Hyperalimentation as preparation for surgery in transmural colitis (Crohn's disease)

Total body potassium, fat and water during total parenteral nutrition in Crohn's disease

The body composition was studied by measurement of body weight (BW) and total body potassium (TBK), fat and water in 13 patients with Crohn's disease (CD), who were given altogether 18 courses of total parenteral nutrition (TPN) with nil by mouth each lasting at least 3 weeks. At the start of TPN, one group of steroid-free patients displayed intracellular potassium depletion, as reflected by the ratio TBK/lean body mass (LBM) (group 1). Another group of steroid-free patients showed no depletion of intracellular potassium (group 2). The patients given prednisolone all showed intracellular potassium depletion and were assigned to a separate group (group 3). During the initial 19-44 days of TPN, TBK, LBM and BW increased in group 1. All patients with intracellular potassium depletion (groups 1 + 3) showed an increase in TBK and TBK/LBM during the initial 19-51 days of TPN. For steroid-free patients (groups 1 + 2) there were linear relationships between the rate of energy supply per kg LBM and the 24 h change in BW during the third and fourth weeks of TPN (r = 0.79) and between the 24 h change in BW and LBM during the first 19-44 days of TPN (r = 0.59). A steady state in BW was found on administering 53 kcal/kg LBM/24 h. It is concluded that CD patients with intracellular potassium depletion are likely to be improved in terms of TBK and TBK/LBM by at least 3 weeks of TPN as given in the present study. Steroid-free CD patients with intracellular potassium depletion are, moreover, likely to show an improvement in LBM by at least 3 weeks of TPN, and an increase in their BW during the initial 3-6 weeks of TPN will probably reflect an increase in LBM. The pre-TPN TBK/LBM ratio may be a predictor of the repletion rate of the LBM compartment during TPN of steroid-free wasted CD patients.

Nutritional factors in inflammatory bowel disease

Dietary antigens may act as important stimuli of the mucosal immune system and have led to the study of nutritional therapy for IBD. Patients with active CD respond to bowel rest, along with total enteral nutrition or TPN. Bowel rest and TPN are as effective as corticosteroids at inducing remission for patients with active CD, although benefits are short-lived. Enteral nutrition is consistently less effective than conventional corticosteroids for treatment of active CD. Use of palatable, liquid polymeric diets in active CD is controversial, but these diets are of equal efficacy when compared with elemental diets. UC has not been treated effectively with either elemental diets or TPN. Fish oil contains n-3-PUFA, which inhibits production of proinflammatory cytokines and has some benefit in the treatment of CD. Topical applications of short-chain fatty acids have benefited diversion colitis and distal UC, whereas probiotics hold promise in the treatment of pouchitis.

Total parenteral nutrition as primary therapy for inflammatory disease of the bowel

Of the series of 21 patients with Crohn's disease who were treated with TPN as primary therapy, there were only four (19 per cent) who did not eventually need surgical intervention. The mean follow-up period for this group of patients was 27.25 months. The remaining 14 patients were operated on an average of 9.9 months after their course of TPN. Of the five patients with mucosal ulcerative colitis who were treated with primary TPN, three are now doing well in response to medical therapy after a mean follow-up period of 27.3 months.

Nutrition and inflammatory bowel disease

This article reviews the nutritional aspects of inflammatory bowel disease (IBD) including the mechanisms and manifestations of malnutrition and the efficacy of nutritional therapies. Nutrient deficiencies in patients with IBD occur via several mechanisms and may complicate the course of the disease. Nutritional status is assessed by clinical examination and the use of nutritional indices such as the Subjective Global Assessment of nutritional status. 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 parenteral nutrition.

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 medical, nutritional and surgical treatment of fistulae in Crohn's disease

Of a total 44 patients with Crohn's disease, 10 patients with 9 internal and 15 external fistulae, some of which were recurrent, were analyzed at the Department of Surgery, Yokohama City University between 1973 and 1988. Twenty-two fistulae were treated with medical and nutritional therapy using either total parenteral or enteral hyperalimentation by which the closure rate of the internal and external fistulae was 0 (0/9) and 42 per cent (9/14), respectively. The nutritional status of all the patients with fistulae treated by nutritional therapy improved, especially those whose fistulae were closed. However, 8 of 9 internal fistulae and 5 of 15 external fistulae finally required resection of the fistula with the distal stenotic bowel segment. The re-opening rate of fistulae following successful medical/nutritional therapy and surgical therapy was 88.9 per cent (8/9) and 53.8 per cent (7/13), respectively, and the mean interval until recurrence was shorter in the patients who underwent medical and nutritional therapy (4.5 months) than in those who underwent surgical therapy (19.4 months). Thus, using medical and nutritional therapy, none of the internal fistulae were closed, but 9 of 14 external fistulae were. The optimal management of internal fistulae is therefore thought to be bowel resection to include the distal stenotic lesion, while medical and nutritional therapy is thought to be of value for external fistulae.

