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Wang W, Yin A, Wang J, Li J, Cheng J, Kang J, Xu Y, Lu Y, Yang Y, Su J, Zhou Q, Liu Y, Tang Z, Ren H, Li W, Dong W, Yu B, An P. Real-world evidence of combined treatment of biologics and exclusive enteral nutrition in patients with ileum-dominant Crohn's disease: A multicenter study. Clin Nutr 2024; 43:1291-1298. [PMID: 38663050 DOI: 10.1016/j.clnu.2024.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 03/26/2024] [Accepted: 04/11/2024] [Indexed: 05/31/2024]
Abstract
BACKGROUND & AIMS Although biologics were prescribed to achieve and maintain clinical remission of active Crohn's disease (CD), almost half of patients experienced a loss of response or intolerance. Here, we investigated the efficacy of combined treatment of biologics and 16-weeks exclusive enteral nutrition (EEN) in moderate-to-severe CD patients with small intestine lesions. METHODS This was a real-world, multicenter retrospective study, from October 2016 to March 2023, medical records of patients registered at three IBD centers were reviewed for patients with ileal or ileocolonic CD in moderate-to-severe activity. All patients received treatment of biologics with concomitant 16-week EEN (BioEEN) or biologics alone (Bio). The clinical outcomes and endoscopic outcomes were assessed at week 16 and 52. RESULTS There was no statistically significant difference between Bio (97 patients) and BioEEN group (100 patients) at baseline for demographic and clinical characteristics. Compared to treatment with biologics alone, patients with BioEEN treatment achieved higher rates of clinical response (95.0% vs. 66.0%), clinical remission (87.0% vs. 52.6%), endoscopic response (91.4% vs. 47.4%) including mucosal healing (85.7% vs. 23.7%) at week 16. The superiority of BioEEN sustained in maintenance, with 84.7% (vs. 49.1%) clinical response, 77.8% (vs. 38.6%) clinical remission, 69.2% (vs. 32.6%) endoscopic response and 51.9% (vs. 18.6%) mucosal healing at week 52. CONCLUSIONS Combined treatment of biologics and 16-week EEN was an efficient therapeutic strategy with affirmative effectiveness for small intestine diseases of active CD.
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Affiliation(s)
- Wei Wang
- Department of Gastroenterology, Renmin Hospital of Wuhan University, 99 Zhangzhidong Road, Wuhan 430060, Hubei Province, China; Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China; Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China; Department of Gastroenterology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, 136 Jingzhou Road, Xiangyang 441021, Hubei Province, China
| | - Anning Yin
- Department of Gastroenterology, Renmin Hospital of Wuhan University, 99 Zhangzhidong Road, Wuhan 430060, Hubei Province, China; Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China; Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China
| | - Jing Wang
- Department of Gastroenterology, Renmin Hospital of Wuhan University, 99 Zhangzhidong Road, Wuhan 430060, Hubei Province, China; Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China; Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China
| | - Jiao Li
- Department of Gastroenterology, Renmin Hospital of Wuhan University, 99 Zhangzhidong Road, Wuhan 430060, Hubei Province, China; Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China; Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China
| | - Jingyun Cheng
- Department of Radiology, Renmin Hospital of Wuhan University, 99 Zhangzhidong Road, Wuhan 430060, Hubei Province, China
| | - Jian Kang
- Department of Gastroenterology, Renmin Hospital of Wuhan University, 99 Zhangzhidong Road, Wuhan 430060, Hubei Province, China; Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China; Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China
| | - Yaqing Xu
- Department of Geriatrics, Renmin Hospital of Wuhan University, 99 Zhangzhidong Road, Wuhan 430060, Hubei Province, China
| | - Yueyue Lu
- Department of Gastroenterology, First Hospital of Yangtze University, Jingzhou 434099, Hubei Province, China
| | - Yuanping Yang
- Department of Gastroenterology, Yichang Central People's Hospital, China Three Gorges University, Yichang 443000, Hubei Province, China
| | - Juan Su
- Department of Gastroenterology, Renmin Hospital of Wuhan University, 99 Zhangzhidong Road, Wuhan 430060, Hubei Province, China; Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China; Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China
| | - Qian Zhou
- Department of Gastroenterology, Renmin Hospital of Wuhan University, 99 Zhangzhidong Road, Wuhan 430060, Hubei Province, China; Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China; Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China
| | - Ya Liu
- Department of Gastroenterology, Renmin Hospital of Wuhan University, 99 Zhangzhidong Road, Wuhan 430060, Hubei Province, China; Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China; Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China
| | - Zhishun Tang
- Sports Rehabilitation, College of Sport Medicine, Wuhan Sports University, Wuhan 430060, Hubei Province, China
| | - Haixia Ren
- Department of Gastroenterology, Renmin Hospital of Wuhan University, 99 Zhangzhidong Road, Wuhan 430060, Hubei Province, China; Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China; Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China
| | - Weiwei Li
- Department of Geriatrics, Renmin Hospital of Wuhan University, 99 Zhangzhidong Road, Wuhan 430060, Hubei Province, China
| | - Weiguo Dong
- Department of Gastroenterology, Renmin Hospital of Wuhan University, 99 Zhangzhidong Road, Wuhan 430060, Hubei Province, China; Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China; Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China
| | - Baoping Yu
- Department of Gastroenterology, Renmin Hospital of Wuhan University, 99 Zhangzhidong Road, Wuhan 430060, Hubei Province, China; Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China; Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China.
| | - Ping An
- Department of Gastroenterology, Renmin Hospital of Wuhan University, 99 Zhangzhidong Road, Wuhan 430060, Hubei Province, China; Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China; Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China.
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Ratajczak AE, Festa S, Aratari A, Papi C, Dobrowolska A, Krela-Kaźmierczak I. Should the Mediterranean diet be recommended for inflammatory bowel diseases patients? A narrative review. Front Nutr 2023; 9:1088693. [PMID: 36704787 PMCID: PMC9871561 DOI: 10.3389/fnut.2022.1088693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 12/07/2022] [Indexed: 01/12/2023] Open
Abstract
Inflammatory bowel diseases (IBD) are chronic, progressive and relapsing inflammatory disorders of unknown etiology that may cause disability over time. Data from epidemiologic studies indicate that diet may play a role in the risk of developing and the course of IBD. It is known that the group of beneficial bacteria was reduced in the IBD and that the Mediterranean diet (MD)-which is defined as eating habits characterized by high consumption of plant foods, mainly cereals, vegetables, fruit as well as olive oil, and small portions of dairy products, sweets, sugar and meat products-affects gut microbiota, enriching beneficial bacteria, which support gut barrier function and reduce inflammation. Although several studies support different favorable effects of MD on IBD, adherence to MD by IBD patients is generally low, including patients from the Mediterranean Basin. Patients avoid many products which are elements of MD because there cause gastrointestinal symptoms. Patients should be encouraged to have a healthy and well-balanced diet according to individual tolerance of products. A good option seems to be good modified MD, changing hard-to-digest products to easy digest.
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Affiliation(s)
- Alicja Ewa Ratajczak
- Department of Gastroenterology, Dietetics and Internal Medicine, Poznan University of Medical Sciences, Poznan, Poland,Doctoral School, Poznan University of Medical Sciences, Poznan, Poland,*Correspondence: Alicja Ewa Ratajczak ✉
| | - Stefano Festa
- Inflammatory Bowel Disease Unit, Department of Gastroenterology, S. Filippo Neri Hospital, Rome, Italy
| | - Annalisa Aratari
- Inflammatory Bowel Disease Unit, Department of Gastroenterology, S. Filippo Neri Hospital, Rome, Italy
| | - Claudio Papi
- Inflammatory Bowel Disease Unit, Department of Gastroenterology, S. Filippo Neri Hospital, Rome, Italy
| | - Agnieszka Dobrowolska
- Department of Gastroenterology, Dietetics and Internal Medicine, Poznan University of Medical Sciences, Poznan, Poland
| | - Iwona Krela-Kaźmierczak
- Department of Gastroenterology, Dietetics and Internal Medicine, Poznan University of Medical Sciences, Poznan, Poland
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Fitzpatrick JA, Melton SL, Yao CK, Gibson PR, Halmos EP. Dietary management of adults with IBD - the emerging role of dietary therapy. Nat Rev Gastroenterol Hepatol 2022; 19:652-669. [PMID: 35577903 DOI: 10.1038/s41575-022-00619-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/12/2022] [Indexed: 02/08/2023]
Abstract
Historically, dietitians played a minor part in the management of inflammatory bowel disease (IBD), including Crohn's disease and ulcerative colitis. Patients were commonly referred for consequences of uncontrolled disease, such as malnutrition and bowel obstruction risk. Today, dietitians are fundamental members of the multidisciplinary IBD team, from educating on the role of diet at diagnosis and throughout the lifespan of a patient with IBD to guiding primary induction therapy. This aspect is reflected in published guidelines for IBD management, which previously placed diet as only a minor factor, but now have diet-specific publications. This Review describes a four-step approach in a dietitian's assessment and management of diet in patients with IBD: (1) identifying and correcting nutritional gaps and dietary imbalances; (2) considering diet to treat active disease with the use of exclusive enteral nutrition (EEN) or emerging diets that could replace EEN; (3) using therapeutic diets to control existing complications of IBD, such as reduced fibre to prevent bowel obstruction in stricturing disease or a fermentable oligosaccharides, disaccharides, monosaccharides and polyols diet to manage co-existing functional gut symptoms; and (4) considering the role of diet in preventing IBD development in high-risk populations.
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Affiliation(s)
- Jessica A Fitzpatrick
- Department of Gastroenterology, The Alfred Hospital and Monash University, Melbourne, Victoria, Australia
| | - Sarah L Melton
- Department of Gastroenterology, The Alfred Hospital and Monash University, Melbourne, Victoria, Australia
| | - Chu Kion Yao
- Department of Gastroenterology, The Alfred Hospital and Monash University, Melbourne, Victoria, Australia
| | - Peter R Gibson
- Department of Gastroenterology, The Alfred Hospital and Monash University, Melbourne, Victoria, Australia
| | - Emma P Halmos
- Department of Gastroenterology, The Alfred Hospital and Monash University, Melbourne, Victoria, Australia.
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Keetarut K, Kikuchi H, King B, Richards N, Lomer M, Fragkos K, Patel PS. Perceived acceptability of partial enteral nutrition (PEN) using oral nutritional supplement drinks in adolescent and adult Crohn's disease outpatients: A feasibility study. Clin Nutr ESPEN 2021; 46:276-287. [PMID: 34857209 DOI: 10.1016/j.clnesp.2021.09.742] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 09/27/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Studies, mainly in Japanese cohorts, have shown that partial enteral nutrition (PEN) including oral nutritional supplement (ONS) drinks can prolong disease remission and increase drug effectiveness in Crohn's disease (CD). Acceptability is a key feasibility parameter to determine whether PEN is a viable treatment option in UK CD patients. We report the results of a single centre cross-sectional feasibility study carried out to investigate perceived acceptability of PEN using ONS drinks and whether ONS preference varies with sex, nutritional status or phenylthiocarbamide (PTC) sensitivity. METHODS Patients with a confirmed CD diagnosis were recruited using convenience sampling from an adult and adolescent gastroenterology outpatient clinic over 3 years. Blind taste testing of 5 polymeric ONS drinks were conducted using a validated 9-point hedonic rating scale followed by completion of an acceptability questionnaire based on the preferred ONS drink. A subset of patients took home the preferred ONS drink for a 7-day ONS study. RESULTS 105 CD patients (55 males), aged 34.9 (±15.4) years were recruited and 28 patients completed the 7-day ONS study. Overall impression scores did not significantly vary with nutritional status, sex, BMI, handgrip strength (HGS), mid-upper arm circumference (MUAC) or PTC sensitivity. Ensure plus milkshake™ rated highest for overall impression (6.5, p=<0.0001) and all other organoleptic properties (p < 0.0001). The main perceived benefits of using ONS drinks as PEN related to assurance of nutrient intake (89%), convenience (86%), and improvement of gut symptoms (85%). The main perceived barriers related to reduction in pleasure from eating and drinking (56%), struggling with drink storage (54%) having less energy and feeling more tired than if eating 3 solid meals daily (52%). 65% of patients would consider using ONS drinks as PEN as a maintenance treatment option. 81% of patients felt confident-very confident about consuming ONS drinks daily as PEN for three months but this dropped to 64% and 37% at 6 and 12 months, respectively. There was a significant drop in perceived ease of use of ONS drinks as PEN after the 7-day ONS study (P = 0.01). CONCLUSION Use of ONS drinks as PEN have high perceived benefits and appear to be a feasible option for short-term use of 3-6 months in CD patients. However, confidence in long-term use of ONS drinks as PEN is low mainly due to the perceived social impact. Future studies should assess longer trial periods and volume of ONS drinks to increase the validity of these findings.
