Polymeric versus elemental diet as primary treatment in active Crohn's disease: a randomized, double-blind trial

An update of the role of nutritional therapy in the management of Crohn's disease

Crohn's disease is an increasingly global health concern. Currently without a cure, it significantly alters the quality of life of Crohn's disease sufferers and places a heavy financial burden on the community. Recent reports show that the rising prevalence of Crohn's disease is no longer confined to Western countries, with considerable increases seen particularly in Asia. Nutritional problems are often associated with Crohn's disease, most notably in the paediatric population, with underweight and stunting commonly seen at presentation. In addition, linear growth retardation and pubertal delay can also manifest in these younger patients. Therefore, exclusive enteral nutrition has been used as a therapeutic option to treat Crohn's disease, in part to address the nutritional complications of the disease. Exclusive enteral nutrition can improve nutrition as well as induce remission at a rate equivalent to corticosteroids. It is safe particularly with long-term use and can induce mucosal healing, considered the gold standard for therapy, at a rate superior to corticosteroids. Exclusive enteral nutrition has thus become the preferred therapeutic option in many centres for the treatment of paediatric Crohn's disease. This review discusses the role of exclusive enteral nutrition as a therapeutic option for the treatment of Crohn's disease, as well as the latest findings into its mechanisms of action.

Nutritional management of adults with inflammatory bowel disease: practical lessons from the available evidence

Inflammatory bowel disease (IBD) is associated with impairment of nutritional status both anthropometrically and biochemically, which results from both qualitative and quantitative changes in dietary intake alongside disease activity. Dietary intervention to replace deficiency is essential and may also be used to treat active disease and to reduce symptoms. The evidence for dietary interventions in this area is reviewed and the following recommendations made: ■Assessment of nutritional status is an essential part of the investigation of all patients with IBD and deficiency should be actively sought.■Any patient with macro- or micronutrient deficiency should be referred for dietetic assessment.■Micronutrient deficiency (most frequently iron, vitamin B12, folate and magnesium) should be replaced aggressively, parenterally if necessary.■Significant improvement in gastrointestinal symptoms can be achieved by low-residue diets (for stricturing disease) and (always under dietetic supervision) management of lactose and other intolerances.■Irritable bowel syndrome symptoms in patients with IBD can respond to low fermentable oligo-, di-, monosaccharide and polyol (FODMAP) diets, again this must be done under dietetic supervision.■Active Crohn's disease can be treated by exclusive enteral nutrition (elemental/polymeric/altered fat formulations all have equivalent efficacy).■Enteral nutrition can maintain remission in Crohn's disease and in this context can be given alongside normal oral intake.■Nutritional support does not have an established role in the treatment of active ulcerative colitis, other than in the management of malnutrition.■Total parenteral nutrition should not be used unless intestinal failure occurs.■There is insufficient evidence to support the routine use of Ω3 fish oil, prebiotics and glutamine in the treatment of active IBD.

Clinical trial: Efficacy of a low or modified fat diet for the prevention of gastrointestinal toxicity in patients receiving radiotherapy treatment for pelvic malignancies

BACKGROUND

Inflammatory responses to pelvic radiotherapy can result in severe changes to normal gastrointestinal function with potentially severe long-term effects. Reduced or modified fat diets may confer benefit.

METHODS

This randomised controlled trial recruited patients with gynaecological, urological or lower gastrointestinal malignancy due to receive radical radiotherapy. Patients were randomised to a low fat (20% total energy from long chain triglycerides), modified fat (20% from long chain triglycerides and 20% from medium chain triglycerides) or normal fat diet (40% total energy from long chain triglycerides). The primary outcome was a difference in change in Inflammatory Bowel Disease Questionnaire--Bowel (IBDQ-B) score, from the start to end of radiotherapy.

RESULTS

A total of 117 patients with pelvic tumours (48% urological; 32% gastrointestinal; 20% gynaecological), with mean (SD) age: 65 (11.0) years, male:female ratio: 79:38, were randomised. The mean (SE) fall in paired IBDQ-B score was -7.3 (0.9) points, indicating a worsening toxicity. Differences between groups were not significant: P = 0.914 (low versus modified fat), P = 0.793 (low versus normal fat) and P = 0.890 (modified versus normal fat). The difference in fat intake between low and normal fat groups was 29.5 g [1109 kJ (265 kcal)] amounting to 11% (of total energy intake) compared to the planned 20% differential. Full compliance with fat prescription was only 9% in the normal fat group compared to 93% in the low fat group.

CONCLUSIONS

A low or modified fat diet during pelvic radiotherapy did not improve gastrointestinal symptom scores compared to a normal fat intake. An inadequate differential in fat intake between the groups may have confounded the results.

International survey of enteral nutrition protocols used in children with Crohn's disease

OBJECTIVE

  Differing protocols have been utilized in published studies evaluating exclusive enteral nutrition (EEN) in the management of active pediatric Crohn's disease. This study aimed to ascertain the protocols currently utilized in different pediatric centers around the world and to highlight their similarities and differences.

METHODS

  A questionnaire was circulated to individuals at pediatric centers in countries in Europe, North America and Asia-Pacific. Respondents were asked to indicate the number of children treated with EEN at their centers in the previous years and to provide details of their protocol used for administering EEN to these children.

RESULTS

  Responses were received from 35 separate centers (42% of those asked). The duration of EEN varied from <6 weeks to >12 weeks, but was most commonly 6 to 8 weeks. Although 23 different formulas were utilized across the centers, most (90%) used polymeric formulas. Flavourings were commonly added to formulas but wide variations existed between centers with the prescription of food and fluids permitted during the EEN period. The reintroduction of food after EEN also varied greatly: the most common recommendations were for an initial low-fiber diet (26%) or the gradual introduction of food quantity as the formula volume decreased (52%).

CONCLUSIONS

  This questionnaire-based study has shown the wide variations in EEN protocols used in different areas of the world. The development of consistent protocols may enhance the acceptance, efficacy and wider utilization of this therapy.

Use of enteral nutrition for the control of intestinal inflammation in pediatric Crohn disease

Exclusive enteral nutrition is an effective yet often underused therapy for the induction of remission in pediatric Crohn disease. The North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition formed the Enteral Nutrition Working Group to review the use of enteral nutrition therapy in pediatric Crohn disease. The group was composed of 5 pediatric gastroenterologists and 1 pediatric nutritionist, all with an interest and/or expertise in exclusive enteral nutrition. Specific attention was placed upon review of the evidence for efficacy of therapy, assessment of the variations in care, identification of barriers to its widespread use, and compilation of the necessary components for a successful program. The present guideline is intended to aid physicians in developing an enteral nutrition therapy program and potentially promote its use.

