Short bowel syndrome

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Last reviewed: 3 Apr 2025

Last updated: 29 Jun 2022

Short bowel syndrome typically presents as a consequence of extensive bowel resection.

The intestine may adapt over time to be more efficient at nutrient absorption; the extent of adaptation determines the extent of recovery.

Treatment and prognosis are dependent on the length, health, and anatomy of the remaining bowel.

Management includes electrolyte and fluid replacement, provision of adequate macronutrients, and prevention and treatment of micronutrient deficiencies during intestinal adaptation.

Primary anastomosis of residual small bowel to colon, when possible, is the most important surgical procedure to reduce the need for parenteral nutrition (PN).

Degree of oral medication absorption varies unpredictably between patients; alternative routes of administration should be sought where possible.

Physicians and patients need to watch closely for signs of dehydration, micronutrient deficiency, liver disease, and PN-related complications such as catheter infections and occlusions.

Definition

Short bowel syndrome (SBS) refers to a condition wherein substantial portions of the small intestine are absent, either congenitally or due to resection.[1][2]

Typically, less than 200 cm of residual short bowel is present. This results in a loss of surface area for fluid, nutrient, and medication absorption, causing an inability to maintain protein-energy, fluid, electrolyte, or micronutrient balance when ingesting a conventionally accepted, normal diet.[1]

History and exam

Key diagnostic factors

weight loss
diarrhea
volume depletion
peripheral or presacral edema

Full details

Other diagnostic factors

fatigue
postprandial epigastric or right upper quadrant abdominal pain
dysuria or renal colic
abnormal neurologic examination
jaundice and pruritus
dermatologic signs
night blindness
motor weakness or altered gait
proximal muscle weakness
excessive bleeding
confusion

Full details

Risk factors

bowel resection
extensive abdominal radiation injury
gastroschisis

Full details

Diagnostic tests

1st tests to order

CBC
serum electrolytes
BUN and creatinine
serum albumin
serum calcium, zinc, selenium, folate
vitamins A, B1, B2, B6, B12, C, D, and E
methylmalonic acid (MMA)
INR

Full details

Tests to consider

serum hepatic aminotransferases, alkaline phosphatase, and bilirubin (total and direct)
urine analysis
serum D-lactate
fecal fat quantification
upper gastrointestinal contrast series
Dual-energy x-ray absorptiometry (DXA) scan
abdominal ultrasound
CT abdomen

Full details

Treatment algorithm

ACUTE

jejunoileocolic anastomosis

jejunoileal anastomosis with fully resected colon

end jejunostomy or duodenostomy

ONGOING

all patients

Contributors

Authors

Alan Buchman, MD, MSPH, FACP, FACG, FACN, AGAF

Medical Director, Gastroenterology

Anthem Health

Indianapolis

Disclosures

AB is an author of references cited in this topic.

Acknowledgements

Dr Alan Buchman would like to gratefully acknowledge Dr Michael Roth, a previous contributor to this topic. MR is an author of a reference cited in this topic.

Peer reviewers

Marian F. Winkler, PhD RD

Professor of Surgery

Surgical Nutrition Specialist

Alpert Medical School of Brown University and Rhode Island Hospital

Providence

Disclosures

MFW declares that she has no competing interests.

Jonathan Shaffer, MBBS

Hospital Dean

Intestinal Failure Unit

Hope Hospital

Salford

Manchester

Disclosures

Not disclosed. JS is the author of references cited in this topic.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

Pironi L, Arends J, Baxter J, et al. ESPEN endorsed recommendations. Definition and classification of intestinal failure in adults. Clin Nutr. 2015 Apr;34(2):171-80.Full text Abstract

Cuerda C, Pironi L, Arends J, et al. ESPEN practical guideline: clinical nutrition in chronic intestinal failure. Clin Nutr. 2021 Sep;40(9):5196-220.Full text Abstract

Buchman AL. Short bowel syndrome. In: Feldman M, Friedman LS, Brandt LJ, eds. Sleisenger and Fordtran's gastrointestinal and liver disease. 11th ed. Philadelphia, PA: Saunders; 2020.

Buchman AL, Scolapio J, Fryer J. AGA technical review on short bowel syndrome and intestinal transplantation. Gastroenterology. 2003 Apr;124(4):1111-34.Full text Abstract

Nightingale JM, Lennard-Jones JE, Gertner DJ, et al. Colonic preservation reduces need for parenteral therapy, increases incidence of renal stones, but does not change high prevalence of gallstones in patients with a short bowel. Gut. 1992 Nov;33(11):1493-7. Abstract

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials
- Active Crohn disease
- Celiac disease
- Small bowel malignancy
More Differentials
Guidelines
- ESPEN guidelines on clinical nutrition in chronic intestinal failure
- ESPEN guidelines on home parenteral nutrition
More Guidelines
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Short bowel syndrome

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic tests

1st tests to order

Tests to consider

Treatment algorithm

jejunoileocolic anastomosis

jejunoileal anastomosis with fully resected colon

end jejunostomy or duodenostomy

all patients

Contributors

Authors

Alan Buchman, MD, MSPH, FACP, FACG, FACN, AGAF

Disclosures

Acknowledgements

Peer reviewers

Marian F. Winkler, PhD RD

Disclosures

Jonathan Shaffer, MBBS

Disclosures

References

Key articles

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials

Guidelines

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice