Treatment of esophageal Crohn's disease by enteral feeding via percutaneous endoscopic gastrostomy

ESPEN guideline on Clinical Nutrition in inflammatory bowel disease

The present guideline is an update and extension of the ESPEN scientific guideline on Clinical Nutrition in Inflammatory Bowel Disease published first in 2017. The guideline has been rearranged according to the ESPEN practical guideline on Clinical Nutrition in Inflammatory Bowel Disease published in 2020. All recommendations have been checked and, if needed, revised based on new literature, before they underwent the ESPEN consensus procedure. Moreover, a new chapter on microbiota modulation as a new option in IBD treatment has been added. The number of recommendations has been increased to 71 recommendations in the guideline update. The guideline is aimed at professionals working in clinical practice, either in hospitals or in outpatient medicine, and treating patients with IBD. General aspects of care in patients with IBD, and specific aspects during active disease and in remission are addressed. All recommendations are equipped with evidence grades, consensus rates, short commentaries and links to cited literature.

Crohn's Disease of the Esophagus, Duodenum, and Stomach

Upper gastrointestinal Crohn's is an under-reported, under-recognized phenotype of Crohn's disease. Routine screening in the pediatric population has shown a higher prevalence compared with adults; however, most adult patients remain asymptomatic with respect to upper gastrointestinal Crohn's disease. For the patients who are symptomatic, medical treatment is the first line of management, except for cases of obstruction, perforation, or bleeding. Though most patients respond to medical therapy, mainly steroids, with the addition of immunomodulators and more recently biologics agents, surgical intervention is usually required only for obstructing gastroduodenal disease secondary to strictures. Strictureplasty and bypass are safe operations with comparable morbidity, although bypass has higher rates of dumping syndrome and marginal ulceration in the long term. Rare cases of gastroduodenal fistulous disease from active distal disease may involve the stomach or duodenum, and esophageal Crohn's disease can fistulize to surrounding structures in the mediastinum which may require the highly morbid esophagectomy.

Oesophageal presentation of Crohn's disease

Crohn's disease (CD) is characterised by a transmural inflammatory process, which can affect any part of the digestive tract; however, CD with oesophageal presentation is rare. We report a case of a previously healthy young woman with symptoms of dysphagia, odynophagia, chest pain and weight loss, who presented oesophageal ulcers at upper endoscopy and whose histology revealed granulomatous oesophagitis. After complementary study, a mild ileocaecal involvement of CD was demonstrated. The patient became asymptomatic with proton pump inhibitor and a course of prednisolone. Mucosal healing was obtained after maintenance therapy with azathioprine. In the absence of extraoesophageal symptoms, oesophageal CD may be overlooked. CD must always be considered as differential diagnosis in the presence of oesophageal ulcers.

Crohn's disease of the esophagus

Esophageal damage is an uncommon manifestation of Crohn's disease. The diagnosis should be considered in patients who have other intestinal manifestations of Crohn's disease and present with esophageal symptoms. Diagnosis should be based on history, known extraesophageal Crohn's disease, endoscopic evaluation with biopsy, and exclusion of gastroesophageal reflux disease. Mild disease should be treated with acid suppression and a short course of steroids. 5-aminosalicylates are not likely to be effective due to drug release characteristics. Patients who have moderate to severe disease should be treated aggressively with acid suppression, a longer course of steroids, and consideration of immunosuppressive therapy with 6-mercaptopurine or azathioprine. Infliximab or other anti-tumor necrosis factor therapy also can be considered in refractory patients to try to prevent the complications of stricturing and fistula formation. In those patients who develop strictures of the esophagus, treatment with balloon dilatation of the stricture followed by injection of a long-acting steroid such as triamcinolone will help to alleviate symptoms. Surgery may be required for severe, refractory symptoms, but it has a high morbidity in this population.

Upper gastrointestinal tract endoscopy in inflammatory bowel disease

Upper gastrointestinal endoscopy is used to evaluate upper gastrointestinal symptoms in patients with inflammatory bowel disease. This article discusses the procedure, which may allow for the diagnosis of Crohn's disease of the esophagus, stomach, and/or duodenum. Biopsies of normal gastric mucosa in patients with indeterminate colitis may be helpful in making a diagnosis of Crohn's colitis. Upper gastrointestinal endoscopy may allow for therapeutic intervention in terms of bleeding and stricturing disease.

[Presentation of Crohn's disease with esophageal involvement]

Inflammatory bowel disease basically consists of two entities: ulcerative colitis (UC) and Crohn's disease (CD). Both processes are characterized by chronic inflammation of the intestine, which in the case of CD may affect the entire digestive tract. We present the case of a young man who was diagnosed with esophageal CD after presenting dysphagia and odynophagia. Intestinal involvement was subsequently found. Esophageal involvement is infrequent and as the first manifestation of CD it is extremely rare. It should, however, be borne in mind in patients with esophageal ulcerations without symptoms or endoscopic signs compatible with peptic etiology, even though other indications of inflammatory disease are absent.

Proximal Crohn's disease: review of the clinicopathologic features and therapy

Crohn's disease in the proximal region of the digestive tract is uncommon. Better diagnostically procedures and more careful histologic examination has led to a higher detection of proximal Crohn's disease. The diagnosis is based on symptoms, endoscopy with serial sections, or double contrast radiography. The most common histologic finding for this diagnosis are granulomas in the mucosa in Helicobacter pylori-negative patients, but the granulomas are not always frequently detected. Endoscopic lesions in the proximal regions look like the lesions that could be found in the distal regions. Notching in the duodenal folds could be a strong indication for Crohn's desease. Radiological lesions are not always characteristic, but should be used in combination with endoscopy. Stenosis is an important complication, but fistula formation and pseudodiverticular formation is possible. There is no uniform medical therapy, but the regular anti-inflammatory management for Crohn's disease is most often used. Sometimes surgery is needed.

Micronutrient status and glutathione peroxidase in bedridden patients on tube feeding

Deficiency of micronutrients, especially selenium, is common in critically ill patients. We investigated the micronutrient status (selenium, zinc, copper and manganese) and glutathione peroxidase (GSH-Px) activity in 30 tube-fed patients and 21 hospitalized non-tube-fed control patients. Serum levels of selenium, copper and manganese in tube-fed patients were significantly lower than in control patients (selenium: 4.85+/-1.38 microg/dl versus 8.67+/-1.45 pg/dl; copper: 44.7+/-36.9 microg/dl versus 92.1+/-21.2 microg/dl; manganese 0.59+/-0.41 microg/dl versus 1.52+/-0.59 microg/dl). However, zinc and log GSH-Px in the serum were similar in the two groups. Serum selenium concentration correlated with the daily intake of selenium in tube-fed patients, but zinc, copper and manganese concentrations did not correlate with the daily intake of the respective trace elements in tube-fed patients. Blood GSH-Px activity correlated positively with serum selenium concentrations in the control patients, but not in tube-fed patients. These results demonstrate that selenium content of enteral feed appears to be insufficient to maintain normal serum levels in elderly bedridden patients. Our findings emphasize the importance of monitoring micronutrient status in patients on enteral feeding to avoid trace element deficiencies.