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Hatamzade Esfahani N, Day AS. The Role of TGF-β, Activin and Follistatin in Inflammatory Bowel Disease. GASTROINTESTINAL DISORDERS 2023; 5:167-186. [DOI: 10.3390/gidisord5020015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/10/2023] Open
Abstract
Inflammatory bowel disease (IBD) is an immune-mediated inflammatory condition predominantly affecting the gastrointestinal (GI) tract. An increasing prevalence of IBD has been observed globally. The pathogenesis of IBD includes a complex interplay between the intestinal microbiome, diet, genetic factors and immune responses. The consequent imbalance of inflammatory mediators ultimately leads to intestinal mucosal damage and defective repair. Growth factors, given their specific roles in maintaining the homeostasis and integrity of the intestinal epithelium, are of particular interest in the setting of IBD. Furthermore, direct targeting of growth factor signalling pathways involved in the regeneration of the damaged epithelium and the regulation of inflammation could be considered as therapeutic options for individuals with IBD. Several members of the transforming growth factor (TGF)-β superfamily, particularly TGF-β, activin and follistatin, are key candidates as they exhibit various roles in inflammatory processes and contribute to maintenance and homeostasis in the GI tract. This article aimed firstly to review the events involved in the pathogenesis of IBD with particular emphasis on TGF-β, activin and follistatin and secondly to outline the potential role of therapeutic manipulation of these pathways.
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Affiliation(s)
| | - Andrew S. Day
- Paediatric Department, University of Otago Christchurch, Christchurch 8140, New Zealand
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2
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Bischoff SC, Bager P, Escher J, Forbes A, Hébuterne X, Hvas CL, Joly F, Klek S, Krznaric Z, Ockenga J, Schneider S, Shamir R, Stardelova K, Bender DV, Wierdsma N, Weimann A. ESPEN guideline on Clinical Nutrition in inflammatory bowel disease. Clin Nutr 2023; 42:352-379. [PMID: 36739756 DOI: 10.1016/j.clnu.2022.12.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 12/05/2022] [Indexed: 01/15/2023]
Abstract
The present guideline is an update and extension of the ESPEN scientific guideline on Clinical Nutrition in Inflammatory Bowel Disease published first in 2017. The guideline has been rearranged according to the ESPEN practical guideline on Clinical Nutrition in Inflammatory Bowel Disease published in 2020. All recommendations have been checked and, if needed, revised based on new literature, before they underwent the ESPEN consensus procedure. Moreover, a new chapter on microbiota modulation as a new option in IBD treatment has been added. The number of recommendations has been increased to 71 recommendations in the guideline update. The guideline is aimed at professionals working in clinical practice, either in hospitals or in outpatient medicine, and treating patients with IBD. General aspects of care in patients with IBD, and specific aspects during active disease and in remission are addressed. All recommendations are equipped with evidence grades, consensus rates, short commentaries and links to cited literature.
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Affiliation(s)
- Stephan C Bischoff
- Institute of Nutritional Medicine, University of Hohenheim, Stuttgart, Germany.
| | - Palle Bager
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark.
| | - Johanna Escher
- Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, the Netherlands.
| | - Alastair Forbes
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia.
| | - Xavier Hébuterne
- Department of Gastroenterology and Clinical Nutrition, CHU of Nice, University Côte d'Azur, Nice, France.
| | - Christian Lodberg Hvas
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark.
| | - Francisca Joly
- Department of Gastroenterology and Nutrition Support, CHU de Beaujon, APHP, University of Paris, Paris, France.
| | - Stansilaw Klek
- Surgical Oncology Clinic, Maria Sklodowska-Curie National Cancer Institute, Krakow, Poland.
| | - Zeljko Krznaric
- Department of Gastroenterology, Hepatology and Nutrition, University Hospital Centre Zagreb, University of Zagreb, Croatia.
| | - Johann Ockenga
- Medizinische Klinik II, Klinikum Bremen-Mitte, Bremen FRG, Bremen, Germany.
| | - Stéphane Schneider
- Department of Gastroenterology and Clinical Nutrition, CHU de Nice, University Côte d'Azur, Nice, France.
| | - Raanan Shamir
- Institute for Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Kalina Stardelova
- University Clinic for Gastroenterohepatology, Clinical Campus "Mother Theresa", University St Cyrul and Methodius, Skopje, North Macedonia.
| | - Darija Vranesic Bender
- Unit of Clinical Nutrition, Department of Internal Medicine, University Hospital Centre Zagreb, Zagreb, Croatia.
| | - Nicolette Wierdsma
- Department of Nutrition and Dietetics, Amsterdam University Medical Centers, Amsterdam, the Netherlands.
| | - Arved Weimann
- Department of General, Visceral and Oncological Surgery, St. George Hospital, Leipzig, Germany.
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3
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Dupont-Lucas C, Marion-Letellier R, Pala M, Guerin C, Bôle-Feysot C, Salameh E, Goichon A, Nicol L, Aziz M, Savoye-Collet C, Savoye G. Magnetic resonance colonography assessment of acute trinitrobenzene sulfonic acid colitis in pre-pubertal rats. PLoS One 2021; 16:e0259135. [PMID: 34735489 PMCID: PMC8568272 DOI: 10.1371/journal.pone.0259135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 10/14/2021] [Indexed: 11/18/2022] Open
Abstract
Pre-pubertal murine models of acute colitis are lacking. Magnetic resonance colonography (MRC) is a promising minimally invasive tool to assess colitis. We aimed to: 1/ Adapt a model of acute experimental colitis to pre-pubertal rats and determine whether MRC characteristics correlate with histological inflammation. 2/ Test this model by administering a diet supplemented in transforming growth factor β2 to reverse inflammation. Twenty-four rats were randomized at weaning to one of 3 groups: Trinitrobenzene Sulfonic Acid (TNBS) group (n = 8) fed a standard diet, that received an intra-rectal 60 mg/kg dose of TNBS-ethanol; Control group (n = 8) fed standard diet, that received a dose of intra-rectal PBS; TNBS+MODULEN group (n = 8) that received a dose of TNBS and were exclusively fed MODULEN-IBD® after induction of colitis. One week after induction of colitis, rats were assessed by MRC, colon histopathology and inflammation markers (Interleukin 1β, Tumor necrosis factor α, Nitric Oxide Synthase 2 and Cyclooxygenase 2). TNBS induced typical features of acute colitis on histopathology and MRC (increased colon wall thickness, increased colon intensity on T2-weighted images, target sign, ulcers). Treatment with MODULEN-IBD® did not reduce signs of colitis on MRC. Inflammatory marker expression did not differ among study groups.
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Affiliation(s)
- Claire Dupont-Lucas
- INSERM UMR 1073, Institute for Biomedical Research, Rouen University, Rouen, France
- * E-mail:
| | | | - Mathilde Pala
- INSERM UMR 1073, Institute for Biomedical Research, Rouen University, Rouen, France
| | - Charlène Guerin
- INSERM UMR 1073, Institute for Biomedical Research, Rouen University, Rouen, France
| | | | - Emmeline Salameh
- INSERM UMR 1073, Institute for Biomedical Research, Rouen University, Rouen, France
| | - Alexis Goichon
- INSERM UMR 1073, Institute for Biomedical Research, Rouen University, Rouen, France
| | - Lionel Nicol
- INSERM UMR 1096, Institute for Biomedical Research, Rouen University, Rouen, France
| | - Moutaz Aziz
- Department of Pathology, Rouen University Hospital, Rouen, France
| | | | - Guillaume Savoye
- Department of Gastroenterology, Rouen University Hospital, Rouen, France
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4
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Herrador-López M, Martín-Masot R, Navas-López VM. EEN Yesterday and Today … CDED Today and Tomorrow. Nutrients 2020; 12:nu12123793. [PMID: 33322060 PMCID: PMC7764146 DOI: 10.3390/nu12123793] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 12/04/2020] [Accepted: 12/08/2020] [Indexed: 12/11/2022] Open
Abstract
The treatment of Pediatric Crohn’s Disease (CD) requires attention both to achieve mucosal healing and to optimize growth, while also maintaining proper bone health. Exclusive Enteral Nutrition (EEN) is recommended as first-line treatment in luminal CD. The therapeutic mechanisms of EEN are being discovered by advances in the study of the gut microbiota. Although the total exclusion of a normal diet during the time of EEN continues to be of high importance, new modalities of dietary treatment suggest a successful future for the nutritional management of CD. In this sense, Crohn’s Disease Exclusion Diet (CDED) is a long-term strategy, it apparently acts on the mechanisms that influence the appearance of inflammation (reducing dietary exposure to products negatively affecting the microbiota), but does so using specific available whole foods to achieve this goal, increases the time of clinical remission and promotes healthy lifestyle habits. The development of CDED, which partly minimizes the problems of EEN, has enabled a turnaround in the treatment of pediatric CD. This review highlights the role of enteral nutrition in the treatment of Crohn’s disease with special emphasis on newer dietary modalities such as CDED.
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Triantafillidis JK, Tzouvala M, Triantafyllidi E. Enteral Nutrition Supplemented with Transforming Growth Factor-β, Colostrum, Probiotics, and Other Nutritional Compounds in the Treatment of Patients with Inflammatory Bowel Disease. Nutrients 2020; 12:E1048. [PMID: 32290232 PMCID: PMC7230540 DOI: 10.3390/nu12041048] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 04/06/2020] [Accepted: 04/08/2020] [Indexed: 02/07/2023] Open
Abstract
Enteral nutrition seems to play a significant role in the treatment of both adults and children with active Crohn's disease, and to a lesser degree in the treatment of patients with active ulcerative colitis. The inclusion of some special factors in the enteral nutrition formulas might increase the rate of the efficacy. Actually, enteral nutrition enriched in Transforming Growth Factor-β reduced the activity index and maintained remission in patients with Crohn's disease. In addition, a number of experimental animal studies have shown that colostrum exerts a significantly positive result. Probiotics of a special type and a certain dosage could also reduce the inflammatory process in patients with active ulcerative colitis. Therefore, the addition of these factors in an enteral nutrition formula might increase its effectiveness. Although the use of these formulas is not supported by large clinical trials, it could be argued that their administration in selected cases as an exclusive diet or in combination with the drugs used in patients with inflammatory bowel disease could benefit the patient. In this review, the authors provide an update on the role of enteral nutrition, supplemented with Transforming Growth Factor-β, colostrum, and probiotics in patients with inflammatory bowel disease.
