Diet and Nutrition in Inflammatory Bowel Disease: A Review of the Literature

Diet is thought to contribute to the development of inflammatory bowel disease (IBD) and may act as a mediator of inflammation in patients with IBD. Patients commonly associate their diet with symptoms and inquire about dietary modifications to manage their IBD. Without clinical guidelines and well-established nutritional data, healthcare providers managing patients with IBD may find it difficult to provide recommendations. Strong evidence for enteral nutrition, particularly in the pediatric population, has been established in Crohn's disease (CD) as a therapeutic option. Enteral nutrition may also serve as an adjunct to an exclusion diet. Recent studies such as the randomized trial comparing the Specific Carbohydrate Diet to a Mediterranean Diet in CD patients provide additional insights in forming dietary plans. A low-fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) diet in quiescent IBD and an anti-inflammatory diet have also been explored as adjunctive therapies. In this review, we discuss the latest evidence for the role of diet in IBD both as a therapeutic modality and as an opportunity to provide patient-centered care.

Sarcopenia Is More Prevalent Among Inflammatory Bowel Disease Patients Undergoing Surgery and Predicts Progression to Surgery Among Medically Treated Patients

BACKGROUND

Sarcopenia is common in inflammatory bowel disease (IBD); however, estimates of its prevalence and impact on clinical outcomes are variable. This study sought to compare the prevalence of sarcopenia in IBD patients starting new biologics vs patients undergoing IBD surgeries, and its association with common clinical predictors of nutritional status, adverse events, and clinical outcomes.

METHODS

This was a multicenter retrospective cohort study of IBD patients who had a computed tomography (CT) scan within 6 months prior to new biologic initiation (medical cohort) or IBD surgery (surgery cohort). The lowest sex-specific quartile of the total psoas area index at the L3 level defined sarcopenia. Prevalence and predictors of sarcopenia, performance of common clinical nutritional markers, and association with adverse events and clinical outcomes at 1 year were determined.

RESULTS

A total of 156 patients were included (48% medical cohort, 52% surgery cohort). Sarcopenia was more common in the surgery cohort (32% vs 16%; P < .02). In the medical cohort, sarcopenia predicted need for surgery at 1 year (odds ratio, 4.75; 95% confidence interval, 1.10-20.57; P = .04). Low albumin and body mass index (BMI) were associated with the presence of sarcopenia; however, 24% of sarcopenic patients had both normal BMI and albumin.

CONCLUSIONS

Sarcopenia is more prevalent among IBD patients undergoing surgery and predicts the need for surgery in patients starting new biologic therapy. Low albumin and BMI were similar between cohorts, suggesting a unique role for sarcopenia as a relevant clinical marker of lean muscle mass depletion for surgically and medically treated IBD patients.

The Safety of the Re-Opening of an Academic Medical Center Outpatient Endoscopy Unit During the COVID-19 Pandemic

Background

The coronavirus disease 2019 (COVID-19) pandemic has spread globally leading to over 3,700,000 deaths. As COVID-19 cases stabilized, the re-opening of endoscopy centers potentially exposed patients and healthcare workers to viral infection. This study aims to determine risk of COVID-19 exposure among patients undergoing outpatient endoscopies in a tertiary care setting during the COVID-19 pandemic.

Methods

Patients undergoing outpatient endoscopy were contacted post-procedure for any new COVID-19 symptoms or COVID-19 test results. Patient experiences and perception of personal safety were also determined.

Results

Of the 1,584 patients who completed elective endoscopy, 996 (62.9%) completed the survey. Two patients were diagnosed with COVID-19 within 14 days of procedure. The majority (99.7%) felt safe during their procedure and apprehension regarding endoscopy decreased over time.

Conclusion

Thus, the risk of COVID-19 transmission during outpatient endoscopy is extremely low when following recommended society guidelines. Patients felt safe during the procedure and experienced less fear of exposure over time.

