A century of home parenteral nutrition for Crohn's disease

Long-term outcome of patients with Crohn's disease on home parenteral nutrition

OBJECTIVES

In patients with Crohn's disease (CD) and intestinal failure, home parenteral nutrition (HPN) is a necessary lifesaving treatment. The aim of this study was to investigate the long-term outcomes of patients with CD after initiation of HPN.

METHODS

This study included patients with CD receiving HPN for intestinal failure. The patients were treated at Osaka University Hospital between January 2000 and December 2019. Patients' demographic characteristics, HPN dependence and complications, and mortality were analyzed. HPN dependence was estimated using the Kaplan-Meier method. Cox regression analysis was used for between-group comparisons.

RESULTS

Twenty-one patients with CD received HPN. HPN dependence rates were 85%, 75%, 75%, and 64%, respectively, at 2, 5, 10, and 15 y after HPN initiation. Patients who weaned off HPN exhibited lower rates of immunomodulator therapy and additional intensive CD treatment (P < 0.05). Multivariate analysis revealed that not requiring additional intensive CD treatment was a significant factor in weaning off HPN. Two patients (9%) died, at a median of 14.9 y after HPN initiation, due to HPN-related liver disease and CD-associated carcinoma. Among all patients, 61% experienced catheter-related bloodstream infections (CRBSIs), with an incidence of 0.32/1000 catheter-days. Methicillin-resistant bacteria and Candida spp. each accounted for 27% of all pathogens detected in CRBSI.

CONCLUSIONS

Patients with CD receiving HPN had a good prognosis, despite frequent CRBSIs in which methicillin-resistant bacteria and fungi were common pathogens. Some patients with CD can wean off HPN, even after a long period of HPN treatment. A stable disease condition during HPN might be an important factor for weaning off HPN.

Preoperative Exclusive Total Parental Nutrition is Associated with Clinical and Laboratory Remission in Severe Active Crohn's Disease-A Pilot Study

BACKGROUND

The effect of 1-3 months of preoperative exclusive total parental nutrition (TPN) in active Crohn's disease (CD) patients is not well established. We investigated the efficacy of exclusive TPN in active CD patients.

METHODS

In a retrospective multi-visit study with data according to our standard care therapy, we assessed clinical and laboratory remission to refractory CD with exclusive preoperative TPN. Inclusion required exclusive preoperative home TPN without additional oral intake for 1-3 months prior to planning surgery.

RESULTS

Twenty preoperative CD patients (65% male; 35% female) were on exclusive TPN. The mean age of the cohort was 30.8 ± 11.6 years. Mean duration of preoperative TPN treatment was 73 days (range: 24-142 days). Most patients had terminal ileal (35%) or ileocolonic CD (30%), and with stricturing (B2) phenotype. All 20 patients had significant clinical improvement in all disease activity indices at the end of preoperative TPN (baseline vs. post TPN): HBI 14.5 vs. 4.0 (p = 0.001); BMI 19.2 vs. 19.7 kg/m² (p = 0.017); CRP 57.2 vs. 10.3 mg/L (p = 0.001); Fecal calprotectin (FC) 672 vs. 200 (μg/g); albumin 2.7 vs. 3.6 g/dL (p = 0.001). Two patients (10%) no longer required surgery after completion of exclusive TPN.

CONCLUSION

Exclusive preoperative TPN was found to provide significant improvement in nutritional status, and clinical and laboratory remission in severe active Crohn's patients.

Intestinal failure: a review

Intestinal failure (IF) is the inability of the gut to absorb necessary water, macronutrients (carbohydrate, protein, and fat), micronutrients, and electrolytes sufficient to sustain life and requiring intravenous supplementation or replacement. Acute IF (types 1 and 2) is the initial phase of the illness and may last for weeks to a few months, and chronic IF (type 3) from months to years. The challenge of caring for patients with IF is not merely the management of the underlying condition leading to IF or the correct provision of appropriate nutrition or both but also the prevention of complications, whether thromboembolic phenomenon (for example, venous occlusion), central venous catheter-related bloodstream infection, IF-associated liver disease, or metabolic bone disease. This review looks at recent questions regarding chronic IF (type 3), its diagnosis and management, the role of the multidisciplinary team, and novel therapies, including hormonal treatment for short bowel syndrome but also surgical options for intestinal lengthening and intestinal transplant.