Management of children and adolescents with inflammatory bowel disease

The management of children and adolescents with inflammatory bowel disease requires all the skills offered by the health care team. This article reviews the principles of therapy, the specifics of therapy, and the attitudes of the authors relating to long-term management of these patients. Specific recommendations relating to nutritional support for patients are also made. A pertinent updated bibliography is also given.

Preoperative total parenteral nutrition for bowel resection in Crohn's disease

To examine the effect of preoperative total parenteral nutrition (TPN) on patients with Crohn's disease undergoing bowel resection, an historical cohort was assembled of 103 patients resected between 1982 and 1984 by a single surgical team. Preoperative, perioperative, and postoperative variables were compared between patients receiving TPN and patients not receiving TPN. Analysis was stratified for three surgical procedures: segmental small bowel resection, ileocectomy, and segmental or total colectomy The effect of TPN was most pronounced in patients having small bowel surgery. For segmental small bowel resection, 12 of 17 patients had TPN, and these patients had 20.4 +/- 14.3 cm less bowel resected than did those in the non-TPN group, an effect not dependent on duration of TPN. For ileocectomy patients, 31 of 62 patients received TPN, and these patients had 11.2 +/- 4.2 cm less small bowel resected than the non-TPN group, an effect not dependent on the duration of TPN. For large bowel resection patients, 6 of 24 patients had TPN, and there was no difference in length of bowel resection, preoperative and perioperative variables, or recurrence. The total hospital stay was 13.5 +/- 2.6 days longer for those having TPN; 3.5 +/- 1.9 days of the longer stay was postoperative. In conclusion, TPN was associated with reduced length of small bowel resection at the expense of longer hospital stay.

Role of total parenteral nutrition in the treatment of Crohn's disease

We studied 49 patients with severe nonresponsive Crohn's disease receiving 73 courses of total parenteral nutrition (TPN) for a total of 2,153 days (30 +/- 18 days/admission). Forty-five percent of all courses of TPN resulted in patients not being operated on, whereas 55 percent resulted in surgical intervention. Fifty percent of patients who did not undergo operation initially as a result of a successful course of bowel rest and TPN had surgery within 15.4 +/- 13.9 months, whereas 75 percent of patients operated on immediately after a course of TPN did not need additional surgery during a follow-up of 36.1 +/- 31.2 months. Thus, a total of 80 percent of patients underwent gastrointestinal surgery sometime during the study and follow-up periods. TPN has an important role in replenishment of nutritional deficits and perioperative nutritional support; however, from the results of the present study, it is difficult to advocate it as the sole primary therapy for Crohn's disease.

Controlled trial of bowel rest and nutritional support in the management of Crohn's disease

To define the role of bowel rest as an independent variable from nutritional support a prospective, randomised controlled trial was undertaken in 51 patients with active Crohn's disease unresponsive to other medical management. Nutritional support for 21 days was randomised to total parenteral nutrition and nil by mouth (n = 17), defined formula diet administered through a nasogastric tube (n = 19), or partial parenteral nutrition and oral food (n = 15). Nutrient input in the first two groups provided 40 non-protein kcal/kg ideal body weight /d and 1g/ kg/d protein respectively, while the third group received 15 non-protein kcal/kg/d and 0.3 g/kg/d protein intravenously and ate unrestricted food. Clinical remissions occurred in 71% of patients on parenteral nutrition, in 58% on the defined formula diet and in 60% on partial parenteral nutrition; the probability for each group of being in remission at one year, after successful therapy was 42%, 55%, and 56% respectively. These differences were not significant. In patients with active Crohn's disease bowel rest was not a major factor in achieving a remission during nutritional support and did not influence outcome during one year's follow-up.

Nutritional therapy of hospitalized patients with inflammatory bowel disease

The use of total parenteral nutrition and enteral nutrition in inflammatory bowel disease has become commonplace. Except for well-documented improvements in nutritional parameters, the efficacy of these treatments for primary therapy or for complications remains largely unproven.

Catheter obstruction during prolonged parenteral alimentation. Are lipids responsible?

Catheter obstruction is a serious incident during prolonged parenteral nutrition (PN). This retrospective study was carried out in order to compare the frequencies of catheter obstruction with nutritive mixtures in bags according to whether or not lipids were mixed with the entire 24 h nutritional supply (Group I, n=33) or infused separately (Group II, n=30). Our results show that obstructions are significantly more frequent in Group I (11 13 ) than in group 2 (3 10 ), appearing within a mean interval of 29 days after inserting the catheter. The global percentages of patients undergoing cyclic PN were the same in both patient groups. In group I, however, the percentage of patients on cyclic PN was significantly higher for the obstructed catheters (100%) than for the unobstructed catheters (59%). In conclusion, the mixture of lipids with the remainder of the nutrients in the conditions of this study is the prime cause of catheter obstruction, although the exact mechanism is not elucidated. The role of cyclic PN appears to be accessory.

