Short bowel is a rare condition in which the small intestine is unable to digest and absorb the correct amounts of nutrients; and the body does not reabsorb fluids, including digestive juices, produced by the intestines (the gut).
This can lead to problems such as malnutrition, weight loss, diarrhoea and dehydration.
To understand why this happens, it is helpful to know what happens in a person without short bowel.
The digestive system
The digestive process
Digestion is the process of the food you eat, being broken down into small nutrients. These nutrients are then absorbed by the intestine and go into the bloodstream to feed the body.
Mouth and Stomach
Digestion begins in the mouth, which is why it is important that you chew your food thoroughly. When this food reaches the stomach it is churned into a liquid by acid produced in your stomach.
Back to topSmall bowel
The small bowel is where most of the digestion of food and the absorption of nutrients into the body occurs. To aid digestion, about four litres of ‘digestive juices’ are made and released by the small intestine each day.
- Most digestion occurs in the first part of the small bowel called the duodenum.
- Once digested most nutrients are absorbed in the second part of the bowel called the jejunum.
- In the third part of the small bowel, the ileum, most of the juices released to aid digestion are reabsorbed.
- Vitamin B12 is also absorbed in the ileum.
Large bowel
The remaining fluid that has not been absorbed will pass into the large bowel, the colon, which reabsorbs water and sodium to form a stool.
When you have a short bowel
When you have had a large part of your bowel removed, the length left behind may not be enough for all the fluids and nutrients to be absorbed. This is often referred to as having a short bowel. This can lead to a person experiencing weight loss or becoming dehydrated; however, having your colon is helpful because it:
- reabsorbs fluid and salt;
- slows the movement of food through the bowel allowing more time for nutrition to be absorbed; and
- absorbs energy from the breakdown of starchy foods in the colon
This information aims to help you change the way you eat and drink to prevent dehydration and weight loss.
Guide to eating and drinking
Eating is important and helps keep the inside of the bowel healthy. Due to the length of bowel, you may need to eat more than you previously did to prevent weight loss or maintain your weight.
Back to topReintroducing food after surgery
After surgery, you may initially have some abdominal pain, bloating and diarrhoea. The following advice can help to reduce these symptoms by:
Do
- eating small regular meals and snacks;
- choosing soft, low fibre foods; and
- chewing your food well.
You may prescribed medications to reduce the amount of acid produced by your stomach (anti-secretory), or slow down the time taken for food to travel through your gut (anti-motility). This is to reduce the number of times you open your bowels.
Over time, these symptoms are likely to decrease as the bowel adapts and your body is able to digest food better.
Long-term dietary changes
To maintain a healthy weight and good health, you should choose a nutritious diet.
The advice given below will help you to choose the rights foods to improve absorption of nutrients and reduce your risk of dehydration and diarrhoea.
Your diet should ideally be:
- high protein and energy;
- moderate in fat;
- high in carbohydrate;
- low in fibre; and
- low in oxalate
High protein and high energy
Eating foods high in energy (calories) and protein will help you recover from surgery and maintain your weight.
Do
- Include a portion of protein at each meal for healing,
for example; meat, fish, eggs, cheese, yoghurt, lentils or pulses (if vegetarian). - Include starchy carbohydrate for energy at each meal,
for example; white bread or chapatis, potatoes, white rice, noodles, pasta or low fibre breakfast cereal. - In between meals, snack on foods such as sandwiches, cereal, crackers, milky drinks, yoghurts, plain biscuits, cakes or crisps, plain scones with butter and jam or muffins are also good options.
- Include desserts such as milk puddings, custard, mousse, ice cream, yoghurt or cheese.
- Try adding sugar to drinks, cereals and puddings.
- Spread jam, marmalade, honey or syrup thickly on bread or add to milk puddings, porridge and yoghurt.
- Try adding custard or ice cream to puddings for extra energy.
** Please note
If you have diabetes, you may need to discuss with your dietitian about adding sugar to your foods.
Fat
Fat is a good source of energy to help you gain weight; however, some people have difficulty digesting fat. If you notice that your stools are pale in colour, look oily, float on the surface and are difficult to flush away, this may suggest you are not digesting fatty foods very well. You may as a result, need to reduce your fat intake or start a new medication to help you digest fat better.