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Affiliation(s)
| | - Maria Tzouvala
- Department of Gastroenterology “St Panteleimon” General Hospital, ZC 18454 Nicea, Greece;
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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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7
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McVeigh L, Payne A. Inducing remission in paediatric Crohn's disease using nutritional therapies - A systematic review. J Hum Nutr Diet 2019; 33:170-186. [PMID: 31797471 DOI: 10.1111/jhn.12714] [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: 02/06/2023]
Abstract
BACKGROUND Exclusive enteral nutrition (EEN) is known to be a safe and effective treatment option for managing active Crohn's disease (CD) in children, although no uniform protocol exists. The aim of this systematic review was to evaluate and compare the clinical effectiveness of aspects of EEN protocols to ascertain whether an optimum regimen can be identified. METHODS A systematic search of the Cochrane Library, PubMed, MEDLINE, EMBASE, CINAHL and AMED was conducted for studies published between 1998 and 2018 that examined paediatric patients being treated with an enteral nutrition protocol to induce remission. Studies that included patients receiving concurrent medication for active disease were excluded. Quality assessment was performed using separate tools for randomised controlled trials, cohort studies and for studies without a control group. RESULTS Sixteen studies met the inclusion criteria. Of these, six found insufficient evidence to support use of a specific formula. One study examined the route of EEN, finding no difference between oral or nasogastric tube administration with respect to inducing remission. Three examined the use of partial enteral nutrition to induce remission, although conflicting results were seen. No studies explored the effect of length of treatment or energy prescription on remission rates CONCLUSIONS: An optimum enteral nutrition protocol for inducing remission cannot be identified. Further focused research is required by well designed, adequately powered prospective clinical trials to examine aspects of enteral feeding protocols that remain uncertain, including the use of partial enteral nutrition as a potential alternative to EEN.
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Affiliation(s)
- L McVeigh
- Nutrition and Dietetics Department, Bristol Royal Hospital for Children, Bristol, UK
| | - A Payne
- Faculty of Health & Human Sciences, School of Health Professions, The University of Plymouth, Plymouth, UK
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Lamb CA, Kennedy NA, Raine T, Hendy PA, Smith PJ, Limdi JK, Hayee B, Lomer MCE, Parkes GC, Selinger C, Barrett KJ, Davies RJ, Bennett C, Gittens S, Dunlop MG, Faiz O, Fraser A, Garrick V, Johnston PD, Parkes M, Sanderson J, Terry H, Gaya DR, Iqbal TH, Taylor SA, Smith M, Brookes M, Hansen R, Hawthorne AB. British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults. Gut 2019; 68:s1-s106. [PMID: 31562236 PMCID: PMC6872448 DOI: 10.1136/gutjnl-2019-318484] [Citation(s) in RCA: 1184] [Impact Index Per Article: 236.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 06/10/2019] [Accepted: 06/10/2019] [Indexed: 02/06/2023]
Abstract
Ulcerative colitis and Crohn's disease are the principal forms of inflammatory bowel disease. Both represent chronic inflammation of the gastrointestinal tract, which displays heterogeneity in inflammatory and symptomatic burden between patients and within individuals over time. Optimal management relies on understanding and tailoring evidence-based interventions by clinicians in partnership with patients. This guideline for management of inflammatory bowel disease in adults over 16 years of age was developed by Stakeholders representing UK physicians (British Society of Gastroenterology), surgeons (Association of Coloproctology of Great Britain and Ireland), specialist nurses (Royal College of Nursing), paediatricians (British Society of Paediatric Gastroenterology, Hepatology and Nutrition), dietitians (British Dietetic Association), radiologists (British Society of Gastrointestinal and Abdominal Radiology), general practitioners (Primary Care Society for Gastroenterology) and patients (Crohn's and Colitis UK). A systematic review of 88 247 publications and a Delphi consensus process involving 81 multidisciplinary clinicians and patients was undertaken to develop 168 evidence- and expert opinion-based recommendations for pharmacological, non-pharmacological and surgical interventions, as well as optimal service delivery in the management of both ulcerative colitis and Crohn's disease. Comprehensive up-to-date guidance is provided regarding indications for, initiation and monitoring of immunosuppressive therapies, nutrition interventions, pre-, peri- and postoperative management, as well as structure and function of the multidisciplinary team and integration between primary and secondary care. Twenty research priorities to inform future clinical management are presented, alongside objective measurement of priority importance, determined by 2379 electronic survey responses from individuals living with ulcerative colitis and Crohn's disease, including patients, their families and friends.
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Affiliation(s)
- Christopher Andrew Lamb
- Newcastle University, Newcastle upon Tyne, UK
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Nicholas A Kennedy
- Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
- University of Exeter, Exeter, UK
| | - Tim Raine
- Cambridge University Hospitals NHS FoundationTrust, Cambridge, UK
| | - Philip Anthony Hendy
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- Imperial College London, London, UK
| | - Philip J Smith
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Jimmy K Limdi
- The Pennine Acute Hospitals NHS Trust, Manchester, UK
- University of Manchester, Manchester, UK
| | - Bu'Hussain Hayee
- King's College Hospital NHS Foundation Trust, London, UK
- King's College London, London, UK
| | - Miranda C E Lomer
- King's College London, London, UK
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Gareth C Parkes
- Barts Health NHS Trust, London, UK
- Barts and the London School of Medicine and Dentistry, London, UK
| | - Christian Selinger
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
- University of Leeds, Leeds, UK
| | | | - R Justin Davies
- Cambridge University Hospitals NHS FoundationTrust, Cambridge, UK
- University of Cambridge, Cambridge, UK
| | - Cathy Bennett
- Systematic Research Ltd, Quorn, UK
- Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
| | | | - Malcolm G Dunlop
- University of Edinburgh, Edinburgh, UK
- Western General Hospital, Edinburgh, UK
| | - Omar Faiz
- Imperial College London, London, UK
- St Mark's Hospital, Harrow, UK
| | - Aileen Fraser
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | | | | | - Miles Parkes
- Cambridge University Hospitals NHS FoundationTrust, Cambridge, UK
| | - Jeremy Sanderson
- King's College London, London, UK
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Daniel R Gaya
- Glasgow Royal Infirmary, Glasgow, UK
- University of Glasgow, Glasgow, UK
| | - Tariq H Iqbal
- Queen Elizabeth Hospital Birmingham NHSFoundation Trust, Birmingham, UK
- University of Birmingham, Birmingham, UK
| | - Stuart A Taylor
- University College London, London, UK
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Melissa Smith
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
- Brighton and Sussex Medical School, Brighton, UK
| | - Matthew Brookes
- Royal Wolverhampton NHS Trust, Wolverhampton, UK
- University of Wolverhampton, Wolverhampton, UK
| | - Richard Hansen
- Royal Hospital for Children Glasgow, Glasgow, UK
- University of Glasgow, Glasgow, UK
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Abstract
Ulcerative colitis and Crohn's disease are the principal forms of inflammatory bowel disease. Both represent chronic inflammation of the gastrointestinal tract, which displays heterogeneity in inflammatory and symptomatic burden between patients and within individuals over time. Optimal management relies on understanding and tailoring evidence-based interventions by clinicians in partnership with patients. This guideline for management of inflammatory bowel disease in adults over 16 years of age was developed by Stakeholders representing UK physicians (British Society of Gastroenterology), surgeons (Association of Coloproctology of Great Britain and Ireland), specialist nurses (Royal College of Nursing), paediatricians (British Society of Paediatric Gastroenterology, Hepatology and Nutrition), dietitians (British Dietetic Association), radiologists (British Society of Gastrointestinal and Abdominal Radiology), general practitioners (Primary Care Society for Gastroenterology) and patients (Crohn's and Colitis UK). A systematic review of 88 247 publications and a Delphi consensus process involving 81 multidisciplinary clinicians and patients was undertaken to develop 168 evidence- and expert opinion-based recommendations for pharmacological, non-pharmacological and surgical interventions, as well as optimal service delivery in the management of both ulcerative colitis and Crohn's disease. Comprehensive up-to-date guidance is provided regarding indications for, initiation and monitoring of immunosuppressive therapies, nutrition interventions, pre-, peri- and postoperative management, as well as structure and function of the multidisciplinary team and integration between primary and secondary care. Twenty research priorities to inform future clinical management are presented, alongside objective measurement of priority importance, determined by 2379 electronic survey responses from individuals living with ulcerative colitis and Crohn's disease, including patients, their families and friends.
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Hojsak I, Matic K, Sila S, Trivić I, Mišak Z, Kolaček S. Characteristics of polymeric formula and route of delivery of exclusive enteral nutrition have no effect on disease outcome and weight gain in pediatric Crohn's disease. Clin Nutr 2019; 39:1108-1111. [PMID: 31031135 DOI: 10.1016/j.clnu.2019.04.015] [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] [Received: 11/17/2018] [Revised: 01/27/2019] [Accepted: 04/11/2019] [Indexed: 02/09/2023]
Abstract
BACKGROUND & AIMS This study aimed to evaluate the effect of the route of exclusive enteral nutrition (EEN) delivery (orally or via nasogastric (NG) tube) and type of polymeric formula (with taste vs tasteless and isocaloric vs hypercaloric) on the disease outcome and nutritional status in children with Crohn's disease (CD). METHODS This was a single center retrospective study which included all CD patients whose active disease at diagnosis was treated with EEN in the period from October 2007 to November 2017. All patients received polymeric formula orally or through a NG tube, which was based on the physicians and child's preference. RESULTS A total of 92 CD patients were included in the study (mean age 13.6 ± 3.0 years; 45.7% female). Overall, 42 (45.7%) patients received EEN via NG tube until the end of the EEN period. Remission was achieved in 71 (77.2%) children. There was no difference in the EEN failure status, remission duration, inflammatory markers, and weight gain at the end of the EEN period between oral intake and NG tube groups. None of the factors including age, disease location, type of formula (with taste vs tasteless and isocaloric vs hypercaloric) and mode of delivery (orally vs through NG tube for the whole duration of EEN) demonstrated an association with EEN failure. CONCLUSION This study failed to demonstrate an effect of the route of EEN delivery and the characteristics of the polymeric formula on the outcome of treatment in pediatric patients with CD.
