How do patients with Crohn's disease fare on home parenteral nutrition?

The United Kingdom and Ireland Register of Home Parenteral Nutrition (HPN) contains details on 237 cases treated between 1977 and 1987. One hundred courses of HPN were given to 89 patients for complications of Crohn's disease. Six registering centers provided 87 percent of the courses of treatment. The short-bowel syndrome was a factor in 60 patients, fistulas in 29 patients, and exacerbation of the disease in 41 patients. Thirty patients had more than one complication. The age distribution of patients with Crohn's disease was the same as for all HPN patients. Nine patients have died and eight have ceased HPN because of complications from the treatment. Fifty two percent of the patients had no complications. Patients with Crohn's disease on HPN had a significantly better lifestyle than the group as a whole (P<.05) and had lower sepsis and complication rates (P<.01 and 0.001, respectively). The 60 Crohn's patients with short-bowel syndrome spent a significantly longer time on HPN than Crohn's patients overall (P<.05). Only 15 of these have been able to cease treatment and resume enteral feeding, compared with 23 of the other 40 patients who were able to resume enteral nutrition after a median of three months. Analysis of the authors' group of 35 patients included in the 100 showed that the only nutritional parameters of use in monitoring the patients' well-being were weight and serum albumin. Eighty percent of the patients with Crohn's disease who were treated by HPN have either successfully resumed enteral feeding or are successfully managing their own HPN. HPN is a safe and effective treatment for patients with acute or chronic intestinal failure from Crohn's disease. Authors writing on behalf of the HPN Register of the United Kingdom and Ireland.     

Role of perioperative parenteral nutrition in severely malnourished patients with Crohn＇s disease

AIM: To evaluate the effect of perioperative parenteral nutrition on serum immunoglobulin, weight change, and post-operative outcome in severely malnourished patients with Crohn's disease. METHODS: Thirty-two severely malnourished patients with Crohn's disease who had undergone surgery in our hospital were reviewed. Sixteen patients who received perioperative parenteral nutrition were enrolled in the study group, and the other 16 patients who did not receive parenteral nutrition were enrolled in the control group. Serum immunoglobulin, body mass index (BMI), liver function, weight change, and postoperative complications were evaluated. RESULTS: Serum IgM levels elevated 1 wk before surgery in both groups, and decreased to normal value (from 139±41 to 105±29 mg/dL, P= 0.04) 4 wk after operation in the study group, while no significant changes was noted in the control group (from 133±16 to 129±13 mg/dL, P=0.34). There were no significant changes in concentrations of IgG and IgA. The BMI of the study group increased from 13.9±0.6 to 15.3±0.7 kg/m~2 (P=0.02) with no significant change in the control group (14.1±0.7 and 14.5±0.5, respectively, P= 0.81). The percentage of resuming work was higher in the study group than in the control group. CONCLUSION: Perioperative parenteral nutrition possibly ameliorates the humoral immunity, reverses malnutrition, and facilitates rehabilitation.     

Exclusive enteral nutrition in children with crohn's disease

Exclusive enteral nutrition involves the use of a complete liquid diet, with the exclusion of normal dietary components for a defined period of time,as a therapeutic measure to induce remission in active Crohn's disease(CD). This very efficacious approach leads to high rates of remission, especially in children and adolescents newly diagnosed with CD. This intervention also results in mucosal healing,nutritional improvements and enhanced bone health.Whilst several recent studies have provided further elaboration of the roles of exclusive enteral nutrition in the management of CD, other reports have provided new understanding of the mechanisms by which this intervention acts.     

Total parenteral nutrition in Crohn's disease

The effect of total parenteral nutrition on 19 patients suffering from severe active Crohn's disease was studied. Total parenteral nutrition was effective as primary therapy in 56 per cent. In the remaining patients, it was highly effective as supportive therapy, enabling them to undergo uneventful major surgery.     

Oral nutritional supplementation is effective in the maintenance of remission in Crohn''s disease

Background. Enteral feeding with either elemental or polymeric diets is an established primary therapy for active Crohn's disease. However, the role of supplementing normal food with elemental diet in the long-term management of Crohn's disease has hitherto not been explored.

Patients and methods. A series of 39 consecutive patients with Crohn's disease in clinical remission were studied. Of these, 21 patients (Group 1) received oral nutritional supplementation, taken in addition to their normal diet. Their outcome (relapse rate, Crohn's disease activity index, inflammatory markers) was compared with that of 18 patients (Group 2), who were maintained on a normal unrestricted diet over an observation period of 12 months.

Results. A total of 17 patients (81%) tolerated the nutritional supplementation. On an intention-to-treat basis, 10 patients (48%) remained in remission for 12 months, compared to 4/18 (22%) patients in Group 2, p<0.0003. Their Crohn's disease activity index and CRP remained stable while their weight and body mass index improved during the period of nutrition therapy. Seven patients in Group 1 and 14 in Group 2 relapsed at a mean of 7.4±0.9 and 6.2±0.4 months, respectively. The response to nutrition supplement was independent of age, sex, disease duration or location. Four patients (1945) were intolerant to enteral feeding.

