1
|
Abstract
The pathogenesis of inflammatory bowel disease (IBD) involves a complex interaction between genetics, immune response, and the environment. Epidemiologic associations between diet and development of IBD plus the ability of diet to modify the microbiota and modulate immune function have led to the hypothesis that diet can prevent and/or treat IBD. It is well established that the induction of remission and healing of the mucosa in Crohn's disease can be accomplished with exclusive enteral nutrition. Whole food-based alternatives such as the Crohn's disease exclusion diet have shown promising results.
Collapse
Affiliation(s)
- Lindsey Albenberg
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 2716 South Street, 14-140, Philadelphia, PA 19146, USA.
| |
Collapse
|
2
|
Cuomo M, Carobbio A, Aloi M, Alvisi P, Banzato C, Bosa L, Bramuzzo M, Campanozzi A, Catassi G, D'Antiga L, Di Paola M, Felici E, Fioretti MT, Gatti S, Graziano F, Lega S, Lionetti P, Marseglia A, Martinelli M, Musto F, Sansotta N, Scarallo L, Zuin G, Norsa L. Induction of Remission With Exclusive Enteral Nutrition in Children With Crohn's Disease: Determinants of Higher Adherence and Response. Inflamm Bowel Dis 2023; 29:1380-1389. [PMID: 36222487 DOI: 10.1093/ibd/izac215] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND Exclusive enteral nutrition (EEN) is the first choice to induce remission and promote mucosal healing in pediatric Crohn's disease (CD). However, full adherence to EEN treatment may be problematic for children with CD. METHODS The goal of the current multicenter retrospective study was to define predictive factors of nonadherence to treatment and nonremission at the end of induction treatment. Those data together were analyzed with the ultimate goal of trying to define an individualized induction treatment for children with CD. RESULTS Three hundred seventy-six children with CD from 14 IBD pediatric referral centers were enrolled in the study. The rate of EEN adherence was 89%. Colonic involvement and fecal calprotectin >600 μg/g at diagnosis were found to be associated with a reduced EEN adherence. Exclusive enteral nutrition administered for 8 weeks was effective for inducing clinical remission in 67% of the total cohort. Factors determining lower remission rates were age >15 years and Pediatric Crohn's Disease Activity Index >50. CONCLUSION Although EEN is extremely effective in promoting disease remission, several patients' related factors may adversely impact EEN adherence and response. Personalized treatments should be proposed that weigh benefits and risks based on the patient's disease location, phenotype, and disease activity and aim to promote a rapid control of inflammation to reduce long-term bowel damage.
Collapse
Affiliation(s)
- Marialaura Cuomo
- Department of Pediatrics, San Carlo Hospital - ASST Santi Paolo e Carlo, Milano, Italy
| | | | - Marina Aloi
- Pediatric Gastroenterology and Liver Unit, Department of Maternal and Child Health, Sapienza University of Rome, Roma, Italy
| | - Patrizia Alvisi
- Pediatric Gastroenterology Unit, Maggiore Hospital, Bologna, Italy
| | - Claudia Banzato
- Pediatric Clinic, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, Pediatric Division, University of Verona, Verona, Italy
| | - Luca Bosa
- Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Matteo Bramuzzo
- Institute for Maternal and Child Health "IRCCS Burlo Garofolo", Trieste, Italy
| | - Angelo Campanozzi
- Pediatrics, Department of Medical and Surgical Sciences, University of Foggia, Italy
| | - Giulia Catassi
- Pediatric Gastroenterology and Liver Unit, Department of Maternal and Child Health, Sapienza University of Rome, Roma, Italy
| | - Lorenzo D'Antiga
- Pediatric Hepatology, Gastroenterology and Transplantation Unit, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Monica Di Paola
- Gastroenterology and Nutrition Unit, Meyer children's Hospital, Department Neurofarba, University of Florence, Florence, Italy
| | - Enrico Felici
- Pediatric and Pediatric Emergency Unit, "U. Bosio" Center for Pediatric Digestive Diseases, Children Hospital, AO SS Antonio e Biagio e C. Arrigo, Alessandria, Italy
| | - Maria Teresa Fioretti
- Department of Translational Medical Science, Section of Pediatrics, University of Naples "Federico II", Napoli, Italy
| | - Simona Gatti
- Department of Pediatrics, Polytechnic University of Marche, G. Salesi Children's Hospital, Ancona, Italy
| | | | - Sara Lega
- Institute for Maternal and Child Health "IRCCS Burlo Garofolo", Trieste, Italy
| | - Paolo Lionetti
- Pediatrics, Department of Medical and Surgical Sciences, University of Foggia, Italy
| | - Antonio Marseglia
- Division of Pediatrics, "IRCCS Casa Sollievo della Sofferenza", San GiovanniRotondo, Italy
| | - Massimo Martinelli
- Gastroenterology and Nutrition Unit, Meyer children's Hospital, Department Neurofarba, University of Florence, Florence, Italy
| | - Francesca Musto
- Pediatric Department, University of Milano Bicocca, Fondazione MBBM, Onlus San Gerardo Hospital, Monza, Italy
| | - Naire Sansotta
- Pediatric Hepatology, Gastroenterology and Transplantation Unit, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Luca Scarallo
- Pediatrics, Department of Medical and Surgical Sciences, University of Foggia, Italy
| | - Giovanna Zuin
- Pediatric Department, University of Milano Bicocca, Fondazione MBBM, Onlus San Gerardo Hospital, Monza, Italy
| | - Lorenzo Norsa
- Pediatric Hepatology, Gastroenterology and Transplantation Unit, ASST Papa Giovanni XXIII, Bergamo, Italy
| |
Collapse
|
3
|
Valvano M, Capannolo A, Cesaro N, Stefanelli G, Fabiani S, Frassino S, Monaco S, Magistroni M, Viscido A, Latella G. Nutrition, Nutritional Status, Micronutrients Deficiency, and Disease Course of Inflammatory Bowel Disease. Nutrients 2023; 15:3824. [PMID: 37686856 PMCID: PMC10489664 DOI: 10.3390/nu15173824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 08/25/2023] [Accepted: 08/28/2023] [Indexed: 09/10/2023] Open
Abstract
During the disease course, most Inflammatory Bowel Disease patients present a condition of malnutrition, undernutrition, or even overnutrition. These conditions are mainly due to suboptimal nutritional intake, alterations in nutrient requirements and metabolism, malabsorption, and excessive gastrointestinal losses. A suboptimal nutritional status and low micronutrient serum levels can have a negative impact on both induction and maintenance of remission and on the quality of life of Inflammatory Bowel Disease patients. We performed a systematic review including all the studies evaluating the connection between nutrition, nutrition status (including undernutrition and overnutrition), micronutrient deficiency, and both disease course and therapeutic response in Inflammatory Bowel Disease patients. This systematic review was performed using PubMed/MEDLINE and Scopus. Four main clinical settings concerning the effect of nutrition on disease course in adult Inflammatory Bowel Disease patients were analyzed (induction of remission, maintenance of remission, risk of surgery, post-operative recurrence, and surgery-related complications). Four authors independently reviewed abstracts and manuscripts for eligibility. 6077 articles were found; 762 duplicated studies were removed. Out of 412 full texts analyzed, 227 were included in the review. The evidence summarized in this review showed that many nutritional aspects could be potential targets to induce a better control of symptoms, a deeper remission, and overall improve the quality of life of Inflammatory Bowel Disease patients.
Collapse
Affiliation(s)
- Marco Valvano
- Gastroenterology Unit, Division of Gastroenterology, Hepatology, and Nutrition, Department of Life, Health and Environmental Sciences, University of L’Aquila, Piazzale Salvatore Tommasi 1, 67100 L’Aquila, Italy; (N.C.); (S.F.); (S.F.); (S.M.); (M.M.); (A.V.); (G.L.)
- Division of Gastroenterology, Galliera Hospital, 16128 Genoa, Italy;
| | - Annalisa Capannolo
- Diagnostic and Surgical Endoscopy Unit, San Salvatore Academic Hospital, 67100 L’Aquila, Italy;
| | - Nicola Cesaro
- Gastroenterology Unit, Division of Gastroenterology, Hepatology, and Nutrition, Department of Life, Health and Environmental Sciences, University of L’Aquila, Piazzale Salvatore Tommasi 1, 67100 L’Aquila, Italy; (N.C.); (S.F.); (S.F.); (S.M.); (M.M.); (A.V.); (G.L.)
| | | | - Stefano Fabiani
- Gastroenterology Unit, Division of Gastroenterology, Hepatology, and Nutrition, Department of Life, Health and Environmental Sciences, University of L’Aquila, Piazzale Salvatore Tommasi 1, 67100 L’Aquila, Italy; (N.C.); (S.F.); (S.F.); (S.M.); (M.M.); (A.V.); (G.L.)
| | - Sara Frassino
- Gastroenterology Unit, Division of Gastroenterology, Hepatology, and Nutrition, Department of Life, Health and Environmental Sciences, University of L’Aquila, Piazzale Salvatore Tommasi 1, 67100 L’Aquila, Italy; (N.C.); (S.F.); (S.F.); (S.M.); (M.M.); (A.V.); (G.L.)
| | - Sabrina Monaco
- Gastroenterology Unit, Division of Gastroenterology, Hepatology, and Nutrition, Department of Life, Health and Environmental Sciences, University of L’Aquila, Piazzale Salvatore Tommasi 1, 67100 L’Aquila, Italy; (N.C.); (S.F.); (S.F.); (S.M.); (M.M.); (A.V.); (G.L.)
| | - Marco Magistroni
- Gastroenterology Unit, Division of Gastroenterology, Hepatology, and Nutrition, Department of Life, Health and Environmental Sciences, University of L’Aquila, Piazzale Salvatore Tommasi 1, 67100 L’Aquila, Italy; (N.C.); (S.F.); (S.F.); (S.M.); (M.M.); (A.V.); (G.L.)
| | - Angelo Viscido
- Gastroenterology Unit, Division of Gastroenterology, Hepatology, and Nutrition, Department of Life, Health and Environmental Sciences, University of L’Aquila, Piazzale Salvatore Tommasi 1, 67100 L’Aquila, Italy; (N.C.); (S.F.); (S.F.); (S.M.); (M.M.); (A.V.); (G.L.)
| | - Giovanni Latella
- Gastroenterology Unit, Division of Gastroenterology, Hepatology, and Nutrition, Department of Life, Health and Environmental Sciences, University of L’Aquila, Piazzale Salvatore Tommasi 1, 67100 L’Aquila, Italy; (N.C.); (S.F.); (S.F.); (S.M.); (M.M.); (A.V.); (G.L.)
| |
Collapse
|
4
|
Zhu Z, Lei Y, Lin Z. Effects of Crohn's disease exclusion diet on remission: a systematic review. Therap Adv Gastroenterol 2023; 16:17562848231184056. [PMID: 37655057 PMCID: PMC10467299 DOI: 10.1177/17562848231184056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 05/26/2023] [Indexed: 09/02/2023] Open
Abstract
Background Dietary therapy may potentially reduce inflammation and promote mucosal healing in patients with Crohn's disease and is associated with fewer side effects and lower cost compared to medical therapy. Recently the Crohn's disease exclusion diet (CDED) has been developed to reduce exposure to individualized dietary components which negatively affect the intestine in patients with Crohn's disease. Objectives This systematic review aimed to explore the effectiveness of CDED in Crohn's disease patients. Design A systematic review. Data sources and methods A systematic search was performed on the PubMed, EBSCOhost, Cochrane library, OVID, Embase, Scopus, and CINHAL to identify relevant clinical trials published from 1 January 2014 to 31 August 2022. Results A total of 1120 studies were identified and 7 studies were finally included in the analysis. The study was reported according to Preferred Reporting Items for Systematic Reviews and Meta-analysis statement. Conclusion Our findings suggested that the use of CDED seemed to be effective for induction and maintenance of remission in children and adults with mild to moderate Crohn's disease. However, heterogeneity and limitations existed among the studies included. Further investigation in the form of well-designed randomized clinical trials is needed to validate the present findings. Registration PROSPERO registration number CRD42022335453.
Collapse
Affiliation(s)
- Zhanhui Zhu
- School of Nursing, Nanjing Medical University, Nanjing, China
| | - Yang Lei
- School of Nursing, Nanjing Medical University, 101 Longmian Avenue, Jiangning District, Nanjing 211166, P.R. China
| | - Zheng Lin
- School of Nursing, Nanjing Medical University, 101 Longmian Avenue, Jiangning District, Nanjing 211166, P.R. China
- Nursing Department, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing 210029, P.R. China
| |
Collapse
|
5
|
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.
Collapse
Affiliation(s)
| | - Andrew S. Day
- Paediatric Department, University of Otago Christchurch, Christchurch 8140, New Zealand
| |
Collapse
|
6
|
Luo J, Xie YM, Wu M, Zhao JG, Hu LL. Global attitudes on and the status of enteral nutrition therapy for pediatric inflammatory bowel disease. Front Med (Lausanne) 2022; 9:1036793. [PMID: 36569124 PMCID: PMC9773139 DOI: 10.3389/fmed.2022.1036793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 11/14/2022] [Indexed: 12/13/2022] Open
Abstract
Enteral nutrition (EN) is a diet-remission therapy for inflammatory bowel disease (IBD) that plays a more important role in children than adults. EN includes exclusive enteral nutrition (EEN), partial enteral nutrition (PEN), and maintenance enteral nutrition (MEN). However, EEN remains an unstandardized treatment for pediatric IBD. The types and methods of EN differ around the world. The current study reviewed the EN literature on children with IBD. A total of 12 survey studies were identified that analyzed the current state of EN use, including clinical opinions, implementation methods, treatment course, EEN formula, IBD classification, progress, dietary reintroduction, and patient feedback. The findings revealed that EEN has a strong effect on mild to moderate Crohn's disease (CD). The usage rates of this treatment in different sites were ileum/colon (Paris classification L3) > ileum (L1) > upper digestive tract (L4) > colon (L2) > perianal disease (P) > ulcerative colitis (UC) > extraintestinal lesions. The polymeric formula was the most used EN formulation. New EN diets include a CD exclusion diet (CDED), a specific carbohydrate diet (SCD), and a CD treatment-with-eating (CD-TREAT) diet. Children with IBD responded similarly to EEN administered orally or using a feeding tube. Most guidelines recommended 6-8 weeks of EEN treatment to induce remission. Many clinicians preferred to combine drug medications during EEN and recommended that MEN accounts for at least 25-35% of daily caloric intake. EN remains an unstandardized therapy that requires teamwork across disciplines.