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Affiliation(s)
- Iva Hojsak
- Referral Center for Pediatric Gastroenterology and Nutrition, Children's Hospital Zagreb, Zagreb, Croatia; University of Zagreb, School of Medicine, Zagreb, Croatia; University J.J. Strossmayer, School of Medicine, Osijek, Croatia.
| | - Karlo Matic
- University of Zagreb, School of Medicine, Zagreb, Croatia
| | - Sara Sila
- Referral Center for Pediatric Gastroenterology and Nutrition, Children's Hospital Zagreb, Zagreb, Croatia
| | - Ivana Trivić
- Referral Center for Pediatric Gastroenterology and Nutrition, Children's Hospital Zagreb, Zagreb, Croatia
| | - Zrinjka Mišak
- Referral Center for Pediatric Gastroenterology and Nutrition, Children's Hospital Zagreb, Zagreb, Croatia; University of Zagreb, School of Medicine, Zagreb, Croatia
| | - Sanja Kolaček
- Referral Center for Pediatric Gastroenterology and Nutrition, Children's Hospital Zagreb, Zagreb, Croatia; University of Zagreb, School of Medicine, Zagreb, Croatia
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Yu Y, Chen KC, Chen J. Exclusive enteral nutrition versus corticosteroids for treatment of pediatric Crohn's disease: a meta-analysis. World J Pediatr 2019; 15:26-36. [PMID: 30666565 PMCID: PMC6394648 DOI: 10.1007/s12519-018-0204-0] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 10/19/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Many studies have examined the effects of exclusive enteral nutrition (EEN) in children with Crohn's disease (CD), but corticosteroids are considered a superior therapy and are frequently used in China. This meta-analysis aims to compare the efficacy of EEN with corticosteroids in treating pediatric CD. METHODS A comprehensive retrieval from medical databases, including PubMed, EMBASE, MEDLINE, Web of Science, Wanfang data, VIP and CNKI, was performed using the search terms "diet therapy", "exclusive enteral nutrition", "Crohn's disease", "inflammatory bowel diseases", "child" and "pediatrics" from January 1990 to April 2017. RESULTS We included 18 studies from 1329 identified sources in this meta-analysis. EEN was as effective as corticosteroids in inducing remission rate of children suffering from CD (OR = 1.35; 95% CI 0.90, 2.10; P = 0.14). Nevertheless, patients who received EEN were more likely to achieve both endoscopic mucosal healing (OR = 5.24; 95% CI 2.06, 13.37; P = 0.0005) and histological mucosal healing (OR = 4.78; 95% CI 1.89, 12.08; P = 0.0009) than those who received corticosteroids; the Pediatric Crohn's Disease Activity Index was lower [mean difference (MD) = - 3.67; 95% CI - 4.91, - 2.43] and weight gain was higher (MD = 1.92; 95% CI 0.02, 3.83; P = 0.05) in those patients who received EEN than in those who received corticosteroids. No difference was found in relapse rate (OR = 0.57; 95% CI 0.25, 1.29; P = 0.18), height for age or body mass index between the patients treated with EEN and corticosteroids at the 1-year end point. CONCLUSIONS This meta-analysis reveals that there is no significant difference between EEN and corticosteroids in the efficacy of inducing remission rate of CD in a pediatric population, but EEN is superior to corticosteroids in improving short-term mucosal inflammation and reducing the PCDAI index.
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Affiliation(s)
- Yu Yu
- 0000 0004 1759 700Xgrid.13402.34Department of Gastroenterology, Children’s Hospital, Zhejiang University School of Medicine, 3333 Binsheng Road, Binjiang District, Hangzhou, 310051 China
| | - Kang-Chen Chen
- 0000 0004 1759 700Xgrid.13402.34First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Shangcheng District, Hangzhou, 310002 China
| | - Jie Chen
- Department of Gastroenterology, Children's Hospital, Zhejiang University School of Medicine, 3333 Binsheng Road, Binjiang District, Hangzhou, 310051, China.
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12
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Enteral Nutrition in the Management of Pediatric and Adult Crohn's Disease. Nutrients 2018; 10:nu10050537. [PMID: 29701656 PMCID: PMC5986417 DOI: 10.3390/nu10050537] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Revised: 04/17/2018] [Accepted: 04/24/2018] [Indexed: 12/11/2022] Open
Abstract
Genetic and environmental factors are thought to profoundly influence the pathophysiology of Crohn’s disease (CD). Changes in dietary and hygiene patterns affect the interactions between the immune system and environment. The gut microbiome is responsible for mediating host immune response with significant dysbiosis observed in individuals with CD. Diet therapy using exclusive enteral nutrition (EEN) has been studied as primary therapy for the management of CD. EEN may cultivate the presence of beneficial microbiota, improve bile acid metabolism, and decrease the number of dietary microparticles possibly influencing disease and immune activity. In this review, we will address the current evidence on EEN in the management of adult and pediatric CD. In adults, EEN appears to be moderately beneficial for the induction of remission of CD; however, its use is understudied and underutilized. Stronger evidence is in place to support the use of EEN in pediatric CD with the added benefit of nutrition support and steroid-sparing therapy during the growth phase. Overall, EEN is an established therapy in inducing CD remission in the pediatric population while its role as primary therapy of adult Crohn’s disease remains to be defined.
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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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Cohen-Dolev N, Sladek M, Hussey S, Turner D, Veres G, Koletzko S, Martin de Carpi J, Staiano A, Shaoul R, Lionetti P, Amil Dias J, Paerregaard A, Nuti F, Pfeffer Gik T, Ziv-Baran T, Ben Avraham Shulman S, Sarbagili Shabat C, Sigall Boneh R, Russell RK, Levine A. Differences in Outcomes Over Time With Exclusive Enteral Nutrition Compared With Steroids in Children With Mild to Moderate Crohn's Disease: Results From the GROWTH CD Study. J Crohns Colitis 2018; 12:306-312. [PMID: 29165666 DOI: 10.1093/ecco-jcc/jjx150] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 11/14/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Exclusive enteral nutrition [EEN] and corticosteroids [CS] induce similar rates of remission in mild to moderate paediatric Crohn's disease [CD], but differ with regard to mucosal healing. Our goal was to evaluate if EEN at diagnosis was superior to CS for improving long-term outcomes. METHODS We prospectively followed newly diagnosed children aged < 17 years, with mild to moderate CD at baseline, for 2 years in the GROWTH CD study. Patients were evaluated at baseline and at 8, 12, 78, and 104 weeks. Remission, relapses, complications [fibrostenotic disease, penetrating disease, and active perianal disease] and growth were recorded throughout the study. A propensity score analysis was performed. RESULTS A total of 147 children [mean age 12.9 ± 3.2 years], treated by EEN [n = 60] or CS [n = 87] were included. New complications developed in 13.7% of CS [12/87] versus 11.6% of EEN [7/60], p = 0.29. Remission was achieved in 41/87 [47%] in CS and 38/60 [63%] EEN, p = 0.036. Median time to relapse did not differ [14.4 ± 1 months with CS, 16.05 ± 1.1 EEN, p = 0.28]. Mean height Z scores decreased from Week 0 to Week 78 with CS [-0.34 ± 1.1 to -0.51 ± 1.2, p = 0.01], but not with EEN [-0.32 ± 1.1 to -0.22 ± 0.9, p = 0.56]. In a propensity score analysis, EEN was superior to CS for inducing remission [p = 0.05] and trended to superiority for height Z score [p = 0.055]. CONCLUSIONS Use of EEN was associated with higher remission rates and a trend toward better growth but with similar relapse and complication rates in new-onset mild to moderate paediatric CD.
