Review article: nutrition and adult inflammatory bowel disease

Factors associated with decreased ovarian reserve in Crohn's disease: A systematic review and meta-analysis

INTRODUCTION

It is still unclear whether Crohn's disease (CD) might be associated with diminished ovarian reserve (OvR) and factors influencing anti-Mullerian hormone (AMH) levels in CD are poorly known.

MATERIAL AND METHODS

We conducted a comprehensive literature search of multiple electronic databases from inception to June 2022 to identify all studies reporting AMH levels or factors associated with diminished OvR in patients with CD.

RESULTS

Of the 48 studies identified in our search, eight (including 418 patients with CD) were finally included. The mean difference (95% confidence interval [CI]) in the AMH level between pooled CD patients and controls was -0.56 (-1.14 to 0.03) (p = 0.06). A history of CD-related surgery was not associated with a lower OvR (odds ratio, OR [95% CI] 1.34, [0.66-2.7]; p = 0.4). While disease activity and perianal disease seems associated with a low OvR, disease location (L2 vs. L1, OR [95% CI] = 95% CI [0.47-7.4]; p = 0.4) and L3 vs. L1 (OR [95% CI] = 1.44 [0.67-3.12]; p = 0.3), CD medication, and disease behavior were not.

CONCLUSIONS

Our systematic review and meta-analysis did not identify a significantly low OvR in patients with CD. Contrary to CD-related surgery risk factor, active disease was associated lower AMH levels.

Oral nutritional supplements improve clinical outcomes and are cost-effective for hospitalized patients in China

OBJECTIVE

This study assessed the therapeutic benefits and modeled the cost-effectiveness of oral nutritional supplements (ONS) in China.

METHODS

Data were collected from 27 152 adult inpatients between January 1, 2018, and December 31, 2020. Propensity score matching was used for balancing the baseline characteristics between the ONS group and non-ONS group. A decision-tree model was developed to assess the cost-effectiveness of ONS for patients with nutritional risk, and the incremental cost-effectiveness ratio was the metric to determine the most cost-effective strategy. One-way sensitivity and probabilistic sensitivity analyses were conducted to assess the model's stability. In addition, subgroup analysis was conducted based on clinical characteristics. Differences in clinical outcomes between the groups were compared using Student's t test, Mann-Whitney U test, or chi-square test.

RESULTS

The ONS group displayed significantly lower levels of prealbumin, albumin, hemoglobin, and BMI than the non-ONS group at admission. The incidence of malignant tumors, intestinal obstruction, and inflammatory bowel disease was significantly higher in the ONS group than the non-ONS group. The ONS group had a significantly higher effective rate than the non-ONS group (51.7% versus 50.3%, P < 0.05). Analysis of the decision-tree model revealed that the ONS group experienced an increase in cost of 19 850.96 yuan but achieved an additional 1.3406 effectiveness rate, resulting in an incremental cost-effectiveness ratio of 14 807.51, which fell below China's 2020 per capita gross domestic product of 71 965 yuan. Sensitivity analysis further confirmed the robustness of the model.

CONCLUSIONS

ONS are demonstrated a high rate of efficacy, although patients currently using ONS are typically in a severe disease state. In addition, ONS is cost-effective. We suggest that the reimbursement coverage of ONS be expanded to include in-hospital patients who are at high nutritional risk.

The Effect of Protein Nutritional Support on Inflammatory Bowel Disease and Its Potential Mechanisms

Inflammatory bowel disease (IBD), a complex chronic inflammatory bowel disorder that includes Crohn's disease (CD) and Ulcerative Colitis (UC), has become a globally increasing health concern. Nutrition, as an important factor influencing the occurrence and development of IBD, has attracted more and more attention. As the most important nutrient, protein can not only provide energy and nutrition required by patients, but also help repair damaged intestinal tissue, enhance immunity, and thus alleviate inflammation. Numerous studies have shown that protein nutritional support plays a significant role in the treatment and remission of IBD. This article presents a comprehensive review of the pathogenesis of IBD and analyzes and summarizes the potential mechanisms of protein nutritional support in IBD. Additionally, it provides an overview of the clinical effects of protein nutritional support in IBD and its impact on clinical complications. Research findings reveal that protein nutritional support demonstrates significant benefits in improving clinical symptoms, reducing the risk of complications, and improving quality of life in IBD patients. Therefore, protein nutritional support is expected to provide a new approach for the treatment of IBD.

Micronutrient deficiencies in inflammatory bowel disease: an incidence analysis

BACKGROUND

Micronutrient deficiencies associated with malnutrition in patients with inflammatory bowel disease (IBD) can lead to complications including anemia, coagulopathy, poor wound healing, and colorectal cancer. This study aimed to investigate micronutrient deficiencies (copper, vitamins A, B9, E, and K) in IBD patients and highlight associated symptoms to aid in the recognition of micronutrient deficiencies.

METHODS

A retrospective electronic chart review was performed on adults diagnosed with Crohn's disease or ulcerative colitis hospitalized at a tertiary care center for IBD flare between January 2013 and June 2017. Patients with serum or whole blood micronutrient levels were included. Pregnant and incarcerated patients were excluded.

RESULTS

A total of 611 IBD patients (440 Crohn's disease, 171 ulcerative colitis) met the inclusion criteria. Micronutrients were assessed in a subset of IBD patients (copper: 12.3%, A: 10.1%, B9 : 95.9%, E: 10.3%, and K: 4.6%). Overall, 10.1% of patients had micronutrient deficiencies. The proportion of patients with copper, A, B9, E, and K deficiencies were 25.4, 53.3, 1.9, 23.7, and 29.4% for Crohn's disease and 50, 52.9, 1.2, 43.8, and 18.2% for ulcerative colitis, respectively. The most common symptoms or historical features associated with micronutrient deficiency were anemia (copper, B9), muscle weakness (copper, E) thrombocytopenia, fatigue (copper, B9), diarrhea (B9), dry skin, hyperkeratosis, pruritus, significant weight loss, elevated C-reactive protein (A), bleeding, and osteoporosis (K).

CONCLUSION

Micronutrient deficiencies are common in IBD patients, yet they are not routinely assessed. Copper, vitamins A, E, and K deficiencies are particularly underrecognized. Associated historical features should raise suspicion and prompt assessment and treatment.

Multimodal Prehabilitation for Patients with Crohn's Disease Scheduled for Major Surgery: A Narrative Review

Approximately 15-50% of patients with Crohn's disease (CD) will require surgery within ten years following the diagnosis. The management of modifiable risk factors before surgery is essential to reduce postoperative complications and to promote a better postoperative recovery. Preoperative malnutrition reduced functional capacity, sarcopenia, immunosuppressive medications, anemia, and psychological distress are frequently present in CD patients. Multimodal prehabilitation consists of nutritional, functional, medical, and psychological interventions implemented before surgery, aiming at optimizing preoperative status and improve postoperative recovery. Currently, studies evaluating the effect of multimodal prehabilitation on postoperative outcomes specifically in CD are lacking. Some studies have investigated the effect of a single prehabilitation intervention, of which nutritional optimization is the most investigated. The aim of this narrative review is to present the physiologic rationale supporting multimodal surgical prehabilitation in CD patients waiting for surgery, and to describe its main components to facilitate their adoption in the preoperative standard of care.

Calcium deficiency is associated with malnutrition risk in patients with inflammatory bowel disease

BACKGROUND AND AIM

Patients with inflammatory bowel disease (IBD) often have the condition of malnutrition, which can be presented as sarcopenia, micronutrient deficiencies, etc. Trace elements (magnesium, calcium, iron, copper, zinc, plumbum and manganese) belonging to micronutrients, are greatly vital for the assessment of nutritional status in humans. Trace element deficiencies are also the main manifestation of malnutrition. Calcium (Ca) has been proved to play an important part in maintaining body homeostasis and regulating cellular function. However, there are still a lack of studies on the association between malnutrition and Ca deficiency in IBD. This research aimed to investigate the role of Ca for malnutrition in IBD patients.

METHODS

We prospectively collected blood samples from 149 patients and utilized inductively coupled plasma mass spectrometry to examine their venous serum trace element concentrations. Logistic regression analyses were used to investigate the association between Ca and malnutrition. Receiver operating characteristic (ROC) curves were generated to calculate the cutoffs for determination of Ca deficiency.