If you are experiencing any of these symptoms, speak to your dietitian about whether decreasing your fat intake is needed at this time. They will be able to discuss your diet with you and advise on ways to reduce your fat intake if necessary.
It is recommended that you avoid very high fat foods in large quantities as these may exacerbate your bowels and you may experience symptoms of malabsorption as previously mentioned. These include deep fried foods, foods in rich and creamy sauces, pies and pastries and desserts with double cream.
Carbohydrate
Carbohydrates or starchy foods are a good source of energy and an important part of everyone’s diet. A high intake of carbohydrates may help you gain or maintain weight because your body can get energy from the breakdown of starchy foods.
Back to topWays to increase your carbohydrate intake
Refer to the section above ‘high energy / high protein’ on ways you can increase your carbohydrate intake.
Do
- Try high energy desserts such as ice cream, sponge puddings, fruit crumbles and milk puddings.
- If fruit is tolerated include it as a dessert or snack removing the skins, seeds and pips if necessary.
- If vegetables are tolerated try carrot, parsnip, swede and turnip or any other root vegetables.
If you are finding it difficult to eat the amount of food recommended then your dietitian may suggest high energy supplements available on prescription. Your dietitian will advise you if these need to be included in your daily fluid allowance. You can get these supplements from your GP on advice from your dietitian.
Fibre
Fibre is not completely digested by the body. Foods high in fibre such as wholegrain cereals, fruit and vegetables pass through your gut quickly. Choosing foods that are lower in fibre, such as those listed below, may help reduce diarrhoea; however, this does depend on the type of fibre you have.
Soluble fibre, such as oats, barley and some fruits are fine to have. Insoluble fibre, which is difficult to digest should be limited such as nuts, potato skins, strawberries, grapes and wholegrain cereals.
Ways to limit your fibre intake
- Use white bread instead of brown, wholemeal or seeded.
- Use refined breakfast cereals such as Cornflakes, Rice Krispies or porridge instead of high fibre varieties such as All Bran, Bran flakes, Weetabix, Shredded Wheat or Muesli.
- Use white pasta and rice instead of brown varieties.
- Try not to eat the skin on potatoes.
- Eat biscuits made with white flour such as Rich Tea, Marie, Malted milk, Nice rather than wholemeal biscuits like Hobnobs or Digestives. Try to avoid biscuits with fruit or nuts such as Garibaldi, figs rolls and fruit shortbread.
- Eat crackers made with white flour such as cream crackers, Ritz biscuits and breadsticks instead of Ryvita, Oat cakes, Krackerwheat or Hovis biscuits.
- Limit your intake of pulses (beans, peas and lentils) unless you are vegetarian when you should include one portion daily as a source of protein. Ensure the lentils you buy do not have the skin on.
- You may include small portions of cooked vegetables but avoid skins, stalks, or seeds if necessary. Root vegetables such as carrots, parsnips, swede etc. are usually tolerated okay.
- Avoid salads.
- You can include small portions of fruit but avoid skins, pips, seeds and piths if necessary. It is okay to have tinned or stewed fruit and peeled fruit.
- Avoid nuts. You can have small amounts of smooth peanut butter.
Oxalate
Oxalate is a substance found in foods and produced by your body during digestion. It normally attaches to calcium and is passed in the stool; however, following a small bowel resection, fats that are not absorbed enter the colon, attach to calcium, leaving the oxalate free to be passed in the urine. This increases your risk of developing kidney stones.
This risk may be reduced by:
- reducing your oxalate intake; (see below)
- taking a moderate fat diet; and
- ensuring you have enough calcium in your diet
Foods high in oxalate which need to be limited
- Spinach
- Nuts
- Sesame seeds,
- Strong black tea
- Chocolate
- Cocoa
- Beetroot
- Bran-containing breakfast cereals
- Wholemeal bread
- Rhubarb,
- Beans (including baked beans in tomato sauce)
- Soybeans
- Soy products.
Ensure an adequate calcium intake
- Aim for 300 – 600 ml of milk each day or the equivalent from cheese or yoghurt.