Enteral feeding therapy for newly diagnosed pediatric Crohn's disease: a double-blind randomized controlled trial with two years follow-up

BACKGROUND

This study compared the efficacy of an elemental formula (EF) to a polymeric formula (PF) in inducing remission for pediatric Crohn's disease (CD).

METHODS

Newly diagnosed CD children were randomized to EF or PF for 6 weeks. Change in the Pediatric Crohn's Disease Activity Index (PCDAI), fecal calprotectin, and plasma fatty acids were measured at 0 and 6 weeks. Patients were followed up for 2 years. Time and treatment choice for first relapse were documented.

RESULTS

Thirty-four children completed the study; EF: 15 (7 M, 8 F), PF: 19 (13 M, 6 F). The mean age was (years) EF: 12.6, PF: 11.7. Ninety-three percent of children (14/15) achieved remission in the EF group and 79% (15/19) in the PF group. One-third of patients maintained remission for 2 years. Mean time to relapse (days); EF: 183 (63-286), PF: 162 (53-301). Most children who relapsed used feed as a treatment for that relapse (EF: 9/10 and PF: 8/13). With PF, an increase of eicosapentanoic acid (EPA) and alpha linolenic acid was found with a reciprocal decrease in arachidonic acid (AA). With EF, AA and EPA levels were reduced with a significant decrease in docosahexaenoic acid. Fecal calprotectin measurements decreased significantly but did not normalize at the end of week 6.

CONCLUSIONS

There was no significant difference between EF and PF in inducing remission. One-third of children maintained remission. Changes in plasma polyunsaturated fatty acid status were subtle and may be relevant; however, further evaluation is recommended.

Relationships among the lactulose breath test, intestinal gas volume, and gastrointestinal symptoms in patients with irritable bowel syndrome

BACKGROUND AND AIMS

Irritable bowel syndrome (IBS) patients frequently complain of gas-related symptoms, and the lactulose breath test (LBT) is a test that assesses the amount of fermented gas generated by bacteria in the bowel. We aimed to assess the relationship among intestinal gas volume, LBT result, and gastrointestinal symptom score in healthy control and functional bowel disorder (FBD) subjects.

METHOD

In 84 IBS subjects, 24 FBD subjects other than IBS, and 25 healthy controls, a symptom questionnaire that enquired about seven main symptoms, plain abdominal radiography and a LBT were checked on the same day. The intestinal gas volume was calculated as the gas volume score (GVS) with a digitalized image of plain supine abdominal radiographs.

RESULTS

The GVS was greater in the LBT (+) group compared to the LBT (-) group (P = 0.02). The GVS was greater in the FBD and IBS groups than in the control group (P < 0.01). The GVS showed low but positive correlations with the severity and frequency of bloating, flatulence, abdominal pain, constipation, and tenesmus (P < 0.05). The severity of flatulence (P = 0.02) and the frequency of bloating (P = 0.02) in the LBT (+) group were significantly higher than those in the LBT (-) group.

CONCLUSIONS

Subjects with positive LBT had more gas-related symptoms and greater gas volume scores. Gas-related symptoms, positive LBT and increased GVS were significantly associated to each other. These findings can broaden the understanding of the pathophysiologic mechanisms of gas-related symptoms in IBS.

Existing dietary guidelines for Crohn's disease and ulcerative colitis

Patients with inflammatory bowel disease (IBD) often question their doctors about diet. The objectives of this article are to provide clinicians with existing dietary advice by presenting the dietary information proposed by medical societies in the form of clinical practice guidelines as it relates to IBD; listing dietary guidelines from patient-centered IBD-related organizations; and creating a new 'global practice guideline' that attempts to consolidate the existing information regarding diet and IBD. The dietary suggestions derived from sources found in this article include nutritional deficiency screening, avoiding foods that worsen symptoms, eating smaller meals at more frequent intervals, drinking adequate fluids, avoiding caffeine and alcohol, taking vitamin/mineral supplementation, eliminating dairy if lactose intolerant, limiting excess fat, reducing carbohydrates and reducing high-fiber foods during flares. Mixed advice exists regarding probiotics. Enteral nutrition is recommended for Crohn's disease patients in Japan, which differs from practices in the USA.

Cost effectiveness of treatments for inflammatory bowel disease

Traditionally, half of the direct costs associated with chronic inflammatory bowel diseases (IBD) [Crohn's disease (CD) and ulcerative colitis (UC)] have related to hospital inpatient treatment for a sub-group of more severely affected, often therapy-resistant individuals. The advent of effective but relatively expensive biological agents has increased the contribution of drugs to overall medical care costs. This has focussed interest on the relative cost effectiveness of rival therapies for IBD and, in particular, on the affordability of long-term biological therapy. The purpose of this article is to review the available literature on this topic and to identify areas for future research. Head-to-head trials of competing treatment options are uncommon and clinical trials have seldom addressed cost effectiveness. In UC, models have explored the cost utility of 'high-' versus 'standard-' dose 5-aminosalicylic acid (5-ASA) therapy and the theoretical impact of improved adherence with once-daily formulations. In CD, cost-utility models for anti-tumour necrosis factor (TNF) drugs versus standard care have suggested consistently that incremental benefits are achieved at increased overall cost. However, studies of varying design have produced a wide spectrum of incremental cost-effectiveness ratio estimates, which highlights the challenges and limitations of existing modelling techniques.

Does evidence exist to include dietary therapy in the treatment of Crohn's disease?

Prescription drugs and surgery are two common medical therapies for Crohn's disease (CD), an inflammatory bowel disease that affects the GI tract. Unfortunately, certain drugs can cause serious side effects, and surgeries must often be repeated. No diet has been established to alleviate the pain and suffering of CD patients. This is curious given the fact that a higher prevalence of food sensitivities exist in this population of patients, and enteral nutrition is not only the first-line of therapy in Japan, but a known research method used to place the majority of CD patients into remission. Although not all patients respond equally to diet, many simply remove symptom-provoking foods, such as dairy, wheat, corn and certain fruits and vegetables. We suggest assisting these patients in their self-assessment of irritating and symptom-provoking foods by educating them in the use of a food-symptom diary followed by a customized elimination diet trialed for 2-4 weeks to determine if there is any benefit to the individual patient.

Review article: diet and inflammatory bowel disease--epidemiology and treatment

BACKGROUND

Diet is thought to have an important role in the immunopathogenesis and treatment of inflammatory bowel disease (IBD).

AIM

To identify dietary constituents as risk factors for development of IBD and the therapeutic efficacy of dietary modifications or enteral nutrition in IBD.

METHODS

The Medline and the Cochrane Library were searched for clinical trials and meta-analyses in the scope of diet and nutrition in IBD.