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Affiliation(s)
- Katie Keetarut
- University College London Hospital NHS Foundation Trust, Department of Nutrition and Dietetics, 3rd Floor East, 250 Euston Road, London, NW1 2PG, UK.
| | - Harumi Kikuchi
- University College London, Institute for Liver and Digestive Health, UCL Division of Medicine, Upper Third Floor, Royal Free Campus, London, NW3 2PF, UK.
| | - Beth King
- University College London, Institute for Liver and Digestive Health, UCL Division of Medicine, Upper Third Floor, Royal Free Campus, London, NW3 2PF, UK.
| | - Nadine Richards
- University College London, Institute for Liver and Digestive Health, UCL Division of Medicine, Upper Third Floor, Royal Free Campus, London, NW3 2PF, UK.
| | - Miranda Lomer
- King's College London, Diabetes and Nutritional Sciences Division, 150 Stamford Street, London, SE1 9NH, UK.
| | - Konstantinos Fragkos
- University College London Hospital NHS Foundation Trust, GI Services, Ground Floor Central, 250 Euston Road, London, NW1 2PG, UK.
| | - Pinal S Patel
- University College London Hospital NHS Foundation Trust, Department of Nutrition and Dietetics, 3rd Floor East, 250 Euston Road, London, NW1 2PG, UK.
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Yang H, Feng R, Li T, Xu S, Hao X, Qiu Y, Chen M. Systematic review with meta-analysis of partial enteral nutrition for the maintenance of remission in Crohn's disease. Nutr Res 2020; 81:7-18. [PMID: 32798791 DOI: 10.1016/j.nutres.2020.06.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 04/30/2020] [Accepted: 06/03/2020] [Indexed: 12/28/2022]
Abstract
Although enteral nutrition (EN) is effective for induction therapy in Crohn's disease (CD), it remains unclear whether partial enteral nutrition (PEN), i.e., EN, along with a daily diet, is effective for maintenance therapy in CD. It was hypothesized that PEN would be effective as a maintenance therapy in CD. This meta-analysis aimed to evaluate the efficacy and safety of PEN for maintenance therapy in CD. PubMed, EMBASE, Web of Science, and Cochrane Library were searched up to January 2019 for eligible prospective controlled trials, and then a meta-analysis was conducted. The primary outcome was clinical relapse, as defined in the primary studies. Eight studies with 429 patients were included in the meta-analysis. The rate of clinical relapse at 0.5 to 2 years was significantly lower in patients receiving PEN (420-1800 kcal/d) than in those not receiving nutrition therapy (RR: 0.67, 95% CI: 0.54-0.82, P < .01; number needed to treat = 5, P < .01). Patients receiving PEN exhibited a higher frequency of clinical remission maintenance at 0.5 to 1 year (67%) than did those not receiving nutrition therapy (48%; RR: 1.32, 95% CI: 1.07-1.64, P = .01). The total adverse event rate was comparable in the two groups (RR: 3.60, 95% CI: 0.70-18.66, P = .13). PEN may be more effective than the absence of EN therapy for the maintenance of remission in CD with a good safety profile.
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Affiliation(s)
- Hongsheng Yang
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-Sen University, No. 58 Zhongshan Road II, Yuexiu district, Guangzhou 510000, P.R. China; Department of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-Sen University, No. 26 Yuancun Road II, Tianhe district, Guangzhou 510000, P.R. China
| | - Rui Feng
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-Sen University, No. 58 Zhongshan Road II, Yuexiu district, Guangzhou 510000, P.R. China
| | - Tong Li
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-Sen University, No. 58 Zhongshan Road II, Yuexiu district, Guangzhou 510000, P.R. China
| | - Shu Xu
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-Sen University, No. 58 Zhongshan Road II, Yuexiu district, Guangzhou 510000, P.R. China
| | - Xiuxue Hao
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-Sen University, No. 58 Zhongshan Road II, Yuexiu district, Guangzhou 510000, P.R. China
| | - Yun Qiu
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-Sen University, No. 58 Zhongshan Road II, Yuexiu district, Guangzhou 510000, P.R. China.
| | - Minhu Chen
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-Sen University, No. 58 Zhongshan Road II, Yuexiu district, Guangzhou 510000, P.R. China.
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Practical Guidance for Dietary Management of Patients With Inflammatory Bowel Disease During the SARS-CoV2 Pandemic. J Acad Nutr Diet 2020; 121:201-209. [PMID: 32855101 PMCID: PMC7369587 DOI: 10.1016/j.jand.2020.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 07/15/2020] [Accepted: 07/17/2020] [Indexed: 11/20/2022]
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Partial enteral nutrition has no benefit on bone health but improves growth in paediatric patients with quiescent or mild Crohn's disease. Clin Nutr 2020; 39:3786-3796. [PMID: 32376096 DOI: 10.1016/j.clnu.2020.04.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 03/28/2020] [Accepted: 04/14/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND AIMS Exclusive enteral nutrition induces remission, improves bone health and growth in paediatric Crohn's disease (CD) patients, but is highly demanding for patients. We investigated efficacy of partial enteral nutrition (PEN) on bone health, growth and course in CD patients and assessed microbial and metabolic changes induced by PEN. METHODS We performed a two centre, non-randomized controlled intervention study in quiescent CD patients aged <19 years. Patients in intervention group received a liquid formula providing ~25% of daily energy for one year. At baseline, after 3, 6, 9 and 12 months, we collected data on bone, muscle (peripheral quantitative computertomography), anthropometry, disease activity (weighted paediatric CD activity index), metabolomic profile (liquid chromatography mass spectrometry), and faecal microbiome (16S rRNA gene sequencing). RESULTS Of 41 CD patients, 22 received the intervention (PEN) (mean age 15.0 ± 1.9 years, 50% male), 19 served as controls (non-PEN) (12.8 ± 3.1 years, 58% male). At baseline, mean bone quality was comparable to reference population with no improvement during the intervention. Relapse rate was low (8/41, PEN 4/22 and non-PEN 4/19, ns). PEN was not associated with microbiota community changes (beta diversity) but significantly reduced species diversity. Metabolome changes with upregulation of phosphatidylcholines in PEN patients are likely related to lipid and fatty acid composition of the formula. PEN significantly improved growth in a subgroup with Tanner stage 1-3. CONCLUSION In our cohort of paediatric CD patients, PEN did not affect bone health but improved growth in patients with a potential to grow.
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Day A, Wood J, Melton S, Bryant RV. Exclusive enteral nutrition: An optimal care pathway for use in adult patients with active Crohn's disease. JGH Open 2020; 4:260-266. [PMID: 32280775 PMCID: PMC7144766 DOI: 10.1002/jgh3.12256] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 08/09/2019] [Accepted: 08/20/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND AIM Exclusive enteral nutrition (EEN) is progressively being used as a therapeutic option for adults with Crohn's Disease (CD); however, there is no standardized approach to delivering this therapy. The aim of this study is to develop an optimal care pathway for using EEN in adults with CD. This will create a standard of care that can be used as a benchmark practice and will provide direction for future research. METHODS A working group of 12 multidisciplinary inflammatory bowel disease specialists across Australia and New Zealand was convened to develop a practical, clinically focused care pathway for using EEN in adults with active CD. Six key areas were identified as part of the care pathway: clinical indications, nutrition assessment, EEN protocol, monitoring, accessing formula, and food reintroduction. Current literature was identified via systematic review, and quality of evidence was graded. Consensus expert opinion was used where literature gaps were identified. RESULTS An optimal care pathway for using EEN in adults with CD was developed with six key consensus statements on how to use EEN in adults with active CD. These key statements identify clinical indications for use, nutrition assessment, enteral prescription and duration of therapy, monitoring criteria, food reintroduction, and the role of partial EEN. An accompanying patient resource was also developed. CONCLUSION EEN is recommended as a treatment option to induce remission in adults with active CD. The consensus statements developed are practical and are based on best available evidence and expert opinion to assist in developing a standardized approach to delivering EEN therapy.
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Affiliation(s)
- Alice Day
- Department of Gastroenterology, The Queen Elizabeth HospitalAdelaideSouth AustraliaAustralia
| | - Jessica Wood
- Department Nutrition and Dietetics, The AlfredMelbourneVictoriaAustralia
| | - Sarah Melton
- Department Nutrition and Dietetics, The AlfredMelbourneVictoriaAustralia
| | - Robert V Bryant
- Department of Gastroenterology, The Queen Elizabeth HospitalAdelaideSouth AustraliaAustralia
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Abstract
PURPOSE OF REVIEW This article provides an updated review on the role of diet in the risk of developing Crohn's disease (CD) and CD management, areas of ongoing study. RECENT FINDINGS Higher intake of dietary fiber (fruit fiber) has been associated with a reduced risk for CD. The exclusive enteral nutrition (EEN) diet remains the most validated nutritional recommendation for inducing remission in CD. The specific carbohydrate diet (SCD) has demonstrated reductions in CD severity scores in conjunction with medical therapies, and larger trials on its efficacy are ongoing. Several new exclusion diets modeled after EEN and SCD have shown potential efficacy in smaller studies that warrant replication. There is a paucity of clear dietary recommendations for the reduction in risk of CD clinical relapse. There are various components of diet that likely impact risk for CD development and contribute to its disease course; however, studies are often limited in their size or ability to demonstrate mechanistic causation. Further studies including diets that aim to expand on the restrictive nature of EEN may lead to stronger evidence for a diet-based approach to CD management.
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Affiliation(s)
- Donald Goens
- Department of Internal Medicine, University of Chicago, Chicago, IL, USA
| | - Dejan Micic
- Department of Internal Medicine, Section of Gastroenterology, Hepatology and Nutrition, University of Chicago, Chicago, IL, 60637, USA.
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Sood A, Singh A, Sudhakar R, Midha V, Mahajan R, Mehta V, Gupta YK, Kaur K. Exclusive enteral nutrition for induction of remission in anti-tumor necrosis factor refractory adult Crohn's disease: the Indian experience. Intest Res 2020; 18:184-191. [PMID: 32092799 PMCID: PMC7206340 DOI: 10.5217/ir.2019.00094] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 10/23/2019] [Indexed: 12/18/2022] Open
Abstract
Background/Aims Exclusive enteral nutrition (EEN) is recommended for induction of remission in pediatric Crohn’s disease (CD). However, it is not currently recommended for inducing remission in adults. This report describes the use of 12-week EEN for induction of remission in anti-tumor necrosis factor (anti-TNF) refractory adult CD. Methods This is a retrospective analysis of adults with moderate to severe active (Crohn’s Disease Activity Index [CDAI] >220) anti-TNF refractory CD, who received EEN for 12 weeks between April 2018 and March 2019 at Dayanand Medical College and Hospital, Ludhiana, India. Primary outcomes included achievement of clinical remission and fistula healing at 12 weeks. Improvement in inflammatory markers and nutritional status were the secondary end points. Results Out of 23 patients who received anti-TNF agents, 7 (30.4%) were refractory and were offered EEN as a salvage therapy. Six patients (66.7% females, mean age 25.6±6.5 years) consented. Four patients (66.6%) achieved clinical remission (CDAI <150). Mean CDAI of patients decreased significantly after 12 weeks of EEN (388.8±74.8 vs. 160.0±25.2, P<0.001). Perianal fistulas showed clinical response (drainage decreased by >50%), though none achieved remission. Entero-enteric fistulae showed complete healing. Mean body mass index improved from 15.6±3.1 to 18.9±1.9 kg/m2 at week 12 (P=0.003). Hemoglobin and serum albumin also improved from 8.2±1.1 g/dL and 2.8±0.3 g/dL at baseline to 12.6±0.6 g/dL and 3.6±0.5 g/dL post-EEN respectively (P<0.001 and P=0.006 respectively). Conclusions EEN appears to be an effective and well tolerated therapy for induction of remission in anti-TNF refractory adult CD. More data from prospective trials with larger number of patients is required.