Collapse
Affiliation(s)
- Juan Luo
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, Sichuan, China
| | - Yong-Mei Xie
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, Sichuan, China,*Correspondence: Yong-Mei Xie,
| | - Mei Wu
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, Sichuan, China
| | - Jin-Gui Zhao
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, Sichuan, China
| | - Liang-Liang Hu
- Department of Pediatrics, Luzhou People’s Hospital, Luzhou, Sichuan, China
| |
Collapse
|
7
|
Xiao F, Gao X, Hu H, Le J, Chen Y, Shu X, Liang Z, Xu Y, Wang Y, Zhang T. Exclusive Enteral Nutrition Exerts Anti-Inflammatory Effects through Modulating Microbiota, Bile Acid Metabolism, and Immune Activities. Nutrients 2022; 14:nu14214463. [PMID: 36364726 PMCID: PMC9657881 DOI: 10.3390/nu14214463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 10/19/2022] [Accepted: 10/21/2022] [Indexed: 11/30/2022] Open
Abstract
Exclusive enteral nutrition (EEN) can induce remission in patients with pediatric Crohn’s disease (CD). This study aims to depict EEN’s modification of bile acid (BA) metabolism in pediatric CD and explores the effect of the EEN-enriched BA in inhibiting the inflammatory response. The twelve enrolled pediatric CD patients showed BA dysmetabolism, represented by decreased levels of fecal secondary and unconjugated BAs as determined by UPLC–TQMS, which were accompanied by gut microbiota dysbiosis and reduced BA-metabolizing bacteria including Eubacterium and Ruminococcus genera, assessed by shotgun metagenomic sequencing. EEN treatment induced remission in these patients at eight weeks, and nine patients remained in stable remission for longer than 48 weeks. EEN improved BA dysmetabolism, with some enriched BAs, including hyocholic acid (HCA), α-muricholic acid (αMCA), strongly associated with decreased severity of CD symptoms. These BAs were significantly correlated with the increased abundance of certain bacteria, including Clostridium innocuum and Hungatella hathewayi, which express 3β-hydroxysteroid dehydrogenase and 5β-reductase. HCA could suppress TNF-α production by CD4+ T cells in the peripheral blood mononuclear cells (PBMCs) of CD patients. Moreover, intraperitoneal injection of HCA could attenuate dextran sulfate sodium (DSS)-induced mouse colitis. Our data suggests that BA modification may contribute to the EEN-induced remission of pediatric CD.
Collapse
Affiliation(s)
- Fangfei Xiao
- Department of Gastroenterology, Hepatology and Nutrition, Shanghai Children’s Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200062, China
- Institute of Pediatric Infection, Immunity and Critical Care Medicine, Shanghai Children’s Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200062, China
| | - Xuefeng Gao
- Central Laboratory, Shenzhen Key Laboratory of Precision Medicine for Hematological Malignancies, International Cancer Center, Shenzhen University General Hospital, Shenzhen 518000, China
- Department of Gastroenterology and Hepatology, Shenzhen University General Hospital, Shenzhen 518000, China
| | - Hui Hu
- Department of Gastroenterology, Hepatology and Nutrition, Shanghai Children’s Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200062, China
| | - Jun Le
- Department of Gastroenterology, Hepatology and Nutrition, Shanghai Children’s Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200062, China
| | - Yongheng Chen
- Department of Physiology, School of Basic Medical Sciences, Shenzhen University Health Science Center, Shenzhen 518000, China
| | - Xingsheng Shu
- Department of Physiology, School of Basic Medical Sciences, Shenzhen University Health Science Center, Shenzhen 518000, China
| | - Ziwei Liang
- School of Medicine, Southern University of Science and Technology, Shenzhen 518100, China
| | - Yang Xu
- School of Medicine, Southern University of Science and Technology, Shenzhen 518100, China
| | - Yizhong Wang
- Department of Gastroenterology, Hepatology and Nutrition, Shanghai Children’s Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200062, China
- Institute of Pediatric Infection, Immunity and Critical Care Medicine, Shanghai Children’s Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200062, China
| | - Ting Zhang
- Department of Gastroenterology, Hepatology and Nutrition, Shanghai Children’s Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200062, China
- Institute of Pediatric Infection, Immunity and Critical Care Medicine, Shanghai Children’s Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200062, China
- Correspondence:
| |
Collapse
|
8
|
Sohouli MH, Fatahi S, Farahmand F, Alimadadi H, Seraj SS, Rohani P. Meta-analysis: efficacy of exclusive enteral nutrition as induction therapy on disease activity index, inflammation and growth factors in paediatric Crohn's disease. Aliment Pharmacol Ther 2022; 56:384-395. [PMID: 35748390 DOI: 10.1111/apt.17109] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 02/14/2022] [Accepted: 06/14/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND There is evidence of inconsistency in sequelae of exclusive enteral nutrition (EEN) as induction therapy in paediatric patients with Crohn's disease (CD). AIM To investigate the potential effects of EEN on paediatric Crohn's disease activity index (PCDAI), inflammation and biochemical parameters in paediatric patients with CD. METHODS We performed a comprehensive systematic search of PubMed/MEDLINE, Web of Science, SCOPUS and Embase until 8 January 2022 regardless of the time of publication or language. Random-effects model was applied to combine the datasets. The main outcomes were analysed through mean difference (MD) and its 95% confidence interval (CI). RESULTS Forty six studies met eligibility criteria and were included in the meta-analysis. Pooled findings indicated that PCDAI score (MD of -27.24; 95% CI -31.84 to -22.64), calprotectin (MD of -842.83 mg/kg; CI -1018.24 to -667.42), CRP (pooled MD of -2.36 mg/dl; CI -2.68 to -2.03), and ESR (MD of -21.09 mm/h; CI -23.79 to -18.38), albumin (MD of 0.65 g/dl; CI 0.58 to 0.72), haemoglobin (MD of 1.12 g/dl; CI 0.87 to 1.37), weight (MD of 4.30 kg; CI 3.39 to 5.22), and height (MD of 0.98 cm; CI 0.35 to 1.62) improved significantly with EEN. CONCLUSIONS Adherence to EEN can have significant, beneficial effects as induction therapy in paediatric patients with CD.
Collapse
Affiliation(s)
- Mohammad Hassan Sohouli
- Pediatric Gastroenterology and Hepatology Research Center, Pediatrics Centre of Excellence, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran.,Student Research Committee, Department of Clinical Nutrition and Dietetics, Faculty of Nutrition and Food Technology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Somaye Fatahi
- Department of Nutrition, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Farahmand
- Pediatric Gastroenterology and Hepatology Research Center, Pediatrics Centre of Excellence, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Hosein Alimadadi
- Pediatric Gastroenterology and Hepatology Research Center, Pediatrics Centre of Excellence, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Shaikh Sanjid Seraj
- Department of Surgery, Walsall Manor Hospital, Walsall Healthcare NHS Trust, Walsall, UK
| | - Pejman Rohani
- Pediatric Gastroenterology and Hepatology Research Center, Pediatrics Centre of Excellence, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
9
|
Jiang J, Chen L, Chen Y, Chen H. Exclusive enteral nutrition remodels the intestinal flora in patients with active Crohn's disease. BMC Gastroenterol 2022; 22:212. [PMID: 35501724 PMCID: PMC9059691 DOI: 10.1186/s12876-022-02293-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 04/21/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although there are many hypotheses, the pathogenesis of Crohn's disease (CD) is not completely clear so far. Exclusive enteral nutrition (EEN) is a routine measure in the treatment of active CD. We aimed at investigating the impact of EEN on patients with active CD from microbial metabolomics. METHODS 16S-rDNA sequencing technology and gas chromatography-mass spectrometer analysis were employed to investigate the modification of the intestinal flora and fecal short-chain fatty acid (SCFA) during the EEN. RESULTS Seven patients with CD, who conducted EEN, were followed up successfully in the present study. The 8-week EEN resulted in a remission of the condition of subjects with active CD, as revealed by a significant decrease in erythrocyte sedimentation rate (ESR) (P = 0.018), C-reactive protein (CRP) (P = 0.028), and Crohn's disease activity index (CDAI) (P = 0.018). The nutrition of the subjects was improved after an 8-week treatment course with EEN, which was associated with an increase in body mess index (BMI) (P = 0.018) and serum albumin (ALB) (P = 0.018) levels. Furthermore, our investigations revealed a significantly increased abundance of Firmicutes paralleled by decreased levels of Proteobacteria. With respect to the genus, five species of bacteria including Ruminococcus (P = 0.01), Lachnospiraceae (P = 0.02), Anaerotruncus (P = 0.04), Flavonifractor (P = 0.04), and Novosphingobium (P = 0.05) showed significantly increased abundance. This was accompanied by relative changes in fecal short-chain fatty acids levels. Moreover, we successfully constructed a stable model by combining these five significantly different genera to predict the therapeutic effect of EEN on patients with CD (AUC = 0.9598). CONCLUSIONS The findings indicated that EEN can alleviate the condition and the nutrition of patients with active CD by regulating the intestinal flora and influencing the expression level of fecal short-chain fatty acids.
Collapse
Affiliation(s)
- Jingjing Jiang
- School of Medicine, Southeast University, Nanjing, 210009, China.,Department of Gastroenterology, Zhongda Hospital, Southeast University, Nanjing, 210009, China
| | - Lu Chen
- Department of Gastroenterology, Zhongda Hospital, Southeast University, Nanjing, 210009, China
| | - Yanfang Chen
- Department of Gastroenterology, Zhongda Hospital, Southeast University, Nanjing, 210009, China.,Nanjing Medical University, Nanjing, China
| | - Hong Chen
- School of Medicine, Southeast University, Nanjing, 210009, China. .,Department of Gastroenterology, Zhongda Hospital, Southeast University, Nanjing, 210009, China.
| |
Collapse
|
10
|
Sturm A, Atreya R, Bettenworth D, Bokemeyer B, Dignaß A, Ehehalt R, Germer C, Grunert PC, Helwig U, Herrlinger K, Kienle P, Kreis ME, Kucharzik T, Langhorst J, Maaser C, Ockenga J, Ott C, Siegmund B, Zeißig S, Stallmach A. Aktualisierte S3-Leitlinie „Diagnostik und Therapie des Morbus Crohn“ der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) – August 2021 – AWMF-Registernummer: 021-004. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:332-418. [PMID: 35263784 DOI: 10.1055/a-1713-3941] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Andreas Sturm
- Klinik für Innere Medizin mit Schwerpunkt Gastroenterologie, DRK Kliniken Berlin Westend, Berlin, Deutschland
| | - Raja Atreya
- Medizinische Klinik 1, Universitätsklinikum Erlangen, Deutschland
| | | | - Bernd Bokemeyer
- Gastroenterologische Gemeinschaftspraxis Minden, Deutschland
| | - Axel Dignaß
- Medizinische Klinik I, Agaplesion Markus Krankenhaus, Frankfurt am Main, Deutschland
| | | | - Christoph Germer
- Chirurgische Klinik I, Universitätsklinikum Würzburg, Deutschland
| | - Philip C Grunert
- Klinik für Innere Medizin IV (Gastroenterologie, Hepatologie und Infektiologie), Universitätsklinikum Jena, Deutschland
| | - Ulf Helwig
- Internistische Praxengemeinschaft, Oldenburg, Deutschland
| | | | - Peter Kienle
- Allgemein- und Viszeralchirurgie, Theresienkrankenhaus und Sankt Hedwig-Klinik GmbH, Mannheim, Deutschland
| | - Martin E Kreis
- Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Charité Campus Benjamin Franklin - Universitätsmedizin Berlin, Deutschland
| | - Torsten Kucharzik
- Klinik für Allgemeine Innere Medizin und Gastroenterologie, Klinikum Lüneburg, Deutschland
| | - Jost Langhorst
- Klinik für Integrative Medizin und Naturheilkunde, Klinikum am Bruderwald, Bamberg, Deutschland
| | | | - Johann Ockenga
- Medizinische Klinik II, Klinikum Bremen Mitte - Gesundheit Nord, Bremen, Deutschland
| | - Claudia Ott
- Gastroenterologie Facharztzentrum, Regensburg, Deutschland
| | - Britta Siegmund
- Medizinische Klinik I, Charité Universitätsmedizin Berlin, Campus Benjamin Franklin, Deutschland
| | - Sebastian Zeißig
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Dresden, Deutschland
| | - Andreas Stallmach
- Klinik für Innere Medizin IV (Gastroenterologie, Hepatologie und Infektiologie), Universitätsklinikum Jena, Deutschland
| | | |
Collapse
|
11
|
Oral exclusive enteral nutrition for induction of clinical remission, mucosal healing, and improvement of nutritional status and growth velocity in children with active Crohn's disease - a prospective multicentre trial. GASTROENTEROLOGY REVIEW 2022; 16:346-351. [PMID: 34976243 PMCID: PMC8690944 DOI: 10.5114/pg.2021.111483] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 03/10/2021] [Indexed: 11/17/2022]
Abstract
Introduction Undernutrition and growth failure are common problems in paediatric patients with active Crohn's disease (CD). Aim The aim of exclusive enteral nutrition (EEN) commencement is not only to induce clinical remission and promote mucosal healing but also to initiate weight and growth gain, especially in patients with poor nutritional status. We assessed the effectiveness of treatment with EEN and its impact on nutritional status in children with active CD. Material and methods Twenty children (male/female: 14/6) in median age of 14 years with active CD had EEN with polymeric industrial diet (Modulen IBD) applied for 6 weeks. The daily caloric intake was established according to the age and nutritional status. In patients with undernutrition, it was increased to 120-150% relative to recommendations for the healthy peers. The Paediatric CD activity index (PCDAI) - a marker of clinical remission, faecal calprotectin (FCP) - a marker of mucosal healing (MH), and nutritional status were assessed at baseline and 4 weeks following the end of the therapy (week 10). Results In the studied group the mean decrease in PCDAI score was statistically significant (from 25.6 ±12 to 5.4 ±10, p < 0.05). Full remission (defined as PCDAI < 10) was achieved in 65% of patients, and clinical response in another 30% of them. Only 5% of children did not respond to the treatment. Mean decline in FCP level was statistically significant as well (from 3380 ±7746 to 1046.6 ±1219, p < 0.05). All patients, apart from one who was fed with a nasogastric tube, accepted oral intake of industrial formula. EEN was generally well tolerated. Initially, in 20% of patients the symptoms of intolerance to the industrial diet were observed, but they receded within the first days of the therapy. The recommended daily intake of the formula was achieved in 95% of children. Only one child was unable to intake the prescribed amount of the diet due to intolerance. At baseline, undernutrition was observed in 30% of patients, which was established by a body mass index (BMI) score below the third percentile according to the recommended charts for the Polish paediatric population. In all patients, improvement in BMI status was reported at the end of the treatment. The mean increase in BMI score was 0.91, and it was greater in the malnourished group compared to patients with normal nutritional status (1.19 vs. 0.62). After the treatment two-thirds of children with malnutrition achieved a BMI score within the normal range. In 25% of patients, growth deficit was observed (defined as growth below the third percentile according to the Polish charts) before the EEN introduction. An increase in body height was obtained generally in 55% of children and in 80% of those with initial growth failure. The mean increase in growth was 1 cm, and it was greater in the group with initial growth deficit relative to patients with baseline normal height (1.5 cm vs. 0.8 cm, respectively). Conclusions A 6-week course of oral EEN was an effective and well-tolerated method of treatment in children with active CD. Nutritional therapy not only induced full clinical remission and led to decline in FCP level (as a marker of MH) in the majority of patients, but also contributed to the improvement in their nutritional status and growth velocity. These are very important observations because proper development is crucial for paediatric CD patients.