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Affiliation(s)
- Noa Cohen-Dolev
- Pediatric Gastroenterology and Nutrition Unit, Wolfson Medical Center, Holon, Israel
| | | | - Seamus Hussey
- National Children's Research Centre, Crumlin; Department of Paediatrics, UCD and RCSI, Dublin, Ireland
| | - Dan Turner
- Juliet Keidan Institute of Paediatric Gastroenterology, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Gabor Veres
- First Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Sibylle Koletzko
- Ludwig Maximilians-Universität München, Dr von Hauner Children's Hospital, Munich, Germany
| | - Javier Martin de Carpi
- Department of Gastroenterology, Hepatology and Pediatric Nutrition, Hospital Sant Joan de Deu, Barcelona, Spain
| | - Annamaria Staiano
- Department of Translational Medical Science, University of Naples 'Federico II', Naples, Italy
| | - Ron Shaoul
- Pediatric Gastroenterology Institute, Rambam Medical Center, Haifa, Israel
| | - Paolo Lionetti
- Paediatric Gastroenterology Unit, University of Florence-Meyer Hospital, Florence, Italy
| | - Jorge Amil Dias
- Pediatric Gastroenterology Unit, Centro Hospitalar de São João, Porto, Portugal
| | - Anders Paerregaard
- Department of Paediatrics 460, Hvidovre University Hospital, Hvidovre, Denmark
| | - Federica Nuti
- Pediatric Gastroenterology and Hepatology Unit, Sapienza University, Rome, Italy
| | - Tamar Pfeffer Gik
- Pediatric Gastroenterology and Nutrition Unit, Wolfson Medical Center, Holon, Israel
| | - Tomer Ziv-Baran
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Chen Sarbagili Shabat
- Pediatric Gastroenterology and Nutrition Unit, Wolfson Medical Center, Holon, Israel
| | - Rotem Sigall Boneh
- Pediatric Gastroenterology and Nutrition Unit, Wolfson Medical Center, Holon, Israel
| | - Richard K Russell
- Department of Paediatric Gastroenterology, Royal Hospital for Children, Glasgow, UK
| | - Arie Levine
- Pediatric Gastroenterology and Nutrition Unit, Wolfson Medical Center, Holon, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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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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Novak G, Parker CE, Pai RK, MacDonald JK, Feagan BG, Sandborn WJ, D'Haens G, Jairath V, Khanna R. Histologic scoring indices for evaluation of disease activity in Crohn's disease. Cochrane Database Syst Rev 2017; 7:CD012351. [PMID: 28731502 PMCID: PMC6483549 DOI: 10.1002/14651858.cd012351.pub2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Histologic assessment of mucosal disease activity has been increasingly used in clinical trials of treatment for Crohn's disease. However, the operating properties of the currently existing histologic scoring indices remain unclear. OBJECTIVES A systematic review was undertaken to evaluate the development and operating characteristics of available histologic disease activity indices in Crohn's disease. SEARCH METHODS Electronic searches of MEDLINE, EMBASE, PubMed, and the Cochrane Library (CENTRAL) databases from inception to 20 July 2016 were supplemented by manual reviews of bibliographies and abstracts submitted to major gastroenterology meetings (Digestive Disease Week, United European Gastroenterology Week, European Crohn's and Colitis Organisation). SELECTION CRITERIA Any study design (e.g. randomised controlled trial, cohort study, case series) that evaluated a histologic disease activity index in patients with Crohn's disease was considered for inclusion. Study participants included adult patients (> 16 years), diagnosed with Crohn's disease using conventional clinical, radiographic or endoscopic criteria. DATA COLLECTION AND ANALYSIS Two authors independently reviewed the titles and abstracts of the studies identified from the literature search. The full text of potentially relevant citations were reviewed for inclusion and the study investigators were contacted as needed for clarification. Any disagreements regarding study eligibility were resolved by discussion and consensus with a third author.Two authors independently extracted and recorded data using a standard form. The following data were recorded from each eligible study: number of patients enrolled; number of patients per treatment arm; patient characteristics: age and gender distribution; description of histologic disease activity index utilized; and outcomes such as content validity, construct validity, criterion validity, responsiveness, intra-rater reliability, inter-rater reliability, and feasibility. MAIN RESULTS Sixteen reports of 14 studies describing 14 different numerical histological indices fulfilled the inclusion criteria.Inter-rater reliability was assessed in one study. For the Naini and Cortina Score, estimates of correlation were 'almost perfect', ranging from r = 0.94 to 0.96. The methodological quality of this study with respect to reliability was 'good'.With respect to validity, correlation estimates between various histological scoring systems and Crohn's disease activity as measured by objective markers of inflammation (including C-reactive protein, erythrocyte sedimentation rate, fecal calprotectin and fecal lactoferrin); endoscopic disease activity scores; clinical disease activity scores; and quality of life questionnaires were reported. Comparisons between histologic scoring indices and endoscopic scoring indices ranged from no correlation to 'substantial' (r = 0.779). The methodological quality of the studies that explored validity ranged form 'poor' to 'good'.Responsiveness data were available in seven studies. After subjects were administered a treatment of known efficacy, statistically significant change in the index score was demonstrated in five studies with respect to six indices. Two studies failed to indicate whether there was statistically significant change in the index score post-treatment. With regard to methodological quality, six of the studies were rated as 'poor' and one of the studies was rated as 'fair'.Feasibility was assessed by one study. The Naini and Cortina Score was shown to be simple to use and feasible for every given case. AUTHORS' CONCLUSIONS Currently there is no fully validated histological scoring index for evaluation of Crohn's disease activity. Development of a validated histological scoring index for Crohn's disease is a clinical and research priority.
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Affiliation(s)
- Gregor Novak
- Academic Medical Center, University of AmsterdamDepartment of GastroenterologyAmsterdamNetherlands
- University Medical CentreDepartment of Gastroenterology and HepatologyLjubljanaSlovenia
| | - Claire E Parker
- Robarts Clinical Trials100 Dundas Street, Suite 200LondonONCanadaN6A 5B6
| | - Rish K Pai
- Mayo ClinicDepartment of PathologyScottsdaleAZUSA
| | - John K MacDonald
- Robarts Clinical TrialsCochrane IBD Group100 Dundas Street, Suite 200LondonONCanadaN6A 5B6
- University of Western OntarioDepartment of MedicineLondonONCanada
| | - Brian G Feagan
- Robarts Clinical TrialsCochrane IBD Group100 Dundas Street, Suite 200LondonONCanadaN6A 5B6
- University of Western OntarioDepartment of MedicineLondonONCanada
- University of Western OntarioDepartment of Epidemiology and BiostatisticsLondonONCanada
| | - William J Sandborn
- University of California San DiegoDivision of GastroenterologyLa JollaCAUSA
| | - Geert D'Haens
- Academic Medical CenterMeibergdreef 9 ‐ C2‐112AmsterdamNetherlands1105 AZ
- Robarts Clinical TrialsAmsterdamNetherlands
| | - Vipul Jairath
- University of Western OntarioDepartment of MedicineLondonONCanada
- University of Western OntarioDepartment of Epidemiology and BiostatisticsLondonONCanada
| | - Reena Khanna
- Robarts Clinical Trials100 Dundas Street, Suite 200LondonONCanadaN6A 5B6
- University of Western OntarioDepartment of MedicineLondonONCanada
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Heerasing N, Thompson B, Hendy P, Heap GA, Walker G, Bethune R, Mansfield S, Calvert C, Kennedy NA, Ahmad T, Goodhand JR. Exclusive enteral nutrition provides an effective bridge to safer interval elective surgery for adults with Crohn's disease. Aliment Pharmacol Ther 2017; 45:660-669. [PMID: 28105752 DOI: 10.1111/apt.13934] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 11/20/2016] [Accepted: 12/18/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Few studies have reported the systematic use of exclusive enteral nutrition in the perioperative setting. AIM To test the hypothesis that exclusive enteral nutrition provides a safe and effective bridge to surgery and reduces post-operative complications, in adult patients with Crohn's disease requiring urgent surgery for stricturing or penetrating complications. METHODS Patients treated with exclusive enteral nutrition prior to surgery were each matched with two control patients for disease behaviour, type of surgery, age at diagnosis and disease duration. Data on disease phenotype, nutritional status, operative course and post-operative complications were obtained. RESULTS Twenty-five per cent [13/51] patients treated with exclusive enteral nutrition avoided surgery. Exclusive enteral nutrition had no effect on pre-operative weight, but it significantly reduced serum CRP [median at baseline 36 (interquartile range, IQR: 13-91] vs. pre-operation 8 (4-31) mg/L, P = 0.02]. The median (IQR) length of surgery was shorter in patients pre-optimised with exclusive enteral nutrition than controls [3.0 (2.5-3.5) vs. 3.5 (3.0-4.0) hours respectively, P < 0.001]. Multivariable logistic regression analysis confirmed that going straight-to-surgery compared exclusive enteral nutrition pre-optimisation was associated with a ninefold increase in the incidence of post-operative abscess and/or anastomotic leak [OR 9.1; 95% CI (1.2-71.2), P = 0.04]. CONCLUSIONS Exclusive enteral nutrition frequently down-stages the need for surgery in patients presenting with stricturing or penetrating complications of Crohn's disease; it is associated with a reduction in systemic inflammation, operative times and the incidence of post-operative abscess or anastomotic leak. Further trials are needed to elucidate how exclusive enteral nutrition may improve operative outcomes.
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Affiliation(s)
- N Heerasing
- Exeter IBD group, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - B Thompson
- Exeter IBD group, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - P Hendy
- Exeter IBD group, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - G A Heap
- Exeter IBD group, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - G Walker
- Exeter IBD group, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - R Bethune
- Exeter IBD group, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - S Mansfield
- Exeter IBD group, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - C Calvert
- Exeter IBD group, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - N A Kennedy
- Exeter IBD group, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - T Ahmad
- Exeter IBD group, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - J R Goodhand
- Exeter IBD group, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
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Abstract
Twenty-five percent of inflammatory bowel disease (IBD) diagnoses present in childhood, with Crohn's disease (CD) being the most common type. Many children have poor nutrition status at presentation of the disease, which may worsen during the clinical course, with a significant number of children having impaired linear growth. The cause of this poor nutrition status is complex, and contributing factors include inadequate intake, malabsorption, altered energy demands, and losses through stool, particularly in colitis. The principal aim of medical management is to induce disease remission, with minimal side effects, thereby enabling normal growth and development. This must include active consideration of the nutrition needs of such children and how they may be best met. However, our understanding of the manner in which the disease process affects the energy demands of children with CD or how poor nutrition, in turn, may affect the disease course is limited. This may constrain the efficacy and effectiveness of standard therapeutic approaches to care. This review explores the many factors of relevance in the delivery of nutrition support to children with inflammatory bowel disease, and explores the role of exclusive enteral nutrition as a corticosteroid-sparing strategy to induce remission in children with active Crohn's disease.