RESULTS

There are many studies in small cohorts of patients that claim that intake of certain diet constituents like fat, refined sugar, fruits, vegetables and fibre affect the expression of IBD. These are often compromised by insufficient data or methodological limitations and do not provide unequivocal evidence to incriminate any particular dietary factor. Among various dietary interventions, none has shown striking efficacy with the possible exception of complete enteral nutrition. Enteral nutrition appears effective in both active and quiescent Crohn's disease (CD), but independent meta-analyses have shown enteral nutrition to be inferior to corticosteroids in the management of active CD, when assessed on an intention-to-treat basis.

CONCLUSIONS

The current levels of knowledge concerning dietary risk factors for IBD, and the therapeutic efficacy of dietary and nutritional interventions need to be supported by well-designed trials in large cohorts of patients.

Symposium on 'The challenge of translating nutrition research into public health nutrition'. Session 3: Joint Nutrition Society and Irish Nutrition and Dietetic Institute Symposium on 'Nutrition and autoimmune disease'. Nutrition in Crohn's disease

The exact aetiology of Crohn's disease remains unknown. The consensus is that the disease results from a complex interaction between genes, immunity and environmental factors. Diet is attractive, in theory, as an environmental risk factor in the aetiology of the disease. The epidemiological data, often impeded by methodological issues, have failed to confirm a direct link between pre-diet illness and the development of Crohn's disease. Once diagnosed, however, nutrition has an important role in disease management. Among the nutritional issues are malnutrition, weight loss and suboptimal nutritional status; these outcomes may be present at any stage of the disease but are likely to be overt during acute illness and hospitalisation. Malnutrition has been identified in approximately 40% of hospital admissions with Crohn's disease and is associated with higher mortality, longer hospital stays and higher healthcare costs. Patients in remission may indeed be overweight and appear to be influenced by the general population trends toward overweight and obesity. Irrespective of BMI, patients are at risk of micronutrient deficiencies. Vitamin D deficiency, for example, is common in Crohn's disease and has important implications for bone health. Moreover, newer evidence suggests that vitamin D has potential anti-inflammatory effects. Dietary approaches, in the form of enteral nutrition, have previously been shown to reduce inflammation and treat the active disease. Current guidelines now recommend that corticosteroids are more effective than enteral nutrition for treating adults. Enteral nutrition has important growth and developmental benefits and continues to be a recommended therapy for children with Crohn's disease.

Nutrition and Crohn's disease: an update of print and Web-based guidance

This article reviews the role of nutrition in Crohn's disease, one of the inflammatory bowel diseases. In addition to presenting a comprehensive review of the state-of-the-evidence on nutritional risks and nutritional therapies in Crohn's disease, and making specific nutrient recommendations, this article includes a list of Web-based resources, including websites, blogs, newsletters, and multimedia podcasts that can be utilized by patients and healthcare providers alike to learn more about the etiology, pathophysiology, and nutritional management of Crohn's disease.

Clinical trial: normal diet vs. partial replacement with oral E028 formula for the prevention of gastrointestinal toxicity in cancer patients undergoing pelvic radiotherapy

BACKGROUND

Acute gastrointestinal symptoms affect 90% of patients during pelvic radiotherapy. Elemental diet is protective in animal models. A nonrandomized study suggested benefit from a partial elemental diet. A pilot study suggested that radiotherapy patients only tolerate oral elemental diet comprising one-third of total calories for 3 weeks.

AIM

To assess the feasibility and efficacy of replacing one-third of normal diet with elemental diet during the first 3 weeks of pelvic radiotherapy in reducing acute gastrointestinal toxicity.

METHODS

Patients were randomized to elemental diet or no intervention. Toxicity was assessed using the Inflammatory Bowel Disease Questionnaire, Vaizey Incontinence scale and Radiation Therapy Oncology Group tool. Faecal calprotectin measured intestinal mucosal inflammation.

RESULTS

Twenty-nine women and 21 men, median age 61.5 years were randomized. Patients taking elemental diet did not have lower gastrointestinal toxicity ratings or inflammatory markers (P > 0.2). The mean dose taken was 21% (2-36%) of total caloric requirements.

CONCLUSIONS

Patients cannot tolerate large volumes of oral elemental diet. The quantities consumed in this study produced no therapeutic benefit. Future studies should aim to replace a higher proportion of nutritional intake for a longer duration of radiotherapy treatment.

Systematic review: nutritional therapy in paediatric Crohn's disease

BACKGROUND

At least 25% of individuals diagnosed with Crohn's disease (CD) have onset of disease in childhood. Almost all children with CD have nutritional impairments, such as weight loss or stunting, at diagnosis or subsequently. Nutritional therapy (exclusive enteral nutrition) is established as a valid and effective treatment in paediatric CD. The advantages of this approach are induction of remission and control of inflammatory changes, mucosal healing, positive benefits to growth and overall nutritional status, and avoidance of other medical therapies.

AIM

To provide a comprehensive up-to-date review of the roles of nutritional therapy in CD and of the data supporting this therapy.

METHODS

A search of PubMed was performed with search terms 'enteral nutrition', 'nutritional therapy', 'Crohn disease' and 'children'. Relevant articles were selected from this search. In addition, the reference lists of available articles were reviewed for further relevant articles.

RESULTS

Nutritional therapy offers numerous benefits in the management of CD. Recent work has begun to elucidate the likely mechanisms of this therapy. These include direct mucosal anti-inflammatory effects and alteration of intestinal microflora.

CONCLUSION

Further studies are required to define longer-term effects of nutritional therapy in patients with CD.

Does polymeric formula improve adherence to liquid diet therapy in children with active Crohn's disease?

BACKGROUND

Active Crohn's disease can be treated using liquid diet therapy (LDT), but non-adherence may limit success, necessitating corticosteroid therapy. Whole-protein polymeric formula (PF) seems to be much more palatable than amino acid-based elemental formula (EF) and thus may significantly improve adherence to LDT.

AIM

To compare adherence to LDT using PF versus EF.

METHODS

Success in completing a 6-week course of LDT, need for nasogastric tube administration of formula and use of LDT for relapses were compared between children presenting with active disease and treated with EF (n = 53) and children given PF (n = 45).

RESULTS

Remission rates were similar (EF 64%, 95% CI 51 to 77 vs PF 51%, 95% CI 37 to 66; p>0.15). 72% (95% CI 60 to 84) given EF completed the initial course of LDT compared with 58% (95% CI 44 to 72) given PF (p = 0.15). Of those failing to complete the initial course, 13% on EF and 16% on PF gave up by choice (non-adherence), the remainder stopping due to treatment failure. Nasogastric administration was more frequent with EF (55%, 95% CI 42 to 68) compared to PF (31%, 95% CI 17 to 45) (p = 0.02). Among those treated successfully at first presentation, LDT was used for 28% of relapses in the EF group (95% CI 12 to 44) and 39% in the PF group (95% CI 19 to 59) (p>0.2) over the next year.

