History

Patients with short-bowel syndrome invariably present with a history of several intestinal resections, as occurs with Crohn disease, or with a history of a major abdominal catastrophe or vascular accident, such as midgut volvulus or embolus to the superior mesenteric vessels. Pursuant to the resultant malabsorption, diarrhea (with or without steatorrhea) is an almost constant clinical finding.

Patients with short-bowel syndrome may describe significant weight loss, fatigue, malaise, and lethargy. These symptoms are protean but consistent with the diarrheic diathesis and resultant dehydration, electrolyte imbalance, protein-calorie malnutrition, and loss of critical vitamins and minerals.

Vitamin and mineral deficiencies can lead to some specific symptoms, as follows:

Patients with vitamin A deficiencies may report night blindness and xerophthalmia
Vitamin D depletion can be associated with paresthesias and tetany
Loss of vitamin E can cause paresthesias, ataxic gait, and visual disturbances because of retinopathy
A history of easy bruisability or prolonged bleeding might suggest vitamin K depletion
Patients reporting dyspnea on exertion or lethargy may be anemic from vitamin B12, folic acid, or iron deficiency
Calcium and magnesium losses can cause paresthesias and tetany
Patients with critically low zinc levels may describe anorexia and diarrhea

Physical Examination

Physical examination of the patient with short-bowel syndrome can reveal many clues to the diagnosis, depending on the duration and severity of the malabsorption.

Patients who are severely protein- and energy-malnourished may present with temporal wasting, loss of digital muscle mass, and peripheral edema. The skin may be dry and flaky. The nails can feature prominent ridges, and the lingual papillae are blunted or atrophic. In children, poor growth performance is a telling feature.

The essential fatty acids are linoleic and linolenic acids. Patients with essential fatty acid deficiency experience growth retardation, dermatitis, and alopecia.

The physical features of vitamin A deficiency include corneal ulcerations and growth delays.

Patients with low levels of the B complex vitamins in general can present with stomatitis, cheilosis, and glossitis. Vitamin B1 deficiency is associated with edema, tachycardia, ophthalmoplegia, and depressed deep tendon reflexes. Vitamin B6 deficiency can cause peripheral neuropathies and seizures. Peripheral neuropathy can be a feature of B12 deficiency also.

Vitamin D depletion is associated with poor growth and bowed extremities.

Severe vitamin E deficiencies can result in ataxia, edema, and depressed deep tendon reflexes.

The physical hallmarks of vitamin K deficiency are related to derangements in hemostasis. These include petechiae, ecchymoses, purpura, or outright bleeding diatheses.

Physical clues to the presence of iron deficiency include pallor, spooned nails, and glossitis.

Zinc deficiency causes angular stomatitis, poor wound healing, and alopecia. Also, a scaly erythematous rash can erupt around the mouth, eyes, nose, and perineum.

Workup

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Author

Burt Cagir, MD, FACS Associate Regional Dean and Professor of Surgery, Geisinger Commonwealth School of Medicine; Director, General Surgery Residency Program, Executive Director, Donald Guthrie Foundation for Research and Education, Guthrie Robert Packer Hospital; Medical Director, Guthrie/RPH Skills and Simulation Lab; Associate in Surgery, Guthrie Robert Packer Hospital and Corning Hospital

Burt Cagir, MD, FACS is a member of the following medical societies: American College of Surgeons, Association of Program Directors in Surgery, Society for Surgery of the Alimentary Tract

Disclosure: Nothing to disclose.

Coauthor(s)

Michael AJ Sawyer, MD Consulting Staff, Department of Surgery, Comanche County Memorial Hospital; Medical Director, Lawton Bariatrics

Michael AJ Sawyer, MD is a member of the following medical societies: American College of Surgeons, American Society for Metabolic and Bariatric Surgery, Society for Surgery of the Alimentary Tract, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoscopic and Robotic Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

David L Morris, MD, PhD, FRACS Professor, Department of Surgery, St George Hospital, University of New South Wales, Australia

David L Morris, MD, PhD, FRACS is a member of the following medical societies: British Society of Gastroenterology

Disclosure: Received none from RFA Medical for director; Received none from MRC Biotec for director.

Chief Editor

John Geibel, MD, MSc, DSc, AGAF Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, Professor, Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow; Fellow of the Royal Society of Medicine

John Geibel, MD, MSc, DSc, AGAF is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, Society for Surgery of the Alimentary Tract

Disclosure: Nothing to disclose.

Additional Contributors

Juan B Ochoa, MD Assistant Professor, Department of Surgery, University of Pittsburgh School of Medicine; Medical and Scientific Director, HCN, Nestle Healthcare Nutrition

Disclosure: Nothing to disclose.

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