Jonathan E. Rhoads Lecture: Experiences and Observations in the Management of Patients With Short Bowel Syndrome

In an era before parenteral nutrition (PN) was made practical by Stanley Dudrick, MD, and his colleagues, patients with prolonged intestinal dysfunction or short bowel syndrome would often die of malnutrition or its sequelae. Over the past 4 decades, the treatment of patients with short bowel syndrome had progressed from PN in the hospital to small bowel transplantation. Multimodal therapies have evolved in the management of these patients, including specialized diets and enteral supplements, oral rehydration fluids, antisecretory medication, and the use of growth factors. Home PN is lifesaving when these modalities are ineffective and a surgical procedure to restore or enhance gastrointestinal tract length or absorptive potential is impossible. Small intestine transplantation had been used to salvage those patients who developed life-threatening complications of home PN, but as the survival after intestinal transplant has approached that of liver transplantation, it may soon be considered as primary therapy for patients with short bowel syndrome. This article presents the author's experiences and observations after a 4-decade experience in the management of patients with short bowel syndrome.

Epidemiology and risk factors for bloodstream infections in a home parenteral nutrition program

BACKGROUND

An increasing number of patients with intestinal failure are receiving home parenteral nutrition (HPN). Associated complications include bloodstream infections (BSIs), but data on rates and risk factors for HPN-related BSIs are scarce.

METHODS

A retrospective review was conducted of patients enrolled in the regional HPN program between 2001 and 2008. Demographic information and data on indication for HPN, duration of PN therapy, type and date of insertion of central venous access device, and blood culture results were recorded.

RESULTS

In total, 155 patients (165 courses of HPN) were included for a total of 45,876 catheter days. The mean patient age was 49 years, and 105 (64%) patients were female. A total of 105 organisms were cultured from 93 distinct episodes of BSIs. The rate of BSI was found to be 2.0 per 1000 catheter days, but excluding BSIs with a single positive culture of coagulase-negative staphylococcus and diphtheroid bacilli, the rate of infection was 1.4 per 1000 catheter days. Male sex and underlying malignancy were significant predictors of BSI, with hazard ratios of 1.69 (95% confidence interval [CI], 1.14-2.60; P = .009) and 2.38 (95% CI, 1.53-3.50; P < .001).

CONCLUSION

In a large heterogeneous group of HPN patients, the BSI rate ranged between 1.4 and 2.0 infections per 1000 catheter days. Isolated organisms were similar to those found in hospitalized patients. Male sex and underlying malignancy were significant risk factors for BSI. These high-risk patients are likely to benefit from interventions aimed at reducing BSIs.

Evidence-based clinical practice guidelines for Crohn's disease, integrated with formal consensus of experts in Japan

Crohn's disease is a disorder of unknown etiology and complicated pathogenesis. A substantial amount of evidence has accumulated recently and has been applied to clinical practice. The present guidelines were developed based on recent evidence and the formal consensus of experts relevant to this disease. Here we provide an overview of these guidelines, as follows. Target disease: Crohn's disease Users: Clinical practitioners in internal medicine, surgery, gastroenterology, and general practice Purpose: To provide appropriate clinical indicators to practitioners Scope of clinical indicators: Concept of Crohn's disease, epidemiology, classifications, diagnosis, treatment, follow up, and special situations Intervention: Diagnosis (interview, physical examination, clinical laboratory tests, imaging, and pathology) and treatment (lifestyle guidance, drug therapy, nutritional therapy, surgery, etc.) Outcome assessment: Attenuation of symptoms, induction and maintenance of remission, imaging findings, quality of life (QOL), prevention of complications and harm of therapy Methods for developing these guidelines: Described in the text Basis of recommendations: Integration of evidence level and consensus of experts Cost-benefit analysis: Not implemented Evaluation of effectiveness: Yet to be confirmed Status of guidelines: Updated version of the first Guidelines published in 2010 Publication sources: Printed publication available and electronic information in preparation Patient information: Not available Date of publication: October 2011 These guidelines were intended primarily to be used by practitioners in Japan, and the goal of these guidelines is to improve the outcomes of patients with Crohn's disease.

Epidemiology of catheter-related infections in adult patients receiving home parenteral nutrition: a systematic review

BACKGROUND AND AIMS

Catheter-related infection (CRI) is the most common and serious complication for adult patients receiving home parenteral nutrition (HPN). Our aim is to provide epidemiological data on infection incidence, infecting pathogens and contributing risk factors.