RESULTS

Except Ca, the concentrations of the other six trace elements presented no statistical significance between non-malnutrition and malnutrition group. In comparison with the non-malnutrition group, the serum concentration of Ca decreased in the malnutrition group (89.36 vs 87.03 mg/L, p = 0.023). With regard to ROC curve, Ca < 87.21 mg/L showed the best discriminative capability with an area of 0.624 (95% CI: 0.520, 0.727, p = 0.023). Multivariate analyses demonstrated that Ca < 87.21 mg/L (OR = 3.393, 95% CI: 1.524, 7.554, p = 0.003) and age (OR = 0.958, 95% CI: 0.926, 0.990, p = 0.011) were associated with malnutrition risk. Serum Ca levels were significantly lower in the malnutrition group than those in the non-malnutrition group among UC patients, those with severe disease state or the female group.

CONCLUSIONS

In patients with IBD, Ca deficiency is an independent factor for high malnutrition risk.

Peri-Operative Optimization of Patients with Crohn's Disease

PURPOSE OF REVIEW

The management of patients with Crohn's disease (CD) undergoing surgery is complex and optimization of modifiable factors perioperatively can improve outcomes. This review focuses on the perioperative management of CD patients undergoing surgery, emphasizing the need for a multi-disciplinary approach.

RECENT FINDINGS

Research highlights the benefits of a comprehensive strategy, involving nutritional optimization, psychological assessment, and addressing septic complications before surgery. Despite many CD patients being on immune-suppressing medications, studies indicate that most of these medications are safe to use and should not delay surgery. However, a personalized approach for each case is needed. This review underscores the importance of multi-disciplinary team led peri-operative management of CD patients. We suggest that this can be done at a dedicated perioperative clinic for prehabilitation, with the potential to enhance outcomes for CD patients undergoing surgery.

Alzheimer's disease-related presenilins are key to intestinal epithelial cell function and gut immune homoeostasis

OBJECTIVE

Mutations in presenilin genes are the major cause of Alzheimer's disease. However, little is known about their expression and function in the gut. In this study, we identify the presenilins Psen1 and Psen2 as key molecules that maintain intestinal homoeostasis.

DESIGN

Human inflammatory bowel disease (IBD) and control samples were analysed for Psen1 expression. Newly generated intestinal epithelium-specific Psen1-deficient, Psen2-deficient and inducible Psen1/Psen2 double-deficient mice were used to dissect the functional role of presenilins in intestinal homoeostasis.

RESULTS

Psen1 expression was regulated in experimental gut inflammation and in patients with IBD. Induced deletion of Psen1 and Psen2 in mice caused rapid weight loss and spontaneous development of intestinal inflammation. Mice exhibited epithelial barrier disruption with bacterial translocation and deregulation of key pathways for nutrient uptake. Wasting disease was independent of gut inflammation and dysbiosis, as depletion of microbiota rescued Psen-deficient animals from spontaneous colitis development but not from weight loss. On a molecular level, intestinal epithelial cells lacking Psen showed impaired Notch signalling and dysregulated epithelial differentiation.

CONCLUSION

Overall, our study provides evidence that Psen1 and Psen2 are important guardians of intestinal homoeostasis and future targets for barrier-promoting therapeutic strategies in IBD.

Subnormal Serum Liver Enzyme Levels: A Review of Pathophysiology and Clinical Significance

Subnormal levels of liver enzymes, below the lower limit of normal on local laboratory reports, can be useful diagnostically. For instance, subnormal levels of aminotransferases can be observed in vitamin B6 deficiency and chronic kidney disease. Subnormal alkaline phosphatase levels may indicate the presence of hypophosphatasia, Wilson's disease, deficiencies of divalent ions, or malnutrition. Subnormal levels of gamma glutamyl transferase may be seen in cases of acute intrahepatic cholestasis, the use of certain medications, and in bone disease. Finally, subnormal levels of 5'-nucleotidase have been reported in lead poisoning and nonspherocytic hemolytic anemia. The aim of this review is to bring attention to the fact that subnormal levels of these enzymes should not be ignored as they may indicate pathological conditions and provide a means of early diagnosis.

Preoperative Exclusive Enteral Nutrition Is Associated With Reduced Skin and Soft Tissue and Intra-abdominal Infections in Patients With Crohn's Disease Undergoing Intestinal Surgery: Results from a Meta-Analysis

BACKGROUND

Malnutrition is an independent risk factor for adverse postoperative outcomes and is common among patients with Crohn's disease (CD). The objective of this meta-analysis was to precisely quantify the association of preoperative exclusive enteral nutrition (EEN) and total parenteral nutrition (TPN) with surgical outcomes in patients undergoing intestinal surgery for CD.

METHODS

PubMed, Embase, and Scopus were queried for comparative studies evaluating the impact of preoperative nutritional support on postoperative outcomes in patients undergoing surgery for CD. Random effects modeling was used to compute pooled estimates of risk difference. Heterogeneity was assessed using I2.

RESULTS

Fourteen studies, all nonrandomized cohort studies, met inclusion criteria for studying EEN. After pooling data from 14 studies (874 EEN treated and 1044 control patients), the relative risk of intra-abdominal septic complications was decreased 2.1-fold in patients receiving preoperative EEN (relative risk 0.47, 95% confidence interval [CI], 0.35-0.63, I2 = 0.0%). After pooling data from 9 studies (638 EEN treated and 819 control patients), the risk of skin and soft tissue infection was decreased 1.6-fold (relative risk 0.63; 95% CI, 0.42-0.94, I2 = 42.7%). No significant differences were identified in duration of surgery, length of bowel resected, or operative blood loss. Among the 9 studies investigating TPN, no significant differences were identified in infectious outcomes.

CONCLUSIONS

Preoperative nutritional optimization with EEN was associated with reduced risk of infectious complications in CD patients undergoing intestinal surgery. Preoperative nutritional support with EEN should be considered for optimizing outcomes in CD patients requiring bowel resection surgery.

The Role of Dietary Habits in the Pathogenesis and Development of Inflammatory Bowel Disease: A Narrative Review

Inflammatory bowel disease (IBD), including Crohn's disease (CD) and ulcerative colitis (UC), is a chronic immune-mediated disease. The incidence of IBD is influenced by various genetic and environmental factors, with dietary habits gaining significant scientific interest. While the role of diet in the pathogenesis and development of IBD is still debated, recent studies have demonstrated its potential impact. However, conflicting findings exist regarding the efficacy of dietary interventions in the treatment and control of IBD. This review aimed to summarize the current understanding of the relationship between diet and IBD, highlighting the different perspectives and reasonings observed in recent studies. Overall, it has been shown that dietary habits play a role in the incidence of IBD, and adopting a controlled dietary approach may help manage the disease. Consequently, diet can be considered a predictive and prognostic factor in IBD.

Zinc Deficiency and Therapeutic Value of Zinc Supplementation in Pediatric Gastrointestinal Diseases

The benefits of zinc in treating certain gastrointestinal (GI) diseases have been recognized for over two decades. This review aims to explore zinc deficiency (ZD) and the potential therapeutic value and safety of zinc supplementation in pediatric GI diseases. A systematic review of published articles on ZD and zinc as adjuvant treatments for GI diseases was conducted using various databases. Children with inflammatory bowel disease (IBD), celiac disease, and those receiving long-term proton pump inhibitor treatments are particularly susceptible to ZD. ZD in children with celiac disease and IBD is attributed to insufficient intake, reduced absorption, and increased intestinal loss as a result of the inflammatory process. Zinc plays a crucial role in maintaining the integrity of the gastric mucosa and exerts a gastroprotective action against gastric lesions. Although considerable evidence supports the use of zinc as adjuvant therapy for certain GI diseases in adults, its use is unspecified in children except for infectious diarrhea. Current evidence suggests that zinc supplementation with well-documented dosages helps reduce the duration of diarrhea in children with acute or persistent diarrhea, while there are no specific guidelines for zinc supplementation in children with IBD and celiac disease. Zinc supplementation appears to be beneficial in peptic ulcer disease or gastroesophageal reflux disease. The available evidence highlights the need for intervention programs to enhance zinc status and reduce the morbidity of certain GI diseases in children.

Role of micronutrients in inflammatory bowel disease

Inflammatory bowel disease (IBD) is an autoimmune intestinal disease that includes ulcerative colitis, Crohn's disease, and indeterminate colitis. Patients with IBD are often at risk for malnutrition, including micronutrient deficiencies, due to dietary restrictions and poor intestinal absorption. Micronutrients, including vitamins and minerals, play an important role in the human body's metabolism and maintenance of tissue functions. This article reviews the role of micronutrients in IBD. Micronutrients can affect the occurrence and progression of IBD by regulating immunity, intestinal flora, oxidative stress, intestinal barrier function, and other aspects. Monitoring and timely supplementation of micronutrients are important to delay progression and improve clinical symptoms in IBD patients.