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Affiliation(s)
- Ajit Sood
- Department of Gastroenterology, Dayanand Medical College, Ludhiana, India
| | - Arshdeep Singh
- Department of Gastroenterology, Dayanand Medical College, Ludhiana, India
| | - Ritu Sudhakar
- Department of Dietetics, Dayanand Medical College, Ludhiana, India
| | - Vandana Midha
- Department of Internal Medicine, Dayanand Medical College, Ludhiana, India
| | - Ramit Mahajan
- Department of Gastroenterology, Dayanand Medical College, Ludhiana, India
| | - Varun Mehta
- Department of Gastroenterology, Dayanand Medical College, Ludhiana, India
| | - Yogesh Kumar Gupta
- Department of Gastroenterology, Dayanand Medical College, Ludhiana, India
| | - Kirandeep Kaur
- Department of Pharmacology, Dayanand Medical College, Ludhiana, India
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11
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Ferreira TMR, Albuquerque A, Cancela Penna FG, Macedo Rosa R, Correia MITD, Barbosa AJA, Salles Cunha A, Ferrari MDLA. Effect of Oral Nutrition Supplements and TGF-β2 on Nutrition and Inflammatory Patterns in Patients With Active Crohn's Disease. Nutr Clin Pract 2019; 35:885-893. [PMID: 31840323 DOI: 10.1002/ncp.10448] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Crohn's disease (CD) is often associated with nutrition disorders. Many nutrition therapeutic alternatives have been studied. Nevertheless, the actual role of nutrition therapy is still controversial. The objective of this study was to assess the effects of nutrition supplementation with and without transforming growth factor-beta 2 (TGF-β2) on inflammatory, endoscopic, histopathologic, and nutrition parameters in active CD. MATERIALS AND METHODS Thirty-eight patients were allocated into 3 groups: group 1 (patients who received only nutrition orientation), group 2 (nutrition orientation and a normoproteic, normocaloric nutrition supplement), and group 3 (nutrition orientation and the nutritional supplement with TGF-β2). Clinical and nutrition evaluation, C-reactive protein (CRP) levels, and assessment of endoscopic and histologic parameters in the intestinal mucosa were performed before and after nutrition intervention. RESULTS The mean follow-up period was 3 months. In the beginning of the study, groups were homogeneous regarding age, gender, CD behavior and localization, and medication in use. In the end of the study, the Clinical Disease Activity Index score was reduced in groups 2 and 3; in group 3, a reduction in CRP levels and an improvement in histologic findings were observed. Among patients who received nutritional supplement, some anthropometric patterns were improved. CONCLUSION The results of the study indicate that nutritional supplementation improved nutrition and inflammatory patterns in patients with active CD. However, only patients receiving TGF-β2-enriched formula showed improvement in histologic parameters and significant reduction in CRP levels.
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Affiliation(s)
| | - Annanda Albuquerque
- Adult Health Post Graduation Program, Medical School, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | | | - Rodrigo Macedo Rosa
- Instituto Alfa de Gastroenterologia, Hospital das Clínicas, Medical School, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | | | | | - Aloísio Salles Cunha
- Department of Clinical Medicine, Universidade Federal de Minas Gerais, Medical School, Belo Horizonte, Brazil
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12
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Di Caro S, Fragkos KC, Keetarut K, Koo HF, Sebepos-Rogers G, Saravanapavan H, Barragry J, Rogers J, Mehta SJ, Rahman F. Enteral Nutrition in Adult Crohn's Disease: Toward a Paradigm Shift. Nutrients 2019; 11:E2222. [PMID: 31540038 PMCID: PMC6770416 DOI: 10.3390/nu11092222] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 09/05/2019] [Accepted: 09/08/2019] [Indexed: 02/06/2023] Open
Abstract
Medical and surgical treatments for Crohn's disease are associated with toxic effects. Medical therapy aims for mucosal healing and is achievable with biologics, immunosuppressive therapy, and specialised enteral nutrition, but not with corticosteroids. Sustained remission remains a therapeutic challenge. Enteral nutrition, containing macro- and micro-nutrients, is nutritionally complete, and is provided in powder or liquid form. Enteral nutrition is a low-risk and minimally invasive therapy. It is well-established and recommended as first line induction therapy in paediatric Crohn's disease with remission rates of up to 80%. Other than in Japan, enteral nutrition is not routinely used in the adult population among Western countries, mainly due to unpalatable formulations which lead to poor compliance. This study aims to offer a comprehensive review of available enteral nutrition formulations and the literature supporting the use and mechanisms of action of enteral nutrition in adult Crohn's disease patients, in order to support clinicians in real world decision-making when offering/accepting treatment. The mechanisms of actions of enteral feed, including their impact on the gut microbiome, were explored. Barriers to the use of enteral nutrition, such as compliance and the route of administration, were considered. All available enteral preparations have been comprehensively described as a practical guide for clinical use. Likewise, guidelines are reported and discussed.
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Affiliation(s)
- Simona Di Caro
- Intestinal Failure Service, GI Services, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
| | - Konstantinos C Fragkos
- Intestinal Failure Service, GI Services, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
| | - Katie Keetarut
- Department of Dietetics, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
| | - Hui Fen Koo
- UCL Medical School, 74 Huntley Street, Bloomsbury, London WC1E 6DE, UK.
| | - Gregory Sebepos-Rogers
- Intestinal Failure Service, GI Services, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
| | - Hajeena Saravanapavan
- Intestinal Failure Service, GI Services, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
| | - John Barragry
- Intestinal Failure Service, GI Services, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
| | - Jennifer Rogers
- Intestinal Failure Service, GI Services, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
| | - Shameer J Mehta
- Intestinal Failure Service, GI Services, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
| | - Farooq Rahman
- Intestinal Failure Service, GI Services, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
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13
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Levine A, Sigall Boneh R, Wine E. Evolving role of diet in the pathogenesis and treatment of inflammatory bowel diseases. Gut 2018; 67:1726-1738. [PMID: 29777041 DOI: 10.1136/gutjnl-2017-315866] [Citation(s) in RCA: 204] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 04/16/2018] [Accepted: 04/17/2018] [Indexed: 12/12/2022]
Abstract
Recent advances in basic and clinical science over the last 3 years have dramatically altered our appreciation of the role of diet in inflammatory bowel diseases (IBD). The marked increase in incidence of these diseases along with the important role of non-genetic susceptibility among patients with IBD has highlighted that these diseases have a strong environmental component. Progress in the field of microbiome and IBD has demonstrated that microbiome appears to play an important role in pathogenesis, and that diet may in turn impact the composition and functionality of the microbiome. Uncontrolled clinical studies have demonstrated that various dietary therapies such as exclusive enteral nutrition and newly developed exclusion diets might be potent tools for induction of remission at disease onset, for patients failing biologic therapy, as a treatment for disease complications and in reducing the need for surgery. We review these advances from bench to bedside, along with the need for better clinical trials to support these interventions.
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Affiliation(s)
- Arie Levine
- Pediatric Gastroenterology and Nutrition Unit, Edith Wolfson Medical Center, Holon, Israel.,Tel Aviv University, Tel Aviv, Israel
| | - Rotem Sigall Boneh
- Pediatric Gastroenterology and Nutrition Unit, Edith Wolfson Medical Center, Holon, Israel.,Tel Aviv University, Tel Aviv, Israel
| | - Eytan Wine
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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14
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Hirschfield GM, Dyson JK, Alexander GJM, Chapman MH, Collier J, Hübscher S, Patanwala I, Pereira SP, Thain C, Thorburn D, Tiniakos D, Walmsley M, Webster G, Jones DEJ. The British Society of Gastroenterology/UK-PBC primary biliary cholangitis treatment and management guidelines. Gut 2018; 67:1568-1594. [PMID: 29593060 PMCID: PMC6109281 DOI: 10.1136/gutjnl-2017-315259] [Citation(s) in RCA: 180] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 01/22/2018] [Accepted: 01/23/2018] [Indexed: 12/12/2022]
Abstract
Primary biliary cholangitis (formerly known as primary biliary cirrhosis, PBC) is an autoimmune liver disease in which a cycle of immune mediated biliary epithelial cell injury, cholestasis and progressive fibrosis can culminate over time in an end-stage biliary cirrhosis. Both genetic and environmental influences are presumed relevant to disease initiation. PBC is most prevalent in women and those over the age of 50, but a spectrum of disease is recognised in adult patients globally; male sex, younger age at onset (<45) and advanced disease at presentation are baseline predictors of poorer outcome. As the disease is increasingly diagnosed through the combination of cholestatic serum liver tests and the presence of antimitochondrial antibodies, most presenting patients are not cirrhotic and the term cholangitis is more accurate. Disease course is frequently accompanied by symptoms that can be burdensome for patients, and management of patients with PBC must address, in a life-long manner, both disease progression and symptom burden. Licensed therapies include ursodeoxycholic acid (UDCA) and obeticholic acid (OCA), alongside experimental new and re-purposed agents. Disease management focuses on initiation of UDCA for all patients and risk stratification based on baseline and on-treatment factors, including in particular the response to treatment. Those intolerant of treatment with UDCA or those with high-risk disease as evidenced by UDCA treatment failure (frequently reflected in trial and clinical practice as an alkaline phosphatase >1.67 × upper limit of normal and/or elevated bilirubin) should be considered for second-line therapy, of which OCA is the only currently licensed National Institute for Health and Care Excellence recommended agent. Follow-up of patients is life-long and must address treatment of the disease and management of associated symptoms.