METHODS

Four electronic databases (Embase, Medline, IPA, CINAHL) were screened for eligible studies published between 1970 and March 2012. Methodological quality was evaluated and terminology/definitions were re-categorized.

RESULTS

Thirty-nine studies were included. Extensive variability was observed in terminology/definitions as well as in expression of CRI rate. After correct interpretation of definitions, overall catheter-related bloodstream infection rate (CRBSI) ranged between 0.38 and 4.58 episodes/1000 catheter days (median 1.31). Gram-positive bacteria of human skin flora caused more than half of infections. An analysis of the reported risk factors showed that the origin of a CRBSI is often multifactorial. The risk factors were related to the patient, the venous access device, the education, HPN therapy and follow-up.

CONCLUSIONS

This review on CRI in adult HPN patients revealed that included studies are of low quality and used poorly described risk factors and different definitions. The human skin flora caused most of infections; therefore, hand hygiene and training remain essential.

Outcome on home parenteral nutrition for benign intestinal failure: a review of the literature and benchmarking with the European prospective survey of ESPEN

BACKGROUND & AIMS

Indications and timing for referral for intestinal transplantation (ITx) were investigated through a review of the literature on home parenteral nutrition (HPN) for benign intestinal failure and a benchmarking to the results of a prospective European survey which evaluated the appropriateness of the current indications for ITx.

METHODS

Manuscripts reporting outcomes of adults and children on HPN were retrieved through a PubMed search. Data from the European survey were compared with those on HPN reported in the literature, and with those on ITx reported by the USA registry and by the Pittsburgh center.

RESULTS

HPN is a safe treatment with a high probability of survival. The risk of death during HPN is increased by the absence of a specialist team, and appears greater during the early period of treatment. Survival probability is decreased in patients with: age >40 or <2 years, very short bowel remnant, presence of a stoma, chronic intestinal pseudo-obstruction of myopathic origin, systemic sclerosis, radiation enteritis, intra-abdominal desmoids, necrotizing enterocolitis, congenital mucosal diseases. Liver failure is the HPN-related complication with the greatest risk of death. Death related to venous catheter complications is rare. The benchmarking supported the results of the European survey.

Risk factors for short bowel syndrome in patients with Crohn's disease

PURPOSE

Patients with Crohn's disease (CD) often need home parenteral nutrition for short bowel syndrome (SBS), as a result of frequent surgery and extended bowel resections. We conducted this study to evaluate the influence of the patient's condition on the occurrence of SBS in CD.

METHODS

The subjects of this study were 721 patients, who underwent bowel resections for CD at Hyogo College of Medicine between September 1974 and September 2010. The collective total of bowel resection operations was 1286. The possible risk factors for SBS were analyzed by univariate and multivariate logistic regression analyses to determine their predictive significance.

RESULTS

SBS was diagnosed in 24 patients. A stepwise logistic regression model revealed that penetrating type (odds ratio 14.9, p = 0.02), remaining small intestine <200 cm (odds ratio 141.4, p < 0.01), ostomy creation (odds ratio 7.5, p = 0.03), and post-total colectomy (odds ratio 17.6, p < 0.01) were independent risk factors for SBS.

CONCLUSION

These results indicate that the length of remaining small bowel is closely related to SBS in patients who have undergone surgery for CD. At least 200 cm of small bowel should be preserved to prevent SBS when total colectomy and ostomy creation are performed for CD.

Nutritional status and nutritional therapy in inflammatory bowel diseases

Underweight and specific nutrient deficiencies are frequent in adult patients with inflammatory bowel disease (IBD). In addition, a significant number of children with IBD, especially Crohn’s disease (CD) have impaired linear growth. Nutrition has an important role in the management of IBD. In adults with CD, enteral nutrition (EN) is effective in inducing clinical remission of IBD, although it is less efficient than corticosteroids. Exclusive EN is an established primary therapy for pediatric CD. Limited data suggests that EN is as efficient as corticosteroids for induction of remission. Additional advantages of nutritional therapy are control of inflammation, mucosal healing, positive benefits to growth and overall nutritional status with minimal adverse effects. The available evidence suggests that supplementary EN may be effective also for maintenance of remission in CD. More studies are needed to confirm these findings. However, EN supplementation could be considered as an alternative or as an adjunct to maintenance drug therapy in CD. EN does not have a primary therapeutic role in ulcerative colitis. Specific compositions of enteral diets-elemental diets or diets containing specific components-were not shown to have any advantage over standard polymeric diets and their place in the treatment of CD or UC need further evaluation. Recent theories suggest that diet may be implicated in the etiology of IBD, however there are no proven dietary approaches to reduce the risk of developing IBD.