Rapid assessment of malnutrition based on GLIM diagnosis in Crohn's disease

Background and aims

Malnutrition is strongly linked to adverse outcomes in patients with Crohn's disease (CD). In this study, our objective was to validate the Global Leadership Initiative on Malnutrition (GLIM) criteria and develop a fast and accurate diagnostic approach for identifying malnutrition in CD patients.

Methods

This study assessed 177 CD patients from four general hospitals. The efficacy of the GLIM criteria for the diagnosis of CD malnutrition was compared. By analyzing the independent factors, a nomogram model was derived and internally validated to predict the diagnosis of malnutrition in patients with CD. Model performance was assessed using discrimination and calibration, decision curves, and net benefit analyses.

Results

Compared with the SGA criteria, the GLIM criteria was consistent in sensitivity (88.89%) and specificity (78.43%) [AUC = 0.84; 95% Confidence Interval (CI): 0.77-0.89]. The Harvey-Bradshaw index(HBI) score (OR: 1.58; 95% CI: 1.15-2.18), body mass index (OR: 0.41; 95% CI: 0.27-0.64), and mid-upper arm circumference (OR: 0.68; 95% CI: 0.47-0.9) were independent factors associated with malnutrition. The nomogram was developed based on these indicators showing good discrimination in malnutrition diagnosis (AUC = 0.953; 95% CI: 0.922-0.984), with agreement after calibration curve and decision curve analysis.

Conclusion

The GLIM criteria are appropriate for diagnosing malnutrition in CD patients. The HBI score may be used to diagnose malnutrition in patients with CD and become a possible selection for the GLIM etiologic criteria of inflammation. The HBM nomogram could be a simple, rapid, and efficient method for diagnosing malnutrition in CD patients.

ECCO Topical Review: Roadmap to Optimal Peri-Operative Care in IBD

BACKGROUND AND AIMS

Despite the advances in medical therapies, a significant proportion of patients with inflammatory bowel diseases [IBD] require surgical intervention. This Topical Review aims to offer expert consensus practice recommendations for peri-operative care to optimize outcomes of IBD patients who undergo surgery.

METHODS

A multidisciplinary panel of IBD healthcare providers systematically reviewed aspects relevant to peri-operative care in IBD. Consensus statements were developed using Delphi methodology.

RESULTS

A total of 20 current practice positions were developed following systematic review of the current literature covering use of medication in the peri-operative period, nutritional assessment and intervention, physical and psychological rehabilitation and prehabilitation, and immediate postoperative care.

CONCLUSION

Peri-operative planning and optimization of the patient are imperative to ensure favourable outcomes and reduced morbidity. This Topical Review provides practice recommendations applicable in the peri-operative period in IBD patients undergoing surgery.

Earlier anti-TNF therapy reduces the risk of malnutrition associated with alterations in body composition in patients with Crohn's disease

Background

Anti-TNF therapy has been found to exert an influence on long-term nutritional status and even reverse malnutrition in patients with Crohn's disease.

Aims

to observe the effect of anti-TNF therapy on nutritional status in patients with Crohn's disease, investigate the correlation between the timing of anti-TNF therapy and the human body composition and examine independent body composition factors for predicting malnutrition in these patients.

Methods

This was a retrospective study of 115 patients with Crohn's disease. Body composition parameters were assessed by bioelectrical impedance analysis. The nutritional status of the patients was determined by NRS2002 and MNA.

Results

The BMI, BFMI, FFMI, BCMI, SMI, BMC, intracellular water, protein and BMR were significantly lower in patients without any biologic agents (p < 0.05). Negative correlations were found between BMC, intracellular water, extracellular water, protein and BMR and the interval between the first symptom and first dose by Spearman's correlation analysis (r < 0, p < 0.05). Low BMI (OR 0.602, 95% CI 0.434-0.836, p = 0.002), low FFMI (OR 0.678, 95% CI 0.507-0.906, p = 0.009), and low BCMI (OR 0.564, 95% CI 0.367-0.868, p = 0.009) were independent risk factors for malnutrition in Crohn's disease patients. Anti-TNF therapy tended to reduce the malnutrition probability as assessed by Cox regression analysis (OR: 0.217, 95% CI 0.057-0.821, p = 0.024).

Conclusion

Body composition analysis is predictive of malnutrition in patients with Crohn's disease. Early application of anti-TNF therapy significantly affected skeletal muscle mass, fat mass and bone mineral content, supporting their long-term nutritional status and reducing their probability of malnutrition.

Dietary Habits and Nutrient Deficiencies in a Cohort of European Crohn's Disease Adult Patients

Wrong dietary habits, such as the Western-style diet, are considered important risk factors for the development of Inflammatory Bowel Diseases (IBDs). Nevertheless, the role of dietary patterns in the clinical management of IBD patients has not been fully investigated yet. Fifty-four patients diagnosed with active Crohn's disease (CD) were enrolled and subjected to nutritional intake analysis through a weekly food diary. Nutritional patterns were analyzed, and nutrient intake was compared with those of 30 healthy subjects (HS). Blood levels of cholesterol, folic acid, minerals (K, Mg, Fe) and amino acids, were measured in CD patients to assess the presence of nutritional deficiencies. CD patients, with respect to HS, consumed significantly lower amounts of fiber, vitamins (A, E, C, B6, folic acid) and β-carotene. Their calcium, potassium, phosphorus, iron, magnesium, copper and iodine intake were also found to be significantly lower. In blood, CD patients had significantly lower concentrations of total cholesterol, potassium, iron, and amino acids. Active CD patient diet was significantly different from those of HS and may contribute to the establishment of nutritional deficiencies. Intestinal malabsorption was evidenced in these patients. Correction of the diet with specific nutritional plans is a necessary therapeutic step for these patients. ClinicalTrials.gov: NCT02580864.

Body impedance analysis to estimate malnutrition in inflammatory bowel disease patients - A cross-sectional study

OBJECTIVE

Malnutrition is a common clinical problem in patients with inflammatory bowel diseases (IBD). However, a gold standard for the detection of malnutrition in IBD patients is lacking.

METHODS

A cross-sectional study to assess malnutrition in patients with IBD and healthy controls (HCs). Clinical characteristics (Montreal classification, disease activity, previous surgery) and mutations in the NOD2 gene in patients with Crohn's disease (CD) were obtained. We performed a nutritional assessment with screening for nutritional risk and diagnosis for malnutrition (Malnutrition Universal Screening Tool [MUST]) score, NRS-2002, European Society for Clinical Nutrition and Metabolism (ESPEN), and Global Leadership Initiative on Malnutrition (GLIM) criteria and performed body impedance analysis (BIA).

RESULTS

101 IBD patients (57 CD and 44 ulcerative colitis (UC) and 50 HC were included in a single northern German tertiary center. GLIM criteria detected malnutrition significantly more often compared to the ESPEN criteria. Active disease, a long-standing disease course, and previous surgery were associated with reduced muscle mass. IBD patients had a higher fat mass index compared to HC. Mutations in the NOD2 gene had no effect on nutritional status.

CONCLUSIONS

The GLIM criteria detect malnutrition at a higher rate compared to ESPEN. Specific disease factors might put IBD patients at a higher risk for the development of malnutrition, so these patients might benefit from a frequently performed screening, which might result in a favorable disease course.

Weight change after colectomy for ulcerative colitis

BACKGROUND AND OBJECTIVE

Weight change after colectomy for ulcerative colitis is unknown. The main objective of this study was to describe weight change during surgical management of ulcerative colitis.

METHODS

All patients, underwent a subtotal colectomy, then a proctectomy with J ileal pouch anal anastomosis protected by an ileostomy, and finally an ileostomy closure in the context of ulcerative colitis at the Nancy University Hospital from May 2014 to October 2020, were included. For each patient, his healthy weight, preoperative weight and postoperative weight were recorded for each step of surgery.

RESULTS

Twenty-six patients were included. The median body mass index of healthy weight was 23.3 kg/m². Before subtotal colectomy, the median body mass index decreased to 21.3 kg/m², a reduction of 8.5%. One month after subtotal colectomy, the median body mass index was at its lowest level of 20.8 kg/m², which represented a 10.7% decrease from the healthy weight. Thereafter a significant increase in body mass index was observed before the proctectomy, reaching the threshold of 22.8 kg/m², an increase of 8.7% from the lowest level. After the last surgical time, which corresponds to the ileostomy closure, the body mass index was 23.2 kg/m², this threshold was comparable to the healthy weight body mass index.

CONCLUSION

Our study showed for the first time that after colectomy for ulcerative colitis, patients regained their healthy weight, which constitutes a reassuring message for patients before surgery.

