ESPEN Guidelines on Parenteral Nutrition: Gastroenterology

Undernutrition as well as specific nutrient deficiencies has been described in patients with Crohn's disease (CD), ulcerative colitis (UC) and short bowel syndrome. In the latter, water and electrolytes disturbances may be a major problem.The present guidelines provide evidence-based recommendations for the indications, application and type of parenteral formula to be used in acute and chronic phases of illness.Parenteral nutrition is not recommended as a primary treatment in CD and UC. The use of parenteral nutrition is however reliable when oral/enteral feeding is not possible.There is a lack of data supporting specific nutrients in these conditions.Parenteral nutrition is mandatory in case of intestinal failure, at least in the acute period.In patients with short bowel, specific attention should be paid to water and electrolyte supplementation. Currently, the use of growth hormone, glutamine and GLP-2 cannot be recommended in patients with short bowel.

Summary of statements: Parenteral nutrition in Crohn's disease
Subject	Recommendations	Grade	Number
Indication	PN is indicated for patients who are malnourished or at risk of becoming malnourished and who have an inadequate or unsafe oral intake, a non (or poorly) functioning or perforated gut, or in whom the gut is inaccessible. Specific reasons in patients with CD include an obstructed gut, a short bowel, often with a high intestinal output or an enterocutaneous fistula.	B	4.1
Active disease	Parenteral nutrition (PN) should not be used as a primary treatment of inflammatory luminal CD.	A	3.5
	Bowel rest has not been proven to be more efficacious than nutrition per se.
Maintenance of remission	In case of persistent intestinal inflammation there is rarely a place for long-term PN.	B	3.7
	The most common indication for long-term PN is the presence of a short bowel.
Perioperative	Use of PN in the perioperative period in CD patients is similar to that of other surgical procedures.	B	3.6
Application	When indicated, PN improves nutritional status and reduces the consequences of undernutrition, providing there is not continuing intra-abdominal sepsis	B	1
	Specific deficits (trace elements, vitamins) should be corrected by appropriate supplementation.	B	1
	The use of PN in patients with CD should follow general recommendations for parenteral nutrition.	B	1
Route	Parenteral nutrition is usually combined with oral/enteral food unless there is continuing intra-abdominal sepsis or perforation. Central and peripheral routes may be selected according to the expected duration of PN	C	3.2
Type of formula	Although there are encouraging experimental data, the present clinical studies are insufficient to permit the recommendation of glutamine, n-3 fatty acids or other pharmaconutrients in CD.	B	4.3
Undernutrition	Parenteral nutrition may improve the quality of life in undernourished CD patients.	C	3.4
Summary of statements: PN in ulcerative colitis
Subject	Recommendations	Grade	Number
Indication	Parenteral nutrition should only be used in patients with UC who are malnourished or at risk of becoming malnourished before or after surgery if they cannot tolerate food or an enteral feed	B	9
Active disease	There is no place for PN in acute inflammatory UC as means of enabling bowel rest.	B	10
Maintenance of remission	Parenteral nutrition is not recommended.	B	11
Application	Treat specific deficiencies when oral route is not possible.	C	5
Type of formula	The value of specific substrates (n-3 fatty acids, glutamine) is not proven.	B	10.2
Summary of statements: Short bowel syndrome (intestinal failure)
Subject	Recommendations	Grade	Number
Indication	Maintenance and/or improvement of nutritional status, correction of water and electrolyte balance, improvement in quality of life.	B	15
Route
Post-op period	Predictions on the route of nutritional support needed can be made from knowledge of the remaining length of small bowel and the presence or absence of the colon. PN is likely to be needed if the remaining small bowel length is very short (e.g., less than 100 cm with a jejunostomy and less than 50 cm with a remaining colon in continuity). With longer lengths parenteral nutrition, water and electrolytes may be needed until oral/enteral intake is adequate to maintain nutrition, water and electrolyte status.	B	17.1
Adaptation phase	Patients with a jejunostomy have little change in their nutritional/fluid requirements with time. Patients with a colon in continuity with the small bowel have an improvement in absorption over 1–3 years and parenteral nutrition can often be reduced or stopped.	B	17.2
	Dietary counseling is important for those with a retained colon and may facilitate intestinal adaptation. In patients with a jejunostomy and a high output stoma advice on oral fluid intake and drug treatments are vital.
Maintenance/Stabilization	Parenteral nutrition, water and electrolytes (especially sodium and magnesium should be continued when oral/enteral intake is insufficient to maintain a normal body weight/hydration or when the intestinal/stool output is so great as to severely reduce the patient's quality of life. Assuming strict compliance with dietary/water and electrolyte advice, after 2 years, dependency on PN is likely to be long-term.	B	17.3
Type of formula	No specific substrate composition of PN is required per se.	B	16
	Specific attention should be paid to electrolyte supplementation (especially sodium and magnesium).	B	16, 17
	Currently, the use of growth hormone, glutamine or GLP-2 cannot be recommended.	B	18

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More than medical treatment: the patient's first encounter with prehospital emergency care

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