The colon as an energy salvage organ for children with short bowel syndrome

Abstract

Background The main cause of intestinal failure is short bowel syndrome (SBS). The management goal for children with SBS is to promote intestinal adaptation while preserving growth and development with the use of parenteral nutrition (PN). Objectives This study evaluated the intestinal absorption rate in children with SBS, focusing on the role of the remnant colon. In addition, the relation between intestinal absorption rate, citrulline concentration, and small bowel length was studied. Methods Thirty-two children with SBS on PN were included. They were divided into 3 groups according to the European Society for Clinical Nutrition and Metabolism (ESPEN) anatomical classification system: type 1 SBS (n = 9), type 2 (n = 13), and type 3 (n = 10). Intestinal absorption rate was assessed by a stool balance analysis of a 3-d collection of stools. Plasma citrulline concentrations were measured and the level of PN dependency was calculated. Results The total energy absorption rate did not differ significantly between the 3 groups: 68% (61–79% ) for type 1, 60% (40–77%) for type 2, and 60% (40–77%) for type 3 ( P = 0.45). Children with type 2 or 3 SBS had significantly shorter small bowel length than children with type 1: 28 cm (19–36 cm) and 16 cm (2–29 cm), respectively, compared with 60 cm (45–78 cm) ( P = 0.04). Plasma citrulline concentrations were lower in type 3 SBS but not significantly different: 15 µmol/L (11–25 µmol/L) in type 1, 14 µmol/L (7–21 µmol/L) in type 2 , and 9 µmol/L (6–14 µmol/L) in type 3 ( P = 0.141). A multivariate analysis confirmed the role of the remnant colon in providing additional energy absorption. Conclusion This study demonstrated the importance of the colon as a salvage organ in children with SBS. Plasma citrulline concentrations should be interpreted according to the type of SBS. Efforts should focus on conservative surgery, early re-establishment of a colon in continuity, and preserving the intestinal microbiota.

Digestive enzyme expression in the large intestine of children with short bowel syndrome in a late stage of adaptation

“…Especially the expression of digestive enzymes in the colon has been poorly investigated in human biopsy specimen under SBS conditions as part of a mechanism of energy salvage, while morphological adaptation has been described . Maltase expression was found in colonic interpositions of a rat model, but there is evidence that the intestinal adaptation process of rodent models differ from the human adaptive response .…”

“…The impact of the remnant colon in SBS has been addressed in several studies. 35,36 Nutritional factors increase colon fermentation, short chain fatty acids and Bifidobacterium spp. ; dietary amylose correlates positively with colon length in pigs.…”

“…[15][16][17][18][19]21,22 Especially the expression of digestive enzymes in the colon has been poorly investigated in human biopsy specimen under SBS conditions as part of a mechanism of energy salvage, while morphological adaptation has been described. 36 Maltase expression was found in colonic interpositions of a rat model, 39 but there is evidence that the intestinal adaptation process of rodent models differ from the human adaptive response. 20,40 This translational study in a small group of SBS children clearly demonstrates intestinalization processes in the colon on a functional level analyzed by IEM, Western blotting, and enzyme activities.…”

European Pediatric Surgeon' Association Survey on the Management of Short-Bowel Syndrome

“…Re-establishing intestinal continuity allows taking advantages of the capacities of the colon to promote energy salvage (fermentation of carbohydrates by gut microbiota), waterelectrolytes absorption, and GLP2 secretion by neuroendocrine L-cells (distal part of the ileum and colon) to optimize bowel adaptation. 17 As an alternative, a distal sigmoid colostomy may be proposed to take advantages of these colonic properties in selected patients with SBS when restoring complete intestinal continuity is not a possible option because of the consequences of perineal soiling. 18 Furthermore, autologous bowel reconstruction procedures (lengthening or slowing procedures) are performed by 77% of respondents in our survey.…”

Short Bowel Syndrome as the Leading Cause of Intestinal Failure in Early Life: Some Insights into the Management

“…When preserved, the colon, by hosting the largest part of intestinal microbiota plays a predominant role in the physiological adaptation of the intestine after large small intestinal resection. Colon is capable of reducing loss of energy and producing trophic factors [39]. In animal models, supplementation of an elemental diet with pectin, which is fermented to short chain fatty acids (SCFAs) in the colon, improved adaptation of the small intestine and colon in SBS [40].…”