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Affiliation(s)
- Gideon M Hirschfield
- NIHR Birmingham Biomedical Research Centre, Birmingham, UK
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Centre for Liver Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Jessica K Dyson
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
- NIHR Newcastle Biomedical Research Centre, Newcastle, United Kingdom
| | - Graeme J M Alexander
- Sheila Sherlock Liver Centre, Royal Free London NHS Foundation Trust, London, UK
- UCL Institute for Liver and Digestive Health, Division of Medicine, University College London, London, UK
| | - Michael H Chapman
- Department of Gastroenterology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Jane Collier
- Translational Gastroenterology Unit, Oxford University Hospitals, University of Oxford, Oxford, UK
| | - Stefan Hübscher
- Centre for Liver Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- Department of Cellular Pathology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Imran Patanwala
- Department of Gastroenterology, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
- University of Liverpool, Liverpool, UK
| | - Stephen P Pereira
- Sheila Sherlock Liver Centre, Royal Free London NHS Foundation Trust, London, UK
- UCL Institute for Liver and Digestive Health, Division of Medicine, University College London, London, UK
- Department of Gastroenterology, University College London Hospitals NHS Foundation Trust, London, UK
| | | | - Douglas Thorburn
- Sheila Sherlock Liver Centre, Royal Free London NHS Foundation Trust, London, UK
- UCL Institute for Liver and Digestive Health, Division of Medicine, University College London, London, UK
| | - Dina Tiniakos
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | | | - George Webster
- Department of Gastroenterology, University College London Hospitals NHS Foundation Trust, London, UK
| | - David E J Jones
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
- NIHR Newcastle Biomedical Research Centre, Newcastle, United Kingdom
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15
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Hisamatsu T, Kunisaki R, Nakamura S, Tsujikawa T, Hirai F, Nakase H, Watanabe K, Yokoyama K, Nagahori M, Kanai T, Naganuma M, Michimae H, Andoh A, Yamada A, Yokoyama T, Kamata N, Tanaka S, Suzuki Y, Hibi T, Watanabe M. Effect of elemental diet combined with infliximab dose escalation in patients with Crohn's disease with loss of response to infliximab: CERISIER trial. Intest Res 2018; 16:494-498. [PMID: 30090050 PMCID: PMC6077314 DOI: 10.5217/ir.2018.16.3.494] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 12/29/2017] [Accepted: 01/09/2018] [Indexed: 01/07/2023] Open
Affiliation(s)
- Tadakazu Hisamatsu
- The Third Department of Internal Medicine, Kyorin University School of Medicine, Mitaka, Japan
| | - Reiko Kunisaki
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Shiro Nakamura
- Department of Inflammatory Bowel Disease, Hyogo College of Medicine, Nishinomiya, Japan
| | - Tomoyuki Tsujikawa
- Department of Gastroenterology and Hepatology, National Hospital Organization, Higashi-Ohmi Medical Center, Higashi-Ohmi, Japan
| | - Fumihito Hirai
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Hiroshi Nakase
- Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Kenji Watanabe
- Division of Gastroenterology, Osaka City General Hospital, Osaka, Japan.,Department of Intestinal Inflammation Research, Hyogo College of Medicine, Nishinomiya, Japan
| | - Kaoru Yokoyama
- Department of Gastroenterology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Masakazu Nagahori
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takanori Kanai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Makoto Naganuma
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Hirofumi Michimae
- Department of Clinical Medicine (Biostatistics), Kitasato University School of Pharmacy, Tokyo, Japan
| | - Akira Andoh
- Division of Gastroenterology, Shiga University of Medical Science, Otsu, Japan
| | - Akihiro Yamada
- Department of Internal Medicine, Toho University Sakura Medical Centre, Sakura, Japan
| | | | - Noriko Kamata
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Shinji Tanaka
- Department of Endoscopy, Hiroshima University Hospital, Hiroshima, Japan
| | - Yasuo Suzuki
- Department of Internal Medicine, Toho University Sakura Medical Centre, Sakura, Japan
| | - Toshifumi Hibi
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Mamoru Watanabe
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
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16
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Duncan H, Painesi A, Buchanan E, McGrogan P, Gerasimidis K, Walker G, Haddock G, Russell RK. Percutaneous endoscopic gastrostomy placement in paediatric Crohn's disease patients contributes to both improved nutrition and growth. Acta Paediatr 2018; 107:1094-1099. [PMID: 29423918 DOI: 10.1111/apa.14268] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 12/11/2017] [Accepted: 02/02/2018] [Indexed: 01/14/2023]
Abstract
AIM This paper describes the outcomes of gastrostomy feeding in patients with Crohn's disease (CD). METHODS Patients with CD who attended the Royal Hospital for Children, Glasgow and received gastrostomy feeding for at least two years between 2003 and 2010 were identified from the clinical database. The data recorded included the anthropometric data, CD phenotype, the surgical technique that was used, complications, medication, feed type, median feed, calories, volume and clinical outcomes. RESULTS The study identified 16 patients (14 male) who had a gastrostomy inserted using a pull technique at a median age of 12.6 years. Of these two required laparoscopic placement. Short-term complications lasting less than one month were experienced by nine (56%) patients and one (6%) experienced long-term complications. Anthropometry significantly improved at follow-up compared to baseline: at 12 months, the body mass index z-score was 1.11 (p = 0.005) and the weight z-score was 0.19 (p < 0.05). At 24 months, the height z-score was -1.03 (p = 0.04). The daily median volume and calories from feeds increased significantly from baseline to post-PEG insertion, from 400 to 738 mL and 705 to 860 kcal/day (p ≤ 0.01). CONCLUSION Gastrostomy feeding for paediatric patients with CD was associated with improved nutrition, weight gain and growth outcomes.
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Affiliation(s)
- H Duncan
- Department of Nutrition & Dietetics; The Royal Hospital for Children; Glasgow UK
| | - A Painesi
- Human Nutrition; School of Medicine; College of Medicine, Veterinary and Life Sciences; New Lister Building; Glasgow Royal Infirmary; University of Glasgow; Glasgow UK
| | - E Buchanan
- Department of Nutrition & Dietetics; The Royal Hospital for Children; Glasgow UK
| | - P McGrogan
- Paediatric Gastroenterology Department; The Royal Hospital for Children; Glasgow UK
| | - K Gerasimidis
- Human Nutrition; School of Medicine; College of Medicine, Veterinary and Life Sciences; New Lister Building; Glasgow Royal Infirmary; University of Glasgow; Glasgow UK
| | - G Walker
- Department of Surgical Paediatrics; The Royal Hospital for Children; Glasgow UK
| | - G Haddock
- Department of Surgical Paediatrics; The Royal Hospital for Children; Glasgow UK
| | - RK Russell
- Paediatric Gastroenterology Department; The Royal Hospital for Children; Glasgow UK
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17
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Nutrition in Pediatric Inflammatory Bowel Disease: A Position Paper on Behalf of the Porto Inflammatory Bowel Disease Group of the European Society of Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr 2018; 66:687-708. [PMID: 29570147 DOI: 10.1097/mpg.0000000000001896] [Citation(s) in RCA: 88] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS A growing body of evidence supports the need for detailed attention to nutrition and diet in children with inflammatory bowel disease (IBD). We aimed to define the steps in instituting dietary or nutritional management in light of the current evidence and to offer a useful and practical guide to physicians and dieticians involved in the care of pediatric IBD patients. METHODS A group of 20 experts in pediatric IBD participated in an iterative consensus process including 2 face-to-face meetings, following an open call to Nutrition Committee of the European Society of Pediatric Gastroenterology, Hepatology and Nutrition Porto, IBD Interest, and Nutrition Committee. A list of 41 predefined questions was addressed by working subgroups based on a systematic review of the literature. RESULTS A total of 53 formal recommendations and 47 practice points were endorsed with a consensus rate of at least 80% on the following topics: nutritional assessment; macronutrients needs; trace elements, minerals, and vitamins; nutrition as a primary therapy of pediatric IBD; probiotics and prebiotics; specific dietary restrictions; and dietary compounds and the risk of IBD. CONCLUSIONS This position paper represents a useful guide to help the clinicians in the management of nutrition issues in children with IBD.
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18
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Ashton JJ, Gavin J, Beattie RM. Exclusive enteral nutrition in Crohn's disease: Evidence and practicalities. Clin Nutr 2018; 38:80-89. [PMID: 29398336 DOI: 10.1016/j.clnu.2018.01.020] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 12/08/2017] [Accepted: 01/11/2018] [Indexed: 12/19/2022]
Abstract
Exclusive enteral nutrition (EEN) is the first line therapy for paediatric Crohn's disease, providing a complete nutritional feed whilst simultaneously inducing remission in up to 80% of cases. The effect of EEN on systemic/local intestinal immune function and subsequent inflammation (including barrier permeability, direct anti-inflammatory effects and cytokine signalling pathways), alongside changes in the microbiome (specific species and broad taxonomic shifts, functional changes) are becoming clearer, however the exact mechanism for induction of remission in Crohn's disease remains uncertain. The evidence of efficacy in paediatric Crohn's disease is strong, with selected adult populations also benefiting from EEN. However despite recommendations from all major societies (ECCO, ESPGHAN, NASPGHAN and ESPEN) first-line use of EEN is varied and Europe/Australasia/Canada show significantly more routine use than other parts of North America. Growth and nutritional status are significantly improved with EEN compared to corticosteroids but long-term outcomes are sparse. This review discusses the evidence underlying the use of EEN, highlighting the mechanisms thought to underlie how EEN induces remission in Crohn's disease, when and how to use EEN, including practical issues in both paediatric and adult practice (formulation, compliance, volumes and administration), and summarises the ongoing research priorities.
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Affiliation(s)
- James J Ashton
- Department of Paediatric Gastroenterology, Southampton Children's Hospital, Southampton, UK; Human Genetics and Genomic Medicine, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Joan Gavin
- Department of Paediatric Dietetics, Southampton Children's Hospital, Southampton, UK
| | - R Mark Beattie
- Department of Paediatric Gastroenterology, Southampton Children's Hospital, Southampton, UK.
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19
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Alhagamhmad MH. Enteral Nutrition in the Management of Crohn's Disease: Reviewing Mechanisms of Actions and Highlighting Potential Venues for Enhancing the Efficacy. Nutr Clin Pract 2018; 33:483-492. [PMID: 29323428 DOI: 10.1002/ncp.10004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 09/12/2017] [Accepted: 10/10/2017] [Indexed: 12/16/2022] Open
Abstract
Crohn's disease (CD) is a chronic condition that affects the gut and has adverse effects on growth and development. There is a global increase in the incidence and prevalence rates, and several factors are believed to contribute to this rise, including dietary habits. In contrast, the use of enteral nutrition (EN) as an exclusive source of nutrition is increasingly becoming the preferred induction treatment of pediatric CD patients in part to address the nutrition complications. However, EN therapy is considered less effective in adults with CD. A better understanding of the molecular mechanisms of enteral therapy will help improve the clinical management of CD. It is increasingly becoming evident that the therapeutic utility of EN is in part due to the reversal of the microbial changes and the direct immunomodulatory effects. Moreover, there is a potential tendency for enhancing the efficacy of EN therapy by improving the palatability of the given formulas and, more important, by magnifying the anti-inflammatory properties. Recent observations have shown that the immunomodulatory effects of EN are mediated at least in part by blocking nuclear factor-κB. Furthermore, it is likely that several ingredients of EN contribute to this activity, in particular glutamine and arginine amino acids. In addition, manipulating the composition of EN therapy by altering concentrations of the key ingredients is found to have the potential for more efficient therapy. In this review, the underlying mechanisms of EN actions will be discussed further with a focus on the potential methods for enhancing the efficacy.
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Affiliation(s)
- Moftah H Alhagamhmad
- Faculty of Medicine, University of Benghazi (Al-Arab Medical University), Benghazi, Libya
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20
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McIlroy J, Ianiro G, Mukhopadhya I, Hansen R, Hold GL. Review article: the gut microbiome in inflammatory bowel disease-avenues for microbial management. Aliment Pharmacol Ther 2018; 47:26-42. [PMID: 29034981 DOI: 10.1111/apt.14384] [Citation(s) in RCA: 130] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 05/29/2017] [Accepted: 09/25/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND The concept of an altered collective gut microbiota rather than identification of a single culprit is possibly the most significant development in inflammatory bowel disease research. We have entered the "omics" era, which now allows us to undertake large-scale/high-throughput microbiota analysis which may well define how we approach diagnosis and treatment of inflammatory bowel disease (IBD) in the future, with a strong steer towards personalised therapeutics. AIM To assess current epidemiological, experimental and clinical evidence of the current status of knowledge relating to the gut microbiome, and its role in IBD, with emphasis on reviewing the evidence relating to microbial therapeutics and future microbiome modulating therapeutics. METHODS A Medline search including items 'intestinal microbiota/microbiome', 'inflammatory bowel disease', 'ulcerative colitis', 'Crohn's disease', 'faecal microbial transplantation', 'dietary manipulation' was performed. RESULTS Disease remission and relapse are associated with microbial changes in both mucosal and luminal samples. In particular, a loss of species richness in Crohn's disease has been widely observed. Existing therapeutic approaches broadly fall into 3 categories, namely: accession, reduction or indirect modulation of the microbiome. In terms of microbial therapeutics, faecal microbial transplantation appears to hold the most promise; however, differences in study design/methodology mean it is currently challenging to elegantly translate results into clinical practice. CONCLUSIONS Existing approaches to modulate the gut microbiome are relatively unrefined. Looking forward, the future of microbiome-modulating therapeutics looks bright with several novel strategies/technologies on the horizon. Taken collectively, it is clear that ignoring the microbiome in IBD is not an option.
