Chronic intestinal failure and short bowel syndrome in Crohn’s disease

Table 6 Major complications of short bowel syndrome: risk factors, prevention and treatment (adapted from Pironi et al[46], 2016)

	Risk factors	Prevention and/or treatment
Bacterial overgrowth/ miscolonization	Ileocecal valve resection; Reduced intestinal motility (Ogilvie syndrome; chronic intestinal pseudo-obstruction)	Metronidazole (500 mg, 2 times per day), vancomycin (125 mg, 4 times per day), neomycin (500 mg, 3 times per day), clindamycin (300 mg, 3 times per day) tetracycline (500 mg, 3 times per day), rifaximin (550 mg, 2 times per day)
Renal failure	Dehydration; CRBSI; Nephrocalcinosis; Kidney stones	Optimize fluid and sodium balance; Optimize CVC care; Prevent urinary calcium oxalate formation
Calcium oxalate, kidney stones	SBS with colon in continuity and fat malabsorption (enteric hyperoxaluria); Pyridoxine or thiamine deficiency; Excess of ascorbic acid; Dehydration; Low urinary citrate; Low urinary magnesium	Reduce or avoid excess lipid in the diet; Reduce food with high oxalate content; Oral calcium at mealtime (1 g); Oral cholestyramine; Optimize fluid balance; Optimize acid-base balance; Optimize magnesium status; Limit ascorbic acid supplementation
BAMS
—Compensated	Extent of resection < 100 cm; Fecal bile acid excretion increased; Adequate hepatic compensation of bile acid loss; ≥ reduction of bile acid pool; no or minimal steatorrhea	Colestyramine/Colesevelam
—Decompensated	Extent of resection > 100 cm, fecal bile acid excretion increased; Inadequate hepatic compensation of bile acid loss; ≥ reduction of bile acid pool ≥ steatorrhea	Fat-modified/-reduced diet; Cholylsarcosine/ox gall1
Gallstones	Prolonged oral fasting; Interrupted bile acid entero-hepatic circulation; Prolonged treatment with anticholinergic and narcotic drugs	Limit periods of oral fasting; Limit narcotic or anticholinergic treatment; Use oral and/or enteral feeding as much as possible
IFALD-cholestasis	SBS with < 50 cm of residual small bowel; SBS without colon; CRBSI episodes; Chronic intraabdominal inflammation and/or small bowel bacterial overgrowth; Interrupted enterohepatic circulation of bile acid; Oral fasting; PN-overfeeding; i.v. soya-based lipid emulsion ≥ 1 g/kg/d	Avoid oral fasting; Optimize CVC care; Treat intraabdominal inflammation foci; Rehabilitative surgical procedures; Optimize i.v. feeding; i.v. soya-based lipid emulsion < 1 g/kg/d and/or i.v. fish oil lipid emulsion
D-lactic acid acidosis	SBS with a colon in continuity; Carbohydrate and soluble fiber-based diet; Ingestion of rapidly fermentable simple sugars; Feeding D-lactate containing food; High blood and urinary oxalate; Thiamine deficiency; Antibiotic and/or probiotic courses; Dehydration; Decreased renal function; Decreased liver function	Low carbohydrate and simple sugar diet; Antibiotics active against D-lactate-producing bacteria orally, such as metronidazole (500 mg, 2 times per day), vancomycin (125 mg, 4 times per day), neomycin (500 mg, 3 times per day), clindamycin (300 mg, 3 times per day), tetracycline (500 mg, 3 times per day), rifaximin (550 mg, 2 times a day); Thiamine supplementation; Reduction of oxalate absorption; Optimize fluid balance

¹If colon has been removed or disabled. BAMS: Bile acid malabsorption syndrome; CRBSI: Catheter-related bloodstream infection; CVC: Central venous catheter; i.v.: Intravenous; PN: Parenteral nutrition; PPI: Proton pump inhibitor; PTH: Parathyroid hormone; SBS: Short bowel syndrome.