reported in animal studies and there is a theoretical risk of colorectal cancer in humans.[31] Therefore, patients with an intact colon require colonoscopy before starting treatment, and then at regular intervals during treatment (no less frequently than every 5 years). Treatment should be discontinued in patients with gastrointestinal malignancy, and caution should be used in patients with non-gastrointestinal malignancy.

Primary options

teduglutide (recombinant): 0.05 mg/kg subcutaneously once daily to alternating quadrants of the abdomen, the thighs, or the arms

Consider – bowel lengthening/tapering surgery

Back
ONGOING
|
all patients
|
parenteral nutrition (PN)-dependent
Consider – 

bowel lengthening/tapering surgery

Additional treatment recommended for SOME patients in selected patient group

Bowel lengthening/tapering surgery using the Bianchi procedure or the serial transverse enteroplasty (STEP) procedure can be performed to aid intestinal adaptation and weaning in parenteral nutrition (PN)-dependent patients with dilated bowel segments.

Inclusion criteria include: an intestinal diameter >3 cm; length of residual small bowel >40 cm with ≥20 cm of dilated small bowel; PN dependence; and an absence of liver disease, Crohn's disease, and radiation enteritis.

The Bianchi procedure takes an immotile segment of small bowel, transects the segment, and re-connects the halves end to end, thereby doubling the length of bowel and helping motility.

The STEP procedure involves applying linear staples along the small bowel in alternating and opposite directions in order to incompletely divide the dilated intestine. It has the same effect as the Bianchi procedure but is technically easier to perform, and has the advantage of avoiding postoperative stricture formation.[37]

No randomised controlled trials have compared the Bianchi and STEP procedures; therefore, it is not clear which procedure is superior.

Patients with SBS and dilated bowel segments may have bacterial overgrowth in the bowel. If persistent, this should be treated before performing bowel lengthening/tapering surgery.

Plus – adjust PN composition

Back
ONGOING
|
all patients
|
parenteral nutrition (PN) failure
Plus – 

adjust PN composition

Treatment recommended for ALL patients in selected patient group

Patients can be considered to be failing PN therapy if they have 1 or more of the following: impending or overt liver failure, at least 2 thromboses of major central venous channels, frequent central line-related sepsis, or frequent severe volume depletion.[15]

PN composition should be adjusted in patients developing intestinal failure-associated liver disease (IFALD). Dextrose over-feeding (>40 kcal/kg/day) should be avoided and intravenous lipid intake reduced to below 1.0 g/kg/day if possible.[2] However, the intravenous soybean oil-based lipid emulsion should still supply at least 4% to 8% of total energy. This usually requires a reduction in overall caloric intake, as over-feeding needs to be avoided. Alternative lipid emulsions, containing fish oil or a combination of fish and olive oils, may be used as an energy source in patients with IFALD.[32][33]

Consider – intestinal transplantation ± liver transplantation

Back
ONGOING
|
all patients
|
parenteral nutrition (PN) failure
Consider – 

intestinal transplantation ± liver transplantation

Additional treatment recommended for SOME patients in selected patient group

Intestinal transplantation can be considered if there is no clinical improvement following parenteral nutrition (PN) adjustment, or PN failure has occurred as a result of recurrent thrombosis of central venous channels or frequent severe volume depletion.

Intestinal transplantation is associated with a risk of morbidity and mortality, and should therefore be regarded as a rescue therapy rather than a therapeutic option.

Patients with end-stage liver failure secondary to long-term intestinal failure will require combined liver and intestinal transplantation.

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Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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