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Affiliation(s)
- J McIlroy
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - G Ianiro
- Internal Medicine, Gastroenterology and Liver Unit, Gastroenterology Area, Fondazione Policlinico Universitario Gemelli, Università Cattolica del Sacro Cuore, Rome, Italy
| | - I Mukhopadhya
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - R Hansen
- Royal Hospital for Children, Glasgow, UK
| | - G L Hold
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
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21
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Sigall Boneh R, Sarbagili Shabat C, Yanai H, Chermesh I, Ben Avraham S, Boaz M, Levine A. Dietary Therapy With the Crohn's Disease Exclusion Diet is a Successful Strategy for Induction of Remission in Children and Adults Failing Biological Therapy. J Crohns Colitis 2017; 11:1205-1212. [PMID: 28525622 DOI: 10.1093/ecco-jcc/jjx071] [Citation(s) in RCA: 110] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 05/18/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Loss of response [LoR] to biologics in Crohn's disease [CD] is a significant clinical problem. Dietary therapy as a treatment strategy in this setting has not been previously reported. We report the use of dietary strategies using enteral nutrition coupled with the Crohn's Disease Exclusion Diet [CDED] for LoR to infliximab or adalimumab as a single-centre experience. METHODS Patients with LoR to a biologic despite dose escalation or combination therapy were treated with partial enteral nutrition [PEN] by a polymeric formula and the CDED for 12 weeks. Paediatric patients with severe flares received 14 days of exclusive enteral nutrition followed by PEN + CDED as above. All patients were seen at weeks 6 and 12 for follow up. Current and prior treatment, Harvey Bradshaw Index [HBI], C-reactive protein [CRP] and albumin were recorded. Remission was defined as HBI <5 at week 6. RESULTS Twenty-one patients, mean age 22.1 ± 8.9 years [11 adults and ten children] met study criteria. Seventeen patients [81%] had used combination therapy, and 10/21 [47.6%] had failed a second biologic. Seven patients had a prior intestinal resection. Dose escalation had failed in 13/21 [62%] patients. Clinical remission by physician's global assessment and HBI after 6 weeks was obtained in 13/21 [61.9%]. Mean HBI decreased from 9.4 ± 4.2 to 2.6 ± 3.8 [p < 0.001], mean CRP decreased from 2.8 ± 3.4 to 0.7 ± 0.5 [p = 0.005] and mean albumin increased from 3.5 ± 0.6 to 3.8 ± 0.5 [p = 0.06]. CONCLUSION Dietary treatment combining PEN with the CDED may be a useful salvage regimen for patients failing biological therapy despite dose escalation.
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Affiliation(s)
- Rotem Sigall Boneh
- Pediatric Gastroenterology and Nutrition Unit, PIBD Research Unit, Wolfson Medical Center, Holon, Israel
| | - Chen Sarbagili Shabat
- Pediatric Gastroenterology and Nutrition Unit, PIBD Research Unit, Wolfson Medical Center, Holon, Israel
| | - Henit Yanai
- IBD Center, Department of Gastroenterology and Liver Diseases, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Irit Chermesh
- Gastroenterology Department, Rambam Health Care Campus, Haifa, Israel
| | - Sivan Ben Avraham
- Pediatric Gastroenterology and Nutrition Unit, PIBD Research Unit, Wolfson Medical Center, Holon, Israel
| | - Mona Boaz
- Epidemiology and Research Unit E, Wolfson Medical Center, Holon, Israel.,Department of Nutrition School of Health Sciences, Ariel University, Ariel, Israel
| | - Arie Levine
- Pediatric Gastroenterology and Nutrition Unit, PIBD Research Unit, Wolfson Medical Center, Holon, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Maintenance of Remission with Partial Enteral Nutrition Therapy in Pediatric Crohn's Disease: A Retrospective Study. Can J Gastroenterol Hepatol 2017; 2017:5873158. [PMID: 28567370 PMCID: PMC5439067 DOI: 10.1155/2017/5873158] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Accepted: 04/11/2017] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Partial enteral nutrition (PEN) may be helpful for the maintenance of remission in pediatric Crohn's disease patients. AIMS To evaluate the efficacy of PEN treatment for preventing clinical relapse. METHODS We retrospectively assessed 42 pediatric Crohn's disease patients who entered clinical remission on 4-12 weeks of exclusive enteral nutrition (EEN) and were maintained on PEN as a supplementary diet. We evaluated the efficacy of the treatment at different time points using the weighted Pediatric Crohn Disease Activity Index (wPCDAI), Physician Global Assessment, laboratory parameters, and growth of each patient. Additionally, we assessed the use of concomitant medications. RESULTS The median length of remission with PEN was 6 (0-36) months. Patients' remission was maintained on PEN without concomitant medications for a median time of zero months (0-16). The mean body mass index in the PEN group increased from 18.1 to 18.8 after six months of PEN. The median wPCDAI decreased from 30 at diagnosis to 5.0 after EEN and increased to 7.5 after three months of PEN. Overall, the median wPCDAI decreased by 26.2. CONCLUSIONS PEN treatment was partially effective in maintaining remission and was able to increase BMI and lower wPCDAI. Most patients required concomitant medication after PEN initiation.
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23
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Zheng XB, Peng X, Xie XY, Lian L, Wu XR, Hu JC, He XW, Ke J, Chen YF, Zhi M, Wu XJ, He XS, Lan P. Enteral nutrition is associated with a decreased risk of surgical intervention in Crohns disease patients with spontaneous intra-abdominal abscess. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2017; 109:834-842. [DOI: 10.17235/reed.2017.5116/2017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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24
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Yamamoto T, Shimoyama T, Kuriyama M. Dietary and enteral interventions for Crohn's disease. Curr Opin Biotechnol 2016; 44:69-73. [PMID: 27940405 DOI: 10.1016/j.copbio.2016.11.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Revised: 11/14/2016] [Accepted: 11/17/2016] [Indexed: 01/18/2023]
Abstract
It is now widely acknowledged that the intestinal bacterial flora together with genetic predisposing factors significantly contribute to the immunopathogenesis of inflammatory bowel disease (IBD) as reflected by mucosal immune dysregulation. Recently, there has been an increased interest in nutraceutical therapies, including probiotics, prebiotics and synbiotics. Other dietary interventions with low carbohydrate diet, omega-3 polyunsaturated fatty acids and glutamine have been attempted to downregulate the gut inflammatory response and thereby alleviate gastrointestinal symptoms. Enteral nutrition has been widely used as induction and maintenance therapies in the management of Crohn's disease (CD). In this review, a critical assessment of the results of clinical trial outcomes and meta-analyses was conducted to evaluate the efficacy of dietary and enteral interventions for CD.
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Affiliation(s)
- Takayuki Yamamoto
- Inflammatory Bowel Disease Center, Yokkaichi Hazu Medical Center, Yokkaichi, Mie, Japan.
| | - Takahiro Shimoyama
- Inflammatory Bowel Disease Center, Yokkaichi Hazu Medical Center, Yokkaichi, Mie, Japan
| | - Moeko Kuriyama
- Inflammatory Bowel Disease Center, Yokkaichi Hazu Medical Center, Yokkaichi, Mie, Japan
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25
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Infliximab Combined with Enteral Nutrition for Managing Crohn's Disease Complicated with Intestinal Fistulas. Gastroenterol Res Pract 2016; 2016:5947926. [PMID: 27738427 PMCID: PMC5055994 DOI: 10.1155/2016/5947926] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 06/23/2016] [Accepted: 06/29/2016] [Indexed: 01/30/2023] Open
Abstract
Aim. This study was performed to evaluate the additional enteral nutrition (EN) in the efficacy of infliximab (IFX) compared with the conventional therapy in managing Crohn's disease (CD) complicated with intestinal fistulas. Methods. A total of 42 CD with intestinal fistulas were randomly divided into infliximab treatment group (n = 20) and conventional therapy group (n = 22). We evaluated the laboratory indexes, Crohn's disease activity index (CDAI), Crohn's disease simplified endoscopic score (SES-CD), and healing of fistula in the two groups before treatment, at 14 weeks, and at 30 weeks, respectively. Results. In the IFX treatment group, the CDAI score, the SES-CD, erythrocyte sedimentation rate, and C-reactive protein levels were significantly decreased during treatment compared with those before treatment. The body mass index and albumin levels were increased in both groups. Moreover, in the IFX treatment group, fistula healing was found in 8 at the 14th week and 18 at the 30th week, respectively, which was greater than that in the conventional therapy group. Conclusion. Our study suggested that infliximab combined with EN is an effective treatment for CD patients complicated with intestinal fistulas.
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26
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Kim HJ, Kim Y, Cho JM, Oh SH, Kim KM. Therapeutic Efficacy of Oral Enteral Nutrition in Pediatric Crohn's Disease: A Single Center Non-Comparative Retrospective Study. Yonsei Med J 2016; 57:1185-91. [PMID: 27401650 PMCID: PMC4960385 DOI: 10.3349/ymj.2016.57.5.1185] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 12/04/2015] [Accepted: 03/11/2016] [Indexed: 02/06/2023] Open
Abstract
PURPOSE Exclusive enteral nutrition (EEN) therapy effectively induces clinical remission in Crohn's disease (CD). It remains unclear, however, whether partial enteral nutrition (PEN) can maintain remission. This study was performed to determine the abilities of oral EEN and oral PEN to induce and maintain clinical remission in pediatric patients with CD, respectively. MATERIALS AND METHODS Pediatric patients with CD who received oral EEN at a single center in 2000-2014 were identified retrospectively. Remission rates of the EEN and PEN during the 2 years study period were determined. Risk factors for EEN and PEN failure were identified. RESULTS Of the 66 patients who started EEN, 61 (92%) completed the course. Clinical remission was achieved in 88% (58/66) of the patients. All 58 patients with remission continued with PEN: 43 (74%) were treatment adherent. The cumulative remission rates at 1 and 2 years were 67% and 52%, respectively. Differing from EEN, limited therapeutic efficacy of PEN was shown in severe CD patients. Female gender associated significantly with non-adherence. CONCLUSION Oral EEN and PEN effectively induced and maintained remission in a pediatric population. Non-adherence was a limiting factor in the success of therapy.
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Affiliation(s)
- Hyun Jin Kim
- Department of Pediatrics, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Young Kim
- Department of Pediatrics, Kwangju Christian Hospital, Gwangju, Korea
| | - Jin Min Cho
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Seak Hee Oh
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyung Mo Kim
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea.
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27
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Basson A. Nutrition management in the adult patient with Crohn’s disease. SOUTH AFRICAN JOURNAL OF CLINICAL NUTRITION 2016. [DOI: 10.1080/16070658.2012.11734423] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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28
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Gunasekeera V, Mendall MA, Chan D, Kumar D. Treatment of Crohn's Disease with an IgG4-Guided Exclusion Diet: A Randomized Controlled Trial. Dig Dis Sci 2016; 61:1148-57. [PMID: 26809868 DOI: 10.1007/s10620-015-3987-z] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 11/30/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM We previously reported an improvement in symptoms in Crohn's disease following an IgG4-guided exclusion diet in an open-label study. We aimed to evaluate, in a double-blinded randomized sham-controlled setting, the efficacy of IgG4-guided diet in improving quality of life in patients with Crohn's disease. METHODS Consecutive patients with Crohn's disease and a Crohn's disease activity index (CDAI) of 80-400 attending tertiary and secondary care centers were screened. All patients had IgG4 titers tested against 16 common food types using ELISA. The true diet group excluded four food types with the highest antibody titers for 4 weeks, and the sham group excluded four foods with the lowest antibody titers. Quality of life was assessed using the Short Inflammatory Bowel Disease Questionnaire (SIBDQ) at beginning and end of the trial. Secondary outcome measures were CDAI, Harvey Bradshaw index, serum C-reactive protein, and fecal calprotectin. RESULTS One hundred and forty-five subjects were screened and 96 subjects had initial food antibody testing performed with 76 patients completing the study. Milk, beef, pork and egg were the most commonly excluded food types in the true diet group. There was a 3.05 (0.01-6.11) p < 0.05 improvement in SIBDQ and 41 (10.4-71.5) in CDAI p = 0.009. CONCLUSION IgG4-guided exclusion diet, as an adjunct, can improve quality of life and symptoms in patients with CD.
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Affiliation(s)
- Viran Gunasekeera
- Colorectal Surgery, St George's Hospital, Blackshaw Road, London, SW17 0QT, UK
| | - Michael A Mendall
- Gastroenterology, Croydon University Hospital, 530 London Rd, Thornton Heath, Surrey, CR7 7YE, UK
| | - Derek Chan
- Gastroenterology, St George's Hospital, Blackshaw Road, London, SW17 0QT, UK
| | - Devinder Kumar
- Colorectal Surgery, St George's Hospital, Blackshaw Road, London, SW17 0QT, UK.
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29
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Burgis JC, Nguyen K, Park KT, Cox K. Response to strict and liberalized specific carbohydrate diet in pediatric Crohn’s disease. World J Gastroenterol 2016; 22:2111-2117. [PMID: 26877615 PMCID: PMC4726683 DOI: 10.3748/wjg.v22.i6.2111] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Revised: 08/18/2015] [Accepted: 09/30/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the specific carbohydrate diet (SCD) as nutritional therapy for maintenance of remission in pediatric Crohn’s disease (CD).
