Integrative clinical judgement: A patient with short bowel (50% small intestine removed) presents months later with steatorrhea and anemia. Which combination of pathophysiologic explanations best evaluates the primary causes of these findings?

• A. Removal of half the small intestine increases bile production which directly destroys enterocytes causing anemia, while fat absorption increases and steatorrhea is unlikely; therefore blood transfusion is the only treatment
• B. The colon takes over all small intestinal functions immediately so steatorrhea and anemia indicate a primary hepatic failure unrelated to bowel resection
• C. Short bowel leads to decreased gastric acid secretion which prevents pepsin activation in the colon causing protein maldigestion only, leading to isolated hypoalbuminemia without steatorrhea
• D. Reduced absorptive surface area results in decreased uptake of fat and fat-soluble vitamins causing steatorrhea and vitamin deficiencies; decreased iron and B12 absorption sites and faster or disrupted transit can also cause anemia—replacement of nutrients and promoting intestinal adaptation are needed

Answer: (D)