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Affiliation(s)
- Anthony E Wiskin
- Paediatric Medical Unit, Southampton General Hospital, Southampton, UK
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Early Changes in Microbial Community Structure Are Associated with Sustained Remission After Nutritional Treatment of Pediatric Crohn's Disease. Inflamm Bowel Dis 2016; 22:2853-2862. [PMID: 27805918 DOI: 10.1097/mib.0000000000000956] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Clinical remission achieved by exclusive enteral nutrition (EEN) is associated with marked microbiome changes. In this prospective study of exclusive enteral nutrition, we employ a hierarchical model of microbial community structure to distinguish between pediatric Crohn's disease patients who achieved sustained remission (SR) and those who relapsed early (non-SR), after restarting a normal diet. METHODS Fecal samples were obtained from 10 patients (age 10-16) and from 5 healthy controls (age 9-14). The microbiota was assessed via 16S rRNA sequencing. In addition to standard measures of microbial biodiversity, we employed Bayesian methods to characterize the hierarchical community structure. Community structure between patients who sustained remission (wPCDAI <12.5) up to their 24-week follow-up (SR) was compared with patients that had not sustained remission (non-SR). RESULTS Microbial diversity was lower in Crohn's disease patients relative to controls and lowest in patients who did not achieve SR. SR patients differed from non-SR patients in terms of the structure and prevalence of their microbial communities. The SR prevalent community contained a number of strains of Akkermansia muciniphila and Bacteroides and was limited in Proteobacteria, whereas the non-SR prevalent community had a large Proteobacteria component. Their communities were so different that a model trained to discriminate SR and non-SR had 80% classification accuracy, already at baseline sampling. CONCLUSIONS Microbial community structure differs between healthy controls, patients who have an enduring response to exclusive enteral nutrition, and those who relapse early on introduction of normal diet. Our novel Bayesian approach to these differences is able to predict sustained remission after exclusive enteral nutrition.
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Poulin Y, Bissonnette R, Juneau C, Cantin K, Drouin R, Poubelle PE. XP-828L in the Treatment of Mild to Moderate Psoriasis: Randomized, Double-Blind, Placebo-Controlled Study. J Cutan Med Surg 2016; 10:241-8. [PMID: 17234108 DOI: 10.2310/7750.2006.00049] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: XP-828L, a protein extract obtained from sweet whey, has demonstrated potential benefit for the treatment of mild to moderate psoriasis in an open-label study. Objective: To study in a randomized, double-blind, placebo-controlled study the safety and efficacy of XP-828L in the treatment of mild to moderate psoriasis. Design: XP-828L 5 g/d (group A, n = 42) or placebo (group B, n = 42) was given orally for 56 days followed by XP-828L 5 g/d in group A and by XP-828L 10 g/d in group B for an additional 56 days. Results: Patients receiving XP-828L 5 g/d for 56 days had an improved Physician's Global Assessment (PGA) score compared with patients under placebo ( p < .05). Considering the data of group A only, the PGA score improved from day 1 to day 56 ( p < .01); the Psoriasis Area and Severity Index score improved as well, but to a lesser extent ( p < .05). Conclusion: Oral administration of 5 g/d XP-828L compared with a placebo significantly improved the PGA score of patients with mild to moderate psoriasis.
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Affiliation(s)
- Yves Poulin
- Centre de Recherche Dermatologique du Québec Métropolitain Québec, Canada
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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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Malmborg P, Hildebrand H. The emerging global epidemic of paediatric inflammatory bowel disease--causes and consequences. J Intern Med 2016; 279:241-58. [PMID: 26355194 DOI: 10.1111/joim.12413] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Two decades ago, paediatric inflammatory bowel disease (IBD) drew only modest interest from the international paediatric community. Since then, dramatically globally increasing incidence rates have made childhood-onset IBD a priority for most paediatric gastroenterologists. The emerging pandemia of paediatric IBD has fuelled a quest to identify the recent changes in early life exposures that could explain the increasing risk for IBD amongst today's children. Treatment of children with IBD should aim for symptom control but should also target restoration of growth and prevention of pubertal delay. The paediatric IBD phenotype seems to be characterized by more extensive disease location, and some comparative studies have suggested that childhood-onset IBD also represents a more severe phenotype than the adult-onset IBD form. In this review, we analyse recent global incidence trends of paediatric IBD. We present an update on the known and suggested risk factors that could explain the emerging global epidemia of paediatric IBD. We also draw attention to differences in treatment between children and adults with IBD. Finally, we highlight latest follow-up studies that question the proposed dynamic and aggressive nature of childhood-onset IBD.
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Affiliation(s)
- P Malmborg
- Department of Women's and Children's Health, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - H Hildebrand
- Department of Women's and Children's Health, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
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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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Exclusive enteral nutrition continues to be first line therapy for pediatric Crohn's disease in the era of biologics. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2015. [DOI: 10.1016/j.anpede.2014.02.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
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Evaluation of transforming growth factor-β2 for radiation-induced diarrhea after pelvic radiotherapy. TUMORI JOURNAL 2015; 101:474-7. [PMID: 25983098 DOI: 10.5301/tj.5000328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2015] [Indexed: 11/20/2022]
Abstract
AIMS AND BACKGROUND Radiotherapy (RT) plays a central role in the management of cancers located in the abdomen and pelvis. However, radiation-induced toxicity remains a major concern for patients receiving RT to the abdominopelvic region. In this context, our study aims to evaluate the use of transforming growth factor (TGF)-β2-enriched formula for amelioration of radiation-induced diarrhea for patients undergoing pelvic RT. METHODS AND STUDY DESIGN Between September 2013 and September 2014, 86 malnourished patients undergoing RT for pelvic cancers who received oral nutritional supplementation with or without TGF-β2-enriched formula were assessed retrospectively in 3 groups. Oral diphenoxylate-atropine tablets were used at onset of diarrhea in all groups. Kruskal-Wallis and chi-square tests were used in the comparison of continuous and categorical variables, respectively. RESULTS Patients receiving nutritional supplemention with TGF-β2-enriched formula (groups I and II) experienced a significantly lower median number of diarrhea episodes compared to patients receiving nutritional supplementation with other products (group III), which was statistically significant (p<0.05). Also, number of patients experiencing grade 2 and grade 3 diarrhea was significantly lower in groups I and II compared to group III (p<0.05). CONCLUSIONS Nutritional supplemention with TGF-β2-enriched formula offers amelioration of radiation-induced diarrhea for patients receiving pelvic RT. Since this is the first study assessing the use of nutritional supplementation with TGF-β2-enriched formula for patients undergoing pelvic RT, future prospective studies are needed to confirm the results.
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Bryant RV, Winer S, Travis SPL, Riddell RH. Systematic review: histological remission in inflammatory bowel disease. Is 'complete' remission the new treatment paradigm? An IOIBD initiative. J Crohns Colitis 2014; 8:1582-97. [PMID: 25267173 DOI: 10.1016/j.crohns.2014.08.011] [Citation(s) in RCA: 212] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Revised: 08/06/2014] [Accepted: 08/12/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Advances in the medical management of inflammatory bowel disease (IBD) have altered treatment targets. Endoscopic mucosal healing is associated with better outcomes in IBD, though less is known about the significance of achieving histological remission. Our aim was to perform a systematic review to investigate whether histological or 'complete' remission constitutes a further therapeutic target in IBD. METHODS A bibliographic search was performed on the 1st of October 2013 and subsequently on the 1st of March 2014 of online databases (OVID SP MEDLINE, OVID EMBASE, National Pubmed Central Medline, Cochrane Library, ISI, conference abstracts), using MeSH terms and key words: ("inflammatory bowel diseases" OR "crohn disease" OR "ulcerative colitis" OR "colitis") AND ("mucosal healing" OR "histological healing" OR "pathological healing" OR "histological scoring" OR "pathological scoring"). RESULTS The search returned 2951 articles. 120 articles were cited in the final analysis. There is no validated definition of histological remission in IBD. There are 22 different histological scoring systems for IBD, none of which are fully validated. Microscopic inflammation persists in 16-100% of cases of endoscopically quiescent disease. There is evidence that histological remission may predict risk of complications in ulcerative colitis beyond endoscopic mucosal healing, though data are scarce in Crohn's disease. CONCLUSIONS Histological remission in IBD represents a target distinct from endoscopic mucosal healing, not yet routinely sought in clinical trials or practice. There remains a need for a standardized and validated histological scoring system and to confirm the prognostic value of histological remission as a treatment target in IBD.
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Affiliation(s)
- R V Bryant
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals, United Kingdom
| | - S Winer
- Department of Pathology and Laboratory Medicine, Mt Sinai Hospital, 600 University Avenue, Toronto, ON M5G 1X5, Canada
| | - S P L Travis
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals, United Kingdom
| | - R H Riddell
- Department of Pathology and Laboratory Medicine, Mt Sinai Hospital, 600 University Avenue, Toronto, ON M5G 1X5, Canada.
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Abstract
BACKGROUND Crohn's disease (CD) is an idiopathic, chronic, transmural inflammatory disorder of the gastrointestinal tract. Because mucosal involvement is near-universal, endoscopic healing has emerged as an important aspect in improving outcome. However, resolution of histologic disease activity has potential to convey additional benefit beyond that attained with endoscopic healing alone. Validated scoring systems of histologic disease activity are required to further assess this possibility. The aim of this study was to systematically review the existing histologic disease activity indices (HDAI) for CD and to assess their operating properties and potential use as outcome measures in clinical trials. METHODS MEDLINE (Ovid), EMBASE (Ovid), PubMed, the Cochrane Library (CENTRAL), and Digestive Disease Week (DDW) abstracts were searched from 1981 to April 2013 for applicable studies to identify relevant studies for review and analysis. RESULTS In total, 3732 citations were screened to obtain 89 articles for inclusion. Sixty-six HDAIs were characterized as either stepwise or numerical instruments. These HDAIs were used for either assessment of response to medical therapy or for comparison with biomarkers or imaging tests. None of the HDAIs identified was developed according to currently accepted methods for developing evaluative instruments, and none have been formally validated. CONCLUSIONS Measurement of histologic disease activity has potential value in CD; however, no validated measures are available. Additional research is needed to develop a methodologically rigorous instrument for use in clinical investigation and potentially for clinical practice.