CONCLUSION

PF did not effect adherence to LDT but was associated with significantly reduced need for nasogastric tube administration of formula.

Polymeric formula has direct anti-inflammatory effects on enterocytes in an in vitro model of intestinal inflammation

Exclusive enteral nutrition using polymeric formula (PF) is a well-established therapeutic option for active Crohn's disease; however, its mechanisms of action are unknown. We investigated the anti-inflammatory effects of PF in an in vitro model of epithelial cell inflammation. PF did not affect cell viability over a range of dilutions, but when PF was added to the culture medium the interleukin (IL)-8 response to proinflammatory stimuli was significantly reduced. This effect was due to PF acting directly on the cells as the IL-8 response was still reduced when PF was separated from the proinflammatory stimuli in a 2-compartment system. In the presence of PF, nuclear factor (NF)-kappaB nuclear migration was not inhibited; however, IkappaBalpha degradation was delayed. PF has direct anti-inflammatory effects upon immortalized colonic enterocytes. Therefore PF may, in part, modulate gut inflammation by directly reducing the inflammatory response of the intestinal epithelium.

Current Medical Therapy for Chronic Inflammatory Bowel Diseases

Chronic idiopathic inflammatory bowel diseases (IBD) include Crohn's disease (CD), ulcerative colitis (UC), and colonic IBD type unclassified (IBDU). This article focuses upon current medical therapies for adult CD and UC, and is organized according to therapy for the corresponding disease type, stage, and severity.

Enteral nutritional therapy for induction of remission in Crohn's disease

BACKGROUND

The role of enteral nutrition in Crohn's disease is controversial. Increasing research on the mechanisms by which nutritional therapy improves the clinical well being of patients with Crohn's disease has led to novel formula design and trials comparing two different forms of enteral nutrition. This meta-analysis aims to provide an update on the existing effectiveness data for both corticosteroids versus enteral nutrition and for one form of enteral nutrition versus another for inducing remission of active Crohn's disease.

OBJECTIVES

To evaluate the effectiveness of exclusive enteral nutrition (EN) as primary therapy to induce remission in Crohn's disease and to examine the importance of formula composition on effectiveness.

SEARCH STRATEGY

Studies were selected using a computer-assisted search of the on-line bibliographic databases MEDLINE (1966-2006) and EMBASE (1984-2006), as well as the Science Citation Index on Web of Science. Additional citations were sought by manual search of references of articles retrieved from the computerized search, abstracts submitted to major gastroenterologic meetings and published in the journals: American Journal of Gastroenterology, Gut, Gastroenterology, Journal of Pediatric Gastroenterology and Nutrition, and Journal of Parenteral and Enteral Nutrition, and from the reviewers' personal files or contact with leaders in the field.

SELECTION CRITERIA

All randomized and quasi-randomized controlled trials involving patients with active Crohn's disease defined by a clinical disease activity index were considered for review. Studies evaluating the administration of one type of enteral nutrition to one group of patients and another type of enteral nutrition or conventional corticosteroids to the other group were selected for review.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by two authors and any discrepancies were resolved by rereading and discussion. For the dichotomous variable, achievement of remission, individual and pooled trial statistics were calculated as odds ratios (OR) with 95% confidence intervals (CI); both fixed and random effect models were used. The results for each analysis were tested for heterogeneity using the chi square statistic. The studies were separated into two groups: A. one form of enteral nutrition compared with another form of enteral nutrition and B. one form of enteral nutrition compared with corticosteroids. Subgroup analyses were conducted on the basis of clinical or disease criteria and formula composition. Sensitivity analyses were conducted on the basis of the inclusion of abstract publications, methodologic quality and by random or fixed effects models.

MAIN RESULTS

In part A, of the 15 included eligible trials (one abstract) comparing different formulations of EN for the treatment of active CD, 11 compared one (or more) elemental formula to a non-elemental one, three compared enteral diets of similar protein composition but different fat composition, and one compared non-elemental diets differing only in glutamine enrichment. Meta-analysis of ten trials comprising 334 patients demonstrated no difference in the efficacy of elemental versus non-elemental formulas (OR 1.10; 95% CI 0.69 to 1.75). Subgroup analyses performed to evaluate the different types of elemental and non-elemental diets (elemental, semi-elemental and polymeric) showed no statistically significant differences. Further analysis of seven trials including 209 patients treated with EN formulas of differing fat content (low fat: < 20 g/1000 kCal versus high fat: > 20 g/1000 kCal) demonstrated no statistically significant difference in efficacy (OR 1.13; 95% CI 0.63 to 2.01). Similarly, the effect of very low fat content (< 3 g/1000 kCal) or type of fat (long chain triglycerides) were investigated, but did not demonstrate a difference in efficacy in the treatment of active CD, although a non significant trend was demonstrated favoring very low fat and very low long chain triglyceride content. This result should be interpreted with caution due to statistically significant heterogeneity and small sample size. Sensitivity analyses had no significant effects on the results. The role of specific fatty acids or disease characteristics on response to therapy could not be evaluated. In part B, eight trials (including two abstracts) comparing enteral nutrition to steroid therapy met the inclusion criteria for review. Meta-analysis of six trials that included 192 patients treated with enteral nutrition and 160 treated with steroids yielded a pooled OR of 0.33 favouring steroid therapy (95% CI 0.21 to 0.53). A sensitivity analysis including the abstracts resulted in an increase in the number of participants to 212 in the enteral nutrition group and 179 in the steroid group but the meta-analysis yielded a similar result (OR 0.36; 95% CI 0.23 to 0.56). There were inadequate data from full publications to perform further subgroup analyses by age, disease duration and disease location.

AUTHORS' CONCLUSIONS

Corticosteroid therapy is more effective than enteral nutrition for inducing remission of active Crohn's disease as was found in previous systematic reviews. Protein composition does not influence the effectiveness of EN in the treatment of active CD. A non significant trend favouring very low fat and/or very low long chain triglyceride content exists but larger trials are required to explore the significance of this finding.

Factors affecting recurrence in patients with Crohn's disease under nutritional therapy

PURPOSE

This retrospective study was designed to determine risk factors for recurrence of Crohn's disease under enteral nutrition.

