Luminally active therapies: Pancreatic enzymes, bile acids, bile acid binders, antimicrobials, probiotics, and prebiotics in short bowel syndrome

Maldigestion and malabsorption are fundamental problems in the patient afflicted by short bowel syndrome (SBS), and several factors may contribute, including pancreatic insufficiency, depletion of the bile salt pool, and small intestinal bacterial overgrowth (SIBO); all are potential targets for therapeutic intervention. Quite apart from symptoms that may result from malabsorption, changes in luminal contents may contribute to symptomatology in other ways in this clinical context. These include spillage of unabsorbed bile acids into the colon leading to cholereic diarrhea and qualitative and quantitative changes in the microbiome of the small intestine and colon such as are now being revealed by high-throughput sequencing and metabolomics studies. This chapter will review the current status of our understanding of these issues and will attempt to provide guidance for therapy.