Collapse
|
12
|
Radhakrishnan ST, Alexander JL, Mullish BH, Gallagher KI, Powell N, Hicks LC, Hart AL, Li JV, Marchesi JR, Williams HRT. Systematic review: the association between the gut microbiota and medical therapies in inflammatory bowel disease. Aliment Pharmacol Ther 2022; 55:26-48. [PMID: 34751954 DOI: 10.1111/apt.16656] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 09/21/2021] [Accepted: 10/06/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND The gut microbiota has been implicated in the pathogenesis of inflammatory bowel disease (IBD), with Faecalibacterium prausnitizii associated with protection, and certain genera (including Shigella and Escherichia) associated with adverse features. The variability of patient response to medical therapies in IBD is incompletely understood. Given the recognised contribution of the microbiota to treatment efficacy in other conditions, there may be interplay between the gut microbiota, IBD medical therapy and IBD phenotype. AIMS To evaluate the bidirectional relationship between IBD medical therapies and the gut microbiota. METHODS We conducted a systematic search of MEDLINE and EMBASE. All original studies analysing interactions between the gut microbiota and established IBD medical therapies were included. RESULTS We screened 1296 records; 19 studies were eligible. There was heterogeneity in terms of sample analysis, treatment protocols, and outcome reporting. Increased baseline α-diversity was observed in responders versus non-responders treated with exclusive enteral nutrition (EEN), infliximab, ustekinumab or vedolizumab. Higher baseline Faecalibacterium predicted response to infliximab and ustekinumab. A post-treatment increase in Faecalibacterium prausnitzii was noted in responders to aminosalicylates, anti-TNF medications and ustekinumab; conversely, this species decreased in responders to EEN. Escherichia was a consistent marker of unfavourable drug response, and its presence in the gut mucosa correlated with inflammation in aminosalicylate-treated patients. CONCLUSIONS Both gut microbiota diversity and specific taxonomic features (including high abundance of Faecalibacterium) are associated with the efficacy of a range of IBD therapies. These findings hold promise for a potential role for the gut microbiota in explaining the heterogeneity of patient response to IBD treatments.
Collapse
Affiliation(s)
- Shiva T Radhakrishnan
- Departments of Gastroenterology and Hepatology, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
- Division of Digestive Diseases, Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, UK
| | - James L Alexander
- Departments of Gastroenterology and Hepatology, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
- Division of Digestive Diseases, Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, UK
| | - Benjamin H Mullish
- Departments of Gastroenterology and Hepatology, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
- Division of Digestive Diseases, Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, UK
| | - Kate I Gallagher
- Division of Digestive Diseases, Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, UK
| | - Nick Powell
- Departments of Gastroenterology and Hepatology, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
- Division of Digestive Diseases, Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, UK
| | - Lucy C Hicks
- Departments of Gastroenterology and Hepatology, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
- Division of Digestive Diseases, Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, UK
| | - Ailsa L Hart
- Division of Digestive Diseases, Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, UK
- Inflammatory Bowel Disease Unit, St Mark's Hospital, London, UK
| | - Jia V Li
- Division of Digestive Diseases, Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, UK
| | - Julian R Marchesi
- Division of Digestive Diseases, Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, UK
| | - Horace R T Williams
- Departments of Gastroenterology and Hepatology, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
- Division of Digestive Diseases, Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, UK
| |
Collapse
|
13
|
Hart L, Verburgt CM, Wine E, Zachos M, Poppen A, Chavannes M, Van Limbergen J, Pai N. Nutritional Therapies and Their Influence on the Intestinal Microbiome in Pediatric Inflammatory Bowel Disease. Nutrients 2021; 14:nu14010004. [PMID: 35010879 PMCID: PMC8746384 DOI: 10.3390/nu14010004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 12/13/2021] [Accepted: 12/15/2021] [Indexed: 12/16/2022] Open
Abstract
Inflammatory bowel disease (IBD) is a chronic, autoimmune disorder of the gastrointestinal tract with numerous genetic and environmental risk factors. Patients with Crohn’s disease (CD) or ulcerative colitis (UC) often demonstrate marked disruptions of their gut microbiome. The intestinal microbiota is strongly influenced by diet. The association between the increasing incidence of IBD worldwide and increased consumption of a westernized diet suggests host nutrition may influence the progression or treatment of IBD via the microbiome. Several nutritional therapies have been studied for the treatment of CD and UC. While their mechanisms of action are only partially understood, existing studies do suggest that diet-driven changes in microbial composition and function underlie the diverse mechanisms of nutritional therapy. Despite existing therapies for IBD focusing heavily on immune suppression, nutrition is an important treatment option due to its superior safety profile, potentially low cost, and benefits for growth and development. These benefits are increasingly important to patients. In this review, we will describe the clinical efficacy of the different nutritional therapies that have been described for the treatment of CD and UC. We will also describe the effects of each nutritional therapy on the gut microbiome and summarize the strength of the literature with recommendations for the practicing clinician.
Collapse
Affiliation(s)
- Lara Hart
- Department of Paediatrics, Division of Paediatric Gastroenterology & Nutrition, McMaster University, Hamilton, ON L8N 3Z5, Canada; (L.H.); (M.Z.)
- McMaster Children’s Hospital, Hamilton, ON L8N 3Z5, Canada
| | - Charlotte M. Verburgt
- Department of Pediatric Gastroenterology and Nutrition, Amsterdam University Medical Centers, Emma Children’s Hospital, 1105 AZ Amsterdam, The Netherlands; (C.M.V.); (J.V.L.)
- Tytgat Institute for Liver and Intestinal Research, Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam University Medical Centers, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Reproduction & Development Research Institute, Amsterdam University Medical Centers, Emma Children’s Hospital, 1105 AZ Amsterdam, The Netherlands
| | - Eytan Wine
- Edmonton Paediatric IBD Clinic, Division of Paediatric Gastroenterology and Nutrition, Departments of Paediatrics & Physiology, University of Alberta, Edmonton, AB T6G 2R3, Canada;
| | - Mary Zachos
- Department of Paediatrics, Division of Paediatric Gastroenterology & Nutrition, McMaster University, Hamilton, ON L8N 3Z5, Canada; (L.H.); (M.Z.)
- McMaster Children’s Hospital, Hamilton, ON L8N 3Z5, Canada
| | - Alisha Poppen
- College of Medicine and Health, University College Cork, T12 K8AF Cork, Ireland;
| | - Mallory Chavannes
- Department of Paediatrics, Division of Paediatric Gastroenterology and Nutrition, Children’s Hospital of Los Angeles, Los Angeles, CA 90027, USA;
| | - Johan Van Limbergen
- Department of Pediatric Gastroenterology and Nutrition, Amsterdam University Medical Centers, Emma Children’s Hospital, 1105 AZ Amsterdam, The Netherlands; (C.M.V.); (J.V.L.)
- Tytgat Institute for Liver and Intestinal Research, Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam University Medical Centers, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Department of Paediatrics, Dalhousie University, Halifax, NS B3H 4R2, Canada
| | - Nikhil Pai
- Department of Paediatrics, Division of Paediatric Gastroenterology & Nutrition, McMaster University, Hamilton, ON L8N 3Z5, Canada; (L.H.); (M.Z.)
- McMaster Children’s Hospital, Hamilton, ON L8N 3Z5, Canada
- Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON L8N 3Z5, Canada
- Centre for Metabolism, Obesity and Diabetes Research, McMaster University, Hamilton, ON L8N 3Z5, Canada
- Correspondence: ; Tel.: +905-521-2100 (ext. 73587); Fax: +905-521-2655
| |
Collapse
|
14
|
Eindor-Abarbanel A, Healey GR, Jacobson K. Therapeutic Advances in Gut Microbiome Modulation in Patients with Inflammatory Bowel Disease from Pediatrics to Adulthood. Int J Mol Sci 2021; 22:ijms222212506. [PMID: 34830388 PMCID: PMC8622771 DOI: 10.3390/ijms222212506] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 11/12/2021] [Accepted: 11/16/2021] [Indexed: 12/12/2022] Open
Abstract
There is mounting evidence that the gut microbiota plays an important role in the pathogenesis of inflammatory bowel disease (IBD). For the past decade, high throughput sequencing-based gut microbiome research has identified characteristic shifts in the composition of the intestinal microbiota in patients with IBD, suggesting that IBD results from alterations in the interactions between intestinal microbes and the host’s mucosal immune system. These studies have been the impetus for the development of new therapeutic approaches targeting the gut microbiome, such as nutritional therapies, probiotics, fecal microbiota transplant and beneficial metabolic derivatives. Innovative technologies can further our understanding of the role the microbiome plays as well as help to evaluate how the different approaches in microbiome modulation impact clinical responses in adult and pediatric patients. In this review, we highlight important microbiome studies in patients with IBD and their response to different microbiome modulation therapies, and describe the differences in therapeutic response between pediatric and adult patient cohorts.
Collapse
Affiliation(s)
- Adi Eindor-Abarbanel
- Department of Pediatrics, British Columbia’s Children’s Hospital, Vancouver, BC V6H 3N1, Canada; (A.E.-A.); (G.R.H.)
- Division of Gastroenterology, Hepatology and Nutrition, British Columbia’s Children’s Hospital, Vancouver, BC V6H 3N1, Canada
- BC Children’s Hospital Research Institute, University of British Columbia, Vancouver, BC V5Z 4H4, Canada
- Division of Gastroenterology, Hepatology and Nutrition, Yitzhak Shamir Medical Center, Affiliated to Tel Aviv University, Beer-Yaakov 7033001, Israel
| | - Genelle R. Healey
- Department of Pediatrics, British Columbia’s Children’s Hospital, Vancouver, BC V6H 3N1, Canada; (A.E.-A.); (G.R.H.)
- Division of Gastroenterology, Hepatology and Nutrition, British Columbia’s Children’s Hospital, Vancouver, BC V6H 3N1, Canada
- BC Children’s Hospital Research Institute, University of British Columbia, Vancouver, BC V5Z 4H4, Canada
| | - Kevan Jacobson
- Department of Pediatrics, British Columbia’s Children’s Hospital, Vancouver, BC V6H 3N1, Canada; (A.E.-A.); (G.R.H.)
- Division of Gastroenterology, Hepatology and Nutrition, British Columbia’s Children’s Hospital, Vancouver, BC V6H 3N1, Canada
- BC Children’s Hospital Research Institute, University of British Columbia, Vancouver, BC V5Z 4H4, Canada
- Department of Cellular and Physiological Sciences, University of British Columbia, Vancouver, BC V6T 1Z4, Canada
- Correspondence:
| |
Collapse
|
15
|
Effectiveness of Crohn's Disease Exclusion Diet for Induction of Remission in Crohn's Disease Adult Patients. Nutrients 2021; 13:nu13114112. [PMID: 34836367 PMCID: PMC8618677 DOI: 10.3390/nu13114112] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 11/11/2021] [Accepted: 11/15/2021] [Indexed: 02/01/2023] Open
Abstract
Exclusive enteral nutrition (EEN) is a first-line treatment in active, mild to moderate Crohn’s disease (CD) in children. The Crohn’s disease exclusion diet (CDED), which avoids products known to have a pro-inflammatory effect on the intestinal mucosa, presents similar effectiveness to EEN for inducing remission in the paediatric population. The aim of the study was to evaluate the effectiveness of the CDED in inducing remission in adult patients. Between March 2020 and May 2021, 32 patients in a gastroenterology outpatient centre were treated according to the assumptions of the CDED. The patients were seen at baseline, at week 6, and at week 12 of the study. During the visits, anthropometric measurements and laboratory tests were performed, Crohn’s disease activity index (CDAI) was calculated, and the Inflammatory Bowel Disease Questionnaire (IBDQ) was completed. The study included a total of 32 participants, 18 women (56.3%) and 14 men (43.7%). Clinical remission was obtained in 76.7% patients after 6 weeks and in 82.1% after 12 weeks of therapy. Calprotectin levels were significantly lower in the second follow-up compared with baseline (p = 0.021). The CDED is an effective therapy for inducing remission in the adult CD population.
Collapse
|
16
|
Ramaswamy PK. Exclusive enteral nutrition with oral polymeric diet helps in inducing clinical and biochemical remission in adults with active Crohn's Disease. JPEN J Parenter Enteral Nutr 2021; 46:423-432. [PMID: 34618355 DOI: 10.1002/jpen.2273] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND AND AIMS Exclusive enteral nutrition (EEN) is not routinely used as induction therapy for adults with active Crohn's Disease (CD). The aim of this study was to assess the effectiveness of EEN with oral polymeric formula as an adjunct for inducing clinical and biochemical remission in adults with active CD. METHODS We performed a retrospective analysis of data from January 2018 to September 2019 on all patients with active CD who commenced EEN. Primary endpoint was clinical remission (CDAI ≤150) or response (100-point decrease in CDAI) at 8 weeks. Secondary endpoint was achievement of biochemical remission (CRP ≤5 mg/L or faeces calprotectin ≤150 mcg/g) at 8 weeks in those whose baseline values were elevated. We also aimed to identify predictors of response to EEN therapy. RESULTS Sixty-six patients commenced EEN, 53/66 (80.3%) completed the prescribed EEN course. At 8 weeks, 42/66 (63.6%) patients achieved primary endpoint and secondary endpoint was achieved in 30/53 (56.6%) of patients. Patients receiving EEN for ≥ 6 weeks achieved primary (72% vs 47.8%, OR 2.8, p = 0.047, CI 0.97 -8.16) and secondary endpoint (67.6% vs 36.8%, OR 3.58, p = 0.035, CI 1.1- 11.63) more frequently when compared with patients who received EEN for <6 weeks. Nine patients reported adverse effects (4 nausea,3 diarrhoea,1 constipation and 1 abdominal pain), none of whom ceased therapy. CONCLUSION Polymeric EEN is well tolerated, safe and effective in inducing clinical and biochemical remission in adults with active CD. EEN duration of ≥ 6 weeks has better outcomes. This article is protected by copyright. All rights reserved.