- 200 mls of milk contains the same amount of calcium as one small carton of yoghurt (150 ml) or a matchbox (30 g) portion of cheese.
Fluids
Your colon absorbs fluid and salt so people with their colon do not usually have problems with dehydration unless part of the colon has been removed and you have a short bowel. Over time, your colon will get better at absorbing fluid and salt and your diarrhoea should improve; however, if your diarrhoea does not improve, then you may be at risk of becoming dehydrated.
Dehydration
To reduce the risk of dehydration you have to drink less, not more. The more you drink, the more fluid and salt you will lose, which will cause you to become more dehydrated.
If you become dehydrated regularly, you may be advised to restrict your fluid intake and to drink an oral rehydration solution.
Back to topYour fluid allowance
It is recommended that you drink ml of oral rehydration solution each day. The allowance for all other fluids is ml each day.
Drinks low in salt (water, tea, coffee, juice, squash)
Drinks low in salt will cause sodium and fluid to move from the body into your intestine resulting in diarrhoea, which will cause dehydration.
Fluid from your body moves into your intestine and causes more diarrhoea.
Oral rehydration solution (high in salt)
Drinks high in salt will cause sodium and fluid to move from inside your intestine into the rest of your body. This may reduce your diarrhoea, which helps prevent dehydration.
Fluid from your intestine moves into your body.
Suitable fluids
If you are on a fluid restriction, it is important that the fluids you drink are the best for your short bowel.
Suitable drinks
- Ovaltine
- Horlicks
- Tea
- Coffee
- Fruit juice (small amounts)
- Sugar free squash
- Oxo
- Bovril
- Bouillon
- Lucozade Sport / Isotonic sports drink*
Unsuitable drinks
- Fizzy drinks
- Fruit smoothies
- High energy drinks
- Lucozade
- Powerade
- Red Bull / Monster / prime or other high caffeine energy drinks
* Isotonic sports drinks advertised as containing electrolytes are available but do not have the correct levels of electrolytes to be effective to work as an oral rehydration solution.
Back to topDehydration
It is very important that you learn to recognise the signs of dehydration. You may experience thirst, a reduction in how much urine you pass, which may also be dark and concentrated, tiredness, cramps, dry skin, dizziness on standing up or notice dark circles under your eyes. If you think that you might be dehydrated, please contact a member of the Nutrition Team.
You may be asked to take any of the following oral rehydration solutions.
Dioralyte (available on prescription)
Mix 8 – 10 sachets with 1 litre (1000 ml) tap water.
St Mark’s electrolyte mix
Mix six level 5 ml spoons of glucose powder, one level 5 ml spoon of sodium chloride and half heaped 5 ml spoon of sodium bicarbonate in 1 litre (1000 ml) of tap water.
You can buy the powders from any pharmacy and some supermarkets, or they can be prescribed from your GP. Sodium chloride is table salt and sodium bicarbonate is also known as bicarbonate of soda or baking soda.
If you need to get electrolyte mix prescribed, please refer your GP to this information .
Rx St Mark’s Electrolyte Mix
- Formula:- Glucose 20 g
- Sodium chloride 3.5 g
- Sodium bicarbonate 2.5 g
Tips to help you take your oral rehydration solution
- The electrolyte mix is best served chilled.
- It can be frozen and taken as a slush.
- Try drinking it through a straw.
- You may wish to add a small amount of no added sugar squash or fruit juice to improve the taste. This is best added, while making up the solution rather than adding to each glass so that the salt content remains high.
- A squeeze of fresh lemon or lime juice may be added.
In hot conditions, we sweat and lose salt and fluid from the body. This means, people with short bowel are more likely to get dehydrated and you may find you need to drink more electrolyte mix to replace these losses. Please note that you can drink as much of these electrolyte mixes as needed
Tips to help you stick to your fluid allowance
- Sip all fluids, including your oral rehydration solution, slowly throughout the day.
- Use smaller cups and glasses.
- Suck boiled sweets or mints.
- Suck ice cubes or ice lollies as part of your fluid allowance.
- Try to keep busy so you are not thinking about feeling thirsty.