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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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Hojsak I, Pavić AM, Mišak Z, Kolaček S. Risk factors for relapse and surgery rate in children with Crohn's disease. Eur J Pediatr 2014; 173:617-21. [PMID: 24310524 DOI: 10.1007/s00431-013-2230-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Revised: 11/20/2013] [Accepted: 11/26/2013] [Indexed: 02/06/2023]
Abstract
UNLABELLED The aim of this study was to evaluate risk factors associated with the relapse rate in the first year and the need for surgery in children with Crohn's disease (CD). Data of all children (n = 74) diagnosed with CD from January 2004 to June 2011 were retrospectively analyzed. Multivariate Cox proportional hazards regression model was used to assess whether important clinical variables at diagnosis (age, presence of perianal disease, first induction therapy, first maintenance therapy, levels of Pediatric CD Activity Index (PCDAI), C-reactive protein (CRP), and standard deviation score (SDS) for height for weight) were associated with the risk of clinical recurrence in the first year and need for surgery during follow-up. Relapse occurred in 36 (48.6 %) patients in the first year from diagnosis. The only significant parameter associated with negative risk of relapse in the first year was exclusive enteral nutrition (EEN) used as induction therapy (hazard ratio (HR) 0.469, 95 % confidence interval (CI) 0.232-0.948). EEN induced remission in 84.2 % of patients. The only risk associated with EEN treatment failure was the involvement of the upper gastrointestinal tract. During the follow-up, 25 (33.7 %) patients underwent surgery. The multivariate Cox regression model failed to recognize significant risk factor for surgery. CONCLUSION This study underlines the importance of early EEN in the treatment of CD; it is not only efficacious in the remission induction but could also prevent relapse in the first year.
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Affiliation(s)
- Iva Hojsak
- Referral Center for Pediatric Gastroenterology and Nutrition, Children's Hospital Zagreb, School of Medicine, University of Zagreb, Klaićeva 16, Zagreb, Croatia,
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Navas-López VM, Blasco-Alonso J, Lacasa Maseri S, Girón Fernández-Crehuet F, Serrano Nieto MJ, Vicioso Recio MI, Sierra Salinas C. [Exclusive enteral nutrition continues to be first line therapy for pediatric Crohn's disease in the era of biologics]. An Pediatr (Barc) 2014; 83:47-54. [PMID: 24704330 DOI: 10.1016/j.anpedi.2014.02.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Revised: 02/08/2014] [Accepted: 02/18/2014] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Exclusive enteral nutrition (EEN) has been to be more effective than corticosteroids in achieving mucosal healing without their side effects. OBJECTIVES To determine the efficacy of EEN in terms of inducing clinical remission in newly diagnosed CD children and to study the efficacy of this therapeutic approach in improving the degree of intestinal mucosa inflammation. MATERIALS AND METHODS The medical records of patients with newly diagnosed Crohn's disease treated with EEN were reviewed retrospectively. The degree of mucosal inflammation was assessed by fecal calprotectin (FC). Remission was defined as a PCDAI<10. RESULTS Forty patients (24 males) were included, the age at diagnosis was 11.6 ± 3.6 years. Of the 34 patients who completed the EEN period, 32 (94% per-protocol analysis) achieved clinical remission. This percentage fell to 80% in the intention-to-treat analysis. The compliance rate was 95%. Duration of EEN was 6.42 weeks (IQR 6.0-8.14). FC was significantly higher in patients with moderate and severe disease. Median baseline FC levels (680 μg/g) decreased significantly to 218 μg/g (P<0.0001) after EEN. We found a statistically significant correlation between FC and PCDAI (rho=0.727; P<0.0001). Early use of thiopurines (< 8 weeks) versus subsequent use was not associated with improved outcomes during the follow-up. CONCLUSIONS EEN administered for 6-8 weeks is effective for inducing clinical remission and decreasing the degree of mucosal inflammation. We did not find differences in terms of maintenance of remission in patients treated early with thiopurines.
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Affiliation(s)
- V M Navas-López
- Unidad de Gastroenterología y Nutrición Infantil. Hospital Materno Infantil, Málaga, España; Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, España.
| | - J Blasco-Alonso
- Unidad de Gastroenterología y Nutrición Infantil. Hospital Materno Infantil, Málaga, España; Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, España
| | - S Lacasa Maseri
- Unidad de Gastroenterología y Nutrición Infantil. Hospital Materno Infantil, Málaga, España
| | | | - M J Serrano Nieto
- Unidad de Gastroenterología y Nutrición Infantil. Hospital Materno Infantil, Málaga, España
| | - M I Vicioso Recio
- Servicio de Laboratorio, Hospital Regional Carlos Haya, Málaga, España
| | - C Sierra Salinas
- Unidad de Gastroenterología y Nutrición Infantil. Hospital Materno Infantil, Málaga, España; Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, España
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Lee J, Allen R, Ashley S, Becker S, Cummins P, Gbadamosi A, Gooding O, Huston J, Le Couteur J, O'Sullivan D, Wilson S, Lomer MCE. British Dietetic Association evidence-based guidelines for the dietary management of Crohn's disease in adults. J Hum Nutr Diet 2013; 27:207-18. [PMID: 24313460 DOI: 10.1111/jhn.12176] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Crohn's disease is a debilitating chronic inflammatory bowel disease. Appropriate use of diet and nutritional therapy is integral to the overall management strategy of Crohn's disease. The aim was to develop evidence-based guidelines on the dietary management of Crohn's disease in adults. METHODS Questions relating to the dietary management of Crohn's disease were developed. These included the roles of enteral nutrition to induce remission, food re-introduction diets to structure food re-introduction and maintain remission, and dietary management of stricturing disease, as well as whether probiotics or prebiotics induce or maintain remission. A comprehensive literature search was conducted and relevant studies from January 1985 to November 2009 were identified using the electronic database search engines CINAHL, Cochrane Library, EMBASE, MEDLINE, Scopus and Web of Science. Evidence statements, recommendations, practical considerations and research recommendations were developed. RESULTS Fifteen research papers were critically appraised and the evidence formed the basis of these guidelines. Although corticosteroids appear to be more effective, enteral nutrition (elemental or non-elemental) can be offered as an alternative option to induce disease remission. After a course of enteral nutrition, food re-introduction diets may be useful to structure food re-introduction and help maintain disease remission. Dietary fibre is contraindicated in the presence of strictures as a result of the risk of mechanical obstruction. The use of probiotics and prebiotics is not currently supported. CONCLUSIONS As an alternative to corticosteroids, evidence supports enteral nutrition to induce disease remission. Food re-introduction diets provide structure to food re-introduction and help maintain disease remission. These guidelines aim to reduce variation in clinical practice.
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Affiliation(s)
- J Lee
- Department of Nutrition and Dietetics, Addenbrookes, Cambridge, UK
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32
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Magro F, Langner C, Driessen A, Ensari A, Geboes K, Mantzaris GJ, Villanacci V, Becheanu G, Borralho Nunes P, Cathomas G, Fries W, Jouret-Mourin A, Mescoli C, de Petris G, Rubio CA, Shepherd NA, Vieth M, Eliakim R. European consensus on the histopathology of inflammatory bowel disease. J Crohns Colitis 2013; 7:827-51. [PMID: 23870728 DOI: 10.1016/j.crohns.2013.06.001] [Citation(s) in RCA: 408] [Impact Index Per Article: 37.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Accepted: 06/05/2013] [Indexed: 02/06/2023]
Abstract
The histologic examination of endoscopic biopsies or resection specimens remains a key step in the work-up of affected inflammatory bowel disease (IBD) patients and can be used for diagnosis and differential diagnosis, particularly in the differentiation of UC from CD and other non-IBD related colitides. The introduction of new treatment strategies in inflammatory bowel disease (IBD) interfering with the patients' immune system may result in mucosal healing, making the pathologists aware of the impact of treatment upon diagnostic features. The European Crohn's and Colitis Organisation (ECCO) and the European Society of Pathology (ESP) jointly elaborated a consensus to establish standards for histopathology diagnosis in IBD. The consensus endeavors to address: (i) procedures required for a proper diagnosis, (ii) features which can be used for the analysis of endoscopic biopsies, (iii) features which can be used for the analysis of surgical samples, (iv) criteria for diagnosis and differential diagnosis, and (v) special situations including those inherent to therapy. Questions that were addressed include: how many features should be present for a firm diagnosis? What is the role of histology in patient management, including search for dysplasia? Which features if any, can be used for assessment of disease activity? The statements and general recommendations of this consensus are based on the highest level of evidence available, but significant gaps remain in certain areas.
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Affiliation(s)
- F Magro
- Department of Pharmacology & Therapeutics, Institute for Molecular and Cell Biology, Faculty of Medicine University of Porto, Department of Gastroenterology, Hospital de Sao Joao, Porto, Portugal.
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Villanacci V, Antonelli E, Geboes K, Casella G, Bassotti G. Histological healing in inflammatory bowel disease: A still unfulfilled promise. World J Gastroenterol 2013; 19:968-78. [PMID: 23467585 PMCID: PMC3582008 DOI: 10.3748/wjg.v19.i7.968] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2012] [Revised: 09/11/2012] [Accepted: 09/19/2012] [Indexed: 02/06/2023] Open
Abstract
Treatment of inflammatory bowel disease (IBD) is traditionally based on several drugs, including salicylates, corticosteroids, and antibiotics; in addition, the therapeutic armamentarium has considerably evolved with the advent of newer, effective therapeutic measures (such as the biological agents) that are able to improve in a considerable manner both the clinical and endoscopic variables. Thus, mucosal healing, at least considered from an endoscopic point of view, is today regarded as the ultimate endpoint for treatment of these conditions. However, it is also increasingly clear that endoscopic healing is not necessarily paralleled by histological healing; There are few doubts that the latter should be considered as a true, objective healing and the ultimate goal to reach when treating patients with IBD. Unfortunately, and surprisingly, only a few, incomplete, and somewhat conflicting data exist on this topic, especially because there is still the need to standardize both histological assessment and the severity grading of these disorders; Issues that have not been yet been resolved for clinical practice and therapeutic trials. Hopefully, with the help of an increased awareness on the clinical researchers’ side, and the availability of dedicated pathologists on the other side, this matter will be effectively faced and resolved in the near future.