METHODS

The clinical course of 145 patients with Crohn's disease, who were primarily induced into remission by total parenteral nutrition, was reviewed. The patients were classified into two groups: enteral nutrition group (n = 98; >/=1,200 kcal/day of enteral nutrition), or nonenteral nutrition group (n = 47;<1,200 kcal/day of enteral nutrition) according to the amount of their daily elemental or polymeric diet. Contributions of enteral nutrition and other clinical variables to the recurrence were analyzed retrospectively. A Crohn's disease activity index of >150 plus an increase in Crohn's disease activity index of >70 from the baseline value was defined as recurrence.

RESULTS

Forty-two patients in the enteral nutrition group and 29 patients in the nonenteral nutrition group recurred during periods ranging from 3 to 159 months. The cumulative rate of recurrence was significantly higher in the nonenteral nutrition group than in the enteral nutrition group (P = 0.047). Among the Crohn's disease patients in the enteral nutrition group, penetrating type (relative risk, 3.89; 95 percent confidence interval, 1.58-9.62), colonic involvement (relative risk, 3.10; 95 percent confidence interval, 1.39-6.9), and previous history of surgery (relative risk, 2.48; 95 percent confidence interval, 1.16-5.33) were factors that significantly affected recurrence. In contrast, penetrating type was the only possible factor associated with recurrence in the nonenteral nutrition group (relative risk, 2.75; 95 percent confidence interval, 0.96-7.81).

CONCLUSIONS

Among patients with Crohn's disease under maintenance enteral nutrition, the risk of recurrence differs according to the disease type and the site of involvement. The maintenance treatment by enteral nutrition alone seems insufficient for patients with penetrating type or with colonic involvement.

Exclusive enteral feeding as primary therapy for Crohn's disease in Australian children and adolescents: a feasible and effective approach

BACKGROUND

Exclusive enteral feeding has been shown to be as efficacious as corticosteroids in inducing remission in children with Crohn's disease (CD), with additional nutritional benefits. The use of polymeric formulae provides superior palatability and acceptance over elemental feeds, but polymeric formulae have not been universally adopted. The present retrospective analysis of enteral feeding in children with Crohn's disease aims to demonstrate the short-term benefits of enteral feeding in children upon disease activity and nutrition parameters.

METHODS

The case records of children with CD managed with exclusive enteral nutrition (EEN) by a multidisciplinary team over a 2-year period were reviewed. Data relating to therapy, background disease details, and outcome were collated. Primary outcome measures established were weight change and disease activity (Pediatric Crohn's Disease Activity Index: PCDAI).

RESULTS

Twenty-seven children received EEN with polymeric formulae. Fifteen children had newly diagnosed CD and 12 had known long-standing CD. Twenty-four children completed the prescribed period of EEN. Twelve of 15 (80%) newly diagnosed CD and seven of 12 (58%) with long-standing disease entered remission. Children with newly diagnosed CD responding to EEN took all feeds orally and gained an average of 4.7+/-3.5 kg with mean PCDAI decreasing from 37.1+/-10.8 to 6.7+/-5.1 after 8 weeks. In addition, four children continued supplementary polymeric formula (without other medical therapies) and all have maintained remission during an average follow-up period of 15.2 months.

CONCLUSION

Exclusive enteral feeds induced remission in 80% of children with newly diagnosed CD (on intention-to-treat basis) when used as sole initial therapy while also improving nutritional status. All newly diagnosed children treated with EEN, who were able to establish feeds, achieved remission. In addition, remission may be prolonged with oral supplementary formula as sole ongoing treatment. Further study of the role(s) of enteral feeds and of longer-term benefits of enteral feeding in children with CD is now required.

Effect of concurrent elemental diet on infliximab treatment for Crohn's disease

BACKGROUND

Infliximab and elemental diet (ED) have been shown to be effective in the management of Crohn's disease. However, few experiences have been reported regarding their combination therapy. The aim of the present study was to investigate the efficacy and safety of infliximab in Japanese patients, the first such study in Asia, as well as the effect of concomitant ED.

METHODS

One hundred and ten consecutive patients receiving infliximab were followed up to week 16 after the last infusion, and clinical response and primary outcome were collected. A response was defined as a reduction in Harvey-Bradshaw Index for inflammatory disease and closure of fistula in fistulizing disease.

RESULTS

Out of 75 inflammatory and 35 fistulizing disease patients, 68 (90.7%) and 25 (71.4%) responded at week 4, and 38 (50.7%) and 14 (40.0%) continued to respond until week 16, respectively. Interestingly, inflammatory disease patients with concurrent ED had a significantly higher response rate at week 16 (68.4%) than those without ED (32.4%, P = 0.0026). The effects of ED were independent of the usage of azathioprine and smoking habit.

CONCLUSIONS

Infliximab was clinically useful in the treatment of Crohn's disease in Japanese patients as well as in those in Western countries. The efficacy of concurrent ED was suggestive and should be confirmed in a randomized controlled study.

Short- and long-term therapeutic efficacy of nutritional therapy and corticosteroids in paediatric Crohn's disease

BACKGROUND

Comparative data on the therapeutic efficacy of different enteral nutrition formulas and corticosteroids to obtain clinical remission and to induce mucosal healing influencing long-term disease course in paediatric Crohn's disease are still scarce.

AIMS

To investigate the efficacy of nutritional therapy using three different formulas versus corticosteroids to achieve clinical remission as well as to induce intestinal mucosal healing in active Crohn's disease children. Duration of remission and effect on growth recovery were also assessed.

PATIENTS AND METHODS

Clinical, laboratory, endoscopic and histological data of all new diagnosed active Crohn's disease paediatric cases were retrospectively recorded and reviewed. Thirty-seven children (median age 12.1 years) received nutritional therapy (12 polymeric; 13 semi-elemental; 12 elemental diet) and 10 subjects (median age 12.4 years) received corticosteroids.

RESULTS

Similar clinical remission rate were observed after 8 weeks of treatment: 86.5% children receiving nutritional therapy versus 90% treated with corticosteroids. Improvement in mucosal inflammation occurred in 26 out of 37 (64.8%) patients on nutritional therapy and in 4 out of 10 (40%) children on steroids (p < 0.05). Finally, seven subjects on nutritional therapy and none on corticosteroids achieved complete mucosal healing (p < 0.005) at the end of the treatment. Nutritional therapy was more effective than corticosteroids in improving nutritional status and linear growth recovery. Compared to corticosteroids, the duration of clinical remission was longer in the nutritional therapy groups without differences among the three different formulas.

CONCLUSIONS

In children with active Crohn's disease, nutritional therapy is more effective than corticosteroids to improve intestinal inflammation and to maintain a more sustained clinical remission.

