Malnutrition and malabsorption in Crohn's disease with reference to the effect of surgery

Oral Cyanocobalamin is Effective in the Treatment of Vitamin B12 Deficiency in Crohn's Disease

Cobalamin deficiency is common in patients with Crohn’s disease (CD). Intramuscular cobalamin continues to be the standard therapy for the deficiency and maintenance treatment in these patients, although oral route has been demonstrated to be effective in other pathologies with impaired absorption. Our aims were to evaluate the efficacy of oral therapy in the treatment of cobalamin deficiency and in long-term maintenance in patients with Crohn’s disease. We performed a multicenter retrospective cohort study that included 94 patients with Crohn’s disease and cobalamin deficiency. Seventy-six patients had B12 deficiency and 94.7% of them normalized their cobalamin levels with oral treatment. The most used dose was 1 mg/day, but there were no significant differences in treatment effectiveness depending on the dose used (≥1 mg/24 h vs. <1 mg/24 h). Eighty-two patients had previous documented B12 deficiency and were treated with oral B12 to maintain their correct cobalamin levels. After a mean follow-up of 3 years, the oral route was effective as maintenance treatment in 81.7% of patients. A lack of treatment adherence was admitted by 46.6% of patients in who the oral route failed. In conclusion, our study shows that oral cyanocobalamin provides effective acute and maintenance treatment for vitamin B12 deficiency caused by CD with or without ileum resection.

Vitamin B12 deficiency in inflammatory bowel disease: prevalence, risk factors, evaluation, and management

BACKGROUND

Management of vitamin B(12) (cobalamin, Cbl) deficiency in inflammatory bowel disease (IBD) is often not evidenced-based because of uncertainty on whether it causes enough malabsorption to result in clinical disease. This systematic review examines whether IBD predisposes to Cbl deficiency. We provide an approach to the management of abnormal Cbl values in IBD based on current literature and consensus-based guidelines.

METHODS

An extensive search of the Ovid MEDLINE and EMBASE databases by independent reviewers identified 42 articles with a total of 3732 patients evaluating Cbl deficiency in IBD.

RESULTS

Crohn's disease without ileal resection, regardless of disease location in the ileum, did not increase the risk for Cbl deficiency. Ileal resections greater than 30 cm were associated with Cbl deficiency in Crohn's disease, whereas those less than 20 cm were not. The effects of 20 to 30 cm resections were inconsistent. Ulcerative colitis did not predispose to deficiency. All studies failed to use confirmatory biomarker testing as stipulated by diagnostic guidelines for Cbl deficiency.

CONCLUSIONS

This literature does not support an association of Crohn's disease in general, regardless of ileal involvement, with Cbl deficiency. Only ileal resections greater than 20 cm in Crohn's disease predispose to deficiency and warrant treatment. Based on these findings, we suggest a diagnostic and therapeutic algorithm. All findings and recommendations require verification in further studies using confirmatory biomarkers as per diagnostic guidelines for Cbl deficiency. Serum Cbl levels alone are likely insufficient to diagnose deficiency in asymptomatic patients.

Should we monitor vitamin B12 and folate levels in Crohn's disease patients?

OBJECTIVE

Crohn's disease commonly involves the small intestine, which is the site of vitamin B12 and folate absorption. Our aim was to define the prevalence of vitamin B12 and folate deficiency in patients with Crohn's disease and to identify predictive factors associated with such abnormalities.

METHODS

Two years prospective study of 180 consecutive Crohn's disease patients. Vitamin B12 and folate deficiency was defined as serum levels below 200 pg/ml and 3 ng/ml, respectively. We analysed prevalence of these deficiencies and possible predictive factors including small intestine resection, disease location, activity and duration of disease. Controls were ulcerative colitis patients (n = 70).

RESULTS

The prevalence of B12 deficiency in Crohn's disease was 15.6% (95%CI 9.7-20%) compared with 2.8% (95%CI 0.8-9.8%) in ulcerative colitis (p = 0.007). With regard to folate deficiency, the prevalence in patients with Crohn's disease was 22.2% (95%CI 16-28%) compared with 4.3% (95%CI 1.4-12%) in ulcerative colitis (p = 0.001); 7.8% of Crohn's disease patients had macrocytic anemia. Ileal resection was found to be a risk factor for B12 deficiency (OR 2.7; 1.2-6.7; p = 0.02), and disease activity a risk factor for folate deficiency (OR 2.4; 1.2-5.1; p = 0.01).

CONCLUSION

A significant proportion of patients with Crohn's disease suffer from vitamin B12 and/or folate deficiency, suggesting that regular screening should be performed, with closer monitoring in patients with ileal resection or active disease.