Collapse
Affiliation(s)
| | -
- Department of Digestive Health, Gold Coast University Hospital.,Department of Nutrition and Food Services, Gold Coast University Hospital.,Faculty of Health Sciences and Medicine, Bond University
| |
Collapse
|
17
|
Mitrev N, Huang H, Hannah B, Kariyawasam VC. Review of exclusive enteral therapy in adult Crohn's disease. BMJ Open Gastroenterol 2021; 8:bmjgast-2021-000745. [PMID: 34580154 PMCID: PMC8477235 DOI: 10.1136/bmjgast-2021-000745] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 09/07/2021] [Indexed: 12/14/2022] Open
Abstract
Background Exclusive enteral nutrition (EEN) is a potentially effective but underused therapy for Crohn’s disease (CD) in adults. It is first-line induction treatment for paediatric patients but remains a second-line or third-line therapy in adults. Objective To analyse the evidence for EEN in adult patients with CD, and summarise this in a narrative review. Methods In April/May 2020 and July 2021, a literature search was performed using the Medical Subject Headings (MeSH) terms: ‘Crohn’s disease’, ‘CD’, ‘inflammatory bowel disease’, ‘IBD’, ‘exclusive enteral nutrition’, ‘enteral nutrition’, ‘EEN’, in PubMed, Scopus, Cochrane. Additional studies were obtained from references of search result articles as well as general reading. Studies with adult patients with CD treated with EEN were selected. 79 articles of relevance were found. Where data in adults were lacking, data from paediatric studies as extrapolated with care. Results EEN in adult patients been shown to improve clinical, biomarker, endoscopic and radiologic measures of disease activity. EEN avoids the potential adverse effects of recurrent corticosteroids for induction such as metabolic derangements and opportunistic infections. EEN has also demonstrated benefits among adult patients with fistulising and stricturing CD. It may avoid surgery in such patients. Preoperative EEN has also been shown to reduce postoperative complications and recurrence. There appears to be benefits in combing EEN with antitumour necrosis factor agents, however, benefits of combination therapy with other biologics are less clear. A major drawback of EEN therapy in adults has been poor compliance. More palatable polymeric formulations improved patient education and dietitian support may overcome this. Evidence in adults is limited to small studies, often with suboptimal control arms and lack of blinding. Larger scale studies with improved study design are needed to confirm these beneficial effects. Conclusion Despite limitations in evidence EEN should be considered in treating adults with CD.
Collapse
Affiliation(s)
- Nikola Mitrev
- Department of Gastroenterology, Blacktown Hospital, Blacktown, New South Wales, Australia.,Western Sydney University Blacktown Mount Druitt Medical School, Blacktown, New South Wales, Australia
| | - Hin Huang
- Western Sydney University Blacktown Mount Druitt Medical School, Blacktown, New South Wales, Australia
| | - Barbara Hannah
- Department of Gastroenterology, Blacktown Hospital, Blacktown, New South Wales, Australia
| | | |
Collapse
|
18
|
Gordon-Dixon A, Hampal R, Miah A, Webb-Butler S, Lewis W, Ross R, Ghosh N, Grimes C. Does exclusive enteral nutrition reduce the rate of stoma formation in patients requiring ileocolic resection for Crohn's disease? A single center experience. Clin Nutr ESPEN 2021; 44:282-286. [PMID: 34330480 DOI: 10.1016/j.clnesp.2021.05.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 05/13/2021] [Accepted: 05/25/2021] [Indexed: 01/12/2023]
Abstract
BACKGROUND AND AIM Nutrition has a role in achieving and maintaining remission in Crohn's disease. The aim of this study was to determine the impact of a strategy of steroid-avoidance and Exclusive Enteral Nutrition (EEN) for 6 weeks (with a minimum of 4 weeks) in adult patients presenting with acute small bowel Crohn's disease followed by an interval ileocolic resection 4-6 weeks later. METHODS Retrospective review of prospectively collected data. Patients were administered exclusive enteral nutrition (EEN) for at least 4 weeks prior to surgery. RESULTS 24 EEN patients included. Median age of 45 (range 23-73). 17/24 patients tolerated Modulen for at least 4 weeks, 5 were switched to Ensures and 2 a liquid diet. 6 patients underwent surgery earlier than planned. Prior to surgery, there was no change in the mean BMI, albumin increased from a mean of 36 g/L (range 25-43) to 40 g/L (range 30-48). CRP levels decreased by a mean of 35.8 mg/L overall. 19 (79%) of operations were performed laparoscopically. 6 of the cases were re-do operations. All but 3 patients avoided a stoma at the time of the original operation. There were 5 post-operative complications: 1 anastomotic leak in a patient with a BMI of 42, 3 cases of paralytic ileus and 2 wound infections. Median length of stay was 7 days (range 3-76 days). Only 2 patients were readmitted within the 30-day post-operative period. CONCLUSION The pre-operative use of EEN appears to avoid unnecessary stoma formation with acceptable clinical outcomes.
Collapse
Affiliation(s)
| | - Rumneek Hampal
- Medway Hospital NHS Foundation Trust, Windmill Way, Gillingham, ME7 5NY, UK.
| | - Anur Miah
- Medway Hospital NHS Foundation Trust, Windmill Way, Gillingham, ME7 5NY, UK.
| | - Shruti Webb-Butler
- Medway Hospital NHS Foundation Trust, Windmill Way, Gillingham, ME7 5NY, UK.
| | - Wendy Lewis
- Medway Hospital NHS Foundation Trust, Windmill Way, Gillingham, ME7 5NY, UK.
| | - Rose Ross
- Medway Hospital NHS Foundation Trust, Windmill Way, Gillingham, ME7 5NY, UK.
| | - Nivedita Ghosh
- Medway Hospital NHS Foundation Trust, Windmill Way, Gillingham, ME7 5NY, UK.
| | - Caris Grimes
- Medway Hospital NHS Foundation Trust, Windmill Way, Gillingham, ME7 5NY, UK.
| |
Collapse
|
19
|
Chandwe K, Kelly P. Colostrum Therapy for Human Gastrointestinal Health and Disease. Nutrients 2021; 13:1956. [PMID: 34200282 PMCID: PMC8228205 DOI: 10.3390/nu13061956] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 05/12/2021] [Accepted: 06/01/2021] [Indexed: 12/12/2022] Open
Abstract
There is increasing awareness that a broad range of gastrointestinal diseases, and some systemic diseases, are characterized by failure of the mucosal barrier. Bovine colostrum is a complex biological fluid replete with growth factors, nutrients, hormones, and paracrine factors which have a range of properties likely to contribute to mucosal healing in a wide range of infective, inflammatory, and injury conditions. In this review, we describe the anatomy and physiology of the intestinal barrier and how it may fail. We survey selected diseases in which disordered barrier function contributes to disease pathogenesis or progression, and review the evidence for or against efficacy of bovine colostrum in management. These disorders include enteropathy due to non-steroidal anti-inflammatory drugs (NSAIDs), inflammatory bowel disease (IBD), necrotizing enterocolitis, infectious diarrhea, intestinal failure, and damage due to cancer therapy. In animal models, bovine colostrum benefits NSAID enteropathy, IBD, and intestinal failure. In human trials, there is substantial evidence of efficacy of bovine colostrum in inflammatory bowel disease and in infectious diarrhea. Given the robust scientific rationale for using bovine colostrum as a promoter of mucosal healing, further work is needed to define its role in therapy.
Collapse
Affiliation(s)
- Kanta Chandwe
- Tropical Gastroenterology & Nutrition Group, University of Zambia School of Medicine, Lusaka 10101, Zambia;
| | - Paul Kelly
- Tropical Gastroenterology & Nutrition Group, University of Zambia School of Medicine, Lusaka 10101, Zambia;
- Blizard Institute, Barts & The London School of Medicine, Queen Mary University of London, London E1 2AT, UK
| |
Collapse
|
20
|
Scarallo L, Lionetti P. Dietary Management in Pediatric Patients with Crohn's Disease. Nutrients 2021; 13:1611. [PMID: 34064976 PMCID: PMC8150738 DOI: 10.3390/nu13051611] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/06/2021] [Accepted: 05/07/2021] [Indexed: 12/11/2022] Open
Abstract
It has been widely endorsed that a multifactorial etiology, including interaction between genetic and environmental factors, can contribute to Crohn's Disease (CD) pathogenesis. More specifically, diet has proven to be able to shape gut microbiota composition and thus is suspected to play a significant role in inflammatory bowel disease (IBD) pathogenesis. Moreover, poor nutritional status and growth retardation, arising from several factors such as reduced dietary intake or nutrient leakage from the gastrointestinal tract, represent the hallmarks of pediatric CD. For these reasons, multiple research lines have recently focused on the utilization of dietary therapies for the management of CD, aiming to target concurrently mucosal inflammation, intestinal dysbiosis and optimization of nutritional status. The forerunner of such interventions is represented by exclusive enteral nutrition (EEN), a robustly supported nutritional therapy; however, it is burdened by monotony and low tolerance in the long term. Novel dietary interventions, such as Crohn's Disease Exclusion Diet or Crohn's Disease treatment with eating, have shown their efficacy in the induction of remission in pediatric patients with CD. The aim of the present narrative review is to provide a synopsis of the available nutritional strategies in the management of pediatric CD and to discuss their application in the dietary management of these patients.
Collapse
Affiliation(s)
- Luca Scarallo
- Gastroenterology and Nutrition Unit, Meyer Children’s Hospital, 50139 Florence, Italy;
| | - Paolo Lionetti
- Gastroenterology and Nutrition Unit, Meyer Children’s Hospital, 50139 Florence, Italy;
- Department NEUROFARBA, University of Florence, 50139 Florence, Italy
| |
Collapse
|
21
|
Boumessid K, Barreau F, Mas E. How Can a Polymeric Formula Induce Remission in Crohn's Disease Patients? Int J Mol Sci 2021; 22:ijms22084025. [PMID: 33919747 PMCID: PMC8070662 DOI: 10.3390/ijms22084025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 04/12/2021] [Accepted: 04/12/2021] [Indexed: 12/12/2022] Open
Abstract
Crohn’s disease is an inflammatory bowel disease whose prevalence is increasing worldwide. Among medical strategies, dietary therapy with exclusive enteral nutrition is recommended as a first-line option, at least for children, because it induces clinical remission and mucosal healing. Modulen®, a polymeric TGF-β2 enriched formula, has good palatability and is widely used. For the first time in the literature, this review outlines and discusses the clinical outcomes obtained with this therapy, as well as the potential mechanisms of action of its compounds. It can be explained by its TGF-β2 content, but also by its protein and lipid composition. Further well-designed studies are required to improve our knowledge and to optimize therapeutic strategies.
Collapse
Affiliation(s)
- Kawthar Boumessid
- INSERM, INRAE, ENVT, Université de Toulouse, UPS, F-31000 Toulouse, France;
| | - Frederick Barreau
- INSERM, INRAE, ENVT, Université de Toulouse, UPS, F-31000 Toulouse, France;
- Correspondence: (F.B.); (E.M.); Tel.: +33-5-62-74-45-04 (F.B.); +33-5-34-55-84-45 (E.M.); Fax: +33-5-62-74-45-58 (F.B.); +33-5-34-55-85-67 (E.M.)
| | - Emmanuel Mas
- INSERM, INRAE, ENVT, Université de Toulouse, UPS, F-31000 Toulouse, France;
- Unité de Gastroentérologie, Hépatologie, Nutrition, Diabétologie et Maladies Héréditaires du Métabolisme, Hôpital des Enfants, CHU de Toulouse, F-31300 Toulouse, France
- Correspondence: (F.B.); (E.M.); Tel.: +33-5-62-74-45-04 (F.B.); +33-5-34-55-84-45 (E.M.); Fax: +33-5-62-74-45-58 (F.B.); +33-5-34-55-85-67 (E.M.)
| |
Collapse
|
22
|
Sigall Boneh R, Van Limbergen J, Wine E, Assa A, Shaoul R, Milman P, Cohen S, Kori M, Peleg S, On A, Shamaly H, Abramas L, Levine A. Dietary Therapies Induce Rapid Response and Remission in Pediatric Patients With Active Crohn's Disease. Clin Gastroenterol Hepatol 2021; 19:752-759. [PMID: 32302709 DOI: 10.1016/j.cgh.2020.04.006] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 03/26/2020] [Accepted: 04/03/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Dietary therapies based on exclusion of usual dietary elements induce remission in children with Crohn's disease (CD), whereas re-exposure induces rebound inflammation. We investigated whether a short trial of dietary therapy, to identify patients with and without a rapid response or remission on the diet (DiRe), can be used to predict success or failure of long-term dietary therapy. METHODS We collected data from the multicenter randomized trial of the CD exclusion diet (CDED). We analyzed data from 73 children with mild to moderate CD (mean age, 14.2 ± 2.7 y) randomly assigned to groups given either exclusive enteral nutrition (EEN, n = 34) or the CDED with 50% (partial) enteral nutrition (n = 39). Patients were examined at baseline and at weeks 3 and 6 of the diet. Remission was defined as CD activity index scores below 10 and response was defined as a decrease in score of 12.5 points or clinical remission. Inflammation was assessed by measurement of C-reactive protein. RESULTS At week 3 of the diet, 82% of patients in the CDED group and 85% of patients in the EEN group had a DiRe. Median serum levels of C-reactive protein had decreased from 24 mg/L at baseline to 5.0 mg/L at week 3 (P < .001). Among the 49 patients in remission at week 6, 46 patients (94%) had a DiRe and 81% were in clinical remission by week 3. In multivariable analysis, remission at week 3 increased odds of remission by week 6 (odds ratio, 6.37; 95% CI, 1.6-25; P = .008) whereas poor compliance reduced odds of remission at week 6 (odds ratio, 0.75; 95% CI, 0.012-0.46; P = .006). CONCLUSIONS For pediatric patients with active CD, dietary therapies (CDED and EEN) induce a rapid clinical response (by week 3). Identification of patients with and without a rapid response to diet might help identify those who, with compliance, will be in clinical remission by week 6 of the diet. ClinicalTrials.gov no: NCT01728870.
Collapse
Affiliation(s)
- Rotem Sigall Boneh
- Wolfson Medical Center, Pediatric Gastroenterology, Holon, Israel; The Sackler Faculty of medicine, Tel Aviv University, Tel Aviv, Israel
| | - Johan Van Limbergen
- Emma Children's Hospital, Amsterdam University Medical Centers - location AMC, Amsterdam, the Netherlands
| | - Eytan Wine
- University of Alberta, Edmonton, Alberta, Canada
| | - Amit Assa
- The Sackler Faculty of medicine, Tel Aviv University, Tel Aviv, Israel; Schneider Hospital, Petach Tikva, Israel
| | | | | | - Shlomi Cohen
- "Dana-Dwek" Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | | | | | - Avi On
- Poriah Hospital, Tiberias, Israel
| | | | - Lee Abramas
- Wolfson Medical Center, Pediatric Gastroenterology, Holon, Israel
| | - Arie Levine
- Wolfson Medical Center, Pediatric Gastroenterology, Holon, Israel; The Sackler Faculty of medicine, Tel Aviv University, Tel Aviv, Israel.
| |
Collapse
|
23
|
Sienkiewicz M, Szymańska P, Fichna J. Supplementation of Bovine Colostrum in Inflammatory Bowel Disease: Benefits and Contraindications. Adv Nutr 2021; 12:533-545. [PMID: 33070186 PMCID: PMC8009748 DOI: 10.1093/advances/nmaa120] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 07/06/2020] [Accepted: 09/03/2020] [Indexed: 12/12/2022] Open
Abstract
Inflammatory bowel disease (IBD) is a group of chronic relapsing disorders whose etiology has not been fully explained. Therefore, available therapeutic approaches for IBD patients are still insufficient. Current treatment strategies are targeted to immune system dysfunctions, often associated with alternations in the microbiota, which contribute to the development of chronic intestinal inflammation. Therapeutics include anti-inflammatory drugs such as aminosalicylates and corticosteroids, immunosuppressive agents, antibiotics, and biological agents such as infliximab and vedolizumab. Auxiliary therapies involve a balanced and personalized diet, healthy lifestyle, avoiding stress, as well as dietary supplements. In this review, we discuss the use of bovine colostrum (BC) as a therapeutic agent, including its advantages and contraindications. We summarize our knowledge on well-researched BC constituents and their effects on the gastrointestinal tract as evidenced in in vitro and in vivo studies.
