Short bowel syndrome (SBS) presents unique challenges in maintaining adequate nutrition. It occurs when the small bowel is unable to properly digest and absorb enough nutrients from foods and beverages to support overall health. This can happen due to surgical removal of a segment of the small bowel or because of impaired function of the small bowel. This article provides detailed dietary guidelines and strategies to manage SBS, improve nutrient absorption, and alleviate symptoms.
Understanding Short Bowel Syndrome
Short bowel syndrome (short gut syndrome) results when patients have large portions of their small intestines removed. Short bowel syndrome is the most common cause of intestinal failure, a condition in which patients don't have enough functional gut mass needed for adequate absorption to meet fluid and nutrient requirements. A variety of disorders can lead to short bowel syndrome, including inflammatory bowel diseases (Crohn's disease and ulcerative colitis), mesenteric vascular thrombosis, recurrent intestinal obstruction, tumors and trauma.
When a part of your bowel is removed, the part that’s left can adapt. It does this by absorbing the nutrients and liquids that would’ve normally been absorbed by the part that was removed. This means your doctor can remove parts of your bowel without having a major impact on your nutritional health. At first, your body may not absorb nutrients, liquids, vitamins, and minerals as well as it did before your surgery. It takes time for your remaining bowel to adapt after your surgery. This usually takes a few months, but everyone’s body heals differently. Short bowel syndrome is a set of symptoms that happen while your remaining bowel adapts after your surgery. You can reduce these symptoms by following the guidelines in this resource.
General Dietary Guidelines
Dietary modifications aim to optimize nutrient and fluid absorption, and reduce diarrhea, malnutrition, and dehydration. SBS management is complex and is adjusted to a person’s individual needs. Depending on the portion and length of your remaining bowel, and how well it functions, your doctor may help create a diet that’s tailored to you.
Frequent, Small Meals
Eat 6 to 8 small meals a day. Eat small, frequent meals to put less stress on your shortened bowel. Small meals help control your symptoms and are easier for your body to digest and absorb. Eat slowly and chew your food well. Once your bowel has adapted, you can go back to having 3 meals a day.
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Chewing Food Thoroughly
Chew foods well to help break down food. This makes it easier for your body to absorb. It will also help stop foods from causing a blockage as they pass through your intestine.
Hydration Strategies
Dehydration can be a serious concern. However, battling dehydration isn’t a matter of simply drinking more water. In fact, this can make the problem worse by increasing diarrhea or ostomy output. It’s important to consult your doctor when you notice signs of dehydration. Oral rehydration solution (ORS) is a simple, yet specific, solution of salt, sugar, and water that is used to aid in dehydration due to diarrhea. The special ratio of ingredients enhances absorption of fluid across the small bowel wall.
Only drink ½ cup (4 ounces) of liquids during each meal. Drink large amounts of liquids with meals. This helps push your food through your bowel more quickly. This means that you may not digest or absorb enough nutrients. Choose drinks that don’t have a lot of sugar. This will keep you from getting dehydrated. Examples include water, coffee, tea, milk, or juices diluted with water.
When it comes to maintaining hydration remember to SIP-with advice from your HCP, follow a recipe to make an ORS from salt, sugars, and baking soda, include with water, then proactively drink slowly throughout the day. Drinking fast does not allow the intestine time to absorb the fluid, passing it out of the body too quickly.
Macronutrient Balance
- High in proteins: Ensure adequate protein intake to support healing and nutrient absorption.
- High in refined or low-fiber complex carbohydrates (starches): Focus on easily digestible carbohydrates. Meal planning should focus on including more complex carbohydrates such as bread, rice, pasta, and potatoes.
- Moderate in fats: Include fats but be mindful of the type and amount. Examples of fatty foods are: Oils, Butter, Margarine, Mayonnaise, Gravies, Cream sauces, Regular salad dressings. For example, it’s okay to have butter on toast or mayonnaise on a sandwich.
Foods to Limit or Avoid
- Low in sugary foods: Limit sugary foods and beverages (e.g., candy, cake, fruit juices, sodas). Examples of sugary foods are: Sugar (cookies, cakes, candies, chocolate, soda, instant teas, fruit drinks), Corn syrup, Molasses, Honey, Pancake syrup. You can use artificial sweeteners like Splenda® or Sweet N’ Low®. However, limit your intake of sugar-free candies or cough drops that contain sugar alcohols. Sugar alcohols include sorbitol, xylitol, mannitol, and isomalt. Fluids with high sugar content, like juice and soda, cause an influx of water into the intestine, resulting in a laxative effect.
- Fiber: Whole-grain products, raw vegetables, fruit peels, and nuts should be excluded due to their high fiber content and propensity to aggravate diarrhea. After your surgery, you may find that fiber, especially insoluble fiber, is hard to digest. Insoluble fiber is found mainly in whole-grain and bran products. It doesn’t break down in water and your body can’t break it down, so it makes stool (poop) more bulky.