Nationwide prevalence and prognostic significance of clinically diagnosable protein-calorie malnutrition in hospitalized inflammatory bowel disease patients

BACKGROUND

Inflammatory bowel disease (IBD) patients are at increased risk of protein-calorie malnutrition. We sought to determine the prevalence of clinically diagnosable malnutrition among those hospitalized for IBD throughout the United States and whether this malnutrition influenced health outcomes.

METHODS

We queried the Nationwide Inpatient Sample between 1998 and 2004 to identify admissions for Crohn's disease (CD) or ulcerative colitis (UC) and a representative sample of non-IBD discharges. We assessed the prevalence and predictors of malnutrition and its association with in-hospital mortality and resource utilization.

RESULTS

The prevalence of malnutrition was greater in CD and UC patients than in non-IBD patients (6.1% and 7.2% versus 1.8%, P < 0.0001). The adjusted odds ratio for malnutrition among IBD admissions compared with non-IBD admissions was 5.57 [95% confidence interval (CI): 5.29-5.86]. More IBD discharges than non-IBD discharges with malnutrition received parenteral nutrition (26% versus 6%, P < 0.0001). There was increased likelihood of malnutrition among those with fistulizing CD (OR 1.65; 95% CI: 1.50-1.82) and among those who had undergone bowel resection (OR 1.37; 95% CI: 1.27-1.48). Malnutrition was associated with increased in-hospital mortality 3.49 (95% CI: 2.89-4.23), length of stay (11.9 days versus 5.8 days, P < 0.00001), and total charges ($45,188 versus $20,295, P < 0.0001).

CONCLUSIONS

Clinically apparent malnutrition is more frequent among IBD admissions than among non-IBD admissions. Its association with greater mortality and resource utilization may reflect more severe underlying disease that can lead to both malnutrition and worse outcomes. Nonetheless, diagnosable malnutrition may serve as a clinical marker of poor IBD prognosis in hospitalized patients.

Prevalence of and risk factors for vitamin B(12) deficiency in patients with Crohn's disease

BACKGROUND

Crohn's disease (CD) can commonly involve the terminal ileum, which is the site of B(12) absorption. The aim of this study was to define the prevalence of vitamin B(12) abnormalities in a population with CD and to identify risk factors associated with B(12) abnormalities in CD.

METHODS

The medical records of 201 patients with CD evaluated at a tertiary care center were retrospectively reviewed to determine the prevalence of B(12) deficiency and to evaluate factors associated with B(12) deficiency. The prevalence of B(12) deficiency in a control population of 40 patients with ulcerative colitis was also assessed.

RESULTS

The prevalence of an abnormal serum B(12) concentration in patients with CD was 18.4% (95% confidence interval [CI] 13.1-23.8%) compared with 5% (95% CI, 0-11.8%) (P = 0.035) in ulcerative colitis controls. Risk factors for B(12) deficiency in patients with CD included prior ileal (odds ratio [OR], 7.22; 95% CI, 1.97-26.51) or ileocolonic (OR, 5.81; 95% CI, 2.09-16.12) resection and the need for ongoing medical therapy (OR, 2.59; 95% CI, 1.03-6.47). Neither disease location nor duration was independently associated with the risk of B(12) deficiency.

CONCLUSIONS

Vitamin B(12) abnormalities are common in patients with CD and patients with a prior ileal or ileocolonic resection are at particular risk. Routine screening for B(12) deficiency in patients with CD is warranted.

Iron and inflammatory bowel disease

Both anaemia of iron deficiency and anaemia of chronic disease are frequently encountered in inflammatory bowel disease. Anaemia of iron deficiency is mostly due to inadequate intake or loss of iron. Anaemia of chronic disease probably results from decreased erythropoiesis, secondary to increased levels of proinflammatory cytokines, reactive oxygen metabolites and nitric oxide. Assessment of the iron status in a condition associated with inflammation, such as inflammatory bowel disease, is difficult. The combination of serum transferrin receptor with ferritin concentrations, however, allows a reliable assessment of the iron deficit. The best treatment for anaemia of chronic disease is the cure of the underlying disease. Erythropoietin reportedly may increase haemoglobin levels in some of these patients. The anaemia of iron deficiency is usually treated with oral iron supplements. Iron supplementation may lead to an increased inflammatory activity through the generation of reactive oxygen species. To date, data from studies in animal models of inflammatory bowel disease support the theoretical disadvantage of iron supplementation in this respect. The results, however, cannot easily be extrapolated to the human situation, because the amount of supplemented iron in these experiments was much higher than the dose used in patients with iron deficiency.

