Recomendaciones del Grupo Español de Trabajo en Enfermedad de Crohn y Colitis Ulcerosa (GETECCU) sobre el cribado y tratamiento de la infección tuberculosa en pacientes con enfermedad inflamatoria intestinal

There is evidence that following the recommendations on screening and treatment of tuberculosis infection does not completely prevent the onset of tuberculosis in patients with inflammatory bowel disease. This fact, and the increasing use of new biologics and immunomodulators, has led the Spanish Group Working on Crohn's Disease and Ulcerative Colitis to update their recommendations for the prevention of tuberculosis in patients with inflammatory bowel disease. Diagnostic methods for latent tuberculosis infection, different scenarios in which screening is to be performed, strategies to reduce the risk of tuberculosis once biological treatment is initiated and chemoprophylaxis guidelines for latent tuberculosis infection are reviewed, as well as the management of active tuberculosis during biological treatment. Finally, there is a summary of the current recommendations within the paper and in an algorithm.     

Diet in irritable bowel syndrome: What to recommend,not what to forbid to patients!

A substantial proportion of patients with irritable bowel syndrome(IBS) associate their symptoms with the ingestion of specific foods. Therefore, in recent years, scientific research has increasingly focused on the role of diet in IBS and dietary management is now considered an important tool in IBS treatment. This article reviews the main dietary approaches in IBS emphasizing evidence from experimental and observational studies and summarizing the main diet and lifestyle recommendations provided by dietary guidelines and scientific literature. Despite the limited evidence for a beneficial role, general advice on healthy eating and lifestyle is recommended as the first-line approach in the dietary management of IBS. Standard recommendations include adhering to a regular meal pattern, reducing intake of insoluble fibers, alcohol, caffeine, spicy foods, and fat, as well as performing regular physical activity and ensuring a good hydration. Second-line dietary approach should be considered where IBS symptoms persist and recommendations include following a low FODMAP diet, to be delivered only by a healthcare professional with expertise in dietary management. The efficacy of this diet is supported by a growing body of evidence. In contrast, the role of lactose or gluten dietary restriction in the treatment of IBS remains subject to ongoing research with a lack of high-quality evidence. Likewise, further clinical trials are needed to conclude the efficacy of probiotics on IBS symptoms.     

Nutrition in inflammatory bowel disease

Nutrition has an important role in the management of inflammatory bowel disease. This role includes the prevention and correction of malnutrition, the prevention of osteoporosis and in children the promotion of optimal growth and development. In active Crohn's disease nutritional therapy (in the form of enteral feeding) is an effective primary therapy for many patients. Corticosteroids, however, are more effective than enteral diet therapy in adults. Enteral diets should be considered as primary therapy in pediatric Crohn's disease, especially in children with poor nutritional status or growth impairment. Enteral nutrition does not have a proven primary therapeutic role in ulcerative colitis. There are many theories that suggest that diet may be implicated in the aetiology of inflammatory bowel disease, however, there are, as yet, no dietary approaches proven to reduce the risk of developing IBD.     

Guidelines for the management of ulcerative colitis

Ulcerative colitis (UC) is a chronic inflammatory bowel disorder characterized by a relapsing and remitting course. The quality of life can decreases significantly during exacerbations of the disease. The incidence and prevalence of UC in Korea are still lower than those of Western countries, but have been rapidly increasing during the past decades. Various medical and surgical therapies are currently used for the management of UC. However, many challenging issues exist and sometimes these lead to differences in practice between clinicians. Therefore, Inflammatory Bowel Diseases (IBD) Study Group of Korean Association for the Study of Intestinal Diseases (KASID) set out the Korean guidelines for the management of UC. These guidelines are made by the adaptation using several foreign guidelines and encompass treatment of active colitis, maintenance of remission and indication for surgery in UC. The specific recommendations are presented with the quality of evidence. These are the first Korean treatment guidelines for UC and will be revised with new evidences on treatment of UC.     