Improvement of Ulcerative Colitis by Aspartate via RIPK Pathway Modulation and Gut Microbiota Composition in Mice

The intestine requires a great deal of energy to maintain its health and function; thus, energy deficits in the intestinal mucosa may lead to intestinal damage. Aspartate (Asp) is an essential energy source in the intestinal mucosa and plays a vital part in gut health. In the current study, we hypothesized that dietary supplementation of Asp could alleviate DSS-induced colitis via improvement in the colonic morphology, oxidative stress, cell apoptosis, and microbiota composition in a mouse model of dextran. Asp administration decreased the disease activity index, apoptosis, myeloperoxidase, eosinophil peroxidase, and proinflammatory cytokine (IL-1β and TNF-α) concentrations in the colonic tissue, but improved the body weight, average daily food intake, colonic morphology, and antioxidant-related gene (GPX1 and GPX4) expression in DSS-treated mice. Expression levels of RIPK1 and RIPK3 were increased in the colon following Asp administration in the DSS-induced mice, whereas the MLKL protein expression was decreased. 16S rRNA sequencing showed that Asp treatment increased the abundance of Lactobacillus and Alistipes at the gene level, and Bacteroidetes at the phylum level, but decreased the abundance of Actinobacteria and Verrucomicrobia at the phylum level. Asp may positively regulate the recovery of DSS-induced damage by improving the immunity and antioxidative capacity, regulating RIPK signaling and modulating the gut microbiota composition.

Ovarian reserve and IVF outcomes in patients with inflammatory bowel disease: A systematic review and meta-analysis

BACKGROUND

Inflammatory bowel disease (IBD) mainly affects people during reproductive age. However, it is unclear whether IBD might be associated with impaired ovarian reserve in female patients or with in vitro fertilization (IVF) outcomes.

METHODS

This systematic review and meta-analysis included articles from inception to May, 2022. Random-effect model was applied to calculate the standardized mean differences (SMDs) and odds ratios (ORs) and their 95% confidence intervals (95%CIs). Studies comparing the ovarian reserve or IVF outcomes of patients with IBD with the population were considered. To be included in this study, necessary measurements such as OR, relative risk (RR), SMD or hazard ratio (HR) or any necessary information to calculate them were provided in the articles. Letters, case reports, review articles including meta-analyses and expert opinions were excluded. For different articles studying the same population, the article with larger scale was selected.

FINDINGS

We included in our analysis 9 studies and data from 2386 IBD records and matched controls. Comparing with women without IBD, women with IBD had lower anti-mullerian hormone (AMH) levels (SMD = -0.38, 95%CI: -0.67, -0.09); (I² = 79.0%, p = 0.000). Patients with IBD of different ages showed distinct ovarian reserves, with patients below 30 years old not showing any decline in ovarian reserve compared to the control group (SMD = -0.56, 95%CI: -2.28, 1.16); (I² = 96.3%; p = 0.000), while patients with IBD over 30 years old (SMD = -0.75, 95%CI: -1.07, -0.43); (I² = 0.0%; p = 0.608) showed a decline compared to control group. Patients with IBD in remission stage had similar ovarian reserves to population (SMD = -0.10, 95%CI: -0.32, 0.12); (I² = 0.0%; p = 0.667), while patients in active stage showed an impaired ovarian reserve (SMD = -1.30, 95%CI: -1.64, -0.96); (I² = 0.0%; p = 0.318). Patients with IBD showed a pregnancy rate after receiving IVF treatment comparable to the control population (OR = 0.87, 95%CI: 0.55, 1.37); (I² = 70.1%, p = 0.035).

INTERPRETATION

The result of this study suggest that IBD may reduce reproductive age women's ovarian reserve and IVF treatment might help pregnancy outcomes in patients with impaired fertility. These results should be further validated in additional studies given the heterogeneity and quality of the studies included.

FUNDING

This study was supported by the National Natural Science Foundation of China (No. 81671423), National Key Research and Development Program of China (No. 2016YFC1000603), 2020 Shenyang Science and Technology Plan Program (No. 20-205-4-006), Scientific and Technological Talents Applied Technology Research Program of Shenyang (No. 18-014-4-56).

Prevalence and Risk Factors for Fatigue in Adults With Inflammatory Bowel Disease: A Systematic Review With Meta-Analysis

BACKGROUND AND AIMS

Inflammatory bowel disease (IBD) is a chronic relapsing and remitting disease with high morbidity, substantial health care costs, and increasing incidence. Fatigue is one of the most common symptoms that impacts quality of life and is a leading concern for patients with IBD. The aim of this study was to determine the global prevalence, risk factors, and impact of fatigue in adults with IBD.

METHODS

A systematic review and meta-analysis was conducted. Data were retrieved from Medline, Embase, CINAHL, and PsycINFO from database inception to October 2019. A pooled prevalence of fatigue was calculated using a random-effects model. Stratified meta-analyses explored sources of between-study heterogeneity. Study quality was assessed using an adapted checklist from Downs and Black.

RESULTS

The search yielded 4524 studies, of which 20 studies were included in the systematic review and meta-analysis. Overall, the studies were of good quality. The pooled prevalence of fatigue was 47% (95% confidence interval, 41%-54%), though between-study heterogeneity was high (I² = 98%). Fatigue prevalence varied significantly by the definition of fatigue (chronic: 28%; high: 48%; P < .01) and disease status (active disease: 72%; remission: 47%; P < .01). Sleep disturbance, anxiety, depression, and anemia were the most commonly reported fatigue-related risk factors.

CONCLUSIONS

The prevalence of fatigue in adults with IBD is high, emphasizing the importance of additional efforts to manage fatigue to improve the care and quality of life for patients with IBD.

Inflammatory Bowel Disease and Reproductive Health: From Fertility to Pregnancy—A Narrative Review

Despite the fact that knowledge on obstetrical management of Inflammatory Bowel Diseases (IBDs) has greatly improved over the years, many patients still actively avoid pregnancy for fear of adverse maternal or neonatal outcomes, of adverse effects of pregnancy on the disease activity, of eventual IBD inheritance, or of an increased risk of congenital malformations. Indeed, though data prove that fertility is hardly affected by the disease, a reduced birth rate is nevertheless observed in patients with IBD. Misconceptions on the safety of drugs during gestation and breastfeeding may influence patient choice and negatively affect their serenity during pregnancy or lactation. Moreover, physicians often showed concerns about starting IBD medications before and during pregnancy and did not feel adequately trained on the safety of IBD therapies. IBD-expert gastroenterologists and gynecologists should discuss pregnancy and breastfeeding issues with patients when starting or changing medications in order to provide appropriate information; therefore, pre-conception counselling on an individualized basis should be mandatory for all patients of reproductive age to reassure them that maintaining disease remission and balancing the eventual obstetrical risks is possible.

NAMPT mitigates colitis severity by supporting redox-sensitive activation of phagocytosis in inflammatory macrophages

Nicotinamide phosphoribosyltransferase (NAMPT) is the rate-limiting enzyme in the nicotinamide adenine dinucleotide (NAD+) salvage pathway and plays a crucial role in the maintenance of the NAD+ pool during inflammation. Considering that macrophages are essential for tissue homeostasis and inflammation, we sought to examine the functional impact of NAMPT in inflammatory macrophages, particularly in the context of inflammatory bowel disease (IBD). In this study, we show that mice with NAMPT deletion within the myeloid compartment (Namptf/fLysMCre+/-, Nampt mKO) have more pronounced colitis with lower survival rates, as well as numerous uncleared apoptotic corpses within the mucosal layer. Nampt-deficient macrophages exhibit reduced phagocytic activity due to insufficient NAD+ abundance, which is required to produce NADPH for the oxidative burst. Nicotinamide mononucleotide (NMN) treatment rescues NADPH levels in Nampt mKO macrophages and sustains superoxide generation via NADPH oxidase. Consequently, Nampt mKO mice fail to clear dead cells during tissue repair, leading to substantially prolonged chronic colitis. Moreover, systemic administration of NMN, to supply NAD+, effectively suppresses the disease severity of DSS-induced colitis. Collectively, our findings suggest that activation of the NAMPT-dependent NAD+ biosynthetic pathway, via NMN administration, is a potential therapeutic strategy for managing inflammatory diseases.