Collapse
Affiliation(s)
- Michał Sienkiewicz
- Department of Biochemistry, Faculty of Medicine, Medical University of Lodz, Lodz, Poland
| | - Patrycja Szymańska
- Department of Hemostasis and Hemostatic Disorders, Faculty of Health Sciences, Medical University of Lodz, Lodz, Poland
| | - Jakub Fichna
- Department of Biochemistry, Faculty of Medicine, Medical University of Lodz, Lodz, Poland
| |
Collapse
|
24
|
Burgess D, Herbison K, Fox J, Collins T, Landorf E, Howley P. Exclusive enteral nutrition in children and adolescents with Crohn disease: Dietitian perspectives and practice. J Paediatr Child Health 2021; 57:359-364. [PMID: 33015922 DOI: 10.1111/jpc.15220] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 09/02/2020] [Accepted: 09/20/2020] [Indexed: 11/30/2022]
Abstract
AIM In newly diagnosed paediatric Crohn disease, exclusive enteral nutrition (EEN) is recommended as a first-line treatment for remission induction. However, EEN protocols vary internationally. The development of best practice protocols may make it easier to make definitive conclusions about optimal EEN therapy, and may improve patient outcomes. This study aims to determine the variations in current dietitian EEN practice within Australia and New Zealand (NZ) to inform a common EEN protocol in the future, and to gather perspectives on the need for nutrition resources for patients with inflammatory bowel disease (IBD). METHODS A questionnaire was created and emailed to paediatric dietitians working with gastroenterologists in public and private paediatric centres in Australia and NZ. Respondents were invited to provide details of their perspectives of EEN therapy and protocol details. RESULTS Eighteen paediatric dietitians responded to the questionnaire, 10 from Australia and 8 from NZ. There was clear consensus between respondents on the duration of EEN being 6 and 8 weeks, the need for close dietitian supervision while on EEN, and the method of food reintroduction. There was lack of consensus between dietitians regarding permitted concomitant foods whilst on EEN. This study also determined a potential benchmarking relationship between IBD dietitian hours and numbers of patients on EEN per year in a centre. CONCLUSIONS Paediatric dietitians in Australia and NZ are mostly aligned in their practice of EEN. Development of a standard EEN protocol, and patient IBD resources, will further align practice and allow for greater research possibilities.
Collapse
Affiliation(s)
- Deirdre Burgess
- Department of Paediatric Gastroenterology, John Hunter Children's Hospital, Newcastle, New South Wales, Australia
| | - Kim Herbison
- Department of Nutrition and Dietetics, Starship Children's Hospital, Auckland, New Zealand
| | - Julia Fox
- Department of Nutrition and Dietetics, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Tanya Collins
- Department of Nutrition and Dietetics, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Emma Landorf
- Department of Nutrition and Dietetics, Womens and Children's Hospital, Adelaide, South Australia, Australia
| | - Peter Howley
- School of Mathematical and Physical Sciences/Statistics, University of Newcastle, Newcastle, New South Wales, Australia
| |
Collapse
|
25
|
Diet and Nutrition in Pediatric Inflammatory Bowel Diseases. Nutrients 2021; 13:nu13020655. [PMID: 33671453 PMCID: PMC7922138 DOI: 10.3390/nu13020655] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 02/10/2021] [Accepted: 02/13/2021] [Indexed: 12/17/2022] Open
Abstract
Both genetic and environmental factors are involved in the onset of inflammatory bowel disease (IBD). In particular, diet composition is suspected to significantly contribute to IBD risk. In recent years, major interest has raised about the role of nutrition in disease pathogenesis and course, and many studies have shown a clear link between diet composition and intestinal permeability impairment. Moreover, many IBD-related factors, such as poor dietary intake, nutrients loss and drugs interact with nutritional status, thus paving the way for the development of many therapeutic strategies in which nutrition represents the cornerstone, either as first-line therapy or as reversing nutritional deficiencies and malnutrition in IBD patients. Exclusive enteral nutrition (EEN) is the most rigorously supported dietary intervention for the treatment of Crohn's Disease (CD), but is burdened by a low tolerability, especially in pediatric patients. Promising alternative regimens are represented by Crohn's Disease Exclusion Diet (CDED), and other elimination diets, whose use is gradually spreading. The aim of the current paper is to provide a comprehensive and updated overview on the latest evidence about the role of nutrition and diet in pediatric IBD, focusing on the different nutritional interventions available for the management of the disease.
Collapse
|
26
|
Verburgt CM, Ghiboub M, Benninga MA, de Jonge WJ, Van Limbergen JE. Nutritional Therapy Strategies in Pediatric Crohn's Disease. Nutrients 2021; 13:212. [PMID: 33450982 PMCID: PMC7828385 DOI: 10.3390/nu13010212] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 01/07/2021] [Accepted: 01/09/2021] [Indexed: 12/12/2022] Open
Abstract
The increase in incidences of pediatric Crohn's Disease (CD) worldwide has been strongly linked with dietary shifts towards a Westernized diet, ultimately leading to altered gut microbiota and disturbance in intestinal immunity and the metabolome. Multiple clinical studies in children with CD have demonstrated the high efficacy of nutritional therapy with exclusive enteral nutrition (EEN) to induce remission with an excellent safety profile. However, EEN is poorly tolerated, limiting its compliance and clinical application. This has spiked an interest in the development of alternative and better-tolerated nutritional therapy strategies. Several nutritional therapies have now been designed not only to treat the nutritional deficiencies seen in children with active CD but also to correct dysbiosis and reduce intestinal inflammation. In this review, we report the most recent insights regarding nutritional strategies in children with active CD: EEN, partial enteral nutrition (PEN), Crohn's disease exclusive diet (CDED), and CD treatment-with-eating diet (CD-TREAT). We describe their setup, efficacy, safety, and (dis)advantages as well as some of their potential mechanisms of action and perspectives. A better understanding of different nutritional therapeutic options and their mechanisms will yield better and safer management strategies for children with CD and may address the barriers and limitations of current strategies in children.
Collapse
Affiliation(s)
- Charlotte M. Verburgt
- Department of Pediatric Gastroenterology and Nutrition, Emma Children’s Hospital, Amsterdam University Medical Centers, 1105 AZ Amsterdam, The Netherlands; (C.M.V.); (M.G.); (M.A.B.)
- Tytgat Institute for Liver and Intestinal Research, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam University Medical Centers, University of Amsterdam, 1105 BK Amsterdam, The Netherlands;
| | - Mohammed Ghiboub
- Department of Pediatric Gastroenterology and Nutrition, Emma Children’s Hospital, Amsterdam University Medical Centers, 1105 AZ Amsterdam, The Netherlands; (C.M.V.); (M.G.); (M.A.B.)
- Tytgat Institute for Liver and Intestinal Research, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam University Medical Centers, University of Amsterdam, 1105 BK Amsterdam, The Netherlands;
| | - Marc A. Benninga
- Department of Pediatric Gastroenterology and Nutrition, Emma Children’s Hospital, Amsterdam University Medical Centers, 1105 AZ Amsterdam, The Netherlands; (C.M.V.); (M.G.); (M.A.B.)
| | - Wouter J. de Jonge
- Tytgat Institute for Liver and Intestinal Research, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam University Medical Centers, University of Amsterdam, 1105 BK Amsterdam, The Netherlands;
- Department of Surgery, University of Bonn, 53127 Bonn, Germany
| | - Johan E. Van Limbergen
- Department of Pediatric Gastroenterology and Nutrition, Emma Children’s Hospital, Amsterdam University Medical Centers, 1105 AZ Amsterdam, The Netherlands; (C.M.V.); (M.G.); (M.A.B.)
- Tytgat Institute for Liver and Intestinal Research, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam University Medical Centers, University of Amsterdam, 1105 BK Amsterdam, The Netherlands;
- Department of Pediatrics, Dalhousie University, Halifax, NS B3K 6R8, Canada
| |
Collapse
|
27
|
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.
Collapse
|
28
|
Mutsekwa RN, Edwards JT, Angus RL. Exclusive enteral nutrition in the management of Crohn's disease: a qualitative exploration of experiences, challenges and enablers in adult patients. J Hum Nutr Diet 2020; 34:440-449. [PMID: 33089552 DOI: 10.1111/jhn.12829] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 09/04/2020] [Accepted: 09/28/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Exclusive enteral nutrition (EEN) is a first-line treatment for Crohn's disease in paediatrics with similar efficiency to corticosteroids. Benefits in adults have not been consistently observed with non-adherence cited as a limiting factor. This study aimed to gain an in depth understanding of the adult patient experience with EEN, identifying challenges and enablers to inform clinicians in the development of strategies to help increase patient adherence. METHODS This exploratory, qualitative study utilised individual semi-structured interviews with 17 adult patients who had completed EEN. Participants were purposively recruited across a range of ages, social backgrounds and clinical experience. Interviews were audio recorded, transcribed and independently thematically analysed by two researchers to provide consensus in identifying key themes. RESULTS Three major themes were identified. (i) Personal experience of EEN evolved over time, with the first few weeks the most challenging, becoming easier as symptoms improved, and participants became used to the EEN regimen. (ii) Participants developed coping strategies to manage challenges, including the impact on meal-based social participation and dietary restriction and monotony. (iii) Enabling factors for adherence to EEN included patient self-efficacy, health system support, supplement characteristics and access, and social support. CONCLUSIONS This study explored the evolving experiences of patients who completed a prescribed course of EEN. Patients described the challenges they faced, how they overcame them identifying enablers for adherence. This provides useful strategies for clinicians to integrate in their assessments and share with patients starting EEN.
Collapse
Affiliation(s)
- R N Mutsekwa
- Gold Coast Hospital and Health Service, Nutrition and Food Service Department, 1 Hospital Boulevard Southport, Southport, QLD, Australia.,Centre for Applied Health Economics, School of Medicine, Griffith University, Sir Samuel Griffith Centre, Nathan, QLD, Australia
| | - J T Edwards
- Gold Coast Hospital and Health Service, Gastroenterology Department, 1 Hospital Boulevard Southport, Southport, QLD, Australia
| | - R L Angus
- Gold Coast Hospital and Health Service, Nutrition and Food Service Department, 1 Hospital Boulevard Southport, Southport, QLD, Australia.,School of Allied Health Sciences, Griffith University, Southport, QLD, Australia
| |
Collapse
|
29
|
van Rheenen PF, Aloi M, Assa A, Bronsky J, Escher JC, Fagerberg UL, Gasparetto M, Gerasimidis K, Griffiths A, Henderson P, Koletzko S, Kolho KL, Levine A, van Limbergen J, Martin de Carpi FJ, Navas-López VM, Oliva S, de Ridder L, Russell RK, Shouval D, Spinelli A, Turner D, Wilson D, Wine E, Ruemmele FM. The Medical Management of Paediatric Crohn's Disease: an ECCO-ESPGHAN Guideline Update. J Crohns Colitis 2020; 15:jjaa161. [PMID: 33026087 DOI: 10.1093/ecco-jcc/jjaa161] [Citation(s) in RCA: 224] [Impact Index Per Article: 56.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE We aimed to provide an evidence-supported update of the ECCO-ESPGHAN guideline on the medical management of paediatric Crohn's disease [CD]. METHODS We formed 10 working groups and formulated 17 PICO-structured clinical questions [Patients, Intervention, Comparator, and Outcome]. A systematic literature search from January 1, 1991 to March 19, 2019 was conducted by a medical librarian using MEDLINE, EMBASE, and Cochrane Central databases. A shortlist of 30 provisional statements were further refined during a consensus meeting in Barcelona in October 2019 and subjected to a vote. In total 22 statements reached ≥ 80% agreement and were retained. RESULTS We established that it was key to identify patients at high risk of a complicated disease course at the earliest opportunity, to reduce bowel damage. Patients with perianal disease, stricturing or penetrating behaviour, or severe growth retardation should be considered for up-front anti-tumour necrosis factor [TNF] agents in combination with an immunomodulator. Therapeutic drug monitoring to guide treatment changes is recommended over empirically escalating anti-TNF dose or switching therapies. Patients with low-risk luminal CD should be induced with exclusive enteral nutrition [EEN], or with corticosteroids when EEN is not an option, and require immunomodulator-based maintenance therapy. Favourable outcomes rely on close monitoring of treatment response, with timely adjustments in therapy when treatment targets are not met. Serial faecal calprotectin measurements or small bowel imaging [ultrasound or magnetic resonance enterography] are more reliable markers of treatment response than clinical scores alone. CONCLUSIONS We present state-of-the-art guidance on the medical treatment and long-term management of children and adolescents with CD.
Collapse
Affiliation(s)
- Patrick F van Rheenen
- Department of Paediatric Gastroenterology, University of Groningen, University Medical Centre Groningen, Beatrix Children's Hospital, Groningen, The Netherlands
| | - Marina Aloi
- Pediatric Gastroenterology and Liver Unit, Maternal and Child Health Department, Sapienza - University of Rome, Rome, Italy
| | - Amit Assa
- Department of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center, Petach Tikvah, Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Jiri Bronsky
- Paediatric Gastroenterology Unit, Department of Paediatrics, University Hospital Motol, Prague, Czech Republic
| | - Johanna C Escher
- Department of Paediatric Gastroenterology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Ulrika L Fagerberg
- Department of Pediatrics/Centre for Clinical Research, Västmanland Hospital, Västeras and Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Marco Gasparetto
- Department of Paediatric Gastroenterology, Barts Health Trust, The Royal London Children's Hospital, London, UK
| | | | - Anne Griffiths
- Department of Paediatrics, Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Paul Henderson
- Child Life and Health, University Of Edinburgh, Edinburgh, UK
| | - Sibylle Koletzko
- Department of Pediatrics, Division of Gastroenterology and Hepatology, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Munich, Germany
- Department of Pediatrics, Gastroenterology and Nutrition, School of Medicine Collegium Medicum University of Warmia and Mazury, Olsztyn, Poland
| | - Kaija-Leena Kolho
- Department of Paediatrics, Children´s Hospital, University of Helsinki and Tampere University, Tampere, Finland
| | - Arie Levine
- Pediatric Gastroenterology and Nutrition Unit, Wolfson Medical Center, Tel Aviv University, Israel
| | - Johan van Limbergen
- Division of Pediatric Gastroenterology and Nutrition, Amsterdam UMC - location AMC, Amsterdam, The Netherlands
| | | | - Víctor Manuel Navas-López
- Pediatric Gastroenterology and Nutrition Unit, IBIMA, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Salvatore Oliva
- Pediatric Gastroenterology and Liver Unit, Maternal and Child Health Department, Sapienza - University of Rome, Rome, Italy
| | - Lissy de Ridder
- Department of Paediatric Gastroenterology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Richard K Russell
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Sick Children, Edinburgh, UK
| | - Dror Shouval
- Pediatric Gastroenterology Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Antonino Spinelli
- Department of Colon and Rectal Surgery, Humanitas Clinical and Research Center - IRCCS, Rozzano Milano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Dan Turner
- Paediatric Gastroenterology, Shaare Zedek Medical Centre, the Hebrew University of Jerusalem, Israel
| | - David Wilson
- Child Life and Health, University Of Edinburgh, Edinburgh, UK
| | - Eytan Wine
- Division of Pediatric Gastroenterology, Edmonton Pediatric IBD Clinic (EPIC), Departments of Pediatrics & Physiology, University of Alberta, Edmonton, Canada
| | - Frank M Ruemmele
- Assistance Publique- Hôpitaux de Paris, Hôpital Necker Enfants Malades, Pediatric Gastroenterology, Paris, France
- Faculté de Médecine, Université Sorbonne Paris Cité, Paris Descartes, Paris, France
| |
Collapse
|
30
|
de Laffolie J, Schwerd T, Simon A, Pauli M, Broekaert I, Classen M, Posovszky C, Schmidt-Choudhury A. [Crohn's Disease Exclusion Diet - an alternative to exlusive enteral nutritional therapy in children and adolescents with Crohn's disease? Statement of the GPGE working groups CEDATA and Nutrition/Nutrition Medicine]. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2020; 58:890-894. [PMID: 32947634 DOI: 10.1055/a-1199-6751] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Epidemiological an clinical observations as well as results from animal studies indicate that nutrition can play a role in the development of inflammatory bowel disease (IBD). Exclusive enteral nutrition therapy represents an example for modulating inflammatory responses solely through diet modification. Therefore, caretakers, patients, families, doctors and nutritionists seek for more dietary options to control IBD. These options include partial enteral nutrition therapy as for example the socalled Crohn's disease exclusion diet. The following statement summarizes existing data and provides recommendations for the current management of enteral nutrition therapy in pediatric Crohn's disease.
