Total parenteral nutrition in Crohn's disease

Nutrition and inflammatory bowel disease

This article reviews the nutritional aspects of inflammatory bowel disease (IBD) including the mechanisms and manifestations of malnutrition and the efficacy of nutritional therapies. Nutrient deficiencies in patients with IBD occur via several mechanisms and may complicate the course of the disease. Nutritional status is assessed by clinical examination and the use of nutritional indices such as the Subjective Global Assessment of nutritional status. Nutritional intervention may improve outcome in certain individuals; however, because of the costs and complications of such therapy, careful selection is warranted, especially in patients presumed to need parenteral nutrition.

Hyperbaric oxygenation in severe perineal Crohn's disease

PURPOSE

Perineal involvement in Crohn's disease is a common and distressing condition, often refractory to medical or surgical treatments. Recent reports suggest the efficacy of hyperbaric oxygenation (HBO) in the healing of perineal lesions. We evaluated HBO in severe patients with perineal Crohn's disease.

METHODS

Ten consecutive patients (8 women, 2 men; mean age, 30 years) were studied. There were four superficial fissures, four cavitating ulcers, six low or superficial fistulas, two high fistulas, and one irreversible anal stenosis. All patients had received one or more medical treatments without healing the perineal lesions, and all had had previous surgery for perineal lesions.

RESULTS

Two patients discontinued HBO after a few sessions and did not complete treatment. Eight patients completed at least 30 HBO sessions and were evaluable. At the end of the procedure, six of eight patients treated were healed, three completely and three partially. All patients who healed completely received HBO as an additional treatment to local perineal surgery.

CONCLUSION

HBO might be useful as a last resort treatment of chronic perineal Crohn's disease, resistant to other treatments or as a complement to surgery.

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.

[What is the role of nutrition in Crohn disease? A contribution to the importance of dietary therapy in regional enteritis]

The clinical appearance of Crohn's disease (CD) is especially marked by nutritional deficits and insufficiencies. For a long time the goal of nutritional care was reduced to the readjustment of the nutritional status. The development and clinical use of controlled parenteral nutrition (TPN) and enteral nutritive solutions (EN) did not only emphasize this therapeutical issue, but furthermore showed positive effects on the conservative as well as on the surgical treatment concepts. Therefore today artificial nutritional support is a firm part of therapy in acute, active phases or in the contact of surgical management of CD. This is especially valid in children, where complications in general and growth failure in particular can be reduced. EN is the preferred feeding method in most of the cases, due to a lower complication rate and reduced cost when compared to TPN. The question regarding the importance of nutritional support as primary therapy has also been investigated. The results differ extensively, but point towards the conclusion that patients with solitary small bowel disease do profit from this therapeutical concept. Nevertheless it is unclear, how TPN or EN interfere in the pathophysiology or -biochemistry in this process. A question about reduction e.g. of allergic components of daily diet did stimulate new theories regarding the hypothesis of a possible causal relationship between diet and the pathogenesis of CD. Investigations on dietary habits and daily dietary therapy did not reveal an overall accepted dietary guideline. Nevertheless it seems obvious that dietary counselling has a positive effect on the disease process. It does appear, that today in the acute, active phase as well as in the long term management of Crohn's disease nutritional-care is an important therapeutical method.

Favorable response to parenteral nutrition and medical therapy in Crohn's colitis. A report of 38 patients comparing severe Crohn's and ulcerative colitis

The courses of 38 patients with severe, uncomplicated acute colitis (16 with Crohn's colitis and 22 with ulcerative colitis) were analyzed retrospectively. The patients were placed on total parenteral nutrition and treated concomitantly with corticosteroids, antibiotics (often metronidazole), sulfasalazine, and/or azathioprine. Fifteen of the 16 Crohn's colitis patients were initially managed without surgery. Four patients subsequently relapsed, two responded to reinstituted medical therapy, and two underwent colon resection 2 and 4 years later. Of 22 ulcerative colitis patients, 16 required surgery during the initial hospitalization, one patient subsequently had surgery, and one died after refusing surgery. Three of the other four continue in remission on medical therapy. Thus, there were significant differences in this series between the clinical courses of severe ulcerative colitis and severe Crohn's colitis. While most of the ulcerative colitis patients with severe disease underwent colectomy, most of the patients with severe but uncomplicated Crohn's colitis responded to aggressive medical therapy, of which total parenteral nutrition and perhaps bowel rest seemed to be an important part. Afterwards, the majority remained in remission on long-term medical therapy.