Impact of environmental and dietary factors on the course of inflammatory bowel disease

Besides their possible effects on the development of inflammatory bowel disease (IBD), some environmental factors can modulate the clinical course of both ulcerative colitis (UC) and Crohn's disease (CD). This review is mainly devoted to describing the current knowledge of the impact of some of these factors on the outcome of IBD, with special emphasis on smoking and diet. Although the impact of smoking on the susceptibility to develop CD and UC is firmly established, its influence on the clinical course of both diseases is still debatable. In CD, active smoking is a risk factor for postoperative recurrence. Beyond this clinical setting, smoking cessation seems to be advantageous in those CD patients who were smokers at disease diagnosis, while smoking resumption may be of benefit in ex-smokers with resistant UC. The role of dietary habits on the development of IBD is far from being well established. Also, food intolerances are very frequent, but usually inconsistent among IBD patients, and therefore no general dietary recommendations can be made in these patients. In general, IBD patients should eat a diet as varied as possible. Regarding the possible therapeutic role of some dietary components in IBD, lessons should be drawn from the investigation of the primary therapeutic effect of enteral nutrition in CD. Low-fat diets seem to be particularly useful. Also, some lipid sources, such as olive oil, medium-chain triglycerides, and perhaps omega-3 fatty acids, might have a therapeutic effect. Fermentable fiber may have a role in preventing relapses in inactive UC.     

Diet therapy for inflammatory bowel diseases: The established and the new

Although patients with inflammatory bowel diseases(IBD) have a strong interest in dietary modifications as part of their therapeutic management, dietary advice plays only a minor part in published guidelines. The scientific literature shows that dietary factors might influence the risk of developing IBD, that dysbiosis induced by nutrition contributes to the pathogenesis of IBD, and that diet may serve as a symptomatic treatment for irritable bowel syndrome-like symptoms in IBD. The role of nutrition in IBD is underscored by the effect of various dietary therapies. In paediatric patients with Crohn’s disease(CD) enteral nutrition(EN) reaches remission rates similar to steroids. In adult patients, however, EN is inferior to corticosteroids. EN is not effective in ulcerative colitis(UC). Total parenteral nutrition in IBD is not superior to steroids or EN. The use of specific probiotics in patients with IBD can be recommended only in special clinical situations. There is no evidence for efficacy of probiotics in CD. By contrast, studies in UC have shown a beneficial effect in selected patients. For patients with pouchitis, antibiotic treatment followed by probiotics, like VSL#3 or Lactobacillus GG, is effective. When probiotics are used, the risk of bacterial translocation and subsequent bacteremia has to be considered. More understanding of the normal intestinal microflora, and better characterization of probiotic strains at the phenotypic and genomic levels is needed as well as clarification of the mechanisms of action in different clinical settings. A FODMAP reduced diet may improve symptoms in IBD.     

The role of dietary factors in inflammatory bowel diseases: New perspectives

The current review aimed to elucidate the role of diet in every stage of inflammatory bowel diseases, from aspects of prevention, treatment and rehabilitation. Western diet, characterized by overconsumption of refined sugar and saturated fat and low consumption of dietary fiber, may partly be blamed for its pathogenesis. Some immune‐modulated nutrients (fibers, monounsaturated fatty acids, n‐3 polyunsaturated fatty acids and vitamin D) exert their potential beneficial effects on gut microbiota and immune function, resulting in clinical remission and/or preventing relapse. However, data is limited to conclude optimal micronutrient levels and therapeutic implications. Further, diet itself is complex; therefore, it is reasonable to evaluate diet as a whole rather than a single type of food. Some specific dietary patterns are generated for the management of inflammatory bowel diseases with controversial results. Only exclusive enteral nutrition has been widely recommended for pediatric patients with non‐stricturing active Crohn's disease. Self‐monitoring, avoidance of certain types of foods, limited intake of alcohol and smoking, supplementation of minerals and vitamins if deficiency is confirmed, and adherence to the diet enriched in vegetables and fruits and low in animal food and un‐digested fiber during flares are the most common dietary recommendation. Further clinical trials with a high evidence rank are warranted.     