Conclusions. Nutritional supplementation is safe, well tolerated and effective in the long-term management of patients with quiescent Crohn's disease.     

Intense nutritional support in inflammatory bowel disease

The value of intense nutritional support in inflammatory bowel disease is still debated. Claims have been made that total enteral nutrition is as effective as total parenteral nutrition. In this review, the use of parenteral and enteral nutritional support as primary therapy in patients with inflammatory bowel disease has been critically evaluated. Most studies have been uncontrolled and nonrandomized with short-term follow-up. The literature does suggest, however, that intense nutritional support may have an adjunctive role to drug therapy in achieving remission in Crohn's disease, especially in corticosteroid-refractory patients. Nutritional support has a lesser role in chronic ulcertive colitis, except for assistance in pre- and postoperative management. The data do not support one variety of nutritional support over another, although enteral support should be used if possible, as it is less costly and potentially less complicated.     

The effect of minimum luminal nutrition on mucosal cellularity and immunity of the gut

Many catabolic patients can only consume small volumes of enteral nutrients. The aim of this study was to evaluate markers of cellularity and immunity in the small intestine of rats randomized to receive 6 days of parenteral nutrition, 25% enteral and 75% parenteral nutrition (i.e. minimum luminal nutrition) or enteral nutrition. The same glutamine-enriched solution was used for both parenteral and enteral nutrition. Enteral nutrition was associated with the least amount of jejunal atrophy ( P < 0.01), with the results from the minimum luminal nutrition group approximating those of the parenteral nutrition group. Parenteral nutrition was associated with the greatest number of CD2+ cells ( P < 0.05) and the lowest CD4/CD8 cell ratio ( P < 0.01) in the jejunal mucosa. In essence, we failed to demonstrate that there are any appreciable benefits associated with the enteral consumption of 25% of a nutrient load.     

Exclusive enteral feeding as primary therapy for Crohn's disease in Australian children and adolescents: a feasible and effective approach

BACKGROUND: Exclusive enteral feeding has been shown to be as efficacious as corticosteroids in inducing remission in children with Crohn's disease (CD), with additional nutritional benefits. The use of polymeric formulae provides superior palatability and acceptance over elemental feeds, but polymeric formulae have not been universally adopted. The present retrospective analysis of enteral feeding in children with Crohn's disease aims to demonstrate the short-term benefits of enteral feeding in children upon disease activity and nutrition parameters. METHODS: The case records of children with CD managed with exclusive enteral nutrition (EEN) by a multidisciplinary team over a 2-year period were reviewed. Data relating to therapy, background disease details, and outcome were collated. Primary outcome measures established were weight change and disease activity (Pediatric Crohn's Disease Activity Index: PCDAI). RESULTS: Twenty-seven children received EEN with polymeric formulae. Fifteen children had newly diagnosed CD and 12 had known long-standing CD. Twenty-four children completed the prescribed period of EEN. Twelve of 15 (80%) newly diagnosed CD and seven of 12 (58%) with long-standing disease entered remission. Children with newly diagnosed CD responding to EEN took all feeds orally and gained an average of 4.7+/-3.5 kg with mean PCDAI decreasing from 37.1+/-10.8 to 6.7+/-5.1 after 8 weeks. In addition, four children continued supplementary polymeric formula (without other medical therapies) and all have maintained remission during an average follow-up period of 15.2 months. CONCLUSION: Exclusive enteral feeds induced remission in 80% of children with newly diagnosed CD (on intention-to-treat basis) when used as sole initial therapy while also improving nutritional status. All newly diagnosed children treated with EEN, who were able to establish feeds, achieved remission. In addition, remission may be prolonged with oral supplementary formula as sole ongoing treatment. Further study of the role(s) of enteral feeds and of longer-term benefits of enteral feeding in children with CD is now required.     

Multiple vitamin status in Crohn's disease

We measured serum, blood, or red cell concentrations of various vitamins in 24 patients with Crohn's disease who had been free from any nutritional treatment, and compared them with those in 24 healthy controls. Twelve of the patients were affected in the small bowel only, two in the large bowel only, and the remaining 10 in both the small and large bowel. The fat-soluble vitamins A and E were significantly decreased in patients with Crohn's disease compared to controls. Among the water-soluble vitamins, vitamins B₁, B₂, and B₆, and folic acid were more depleted in patients with Crohn's disease than in the controls, whereas vitamins B₁₂ and C, nicotinic acid, and biotin were not different between the two groups, and pantothenic acid was increased in patients with Crohn's disease. In addition, vitamin B₂ and nicotinic acid showed a negative correlation with the Crohn's disease activity index. These findings suggest that there is a variety of vitamin deficiencies in Crohn's disease prior to treatment and also that concentrations of some vitamins, such as vitamin B₂ and nicotinic acid, may reflect the severity of the disease.     