METHODS: Retrospective chart review was conducted in 11 pediatric patients with CD who initiated the SCD as therapy at time of diagnosis or flare. Two groups defined as SCD simple (diet alone, antibiotics or 5-ASA) or SCD with immunomodulators (corticosteroids and/or stable thiopurine dosing) were followed for one year and compared on disease characteristics, laboratory values and anthropometrics.
RESULTS: The mean age at start of the SCD was 11.8 ± 3.0 years (range 6.6-17.6 years) with five patients starting the SCD within 5 wk of diagnosis. Three patients maintained a strict SCD diet for the study period and the mean time for liberalization was 7.7 ± 4.0 mo (range 1-12) for the remaining patients. In both groups, hematocrit, albumin and ESR values improved while on strict SCD and appeared stable after liberalization (P-value 0.006, 0.002, 0.002 respectively). The majority of children gained in weight and height percentile while on strict SCD, with small loss in weight percentile documented with liberalization.
CONCLUSION: Disease control may be attainable with the SCD in pediatric CD. Further studies are needed to assess adherence, impact on mucosal healing and growth.
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30
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Tsertsvadze A, Gurung T, Court R, Clarke A, Sutcliffe P. Clinical effectiveness and cost-effectiveness of elemental nutrition for the maintenance of remission in Crohn's disease: a systematic review and meta-analysis. Health Technol Assess 2015; 19:1-138. [PMID: 25831484 DOI: 10.3310/hta19260] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Although enteral nutrition has been shown to be a viable treatment option for the management of active Crohn's disease (CD), the evidence regarding its clinical benefits compared with standard treatments (e.g. steroids) for maintaining remission in patients with CD has been inconsistent. If enteral nutrition was to be effective, the use of drugs such as steroids and immunosuppressive drugs could be reduced, thereby reducing the likelihood of adverse events associated with these medications. OBJECTIVES This systematic review aimed to assess the clinical effectiveness and cost-effectiveness of elemental nutrition (a type of enteral nutrition) for maintenance of remission in patients with CD. DATA SOURCES Major bibliographic databases (e.g. MEDLINE, EMBASE, Cochrane Database of Systematic Reviews) were searched from inception to August/September 2013. Searches were not limited by study design, language or publication date. Websites for relevant organisations and references of included studies were checked. METHODS Experimental randomised and non-randomised controlled trials (RCTs and nRCTs) reporting clinical effectiveness and cost-effectiveness of elemental nutrition in the maintenance of remission in patients with CD were eligible. Study selection, data extraction and risk of bias (RoB) assessment were performed independently. Risk ratios (RRs) and mean differences (MDs) were pooled using a random-effects model. Heterogeneity was assessed via forest plots, Cochran's Q and the I2 statistics. Overall, quality of evidence for each outcome was rated using the Grading of Recommendations, Assessment, Development, and Evaluation approach. RESULTS Eight studies (three RCTs and five nRCTs) were included in the review. RCTs indicated a significant benefit of elemental nutrition vs. no intervention (an unrestricted diet) in maintaining remission at 24 months [one RCT; RR 2.06, 95% confidence interval (CI) 1.00 to 4.43; very low-grade evidence] and preventing relapse at 12-24 months post baseline (two RCTs; pooled RR 0.57, 95% CI 0.38 to 0.84; I2 = 0%; high-grade evidence). Similarly, three nRCTs showed significant benefits of elemental nutrition over no intervention in maintaining remission at 12-48 months and preventing relapse at 12 months post baseline (MD 1.20 months, 95% CI 0.35 to 2.04 months). The incidence of mucosal healing was not significantly different in the intervention and control groups (RR 2.70, 95% CI 0.62 to 11.72). Adherence to an elemental nutrition regime was significantly worse than adherence to polymeric nutrition (RR 0.68, 95% CI 0.50 to 0.92) and, when compared with other active treatments (medications, polymeric nutrition or a combination), elemental nutrition yielded non-significant results with wide 95% CIs, rendering these results inconclusive. Complications and adverse events were too sparse to allow meaningful comparisons. None of the studies reported cost-effectiveness of elemental nutrition. Owing to scarcity of data, subgroup and sensitivity analyses could not be performed to explore methodological and clinical sources of heterogeneity. LIMITATIONS The findings warrant cautious interpretation given the limitations of the evidence in methodological quality (small samples, short follow-up) and the RoB in individual studies (lack of blinding, confounding). CONCLUSIONS Limited evidence indicates potential benefits of elemental nutrition against no intervention in the maintenance of remission and prevention of relapse in adult patients with CD. There was a lack or insufficient evidence on adverse events and complications. Future large and long-term randomised trials are warranted to draw more definitive conclusions regarding the effects of elemental nutrition in maintaining remission in CD. TRIAL REGISTRATION This study is registered as PROSPERO CRD42013005134. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Alexander Tsertsvadze
- Warwick Evidence, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Tara Gurung
- Warwick Evidence, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Rachel Court
- Warwick Evidence, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Aileen Clarke
- Warwick Evidence, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Paul Sutcliffe
- Warwick Evidence, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
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31
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El-Matary W, Otley A, Critch J, Abou-Setta AM. Enteral Feeding Therapy for Maintaining Remission in Crohn’s Disease: A Systematic Review. JPEN J Parenter Enteral Nutr 2015; 41:550-561. [DOI: 10.1177/0148607115621051] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Wael El-Matary
- Section of Pediatric Gastroenterology and Children’s Hospital Research Institute of Manitoba, Department of Pediatrics, College of Medicine, University of Manitoba, Winnipeg, Canada
| | - Anthony Otley
- Division of Gastroenterology and Nutrition, Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Jeff Critch
- Department of Pediatrics, Memorial University, St John’s, Newfoundland, Canada
| | - Ahmed M. Abou-Setta
- George and Fay Yee Center for Healthcare Innovation, College of Medicine, University of Manitoba, Winnipeg, Canada
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32
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What is known about the mechanisms of dietary influences in Crohn's disease? Nutrition 2015; 31:1195-203. [PMID: 26333887 DOI: 10.1016/j.nut.2015.04.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Revised: 03/23/2015] [Accepted: 04/16/2015] [Indexed: 12/17/2022]
Abstract
Much has been written about the role of diet and risk for Crohn's disease (CD). However, the evidence is contradictory. Recent evidence has pointed to fiber playing an important role along with the possibility that dietary fat and overnutrition also have a role. Diet has a clearer place in disease modification, with some diets used in the treatment of CD. The lack of clarity stems from a poor understanding of the mechanisms underlying the relationship between diet and CD. Gut permeability is likely to play a key role in the risk for CD. Mechanisms whereby diet can affect gut permeability, including the effects of the gut microbiota, are reviewed. Modification of disease behavior is likely to be influenced by additional mechanisms, including recognition of complex food antigens. As with many other chronic diseases, a surrogate marker of CD risk would greatly aid evaluation of the dietary factors involved. Formal measures of gut permeability are too cumbersome for large-scale use, but fecal calprotectin may be a convenient measure of this. There are only preliminary data on the effect of diet and microbiota composition on fecal calprotectin and these require further investigation.
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33
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Hida N, Nakamura S, Hahm KB, Sollano JD, Zhu Q, Rani AA, Syam AF, Kachintorn U, Ueno F, Joh T, Naito Y, Suzuki H, Takahashi SI, Fukudo S, Fujiwara Y, Kinoshita Y, Uchiyama K, Yamaguchi Y, Yoshida A, Arakawa T, Matsumoto T. A questionnaire-based survey on the diagnosis and management of inflammatory bowel disease in East Asian countries in 2012. Digestion 2014; 89:88-103. [PMID: 24458117 DOI: 10.1159/000356706] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIM The prevalence and incidence of inflammatory bowel disease (IBD) are lower in East Asia than in Western countries; however, marked increases have recently been reported. The clinical diagnosis and medical management of IBD in East Asia differ from those in Western countries. A questionnaire-based survey was performed to gather physicians' current opinions on IBD in different East Asian countries. METHODS Representative International Gastrointestinal Consensus Symposium (IGICS) committee members provided a questionnaire to physicians in each East Asian country studied. The questionnaire mainly focused on the diagnosis and management of IBD. RESULTS There were 19 respondents from Japan, 10 from South Korea, 9 from the Philippines, 6 from China and 4 from Indonesia. Colonoscopy (100%) and histopathology (63%) were commonly used for the diagnosis in ulcerative colitis (UC). Conventional small bowel enteroclysis was still the most common diagnostic tool for assessing small bowel lesions in Crohn's disease (CD) in East Asia. The percentage of physicians who investigated the reactivation of Cytomegalovirus in severe or refractory patients with UC ranged from 0% in the Philippines and Indonesia to 100% in Japan and Korea. Most physicians in Korea, the Philippines, China and Indonesia chose thiopurines or anti-TNF therapy as the second-line treatment in severe refractory UC, whereas Japanese physicians preferred to use tacrolimus or leukocyte apheresis. Physicians in the Philippines and Indonesia preferred to use oral 5-aminosalicylic acid for newly diagnosed severe ileocecal CD. In contrast, Korean physicians chose oral steroids and most physicians in China and Japan preferred to use anti-TNF. Nutritional therapy to induce or maintain remission in patients with CD was commonly used in Indonesia, Japan and China. Targeted biopsies by conventional colonoscopy were the most preferred strategy for cancer surveillance in long-standing UC over random biopsies in this region. CONCLUSIONS The present survey found that current diagnostic approaches and clinical management of IBD vary within East Asian countries.
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Affiliation(s)
- Nobuyuki Hida
- Digestive Disease Center, CHA University School of Medicine and CHA University Bundang Medical Center, Seongnam, South Korea
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34
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Ruemmele FM, Veres G, Kolho KL, Griffiths A, Levine A, Escher JC, Amil Dias J, Barabino A, Braegger CP, Bronsky J, Buderus S, Martín-de-Carpi J, De Ridder L, Fagerberg UL, Hugot JP, Kierkus J, Kolacek S, Koletzko S, Lionetti P, Miele E, Navas López VM, Paerregaard A, Russell RK, Serban DE, Shaoul R, Van Rheenen P, Veereman G, Weiss B, Wilson D, Dignass A, Eliakim A, Winter H, Turner D. Consensus guidelines of ECCO/ESPGHAN on the medical management of pediatric Crohn's disease. J Crohns Colitis 2014; 8:1179-207. [PMID: 24909831 DOI: 10.1016/j.crohns.2014.04.005] [Citation(s) in RCA: 737] [Impact Index Per Article: 73.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Revised: 04/14/2014] [Accepted: 04/14/2014] [Indexed: 02/07/2023]
Abstract
Children and adolescents with Crohn's disease (CD) present often with a more complicated disease course compared to adult patients. In addition, the potential impact of CD on growth, pubertal and emotional development of patients underlines the need for a specific management strategy of pediatric-onset CD. To develop the first evidenced based and consensus driven guidelines for pediatric-onset CD an expert panel of 33 IBD specialists was formed after an open call within the European Crohn's and Colitis Organisation and the European Society of Pediatric Gastroenterolog, Hepatology and Nutrition. The aim was to base on a thorough review of existing evidence a state of the art guidance on the medical treatment and long term management of children and adolescents with CD, with individualized treatment algorithms based on a benefit-risk analysis according to different clinical scenarios. In children and adolescents who did not have finished their growth, exclusive enteral nutrition (EEN) is the induction therapy of first choice due to its excellent safety profile, preferable over corticosteroids, which are equipotential to induce remission. The majority of patients with pediatric-onset CD require immunomodulator based maintenance therapy. The experts discuss several factors potentially predictive for poor disease outcome (such as severe perianal fistulizing disease, severe stricturing/penetrating disease, severe growth retardation, panenteric disease, persistent severe disease despite adequate induction therapy), which may incite to an anti-TNF-based top down approach. These guidelines are intended to give practical (whenever possible evidence-based) answers to (pediatric) gastroenterologists who take care of children and adolescents with CD; they are not meant to be a rule or legal standard, since many different clinical scenario exist requiring treatment strategies not covered by or different from these guidelines.