A review of the instruments used to assess the quality of life of adult patients with chronic intestinal failure receiving parenteral nutrition at home

Home parenteral nutrition is an established method of supporting patients with intestinal failure, but this treatment may be life long and imposes severe restrictions on daily life. Impact on quality of life is an important outcome when considering the management of home parenteral nutrition patients. This paper reviews studies in which the quality of life of patients receiving home parenteral nutrition has been assessed. A systematic search of electronic databases and relevant publications was undertaken to identify generic or treatment-specific questionnaires used with home parenteral nutrition patients. Many of the thirty-four reports discovered were small studies. Nineteen used non-specific generic instruments, eight used non-validated questionnaires, four used a combination of both, and three did not use any formal tool. Few systematic patterns emerged. There are few available data on the quality of life of home parenteral nutrition patients, and there is a need for standardised, scientifically validated, treatment-specific instruments to measure quality of life in this population.

A review of the quality of life of adult patients treated with long-term parenteral nutrition

BACKGROUND AND AIMS

Some previous studies have assessed quality of life (QoL) in home parenteral nutrition (HPN) using generic instruments or non-validated questionnaires. A systematic search of electronic databases and relevant publications identified 50 publications. This paper reviews the QoL of patients receiving HPN and discusses the factors affecting QoL.

RESULTS

There is little available data about the QoL of HPN patients. Both HPN and the underlying disease may affect QoL, and an evaluation of QoL requires the separation of these two issues.

CONCLUSIONS

There is a need for a standardised, scientifically validated, treatment-specific instrument to measure QoL in this population. The use of a treatment-specific QoL questionnaire should become part of the routine clinical management of HPN patients.

Intestinal transplantation: an update

PURPOSE OF REVIEW

As outcomes with intestinal transplantation continue to improve, its role in the management of intestinal failure patients becomes clearer. Some intestinal failure patients do well with long-term total parenteral nutrition (TPN), while others develop life-threatening complications and need to be evaluated for intestinal transplants (ITs). The purpose of this review is to update the current status of intestinal transplantation and its role in the management of intestinal failure patients.

RECENT FINDINGS

Current outcomes indicate that intestinal transplants should be considered earlier in intestinal failure patients that develop liver injury, to prevent irreversible liver disease that would mandate a simultaneous liver transplant. Due to the small bowel (SB) graft's unique immunobiologic features, it is especially challenging to transplant successfully. Although new immunosuppressive strategies have been developed that appear to improve short-term results, their impact on long-term outcomes has yet to be shown. A better understanding of the interactions that occur between the SB's inherent immune system and its luminal flora may be required to devise strategies that will significantly curtail the SB graft's immunogenicity.

SUMMARY

Intestinal transplantation remains a significant challenge. Ongoing efforts to better define the parameters that best predict total parenteral nutrition failure and the unique mechanisms that influence small bowel allograft outcomes are necessary before a broader application of small bowel transplantation can be indicated.

The SF-36 instrument for the follow-up of health-related quality-of-life assessment of patients undergoing home parenteral nutrition for benign disease

INTRODUCTION

The non-disease-specific SF-36 instrument was applied to detect changes in quality of life among patients at a single center who were receiving home parenteral nutrition (HPN) for intestinal failure.

METHODS

All HPN patients completed the questionnaire during routine visits. The SF-36 examines eight domains (scores: 0% to 100%): physical functioning (PF), role-functioning physical (RP), body pain (BP), general health (GH), vitality (VT), social functioning (SF), as well as role-functioning emotional (RE) and mental health (MH). Patient responses were standardized for the sex- and age-matched group scores of the healthy population by calculating the Z-score: (healthy population mean score - patient raw score)/healthy population standard deviation (reduced value: Z-score < -1). A difference in a domain score was considered significant in the individual patient if it was greater than the 90% confidence interval for healthy subjects and if it produced a change in Z-score category. General, sociodemographic, underlying disease and HPN-related factors were collected.

RESULTS

For 31 enrolled adult patients, the baseline mean Z-score was reduced in five domains: PF, RP, BP, GH and SF. Twenty patients underwent a second SF-36 assessment 10 +/- 2 months later: the HRQOL worsened in eight and improved in 10 (no. worsened domains > no. improved or vice versa). The worsened subgroup showed a decrease in body mass index (P =.104), an increase in the number of HPN infusions per week (P =.065), and a greater incidence of intestinal motility disorders (P =.161), of liquid oral diet (P =.027), and of nycturia (P =.028).