Use of thiopurines in inflammatory bowel disease

The use of thiopurines as immunosuppression for the treatment of refractory or chronic active inflammatory bowel disease is established for both Crohn’s disease and ulcerative colitis.Nevertheless,many questions remain concerning the optimal treatment regimens of azathioprine,6-mercaptopurine and thioguanine.We will briefly summarize dose recommendations,indications for thiopurine therapy and side effects which are relevant in clinical practice.We discuss some currently debated topics,including the combination of azathioprine and allopurinol,switching of thiopurine therapy in case of side effects,the use of azathioprine in pregnancy,the infection risk using thiopurines and the evidence when to stop thiopurines.Excellent reviews have been published on the thiopurine metabolic pathway which will not be discussed here in detail.     

Mediterranean diet and non-alcoholic fatty liver disease: New therapeutic option around the corner?

Non-alcoholic fatty liver disease (NAFLD) represents the most common chronic liver disease in Western countries, being considered as the hepatic manifestation of metabolic syndrome. NAFLD has a common pathogenic background to that of metabolic syndrome, and shares many risk factors such as obesity, hypertension, insulin resistance and dyslipidemia. Although there is no currently available evidence-based established treatment for NAFLD, all the recommendations from the medical associations indicate that the most effective treatment is to reduce weight through lifestyle modifications. Diet, indeed, plays a key role in the management of NAFLD patients, as both the quantity and quality of the diet have been reported to have a beneficial role in the onset and severity of the liver disease. Among all the diets that have been proposed, a Mediterranean diet was the most effective dietary option for inducing weight loss together with beneficial effects on all the risk factors associated with metabolic syndrome and NAFLD. Over the last few years, research has demonstrated a beneficial effect of a Mediterranean diet in NAFLD. In this review, we will examine all the available data on the association between diet, nutrients and the Mediterranean diet in association with onset and severity of NAFLD.     

AINE,toxicidad gastrointestinal y enfermedad inflamatoria intestinal

Non-steroidal antiinflammatory drugs (NSAIDs) are currently one of the most widely used drugs. The use of NSAIDs is associated with gastrointestinal toxicity, affecting both upper gastrointestinal tract (peptic ulcer disease) and lower gastrointestinal tract (NSAID-induced enteropathy).NSAIDs use has been associated with an increased risk of clinical relapse in inflammatory bowel disease patients. In this article, we review the upper and lower gastrointestinal toxicity of NSAIDs, with a focus on the risks and specific data of these drugs in inflammatory bowel disease patients, giving recommendations for its appropriate use in the clinical practice. Although evidence is scarce, short-term use of NSAIDs appears to be safe, and the data available suggest that selective COX-2 inhibitors are the safer option. NSAIDs should be avoided as long-term treatment or with high doses, especially in patients with active inflammation.     

Respiratory symptoms in patients with inflammatory bowel disease and the impact of dietary salicylates

BACKGROUND: Respiratory symptoms are over-represented in inflammatory bowel disease. There are similarities between the epidemiology of inflammatory bowel disease and that of respiratory conditions for which an adverse influence of salicylate has been identified. Natural salicylates exist within our diet. AIMS: To determine whether a lower intake of dietary salicylates is associated with less active inflammatory bowel disease and fewer concurrent respiratory symptoms. PATIENTS AND METHODS: Respiratory status, inflammatory bowel disease activity, quality of life, and dietary habits were established in 73 patients with Crohn's disease and 69 with ulcerative colitis, using a self-administered questionnaire and peak expiratory flow rate readings. Harvey-Bradshaw and Simple Birmingham/Royal Free Colitis indices, an internally validated respiratory score, and estimated weekly dietary salicylate intake, were calculated for each patient. RESULTS: There was at least one respiratory symptom in 63.4% of patients. The commonest underlying respiratory diagnosis was asthma. Respiratory impairment was similar in ulcerative colitis and Crohn's disease; 56.3% of Crohn's disease patients with an active respiratory diagnosis had other extra-intestinal manifestations. The dietary salicylate intake was independent of respiratory status, but inversely correlated with ulcerative colitis activity (dietary salicylate intake 37.0mg versus 21.4mg for low and higher Simple Birmingham/Royal Free Colitis index, respectively; p<0.02). A similar association was not seen in Crohn's disease. CONCLUSIONS: Respiratory impairment is common in inflammatory bowel disease. Higher intake of dietary salicylates is associated with less active colitis and possibly causally so.     

