Total parenteral nutrition in Crohn's disease

A personal experience involving use of total parenteral nutrition in 115 patients with Crohn's disease is reported from a medical unit. Remission occurred without surgery in 24 patients. The regimen was considered to have failed in its objectives in 50 patients, and complications were recorded in 57.

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Résumé Dans une unité médico-chirurgicale, la nutrition parentérale totale a été appliquée à 115 cas de maladie de Crohn. Chez 24 patients, une rémission a été obtenue, sans opération. Le traitement a été considéré comme un échec dans 50 cas. Il y a eu 97 complications.

     

Total parenteral nutrition in the management of Crohn's disease

A review of the recent literature is cited in support of the use of total parenteral nutrition (TPN) in Crohn's disease. The principal indications for this use are described and some of the disadvantages are discussed.

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Résumé Revue de la littérature en faveur de la nutrition parentérale totale dans la maladie de Crohn. Les indications principales et certains inconvénients sont discutés.

     

Preoperative home elemental enteral nutrition in complicated Crohn's disease

Home elemental nutrition (HEN) was used in 11 children and adolescents with complicated Crohn's disease to relieve their immediate symptoms and make them more fit for definitive surgery. HEN resulted in symptomatic relief, weight gain from a mean of 47 to 53 kg (P less than .001) and reduction in prednisone requirements from a mean daily dose of 30 to 6 mg (P less than .001). The seven patients who subsequently underwent definitive bowel resection suffered no surgical complications. HEN was well tolerated by all patients. HEN offers a simple, safe, and cost effective means of preparing patients with complicated Crohn's disease for operation.     

Role of total parenteral nutrition in the treatment of Crohn's disease

We studied 49 patients with severe nonresponsive Crohn's disease receiving 73 courses of total parenteral nutrition (TPN) for a total of 2,153 days (30 +/- 18 days/admission). Forty-five percent of all courses of TPN resulted in patients not being operated on, whereas 55 percent resulted in surgical intervention. Fifty percent of patients who did not undergo operation initially as a result of a successful course of bowel rest and TPN had surgery within 15.4 +/- 13.9 months, whereas 75 percent of patients operated on immediately after a course of TPN did not need additional surgery during a follow-up of 36.1 +/- 31.2 months. Thus, a total of 80 percent of patients underwent gastrointestinal surgery sometime during the study and follow-up periods. TPN has an important role in replenishment of nutritional deficits and perioperative nutritional support; however, from the results of the present study, it is difficult to advocate it as the sole primary therapy for Crohn's disease.     

Experience with home parenteral nutrition

Twenty-nine patients underwent courses of home parenteral nutrition therapy ranging from 1.5 to 52 months (mean 14.5 months). The primary diagnoses responsible for the requirement of home parenteral nutrition were radiation enteritis in seven patients, short bowel syndrome secondary to resection in seven, Crohn's disease in two, malabsorption states in six, and other reasons in seven. Seventeen patients (57 percent) had at least one complication. Nine patients had intravenous catheter complications and nine had metabolic complications. Nine patients have died, 11 have been successfully weaned from home parenteral nutrition, and 9 continue to receive home parenteral nutrition. Home parenteral nutrition is useful in a variety of catastrophic clinical situations, including preparation for subsequent operative therapy, temporary malabsorption, and permanent disability of the gastrointestinal tract. Complications are frequent and may be life-threatening.     

Is preoperative parenteral nutrition necessary for patients with predominantly ileal Crohn's disease?

We reviewed 46 consecutive patients with Crohn's disease predominantly affecting the ileum who specifically underwent right-sided ileocolectomy with primary anastomosis. All had a primary ileocolic anastomosis done by suture in a single-layer closed fashion. Of these 46 patients, 19.6% had overt intra-abdominal sepsis, 30.4% had prior surgery, and 95.7% were taking corticosteroid drugs just before their operation. The mean (+/- SE) age was 31.5 +/- 2.0 years. The serum albumin level was less than 35 g/L in 93.5% of patients; all had a hematocrit value less than 0.36, and 80.4% lost more than 15% of their normal body weight. No patient received parenteral nutrition either preoperatively or postoperatively. No change in the preoperative, intraoperative, or postoperative approach to treating patients with predominantly ileal Crohn's disease occurred during the 10-year period of review. There was a 2.2% incidence of perioperative complications (one superficial wound infection) and a 6.5% incidence of late (>1.49 months) complications (two suture sinuses and one wound abscess unassociated with a fistula). Our findings suggest that preoperative parenteral nutrition is unnecessary in the majority of patients with predominantly ileal Crohn's disease specifically undergoing right-sided ileocolectomy and primary ileocolic anastomosis.     