Acute Esophageal Necrosis Secondary to a Paraesophageal Hernia

Acute esophageal necrosis (AEN) or “black esophagus” is a rare clinical entity caused by necrosis of distal esophageal mucosa stemming from esophageal ischemia. Possible etiologies are broad but most commonly include possible triggers of low-flow vascular states in the esophagus, including infections, broad-spectrum antibiotic use, and gastric volvulus, among others. Patients most commonly present clinically with acute onset hematemesis and melena. Here, we describe a patient who initially presented with multiple nonspecific gastrointestinal symptoms, including abdominal pain and nausea, that progressed over a 10-day period, culminating in multiple episodes of hematemesis prior to presentation. Endoscopic evaluation confirmed the diagnosis of AEN and unveiled a possible paraesophageal hernia (PEH) as the causative factor. A subsequent videofluoroscopic barium swallow was utilized to better characterize the upper gastrointestinal anatomy and confirmed the PEH as a likely etiology. Esophagogastroduodenoscopy (EGD) can often identify PEH independently, but in patients with AEN secondary to a possible, but unclear, PEH on EGD, a videofluoroscopic barium swallow is an appropriate and useful next step in confirming the diagnosis. While treatment of AEN traditionally involves fluid resuscitation, intravenous protein pump inhibitors, and total parenteral nutrition, surgical intervention is often indicated in patients who have a contributing and symptomatic PEH.

Presence of Obstructive Symptoms and Absence of Perianal Crohn Disease Is Predictive of Surgery After Endoscopic Balloon Dilation

BACKGROUND

Patients with Crohn disease (CD) often develop strictures that require surgery. Endoscopic balloon dilation (EBD) is an alternative treatment that can be safe and effective. The objective of this study was to assess factors associated with the need for repeat EBD and surgery after initial EBD for stricturing CD.

METHODS

Patients with stricturing CD who underwent EBD from 2007 to 2017 were identified. Demographic and clinical information was obtained from the electronic medical record. A Cox proportional hazards regression model and Kaplan-Meier curves were generated for variables associated with repeat EBD and surgical resection.

RESULTS

Ninety-nine patients underwent a total of 240 EBD proedures; 35% had a history of perianal disease, and 63% were on a biologic at the time of initial EBD. Fifty-one percent of patients had obstructive symptoms at the time of initial EBD, and 75% of the EBDs were successful. Complications occurred in 8 EBDs (3.3%). Repeat intervention after EBD was more likely in patients on biologics at baseline EBD (76% vs 54%; P = 0.029). Thirty-three percent of patients had surgical resection at a median of 5 months (interquartile ratio = 2.0-13.0 months) after initial EBD. The presence of obstructive symptoms at the time of EBD was associated with surgical resection (hazard ratio = 3.18; 95% confidence interval, 1.28-7.86). Conversely, a history of perianal disease was negatively associated with surgical resection (hazard ratio = 0.27; 95% confidence interval, 0.10-0.68).

CONCLUSIONS

Patients on biologic treatment at the time of EBD are more likely to need an intervention in the future. Patients with obstructive symptoms at the time of initial EBD and those without a history of perianal involvement are more likely to undergo surgical intervention.

Miliary pattern on chest imaging as a presentation of EGFR-negative primary lung adenocarcinoma

A 64-year-old African American man, with a history of prostate adenocarcinoma treated in 2009 and a greater than 50-pack-year tobacco smoking history, presented with 2-3 weeks of non-productive cough, frontal headache and generalised myalgias and arthralgias. CT was positive for diffuse, miliary opacities in bilateral lung fields. He was diagnosed with stage four lung adenocarcinoma, negative for epidermal growth factor receptor (EGFR) gene mutation. The patient was unable to tolerate therapy and passed away approximately 4 months after his diagnosis. Previous case reports and research have suggested an association between EGFR gene mutation and miliary patterned lung metastases in non-small cell lung cancer. This case suggests that the mechanism by which miliary patterned metastases occur is more complex than purely mutation of the EGFR gene. Further study may elucidate novel molecular targets for treatment, especially in patients with rapidly progressive disease such as the patient we describe.