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Affiliation(s)
- F M Ruemmele
- Department of Paediatric Gastroenterology, APHP Hôpital Necker Enfants Malades, 149 Rue de Sèvres 75015 Paris, France; Université Paris Descartes, Sorbonne Paris Cité, 2 Rue de l'École de Médecine, 75006 Paris, France; INSERM U989, Institut IMAGINE, 24 Bd Montparnasse, 75015 Paris, France.
| | - G Veres
- Department of Paediatrics I, Semmelweis University, Bókay János str. 53, 1083 Budapest, Hungary
| | - K L Kolho
- Department of Gastroenterology, Helsinki University Hospital for Children and Adolescents, Stenbäckinkatu 11, P.O. Box 281, 00290 Helsinki, Finland
| | - A Griffiths
- Department of Paediatrics, Hospital for Sick Children, University of Toronto, 555 University Avenue, M5G 1X8 Toronto, ON, Canada
| | - A Levine
- Paediatric Gastroenterology and Nutrition Unit, Tel Aviv University, Edith Wolfson Medical Center, 62 HaLohamim Street, 58100 Holon, Israel
| | - J C Escher
- Department of Paediatric Gastroenterology, Erasmus Medical Center, Wytemaweg 80, 3015 CN Rotterdam, Netherlands
| | - J Amil Dias
- Unit of Paediatric Gastroenterology, Hospital S. João, A Hernani Monteiro, 4202-451, Porto, Portugal
| | - A Barabino
- Gastroenterology and Endoscopy Unit, Istituto G. Gaslini, Via G. Gaslini 5, 16148 Genoa, Italy
| | - C P Braegger
- Division of Gastroenterology and Nutrition, and Children's Research Center, University Children's Hospital Zurich, Steinwiesstrasse 75, 8032 Zurich, Switzerland
| | - J Bronsky
- Department of Pediatrics, University Hospital Motol, Uvalu 84, 150 06 Prague, Czech Republic
| | - S Buderus
- Department of Paediatrics, St. Marien Hospital, Robert-Koch-Str.1, 53115 Bonn, Germany
| | - J Martín-de-Carpi
- Department of Paediatric Gastroenterolgoy, Hepatology and Nutrition, Hospital Sant Joan de Déu, Paseo Sant Joan de Déu 2, 08950 Barcelona, Spain
| | - L De Ridder
- Department of Paediatric Gastroenterology, Erasmus Medical Center, Wytemaweg 80, 3015 CN Rotterdam, Netherlands
| | - U L Fagerberg
- Department of Pediatrics, Centre for Clinical Research, Entrance 29, Västmanland Hospital, 72189 Västerås/Karolinska Institutet, Stockholm, Sweden
| | - J P Hugot
- Department of Gastroenterology and Nutrition, Hopital Robert Debré, 48 Bd Sérurier, APHP, 75019 Paris, France; Université Paris-Diderot Sorbonne Paris-Cité, 75018 Paris France
| | - J Kierkus
- Department of Gastroenterology, Hepatology and Feeding Disorders, Instytut Pomnik Centrum Zdrowia Dziecka, Ul. Dzieci Polskich 20, 04-730 Warsaw, Poland
| | - S Kolacek
- Department of Paediatric Gastroenterology, Children's Hospital, University of Zagreb Medical School, Klaićeva 16, 10000 Zagreb, Croatia
| | - S Koletzko
- Department of Paediatric Gastroenterology, Dr. von Hauner Children's Hospital, Lindwurmstr. 4, 80337 Munich, Germany
| | - P Lionetti
- Department of Gastroenterology and Nutrition, Meyer Children's Hospital, Viale Gaetano Pieraccini 24, 50139 Florence, Italy
| | - E Miele
- Department of Translational Medical Science, Section of Paediatrics, University of Naples "Federico II", Via S. Pansini, 5, 80131 Naples, Italy
| | - V M Navas López
- Paediatric Gastroenterology and Nutrition Unit, Hospital Materno Infantil, Avda. Arroyo de los Ángeles s/n, 29009 Málaga, Spain
| | - A Paerregaard
- Department of Paediatrics 460, Hvidovre University Hospital, Kettegård Allé 30, 2650 Hvidovre, Denmark
| | - R K Russell
- Department of Paediatric Gastroenterology, Yorkhill Hospital, Dalnair Street, Glasgow G3 8SJ, United Kingdom
| | - D E Serban
- 2nd Department of Paediatrics, "Iuliu Hatieganu" University of Medicine and Pharmacy, Emergency Children's Hospital, Crisan nr. 5, 400177 Cluj-Napoca, Romania
| | - R Shaoul
- Department of Pediatric Gastroenterology and Nutrition, Rambam Health Care Campus Rappaport Faculty Of Medicine, 6 Ha'alya Street, P.O. Box 9602, 31096 Haifa, Israel
| | - P Van Rheenen
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, University Medical Center Groningen, P.O. Box 30001, 9700 RB Groningen, Netherlands
| | - G Veereman
- Department of Paediatric Gastroenterology and Nutrition, Children's University Hospital, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - B Weiss
- Paediatric Gastroenterology and Nutrition Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, 52625 Tel Hashomer, Israel
| | - D Wilson
- Child Life and Health, Paediatric Gastroenterology, Royal Hospital for Sick Children, 9 Sciennes Road, Edinburgh EH9 1LF, United Kingdom
| | - A Dignass
- Department of Medicine I, Agaplesion Markus Hospital, Wilhelm-Epstein-Str. 4, 60431 Frankfurt/Main, Gemany
| | - A Eliakim
- 33-Gastroenterology, Sheba Medical Center, 52621 Tel Hashomer, Israel
| | - H Winter
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Mass General Hospital for Children, 175 Cambridge Street, 02114 Boston, United States
| | - D Turner
- Pediatric Gastroenterology Unit, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Israel
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Duncan H, Buchanan E, Cardigan T, Garrick V, Curtis L, McGrogan P, Barclay A, Russell RK. A retrospective study showing maintenance treatment options for paediatric CD in the first year following diagnosis after induction of remission with EEN: supplemental enteral nutrition is better than nothing! BMC Gastroenterol 2014; 14:50. [PMID: 24645851 PMCID: PMC4234202 DOI: 10.1186/1471-230x-14-50] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Accepted: 03/14/2014] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND A limited body of research suggests that ongoing maintenance enteral nutrition (MEN) can be beneficial in maintaining disease remission in Crohn's Disease (CD). We aimed to assess how achievable MEN is and whether it helps to prolong remission. METHODS Patients newly diagnosed with CD in 2010 and 2011 who commenced exclusive enteral nutrition (EEN) for 8 weeks were followed up for a year post diagnosis. All patients who took EEN were encouraged to continue MEN post EEN. Data on azathioprine use was also collected. Categorical variables were compared using chi-square/Fischer's exact test. Medians were expressed along with complete data ranges. RESULTS 59 patients (34 male, median age 11.07 years, range 2.5-16.33 years) were identified. 11/59 (18%) had a poor response to EEN and were switched to steroids. 48/59 patients completed 8 weeks EEN and achieved clinical remission/response. 46/48 patients received Modulen IBD®, 29/48 (60%) consumed EEN orally and 19/48 (40%) via NGT. 15/48 (31%) patients were able to continue MEN post EEN completion. MEN was consumed for a mean of 10.8 months (range 4-14 months). 14/15 patients drank MEN and 1/15 had MEN via NGT. Remission rates at 1 year in patients continuing MEN were 60% (9/15) compared to 15% (2/13) in patients taking no treatment (p = 0.001) and 65% (13/20) in patients taking azathioprine (p = 0.14). CONCLUSION A sub group of patients can continue MEN as a maintenance treatment and this seems a useful strategy, especially in those who are not commencing azathioprine.
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Affiliation(s)
- Hazel Duncan
- Department of Nutrition & Dietetics, Yorkhill Hospital Glasgow, Dalnair Street, Glasgow G3 8SJ, United Kingdom
| | - Elaine Buchanan
- Department of Nutrition & Dietetics, Yorkhill Hospital Glasgow, Dalnair Street, Glasgow G3 8SJ, United Kingdom
| | - Tracey Cardigan
- Department of Nutrition & Dietetics, Yorkhill Hospital Glasgow, Dalnair Street, Glasgow G3 8SJ, United Kingdom
| | - Vikki Garrick
- Paediatric Gastroenterology Department, Yorkhill Hospital Glasgow, Glasgow, United Kingdom
| | - Lee Curtis
- Paediatric Gastroenterology Department, Yorkhill Hospital Glasgow, Glasgow, United Kingdom
| | - Paraic McGrogan
- Paediatric Gastroenterology Department, Yorkhill Hospital Glasgow, Glasgow, United Kingdom
| | - Andrew Barclay
- Paediatric Gastroenterology Department, Yorkhill Hospital Glasgow, Glasgow, United Kingdom
| | - Richard K Russell
- Paediatric Gastroenterology Department, Yorkhill Hospital Glasgow, Glasgow, United Kingdom
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Yan D, Ren J, Wang G, Liu S, Li J. Predictors of response to enteral nutrition in abdominal enterocutaneous fistula patients with Crohn's disease. Eur J Clin Nutr 2014; 68:959-63. [DOI: 10.1038/ejcn.2014.31] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Revised: 11/26/2013] [Accepted: 12/07/2013] [Indexed: 12/17/2022]
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Richman E, Rhodes JM. Review article: evidence-based dietary advice for patients with inflammatory bowel disease. Aliment Pharmacol Ther 2013; 38:1156-71. [PMID: 24102340 DOI: 10.1111/apt.12500] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Revised: 08/02/2013] [Accepted: 08/30/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND The therapeutic effect of enteral nutrition in Crohn's disease (CD) and the epidemiological associations between diet and inflammatory bowel disease (IBD) implicate diet in IBD causation. There is little evidence, however, to support specific dietary changes and patients often receive contradictory advice. AIM To review the literature on the impacts of diet on IBD causation and activity to produce guidance based on 'best available evidence'. METHOD Review of Medline, Embase and Cochrane databases from 1975 to 2012 using MeSH headings 'crohn's disease' 'ulcerative colitis' 'enteral' 'diet' 'nutrition' 'fatty acid' and 'food additives'. RESULTS Enteral nutrition with a formula-defined feed is effective treatment for CD, but approximately 50% of patients relapse within 6 months of return to normal diet. There is no direct evidence of benefit from any other specific dietary modification in CD, but indirect evidence supports recommendation of a low intake of animal fat, insoluble fibre and processed fatty foods containing emulsifiers. Foods tolerated in sustained remission may not be tolerated following relapse. Some evidence supports vitamin D supplementation. In ulcerative colitis (UC), evidence is weaker, but high intakes of meat and margarine correlate with increased UC incidence and high meat intake also correlates with increased likelihood of relapse. CONCLUSIONS There is little evidence from interventional studies to support specific dietary recommendations. Nevertheless, people with IBD deserve advice based on 'best available evidence' rather than no advice at all, although dietary intake should not be inappropriately restrictive. Further interventional studies of dietary manipulation are urgently required.
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Affiliation(s)
- E Richman
- Department of Dietetics, Royal Liverpool University Hospital, Liverpool, UK
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Massironi S, Rossi RE, Cavalcoli FA, Della Valle S, Fraquelli M, Conte D. Nutritional deficiencies in inflammatory bowel disease: therapeutic approaches. Clin Nutr 2013; 32:904-10. [PMID: 23602613 DOI: 10.1016/j.clnu.2013.03.020] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Revised: 03/19/2013] [Accepted: 03/24/2013] [Indexed: 02/05/2023]
Abstract
BACKGROUND & AIMS Malnutrition is common in inflammatory bowel diseases (IBD), mainly in Crohn's disease (CD) because the small bowel is primarily affected. We reviewed the literature to highlight the importance of proper nutrition management. METHODS A PubMed search was performed for English-language publications from 1999 through 2012. Manuscripts comparing nutritional approaches for IBD patients were selected. RESULTS We identified 2025 manuscripts: six meta-analyses, 170 clinical-trials, 692 reviews. The study findings are discordant. In adult CD, enteral nutrition plays a supportive role, steroid therapy remaining the first choice treatment. In CD children enteral nutrition may represent the primary therapy. As regards parenteral nutrition, there are no large randomized studies, although mild improvements in morbidity have been described as a result of parenteral nutrition in malnourished surgical IBD patients. Specific micronutrient deficiencies are common in IBD. A number of factors may contribute to micronutrient deficiencies, and these include: dietary restriction, disease activity and surgery. The possible therapeutic roles of omega-3 fatty-acids, probiotics and prebiotics have been studied, but the results are still preliminary. CONCLUSION Protein-energy malnutrition and micronutrient depletion are clinical concerns in IBD patients. Enteral nutrition, parenteral nutrition and micronutrient supplementation are cornerstone of the multidisciplinary management of IBD patients.