- Oxalates: Low in oxalates if you’ve had a kidney stone. Oxalate in foods combine with calcium in urine to form a common type of kidney stone. If you have fat malabsorption (trouble absorbing fats from foods), you may develop kidney stones. Limit eating foods that are high in oxalates, such as spinach & rhubarb.
Specific Dietary Considerations
Soluble vs. Insoluble Fiber
While both types of fiber are important for health, soluble fiber is better tolerated by short bowel syndrome patients because it helps slow digestion. Soluble fiber is also fermented by gut bacteria in the colon to produce beneficial by-products like short-chain fatty acids2, which can nourish the gut barrier and help prevent inflammation. Soluble fiber breaks down in water and can be broken down by your body. It also helps slow digestion. This usually makes it easier to tolerate. Psyllium (fiber supplement). Many foods have a mixture of both soluble and insoluble fibers. Legumes, such as chickpeas, lima beans, kidney beans, and lentils. Be careful; legumes may cause gas.
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Managing FODMAPs
FODMAPs are carbohydrates and sugar alcohols that are poorly absorbed in the small intestine. They can increase intestinal water content, gas production and cause more GI symptoms like stomach pain, bloating and motility changes. FODMAP foods include dairy, wheat, legumes and certain fruits and vegetables. They are also found in many processed foods, especially those with added sweeteners. A low-FODMAP diet is appropriate for patients with specific GI diseases like irritable bowel syndrome.
Lactose Intolerance
Lactose is a sugar that’s found in dairy products. It can cause symptoms such as gas, cramps, and diarrhea. These symptoms usually start within the first 30 minutes of eating or drinking dairy. Sometimes, having part of your bowel removed can make you lactose intolerant. To see if you can tolerate lactose, drink one half cup (4 ounces) of milk. If you have any symptoms, try lactose-free dairy products, such as Lactaid® milk or almond, rice, or soy milk. You can also use Lactaid® tablets or Lactaid® drops before you eat dairy items to help you digest them. Some foods have less lactose than others. If you can’t drink dairy milk, try cultured yogurt and aged cheeses. These include hard cheeses such as cheddar and Swiss. If you can eat those, try soft cheeses, such as cream cheese and cottage cheese. If you still have symptoms, try to avoid all dairy products for 1 to 2 months before trying them again.
Oral Rehydration Solutions (ORS)
Oral rehydration solutions (ORS) are recommended as the main beverage in SBS when there is diarrhea. ORS have specific amounts of water, sugar and salt to improve hydration. Readymade ORS as well as recipes to make ORS at home are available. Oral rehydration solutions contain specific amounts of sodium, carbohydrate, and water, which increase fluid absorption in the small bowel. Salty meals and/or snacks, plus a soluble fiber supplement can be helpful when the absorptive colon segment is present.
You can buy an oral rehydration solution, such as Hydralyte®, from your local pharmacy. This isn’t the same as sports drinks, such as Gatorade®, which don’t have the same amount of nutrients. You do not need a prescription for an oral rehydration solution. Ideally, patients should consume fluid known as oral rehydration solution, which has a balanced ratio of sugar to sodium. Contrary to common beliefs, most sport drinks are not the best choice for this population, due to their high sugar and low sodium contents. Water and other fluids with no sodium or sugar, may be tolerated in some individuals who have their colon. However, these beverages tend to promote sodium and fluid loss, leading to further dehydration in individuals who have their colon removed. Oral rehydration solutions are recommended for all who have short bowel syndrome.
Vitamin and Mineral Supplementation
You’re probably not eating some of the foods you did before your surgery. You may choose to take one multivitamin each day. This can help you get all of the vitamins and minerals you need. The multivitamin should have the recommended daily allowance (RDA) for vitamins and minerals. You may also need more of certain vitamins or minerals. Ask your doctor or clinical dietitian-nutritionist what to take. Vitamins A, D, and E. You may need water-soluble forms of vitamins A, D, and E. Vitamin B12. Calcium. Potassium. If you’re having a lot of diarrhea, your potassium levels may go down. Ask your doctor or clinical dietitian-nutritionist if you should eat foods that are high in potassium. These include oranges, potatoes, tomatoes, and bananas. Don’t take potassium supplements without talking to your doctor first. In addition, a probiotic supplement, multivitamin, and mineral supplements may also be advised.
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Liquid Nutritional Supplements
If you’re losing weight, a high-calorie liquid nutritional supplement may be helpful. However, depending on your surgery, some supplements may not be right for you. This is mainly because they have a high sugar content. Your doctor or clinical dietitian-nutritionist may recommend a special supplement for you. These supplements are low in sugar and has ingredients that are “pre-digested.” This makes them easier to absorb. They may also recommend medium chain triglycerides (MCT). This is a type of fat that’s easy to digest for extra calories. Always ask your doctor or clinical dietitian-nutritionist before taking a supplement. A supplement of pancreatic enzymes is often used to aid in digestion and help prevent gas and passing fat in stools (steatorrhea) when other measures are not effective.
Fortified Milk Recipe
If you can eat or drink dairy products, this recipe can add calories and protein to your diet. Mix 1 quart (4 cups) of milk with 1⅓ cup of instant powdered milk (usually 1 envelope).