ESPEN Guidelines on Enteral Nutrition: Gastroenterology

Undernutrition as well as specific nutrient deficiencies have been described in patients with Crohn's disease (CD), ulcerative colitis (UC) and short bowel syndrome (SBS). The present guideline gives evidence-based recommendations for the indication, application and type of formula of enteral nutrition (EN) (oral nutritional supplements (ONS) or tube feeding (TF)) in these patients. It was developed in an interdisciplinary consensus-based process in accordance with officially accepted standards and is based on all relevant publications since 1985. ONS and/or TF in addition to normal food is indicated in undernourished patients with CD or CU to improve nutritional status. In active CD EN is the first line therapy in children and should be used as sole therapy in adults mainly when treatment with corticosteroids is not feasible. No significant differences have been shown in the effects of free amino acid, peptide-based and whole protein formulae for TF. In remission ONS is recommended only in steroid dependent patients in CD. In patients with SBS TF should be introduced in the adaptation phase and should be changed with progressing adaptation to ONS in addition to normal food.

Traitements nutritionnels au cours des MICI :où en est-on ?

Protein-energy malnutrition and specific nutrient deficiencies are common in inflammatory bowel diseases (IBD), more particularly in Crohn's disease. In adults, the use of artificial nutrition is indicated in the event of malnutrition, short bowel syndrome, or IBD refractory to all other treatments. In children, enteral nutrition has a place as first-line treatment to avoid side effects of corticosteroids on growth. The use, as a therapeutic tool, of specific nutrients (n-3 fatty acids, glutamine, antioxydant vitamins and minerals, TGF-beta, probiotics...) seems interesting at the pathophysiological level. Nevertheless, these nutrients are still under evaluation and there are not enough available studies to recommend them in clinical routine. A very promising solution is the use of probiotics for the treatment of refractory pouchitis.

Nutrition in inflammatory bowel disease

Nutrition has an important role in the management of inflammatory bowel disease. This role includes the prevention and correction of malnutrition, the prevention of osteoporosis and in children the promotion of optimal growth and development. In active Crohn's disease nutritional therapy (in the form of enteral feeding) is an effective primary therapy for many patients. Corticosteroids, however, are more effective than enteral diet therapy in adults. Enteral diets should be considered as primary therapy in pediatric Crohn's disease, especially in children with poor nutritional status or growth impairment. Enteral nutrition does not have a proven primary therapeutic role in ulcerative colitis. There are many theories that suggest that diet may be implicated in the aetiology of inflammatory bowel disease, however, there are, as yet, no dietary approaches proven to reduce the risk of developing IBD.

Preventive effect of nutritional therapy against postoperative recurrence of Crohn disease, with reference to findings determined by intra-operative enteroscopy

OBJECTIVE

The aim of this study was to elucidate the predictive value of intra-operative enteroscopy (IOE) and the effect of enteral nutrition (EN) with regard to the postoperative recurrence of Crohn disease (CD).

MATERIAL AND METHODS

Forty patients requiring surgery for severe intestinal complications of CD were examined by IOE, and the severity of the remnant small intestine was determined. Patients were subclassified into either an EN group (>1,200 kcal/day) or a non-EN group (<1,200 kcal/day) according to the amount of daily EN intake after surgery. Contributions of IOE findings and EN to postoperative recurrence were analysed retrospectively.

RESULTS

IOE identified intestinal lesions in 39 patients and active intestinal lesions in 24 patients. The cumulative rate of postoperative recurrence was significantly higher in patients with cobblestone appearance confirmed by IOE (p=0.006). However, other active intestinal lesions were not related to postoperative recurrence. EN reduced the cumulative rate of postoperative recurrence (p=0.017), especially in patients with penetrating type (p=0.005), in patients who did not have colitis (p=0.051) and in patients who did not have active intestinal lesions confirmed by IOE (p=0.02).

CONCLUSIONS

EN is a prophylactic that prevents the postoperative recurrence of small intestinal CD. Patients with the penetrating type of CD, and those who do not have active lesions in the small intestine according to IOE, are candidates for EN after surgery.

Therapeutic efficacy of infliximab on active Crohn's disease under nutritional therapy

OBJECTIVE

The aim of this investigation was to elucidate retrospectively the therapeutic effect of infliximab in patients with active Crohn's disease (CD) under nutritional therapy.

MATERIAL AND METHODS

Using a review of the clinical records in 24 nationwide institutions specializing in inflammatory bowel disease, the short-term effect of infliximab in 97 patients with active CD was retrospectively investigated. The Crohn's disease activity index (CDAI) at baseline and after 2 weeks of a single infliximab administration (5 mg/kg) was compared among patients under total parenteral nutrition (TPN group, n=36), those following an elemental or polymeric diet (EN group, n=49) and those without TPN and EN (NN group, n=12). A decrease in CDAI >or= 70 or a CDAI value <150 at 2 weeks was regarded as effective.

RESULTS

There was no difference in CDAI at baseline among the three groups. In each group, CDAI decreased significantly (from 250 (195-290) [median (interquartiles)] to 152 (123-233) in the TPN group, p<0.0001; from 259 (200-325) to 180 (130-238) in the EN group, p<0.0001; from 278 (222-291) to 164 (132-196) in the NN group, p=0.003). Infliximab was effective in 63.9% of patients in the TPN group, in 55.1% of those in the EN group and in 75% of the NN group. There was no statistical difference in efficacy among the three groups (p=0.4). Multivariate logistic regression analysis revealed younger age to be a significant factor related to the efficacy of infliximab.

CONCLUSIONS

Infliximab is effective in patients with CD under TPN or EN. Age at infliximab administration may be predictive of response to infliximab.

Enteral nutrition and microflora in pediatric Crohn's disease

BACKGROUND

Exclusive enteral nutrition (EN) is an established primary therapy for pediatric Crohn's disease (CD). The mechanism of action of such treatment is still conjectural. The aim of the present study was to investigate if EN-induced remission is associated with modification of the fecal microflora in CD.

METHODS

Stool samples were collected from 5 healthy children and adolescents over a period of 3 months, and from 9 children and adolescents with active CD. To induce disease remission, children with CD received a course of exclusive EN for 8 weeks with a polymeric formula (Modulen IBD, Nestlè). At the end of the course of exclusive EN, children returned to a free diet but continued to take 40% of the daily caloric intake as polymeric formula. Fecal microflora was analyzed by 16S ribosomal DNA polymerase chain reaction and temperature gradient gel electrophoresis (TGGE) with direct visual comparison of band profiles of PCR products.

RESULTS

In 8 of 9 children, the exclusive EN alone induced disease remission. In 1 child, it was necessary to add steroids to the exclusive EN course to achieve remission. In all children with CD, analysis of gel band distribution revealed profound modification of the fecal microflora after exclusive EN. Variations of band distribution corresponding to different bacterial species were observed also in children on partial EN and required time to achieve stability of the band profile. In contrast, control healthy children showed a host-specific and stable TGGE profile over time.