Homocysteine in inflammatory bowel disease: a risk factor for thromboembolic complications?

OBJECTIVE

Patients with inflammatory bowel disease (IBD) are at increased risk for thromboembolic events. Hyperhomocysteinemia, which is an established risk factor for arterial as well as venous thrombosis, may be more prevalent in IBD because of vitamin deficiencies.

METHODS

In this retrospective study, we studied the concentrations of total homocysteine (tHcy), cobalamin, folate, and pyridoxine in 231 consecutive patients with IBD, of whom 16 patients had a history of venous thrombosis, and nine a history of arterial thrombosis. Age- and gender-matched healthy volunteers served as controls (n = 102).

RESULTS

Homocysteine concentrations in patients were higher (12.3 micromol/L [range 4.6-51.3] vs 11.1 micromol/L [range 3.9-27.6], p = 0.001) and hyperhomocysteinemia tended to be more prevalent in patients than in the controls (11.1% vs 5%, p = 0.07). Folate, cobalamin, creatinine, and pyridoxine concentrations were correlated with tHcy. Folate deficiency was infrequently encountered in IBD patients (4.3%). The tHcy concentration in patients with a history of venous or arterial thrombosis was not higher than in patients without a history of thrombosis (12.7 micromol/L [range 4.6-40.1] and 15.2 micromol/L (range 10.5-26.8) vs 12.3 micromol/L [range 10.5-26.8], not significant). Hyperhomocysteinemia was found in 18.8% of the patients with venous thrombosis, 11.1% of the patients with arterial thrombosis, and 10.5% of the patients without thrombosis (not significant).

CONCLUSIONS

Hyperhomocysteinemia is a common phenomenon in IBD and correlates with serum folate, cobalamin, creatinine, and pyridoxine concentrations. No correlation between tHcy and a history of venous or arterial thromboembolic complications is found. Hyperhomocysteinemia does not seem to be a major contributory factor in the development of venous or arterial thrombosis in IBD patients.

[Nutritional deficiencies and complications in chronic inflammatory bowel diseases]

BACKGROUND

Deficiencies of vitamins and trace elements are frequent in inflammatory bowel disease. Aim of this study was to evaluate retrospectively the prevalence of these deficiencies and of liver complications in a large population.

PATIENTS AND METHODS

The records from 392 out-patients, 279 with Crohn's disease (160 female, 119 male) and 113 with ulcerative colitis (56 female, 57 male) were analyzed.

RESULTS

Deficiencies were found in 85% of patients with Crohn's disease vs 68% with ulcerative colitis during the course of the disease, predominantly a deficiency of iron and of calcium. Less frequently deficiencies of zinc, protein, cyanocobalamin, and folic acid were found. Elevated liver enzymes were seen in 38% of patients with Crohn's disease vs 27% with ulcerative colitis. In order of frequency: gamma-glutamyl-transferase, ALAT, AP, ASAT, and bilirubin. Gallstones were present in 12% of patients with Crohn's disease and 4% with ulcerative colitis. 6% of patients with Crohn's disease and 4% with ulcerative colitis had kidney stones.

CONCLUSIONS

In view of the high frequency of deficiencies in patients with inflammatory bowel disease it seems to be important to check frequently for extraintestinal complications.

Medical management of severe inflammatory disease of the rectum: nutritional aspects

It is clear that the nutritional state of patients with inflammatory bowel disease is often impaired and can be improved by the provision of nutritional support. Improvement in nutritional status can be achieved as effectively with enteral as with parenteral nutrition. Nutritional support appears to have no primary therapeutic effect in patients with ulcerative colitis. With regard to nutritional support in Crohn's disease, parenteral nutrition should be restricted to use as supportive rather than primary therapy. Available information now seems to suggest that most of the benefits of parenteral nutrition in Crohn's disease are related to an improvement in nutritional state rather than as primary therapy, and its use should be restricted to the treatment of specific complications of Crohn's disease, such as intestinal obstruction related to stricture formation or short bowel syndrome following repeated resection. Although some doubt exists over the efficacy of oligopeptide-containing elemental and polymeric enteral diets, the present evidence indicates that chemically defined free amino acid-containing elemental diets have primary therapeutic efficacy in the management of acute exacerbations of Crohn's disease. As such, these diets are worthy of therapeutic trial in patients with severe Crohn's disease involving the distal colon and rectum, particularly in those patients who are malnourished and who prove to be resistant to treatment with a combination of topical corticosteroids and 5-aminosalicylic acid-containing compounds. Clinicians should be aware, though, that the beneficial effects are likely to be restricted to the short term, with high relapse rates by 1 year, this being particularly so in patients with distal Crohn's proctocolitis (Teahon et al, 1988). Volatile fatty acid enemas clearly have potential in the management of patients with severe steroid-resistant proctitis. Finally, one of the most important observations made in recent years is the one concerning the large losses of nitrogen that will occur in patients with inflammatory bowel disease treated with corticosteroids in the absence of adequate protein intake (O'Keefe et al, 1989). Hopefully the days of treating patients with severe inflammatory bowel disease with high dose corticosteroids and a peripheral dextrose or dextrose-saline drip have passed into history.