Preoperative total parenteral nutrition (TPN) in severe Crohn's disease

This study was performed to evaluate the effect of preoperative total parenteral nutrition (TPN) on the results after surgical treatment of patients with severe Crohn's disease. Of 67 patients admitted with complications of Crohn's disease, 51 had severe active disease and abdominal masses, fistulas and/or obstruction (mean Crohn's disease activity index score, 301). Forty-four patients received preoperative TPN for a mean period of 33 days. Complications of TPN were limited. Spontaneous closure of fistulas was achieved in 75% of the cases. Serum albumin levels improved significantly, from 29.1 +/- 1.1 gm/L to 35.4 +/- 0.7 gm/L (p less than 0.001). Mean body weights improved from 81% to 89% ideal body weights or 52.6 kg to 57.2 kg, respectively (p less than 0.05). Surgical procedures were facilitated by remission of the active inflammatory process and associated with a major complications rate of only 6%. No deaths occurred. the mean hospital stay for the TPN-treated group of patients was 63 days. TPN is an effective preoperative treatment for patients with severe complicated Crohn's disease. The prolonged hospital stay and high costs, however, are disadvantages of this approach. Preoperative TPN treatment should therefore be limited to patients with severe active disease.     

100 patient-years of ambulatory home total parenteral nutrition

More than 100 patient-years' experience has been acquired in the treatment of 133 patients with ambulatory home total parenteral nutrition (TPN) between May 1974 and December 1983. Indications for chronic or permanent home TPN include short bowel syndrome, malabsorption, scleroderma, and vasoactive intestinal polypeptide syndrome. Indications for acute or temporary home TPN include Crohn's disease, malignancies, gastrointestinal fistulas, ulcerative colitis, anorexia nervosa, and numerous other disorders. Eighty-two patients in the acute group were treated primarily with percutaneously placed standard subclavian catheters and 51 patients in the chronic group have been treated thus far with implanted silicone rubber, Dacron-cuffed catheters for a cumulative total of 38,939 patient days. Of the 125 implanted catheters, 115 were placed in the superior vena cava and ten in the inferior vena cava for an average duration of 250 catheter-days, the longest single catheter remaining in situ for more than 8 1/2 years. Catheter-related sepsis occurred 33 times with the implanted catheters, or once every 2.6 catheter-years. One hundred and fourteen temporary catheters were placed percutaneously in the superior vena cava via a subclavian vein for an average duration of 68 days, the longest single catheter remaining in situ for 213 days. Catheter-related sepsis occurred seven times, equivalent to one episode per 3 catheter-years. Total catheter-related complications were quite infrequent and were directly related to duration of catheterization. They included venous thrombosis (12), clotted catheter (11), catheter failure or rupture (8), catheter compression (5) and inadvertent catheter removal (4). Twenty-six catheters were repaired or spliced in situ when the external segment was accidentally damaged or deteriorated secondary to long-term material fatigue. One remarkable patient has been maintained exclusively by TPN originally as an inpatient and subsequently as an outpatient for the entire 13 years of his life.     

Catheter-related complications in patients receiving home parenteral nutrition

Twenty-seven patients (22 adults, five adolescents, and one child) were treated with home parenteral nutrition (HPN) for 662 patient-months. A Broviac Silastic right atrial catheter which is tunnelled subcutaneously down the anterior chest wall served as a venous access. Thirty-four catheters were used in 27 patients, and the mean catheter life spans to date for adults and adolescents have been 21 and 14 months, respectively. There were no deaths attributable to the catheters. Infections and damaged external catheter segments were clustered in adult patients, whereas serious mechanical problems occurred in adolescents. Five of 27 patients (19%) experienced septicemia and one patient had two episodes. These six episodes (five of Staphylococcus aureus, one of Candida parapsilosis) in 662 patient-months represented only one case of sepsis every 9.1 patient-years on HPN. The external segments of 12 catheters were damaged and all were repaired in the outpatient setting. Eight of nine major mechanical problems occurred in five adolescents and one child; the most serious being four intravascular displacements, one extravascular displacement with mediastinitis, and a fractured catheter with a retained intravascular catheter segment. Although the HPN catheter is associated with definite risks, there has been a very acceptable incidence of complications resulting in a high benefit-to-risk ratio for HPN.     

Crohn's disease and nutrition.