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Affiliation(s)
- Sara Massironi
- Gastroenterology Unit II, Fondazione IRCCS Ca' Granda- Ospedale Maggiore Policlinico, Milan, Italy.
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Abstract
PURPOSE OF REVIEW Diet is known to have a major role in the expression of inflammatory bowel disease (IBD). The role of dietary interventions and enteral nutrition in the management of IBD remains unelucidated. This study was to review the current evidence for dietary risk factors for the development of IBD and the efficacies of dietary and enteral interventions. RECENT FINDINGS High dietary intakes of total fats, polyunsaturated fatty acids, omega-6 fatty acids, and meat are associated with an increased risk of Crohn's disease and ulcerative colitis. Further prospective studies are required to confirm these observations. Among various dietary interventions, none has shown striking efficacy. Meta-analyses have shown enteral nutrition to be inferior to corticosteroids in adults with active Crohn's disease. However, in children, a meta-analysis has shown no significant difference in the remission rates between enteral nutrition and corticosteroid therapy. Although the evidence level is not striking, enteral nutrition may be useful for maintaining remission in patients with quiescent Crohn's disease. SUMMARY Dietary risk factors for IBD and the therapeutic benefit of dietary and enteral interventions need to be confirmed by further well designed studies in large cohorts of patients.
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Yamamoto T, Shiraki M. Comment to 'Nutritional therapy versus 6-mercaptopurine as maintenance therapy in patients with Crohn's disease'. Dig Liver Dis 2013; 45:264. [PMID: 22981244 DOI: 10.1016/j.dld.2012.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2012] [Revised: 08/08/2012] [Accepted: 08/11/2012] [Indexed: 12/11/2022]
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Long-term efficacy of enteral nutrition for patients with Crohn's disease. Dig Dis Sci 2012; 57:3310-1; author reply 3311. [PMID: 23086121 DOI: 10.1007/s10620-012-2444-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Accepted: 09/27/2012] [Indexed: 01/07/2023]
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Cabré E, Domènech E. Impact of environmental and dietary factors on the course of inflammatory bowel disease. World J Gastroenterol 2012; 18:3814-22. [PMID: 22876032 PMCID: PMC3413052 DOI: 10.3748/wjg.v18.i29.3814] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Revised: 03/26/2012] [Accepted: 03/29/2012] [Indexed: 02/06/2023] Open
Abstract
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.
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Latella G, Papi C. Crucial steps in the natural history of inflammatory bowel disease. World J Gastroenterol 2012; 18:3790-9. [PMID: 22876029 PMCID: PMC3413049 DOI: 10.3748/wjg.v18.i29.3790] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Revised: 04/18/2012] [Accepted: 05/05/2012] [Indexed: 02/06/2023] Open
Abstract
Inflammatory bowel diseases (IBD), including ulcerative colitis (UC) and Crohn’s disease (CD), are chronic, progressive and disabling disorders. Over the last few decades, new therapeutic approaches have been introduced which have led not only to a reduction in the mortality rate but also offered the possibility of a favorable modification in the natural history of IBD. The identification of clinical, genetic and serological prognostic factors has permitted a better stratification of the disease, thus allowing the opportunity to indicate the most appropriate therapy. Early treatment with immunosuppressive drugs and biologics has offered the opportunity to change, at least in the short term, the course of the disease by reducing, in a subset of patients with IBD, hospitalization and the need for surgery. In this review, the crucial steps in the natural history of both UC and CD will be discussed, as well as the factors that may change their clinical course. The methodological requirements for high quality studies on the course and prognosis of IBD, the true impact of environmental and dietary factors on the clinical course of IBD, the clinical, serological and genetic predictors of the IBD course (in particular, which of these are relevant and appropriate for use in clinical practice), the impact of the various forms of medical treatment on the IBD complication rate, the role of surgery for IBD in the biologic era, the true magnitude of risk of colorectal cancer associated with IBD, as well as the mortality rate related to IBD will be stressed; all topics that are extensively discussed in separate reviews included in this issue of World Journal of Gastroenterology.
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Alhagamhmad MH, Day AS, Lemberg DA, Leach ST. An update of the role of nutritional therapy in the management of Crohn's disease. J Gastroenterol 2012; 47:872-82. [PMID: 22699323 DOI: 10.1007/s00535-012-0617-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2012] [Accepted: 05/14/2012] [Indexed: 02/04/2023]
Abstract
Crohn's disease is an increasingly global health concern. Currently without a cure, it significantly alters the quality of life of Crohn's disease sufferers and places a heavy financial burden on the community. Recent reports show that the rising prevalence of Crohn's disease is no longer confined to Western countries, with considerable increases seen particularly in Asia. Nutritional problems are often associated with Crohn's disease, most notably in the paediatric population, with underweight and stunting commonly seen at presentation. In addition, linear growth retardation and pubertal delay can also manifest in these younger patients. Therefore, exclusive enteral nutrition has been used as a therapeutic option to treat Crohn's disease, in part to address the nutritional complications of the disease. Exclusive enteral nutrition can improve nutrition as well as induce remission at a rate equivalent to corticosteroids. It is safe particularly with long-term use and can induce mucosal healing, considered the gold standard for therapy, at a rate superior to corticosteroids. Exclusive enteral nutrition has thus become the preferred therapeutic option in many centres for the treatment of paediatric Crohn's disease. This review discusses the role of exclusive enteral nutrition as a therapeutic option for the treatment of Crohn's disease, as well as the latest findings into its mechanisms of action.
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Affiliation(s)
- Moftah H Alhagamhmad
- School of Women's and Children's Health, University of New South Wales, Sydney, NSW, Australia
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Abstract
Many foods have been implicated in theories about the etiology of inflammatory bowel disease. While evidence has accumulated that nutritional factors as part of overall lifestyle changes may play a role in the growing incidence, no specific dietary recommendations except the promotion of breastfeeding can currently be given to decrease the risk of developing Crohn's disease or ulcerative colitis. For the treatment of Crohn's disease in children and adolescents, however, enteral feeding with a semi-elemental diet seems to be as effective as corticosteroids in inducing and maintaining remission. In the meta-analyses, advantages of one formula over the other are evened out, and more research is warranted into the anti-inflammatory properties of different nutrients, such as polyunsaturated fatty acids, butyrate, glutamine, and cytokines, such as transforming growth factors-beta. Unfortunately, for practical reasons, nutritional therapy remains underutilized, even though pediatric patients are most vulnerable to the harmful effects of nutrient deficiencies on growth, pubertal development, and bone health. There is hope that in the future the new field of nutrigenomics may enable physicians to more accurately tailor a specific diet to the patient genotype.
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Affiliation(s)
- Dietmar Scholz
- Department of Pediatrics, Justus-Liebig-University, Giessen, Germany
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Use of ghrelin as a treatment for inflammatory bowel disease: mechanistic considerations. INTERNATIONAL JOURNAL OF PEPTIDES 2011; 2011:189242. [PMID: 21845198 PMCID: PMC3154487 DOI: 10.1155/2011/189242] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/27/2011] [Accepted: 06/21/2011] [Indexed: 12/24/2022]
Abstract
Inflammatory bowel diseases (IBD)-and in particular Crohn's disease-are immune-mediated processes that result in denuded intestinal mucosa and can produce decreased appetite, weight loss, and systemic inflammation. Current treatments include anti-inflammatory medications, immunomodulators, and feeding interventions. Ghrelin is an endogenous orexigenic hormone that directly stimulates growth hormone release, increases gut motility, and has cardiovascular and anti-inflammatory properties. Although ghrelin levels are elevated in active IBD, administration of ghrelin in most (but not all) animal models of colitis has produced improvements in disease activity and systemic inflammation. The mechanism for these effects is not known but may relate to decreased inflammation, increased motility, increased appetite, and increased colonic blood flow. Human trials have not been performed, however, and more research is clearly needed.
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Kang Y, Lee HS, Paik NJ, Kim WS, Yang M. Evaluation of enteral formulas for nutrition, health, and quality of life among stroke patients. Nutr Res Pract 2010; 4:393-9. [PMID: 21103085 PMCID: PMC2981722 DOI: 10.4162/nrp.2010.4.5.393] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2010] [Revised: 09/01/2010] [Accepted: 09/16/2010] [Indexed: 12/21/2022] Open
Abstract
Enteral nutritional support has been used via tube feeding for dysphagic stroke patients. We performed long and short term trials to evaluate the effects of commercial enteral nutritional supports on nutrition and health in stroke patients (mRS = 3~5) and quality of life in their caregivers. For a long term study, we recruited chronic (≥ 1 yrs) stroke patients (n = 6) and administered them 6 cans/day (1,200 kcal) of the commercial enteral formula N for 6 months according to IRB-approved protocol. We collected peripheral blood at 0, 2, 4 and 6 months. For a short term study, we recruited acute (≤ 3 months) stroke patients (n = 12) and randomly administered them two different commercial enteral formulas, N or J, for 2 weeks. We collected their blood at 0, 4, 7 and 14 day of the administration. Blood samples were analyzed to quantify 19 health and nutritional biomarkers and an oxidative stress biomarker, malondialdehyde (MDA). In order to evaluate quality of life, we also obtained the sense of competence questionnaire (SCQ) from all caregivers at 'before' and 'after trials'. As results, the enteral formula, N, improved hemoglobin and hematocrit levels in the long term trial and maintained most of biomarkers within normal ranges. The SCQ levels of caregivers were improved in the long term treatment (P < 0.05). In a case of the short term study, both of enteral formulas were helpful to maintain nutritional status of the patients. In addition, MDA levels were decreased in the acute patients following formula consumption (0.05 < P < 0.1). Most of health and nutrition outcomes were not different, even though there is a big difference in price of the two products. Thus, we evaluate the formula N has equal nutritional efficacy compared to the formula J. In addition, long term use of enteral formula N can be useful to health and nutrition of stroke patients, and the quality of life for their caregivers.
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Affiliation(s)
- Yunkyeong Kang
- College of Pharmacy, Sookmyung Women's University, Cheongpa-dong 2-ga, Yongsan-gu, Seoul 140-742, Korea
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Prospective clinical trial: enteral nutrition during maintenance infliximab in Crohn's disease. J Gastroenterol 2010; 45:24-9. [PMID: 19798465 DOI: 10.1007/s00535-009-0136-5] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2009] [Accepted: 08/31/2009] [Indexed: 02/08/2023]
Abstract
PURPOSE Hitherto, the efficacy of enteral nutrition (EN) on clinical outcomes during biological maintenance therapy in Crohn's disease (CD) has not been investigated. This prospective study was to assess the efficacy of EN on the maintenance rate of clinical remission in patients with quiescent CD receiving infliximab as maintenance therapy. METHODS Fifty-six patients who achieved clinical remission with infliximab induction therapy received infliximab as maintenance therapy (5 mg/kg, every 8 weeks). Thirty-two of the 56 patients received concomitant EN: elemental diet infusion during night-time and a low fat diet during daytime (EN group), while the remaining 24 patients received neither nutritional therapy nor food restriction (non-EN group). All patients were followed for 56 weeks; CD activity index (CDAI) was assessed and CDAI < 150 was defined as clinical remission. RESULTS During the 56-week observation, the mean CDAI was not significantly different between the 2 groups. Seven patients in the EN group ceased EN therapy because they maintained complete remission. On an intention-to-treat basis, 25 patients in the EN group (78%) and 16 patients in the non-EN group (67%) remained in clinical remission during the 56-week observation (P = 0.51). CONCLUSIONS The outcomes of this prospective study showed that concomitant EN during infliximab maintenance therapy does not significantly increase the maintenance rate of clinical remission in patients with CD.
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