The influence of zinc status and malnutrition on immunological function in Crohn's disease

Cellular immunity is likely to be important in the pathogenesis of Crohn's disease; whether it is abnormal is not clear. The heterogeneity of patients with Crohn's disease probably underlies the disparity of reports, but attempts to determine which clinical features influence cellular immunity have been largely unsuccessful. This is probably caused by the omission of nutritional status as a potential factor, even though zinc deficiency has frequently been linked with abnormal immunity. Therefore, a detailed study of nutritional and tissue zinc status, nonspecific cellular immunity, and a measure of phagocytic function was performed in 32 patients with Crohn's disease and in a control group of 18 normal subjects and 12 patients with anorexia nervosa. Fourteen patients with Crohn's disease, all patients with anorexia nervosa, but none of the normal controls were malnourished. Peripheral blood lymphocyte population levels were normal in patients with Crohn's disease and in normal controls, but there was a small decrease in the levels of patients with anorexia nervosa. In vivo delayed hypersensitivity skin test responses were profoundly depressed in patients with anorexia nervosa and decreased in patients with Crohn's disease who were malnourished or receiving systemic glucocorticoids. In vitro lymphocyte transformation was reduced in malnourished patients with Crohn's disease, but there were only minor changes in patients with anorexia nervosa. There were alterations of in vitro immunoregulation in Crohn's disease, but they were not responsible for the abnormal lymphocyte transformation responses in malnourished patients. In vitro phagocytic function was reduced in patients with active Crohn's disease. These findings suggest that depressed in vivo and in vitro cellular immunity in malnourished patients with Crohn's disease is caused by a qualitative lymphocyte defect and that depressed in vivo but normal in vitro cellular immunity in anorexia nervosa is caused by a quantitative defect. Thus, malnutrition in Crohn's disease resembles kwashiorkor; in anorexia nervosa, it resembles marasmus. Tissue zinc status was mostly normal in Crohn's disease and anorexia nervosa, and zinc deficiency was not responsible for depressed nonspecific cellular immunity in either condition.

Inflammatory bowel disease: nutritional implications and treatment

It is clear that the nutritional state of patients with inflammatory bowel disease is often impaired and that the provision of nutritional support results in an improvement in nutritional state of these patients. Improvement in nutritional status can be achieved as effectively with enteral as with parenteral nutrition. The nutritional support appears to have no primary therapeutic effect in patients with ulcerative colitis. With regard to nutritional support in Crohn's disease, parenteral nutrition should be restricted to use as supportive rather than primary therapy. Available information now seems to suggest that most of the benefits of parenteral nutrition in Crohn's disease are related to improvement in nutritional state rather than as primary therapy, and its use should be restricted to treatments of specific complications of Crohn's disease, such as intestinal obstruction, related to stricture formation or short bowel syndrome following repeated resection. The present available evidence indicates that defined elemental diets may have a primary therapeutic role in the management of first acute attacks of Crohn's disease when there is a need to improve the nutritional status of patients with inflammatory bowel disease as an adjunct to primary drug therapy. Enteral nutrition is as efficacious as parenteral nutrition; moreover, it is safer to administer and more cost-effective.

Assessing nutritional state in inflammatory bowel disease

Nutrient depletion is a common complication of inflammatory bowel disease, and some of the consequences can be severe. Although it is often easy to recognise the most severely undernourished subjects, those with lesser degrees of malnutrition may prove more difficult to detect. Measurements of many nutritional variables will be abnormal in patients with inflammatory bowel disease, especially in those with Crohn's disease, but are not always relevant to the clinical management of patients. Anthropometric means of assessment, in particular, measurement of mid arm circumference, can act as a simple, reproducible method of detecting those most at risk of appreciable undernutrition.