Malnutrition was included by Crohn as one of the features of the new disease he described. Most patients with Crohn's disease are malnourished even if their disease is not active. Nutritional factors may be implicated in the aetiology of the disease, but this remains unproven. The role of nutritional support and therapy is discussed and it is suggested that improving the patient's nutritional status may have a primary therapeutic as well as a supportive role in the treatment of the disease.     

Combined oral and home parenteral nutrition for the short bowel syndrome

Combined parenteral and peroral nutrition is necessary when a large small bowel resection leads to inadequate intestinal absorption and starvation. We report the case of a 17-year old schoolgirl in whom, following a rupture of the spleen and splenectomy, extensive small bowel necrosis necessitated small bowel resection from the lig. Treitz to the terminal ileum saving the last ten centimeters of the ileum. The serious starvation which developed after the operation was first treated with a one-month course of parenteral nutrition in hospital. Thereafter the patient took care of the infusions herself. Home parenteral nutrition took place during a 10-12 h overnight period 5 times a week. The proportion of peroral dietary intake was increased gradually during the first year, after which a 1 to 1 ratio between peroral and parenteral intake of energy and protein was maintained. The patient's subjective and objective well-being after two-years' of follow-up is good. Regular examinations at 3-6 month intervals are needed for the maintenance of adequate nutritional replacement.     

Complications of home parenteral nutrition in a large pediatric series

When adequate nutrition cannot be provided by enteral route as a consequence of failure of intestinal functions, parenteral nutrition (PN) become the only way to maintain adequate nutrition; however, prolonged periods of PN can lead to severe complications. Furthermore, long hospital admissions for this form of nutrition can be detrimental for the child and the family. In the past 20 years, home parenteral nutrition (HPN) programs have been developed. The aim of our study was to retrospectively evaluate the kind and the frequency of complications in a HPN pediatric case series. We had 61 patients on HPN. Total duration of the program was 27,740 days (76 total years, mean 1.2 years per patient). We observed a total of 58 complications; mean 0.79 per patient per year with a prevalence of central venous catheter-related complications (mechanical, 52%; infective, 26%). We had a very low incidence of metabolic complications (3%) and a low incidence of PN-related hepatic complications (19%). None of the complications described was the cause of death. Half of our patients have been able to stop the program. We had a low incidence (0.20 per patient per year) of septic episodes, lower than we had in patients on hospital PN in the same period (0.38 per patient per year). We had to replace 20 catheters, 18 of them for mechanical problems. Our study shows that HPN still can be a valid alternative to small intestinal transplantation in patients affected by intestinal failure and that only patients with PN-related liver disease must be considered early candidates for combined liver-small bowel transplant.     

The SF-36 instrument for the follow-up of health-related quality-of-life assessment of patients undergoing home parenteral nutrition for benign disease

INTRODUCTION: The non-disease-specific SF-36 instrument was applied to detect changes in quality of life among patients at a single center who were receiving home parenteral nutrition (HPN) for intestinal failure. METHODS: All HPN patients completed the questionnaire during routine visits. The SF-36 examines eight domains (scores: 0% to 100%): physical functioning (PF), role-functioning physical (RP), body pain (BP), general health (GH), vitality (VT), social functioning (SF), as well as role-functioning emotional (RE) and mental health (MH). Patient responses were standardized for the sex- and age-matched group scores of the healthy population by calculating the Z-score: (healthy population mean score - patient raw score)/healthy population standard deviation (reduced value: Z-score < -1). A difference in a domain score was considered significant in the individual patient if it was greater than the 90% confidence interval for healthy subjects and if it produced a change in Z-score category. General, sociodemographic, underlying disease and HPN-related factors were collected. RESULTS: For 31 enrolled adult patients, the baseline mean Z-score was reduced in five domains: PF, RP, BP, GH and SF. Twenty patients underwent a second SF-36 assessment 10 +/- 2 months later: the HRQOL worsened in eight and improved in 10 (no. worsened domains > no. improved or vice versa). The worsened subgroup showed a decrease in body mass index (P =.104), an increase in the number of HPN infusions per week (P =.065), and a greater incidence of intestinal motility disorders (P =.161), of liquid oral diet (P =.027), and of nycturia (P =.028). CONCLUSIONS: The SF-36 instrument reflecting the generic HRQOL assessment may be a suitable tool for patients on HPN.     

Preoperative parenteral feeding in Crohn's disease: preoperatively, to induce remission, and at home.