Protective effect of naringin ameliorates TNBS-induced colitis in rats via improving antioxidant status and pro-inflammatory cytokines

Aim: Ulcerative colitis (UC) is a chronic inflammatory bowel disease that disturbs the colon mucosal lining and is characterized by oxido-nitrosative stress and the release of pro-inflammatory cytokines. Naringin (NG) belongs to a group of chemicals called bioflavonoids derived from grapefruit and related citrus species. NG has been widely used as folk medicine in many countries, due to its several health benefits.Method: This study examined the effect of NG on 2,4,6 trinitrobenzene sulfonic acid (TNBS)-induced colitis in rats. Forty-two male Wistar rats were divided into seven groups like Normal Control (NC), Ethanol Control (EC), Disease Control (DC), NG 20 (20 mg/kg, p.o.), NG 40 (40 mg/kg, p.o.), NG 80 (80 mg/kg, p.o.), and Dexamethasone (DEX) (2 mg/kg, p.o.). Colitis was induced in Wistar albino rats by administering TNBS intra-rectally (in 50% ethanol). The rats were then given 14 days of NG (20, 40, and 80 mg/kg) and DEX (2 mg/kg) treatment. Several behavioral, biochemical, molecular, and histological analyses were performed.Result: The treatment of rats with NG significantly increased the body weight (p < .05, p < .01), hematological parameters like hemoglobin (p < .05, p < .01, p < .001), red blood cells (p < .01, p < .001), and platelets count (p < .01, p < .001) and decreased in spleen weight (p < .01, p < .001), colon weight (p < .01, p < .001), colon weight to length ratio (p < .05, p < .01, p < .001), macroscopic score (p < .01, p < .001), adhesion score (p < .01, p < .001), diarrhea score (p < .05, p < .001), stool consistency (p < .01, p < .001), rectal bleeding score (p < .05, p < .01, p < .001), white blood cells count (p < .01, p < .001). NG significantly (p < .01, p < .001) increased colonic superoxide, glutathione, and catalase levels and decreased malondialdehyde and myeloperoxidase levels. It also significantly (p < .01, p < .001) decreased the biochemical parameters, proinflammatory cytokines and reduced the histological damage in the colon tissue caused by TNBS.Conclusion: Our results demonstrated that NG treatment attenuated pathologic changes of TNBS-induced colitis in rats through restoring colonic damage and reducing inflammatory response in the colon tissue. Thus, NG might be considered as an effective candidate for the treatment of UC patients.

Female reproductive health and inflammatory bowel disease: A practice-based review

Inflammatory bowel diseases, namely ulcerative colitis and Crohn's disease, occur worldwide and affect people of all ages, with a high impact on their quality of life. Sex differences in incidence and prevalence have been reported, and there are also gender-specific issues that physicians should recognize. For women, there are multiple, important concerns regarding issues of body image and sexuality, menstruation, contraception, fertility, pregnancy, breastfeeding and menopause. This practice-based review focuses on the main themes that run through the life of women with inflammatory bowel diseases from puberty to menopause. Gastroenterologists who specialize in inflammatory bowel diseases and other physicians who see female patients with inflammatory bowel diseases should provide support for these problems and offer adequate therapy to ensure that their patients achieve the same overall well-being and health as do women without inflammatory bowel diseases.

Relationship between Nutritional Screening Tools and GLIM in Complicated IBD Requiring Surgery

BACKGROUND

Accurate identification of malnutrition and preoperative nutritional care in Inflammatory Bowel Disease (IBD) surgery is mandatory. There is no validated nutritional screening tool for IBD patients. We developed a novel nutritional screening tool for IBD patients requiring surgery and compared it with other tools.

METHODS

we included 62 consecutive patients scheduled for elective surgery. The IBD Nutritional Screening tool (NS-IBD) was developed to screen patients for further comprehensive assessment. NRS-2002, MUST, MST, MIRT, SaskIBD-NR are compared with the new test. All screening tests were subsequently related to new GLIM criteria.

RESULTS

according to GLIM criteria, 25 (40%) IBD patients were malnourished (15 CD and 10 UC, 33% vs. 63%, p = 0.036). Stage 1 malnutrition was reported in ten patients, while stage 2 was detected in 15 patients. The comparison of each nutritional risk tool with GLIM criteria showed sensitivity of 0.52, 0.6, 0.6, 0.84, 0.84 and 0.92 for SASKIBD-NR, MUST, MST, NRS-2002, MIRT, and the new NS-IBD, respectively.

CONCLUSIONS

in IBD, currently adopted nutritional screening tools are characterized by a low sensitivity when malnutrition diagnosis is performed with recent GLIM criteria. Our proposed tool to detect malnutrition performed the best in detecting patients that may require nutritional assessment and preoperative intervention.

Review of exclusive enteral therapy in adult Crohn's disease

Background

Exclusive enteral nutrition (EEN) is a potentially effective but underused therapy for Crohn’s disease (CD) in adults. It is first-line induction treatment for paediatric patients but remains a second-line or third-line therapy in adults.

Objective

To analyse the evidence for EEN in adult patients with CD, and summarise this in a narrative review.

Methods

In April/May 2020 and July 2021, a literature search was performed using the Medical Subject Headings (MeSH) terms: ‘Crohn’s disease’, ‘CD’, ‘inflammatory bowel disease’, ‘IBD’, ‘exclusive enteral nutrition’, ‘enteral nutrition’, ‘EEN’, in PubMed, Scopus, Cochrane. Additional studies were obtained from references of search result articles as well as general reading. Studies with adult patients with CD treated with EEN were selected. 79 articles of relevance were found. Where data in adults were lacking, data from paediatric studies as extrapolated with care.

Results

EEN in adult patients been shown to improve clinical, biomarker, endoscopic and radiologic measures of disease activity. EEN avoids the potential adverse effects of recurrent corticosteroids for induction such as metabolic derangements and opportunistic infections. EEN has also demonstrated benefits among adult patients with fistulising and stricturing CD. It may avoid surgery in such patients. Preoperative EEN has also been shown to reduce postoperative complications and recurrence. There appears to be benefits in combing EEN with antitumour necrosis factor agents, however, benefits of combination therapy with other biologics are less clear. A major drawback of EEN therapy in adults has been poor compliance. More palatable polymeric formulations improved patient education and dietitian support may overcome this. Evidence in adults is limited to small studies, often with suboptimal control arms and lack of blinding. Larger scale studies with improved study design are needed to confirm these beneficial effects.

Conclusion

Despite limitations in evidence EEN should be considered in treating adults with CD.

Protective effect of sarsasapogenin in TNBS induced ulcerative colitis in rats associated with downregulation of pro-inflammatory mediators and oxidative stress

BACKGROUND

Ulcerative colitis (UC) is a chronic inflammatory bowel condition considered by oxido-nitrosative stress and the release of pro-inflammatory cytokines that affects the mucosal lining of the colon. Sarsasapogenin (SG), as an active component, has been found in many plants, and it exhibits potential protective effects, such as anti-inflammatory, antioxidant, anti-psoriasis, anti-arthritis, anti-asthma, anti-depressant and anti-cancer. However, the effects of SG on UC remain unknown.

OBJECTIVE

The purpose of this study was to investigate the effects of SG on 2, 4, 6-trinitrobenzene sulfonic acid (TNBS)-induced UC in rats.

METHOD

Thirty Wistar rats were randomized into five groups: (i) Normal control, (ii) Disease control (TNBS), (iii) Sarsasapogenin (SG) (50 µg/rat), (iv) Fluticasone (FC) (50 µg/rat), (v) Sarsasapogenin + Fluticasone (SG + FC) (25 µg/rat). UC was induced in rats by trans-rectal instillation of TNBS (10 mg/kg). SG, FC and SG + FC were administered for 11 days and on the 8th day colitis was induced. Several molecular, biochemical and histological alterations were evaluated in the colon tissue. All treatment group results were compared to the TNBS group results.

RESULT

The study results revealed that treatment of rats with SG and SG + FC combination significantly decreased the colon weight/length ratio, macroscopic inflammation score, lesions score, diarrhea score and adhesion score. Combination treatment in rats significantly reduced the production of biochemical parameters, proinflammatory cytokines, haematological parameters, serum IgE levels and restored the oxidative stress markers. SG and SG + FC treatment also considerably restored the histopathological changes induced by TNBS.

CONCLUSION

Thus, SG and SG + FC combination could alter the disease progression and could be a hopeful therapeutic target for the management of UC by reducing its dose in combination with FC to elude the long term adverse effects of FC.