CONCLUSIONS

The SF-36 instrument reflecting the generic HRQOL assessment may be a suitable tool for patients on HPN.

Management of complications in patients receiving home parenteral nutrition

Patients receiving long-term home parenteral nutrition tend to fall under the care of adult and pediatric gastroenterologists. This article reviews the management of potential infectious, mechanical and metabolic complications and describes common psychosocial issues related to the therapy. The point at which to refer the patient to an intestinal failure program offering autologous bowel reconstruction and small bowel transplantation is discussed.

Safety and efficacy of home parenteral nutrition for chronic intestinal failure: a 16-year experience at a single centre

BACKGROUND

Comparisons between safety and efficacy of home parenteral nutrition and of intestinal transplantation for treatment of chronic intestinal failure derived from observational studies.

AIMS

To present the 16-year experience of home parenteral nutrition by the Chronic Intestinal Failure Centre of Bologna University.

PATIENTS

A total of 40 adult patients were enrolled between 1986 and 2001.

METHODS

Safety indices: survival and cause of death, catheter-related bloodstream infection, deep vein thrombosis, liver disease. Efficacy indices: nutritional and rehabilitation status, quality of life (SF36 instrument), re-hospitalisation rate.

STATISTICS

Kaplan-Maier analysis and Cox model for survival probability and risk factors; logistic regression for catheter-related bloodstream infection risk factors.

RESULTS

Survival rates at 1, 3 and 5 years were 97, 82 and 67% respectively. Survival was higher in patients < or = 40 years. One death was home parenteral nutrition-related. Incidence of catheter-related bloodstream infection: 0.30/year home parenteral nutrition, was lower in patients treated by a specialized nursing protocol. Incidence of deep vein thrombosis was 0.05/year home parenteral nutrition. Hepatosteatosis occurred in 55%. Body weight remained stable or increased in 80%. Rehabilitation was total or partial in 74%. Re-hospitalisation rate was 0.70/year home parenteral nutrition. Quality of life scored significantly lower than in healthy populations in six out of eight domains.

CONCLUSIONS

Home parenteral nutrition is a safe and efficacious therapy for chronic intestinal failure. Survival compares favourably with survival after intestinal transplantation.

Review article: nutrition and adult inflammatory bowel disease

Major advances in the understanding of the aetio-pathogenesis and genetics of inflammatory bowel disease have been accompanied by an escalation in the sophistication of immunomodulatory inflammatory bowel disease therapeutics. However, the basic 'triple' therapy (5-aminosalicylates, corticosteroids, azathioprine) and nutrition have maintained their central role in the management of patients with inflammatory bowel disease over recent decades. This review provides an overview of the supportive and therapeutic perspectives of nutrition in adult inflammatory bowel disease. The objective of supportive nutrition is to correct malnutrition in terms of calorie intake or specific macro- or micronutrients. Of particular clinical relevance is deficiency in calcium, vitamin D, folate, vitamin B12 and zinc. There is justifiably a growing sense of unease amongst clinicians and patients with regard to the long-term use of corticosteroids in inflammatory bowel disease. This, rather than arguments about efficacy, should be the catalyst for revisiting the use of enteral nutrition as primary treatment in Crohn's disease. Treatment failure is usually related to a failure to comply with enteral nutrition. Potential factors that militate against successful completion of enteral nutrition are feed palatability, inability to stay on a solid-free diet for weeks, social inconvenience and transient feed-related adverse reactions. Actions that can be taken to improve treatment outcome include the provision of good support from dietitians and clinicians for the duration of treatment and the subsequent 'weaning' period. There is evidence to support a gradual return to a normal diet through exclusion-re-introduction or other dietary regimen following the completion of enteral nutrition to increase remission rates. We also review the evidence for emerging therapies, such as glutamine, growth factors and short-chain fatty acids. The future may see the evolution of enteral nutrition into an important therapeutic strategy, and the design of a 'Crohn's disease-specific formulation' that is individually tailored, acceptable to patients, cost-effective, free from adverse side-effects and combines enteral nutrition with novel pre- and pro-biotics and other factors.