Extended courses of preoperative parenteral nutrition were used in eight cases of complicated Crohn's disease. Impressive gains in weight and strength were demonstrated, as well as radiologic improvement in the diseased bowel. It is recommended that preoperative parenteral feeding be carried out for a minimum of 20-30 days, in order that full nutritional benefits be realized, as well as the resolution of inflammatory changes in the bowel and supporting structures.     

Benefits of total parenteral nutrition (TPN) in the treatment of Crohn's disease and ulcerative colitis. A clinical review

During the last 15 years total parenteral nutrition (TPN) has played a role of increased importance in the treatment of chronic inflammatory bowel diseases, alongside conventional medical and surgical therapy. Ten cases, both inveterate and recently discovered ones, which illustrate the possible applications and great benefits of TPN are reported. The importance of a balanced, complete intravenous feeding regimen using a special aseptic infusion technique for obtaining optimal results is stressed. The difficulties involved in a scientific evaluation of the therapeutic results are discussed.     

Quality of life on home parenteral nutrition or after intestinal transplantation

AIM: We compared the health related quality of life (HRQOL) of stable patients on home parenteral nutrition (HPN) and of patients who underwent successful intestinal transplantation (ITx). METHODS: HRQOL was evaluated by the non-disease-specific Short Form 36 instrument, which examines eight specific domains and scores them on a scale of 0% to 100%. Patient scores were standardized for the sex-matched and age-matched group scores of the healthy population by calculating the Z-score (reduced value: Z-score < -1). RESULTS: Eighteen patients on HPN and 12 patients who underwent ITx were studied. The two groups did not differ for primary intestinal disease, cause of intestinal failure, presence of a stoma, body mass index, and employment and marital status. HPN Z-scores were physical functioning -2.3, physical role -1.5, body pain -1.0, general health -1.2, vitality -0.5, social functioning -0.9, emotional role -0.7, and mental health 0.0. ITx Z-scores were physical functioning -1.7, physical role -0.8, body pain 0.0, general health -0.4, vitality 0.0, social functioning -0.4, emotional role -0.3, and mental health 0.0. Only the body pain Z-scores differed significantly (P = .012). CONCLUSIONS: The value of the physical components of the SF-36 was reduced in all the components in the HPN patients and in the physical functioning component in the ITx patients. The mental health components were normal in both. Successful ITx showed a better subjective physical health feeling than stable HPN.     

Total parenteral nutrition in pancreatic disease.

Total parenteral nutrition (TPN) was given to 121 patients admitted with severe pancreatitis (73), chronic pancreatitis (23), or pancreatic malignancy (25) over 104 months. No adverse effects on the pancreas were detected from the TPN, including the provision of intravenous (IV) fat. Nutritional status was maintained or improved in all groups, including patients undergoing surgical procedures and those experiencing marked stress. No significant impact on the clinical course of pancreatitis was observed, although the death rate in acute pancreatitis (15.2%) and complicated pancreatitis (18.5%) compares favorably with other published series where early surgical intervention was undertaken. There was an increased risk of catheter-related sepsis in patients with complicated pancreatitis (14.8%) and with chronic pancreatitis (17.4%). No increase septic risk was seen in patients with acute pancreatitis or pancreatic malignancy. Eighty-two per cent of patients with acute pancreatitis required an average of 87 units of insulin per day while 78% of patients with chronic pancreatitis required an average of 54 units per day. In summary, TPN proved to be safe, effective, and well-tolerated in those patients with disorders of the pancreas.     

Total parenteral nutrition as the sole therapy in Crohn's disease--a prospective study

The effect of total parenteral nutrition (TPN) as sole therapy was studied in 30 consecutive cases of complicated Crohn's disease. After insertion of a Broviac-type central venous catheter patients were nourished parenterally for 3 weeks in the hospital and then for an additional 9 weeks at home. During this time no medication or oral intake was allowed. Surgery was avoided in 25 patients by TPN. These patients returned to work, ate normal meals and needed no medical support. In 5 cases it was not possible to control the acute disease and the patients were treated by resection. During TPN, catheter-related sepsis occurred in 3 patients (0.9 cases/1000 days TPN) and catheter embolism in 2. Four other patients developed intrahepatic cholestasis. A relapse of Crohn's disease was observed in 17 cases 3-48 months after the course of TPN. The cumulative recurrence rate is 60 per cent after 2 years and 85 per cent after 4 years. Compared with the results of resection, obtained from a 10-year period before TPN was instituted at our hospital, the cumulative recurrence rate after TPN is four times higher. It is concluded that TPN is not an alternative to resection in the treatment of Crohn's disease and should be reserved for patients with multifocal lesions, when surgery is not advisable because of the risk of a short bowel syndrome.