Dietary Management in Pediatric Patients with Crohn's Disease

It has been widely endorsed that a multifactorial etiology, including interaction between genetic and environmental factors, can contribute to Crohn's Disease (CD) pathogenesis. More specifically, diet has proven to be able to shape gut microbiota composition and thus is suspected to play a significant role in inflammatory bowel disease (IBD) pathogenesis. Moreover, poor nutritional status and growth retardation, arising from several factors such as reduced dietary intake or nutrient leakage from the gastrointestinal tract, represent the hallmarks of pediatric CD. For these reasons, multiple research lines have recently focused on the utilization of dietary therapies for the management of CD, aiming to target concurrently mucosal inflammation, intestinal dysbiosis and optimization of nutritional status. The forerunner of such interventions is represented by exclusive enteral nutrition (EEN), a robustly supported nutritional therapy; however, it is burdened by monotony and low tolerance in the long term. Novel dietary interventions, such as Crohn's Disease Exclusion Diet or Crohn's Disease treatment with eating, have shown their efficacy in the induction of remission in pediatric patients with CD. The aim of the present narrative review is to provide a synopsis of the available nutritional strategies in the management of pediatric CD and to discuss their application in the dietary management of these patients.

Optimizing Inpatient Nutrition Care of Adult Patients with Inflammatory Bowel Disease in the 21st Century

Malnutrition is highly prevalent in inflammatory bowel disease (IBD) patients and disproportionately affects those admitted to hospital. Malnutrition is a risk factor for many complications in IBD, including prolonged hospitalization, infection, greater need for surgery, development of venous thromboembolism, post-operative complications, and mortality. Early screening for malnutrition and prompt nutrition intervention if indicated has been shown to prevent or mitigate many of these outlined risk factors. There are many causes of malnutrition in IBD including reduced oral food intake, medications, active inflammation, and prior surgical resections. Hospitalization can further compound pre-existing malnutrition through inappropriate diet restrictions, nil per os (NPO) for endoscopy and imaging, or partial bowel obstruction, resulting in "post-hospital syndrome" after discharge and readmission. The aim of this article is to inform clinicians of the prevalence and consequences of malnutrition in IBD, as well as available screening and assessment tools for diagnosis, and to offer an organized approach to the nutritional care of hospitalized adult IBD patients.

Food-related quality of life is impaired in inflammatory bowel disease and associated with reduced intake of key nutrients

BACKGROUND

Inflammatory bowel disease (IBD) may impact the extent to which food, eating, and drinking bring satisfaction and enjoyment to peoples' lives, and this may impact dietary intake. The prevalence of an impaired food-related quality of life (FR-QoL), its associated factors, and its impact on diet have not been explored.

OBJECTIVES

To measure the prevalence and nature of the burden of impaired FR-QoL in people with IBD, the factors associated with these, and their associations with nutrient intake.

METHODS

We recruited 1576 outpatients with IBD (≥16 years old) in person from 7 IBD centers across the United Kingdom. Patients completed validated questionnaires to measure their FR-QoL, quality of life (QoL), distress, fatigue, anxiety, and depression. Dietary intake was recorded using the European Prospective Investigation into Cancer FFQ. A health professional recorded disease activity, Montreal classification, blood results, BMI, and malnutrition risk. FR-QoL was regressed onto explanatory variables using univariable and multivariable analyses.

RESULTS

Data from 1221 patients were available (77.4% response; Crohn's disease, 65%; ulcerative colitis, 35%). The FR-QoL mean (± SD) score was 80.8 ± 26.9, with wide ranges (minimum, 29; maximum, 145). Following multivariable regression, the strongest associations with FR-QoL were the number of recent disease flares (5 flares β = -12.7; P < 0.001), the IBD-specific QoL (β = 0.33; P < 0.001), and IBD-related distress (β = -0.26; P < 0.001). Patients with poorer FR-QoL had lower intakes of fiber (nonstarch polysaccharide; Q1 to Q5 difference = 2.1 g/d; 95% CI: 0.4-3.8; P = 0.048), calcium (192.6 mg/d; 95% CI: 112.5-272.6; P < 0.001), phosphorus (167 mg/d; 95% CI: 58-276; P = 0.041), and magnesium (34.4 mg/d; 95% CI: 9.3-59.4; P = 0.041).

CONCLUSIONS

Impaired FR-QoL is prevalent in IBD and is associated with recurrent disease flares, a reduced IBD-specific QoL, and greater IBD-related distress. A poorer FR-QoL was associated with lower intakes of key nutrients of importance to IBD, including those relating to gut health and bone mineralization.

Comparison of outcome after right colectomy with an enhanced recovery programme in patients with inflammatory bowel disease and patients operated on for other conditions: a monocentric retrospective study

PURPOSE

Enhanced recovery programmes (ERPs) after surgery reduce postoperative complications and hospital stay. Patients with inflammatory bowel disease (IBD) often present risk factors for postoperative complications. This accounts for reluctance to include them in ERPs. We compared outcome after right colectomy with an ERP in IBD and non-IBD patients.

METHODS

In our GRACE colorectal surgery database comprising 508 patients, we analysed patients scheduled for right colectomy (n = 160). Adherence to the protocol, postoperative complications and length of hospital stay of IBD patients (n = 45) were compared with those of non-IBD patients (n = 115). Data (mean ± SD, median [IQR], count (%)) were compared by Student's t, Mann-Whitney U and chi-square tests when appropriate; p < 0.05 taken as statistically significant.

RESULTS

IBD patients were significantly younger (38.9 ± 13.8 vs. 58.9 ± 18.5 years, p < 0.001) and had lower BMI (23.0 ± 5.0 vs. 25.1 ± 5.0 kg m^-2, p < 0.01). Adherence to ERP was similar in the two groups. Resumption of eating on the day of the operation was less well tolerated (73.3% vs. 85.2%, p < 0.05) and postoperative pain (p < 0.001) was greater in IBD patients. The incidence of postoperative complications (13.3% vs. 17.3%) and the length of hospital stay (3 [3-4.5] vs. 3 [2-5] days) were comparable in IBD and non-IBD patients, respectively.

CONCLUSION

The management of IBD patients in an ERP is not only feasible but also indicated. These patients benefit as much from ERP as non-IBD patients.

Incidence and risk factors of micronutrient deficiency in patients with IBD and intestinal Behçet's disease: folate, vitamin B12, 25-OH-vitamin D, and ferritin

BACKGROUND

Patients with inflammatory bowel disease (IBD) and intestinal Behçet's disease (BD) are vulnerable to micronutrient deficiencies due to diarrhea-related gastrointestinal loss and poor dietary intake caused by disease-related anorexia. However, few studies have investigated the incidence and risk factors for micronutrient deficiency.

METHODS

We retrospectively analyzed 205 patients with IBD who underwent micronutrient examination, including folate, vitamin B12, 25-OH-vitamin D, and/or ferritin level quantification, with follow-up blood tests conducted 6 months later.

RESULTS

Eighty patients (39.0%), who were deficient in any of the four micronutrients, were classified as the deficiency group, and the remaining 125 (61.0%) were classified as the non-deficient group. Compared to those in the non-deficiency group, patients in the deficiency group were much younger, had more Crohn's disease (CD) patients, more patients with a history of bowel operation, and significantly less 5-amino salicylic acid usage. Multivariate analysis revealed that CD and bowel operation were significant independent factors associated with micronutrient deficiency.

CONCLUSIONS

The incidence of micronutrient deficiency was high (39.0%). Factors including CD, bowel operation, and younger ages were found to be associated with higher risks of deficiency. Therefore, patients with IBD, especially young patients with CD who have undergone bowel resection surgery, need more attention paid to micronutrition.

Hecogenin and fluticasone combination attenuates TNBS-induced ulcerative colitis in rats via downregulation of pro-inflammatory mediators and oxidative stress

OBJECTIVE

Ulcerative colitis is common types of severe, progressive, idiopathic inflammatory bowel disease that involves the mucosal lining of the large intestine. The purpose of the study is to explore the effects of hecogenin in TNBS (2, 4, 6- trinitrobenzene sulfonic acid) induced ulcerative colitis model in rats.

MATERIAL AND METHODS

Thirty Wistar rats were randomized into five groups: (i) Normal Control (NC), (ii) Disease Control (DC), (iii) Hecogenin (HG) (50 µg/rat), (iv) Fluticasone (FC) (50 µg/rat), (v) Hecogenin + Fluticasone (HG + FC) combination (25 µg/rat). Colitis was induced by trans-rectal administration of TNBS using a catheter inserted 8 cm into the rectal portion of the rat. Colitis was evaluated by an independent observer who was blinded to the treatment. All treatment group results were compared to the TNBS group results.