Early complications following surgical treatment for Crohn's disease

One hundred thirty patients with Crohn's disease operated at the Mount Sinai Hospital were studied to determine the incidence of early postoperative complications. Thirty per cent of patients developed postoperative complications, while eight per cent had major complications requiring readmission to the hospital, reoperation, or suture of a bleeding vessel. Patients with a low preoperative serum albumin concentration had a significantly higher incidence of nonseptic and multiple complications. Septic complications were more common in patients having extensive resections and in those with multiple previous operations. There was also a significantly higher complication rate in patients requiring permanent or temporary ileostomy as opposed to those having intestinal anastomosis. The majority of complications in the patients with ileostomy were nonseptic in nature. There were no mortalities in this series.

Exaggerated response of thyrotropin to thyrotropin-releasing hormone in patients resected for Crohn's ileitis

We have studied the response of thyrotropin to exogenous thyrotropin-releasing hormone in 13 patients who had previous intestinal resection for Crohn's disease, and in 42 healthy controls. An exaggerated and prolonged response curve was found in eight of the patients and one control (P less than 0.01), while baseline hormone levels were normal in all. These results may be related to the state of iodine deficiency known to develop in inflammatory bowel disease, but the pathophysiology requires further elucidation.

Influence of nutritional status on immune functions in patients with Crohn's disease

Nutritional status and immune function were correlated with clinical features in 56 patients with Crohn's disease. These were divided arbitrarily into either undernourished or well nourished groups according to whether their midarm circumference was below or above 90% of ideal standard. Results were also compared with 33 patients with ulcerative colitis and 28 normal subjects. Undernourished patients with Crohn's disease had significantly reduced total lymphocyte and T lymphocyte counts and a reduced proportion of monocytes that ingested latex particles. Well nourished patients with Crohn's disease were similar to the two control groups. Twenty one undernourished patients with Crohn's disease were also followed during the course of two to four months' nutritional treatment with an enteral supplement. Nutritional therapy was associated with significant anthropometric gains as well as significant rises in total lymphocyte and T lymphocyte counts. Serum orosomucoids were significantly higher in undernourished patients and decreased significantly during nutritional therapy. The results show that undernutrition and disease acuity may be associated with reduced immunological competence in patients with Crohn's disease, but all these measurements can be improved by short term nutritional treatment.

Malabsorption of fat and vitamin B12 before and after intestinal resection for Crohn's disease

Intestinal absorption of fat and vitamin B12 was studied prospectively in 136 patients with Crohn's disease localized to the ileum and/or the colon. Fecal fat was measured in 3-day periods on a high fat diet, and vitamin B12 absorption was assessed by the Schilling test. When related to the extent of the ileal disease there was a poor correlation to both fecal fat excretion and the result from the Schilling tests, but an exponential and highly significant correlation was found between the results of both tests and the length of the resected ileal segment. Accepting a change in either direction not exceeding 10% of the preoperative test value as unchanged, three-fifths of the patients deteriorated and one-fifth improved in fat-absorption, whereas half the patients deteriorated and one-third improved in vitamin-B12 absorption after surgery. When related to the length of the ileum resected, the test results were about the same in patients subjected to a restorative procedure sparing the major part of the colon and in ileostomy patients. Absorption of fat and vitamin B12 did not change with time elapsing from operation, indicating that there were no compensatory mechanisms as regards absorption of these substances.

A survey of protein nutrition in patients with inflammatory bowel disease--a rational basis for nutritional therapy

The incidence of protein malnutrition was studied in 74 unselected patients with inflammatory bowel disease who were in the following categories: ileostomy (16), remission (15), elective surgery (12), acute attack (12), urgent surgery (10) and post-surgical complications (9). Compared with a control group, the patients in the urgent surgery group had low values for plasma albumin transferrin, pre-albumin and haemoglobin and these values were even lower in the patients who developed a major complication after surgery. There was no evidence of protein malnutrition in the ileostomy patients or in those in whom the disease was in remission. Nutritional therapy is strongly indicated in patients who are admitted to hospital with a severe attack of colitis and in whom urgent surgery is probable.

Is the xylose test still a worth-while investigation?

In a retrospective survey the results of a D-xylose absorption test have been assessed in relation to jejunal morphology and final diagnosis in 152 adult patients with various types of gastrointestinal disease. Neither urine excretion rates nor serum concentrations alone provide an adequate separation between patients with definite mucosal lesions and those without evidence of gut disease or with other types of gastrointestinal pathology.It is suggested that when a jejunal biopsy can readily be performed the xylose test serves little useful purpose in routine practice and can be positively misleading. It may still be useful as a screening test for referral for jejunal biopsy, provided that strict criteria of normality are applied.