Recognition, prevention, and treatment of home total parenteral nutrition central venous access complications

Placement of central venous catheters for long-term administration of i.v. solutions in the home is associated with potential immediate and long-term complications. These complications can seriously threaten a patient's well-being and greatly increase costs. An understanding of anatomy and careful attention to detail can minimize the immediate complications, whereas thorough patient education and strict aseptic care techniques can reduce long-term complications. Early recognition and treatment of complications when they do occur can reduce patient injury and costs. In this document, the incidence, recognition, prevention, and treatment of various immediate and long-term complications will be discussed.

AGA technical review on parenteral nutrition

This literature review and the recommendations therein were prepared for the American Gastroenterological Association Clinical Practice and Practice Economics Committee. The paper was approved by the Committee on September 13, 2001, and by the AGA Governing Board on May 18, 2001.

The role of intestinal transplantation in the management of intestinal failure

Significantly reduced morbidity and mortality is needed before intestinal transplantation will be applicable in most patients with intestinal failure who are on long-term total parenteral nutrition (TPN). However, transplantation does play a role if TPN fails, with failure defined by Medicare as liver failure, frequent line sepsis, major central vein thrombosis, or recurrent dehydration. Of these complications, the relationship between liver failure and subsequent death in high-risk subgroups of long-term TPN patients has been shown clearly. Patients with less than 100 cm of postduodenal small bowel, an end-jejunostomy, no ileocecal valve or cecum, or persistently elevated liver function levels are at high risk for end-stage liver disease (ESLD). Early referral to experienced centers is suggested in these circumstances. High-risk patients may also take part in clinical trials of promising therapies to increase intestinal adaptation and prevent liver failure. Living donors should be considered for transplant candidates to minimize waiting time and optimize HLA matching. ESLD patients need a liver-intestine transplant. Because their waiting-list mortality is very high, their status on the liver waiting list should be elevated if possible. High incidence of early death from sepsis is reported after intestinal transplant, even at experienced centers. Aggressive measures should be taken if uncontrolled sepsis occurs, including discontinuing immunosuppression and removing the graft. Further research is needed in intestinal immunology and in development of strategies to decrease the need for aggressive immunosuppression in these transplant recipients. The ultimate role of intestinal transplantation will be determined by its capacity to show superiority, both in effectiveness and safety, to long-term TPN.

Disseminated intra-abdominal cystic lymphangiomatosis with severe intestinal bleeding. A case report

We describe cystic lymphangiomatosis with intestinal bleeding developing multiple lymphangiomas in the small intestine, mesentery, mesocolon, omentum, retroperitoneum, and spleen. Small intestinal fluorography showed multiple polypoid lesions, mainly in the jejunum. Ultrasonography, computed tomography, and magnetic resonance imaging showed diffuse cystic tumors in the mesentery and spleen. Cystic lymphangiomatosis was proved by histologic findings of the biopsied specimen at laparotomy.

Surgical therapy for Crohn's disease of the colon and rectum

Crohn's disease remains incurable by either medical or surgical treatment. Both physician and surgeon must work together with the common objective of restoring health by eliminating or alleviating the complications of Crohn's disease. From the surgeon's viewpoint, operation is performed for complications of the disease or for failure of medical management. Although aggressive surgical excision of affected bowel rids the patient of disease for a period of time, the beneficial effects of operation have to be considered in the context that disease recurrence is always a possibility and that reoperation for such complications may be necessary. The aim of the surgeon is to deal with the current problem as simply as possible and to maintain a long-term, strategic view of the disease process with the understanding that what is done today may affect the patient for life.

Effect of intervention in inflammatory bowel disease on health-related quality of life: a critical review

Health-related quality of life (HRQOL) is a quantitative measurement of subjective perception of health state, including emotional and social aspects. It can be reliably measured with several valid instruments. Previous reviews of the literature suggested inadequate attention to HRQOL in studies of interventions in inflammatory bowel disease.

PURPOSE

This study was undertaken to assess the current status of the quality of measurement of HRQOL in studies of inflammatory bowel disease and to review the clinical conclusions warranted by the literature.

METHOD

Medicine was searched for articles relating to ulcerative colitis, Crohn's disease, or inflammatory bowel disease and quality of life since 1981. The articles found were reviewed for citations of further articles. The adequacy of HRQOL measure was assessed and graded, and the study design was categorized to assess the strength of the literature on the whole.