Collapse
Affiliation(s)
- Jan de Laffolie
- Zentrum für Kinderheilkunde, Justus Liebig Universität Gießen, Germany
| | - Tobias Schwerd
- Kindergastroenterologie, Dr. von Haunersches Kinderspital, Kinderklinik und Kinderpoliklinik der Ludwig-Maximilians-Universität München, München, Germany
| | - Annette Simon
- Zentrum für Kinderheilkunde, Justus Liebig Universität Gießen, Germany
| | | | | | | | | | - Anjona Schmidt-Choudhury
- Klinik für Kinder- und Jugendmedizin der Ruhr-Universität Bochum im St. Josef-Hospital, Katholisches Klinikum Bochum, Germany
| | | |
Collapse
|
31
|
Effect of Exclusive Enteral Nutrition on Th17 Cells in Juvenile Rats with Inflammatory Bowel Disease. Inflammation 2020; 44:261-269. [PMID: 32897457 DOI: 10.1007/s10753-020-01328-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 08/15/2020] [Accepted: 08/19/2020] [Indexed: 10/23/2022]
Abstract
The objective was to investigate the effect of exclusive enteral nutrition (EEN) on T helper (Th) 17 cells by observing the effects of EEN on colon and serum interleukin (IL)-17A levels in juvenile inflammatory bowel disease (IBD) rat models and to reveal the potential mechanism of the therapeutic effect of EEN on IBD. ATNBS-induced IBD rat model was established. Feeding Peptison, a type of enteric nutrition (EN) for EEN-IBD group and EEN group, normal feed for IBD model group and control group for six consecutive days. Four groups of juvenile rats were sacrificed on day 7. The pathology of the intestinal mucosa was examined, the expression of IL-17A in serum was detected by ELISA, and the expression of IL-17A in intestinal tissue was detected by both western blot and real-time PCR (RT-PCR). Diarrhea, bloody stools, and weight loss were found in both the IBD group and the EEN-IBD group. After 5 days of EEN feeding, the stool characteristics, and blood in the stools of the rats in the EEN-IBD group were significantly relieved compared with those of the IBD group. There was no significant difference in the body mass growth rate between the IBD group and EEN-IBD group (P > 0.05). The growth rate of the EEN group was 51.29 ± 3.61%, which was significantly lower than that of the control group (60.17 ± 9.32%) with P < 0.05. The disease activity index (DAI) score of the EEN-IBD group was significantly lower than that of the IBD group (P < 0.05). In the IBD group, colonic congestion and edema were obvious, scattered ulcers were observed, and the intestinal mucosa had a large amount of inflammatory cell infiltration. In the EEN-IBD group, the intestinal mucosa was slightly congested and a small amount of inflammatory cell infiltrated. The serum IL-17A expression level in the IBD group was significantly higher than in the EEN-IBD group, control group, and EEN group (P < 0.05). Both the gene and protein expressions of IL-17A in the intestinal tissue of the EEN-IBD group were significantly lower than in the IBD group (P < 0.01), and it was significantly higher in the IBD group than in the control and EEN groups (P < 0.01). EEN effectively reduced the intestinal inflammation in the juvenile rats with IBD. The mechanism could be related to the regulation of Th17 cells and the expression of the corresponding cytokine, IL-17A. EEN may play a role in downregulating the expression of IL-17A in the intestinal mucosa.
Collapse
|
32
|
Yang H, Feng R, Li T, Xu S, Hao X, Qiu Y, Chen M. Systematic review with meta-analysis of partial enteral nutrition for the maintenance of remission in Crohn's disease. Nutr Res 2020; 81:7-18. [PMID: 32798791 DOI: 10.1016/j.nutres.2020.06.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 04/30/2020] [Accepted: 06/03/2020] [Indexed: 12/28/2022]
Abstract
Although enteral nutrition (EN) is effective for induction therapy in Crohn's disease (CD), it remains unclear whether partial enteral nutrition (PEN), i.e., EN, along with a daily diet, is effective for maintenance therapy in CD. It was hypothesized that PEN would be effective as a maintenance therapy in CD. This meta-analysis aimed to evaluate the efficacy and safety of PEN for maintenance therapy in CD. PubMed, EMBASE, Web of Science, and Cochrane Library were searched up to January 2019 for eligible prospective controlled trials, and then a meta-analysis was conducted. The primary outcome was clinical relapse, as defined in the primary studies. Eight studies with 429 patients were included in the meta-analysis. The rate of clinical relapse at 0.5 to 2 years was significantly lower in patients receiving PEN (420-1800 kcal/d) than in those not receiving nutrition therapy (RR: 0.67, 95% CI: 0.54-0.82, P < .01; number needed to treat = 5, P < .01). Patients receiving PEN exhibited a higher frequency of clinical remission maintenance at 0.5 to 1 year (67%) than did those not receiving nutrition therapy (48%; RR: 1.32, 95% CI: 1.07-1.64, P = .01). The total adverse event rate was comparable in the two groups (RR: 3.60, 95% CI: 0.70-18.66, P = .13). PEN may be more effective than the absence of EN therapy for the maintenance of remission in CD with a good safety profile.
Collapse
Affiliation(s)
- Hongsheng Yang
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-Sen University, No. 58 Zhongshan Road II, Yuexiu district, Guangzhou 510000, P.R. China; Department of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-Sen University, No. 26 Yuancun Road II, Tianhe district, Guangzhou 510000, P.R. China
| | - Rui Feng
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-Sen University, No. 58 Zhongshan Road II, Yuexiu district, Guangzhou 510000, P.R. China
| | - Tong Li
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-Sen University, No. 58 Zhongshan Road II, Yuexiu district, Guangzhou 510000, P.R. China
| | - Shu Xu
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-Sen University, No. 58 Zhongshan Road II, Yuexiu district, Guangzhou 510000, P.R. China
| | - Xiuxue Hao
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-Sen University, No. 58 Zhongshan Road II, Yuexiu district, Guangzhou 510000, P.R. China
| | - Yun Qiu
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-Sen University, No. 58 Zhongshan Road II, Yuexiu district, Guangzhou 510000, P.R. China.
| | - Minhu Chen
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-Sen University, No. 58 Zhongshan Road II, Yuexiu district, Guangzhou 510000, P.R. China.
| |
Collapse
|
33
|
Martin NG, Roberts AJ, Evans HM, Bishop J, Day AS. Three-year outcomes of childhood inflammatory bowel disease in New Zealand: A population-based cohort study. JGH OPEN 2020; 4:642-648. [PMID: 32782951 PMCID: PMC7411647 DOI: 10.1002/jgh3.12310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 01/16/2020] [Accepted: 01/23/2020] [Indexed: 12/19/2022]
Abstract
Background and Aim High rates of inflammatory bowel disease (IBD) have been documented in New Zealand (NZ) children. The objectives of this study were to describe the outcomes and disease course of childhood IBD in the first 3 years following diagnosis. Methods All children diagnosed with IBD in 2015 in NZ were included. Clinical data obtained during routine care for 3 years following diagnosis were analyzed. Growth parameters, disease activity scores, and blood parameters were compared at diagnosis and follow up. Results Three‐year outcome data were available for 48 of 51 children. At follow up, median age was 15.1 years, and 34 had Crohn's disease (CD), 11 had ulcerative colitis (UC), and three had IBD‐unclassified (IBDU). Although disease progression including development of perianal disease occurred in 13 (38%) of 34 children with CD, the majority (n = 30) had inflammatory disease at follow up. Disease extension occurred in 25% (2/8) of children initially diagnosed with UC. Of all IBD patients, the mean body mass index z‐score increased from −0.40 to +0.10 (P = 0.01). Disease activity scores reduced from diagnosis to follow up in both CD (mean pediatric Crohn's disease activity index 35–6, P < 0.001) and UC (mean pediatric ulcerative colitis activity index 44–6, P < 0.001). Overall, 56% of children received steroids, 44% of children with CD received biologic therapy, and four children with CD or UC had intestinal surgery. Conclusions Most children with IBD were in remission with improved growth 3 years after diagnosis. Biologic therapies were commonly prescribed. This is the first NZ study assessing disease course in pediatric IBD. Ongoing follow up will continue to inform outcomes.
Collapse
Affiliation(s)
- Natalie G Martin
- Department of Paediatrics University of Otago Christchurch Christchurch New Zealand
| | - Amin J Roberts
- Starship Child Health Starship Children's Hospital Auckland New Zealand
| | - Helen M Evans
- Starship Child Health Starship Children's Hospital Auckland New Zealand
| | - Jonathan Bishop
- Starship Child Health Starship Children's Hospital Auckland New Zealand
| | - Andrew S Day
- Department of Paediatrics University of Otago Christchurch Christchurch New Zealand
| |
Collapse
|
34
|
A dietary intervention to improve the microbiome composition of pregnant women with Crohn's disease and their offspring: The MELODY (Modulating Early Life Microbiome through Dietary Intervention in Pregnancy) trial design. Contemp Clin Trials Commun 2020; 18:100573. [PMID: 32617430 PMCID: PMC7322804 DOI: 10.1016/j.conctc.2020.100573] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 04/13/2020] [Accepted: 04/26/2020] [Indexed: 12/18/2022] Open
Abstract
Crohn's disease (CD), a type of inflammatory bowel disease (IBD), is a chronic condition of the gastrointestinal tract that is caused by the loss of mucosal tolerance towards the commensal bacteria resulting in inflammatory responses. It has long been postulated that the gut microbiota, a complex and dynamic population of microorganisms, plays a key role in the pathogenesis of IBD. Maternal diagnosis of IBD has been identified as the greatest risk factor for IBD in offspring increasing the odds of developing the disease >4.5-fold. Moreover, babies born to mothers with IBD have demonstrated reduced gut bacterial diversity. There is accumulating evidence that the early life microbiota colonization is informed by maternal diet within the 3rd trimester of pregnancy. While babies born to mothers with IBD would pose an ideal cohort for intervention, no primary prevention measures are currently available. Therefore, we designed the MELODY (Modulating Early Life Microbiome through Dietary Intervention in Pregnancy) trial to test whether the IBD-AID™ dietary intervention during the last trimester of pregnancy can beneficially shift the microbiome of CD patients and their babies, thereby promoting a strong, effective immune system during a critical time of the immune system development. We will also test if favorable changes in the microbiome can lead to a reduced risk of postpartum CD relapse and lower mucosal inflammation in the offspring. This study will help create new opportunities to foster a healthy microbiome in the offspring at high risk of other immune-mediated diseases, potentially reducing their risk later in life.
Collapse
|
35
|
Gurram B, Patel AS. Recent advances in understanding and managing pediatric inflammatory bowel disease. F1000Res 2019; 8. [PMID: 31885858 PMCID: PMC6913196 DOI: 10.12688/f1000research.19609.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/06/2019] [Indexed: 12/07/2022] Open
Abstract
The landscape of pediatric inflammatory bowel disease is rapidly evolving. The therapeutic advances seen in the adult arena are rapidly being adopted by pediatric gastroenterologists and evaluated in both controlled trials and real-world experience. Though anti-tumor necrosis factor agents have been the primary therapy over the last decade, recently there has been an expansion of therapeutic targets and alternative mechanism of action drugs with a focus on individualized and personalized therapy. By reviewing epidemiology, pathophysiology, and goals of treatment, we hope to frame the discussion of current and novel therapeutics for the pediatric gastroenterologist. As scientific discovery continues to push the envelope in defining our understanding of pediatric inflammatory bowel disease, the current era of therapeutics gives us hope that a cure may be realized soon.
Collapse
Affiliation(s)
- Bhaskar Gurram
- University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Ashish S. Patel
- University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| |
Collapse
|
36
|
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.
Collapse
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
| |
Collapse
|
37
|
Comeche JM, Caballero P, Gutierrez-Hervas A, García-Sanjuan S, Comino I, Altavilla C, Tuells J. Enteral Nutrition in Patients with Inflammatory Bowel Disease. Systematic Review, Meta-Analysis, and Meta-Regression. Nutrients 2019; 11:nu11112657. [PMID: 31689999 PMCID: PMC6893586 DOI: 10.3390/nu11112657] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 10/23/2019] [Accepted: 10/25/2019] [Indexed: 02/07/2023] Open
Abstract
Inflammatory bowel disease (IBD) is a chronic disease mediated by the immune system and is characterized by inflammation of the gastrointestinal tract. One of the possible treatments for this pathology is a change in the type of diet, of which enteral nutrition (EN) is one. This study is to understand how the use of EN can affect the adult population diagnosed with IBD. We conducted a systematic review, meta-analysis, and a meta-regression. On the different databases (MEDLINE, Scopus, Cochrane, LILACS, CINAHL, WOS), we found 363 registers with an accuracy of 12% (44 registers). After a full-text review, only 30 research studies were selected for qualitative synthesis and 11 for meta-analysis and meta-regression. The variables used were Crohn's disease activity index (CDAI), C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR). EN has been shown to have efficacy for the treatment of Crohn's disease and is compatible with other medicines. As for the CDAI or rates of remission, there were no differences between enteral and parenteral nutrition. Polymeric formulas have shown better results with respect to the CRP. The long-term treatment could dilute the good CDAI results that are obtained at the start of the EN treatment.
