Patient 3 was born at 35 weeks' gestation with gastrochisis. During the next 2 years, home parenteral nutrition was discontinued gradually as growth and development were maintained with nighttime enteral nutrition and a high-fat diet by mouth. This therapy was effective, and during the next year, antiinflammatory therapy was discontinued, and stable antibiotic therapy for SBBO was used without recurrent D-lactic acidosis. Because bacteria embedded with mucus were repeatedly identified on the surface of gastric and intestinal biopsy specimens, a 2000 ml of hypertonic PEG-3350 solution (GoLYTELY, Braintree Laboratories, Braintree, MA, U.S.A.) in 10 hours was administered enterally twice a week to control SBBO. Sulfasalazine and corticosteroids were used temporarily to control intestinal inflammation. Numerous antibiotic regimens were tried without prolonged success. At this time, recurrent central catheter infections and encephalopathy related to D-lactic acidosis occurred in association with enterocolitis from SBBO. At 4 years of age he was receiving 75% of calories by parenteral nutrition and 25% by gastrostomy with an intact protein formula. Patient 2 was born after a full-term pregnancy and had a mid-gut volvulus soon after birth. Regular evacuations through the rectum were established and at 1-year follow-up, and the patient has had no reoccurrence of SBBO. After 2 years, the colostomy was reversed. Ultimately, nutrition and growth were maintained with an 8-hour nighttime infusion of an elemental formula. Antibiotics were discontinued, permitting progressive discontinuation of parenteral nutrition. Because of concern about the long-term use of this product, a transverse colostomy was performed. Short-term therapy with bisacodyl suppositories resulted in good colonic evacuation, which corrected SBBO, abdominal distention, and D-lactic acidosis. It became apparent when interviewing the family in more detail that SBBO began with attempts at toilet training and the patient quickly learned to withhold stools to continue uninterrupted play activities. Ongoing evaluation demonstrated the lack of significant bowel dilatation. Various antibiotic regimens based on small bowel culture and sensitivity determination and intermittent intestinal flushes with magnesium citrate were unsuccessful in controlling overgrowth. At this time, SBBO developed for the first time, with acidosis and dehydration requiring hospitalization. After 2 years of home parenteral nutrition, intravenous nutrition constituted 80% and elemental enteral nutrition 20% of total calories. Patient 1 was born at 26 weeks' gestation, and necrotizing enterocolitis developed. Patient characteristics are summarized in Table 2. These patients required additional interventions because of failure of antibiotic treatment. Six cases of SBBO related to short bowel syndrome are presented, all with varying clinical manifestation. Effective treatment strategies with limited side effects are still needed to deal more effectively with this common complication of short bowel syndrome. The problem may be persistent despite numerous medical therapies, and surgery is often not curative.
Identifying the underlying cause of SBBO is helpful in determining effective treatment. Treatment in short bowel syndrome, however, may involve simplistic measures such as a decrease in enteral feeding or more drastic measures such as bowel tapering and/or lengthening (3). Surgical correction of such localized anatomic abnormalities such stricture, fistulas, or diverticula is often immediately corrective. Broad-spectrum oral antibiotics, initially given intermittently, are often effective in reducing the number of bacteria. Treatment of SBBO most commonly entails use of antibiotics. The nature of the treatment depends on precipitating factors, bacterial species involved, and severity of symptoms. When symptoms become severe, treatment is warranted. Symptoms of SBBO include varying combinations of pain, diarrhea, dyspepsia, and weight loss. Etiologic factors associated with small bowel bacterial overgrowth
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