Alcohol
Any alcohol you wish to drink must be included in your fluid allowance. Some medications should not be taken with alcohol. Please discuss this with your doctor or pharmacist.
Salt
If diarrhoea is a regular issue for you, you will lose a lot of salt (sodium) and it is important to try and replace these losses by following a diet high in salt.
- Salt should be added when cooking potatoes, rice, pasta and vegetables.
- Salt should be added to your meals at the table.
- Flavour foods with soya sauce, garlic or celery salt.
- Use tomato ketchup, brown sauce or gravy with meals.
The following foods are high in salt and should be eaten regularly:
- cheese, bacon, ham, gammon, grilled sausages;
- smoked fish such as kippers, salmon and mackerel;
- canned fish such as tuna, sardines, salmon, pilchards, mackerel in brine;
- meat and fish pastes;
- tinned foods such as spaghetti and ravioli;
- use Oxo, Bovril, gravy granules or stock cubes to add flavour and make sauces / gravy;
- yeast extracts such as Marmite and Vegemite;
- salty crisps, savoury biscuits and crackers; and
- pot noodles and packet savoury rice.
Medicines used in short bowel
The medicines prescribed for people with short bowel work in one of two ways, either slowing down the passage of food and drink in the intestines (anti-motility), or reducing the amount of acid produced by your stomach (anti-secretory).
Anti-motility medications
- Loperamide.
- Codeine Phosphate.
These need to be taken 30 – 60 minutes before food to work best. These medications are usually prescribed in much higher doses than for someone who does not have short bowel. Your GP will be advised of this by your nutrition team.
Anti-secretory medications
- Omeprazole • Ranitidine • Lansoprazole
Any fluid used to take your medicine should come from your fluid allowance so you may find it helpful to take your medications with electrolyte mix.
It is important that you do not take any other medications from a chemist or health food shop without discussing it first with your doctor or pharmacist as they may interfere with your prescribed medications.
If you have had the last part of your small bowel (ileum)removed, you will require vitamin B12 injections every
3 months to prevent anaemia. Your GP or clinician can discuss this with you.
Long-term monitoring
The treatment you are offered and advice given in this leaflet is to help prevent you becoming malnourished and dehydrated. It is important that your progress is monitored regularly. When you attend the Outpatients Clinic, you will be weighed, have blood taken and be asked for a urine sample to help us monitor your condition.
Weight
Your weight is important because it tells us how well nourished you are. Your weight will fluctuate daily due to the amount of fluid in your body. It is important that you weigh yourself once per week at home and if you are losing weight, please contact a member of the Nutrition Team on the contact numbers at the end of this leaflet.
Urine
Your urine is important because it tells us if you are dehydrated. The colour of your urine is a good guide to see how well hydrated you are and the guide below will help you assess this.
Check the colour of your urine everyday.
If your urine matches 1, 2 or 3 you are well-hydrated
If your urine matches 4 – 6 you are dehydrated
If you think you are dehydrated, a random urinary sodium is the best test and you should ask your GP surgery to check this for you. If it is below 20, you are dehydrated and should contact the Nutrition Team as soon as possible and they will advise you accordingly.
Please show this leaflet to any other health professionals you may come into contact with such as your GP or district nurse. You may find that you are given incorrect advice by people who are not used to caring for people with short bowel.
If you ever need to seek treatment elsewhere it is important to let whoever is caring for you know that you have short bowel and are a patient under the Leeds Nutrition Team.
Additional information
This booklet has been produced by the Leeds Teaching Hospitals Dietetic Department with information provided by The St Mark’s Hospital Dietetic Department in London.
Back to topOther useful contacts:
Please contact us for more information
Nutrition Team Office
Dietetic Office
PINNT – National Support Group
(Patients On Intravenous & Nasogastric Nutrition Therapy)
PALS Information
If you have any concerns or questions about your care, you can contact using the telephone number below, alternatively you can download a PALS form from the trust website, and submit it electronically, or contact us via email.
The Leeds Nutrition Team are always happy to advise health care professionals regarding the treatment of patients with short bowel.
If you have any questions in relation to your diet and stoma / fistula output, speak to your dietitian who will be able to advise further.
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