Collapse
Affiliation(s)
- Jose M Comeche
- Department of Community Nursing, Preventive Medicine and Public Health and History of Science (SPAIN), University of Alicante, San Vicente del Raspeig, 03690 Alicante, Spain.
| | - Pablo Caballero
- Department of Community Nursing, Preventive Medicine and Public Health and History of Science (SPAIN), University of Alicante, San Vicente del Raspeig, 03690 Alicante, Spain.
| | - Ana Gutierrez-Hervas
- Department of Nursing (SPAIN), University of Alicante, San Vicente del Raspeig, 03690 Alicante, Spain.
| | - Sofia García-Sanjuan
- Department of Nursing (SPAIN), University of Alicante, San Vicente del Raspeig, 03690 Alicante, Spain.
| | - Iris Comino
- Department of Community Nursing, Preventive Medicine and Public Health and History of Science (SPAIN), University of Alicante, San Vicente del Raspeig, 03690 Alicante, Spain.
| | - Cesare Altavilla
- Department of Community Nursing, Preventive Medicine and Public Health and History of Science (SPAIN), University of Alicante, San Vicente del Raspeig, 03690 Alicante, Spain.
| | - Jose Tuells
- Department of Community Nursing, Preventive Medicine and Public Health and History of Science (SPAIN), University of Alicante, San Vicente del Raspeig, 03690 Alicante, Spain.
| |
Collapse
|
38
|
Xu Y, Guo Z, Huang L, Gong J, Li Y, Gu L, Shen W, Zhu W. A nomogram for predicting the response to exclusive enteral nutrition in adult patients with isolated colonic Crohn's disease. Therap Adv Gastroenterol 2019; 12:1756284819881301. [PMID: 31656533 PMCID: PMC6791043 DOI: 10.1177/1756284819881301] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 09/18/2019] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Isolated colonic Crohn's disease (cCD) responds less well to induction therapy with exclusive enteral nutrition (EEN) compared with ileal or ileocolonic disease in adult patients; therefore, we aimed to identify the factors that influence the response to EEN and develop a predictive nomogram model to optimize the use of EEN in cCD patients. MATERIALS AND METHODS Eighty-five cCD patients treated with EEN as first-line therapy at our center between 1 June 2012 and 30 June 2018 were retrospectively analyzed as the primary cohort. The primary endpoint was clinical remission after EEN therapy. Potential predictive factors for the efficacy of EEN were assessed by univariate and multivariate analyses, and a nomogram to predict the response to EEN therapy in cCD patients was designed. Another 19 cCD patients were retrospectively included in the validation cohort to verify the accuracy of the nomogram model. RESULTS The clinical remission rates for the primary cohort and validation cohort were 52.9% and 47.4%, respectively. Pancolitis was the greatest contributor to the risk of failure to respond to EEN [odds ratio (OR) = 4.896; 95% confidence interval (CI) = 1.223-19.607; p = 0.025], lean body mass index (LBMI), colonic lesion features, simple endoscopic scores for Crohn's disease, C-reactive protein before treatment and ∆prealbumin were also related to the efficacy of EEN in cCD. The nomogram model showed robust discrimination, with an area under the receiving operating characteristic curve of 0.906. CONCLUSION Several predictive factors for response to EEN therapy in cCD adult patients were identified, and a promising nomogram that can predict the effect of EEN in cCD was developed.
Collapse
Affiliation(s)
- Yihan Xu
- Nanjing Medical University, Nanjing, China Research Institute of General Surgery, Jinling Hospital, Nanjing, China
| | - Zhen Guo
- Research Institute of General Surgery, Jinling Hospital, Nanjing, China
| | - Liangyu Huang
- Research Institute of General Surgery, Jinling Hospital, Nanjing, China
| | - Jianfeng Gong
- Research Institute of General Surgery, Jinling Hospital, Nanjing, China
| | - Yi Li
- Research Institute of General Surgery, Jinling Hospital, Nanjing, China
| | - Lili Gu
- Research Institute of General Surgery, Jinling Hospital, Nanjing, China
| | - Weisong Shen
- Research Institute of General Surgery, Jinling Hospital, Nanjing, China
| | - Weiming Zhu
- Research Institute of General Surgery, Nanjing Jinling Hospital, 305 Zhongshan East Road, Nanjing 210002, China
- Nanjing Medical University, 305 Zhongshan East Road, Nanjing, Jiangsu 210029, China
| |
Collapse
|
39
|
Agin M, Yucel A, Gumus M, Yuksekkaya HA, Tumgor G. The Effect of Enteral Nutrition Support Rich in TGF-β in the Treatment of Inflammatory Bowel Disease in Childhood. ACTA ACUST UNITED AC 2019; 55:medicina55100620. [PMID: 31546703 PMCID: PMC6843769 DOI: 10.3390/medicina55100620] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Revised: 09/16/2019] [Accepted: 09/18/2019] [Indexed: 01/07/2023]
Abstract
Background and Objective: Malnutrition is a major complication of inflammatory bowel disease (IBD). Our aim of the study was to examine the effects of Modulen IBD supplementation, which was administered to IBD patients without limiting their daily diet in addition to medical treatment, on the clinical, laboratory, anthropometric values, and disease activities of these patients. Materials and Methods: Seventy three children with IBD were evaluated retrospectively. The cases were classified as those who had Crohn disease receiving (CD-M; n = 16) or not receiving Modulen IBD (CD; n = 19) and those who had ulcerative colitis receiving (UC-M; n = 13) or not receiving Modulen IBD (UC; n = 25). Disease activities, laboratory values, remission rates, and anthropometric measurements of the groups were compared. In addition to IBD treatment, Modulen IBD in which half of the daily calorie requirement was provided was given for eight weeks. Results: In the third month of treatment, 14 (88%) patients were in remission in CD-M group and eight (42%) patients were in remission in CD group. The height and weight z scores, which were low at the time of diagnosis, improved in the first week in CD-M group. Inflammatory parameters (UC) were significantly lower in the UC-M group compared to the UC group in first and third months. In the third month, eight (62%) patients in the UC-M group and four (16%) in the UC group were remitted clinically and in terms of laboratory values. Conclusions: TGF-β-rich enteral nutrition support in children with IBD is an easy, effective, and reliable approach. It was shown that TGF-β-rich enteral nutritional supplementation enabled the disease to enter the remission earlier, and contributed to the early recovery of weight and height scores.
Collapse
Affiliation(s)
- Mehmet Agin
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Cukurova University Medical Faculty, Saricam, 01380 Adana, Turkey.
| | - Aylin Yucel
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Necmettin Erbakan University Medical Faculty, Meram, 42080 Konya, Turkey.
| | - Meltem Gumus
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Necmettin Erbakan University Medical Faculty, Meram, 42080 Konya, Turkey.
| | - Hasan Ali Yuksekkaya
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Necmettin Erbakan University Medical Faculty, Meram, 42080 Konya, Turkey.
| | - Gokhan Tumgor
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Cukurova University Medical Faculty, Saricam, 01380 Adana, Turkey.
| |
Collapse
|
40
|
Di Caro S, Fragkos KC, Keetarut K, Koo HF, Sebepos-Rogers G, Saravanapavan H, Barragry J, Rogers J, Mehta SJ, Rahman F. Enteral Nutrition in Adult Crohn's Disease: Toward a Paradigm Shift. Nutrients 2019; 11:E2222. [PMID: 31540038 PMCID: PMC6770416 DOI: 10.3390/nu11092222] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 09/05/2019] [Accepted: 09/08/2019] [Indexed: 02/06/2023] Open
Abstract
Medical and surgical treatments for Crohn's disease are associated with toxic effects. Medical therapy aims for mucosal healing and is achievable with biologics, immunosuppressive therapy, and specialised enteral nutrition, but not with corticosteroids. Sustained remission remains a therapeutic challenge. Enteral nutrition, containing macro- and micro-nutrients, is nutritionally complete, and is provided in powder or liquid form. Enteral nutrition is a low-risk and minimally invasive therapy. It is well-established and recommended as first line induction therapy in paediatric Crohn's disease with remission rates of up to 80%. Other than in Japan, enteral nutrition is not routinely used in the adult population among Western countries, mainly due to unpalatable formulations which lead to poor compliance. This study aims to offer a comprehensive review of available enteral nutrition formulations and the literature supporting the use and mechanisms of action of enteral nutrition in adult Crohn's disease patients, in order to support clinicians in real world decision-making when offering/accepting treatment. The mechanisms of actions of enteral feed, including their impact on the gut microbiome, were explored. Barriers to the use of enteral nutrition, such as compliance and the route of administration, were considered. All available enteral preparations have been comprehensively described as a practical guide for clinical use. Likewise, guidelines are reported and discussed.
Collapse
Affiliation(s)
- Simona Di Caro
- Intestinal Failure Service, GI Services, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
| | - Konstantinos C Fragkos
- Intestinal Failure Service, GI Services, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
| | - Katie Keetarut
- Department of Dietetics, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
| | - Hui Fen Koo
- UCL Medical School, 74 Huntley Street, Bloomsbury, London WC1E 6DE, UK.
| | - Gregory Sebepos-Rogers
- Intestinal Failure Service, GI Services, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
| | - Hajeena Saravanapavan
- Intestinal Failure Service, GI Services, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
| | - John Barragry
- Intestinal Failure Service, GI Services, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
| | - Jennifer Rogers
- Intestinal Failure Service, GI Services, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
| | - Shameer J Mehta
- Intestinal Failure Service, GI Services, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
| | - Farooq Rahman
- Intestinal Failure Service, GI Services, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
| |
Collapse
|
41
|
Kim SE. Importance of nutritional therapy in the management of intestinal diseases: beyond energy and nutrient supply. Intest Res 2019; 17:443-454. [PMID: 31474088 PMCID: PMC6821938 DOI: 10.5217/ir.2019.00075] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 07/05/2019] [Indexed: 12/16/2022] Open
Abstract
The gut is an immune-microbiome-epithelial complex. Gut microbiome-host interactions have widespread biological implications, and the role of this complex system extends beyond the digestion of food and nutrient absorption. Dietary nutrients can affect this complex and play a key role in determining gut homeostasis to maintain host health. In this article, we review various dietary nutrients and their contribution to the pathogenesis and treatment of various intestinal diseases including inflammatory bowel disease, irritable bowel syndrome, colorectal cancer, and diverticulitis, among other such disorders. A better understanding of diet-host-gut microbiome interactions is essential to provide beneficial nutrients for gut health and to limit nutritional hazards to ensure successful nutritional management of gastrointestinal conditions in clinical practice.
Collapse
Affiliation(s)
- Seong-Eun Kim
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| |
Collapse
|
42
|
Britto S, Kellermayer R. Carbohydrate Monotony as Protection and Treatment for Inflammatory Bowel Disease. J Crohns Colitis 2019; 13:942-948. [PMID: 30715243 DOI: 10.1093/ecco-jcc/jjz011] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 12/17/2018] [Accepted: 01/24/2019] [Indexed: 02/07/2023]
Abstract
The nutritional developmental origins of inflammatory bowel disease[s] (IBDs: Crohn's disease or Crohn disease [CD] and ulcerative colitis [UC]) and their diet-based treatments continue to receive increasing attention. There is growing evidence for the success of nutrition-based treatments, such as exclusive enteral nutrition [EEN] and the specific carbohydrate diet [SCD], in both paediatric and adult patients. Beyond these two dietary interventions, symptomatic benefit in IBD has also been shown from a gluten-free diet [GFD] and paleolithic diet [PALEO], among others. These nutritional therapies may point to critical factors in not only the pathology, but also the pathogenesis of the disease group. It is difficult, however, to discern a common element within the large number of diet-based causation theories [e.g. emulsifiers, processed foods, refrigeration, increased total fat intake, low fibre intake, carbohydrate dominant food, etc.] and the varied dietary treatments of IBD. This Viewpoint article highlights that carbohydrate variation links diet-based causation theories, and that carbohydrate monotony or persistence is the commonly shared characteristic of diet-based IBD therapy. Further research directed towards carbohydrate monotony may critically advance the prevention and treatment of these highly morbid conditions.
Collapse
Affiliation(s)
- Savini Britto
- Section of Pediatric Gastroenterology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Richard Kellermayer
- Section of Pediatric Gastroenterology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA.,USDA/ARS Children's Nutrition Research Center, Houston, TX, USA
| |
Collapse
|
43
|
Pigneur B, Lepage P, Mondot S, Schmitz J, Goulet O, Doré J, Ruemmele FM. Mucosal Healing and Bacterial Composition in Response to Enteral Nutrition Vs Steroid-based Induction Therapy-A Randomised Prospective Clinical Trial in Children With Crohn's Disease. J Crohns Colitis 2019; 13:846-855. [PMID: 30541015 DOI: 10.1093/ecco-jcc/jjy207] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
AIMS Exclusive enteral nutrition [EEN] is as efficacious as corticosteroids [CS] to induce remission in Crohn's disease [CD], without their adverse effects. EEN seems to be more efficient than steroids to induce mucosal healing, but the underlying molecular mechanisms are only sparsely understood. We aimed in the present work to study the anti-inflammatory effects of EEN with Modulen IBD® vs CS in active paediatric CD, and to assess its modulatory effects on the intestinal microbiota as compared with steroids. MATERIALS AND METHODS Nineteen patients with new-onset active CD (Harvey-Bradshaw index [HBI] >5), aged from 6 to 17 years, were included in this prospective randomised induction trial with CS [n = 6] or EEN [n = 13]. Patients were assessed at Weeks 0 and 8 using clinical parameters HBI, endoscopic findings (Crohn's Disease Endoscopic Index of Severity [CDEIS] score) and analysis of faecal microbiota composition. RESULTS At 8 weeks, clinical remission [HBI <5] was achieved in 13/13 patients on EEN and 5/6 patients on steroids; the mucosal healing rate was significantly higher in the EEN [89%] compared with steroid group [17%]. There were no significant differences between groups regarding biological markers, but the intestinal microbiota profiles shifted upon EEN-induced remission to a higher proportion of Ruminococcus bacteria compared with steroid-induced remission [p = 0.049], and with higher proportions of bacteria belonging to Clostridium in EEN-treated patients. CONCLUSIONS Both steroid and EEN induced clinical remission. However, patients with EEN-induced remission showed a higher rate of mucosal healing and this was associated with a different gut microbiota compositional shift in these children.
Collapse
Affiliation(s)
- Bénédicte Pigneur
- Hôpital Necker Enfants Malades Université Sorbonne Paris Cité, Paris, APHP.,INSERM UMR1163, Laboratory of Intestinal Immunity, Institut Imagine, Paris, France
| | - Patricia Lepage
- Micalis Institute, INRA, University Paris-Saclay, Jouy-en-Josas, France
| | - Stanislas Mondot
- Micalis Institute, INRA, University Paris-Saclay, Jouy-en-Josas, France
| | - Jacques Schmitz
- Hôpital Necker Enfants Malades Université Sorbonne Paris Cité, Paris, APHP
| | - Olivier Goulet
- Hôpital Necker Enfants Malades Université Sorbonne Paris Cité, Paris, APHP
| | - Joël Doré
- INRA, Metagenopolis, Jouy-en-Josas, France
| | - Frank M Ruemmele
- Hôpital Necker Enfants Malades Université Sorbonne Paris Cité, Paris, APHP.,INSERM UMR1163, Laboratory of Intestinal Immunity, Institut Imagine, Paris, France
| |
Collapse
|
44
|
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.