RESULTS

The study results revealed that treatment of rats with HG and HG + FC significantly improved the body weight and colon length whereas; decreased the spleen weight, colon weight/length ratio, macroscopic lesions score, diarrhea score and adhesion score. The drug treatment in rats substantially decreased the development of inflammatory cytokines, levels of serum immunoglobulin E, colonic nitric oxide contents and restoration of antioxidant stress markers. Histopathological colon sample study significantly reduced colonic inflammation with a substantial decrease in inflammation score.

CONCLUSION

Thus, HG and HG + FC combination could change the pathogenesis of the disease and may be a potential therapeutic target for the treatment of ulcerative colitis by a reduction in dose in conjunction with FC to prevent the persistent adverse effects associated with FC.

Depression, Anxiety, Related Risk Factors and Cognitive Distortion in Korean Patients with Inflammatory Bowel Disease

OBJECTIVE

To evaluate the severity of depression, anxiety, associated risk factors, and cognitive distortion in Korean patients with ulcerative colitis (UC) and Crohn's disease (CD).

METHODS

This study included 369 patients with inflammatory bowel disease. The severity of depression and anxiety was examined using Patient Health Questionnaire-9 and Hospital Anxiety and Depression Scale. The Anxious Thoughts and Tendencies scale was used to measure catastrophizing tendency. Multivariate regression analyses were performed.

RESULTS

The predictors of depression were marital status, anti-tumor necrosis factor-α (TNF-α) agent use, age, and body mass index in UC patients and marital status, disease activity, alcohol use, and employment status in CD patients. For anxiety, sex and marital status were the associated factors in UC patients, whereas steroid use was the only significant predictor in CD patients. Comparing the cognitive distortion level, there were no significant differences between UC and CD patients although there was an increasing tendency according to the severity of depression or anxiety.

CONCLUSION

If patients are accompanied by high levels of depression or anxiety and their associated risk factors including TNF-α agent or steroid use, it is recommended that not only symptoms are treated but also cognitive approach and evaluation be performed.

Body weight, serum albumin and food intolerance were linked to upper gastrointestinal Crohn's disease: a 7-year retrospective analysis

Background

The clinical features of upper gastrointestinal (L4) Crohn’s disease (CD) and its subtypes, along with the associated and nutritional status, remain poorly described. Our aim was to evaluate the clinical characteristics of L4 CD phenotype and its subtypes at diagnosis, and their relationship with the nutritional status.

Methods

A retrospective study was conducted on 869 CD patients diagnosed between 2013 and 2019, and the association between the clinical characteristics and nutritional status of L4 patients was determined using Random forest importance ranking and logistic regression.

Results

The majority of the patients (59.72%) presented L4 lesions, of which 335, 158 and 26 had proximal ileal, jejunal and esophago-gastroduodenal (EGD) lesions respectively. L4 patients were predominantly male (OR 2.07), smoker (OR 1.80), and had higher body weight and BMI, longer disease course, and stricturing disease (OR 1.88). Furthermore, the serum albumin level, body weight and disease course showed higher MDG in the random forest importance ranking test for L4 CD and L4-proximal ileal types. According to logistic regression, body weight (OR 1.054), disease course (OR 1.010), stricturing behavior (OR 4.998) and tomato intolerance (OR 1.313) were the independent risk factors for L4. In addition, body weight (OR 1.042) and stricturing behavior (OR 3.152) were the relevant factors for proximal ileal subtype, and stricturing behavior (OR 4.206) and perianal disease (OR 0.339) for jejunal subtype.

Conclusions

L4 disease has a higher incidence rate compared to the non-L4 CD, and mainly affects males, and those with prolonged disease course, stricturing behavior, higher weight, BMI, albumin levels and food intolerance (FI).

Perioperative management of ileocecal Crohn's disease in the current era

INTRODUCTION

The ileocecal region is most commonly involved in patients with Crohn's disease (CD).

AREAS COVERED

In the management of ileocecal CD, this review discusses the underlying clinical issues with perioperative management and surgical intervention.

EXPERT OPINION

Despite advances in medical treatments, surgery is required in a proportion of patients. Preoperative optimization including weaning of corticosteroids, initiation of enteral feeds, venous thromboembolism prophylaxis and smoking cessation may lead to improved postoperative outcomes. Several surgical approaches regarding anastomotic technique and range of mesentery division are now attempted to reduce the incidence of postoperative recurrence. Disease recurrence is common after surgery for CD. Early endoscopic assessment and subsequent treatment adjustment are optimal strategies for the prevention of recurrence after ileocolonic resection.

GLIM Criteria for Malnutrition in Surgical IBD Patients: A Pilot Study

Background: A gold standard method for malnutrition diagnosis is still lacking in Inflammatory Bowel Disease (IBD). Objective: The aims of this study are to determine the prevalence of malnutrition in IBD patients according with recently published Global Leadership Initiative on Malnutrition (GLIM) criteria, to detect the factors contributing to the onset of malnutrition, and to evaluate the most accurate predictor of malnutrition risk within the available nutritional screening tools. Methods: Fifty-three consecutive adult IBD patients [38 Crohn’s disease (CD) and 15 ulcerative colitis (UC)] had been assessed preoperatively by a multidisciplinary IBD team before undergoing elective surgery. Several malnutrition risk tools were tested, such as NRS-2002, MUST, MST, MIRT, and SaskIBD-NR. The statistical association of independent GLIM variables with baseline characteristics of patients was explored as well as the concordance with the European Society for Clinical Nutrition and Metabolism (ESPEN 2015) and the screening tools. Results: Twenty-two IBD patients (42%) were malnourished according to GLIM criteria, of which 13 were CD (34%) and 9 UC (60%). The etiological criteria of inflammation and reduction of food intake were present in 51% and 19% of our patients, respectively. The prevalence of GLIM phenotypic criteria was 28%, 28% and 34% for BMI, Free Fat Mass Index (FFMI) and unintended weight loss (UWL), respectively. The presence of ileostomy was statistically associated with a higher prevalence of BMI (p = 0.030), FFMI (p = 0.030) and UWL (p = 0.002) values lower than the GLIM criteria cut-offs, while secondary surgery is associated with a decrease in FFMI (p = 0.017) and UWL (p = 0.041). The sensitivity of the tested nutritional screening tools, compared with the GLIM prevalence of malnutrition, was not satisfactory (between 50 and 82%). Conclusions: GLIM has a higher rate of malnutrition detection than ESPEN 2015, as malnutrition in IBD seems linked to inflammation and secondary malabsorption even without a reduction of food intake. The sensitivity of the screening tools is lower than the specificity when compared with GLIM criteria for malnutrition diagnosis.

Intervention with the crude polysaccharides of Physalis pubescens L. mitigates colitis by preventing oxidative damage, aberrant immune responses, and dysbacteriosis

In this study, a colitis mouse model induced by dextran sulfate sodium (DSS) was used to investigate the mechanisms of action of an extract of crude polysaccharides (POL) from Physalis pubescens L. as a dietary intervention for colitis. Our results showed that the administration of POL prior to DSS-induced colitis protected the colon mucosal layer; maintained intestinal barrier integrity; alleviated oxidative damage; and lowered neutrophil infiltration by downregulating intercellular cell adhesion molecule-1 and monocyte chemoattractant protein-1 expression. More importantly, POL pretreatment reduced the expression of the proinflammatory factors tumor necrosis factor-α, inducible nitric oxide synthase (iNOS), and cyclooxygenase-2 (COX-2), thereby modulating the nuclear factor-κB/iNOS-COX-2 signal transduction pathway. In addition, POL reversed DSS-induced gut dysbiosis, accompanied by reducing the relative abundance of Helicobacter, Mucispirillum, and Erysipelatoclostridium. In conclusion, POL ameliorated DSS-induced intestinal injury in mice, indicating that POL could be a useful dietary nutrient to protect against colitis. PRACTICAL APPLICATION: Physalis pubescens L. is an edible fruit. The results of this study show that the intervention with Physalis pubescens L. crude polysaccharides may help prevent ulcerative colitis.

Zinc Deficiency Activates the IL-23/Th17 Axis to Aggravate Experimental Colitis in Mice

BACKGROUND AND AIMS

Patients with inflammatory bowel disease [IBD], especially Crohn's disease, often develop zinc deficiency. However, the precise mechanisms by which zinc deficiency affects IBD pathology, particularly intestinal macrophage function, remain unclear. We studied the effects of zinc deficiency on the development and progression of colitis in mice.

METHODS

To induce colitis, mice were treated with 2,4,6-trinitrobenzene sulphonic acid. Rag1-/- mice were then given injections of naïve CD4+CD62L+ T cells. The respective degrees of mucosal injury of mice that had received a zinc chelator (TPEN; N,N,N',N'-tetrakis [2-pyridylmethyl]ethylenediamine) and of control mice were subsequently compared. Colonic lamina propria mononuclear cells were isolated by enzymatic digestion and were examined using flow cytometry. To generate mouse bone marrow-derived macrophages [BMDMs], bone marrow cells were stimulated with mouse macrophage-colony stimulating factor.