Prevention of colorectal cancer

Colorectal cancer (CRC) is the second leading cause of cancer death in Argentina. The cumulative lifetime risk of developing CRC for both men and women is 4-6%. Despite advances in the management of this disease, the 5-year survival rate is about 60% because only 35% of patients are diagnosed when the disease is localized. Risk factors for CRC include age, diet and life style factors, personal or family history of adenomas or CRC and personal history of inflammatory bowel disease. Scientific evidence shows that primary and secondary prevention, through screening programs, permit to reduce incidence and mortality significantly. Chemopreventive agents, including nonsteroidal antiinflammatory drugs, folate, and calcium, have been shown to have some preventive effect. Physical inactivity and excess body weight are consistent risk factors for CRC. Tobacco exposure, diet high in red meat and low in vegetables and alcohol consumption, probably in combination with a diet low in folate, appear to increase risk. The dietary fiber and risk of CRC has been studied but the results are still inconclusive. Screening for CRC is cost-effective compared with no screening, but a single optimal strategy cannot be determined from the currently available data. The advantages and disadvantages or limitations of screening modalities for CRC are analyzed. The literature and clinical practice guidelines are reviewed, with an emphasis on advances and evolving screening methods and recommendations for patients with average, moderate and high-risk CRC.     

Original research: Dietary beliefs and recommendations in inflammatory bowel disease: a national survey of healthcare professionals in the UK

BackgroundThe role of diet in inflammatory bowel disease (IBD) remains incompletely understood. Knowledge around the actual dietary advice healthcare professionals provide to individuals with IBD is scarce. Our objective was to describe the dietary beliefs of healthcare professionals and dietary recommendations made to people with IBD.MethodologyAn online survey regarding IBD-related dietary beliefs and advice provided to patients was distributed to gastroenterologists, dietitians and IBD nurses in the UK.ResultsTwo-hundred and twenty-three eligible healthcare professionals participated: 107 (48%) believed that diet was involved in IBD development. The most frequently implicated dietary components were processed foods (78%), additives/preservatives (71%), sweet/sugary foods (36%), red meat (36%) and fatty foods (31%). Views were broadly consistent across professions, however, gastroenterologists were significantly more likely to believe red meat and additives/preservatives initiated IBD. One hundred and thirteen participants (53%) believed that diet could trigger disease relapse and 128 (61%) recommended limiting specific foodstuffs to reduce this risk, most commonly high fibre foods. Forty-six (23%) considered recommending a low Fermentable Oligo-, Di- and Monosaccharides and Polyols diet to reduce relapse risk. IBD nurses and healthcare professionals with <5 years experience were most likely to recommend this. Dietitians felt most comfortable providing dietary advice for functional gastrointestinal symptoms in quiescent IBD.ConclusionDietary advice in IBD is inconsistent reflecting uncertainty among healthcare professionals. While some consensus exists regarding dietary components implicated in IBD development and relapse, dietary recommendations varied. Future research is required to disentangle these complex relationships, alongside better training and education.     