CONCLUSION

These data suggest that a possible mechanism of action of EN in inducing disease remission in CD is the capacity of modification of gut microflora. Possible explanations of such capacity are both low residue and prebiotic properties of the polymeric liquid formula.

An elemental diet controls inflammation in indomethacin-induced small bowel disease in rats: the role of low dietary fat and the elimination of dietary proteins

Elemental diets (EDs) are effective in treating Crohn's disease. We hypothesize that low dietary fat and amino acids used as the sole nitrogen source are the major contributors for the success of EDs. We examined the influences of the addition of dietary fat and protein to an ED using an indomethacin-induced inflammation model in rat small intestine. In the ED-fed rats, the intestinal damage score was decreased compared with that in the standard chow group with decreasing intestinal permeability. By supplementing an ED with soybean oil (SO), intestinal permeability was increased to a level similar to that of the standard chow group. For this group, the intestinal damage score also increased compared with that of the ED group but did not reach the levels observed in the standard chow group. The addition of dietary proteins (using heat-denatured pancreatin) resulted in intestinal damage scores that were significantly higher than those of the ED+SO-fed group. The dietary protein increased the intestinal damage score. These results suggest that EDs control inflammation by decreasing intestinal permeability and the elimination of dietary proteins.

Fatty acid compositions of lipids in mesenteric adipose tissue and lymphoid cells in patients with and without Crohn's disease and their therapeutic implications

BACKGROUND

The physiological bases for roles of adipose tissue and fatty acids in the symptoms and dietary treatments of Crohn's disease (CD) are poorly understood. The hypothesis developed from experiments on rodents that perinodal adipocytes are specialized to provision adjacent lymphoid tissues was tested by comparing the composition of triacylglycerol and phospholipid fatty acids in homologous samples of mesenteric adipose tissue and lymph nodes from patients with or without CD.

METHODS

Mesenteric perinodal and other adipose tissue and lymph nodes were collected during elective surgery for CD and other conditions. Fatty acids were extracted, identified, and quantified by thin-layer and gas-liquid chromatography.

RESULTS

Perinodal adipose tissue contained more unsaturated fatty acids than other adipose tissue in controls, as reported for other mammals, but site-specific differences were absent in CD. Lipids from adipose and lymphoid tissues had more saturated fatty acids but fewer polyunsaturates in patients with CD than controls. In adipose tissue samples, depletion of n-3 polyunsaturates was greatest, but n-6 polyunsaturates, particularly arachidonic acid, were preferentially reduced in lymphoid cells. Ratios of n-6/n-3 polyunsaturates were higher in adipose tissue but lower in lymphoid cells in patients with CD than in controls.

CONCLUSIONS

Site-specific differences in fatty acid composition in normal human mesentery are consistent with local interactions between lymph node lymphoid cells and adjacent adipose tissue. These site-specific properties are absent in CD, causing anomalies in composition of lymphoid cell fatty acids, which may explain the efficacy of elemental diets containing oils rich in n-6 polyunsaturates.

Enteral nutrition as a primary therapy for intestinal lymphangiectasia: value of elemental diet and polymeric diet compared with total parenteral nutrition

Intestinal lymphangiectasia (IL) is a rare disease requiring oral fat restriction. The aim of this study was to evaluate the efficacy of enteral nutrition compared to that of total parenteral nutrition (TPN). We retrospectively reviewed nine patients with IL presenting with protein-losing enteropathy. Of these, seven patients not responding to a low-fat diet were treated with elemental diet (ED), polymeric diet (PD) containing medium-chain triglycerides, or TPN. Improvement in serum total protein was observed in two of three on ED and in one of two on PD, compared with three of three on TPN. Enteric protein loss was improved in two of two on ED, one of two on PD, and two of two on TPN. Outpatients who continued to receive enteral nutrition maintained a total protein level. Enteral nutirition appears to be as effective as TPN for patients with IL, and it may provide a valid and safe alternative therapy.

Nutritional therapy for Crohn's disease in Japan

In Japan, nutritional therapy as both a primary and as a secondary treatment is widely used for Crohn's disease (CD). The rationale for its use is based on a variety of reasons. The first is its ability to induce remission and to ameliorate the activity of intestinal lesions in the short term by enteral (EN) or by parenteral nutritional therapy in which overexpressions of chemokine receptors in an active stage are decreased significantly in the remission stage. Second is its ability to maintain remission over the long term through home-based enteral nutrition in which tube feeding during the nighttime is encouraged. Third is its ability to reduce the steroid dosage over the period of a long-term treatment course. However, several disadvantages of this therapy such as unpalatability and sluggish effect have been pointed out. Several studies have attempted to resolve this issue and determine the best components of EN, especially in fat composition. Some data have been suggestive of too much long-chained fatty acid having a hazardous effect on EN's clinical efficacy because it works as a precursor of inflammatory prostaglandins. Our recent data show that medium-chained triglyceride did not have such a hazardous effect on clinical efficacy. Several studies suggested that the patient factors that were resistant to inducing remission in the short term were a long period of suffering CD, a high activity (on Crohn's Disease Activity Index, CDAI), hemorrhagic colitis, and colitis with marked cobblestoning. Japanese guidelines for the treatment of CD recommended nutritional therapy as a first-line therapy and as a maintenance therapy after inducing remission. This treatment policy has led to Japanese CD patients having lower mortality rates than that of patients who do not receive EN. If this therapy could be combined with other drug therapies, including strong immunosuppressants, treatment strategies would be improved over those we have at present.

Management of inflammatory bowel disease

Ulcerative colitis and Crohn's disease result from an interaction between genetic and environmental factors. Only one gene, NOD2/CARD15, has been clearly identified; a minority of people with alteration of this gene develop Crohn's disease. The NOD2/CARD15 protein is thought to be involved in defence against intracellular bacteria. This supports the idea that Crohn's disease and ulcerative colitis result from altered immunological responses to the normal intestinal flora. Life expectancy is normal in ulcerative colitis and nearly so in Crohn's disease, but both conditions cause considerable morbidity. Approximately 80% of patients with Crohn's disease eventually require surgery, and about 25% of patients with ulcerative colitis require colectomy. Treatment of ulcerative colitis is generally by corticosteroids for acute disease and mesalazine for maintenance, but the range of therapies for Crohn's disease is expanding. Alternative therapies include immunosuppressives, enteral nutrition, antibiotics, anti-TNF antibody (infliximab), corticosteroids, and surgery. High dosages of corticosteroids may provide symptomatic relief in Crohn's disease but do not affect the long term natural history of the disease, and management strategies should avoid using steroids whenever possible.