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Abstract
In addition to supplying essential nutrients, some food proteins can confer additional health benefits beyond nutrition. The presence of bioactive proteins and peptides in different foods is a factor not currently taken into consideration when assessing the dietary quality of food proteins. The range of described physiological benefits attributed to bioactive proteins and peptides is diverse. Multiple factors can potentially impact on the ability of a bioactive peptide or protein to elicit an effect. Although some food proteins act directly in their intact form to elicit their effects, generally it is peptides derived from digestion, hydrolysis or fermentation that are of most interest. The levels of bioactive peptides generated must be sufficient to elicit a response, but should not be so high as to be unsafe, thus causing negative effects. In addition, some peptides cause systemic effects and therefore must be absorbed, again in sufficient amounts to elicit their action. Many studies to date have been carried out in vitro; therefore it is important that further trials are conducted in vivo to assess efficacy, dose response and safety of the peptides, particularly if health related claims are to be made. Therefore, methods must be developed and standardised that enable the measurement of health benefits and also the level of bioactive peptides which are absorbed into the bloodstream. Once standardised, such methods may provide a new perspective and an additional mechanism for analysing protein quality which is currently not encompassed by the use of the protein digestibility-corrected amino acid score (PDCAAS).
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35
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Stewart MJ, Garg SK, Seow CH, Storr M. Interventions for induction and maintenance of mucosal healing in Crohn's disease. Hippokratia 2012. [DOI: 10.1002/14651858.cd010141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Michael J Stewart
- Dalhousie University; Department of Medicine; 9th Floor Victoria Building Victoria General Hospital Site 1276 South Park Street Halifax Nova Scotia, Canada B3H 2Y9
| | - Sushil K Garg
- University of Minnesota; Department of Surgery; 420 Delaware Street SE Mayo Mail Code 195 Minneapolis USA 55455
| | - Cynthia H Seow
- University of Calgary; Departments of Medicine & Community Health Sciences; TRW Building Rm 6D18 3280 Hospital Drive NW Calgary Alberta Canada T2N 4Z6
| | - Martin Storr
- University of Munich; Department of Medicine; Marchioninistr 15 Munich Germany 81377
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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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Hébuterne X, Filippi J, Al-Jaouni R, Schneider S. Nutritional consequences and nutrition therapy in Crohn's disease. ACTA ACUST UNITED AC 2010; 33 Suppl 3:S235-44. [PMID: 20117347 DOI: 10.1016/s0399-8320(09)73159-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
75% of hospital patients with Crohn's disease (CD) suffer from malnutrition and one third of CD patients have a body mass index below 20. Inflammatory bowel diseases (IBD) patients have many vitamin and nutrient deficiencies which can lead to important consequences such as hyperhomocysteinemia which is associated with a higher risk of thromboembolic disease. Nutritional deficiencies in IBD patients are the result of insufficient intake, malabsorption and protein-losing enteropathy as well as the metabolic distubances directly induced by the chronic disease and its treatments, in particular corticosteroids. Screening for nutritional deficiencies in chronic disease patients is warranted. Managing the deficiencies involves simple nutritional guidelines, vitamin supplements, and nutritional support in the worst cases, in particular in children in order to limit the impact of IBD on growth. In active CD, enteral nutrition is the first line therapy in children and should be used as sole therapy in adults mainly when treatment with corticosteroids is not feasible.
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Affiliation(s)
- X Hébuterne
- Centre Hospitalier Universitaire de Nice, Pôle Digestif, Service de Gastro-entérologie et Nutrition Clinique, Hôpital de l'Archet 2, CHU de Nice, 06202 Nice cedex 03, France.
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38
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New insights into the immunological effects of food bioactive peptides in animal models of intestinal inflammation. Proc Nutr Soc 2010; 69:454-62. [PMID: 20598199 DOI: 10.1017/s0029665110001783] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Bioactive peptides have proven to be active in several conditions, including inflammatory bowel disease (IBD). This is a chronic and relapsing condition of unknown aetiology that comprises chiefly ulcerative colitis and Crohn's disease. Although there are treatments for IBD, they have frequent side effects and they are not always effective; therefore there is a need for new therapies that could alleviate this condition. Two bioactive peptides present in milk (transforming growth factor-beta (TGF-beta) and casein macropeptide, also named glycomacropeptide) have been shown to have intestinal anti-inflammatory activities. In fact, TGF-beta is currently added to formulas intended for patients with IBD, and several studies indicate that these formulas could induce clinical remission. In this paper, evidence supporting the anti-inflammatory effect of TGF-beta and bovine glycomacropeptide, as well as their mechanisms of action, is reviewed, focusing on the evidence obtained in animal models.
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Van Assche G, Dignass A, Panes J, Beaugerie L, Karagiannis J, Allez M, Ochsenkühn T, Orchard T, Rogler G, Louis E, Kupcinskas L, Mantzaris G, Travis S, Stange E. The second European evidence-based Consensus on the diagnosis and management of Crohn's disease: Definitions and diagnosis. J Crohns Colitis 2010; 4:7-27. [PMID: 21122488 DOI: 10.1016/j.crohns.2009.12.003] [Citation(s) in RCA: 776] [Impact Index Per Article: 55.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2009] [Revised: 12/07/2009] [Accepted: 12/07/2009] [Indexed: 12/11/2022]
Affiliation(s)
- Gert Van Assche
- Division of Gastroenterology, Leuven University Hospitals, 49 Herestraat, BE 3000 Leuven, Belgium.
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Goulet O. Nutrition in paediatric Crohn’s disease. SOUTH AFRICAN JOURNAL OF CLINICAL NUTRITION 2010. [DOI: 10.1080/16070658.2010.11734267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Post-weaning effects of milk and milk components on the intestinal mucosa in inflammation. Mutat Res 2009; 690:64-70. [PMID: 20036674 DOI: 10.1016/j.mrfmmm.2009.12.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2009] [Revised: 12/14/2009] [Accepted: 12/15/2009] [Indexed: 12/16/2022]
Abstract
Many milk-derived components have immunomodulatory and anti-inflammatory properties, and some of these reduce intestinal inflammation when orally administered to animal models of colitis. However, the potential for ruminant milk or milk components to benefit people with intestinal inflammatory disorders (such as Inflammatory Bowel Disease) has not been well-researched. This review describes published research into mechanisms by which ruminant milk and its components may have beneficial effects when consumed by people who have intestinal inflammation.
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Hartman C, Eliakim R, Shamir R. Nutritional status and nutritional therapy in inflammatory bowel diseases. World J Gastroenterol 2009; 15:2570-8. [PMID: 19496185 PMCID: PMC2691486 DOI: 10.3748/wjg.15.2570] [Citation(s) in RCA: 130] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Underweight and specific nutrient deficiencies are frequent in adult patients with inflammatory bowel disease (IBD). In addition, a significant number of children with IBD, especially Crohn’s disease (CD) have impaired linear growth. Nutrition has an important role in the management of IBD. In adults with CD, enteral nutrition (EN) is effective in inducing clinical remission of IBD, although it is less efficient than corticosteroids. Exclusive EN is an established primary therapy for pediatric CD. Limited data suggests that EN is as efficient as corticosteroids for induction of remission. Additional advantages of nutritional therapy are control of inflammation, mucosal healing, positive benefits to growth and overall nutritional status with minimal adverse effects. The available evidence suggests that supplementary EN may be effective also for maintenance of remission in CD. More studies are needed to confirm these findings. However, EN supplementation could be considered as an alternative or as an adjunct to maintenance drug therapy in CD. EN does not have a primary therapeutic role in ulcerative colitis. Specific compositions of enteral diets-elemental diets or diets containing specific components-were not shown to have any advantage over standard polymeric diets and their place in the treatment of CD or UC need further evaluation. Recent theories suggest that diet may be implicated in the etiology of IBD, however there are no proven dietary approaches to reduce the risk of developing IBD.
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Abstract
BACKGROUND Neither the rate of endoscopic remission (ER) in Crohn's disease (CD) after therapy nor its role in patients' prognosis is well defined. AIM To systematically review the current evidence on the proportion of ER of different therapies in patients with Crohn's disease and its relation with clinical outcomes. METHODS Databases (MEDLINE and Cochrane) and manual search of manuscripts found 482 titles. Data was extracted from 24 manuscripts. RESULTS Ten different methods were used to assess endoscopic outcomes. Corticosteroids induced a pooled proportion of patients with no ulcerations at endoscopic follow-up of 17% (95% confidence interval: 12-22%) lower than that found with infliximab [44% (34-53%)], diet [43% (33-52%)] or azathioprine [54% (38-69%)] (P<0.0001). Enteric diets and infliximab were associated with 61% (52-70%) and 70% (62-78%) reduction in endoscopic scores, respectively, significantly higher than corticosteroids [45% (39-52%)] (P=0.01) and placebo [12% (1-22%)] (P<0.0001). A linear relation between ER and clinical remission was observed with infliximab (r=0.931). Only one study tried to assess the direct correlation between ER and patients' prognosis. CONCLUSION Available treatments induce significant endoscopic improvement. However, pooled results should be cautiously interpreted because of the diversity of measurements. A better definition of endoscopic outcomes and a prospective validation of their relevance in patients with Crohn's disease are needed.