Guidelines for the management of inflammatory bowel disease in adults

The management of inflammatory bowel disease represents a key component of clinical practice for members of the British Society of Gastroenterology (BSG). There has been considerable progress in management strategies affecting all aspects of clinical care since the publication of previous BSG guidelines in 2004, necessitating the present revision. Key components of the present document worthy of attention as having been subject to re-assessment, and revision, and having direct impact on practice include: The data generated by the nationwide audits of inflammatory bowel disease (IBD) management in the UK in 2006, and 2008. The publication of 'Quality Care: service standards for the healthcare of people with IBD' in 2009. The introduction of the Montreal classification for Crohn's disease and ulcerative colitis. The revision of recommendations for the use of immunosuppressive therapy. The detailed analysis, guidelines and recommendations for the safe and appropriate use of biological therapies in Crohn's disease and ulcerative colitis. The reassessment of the role of surgery in disease management, with emphasis on the importance of multi-disciplinary decision-making in complex cases. The availablity of new data on the role of reconstructive surgery in ulcerative colitis. The cross-referencing to revised guidelines for colonoscopic surveillance, for the management of metabolic bone disease, and for the care of children with inflammatory bowel disease. Use of the BSG discussion forum available on the BSG website to enable ongoing feedback on the published document http://www.bsg.org.uk/forum (accessed Oct 2010). The present document is intended primarily for the use of clinicians in the United Kingdom, and serves to replace the previous BSG guidelines in IBD, while complementing recent consensus statements published by the European Crohn's and Colitis Organisation (ECCO) https://www.ecco-ibd.eu/index.php (accessed Oct 2010).     

Prevention and treatment of osteoporosis in patients with inflammatory bowel disease

Osteopenia or osteoporosis is common in patients with inflammatory bowel disease. The use of corticosteroids contributes to the decline in bone loss; however, osteoporosis may develop in patients with inflammatory bowel disease independent of corticosteroid use. Risk factors for the development of low bone mass in patients with inflammatory bowel disease include the general risk factors for osteoporosis as well as additional factors such as the presence of chronic inflammation, use of corticosteroids and other pharmaceuticals, and nutritional deficiencies as the result of small bowel disease or small bowel resections. Despite the high prevalence, few patients are entered into prophylactic regimens to prevent corticosteroid-induced bone loss. The American College of Rheumatology has recently published recommendations for the prevention and treatment of corticosteroid-induced osteoporosis. In this article, we highlight the special risks for osteoporosis in patients with IBD and adapt the recommendations for prevention and treatment of osteoporosis to this clinical setting.     

Diet in neurogenic bowel management: A viewpoint on spinal cord injury

The aim of this review is to offer dietary advice for individuals with spinal cord injury(SCI) and neurogenic bowel dysfunction. With this in mind, we consider health conditions that are dependent on the level of lesion including skeletal muscle atrophy, autonomic dysreflexia and neurogenic bladder. In addition, SCI is often associated with a sedentary lifestyle, which increases risk for osteoporosis and diseases associated with chronic low-grade inflammation, including cardiovascular and chronic kidney diseases. The Mediterranean diet, along with exercise and dietary supplements, has been suggested as an anti-inflammatory intervention in individuals with SCI. However, individuals with chronic SCI have a daily intake of whole fruit, vegetables and whole grains lower than the recommended dietary allowance for the general population. Some studies have reported an increase in neurogenic bowel dysfunction symptoms after high fiber intake; therefore, this finding could explain the low consumption of plant foods.Low consumption of fibre induces dysbiosis, which is associated with bothendotoxemia and inflammation. Dysbiosis can be reduced by exercise and diet in individuals with SCI. Therefore, to summarize our viewpoint, we developed a Mediterranean diet-based diet and exercise pyramid to integrate nutritional recommendations and exercise guidelines. Nutritional guidelines come from previously suggested recommendations for military veterans with disabilities and individuals with SCI, chronic kidney diseases, chronic pain and irritable bowel syndrome. We also considered the recent exercise guidelines and position stands for adults with SCI to improve muscle strength, flexibility and cardiorespiratory fitness and to obtain cardiometabolic benefits. Finally, dietary advice for Paralympic athletes is suggested.     