RESULTS

A trend was found toward higher quality of HRQOL measurement in the period 1988 to 1994 compared with 1981 to 1987. Most of the improvement was because of increased use of standardized and multidomain but unvalidated and unpublished questionnaires for measurement.

CONCLUSIONS

Confidence in the following clinical conclusions in studies of surgical interventions in inflammatory bowel disease is limited by study design: that pelvic pouch is not inferior to ileostomy, that specific domains of HRQOL are differentially affected by different surgical procedures, and (with less confidence) that surgery is helpful in Crohn's disease. Medical studies have demonstrated that high quality HRQOL measures can be integrated into randomized, prospective trials. Clinically equivalent treatments have shown differential effects or HRQOL: 9 mg daily of budesonide is superior to 15 mg, and hydrocortisone foam enemas are superior to prednisolone. Home parenteral nutrition has received modest support, limited again by study design. It is recommended that standard tests of HRQOL be used to increase comparability of studies and to increase the quality of this literature in general. In particular the Inflammatory Bowel Disease Questionnaire, Rating Form of Inflammatory Bowel Disease Concerns, and Direct Questioning of Objectives are recommended.

A managed care model for home infusion therapy

Home infusion therapy began in response to the medical needs of the patients. In the traditional model, products and services were delivered in the home on a physician's prescription. Limitations related to medical quality management and cost were recognized in this model. Because of these limitations, the changes that continue to occur in health care delivery and the increase in number and acuity of patients requiring non-hospital services, a managed care model was conceived and implemented at the University of Minnesota Medical School and Hospital. This model emphasizes physician-based case management, total quality management, a point of contact medical information system, outcomes assessment and management, and research and education activities designed to evaluate and improve home infusion therapies. The model was implemented through a public-private partnership. This application of managed care to home infusion therapies is described in this communication.

TOTAL PARENTERAL NUTRITION

Total parenteral nutrition has been used in clinical practice for over a quarter of a century. It has revolutionized the management of potentially fatal condition like the short bowel syndrome in infants as well as adults. Refinements in techniques have led to development of sophisticated catheters and delivery systems. Better understanding of human nutrition and metabolic processes has lead to formulation of scientific parenteral solutions to suit specific situations. This article addresses the role of total parenteral nutrition in modern surgical practice.

Nutrition support in inflammatory bowel disease

The mechanisms of nutritional therapy in inflammatory bowel disease have not been thoroughly established. It is likely that a further understanding of the underlying disease process will allow better understanding of these forms of therapy, with a sounder rationale for the construction of specific diet constituents for therapy. Regardless, nutritional therapy is likely to be multidimensional, and various forms may affect different aspects of the disease process. Decreased inflammatory factors, decreased antigenic stimuli, provision of essential nutrients, improved immune function, and other factors may all be of varying importance in different patients with inflammatory bowel disease. Little work has been done on the role of diet therapy in the long-term treatment of patients with inflammatory bowel disease as a method of preventing relapse. Parenteral nutrition and elemental diets appear to have limited roles in this area. Some investigation has been done to see if minor modifications of the normal diet can prolong remission periods. Low-fiber diets are frequently recommended for patients with strictures. Whether this has any significant effect on symptoms, inflammation, or complications is unclear. Heaton et al suggested that a high-fiber, unrefined carbohydrate diet resulted in fewer and shorter hospitalizations. In a prospective follow-up study by Ritchie et al, however, these results were not able to be reproduced. Exclusion diets have also been suggested as a means of reducing relapse rates in patients with Crohn's disease. In a small, randomized, controlled trial of an exclusion diet versus an unrefined carbohydrate, fiber-rich diet, there were significantly fewer relapses among the patients treated with the exclusion diet at 6 months. These diets require intensive patient cooperation, but the potential side effects are minimal. Clearly, these findings need to be reproduced in large, prospective, randomized, controlled studies before widespread use can be advocated. A great deal of data exists on the use of nutritional supplementation in the treatment of inflammatory bowel disease, although little of it is in the form of large, randomized, controlled studies. Nutritional manipulation currently has a limited role in patients with ulcerative colitis; a much broader role exists in patients with Crohn's disease. The mechanisms by which nutritional therapy affects these diseases may include a combination of factors--decreased antigenic exposure, improved immune function, and provision of essential nutrients and calories needed for bowel regeneration.(ABSTRACT TRUNCATED AT 400 WORDS)