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El-Matary W. Enteral Nutrition as a Primary Therapy of Crohn's Disease: The Pediatric Perspective. Nutr Clin Pract 2009; 24:91-7. [DOI: 10.1177/0884533608329660] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Affiliation(s)
- Wael El-Matary
- From Pediatric Gastroenterology, University of Alberta, Edmonton, Alberta, Canada
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Navas López V, Blasco Alonso J, Sierra Salinas C, Barco Gálvez A, Vicioso Recio M. Eficacia del tratamiento nutricional primario en la enfermedad de Crohn pediátrica. An Pediatr (Barc) 2008; 69:506-14. [DOI: 10.1016/s1695-4033(08)75232-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
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Issa M, Binion DG. Bowel Rest and Nutrition Therapy in the Management of Active Crohn's Disease. Nutr Clin Pract 2008; 23:299-308. [DOI: 10.1177/0884533608318675] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
- Mazen Issa
- From the Division of Gastroenterology and Hepatology, Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - David G. Binion
- From the Division of Gastroenterology and Hepatology, Department of Medicine, Medical College of Wisconsin, Milwaukee
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Heuschkel R, Salvestrini C, Beattie RM, Hildebrand H, Walters T, Griffiths A. Guidelines for the management of growth failure in childhood inflammatory bowel disease. Inflamm Bowel Dis 2008; 14:839-49. [PMID: 18266237 DOI: 10.1002/ibd.20378] [Citation(s) in RCA: 142] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Around 1 in 4 patients with inflammatory bowel disease (IBD) present in childhood, the majority around the time of their pubertal growth spurt. This presents challenges over and above those of managing IBD in adults as this period is a time of dramatic psychological and physical transition for a child. Growth and nutrition are key priorities in the management of adolescents and young adults with IBD. Growth failure in IBD is characterized by delayed skeletal maturation and a delayed onset of puberty, and is best described in terms of height-for-age standard deviation score (Z score) or by variations in growth velocity over a period of 3-4 months. Growth failure is common at presentation in Crohn's disease (CD), but less common in ulcerative colitis (UC). The etiology of growth failure is multifactorial. Principal determinants, however, include the inflammatory process per se, with proinflammatory cytokines (e.g., IL-1beta, IL-6) being directly implicated. Furthermore, poor nutrition and the consequences of prolonged corticosteroid use also contribute to the significant reduction in final adult height of almost 1 in 5 children. Initially a prompt, where possible steroid-free, induction of remission is indicated. The ideal is then to sustain a relapse-free remission until growth is complete, which is often not until early adulthood. These goals can often be achieved with a combination of exclusive enteral nutrition (EEN) and early use of immunosuppressants. The advent of potent and efficacious biological agents considerably improves the range of growth-sparing interventions available to children around puberty, although well-timed surgery remains another highly effective means of achieving remission and significant catch-up growth. We carried out a systematic review of publications to identify the best available evidence for managing growth failure in children with IBD. Despite the paucity of high-quality publications, sufficient data were available in the literature to allow practical, evidence-based where possible, management guidelines to be formulated. Although there is clear evidence that exclusive enteral nutrition achieves mucosal healing, its effect on growth has only been assessed at 6 months. In contrast to corticosteroids, EEN has no negative effect on growth. Corticosteroids remain the key therapy responsible for medication-induced growth impairment, although the use of budesonide in selected patients may minimize the steroid effect on dividing growth plates. Immunosuppressants have become a mainstay of treatment in children with IBD, and are being used earlier in the disease course than ever before. However, there are currently no long-term data reporting better growth outcome if these agents are introduced very soon after diagnosis. In comparison, recent data from a large prospective trial of infliximab in children with moderate to severe CD suggested significant catch-up growth during the first year of regular infusions. The only other intervention that has documented clear catch-up growth has been surgical resection. Resection of localized CD, in otherwise treatment-resistant children, early in the disease process achieves clear catch-up growth within the next 6 months. There are no data available that growth hormone improves final adult height in children with CD. In conjunction with expert endocrinological support, pubertal delay, more common in boys, may be treated with parenteral testosterone if causing significant psychological problems. The optimal management of children and adolescents requires a multidisciplinary approach frequently available within the pediatric healthcare setting. Dedicated dietetic support, along with nurse-specialist, child psychologist, and with closely linked medical and surgical care will likely achieve the best possible start for children facing a lifetime of chronic gut disease.
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Affiliation(s)
- Robert Heuschkel
- Royal Free Hampstead NHS Trust, Centre for Paediatric Gastroenterology, Hampstead, London, UK.
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Dziechciarz P, Horvath A, Shamir R, Szajewska H. Meta-analysis: enteral nutrition in active Crohn's disease in children. Aliment Pharmacol Ther 2007; 26:795-806. [PMID: 17767463 DOI: 10.1111/j.1365-2036.2007.03431.x] [Citation(s) in RCA: 168] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Controversy exists surrounding the optimal treatment for inducing remission in active Crohn's disease. AIM To review and update evidence on the effectiveness of enteral nutrition (EN) in treating active Crohn's disease in children. METHODS MEDLINE, EMBASE and The Cochrane Library (up to February 2007) were searched for randomized controlled trials (RCTs) relevant to Crohn's disease and EN in children. RESULTS We included 11 RCTs (n = 394). Seven RCTs (n = 204) compared EN with corticosteroid therapy. On the basis of pooled results of four RCTs (n = 144), we found no significant difference in the remission rates between groups (relative risk, RR 0.97, 95% CI 0.7-1.4, random effect model). Four RCTs (n = 190) compared two EN regimens. One of the four RCTs (n = 50) revealed a significant increase in the percentage of patients achieving remission in the total EN group compared with the partial EN group (RR 2.7, 95% CI 1-7.4). Because of lack of data, formal pooling of results was not possible for many outcomes (e.g., time until remission, duration of remission, growth data). CONCLUSIONS Limited data suggest similar efficacy for EN and corticosteroids. As the number of patients needed to provide a definite answer is too large, future studies should focus on detailed outcome measurements including growth and quality of life.
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Affiliation(s)
- P Dziechciarz
- The Second Department of Paediatrics, The Medical University of Warsaw, Warsaw, Poland.
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Rodrigues AF, Johnson T, Davies P, Murphy MS. Does polymeric formula improve adherence to liquid diet therapy in children with active Crohn's disease? Arch Dis Child 2007; 92:767-70. [PMID: 17475695 PMCID: PMC2084047 DOI: 10.1136/adc.2006.103416] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Active Crohn's disease can be treated using liquid diet therapy (LDT), but non-adherence may limit success, necessitating corticosteroid therapy. Whole-protein polymeric formula (PF) seems to be much more palatable than amino acid-based elemental formula (EF) and thus may significantly improve adherence to LDT. AIM To compare adherence to LDT using PF versus EF. METHODS Success in completing a 6-week course of LDT, need for nasogastric tube administration of formula and use of LDT for relapses were compared between children presenting with active disease and treated with EF (n = 53) and children given PF (n = 45). RESULTS Remission rates were similar (EF 64%, 95% CI 51 to 77 vs PF 51%, 95% CI 37 to 66; p>0.15). 72% (95% CI 60 to 84) given EF completed the initial course of LDT compared with 58% (95% CI 44 to 72) given PF (p = 0.15). Of those failing to complete the initial course, 13% on EF and 16% on PF gave up by choice (non-adherence), the remainder stopping due to treatment failure. Nasogastric administration was more frequent with EF (55%, 95% CI 42 to 68) compared to PF (31%, 95% CI 17 to 45) (p = 0.02). Among those treated successfully at first presentation, LDT was used for 28% of relapses in the EF group (95% CI 12 to 44) and 39% in the PF group (95% CI 19 to 59) (p>0.2) over the next year. CONCLUSION PF did not effect adherence to LDT but was associated with significantly reduced need for nasogastric tube administration of formula.
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Affiliation(s)
- A F Rodrigues
- Department of Paediatric Gastroenterology, Birmingham Children's Hospital NHS Trust, Birmingham, UK
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Day AS, Whitten KE, Lemberg DA, Clarkson C, Vitug-Sales M, Jackson R, Bohane TD. Exclusive enteral feeding as primary therapy for Crohn's disease in Australian children and adolescents: a feasible and effective approach. J Gastroenterol Hepatol 2006; 21:1609-14. [PMID: 16928225 DOI: 10.1111/j.1440-1746.2006.04294.x] [Citation(s) in RCA: 125] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Exclusive enteral feeding has been shown to be as efficacious as corticosteroids in inducing remission in children with Crohn's disease (CD), with additional nutritional benefits. The use of polymeric formulae provides superior palatability and acceptance over elemental feeds, but polymeric formulae have not been universally adopted. The present retrospective analysis of enteral feeding in children with Crohn's disease aims to demonstrate the short-term benefits of enteral feeding in children upon disease activity and nutrition parameters. METHODS The case records of children with CD managed with exclusive enteral nutrition (EEN) by a multidisciplinary team over a 2-year period were reviewed. Data relating to therapy, background disease details, and outcome were collated. Primary outcome measures established were weight change and disease activity (Pediatric Crohn's Disease Activity Index: PCDAI). RESULTS Twenty-seven children received EEN with polymeric formulae. Fifteen children had newly diagnosed CD and 12 had known long-standing CD. Twenty-four children completed the prescribed period of EEN. Twelve of 15 (80%) newly diagnosed CD and seven of 12 (58%) with long-standing disease entered remission. Children with newly diagnosed CD responding to EEN took all feeds orally and gained an average of 4.7+/-3.5 kg with mean PCDAI decreasing from 37.1+/-10.8 to 6.7+/-5.1 after 8 weeks. In addition, four children continued supplementary polymeric formula (without other medical therapies) and all have maintained remission during an average follow-up period of 15.2 months. CONCLUSION Exclusive enteral feeds induced remission in 80% of children with newly diagnosed CD (on intention-to-treat basis) when used as sole initial therapy while also improving nutritional status. All newly diagnosed children treated with EEN, who were able to establish feeds, achieved remission. In addition, remission may be prolonged with oral supplementary formula as sole ongoing treatment. Further study of the role(s) of enteral feeds and of longer-term benefits of enteral feeding in children with CD is now required.
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Affiliation(s)
- Andrew S Day
- Department of Gastroenterology, Sydney Children's Hospital and School of Women's and Children's Health, University of New South Wales, Sydney, Australia.
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