A century of home parenteral nutrition for Crohn's disease

During an 11-year period, 41 patients with Crohn's disease were placed on home parenteral nutrition (HPN) for a mean of 1,083 days (range: 33 to 3,258 days). Data were retrospectively analyzed to determine whether HPN had an effect on the course of their disease, i.e., on the number of operative procedures performed and the intensity of required medical therapy. Data represented information obtained during a total of 121 patient-years of HPN for Crohn's disease. The main indications for HPN were short bowel syndrome (66%) and high stoma output. Twenty-four of 41 patients (59%) underwent surgery for Crohn's disease during the course of HPN. There was no significant difference between the number of procedures performed per patient per year of Crohn's disease during pre-HPN and HPN periods (p greater than 0.25). Although there was no significant change in body weight, both serum albumin and transferrin levels increased during HPN (p less than 0.01 and p less than 0.01, respectively). Twenty-nine percent of patients were taking prednisone while on HPN, compared with 54% of patients during the pre-HPN period (p less than 0.01). HPN appeared to result in a significant improvement in the numerically assessed quality of life. During the HPN period, 24 patients had 1 or more HPN-related complications that required 1 to 13 hospital admissions (mean: 1.8). These complications included catheter sepsis in 19 patients, blocked or damaged catheters in 15 patients, and dehydration and/or electrolyte imbalance in 5 patients. Eight patients died, with 7% of deaths secondary to catheter-related sepsis. Although permanent HPN is associated with an identifiable morbidity and mortality and is not associated with a reduction in the frequency of surgery for Crohn's disease, benefits include a decrease in the intensity of medical therapy, an improvement in patients' nutritional state, and a significant perceived improvement in patients' quality of life. Without HPN, we believe all patients would have died secondary to malnutrition and/or dehydration.

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.

Controlled trial of bowel rest and nutritional support in the management of Crohn's disease

To define the role of bowel rest as an independent variable from nutritional support a prospective, randomised controlled trial was undertaken in 51 patients with active Crohn's disease unresponsive to other medical management. Nutritional support for 21 days was randomised to total parenteral nutrition and nil by mouth (n = 17), defined formula diet administered through a nasogastric tube (n = 19), or partial parenteral nutrition and oral food (n = 15). Nutrient input in the first two groups provided 40 non-protein kcal/kg ideal body weight /d and 1g/ kg/d protein respectively, while the third group received 15 non-protein kcal/kg/d and 0.3 g/kg/d protein intravenously and ate unrestricted food. Clinical remissions occurred in 71% of patients on parenteral nutrition, in 58% on the defined formula diet and in 60% on partial parenteral nutrition; the probability for each group of being in remission at one year, after successful therapy was 42%, 55%, and 56% respectively. These differences were not significant. In patients with active Crohn's disease bowel rest was not a major factor in achieving a remission during nutritional support and did not influence outcome during one year's follow-up.

Nutritional therapy of hospitalized patients with inflammatory bowel disease

The use of total parenteral nutrition and enteral nutrition in inflammatory bowel disease has become commonplace. Except for well-documented improvements in nutritional parameters, the efficacy of these treatments for primary therapy or for complications remains largely unproven.

Long term parenteral nutrition in the management of severe Crohn's disease

Twelve patients with active severe Crohn's disease, who failed to respond to medical treatment, received total parenteral nutrition (T.P.N.) via a Broviac long term feeding catheter for periods of 35-190 days prior to surgery. The 10 patients who were non-oedematous increased their mean weight by 3.3 Kg (p<0.01) and their mean plasma albumin by 5.80 g/l (p<0.025) after 28 days T.P.N. There were two episodes of catheter-related sepsis. Although the mean Crohn's disease activity index was significantly reduced from 364.50 (+/-91.51) to 236.75 (+/-121.29) (p<0.005) after 28 days T.P.N., all 12 patients were found to have active disease at operation. There was no post-operative mortality and the only major post-operative morbidity was a pelvic abscess following a panproctocolectomy. It is concluded that long term T.P.N. does not eliminate the need for surgery, but it may improve the nutritional status and reduce the post operative morbidity of malnourished patients with severe Crohn's disease.

Total parenteral nutrition and complete bowel rest in the management of Crohn's disease

The role of parenteral nutrition with complete bowel rest in the management of active Crohn's disease was evaluated retrospectively in 100 patients who were otherwise refractory to conventional medical management. Ninety patients received complete nutrient replacement and 10 received protein-sparing therapy. In 77 patients, a clinical remission was achieved. Analysis of subgroups revealed that the remission rate was equivalent in patients with subacute bowel obstruction (76%), inflammatory mass (82%), and otherwise uncomplicated severe active disease (89%). However, those patients with fistulae responded less well (63%). The location of the intestinal involvement with the disease did not influence the remission rate (73% in those with small bowel disease only and 78% in those with combined small and large bowel disease). All six patients with only large bowel involvement achieved a remission. In 81% of those patients with a remission, no corticosteroids were given, or the dose prior to TPN was maintained. The serum albumin improved significantly (p less than 0.001) from 3.2 +/- 0.1 to 3.6 +/- 0.1 g/dl with total parenteral nutrition, but there was no significant effect on the hematocrit (p greater than 0.5). The percentage of patients still in remission after 3 months and 1 yr of follow-up was 75 to 79 and 58 to 61%, respectively, in the three nonfistulous groups, and 46 and 36%, respectively, in those with fistulous disease. Thus total parenteral nutrition with complete bowel rest appears to be an effective therapeutic modality in the primary management of complicated Crohn's disease.

Total parenteral nutrition in Crohn's disease. Is it a primary or supportive mode or therapy?

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.