RESULTS

Zinc deficiency aggravates colonic inflammation through the activation of type 17 helper T [Th17] cells in mice. Flow cytometric analysis revealed that zinc deficiency significantly increases the proportion of pro-inflammatory [M1] macrophages in colonic lamina propria mononuclear cells obtained from inflamed colon. Interferon-γ plus lipopolysaccharide-mediated M1 skewing alters the expression of zinc transporters in BMDMs and thereby decreases the intracellular free zinc. TPEN treatment mimicking the effects of the M1 skewing up-regulates IL-23p19 expression, which is strongly related to Th17 development. Furthermore, the nuclear accumulation of interferon-regulatory factor 5 is closely involved in IL-23p19 induction in zinc-deficient macrophages.

CONCLUSIONS

Zinc deficiency aggravates colonic inflammation through activation of the IL-23/Th17 axis. This activation is controlled by subcellular distribution of interferon-regulatory factor 5.

Monitoring of inflammatory bowel disease in 2019: A French consensus for clinical practice

For inflammatory bowel disease, traditional dose escalation approaches that are based on clinical symptoms are being replaced by more aggressive treat-to-target approaches, in which treatment is adjusted promptly when predefined clinical and mucosal targets are not met. There is, however, an ongoing need to combine up-to-date treat-to-target strategies with easy-to-implement recommendations. Herein, we present consensus-recommendations for treatment targets that reflect current best practices in France. Methods Thirty-four gastroenterologists practicing in France participated in a meeting during which consensus statements about treat-to-target strategies for following patients with Crohn's disease (CD) and ulcerative colitis were developed. Targets, their definitions, and the timeframes for reaching them were defined. Consensus was defined as ≥66% of experts agreeing with a statement. Results For both diseases, the agreed targets were: patient related outcomes on disease (PRO-1), patient related outcomes on gastrointestinal symptoms (PRO-2), endoscopic healing and biomarkers of inflammation. Nutritional status has been defined as a target for CD only. Histological healing and transmural healing were not defined as targets. Deadlines to achieve targets and monitoring frequency have been agreed as well. Conclusions These consensus statements provide simple, easy-to-follow guidelines that should help gastroenterologists in France implement treat-to-target approaches, optimize treatments, and thus, reduce the burden of disease.

Effect of long-lasting nutritional prehabilitation on postoperative outcome in elective surgery for IBD

BACKGROUND & AIMS

Preoperative patient care optimisation appears to be crucial for obtaining good surgical outcomes. Enhanced Recovery After Surgery (ERAS) underlines the necessity to recognize and treat malnutrition perioperatively and to prehabilitate with interventions that can modulate the lean body mass before and after surgery. This procedure has been extensively reported in colorectal cancer patients but in Inflammatory Bowel Disease (IBD) it has not yet been clearly evaluated. The aim of this study was to implement the perioperative nutritional items in surgical Crohn's disease (CD) and ulcerative colitis (UC) patients electively operated in an ERAS setting, thus to clarify the impact of a long-lasting prehabilitation program in IBD.

METHODS

Consecutive adult patients (age ≥18) were included as soon as scheduled for elective surgery for CD or UC. The nutritional intervention included personalized dietary counseling and oral nutritional supplements when necessary. Data prospectively recorded in each phase were: FFM, FM, FFMI and phase angle detected with BIVA, weight, BMI, unintended weight loss, DASI, energy and nutritional intake, gastrointestinal symptoms and bowel functions. Nutritional risk was detected according to the NRS 2002 screening tool. The impact of early oral nutrition on postoperative recovery was analysed.

RESULTS

A total of 61 IBD patients (45 CD and 16 UC) were included. Muscle wasting was present at baseline assessment in 28% of cases, significantly associated with the presence of ileostomy (p < 0.011) and of a previous IBD surgery (p < 0.011). During the preoperative phase, there was a significant improvement in weight, BMI, FFM (CD p = 0.035; UC p = 0.017), FFMI (CD ns; UC p = 0.011) and phase angle (CD p = 0.014; UC p = 0.027). During the intra-hospital phase, weight and FFM decreased due to the catabolic effect of surgery, but in the whole perioperative period, both CD and UC patients did not change significantly in terms of body composition. Patients with earlier resumption of oral feeding had a significantly shorter hospital stay and a faster recovery of bowel function with no significant relationship with early postoperative complications.

CONCLUSIONS

Nutritional prehabilitation positively modulated the body composition of IBD patients scheduled for elective surgery and therefore could represent a beneficial strategy to attenuate the impact of the surgical stress response on lean tissue in an ERAS setting. This effect is even more evident in high nutritional risk patients. Early postoperative oral feeding seems feasible and well tolerated in IBD. This approach positively influences the restoration of bowel function and the duration of hospital stay.

Does preoperative enteral nutrition reduce the incidence of surgical complications in patients with Crohn's disease? A case-matched study

AIM

Currently, the notion that preoperative optimization with enteral nutrition (EN) reduces the incidence of complication after surgery in Crohn's disease (CD) patients is being debated. This case-matched study was to evaluate the impact of preoperative EN on surgical outcomes in patients with CD.

METHOD

Twenty-four patients received EN therapy with an elemental diet (1800-2400 kcal/day) for at least 2 weeks before the planned surgery (EN group). A further 24 patients who underwent surgery without receiving preoperative EN or parenteral nutrition formed a control group based on four matched criteria: age (≤/>40 years), the use of preoperative medications (corticosteroids/azathioprine/biologics), disease behaviour (inflammatory/stricturing/penetrating) and main surgical procedure (ileal resection/ileocolonic resection/colectomy). The incidence of complications observed within 30 days after surgery was compared between the two groups. Septic complications were defined as anastomotic leak, intra-abdominal abscess, entero-cutaneous fistula or wound infection.

RESULTS

In the EN group, the median serum albumin level significantly increased, while C-reactive protein (CRP) significantly decreased during the preoperative EN (albumin, from 3.0 mg/dl to 3.1 mg/dl, P = 0.04; CRP, from 3.05 mg/dl to 2.52 mg/dl, P = 0.02). The incidence of postoperative septic complications was significantly lower in the EN group compared with the control group (4% vs 25%, P = 0.04). The occurrence rate of overall complications was lower in the EN group (21% vs 29%, P = 0.51), but not statistically significant.

CONCLUSION

In patients with CD, preoperative optimization with EN reduced the overall rate of postoperative complications and significantly decreased postoperative septic complications.

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.

Exclusive enteral nutrition for induction of remission in anti-tumor necrosis factor refractory adult Crohn's disease: the Indian experience

Background/Aims

Exclusive enteral nutrition (EEN) is recommended for induction of remission in pediatric Crohn’s disease (CD). However, it is not currently recommended for inducing remission in adults. This report describes the use of 12-week EEN for induction of remission in anti-tumor necrosis factor (anti-TNF) refractory adult CD.

Methods

This is a retrospective analysis of adults with moderate to severe active (Crohn’s Disease Activity Index [CDAI] >220) anti-TNF refractory CD, who received EEN for 12 weeks between April 2018 and March 2019 at Dayanand Medical College and Hospital, Ludhiana, India. Primary outcomes included achievement of clinical remission and fistula healing at 12 weeks. Improvement in inflammatory markers and nutritional status were the secondary end points.

Results

Out of 23 patients who received anti-TNF agents, 7 (30.4%) were refractory and were offered EEN as a salvage therapy. Six patients (66.7% females, mean age 25.6±6.5 years) consented. Four patients (66.6%) achieved clinical remission (CDAI <150). Mean CDAI of patients decreased significantly after 12 weeks of EEN (388.8±74.8 vs. 160.0±25.2, P<0.001). Perianal fistulas showed clinical response (drainage decreased by >50%), though none achieved remission. Entero-enteric fistulae showed complete healing. Mean body mass index improved from 15.6±3.1 to 18.9±1.9 kg/m² at week 12 (P=0.003). Hemoglobin and serum albumin also improved from 8.2±1.1 g/dL and 2.8±0.3 g/dL at baseline to 12.6±0.6 g/dL and 3.6±0.5 g/dL post-EEN respectively (P<0.001 and P=0.006 respectively).

Conclusions

EEN appears to be an effective and well tolerated therapy for induction of remission in anti-TNF refractory adult CD. More data from prospective trials with larger number of patients is required.