Diet and risk of inflammatory bowel disease

BackgroundA better understanding of the environmental factors leading to inflammatory bowel disease should help to prevent occurrence of the disease and its relapses.AimTo review current knowledge on dietary risk factors for inflammatory bowel disease.MethodsThe PubMed, Medline and Cochrane Library were searched for studies on diet and risk of inflammatory bowel disease.ResultsEstablished non-diet risk factors include family predisposition, smoking, appendectomy, and antibiotics. Retrospective case–control studies are encumbered with methodological problems. Prospective studies on European cohorts, mainly including middle-aged adults, suggest that a diet high in protein from meat and fish is associated with a higher risk of inflammatory bowel disease. Intake of the n-6 polyunsaturated fatty acid linoleic acid may confer risk of ulcerative colitis, whereas n-3 polyunsaturated fatty acids may be protective. No effect was found of intake of dietary fibres, sugar, macronutrients, total energy, vitamin C, D, E, Carotene, or Retinol (vitamin A) on risk of ulcerative colitis. No prospective data was found on risk related to intake of fruits, vegetables or food microparticles (titanium dioxide and aluminium silicate).ConclusionsA diet high in protein, particular animal protein, may be associated with increased risk of inflammatory bowel disease and relapses. N-6 polyunsaturated fatty acids may predispose to ulcerative colitis whilst n-3 polyunsaturated fatty acid may protect. These results should be confirmed in other countries and in younger subjects before dietary counselling is recommended in high risk subjects.     

Probiotics in dietary guidelines and clinical recommendations outside the European Union

Fermented foods have been consumed for centuries across many geographical locales and have traditionally been considered healthy foods,partly because of the live microbes contained in them.The concept of“probiotics”further requires that the microbes be defined and their health effects be demonstrated through human intervention studies or other suitable investigations before marketing with corresponding health messages.Here,we review recommendations for fermented foods and probiotics in several countries outside the EU,focusing on food-based dietary guidelines.We emphasize recommendations on yoghurt and probiotics made by expert bodies.We found that dietary guidelines commonly advocate the consumption of yoghurt or similar products,but specific comments on probiotics are rare.Further,we reviewed guidelines from clinical associations.In general,they acknowledge the beneficial effects of probiotics,but often suggest the need for further research.This is true despite good quality evidence supporting the role of probiotics for certain health effects,such as prevention of eczema in infants,management of side effects from antibiotics and alleviation of functional bowel symptoms.Additional research to support future dietary recommendations should focus on determining effect size,identifying responders and non-responders,clarifying strain-specificity of effects and confirming mechanisms.     

Endoscopy in inflammatory bowel diseases

A correct diagnosis, adequate assessment of disease activity, avoidance of surgery by endoscopic interventions, and effective cancer surveillance make endoscopy crucial in the management of inflammatory bowel diseases (IBDs). Impressive technical developments of several endoscopic techniques over the past few decades have allowed a detailed visual impression of the affected gut and enable tissue sampling and various therapeutic interventions. Here we propose guidelines for endoscopy in inflammatory bowel disease, and review all currently available endoscopic techniques relevant to the proper treatment of IBD patients.     

Diet counselling improves the clinical course of patients with Crohn's disease

A prospective study was undertaken to establish the role of individualized diet counselling in the management of 137 outpatients with Crohn's disease. Individualized dietary counselling for 6 months was associated with a significant decrease in the Crohn's disease activity index, an increased incidence of disease remission, a decreased need for prednisone and Salazopyrin therapy, a reduction in the number of days spent in hospital, and a reduction in the amount of time lost from work due to Crohn's disease, when compared with control patients who did not receive dietary counselling but who were seen regularly in follow-up under similar circumstances. Improvement with diet counselling was more likely to occur in patients who had not previously been subjected to small bowel resection, and occurred in patients with active or inactive disease. The effect of counselling 58 patients was assessed over a further 6 months (for a total 12-month period); there was a persistently reduced Crohn's disease activity index and a continued decreased number of lost days of work. The mechanism for these beneficial effects of diet counselling was not established. It is suggested that individualized diet counselling, aimed at optimizing the patient's nutritional status, may play a role in the management of patients with Crohn's disease.