Home parenteral nutrition after near total enterectomy

Six patients with extreme short bowel syndrome (4.2 +/- 4.9 cm of residual small bowel) were provided home parenteral nutrition (HPN) for 14,397 days. The average age at onset of HPN was 38 years (18-64 years). Patients maintained body weight at 97% of ideal (86-112%) with mean serum albumin of 3.7 +/- 0.6 g/dL (normal 3.5-5.8 g/dL), serum transferrin of 341 +/- 104 mg/dL (normal 200-400 mg/dL), and mean serum pre-albumin of 27.5 +/- 12.6 mg/dL (normal 16.6-43 mg/dL). Hospital admission for HPN-related complications was required 10.3 times/patient for a total of 864 hospital days and was catheter related in 71% of episodes. Catheter sepsis occurred once per 436 catheter days and required catheter removal in only 33% of instances. Five patients were able to resume an oral diet, five had returned to work or school, and three were married with family. HPN allowed return to a quality productive life with acceptable morbidity following catastrophic massive bowel resection.

The role of home parenteral nutrition in the management of intestinal failure — report of 400 cases

Between 1977 and January 1991, 400 patients were entered on the United Kingdom Home Parenteral Nutrition (HPN) Register. Almost half suffered from Crohn's disease. Most commenced HPN while between 20-50 years of age. In terms of life quality while on HPN, most (63%) were able to work or look after their families unaided. A further 89 (22%) were able to cope with HPN independently. 221 patients ceased HPN during the study period, mostly (41%) due to intestinal adaptation. Of 69 patients who died, over half (57%) did so due to disease progression. Complications of HPN resulted in death in 22% of this subgroup. In terms of specific disease groups, those with Crohn's disease had the lowest mortality rate (8%).

Haematological disorders and lung alveolar macrophage function following total parenteral nutrition in rats

Alterations in haematological parameters have been reported both clinically and experimentally following administration of total parenteral nutrition (TPN). Fat emulsions also affect function of the mononuclear phagocytic system. We have examined haematological parameters and pulmonary alveolar macrophages in rats fed intravenously with the individual components of TPN; a 20 % fat emulsion (Intralipid) and an amino acid solution (Vamin-Glucos), for 1, 3 and 7 days as a continuous infusion. The control groups were given saline infusion for the same periods of time. Haemoglobin, haematocrit, red blood cells, leukocytes, leukocyte superoxide anion production, leukocyte distribution, platelets and platelet aggregation were measured. Lung lavage fluid was examined for alveolar macrophage concentration and procoagulant activity of macrophages. Several of the animals in the experimental groups developed superior caval vein thrombosis. Both experimental groups developed anaemia after 7 days of infusion. Thrombocytopaenia occurred in both experimental groups after 3 and 7 days of infusion. Platelet aggregation decreased already after 1 day of infusion. We did not observe any alteration in counts, distribution in peripheral blood, or superoxide production of leukocytes. The concentration of alveolar macrophages in the lung lavage fluid increased in the experimental groups. The tissue factor activity of the alveolar macrophages increased in the group receiving Intralipid. Our observations are consistent with a granulomatous inflammation reaction.

Nutrition support in inflammatory bowel disease

Many patients with the inflammatory bowel diseases, Crohn's disease, or ulcerative colitis have significant protein-calorie malnutrition and micronutrient deficiencies. Factors that contribute to these nutritional deficits include inadequate nutrient intake, malabsorption, excessive nutrient secretion across the diseased gastrointestinal tract, drug-nutrient interactions, and increased nutrient requirements. In this review, the use of enteral and parenteral nutrition support as primary therapy for active Crohn's disease and ulcerative colitis is discussed. Other roles for nutrition support in patients with inflammatory bowel disease, including preoperative nutrition support, nutritional treatment of intestinal fistulas and growth retardation, and home parenteral nutrition for gut failure, are also reviewed.

Nutritional support in patients with inflammatory bowel disease

Total parenteral nutrition with bowel rest has been used as primary therapy to reduce disease activity and achieve remission in patients with inflammatory bowel disease (IBD). However, results are short-lived and similar success can be attained through total enteral nutrition with highly specialized elemental or semielemental formulas. Enteral nutrition costs less than parenteral nutrition, maintains gut integrity, stimulates immunocompetence, and helps to control symptoms and overall disease activity. Increased use of enteral formulas can be expected in the future. The role of diet in management of IBD is currently under scrutiny. No one diet is appropriate for all patients, but restriction of fat, fiber, lactose, or oxalate may be necessary to help alleviate symptoms and minimize the risk of complications.