Foods to Help You Stay Healthy and Hydrated
It’s also important to maintain a diverse and nutrient-rich diet even when you are in remission and your symptoms have subsided or even disappeared. Introduce new foods slowly. Remember to stay hydrated with water, broth, tomato juice, and rehydration solutions. Consult with your doctor or dietitian before making any changes to your diet.
These foods can help you stay healthy and hydrated:
- Fiber-rich foods: oat bran, beans, barley, nuts, and whole grains, unless you have an ostomy, intestinal narrowing, or if your doctor advises you to continue a low-fiber diet due to strictures, or recent surgery.
- Lean protein: lean meats, fish, eggs, nuts, and tofu.
- Fruits and vegetables: try to eat as many “colors” as you can, and remove the peel and seeds if they bother you.
- Calcium-rich foods: collard greens, yogurt, kefir, and milk (if you are lactose intolerant, choose lactose-free dairy products or use a lactase digestive enzyme).
- Foods with probiotics: yogurt, kimchi, miso, sauerkraut, and tempeh.
- Refined grains: sourdough, potato or gluten-free bread, white pasta, white rice, and oatmeal.
- Fully cooked, seedless, skinless, non-cruciferous vegetables: asparagus tips, cucumbers, potatoes, and squash.
- Oral nutritional supplements or homemade protein shakes: ask your doctor or your dietitian about what supplements may fit your nutritional needs.
Helpful Food Preparation Tips
Here are some helpful hints for you:
- Eat four to six small meals daily.
- Stay hydrated - drink enough to keep your urine light yellow to clear - with water, broth, tomato juice, or a rehydration solution.
- Drink slowly and avoid using a straw, which can cause you to ingest air, which may cause gas.
- Prepare meals in advance, and keep your kitchen stocked with foods that you tolerate well (see list below).
- Use simple cooking techniques - boil, grill, steam, poach.
- Use a food journal to keep track of what you eat and any symptoms you may experience.
Managing SBS: A Team Approach
Managing SBS requires the patient and often family members working together with a team of healthcare professionals. Members of the health care team may include primary care physicians, gastroenterologist surgeons, nutritional specialists, nursing specialists, and pharmacists. Often, the primary care physician will take the lead in managing and coordinating the patient’s care. The most important member of the healthcare team is the person with SBS. Family members or parents of children with SBS play essential roles as caregivers. Patients and caregivers need to have a thorough understanding of the condition and how it may best be managed to meet the individual’s needs.
Additional Considerations
- Intestinal Adaptation: Intestinal adaptation begins naturally soon after surgery and may last 1 to 2 years, or sometimes longer. Adaptation involves changes to the structure and function of the remaining bowel, such as growth of new cells, as the body tries to compensate for the loss of intestine from surgery.
- Enteral vs. Parenteral Nutrition: When possible after surgery, enteral feeding-that is, through the gut-should be prioritized over intravenous (IV) nutrition. The goal of oral and tube feeding is to stimulate and maintain or improve the intestine’s ability to absorb nutrients. Restoring the body’s natural ability to absorb nutrients is a key factor in returning people with SBS to as normal a lifestyle as possible. Parenteral nutrition bypasses the digestive system. It involves the delivery of fluids, electrolytes, and liquid nutrients into the bloodstream through a tube placed in a vein (intravenous or IV). It is often needed short-term after resection while the remaining bowel adapts. It may be needed long-term depending on the bowel’s ability to absorb nutrients.
- Surgical Interventions: Ostomy closures restore continuity for the GI tract, for example by reconnecting the small intestine to the colon, and are generally recommended when possible. Other nontransplant surgeries are used to slow movement of food, expand the surface area for absorption, or lengthen the remaining bowel.
Potential Complications of Parenteral Support (PS)
Some people with short bowel syndrome (SBS) rely on PS for essential nutrition, and it is a lifesaving requirement following surgery. This is a common PS complication. Intestinal failure associated liver disease (IFALD) is a serious and potentially life-threatening complication that can occur in those on long-term parenteral nutrition. Hyperglycemia is an increase in glucose (sugar) in the blood. If the rate of fluid intake is too fast, or if all fluids haven’t been properly tracked, the result may be fluid overload. During the process of weaning off of PS, this is a potential risk as the bowel adapts and begins to absorb more.
Living with SBS: Practical Tips
- Food Diary: Keeping a food diary is a helpful way to find out what foods are best for you. If you have an ileostomy or colostomy, it’s also helpful to record your output from your stoma. Measure the amount of stool in your bag for 1 week. Measure it each time you change or empty the bag. Then, if it’s about the same each day, measure it once a month for 1 or 2 days.
- Consider setting boundaries around handling your insertion site.
- Getting the hang of all your new medical equipment takes time. Dealing with clogged tubing or managing the pump can pose challenges. While these adjustments can be difficult to manage, you are not alone. There are many others who are going through the same difficulties.
- If available, register with your local emergency management agency or office and understand any assistance that may be available.
- Building a support circle can help ensure that you meet your goals for living with SBS.