Total parenteral nutrition and complete bowel rest in the management of Crohn's disease

The role of parenteral nutrition with complete bowel rest in the management of active Crohn's disease was evaluated retrospectively in 100 patients who were otherwise refractory to conventional medical management. Ninety patients received complete nutrient replacement and 10 received protein-sparing therapy. In 77 patients, a clinical remission was achieved. Analysis of subgroups revealed that the remission rate was equivalent in patients with subacute bowel obstruction (76%), inflammatory mass (82%), and otherwise uncomplicated severe active disease (89%). However, those patients with fistulae responded less well (63%). The location of the intestinal involvement with the disease did not influence the remission rate (73% in those with small bowel disease only and 78% in those with combined small and large bowel disease). All six patients with only large bowel involvement achieved a remission. In 81% of those patients with a remission, no corticosteroids were given, or the dose prior to TPN was maintained. The serum albumin improved significantly (p less than 0.001) from 3.2 +/- 0.1 to 3.6 +/- 0.1 g/dl with total parenteral nutrition, but there was no significant effect on the hematocrit (p greater than 0.5). The percentage of patients still in remission after 3 months and 1 yr of follow-up was 75 to 79 and 58 to 61%, respectively, in the three nonfistulous groups, and 46 and 36%, respectively, in those with fistulous disease. Thus total parenteral nutrition with complete bowel rest appears to be an effective therapeutic modality in the primary management of complicated Crohn's disease.

Nutritional management of inflammatory bowel disease

Malnutrition and growth failure are frequent complications of inflammatory bowel disease in childhood owing to inadequate dietary nutrient intakes, excessive intestinal losses, malabsorption, and increased nutrient requirements. Aggressive nutritional therapy is indicated for primary and supportive management of disease activity, drug nutrient interactives, individual nutrient abnormalities, and the overall complications of inflammatory bowel disease, malnutrition, and growth failure. The prevention of nutritional disorders in inflammatory bowel disease is accomplished by monitoring anthropometric and biochemical indices and by instituting appropriate enteral or parenteral nutritional therapy when indicated.

Total body potassium depletion and the need for preoperative nutritional support in Chrohn's disease

Significant intracellular potassium depletion was documented in 57 patients with Crohn's disease by measurements of total body potassium, body water compartments, and red cell Na,K-ATPase units. Total body potassium deficits paralleled the activity of illness, but were not correlated to serum potassium levels. Treatment before surgery to improve individual body potassium content resulted in a reduced surgical mortality and complication rate compared with a retrospective series of 56 patients in whom pretreatment had simply been aimed at normalizing serum albumin and other standard serum parameters. In conclusion, preoperative nutritional support in Crohn's disease is recommended for patients with a total body potassium level less than 70% of normal. If whole body counting for direct measurement of total body potassium is not available, a Crohn's Disease Activity Index above 225 is proposed as the deciding level, and the parenteral administration of a standardized regimen consisting of 150 to 200 mval potassium plus 2500 to 3000 kcal daily for a two-week period is recommended.

Home enteral tube feeding with a liquid diet in the long term management of inflammatory bowel disease and intestinal failure

A 35-year-old man, who had spent 10 1/2 out of 18 months in hospital, has required repeated courses of intravenous nutrition (IVN) because of nutritional failure due to severe inflammatory bowel disease. He has been maintained on a nocturnal pump-fed liquid diet supplementing his day-time oral diet for five months, four of which have been at home. The cost of such therapy is less than with an elemental diet and there are other advantages. This regime has been shown to be nutritionally adequate. The need to assess other cheaper liquid diets in patients with intestinal failure is recognised.

Total parenteral nutrition in the management of Crohn's disease

A review of the recent literature is cited in support of the use of total parenteral nutrition (TPN) in Crohn's disease. The principal indications for this use are described and some of the disadvantages are discussed.

An evaluation of total parenteral nutrition in the management of inflammatory bowel disease

Total parenteral nutrition (TPN) is commonly used in the management of inflammatory bowel disease (IBD). Claims of its effectiveness are conflicting, and most reports have been limited to short-term assessments. We undertook a nonrandomized prospective study of the effects of TPN on the course of IBD in 30 patients whose disease was refractory to medical therapy, 20 with Crohn's disease and 10 with ulcerative colitis. Parameters of nutritional improvement, subjective and objective clinical response during TPN, and long-term outcome were assessed. All but one of the patients gained weight. Seven of the 20 Crohn's patients, including 3 of 4 with fistulas, had no response to TPN. The other 13 had reduction of diarrhea, relief of abdominal pain, and an improved sense of well-being during TPN. On long-term follow-up, five of these patients relapsed and required surgery; five remain improved with active disease controlled by medication 2--24 months later, and three are symptom-free and off all medication 20--48 months later. Clinical improvement during TPN was observed in only four of the 10 ulcerative colitis patients; six required colectomy after 9--24 days of TPN. Of the four responders, one relapsed and had colectomy one month later, two continue to have active disease controlled by medication five and 43 months later, and one has been symptom-free and off all medication for over three years. We conclude that TPN is useful adjunctive therapy for IBD patients requiring bowel rest and nutritional repletion. Dramatic clinical improvement occurs in some patients but is unpredictable.