Collapse
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
| |
Collapse
|
45
|
Chen JM, He LW, Yan T, Guo XF, Hu PJ, Peng JS, Cheng WJ, Li LL, He Q. Oral exclusive enteral nutrition induces mucosal and transmural healing in patients with Crohn's disease. Gastroenterol Rep (Oxf) 2019; 7:176-184. [PMID: 31217981 PMCID: PMC6573804 DOI: 10.1093/gastro/goy050] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 11/16/2018] [Accepted: 12/05/2018] [Indexed: 12/21/2022] Open
Abstract
Background and aims Mucosal healing is regarded as a clinical endpoint of Crohn’s disease (CD), and transmural healing is correlated to the concept of deep remission. Current therapies to induce mucosal and transmural healing in CD are not satisfactory. Exclusive enteral nutrition (EEN) is underestimated therapy and its value has not been fully evaluated. Our aim was to investigate the efficacy of oral EEN for inducing mucosal and transmural healing in CD patients. Methods This was a prospective, single-center, open-label study including diagnosed CD children and adults conducted between January 2015 and December 2016 in the Sixth Affiliated Hospital of Sun Yat-sen University. All patients were treated with oral EEN and underwent paired assessment at baseline and completion using C-reaction protein, erythrocyte sedimentation rate, platelets, hemoglobin, body mass index, CD activity index, simple endoscopic score for CD and bowel sonography. Azathioprine was combined to prevent relapse. Results In this prospective observational study, 29 CD patients with an average age of 28.9 years were identified. After oral EEN treatment, 23 patients (79%) achieved complete mucosal healing, and the mean time to reach mucosal healing was 123 days (ranged from 50 to 212 days). Although only five patients (17%) achieved transmural healing, a significant reduction was observed in bowel-wall thickness (9.41 ± 3.06 vs 4.97 ± 1.76 mm, P < 0.001) and a significant improvement was observed in complications (including fistulas, abscess, ascites, stricture) assessed by bowel sonography (all P < 0.05). Conclusions Oral EEN therapy is highly effective for inducing mucosal healing in CD patients. Both CD patients at active stage and those at clinical remission show excellent clinical response to oral EEN.
Collapse
Affiliation(s)
- Jia-Min Chen
- Department of Gastroenterology, The Sixth Affiliated Hospital of Sun Yat-sen University (Guangdong Gastrointestinal Hospital), Guangzhou, Guangdong, China
| | - Li-Wen He
- Department of Gastroenterology, The Sixth Affiliated Hospital of Sun Yat-sen University (Guangdong Gastrointestinal Hospital), Guangzhou, Guangdong, China
| | - Ting Yan
- Department of Clinical Nutrition, The Sixth Affiliated Hospital of Sun Yat-sen University (Guangdong Gastrointestinal Hospital), Guangzhou, Guangdong, China
| | - Xue-Feng Guo
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University (Guangdong Gastrointestinal Hospital), Guangzhou, Guangdong, China
| | - Pin-Jin Hu
- Department of Gastroenterology, The Sixth Affiliated Hospital of Sun Yat-sen University (Guangdong Gastrointestinal Hospital), Guangzhou, Guangdong, China
| | - Jun-Sheng Peng
- Department of Gastrointestinal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University (Guangdong Gastrointestinal Hospital), Guangzhou, Guangdong, China
| | - Wen-Jie Cheng
- Department of Medical Ultrasound, The Sixth Affiliated Hospital of Sun Yat-sen University (Guangdong Gastrointestinal Hospital), Guangzhou, Guangdong, China
| | - Ling-Ling Li
- Department of Clinical Nutrition, The Sixth Affiliated Hospital of Sun Yat-sen University (Guangdong Gastrointestinal Hospital), Guangzhou, Guangdong, China
| | - Qing He
- Department of Gastroenterology, The Sixth Affiliated Hospital of Sun Yat-sen University (Guangdong Gastrointestinal Hospital), Guangzhou, Guangdong, China.,Department of Clinical Nutrition, The Sixth Affiliated Hospital of Sun Yat-sen University (Guangdong Gastrointestinal Hospital), Guangzhou, Guangdong, China
| |
Collapse
|
46
|
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.
Collapse
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.
| |
Collapse
|
47
|
Copova I, Hradsky O, Zarubova K, Gonsorcikova L, Potuznikova K, Lerchova T, Nevoral J, Bronsky J. Fecal calprotectin is not a clinically useful marker for the prediction of the early nonresponse to exclusive enteral nutrition in pediatric patients with Crohn disease. Eur J Pediatr 2018; 177:1685-1693. [PMID: 30128744 DOI: 10.1007/s00431-018-3228-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 07/28/2018] [Accepted: 07/30/2018] [Indexed: 12/22/2022]
Abstract
Exclusive enteral nutrition (EEN) has been recommended as the first-line therapy in children with active Crohn disease (CD). The primary aim of our study was to determine whether it is possible to use the difference between basal fecal calprotectin (F-CPT) and the value at week 2 of EEN to predict clinical response at week 6. We prospectively collected stool samples for F-CPT analysis and clinical and laboratory parameters during EEN from 38 pediatric patients (28 boys, median age 12.8 years) with newly diagnosed active luminal CD. The difference between F-CPT concentrations before EEN and at week 2 did not predict clinical non-response at week 6 (OR 0.9996 95% CI 0.9989-1.0002, p = 0.18); however, it predicted patients who did not achieve clinical remission at week 6 (OR 0.9993, 95% CI 00.9985-0.9998, p = 0.006) with sensitivity of 58%, and specificity of 92% for cut-off of F-CPT increase by 486 μg/g.Conclusions: An early decrease in F-CPT levels in children with newly diagnosed active luminal CD did not predict clinical response at week 6 of EEN induction therapy, and clinical remission was predicted with low accuracy. Therefore, F-CPT cannot be used as a predictor to select the patients in whom EEN should be terminated. What is Known: • The fecal calprotectin (F-CPT) is an important marker of intestinal inflammation. • Approximately 25% of pediatric patients with Crohn disease (CD) do not achieve clinical remission, and there is still no sufficient predictor of response to exclusive enteral nutrition (EEN) treatment. What is New: • The difference between the F-CPT concentrations before EEN treatment and at week 2 did not predict clinical response to treatment at week 6, even if it predicted clinical remission, however, with low accuracy. F-CPT is not a suitable predictor to select the patients for discontinuing of EEN induction therapy.
Collapse
Affiliation(s)
- Ivana Copova
- Department of Pediatrics, University Hospital Motol and Second Faculty of Medicine, Charles University in Prague, V Uvalu 84, 150 06, Prague 5, Czech Republic.
| | - Ondrej Hradsky
- Department of Pediatrics, University Hospital Motol and Second Faculty of Medicine, Charles University in Prague, V Uvalu 84, 150 06, Prague 5, Czech Republic
| | - Kristyna Zarubova
- Department of Pediatrics, University Hospital Motol and Second Faculty of Medicine, Charles University in Prague, V Uvalu 84, 150 06, Prague 5, Czech Republic
| | - Lucie Gonsorcikova
- Department of Pediatrics, University Hospital Motol and Second Faculty of Medicine, Charles University in Prague, V Uvalu 84, 150 06, Prague 5, Czech Republic
| | - Kristyna Potuznikova
- Department of Pediatrics, University Hospital Motol and Second Faculty of Medicine, Charles University in Prague, V Uvalu 84, 150 06, Prague 5, Czech Republic
| | - Tereza Lerchova
- Department of Pediatrics, University Hospital Motol and Second Faculty of Medicine, Charles University in Prague, V Uvalu 84, 150 06, Prague 5, Czech Republic
| | - Jiri Nevoral
- Department of Pediatrics, University Hospital Motol and Second Faculty of Medicine, Charles University in Prague, V Uvalu 84, 150 06, Prague 5, Czech Republic
| | - Jiri Bronsky
- Department of Pediatrics, University Hospital Motol and Second Faculty of Medicine, Charles University in Prague, V Uvalu 84, 150 06, Prague 5, Czech Republic
| |
Collapse
|
48
|
Levine A, Sigall Boneh R, Wine E. Evolving role of diet in the pathogenesis and treatment of inflammatory bowel diseases. Gut 2018; 67:1726-1738. [PMID: 29777041 DOI: 10.1136/gutjnl-2017-315866] [Citation(s) in RCA: 204] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 04/16/2018] [Accepted: 04/17/2018] [Indexed: 12/12/2022]
Abstract
Recent advances in basic and clinical science over the last 3 years have dramatically altered our appreciation of the role of diet in inflammatory bowel diseases (IBD). The marked increase in incidence of these diseases along with the important role of non-genetic susceptibility among patients with IBD has highlighted that these diseases have a strong environmental component. Progress in the field of microbiome and IBD has demonstrated that microbiome appears to play an important role in pathogenesis, and that diet may in turn impact the composition and functionality of the microbiome. Uncontrolled clinical studies have demonstrated that various dietary therapies such as exclusive enteral nutrition and newly developed exclusion diets might be potent tools for induction of remission at disease onset, for patients failing biologic therapy, as a treatment for disease complications and in reducing the need for surgery. We review these advances from bench to bedside, along with the need for better clinical trials to support these interventions.
Collapse
Affiliation(s)
- Arie Levine
- Pediatric Gastroenterology and Nutrition Unit, Edith Wolfson Medical Center, Holon, Israel.,Tel Aviv University, Tel Aviv, Israel
| | - Rotem Sigall Boneh
- Pediatric Gastroenterology and Nutrition Unit, Edith Wolfson Medical Center, Holon, Israel.,Tel Aviv University, Tel Aviv, Israel
| | - Eytan Wine
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| |
Collapse
|
49
|
Xu Y, Guo Z, Cao L, Xie T, Shen W, Li Y, Gong J, Zhu W. Isolated colonic Crohn's disease is associated with a reduced response to exclusive enteral nutrition compared to ileal or ileocolonic disease. Clin Nutr 2018; 38:1629-1635. [PMID: 30193873 DOI: 10.1016/j.clnu.2018.08.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Revised: 08/12/2018] [Accepted: 08/17/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Exclusive enteral nutrition (EEN) as a primary therapy is safe and effective for inducing the clinical remission of active luminal Crohn's disease (CD). Whether isolated colonic involvement affects the efficacy of EEN is controversial. We aimed to identify the influence of isolated colonic CD on the efficacy of EEN and to determine other potential predictors of the response to induction therapy with EEN in adult patients with CD. METHODS Data for adult CD patients treated with EEN as an induction therapy at our centre from January 1, 2014, to May 31, 2017, were reviewed. Eligible patients were divided into an isolated colonic Crohn's disease (cCD) group and a non-isolated colonic Crohn's disease (non-cCD) group according to the disease location. The rates of clinical remission and inflammatory and nutritional serum markers were compared between the groups. Possible relationships between isolated colonic involvement or other potential factors and the efficacy of EEN were assessed by univariate and multivariate analyses. The propensity score matching method was used to confirm the results. RESULTS Overall, 241 patients were included in the analysis: 52 patients in the cCD group and 189 patients in the non-cCD group. The rates of clinical remission differed between the two groups (cCD group: 51.9% versus non-cCD group: 68.3%, P = 0.029). Multivariate analyses indicated that isolated colonic involvement was associated with a reduced response to EEN (OR = 2.74; [CI] 95% = [1.2-6.23], P = 0.016). Additionally, the lean body mass index (LBMI) before treatment was associated with the efficacy of EEN (OR = 0.636; [CI] 95% = [0.444-0.912], P = 0.014). These associations were confirmed using the propensity score model. For patients with isolated colonic CD, multivariate analysis showed that pancolitis (OR = 16.7; [CI] 95% = [1.074-260.5], P = 0.044) was another independent factor for the efficacy of EEN. Further analysis showed that even in patients who achieved clinical remission after EEN, inflammatory serum markers declined more slowly in the cCD group than in the non-cCD group, and the time to remission was longer in the cCD group. CONCLUSIONS Isolated colonic CD showed a reduced response to induction therapy with EEN compared with ileal or ileocolonic disease in adult patients. Patients with isolated colonic CD required more time to benefit from EEN therapy compared with patients with non-colonic CD. Additionally, LBMI before treatment was associated with the efficacy of EEN.
Collapse
Affiliation(s)
- Yihan Xu
- Research Institute of General Surgery, Jinling Hospital, Nanjing, China; Nanjing Medical University, Nanjing, China
| | - Zhen Guo
- Research Institute of General Surgery, Jinling Hospital, Nanjing, China
| | - Lei Cao
- Research Institute of General Surgery, Jinling Hospital, Nanjing, China
| | - Tingbin Xie
- Research Institute of General Surgery, Jinling Hospital, Nanjing, China
| | - Weisong Shen
- Research Institute of General Surgery, Jinling Hospital, Nanjing, China
| | - Yi Li
- Research Institute of General Surgery, Jinling Hospital, Nanjing, China
| | - Jianfeng Gong
- Research Institute of General Surgery, Jinling Hospital, Nanjing, China
| | - Weiming Zhu
- Research Institute of General Surgery, Jinling Hospital, Nanjing, China.
| |
Collapse
|
50
|
Using Quality Improvement to Increase Utilization of Enteral Therapy in Pediatric Crohn Disease: Results and Outcomes. J Pediatr Gastroenterol Nutr 2018; 66:909-914. [PMID: 29315161 DOI: 10.1097/mpg.0000000000001879] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
INTRODUCTION Exclusive enteral nutrition (EEN) for induction of remission in children with Crohn disease (CD) is recommended as first-line therapy, but underutilized in the United States related to real and perceived barriers. We hypothesized that quality improvement (QI) methodology could increase use of EEN. METHODS We developed, implemented, and revised an algorithm and a set of tools to facilitate use of EEN. Through a series of Plan Do Study Act cycles, the approach was modified to overcome provider and patient/family barriers. The primary outcome, the percentage of newly diagnosed CD patients who receive EEN per month between July 2013 and October 2015, assessed using statistical process control. Secondary outcomes, including the short pediatric Crohn disease activity index (sPCDAI), body mass index (BMI) z score, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), albumin, and hemoglobin were compared before and after EEN. RESULTS Among patients newly diagnosed with CD, 73 patients initiated EEN and were included (mean age 12.7 ± 2.9 years, 49% girls, 86% white). Rates of utilization of EEN increased significantly from a baseline of <5% to an average of approximately 50%. Of the 73 patients who started EEN, 37 (50%) completed a minimum of 8 weeks. Of those completing therapy, 25 (71%) achieved remission, with a significant reduction of sPCDAI (33.6 ± 14.4 to 10.7 ± 12.3, P < 0.0001) CONCLUSIONS:: Use of QI methodology to systematically implement tools designed to improve utilization was effective in increasing the use of EEN. Among those completing therapy, EEN was effective in inducing remission.
Collapse
|