Chronic liver disease in children on long-term parenteral nutrition

Use of long-term total parenteral nutrition (TPN) is often presumed to be associated with serious hepatic dysfunction. In this retrospective study, we reviewed the complete charts of patients who had received TPN for more than 2.5 years, starting in infancy or childhood, for evidence of liver dysfunction. There were 16 male and 10 female patients with a total of 254.5 patient years on TPN. Seventeen patients have been on TPN since birth or early infancy. Thirteen of 26 patients derive ≥90% of their calorie intake from TPN. Six patients had hepatomegaly; two of them also had splenomegaly. Twenty-one patients had normal transaminases, nine have had past episodes of raised enzymes ranging from 2.5 to 7.5 times normal. Seventeen patients always had normal bilirubin levels, five had past episodes of hyperbilirubinaemia, while four patients had persistently raised bilirubin levels (range 1.5–20.7 g/dL). Alkaline phosphatase was normal for age in all patients except two. Hepatic synthetic function, as measured by albumin, pre-albumin levels and prothrombin time, was within the normal range in all patients except one. Liver biopsies were performed in eight patients. Two biopsies showed cirrhosis, one showed chronic active hepatitis (CAH) with cholestasis, two patients had fibrosis, one showed cholestasis and two biopsies were normal. One patient with cirrhosis and one with CAH were positive for hepatitis C antibody. Another asymptomatic patient was positive for hepatitis B. Only the patient with CAH had hepatic decompensation. We conclude that clinical hepatic failure is uncommon in our group of patients on long-term TPN for 2.5 years or more. Cirrhosis and fibrosis, when found, could not be solely attributed to TPN.     

Anorectal Crohn's disease

A group of 86 patients with anorectal Crohn's disease were followed up from ten to 40 years to determine the course of the disease and the number of patients who later required proctectomy. The overall cumulative probability of avoiding proctectomy was 91.6 percent at ten years and 82.5 percent at 20 years. Resection of all proximal Crohn's disease did not ameliorate the anorectal disease, except in patients who had all proximal disease removed and had no recurrence. Read at the meeting of the American Society of Colon and Rectal Surgeons, San Diego, California, May 5 to 10, 1985.     

Nutritional therapy for active Crohn’s disease

Nutritional therapy for active Crohn’s disease （CD） is an underutilised form of treatment in adult patients, though its use is common in the paediatric population. There is evidence that nutritional therapy can effectively induce remission of CD in adult patients. Enteral nutrition therapy is safe and generally well tolerated. Meta-analysis data suggest that corticosteroids are superior to nutritional treatment for induction of remission in active CD. However, the potential side effects of such pharmacotherapy must be taken into consideration. This review examines the evidence for the efficacy of elemental and polymeric diets, and the use of total parenteral nutrition in active CD.     

Parenteral nutrition in adults during acute illness: a clinical perspective for clinicians

Parenteral nutrition (PN) is the administration of a nutritional formula by means other than the gastrointestinal (GI) tract. The formula may include carbohydrates, amino acids, lipids, electrolytes and/or micronutrients. The primary indications for PN are intestinal failure (IF) due to an underlying disease or treatment, or if the GI tract is not accessible. The goals of PN should be to ensure adequate nutrition provision to meet patient needs while minimising the risk of complications. PN should be commenced in <48 h in patients who are malnourished or otherwise within 7 days if oral or enteral nutrition is not possible or insufficient. There has been evolution in PN techniques and technology, and the risks associated with PN administration have been reduced. Monitoring clinical, laboratory and metabolic parameters in acute IF is essential to provision of safe nutritional support. When provided to appropriate patients with IF in a timely and considered manner, PN has been shown to be safe, improve nutritional parameters and reduce complications associated with malnutrition. This review aims to provide clinicians a practical guide for the management of PN in adult patients within the acute setting.     

Preoperative total parenteral nutrition for bowel resection in Crohn's disease

To examine the effect of preoperative total parenteral nutrition (TPN) on patients with Crohn's disease undergoing bowel resection, an historical cohort was assembled of 103 patients resected between 1982 and 1984 by a single surgical team. Preoperative, perioperative, and postoperative variables were compared between patients receiving TPN and patients not receiving TPN. Analysis was stratified for three surgical procedures: segmental small bowel resection, ileocecectomy, and segmental or total colectomy. The effect of TPN was most pronounced in patients having small bowel surgery. For segmental small bowel resection, 12 of 17 patients had TPN, and these patients had 20.4 ±14.3 cm less bowel resected than did those in the non-TPN group, an effect not dependent on duration of TPN. For ileocectomy patients, 31 of 62 patients received TPN, and these patients had 11.2±4.2 cm less small bowel resected than the non-TPN group, an effect not dependent on the duration of TPN. For large bowel resection patients, 6 of 24 patients had TPN, and there was no difference in length of bowel resection, preoperative and perioperative variables, or recurrence. The total hospital stay was 13.5±2.6 days longer for those having TPN;3.5±1.9 days of the longer stay was postoperative. In conclusion, TPN was associated with reduced length of small bowel resection at the expense of longer hospital stay.This research supported in part by the Gastrointestinal Research Foundation Junior Board.