Nutrition support for pediatric patients with inflammatory bowel disease: a clinical report of the North American Society for Pediatric Gastroenterology, Hepatology And Nutrition

Impairment of growth and malnutrition are significant complications of inflammatory bowel disease (IBD) in pediatric patients. Since this topic was last reviewed in these pages (), a number of studies have further explored the epidemiology and pathogenesis of these nutritional complications of IBD in an effort to provide more effective interventions to prevent the long-term consequences of chronic nutrient deficiencies in childhood. In addition, during the past 15 years, the use of selected nutrients and microorganisms (probiotics) as primary or adjunctive therapy for the treatment of IBD has become an emerging area of great interest. The following is a Clinical Report from the Nutrition and Inflammatory Bowel Disease Committees of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition.

Inflammatory bowel diseases: principles of nutritional therapy

Inflammatory Bowel Diseases - ulcerative colitis and Crohn's disease- are chronic gastrointestinal inflammatory diseases of unknown etiology. Decreased oral intake, malabsorption, accelerated nutrient losses, increased requirements, and drug-nutrient interactions cause nutritional and functional deficiencies that require proper correction by nutritional therapy. The goals of the different forms of nutritional therapy are to correct nutritional disturbances and to modulate inflammatory response, thus influencing disease activity. Total parenteral nutrition has been used to correct and to prevent nutritional disturbances and to promote bowel rest during active disease, mainly in cases of digestive fistulae with high output. Its use should be reserved for patients who cannot tolerate enteral nutrition. Enteral nutrition is effective in inducing clinical remission in adults and promoting growth in children. Due to its low complication rate and lower costs, enteral nutrition should be preferred over total parenteral nutrition whenever possible. Both present equal effectiveness in primary therapy for remission of active Crohn's disease. Nutritional intervention may improve outcome in certain individuals; however, because of the costs and complications of such therapy, careful selection is warranted, especially in patients presumed to need total parenteral nutrition. Recent research has focused on the use of nutrients as primary treatment agents. Immunonutrition is an important therapeutic alternative in the management of inflammatory bowel diseases, modulating the inflammation and changing the eicosanoid synthesis profile. However, beneficial reported effects have yet to be translated into the clinical practice. The real efficacy of these and other nutrients (glutamine, short-chain fatty acids, antioxidants) still need further evaluation through prospective and randomized trials.

Dietary fat attenuates the benefits of an elemental diet in active Crohn's disease: a randomized, controlled trial

OBJECTIVES

Although an elemental diet has been established as the primary treatment for patients with Crohn's disease, the influence of dietary fat on the elemental diet remains unclear. We have designed the first randomized, controlled trial for elemental diets containing different fat percentages in patients with active Crohn's disease.

METHODS

Each patient was randomized to receive one of three dose levels of fat in an elemental diet (Elental) for 4 weeks: 10 patients received low fat (3.06 g/day), 10 patients received medium fat (16.56 g/day) and eight patients received high fat (30.06 g/day). The additional fat was composed of long-chain fatty acids. All patients were evaluated using the International Organization of Inflammatory Bowel Disease rating, plus C-reactive protein level and erythrocyte sedimentation rate, which were measured at weekly intervals.

RESULTS

Although the International Organization of Inflammatory Bowel Disease rating, C-reactive protein level and erythrocyte sedimentation rate in the low-fat group decreased, the values in the medium- and high-fat groups fluctuated during the study. The remission rate after 4 weeks in each group was 80%, 40% and 25% for patients in the low-, medium- and high-fat groups, respectively.

CONCLUSIONS

When the fat consisted of long-chain triglycerides, a high amount of this fat in the elemental diet formula decreased its therapeutic effect against active Crohn's disease.

Nutritional support

Despite the increasing obesity of the American population, many chronically ill patients are malnourished. When this malnutrition is combined with the hypermetabolic response and protein catabolism of an acute event, such as an operation, nutritional support becomes an important facet for optimal critical care. This chapter reviews the basic tenants of nutritional support with special emphasis on patients with pulmonary compromise. Important aspects of caloric and protein support are discussed and enteral nutrition is emphasized because of its numerous advantages and documented improvement in outcome.

Medical treatment of Crohn's disease

Crohn's disease is not medically (and is rarely surgically) curable. Patients do, however, live a normal life span. The goal of therapy is to optimize the quality of life, minimize disease activity and disease-related complications, and avoid therapeutic toxicity.

Lymphonodular hyperplasia of the terminal ileum associated with colitis shows an increase gammadelta+ t-cell density in children

OBJECTIVE

Recently we reported a close association between lymphonodular hyperplasia (LNH) of the bulb of the duodenum and increased densities of intraepithelial gammadelta+ T-cells in subjects with untreated food allergies. In this study we sought to determine whether children with LNH of the terminal ileum (TI) show a similar correlation.

METHODS

The mucosal specimens taken by colonoscopy from the TIs of 22 children with LNH of the TI without colitis, 13 with right-sided colitis or pancolitis, nine with left-sided colitis, eight with Crohn's disease, and three endoscopically healthy subjects were studied for T-cell subsets with monoclonal antibodies using a three-layer peroxidase staining method.

RESULTS

LNH of the TI was found in 32 of the 55 subjects (58%). In 22 it was the only endoscopic finding, but in nine of 13 subjects (69%) it was related to right-sided colitis or pancolitis. In patients with left-sided colitis or Crohn's disease it was diagnosed only rarely. In the whole study population, LNH of the of the TI showed a significant association with the increment in the density of gammadelta+ T-cells. The subjects with LNH of the TI and colitis starting from the cecum showed the highest values, discriminating them statistically from any other study group. Accordingly their gammadelta+/CD3+ ratio was high. Even in the subjects with LNH of the TI without colitis, the increment in gammadelta+ T-cells was significant as compared with the subjects with left-sided colitis. Upregulations of D-related expression on the mucosa of the TI were similar regardless of the presence of LNH or colitis or an increment in gammadelta+ T-cells.

CONCLUSION

Our preliminary observations showed increased densities of intraepithelial gammadelta+ T-cells and elevated gammadelta+/CD3+ ratios in subjects with LNH on the mucosa of the TI, especially if related to colitis starting at the cecem, but not in subjects with typical left-sided colitis or granulomatous Crohn's disease. The study also provides further evidence suggesting the significance of food-borne antigens in the pathogenetic mechanism of right-sided colitis or pancolitis. The finding also indicates the significance of classifying colitis into gammadelta-positive and -negative diseases, and has implications for the treatment of these entities.