Assessing nutritional state in inflammatory bowel disease

British Society of Gastroenterology endorsed guidance for the management of immune checkpoint inhibitor-induced enterocolitis

Immune checkpoint inhibitors are a novel class of cancer treatment that have improved outcomes for a subset of cancer patients. They work by antagonising inhibitory immune pathways, thereby augmenting immune-mediated antitumour responses. However, immune activation is not cancer-specific and often results in the activation of immune cells in non-cancer tissues, resulting in off-target immune-mediated injury and organ dysfunction. Diarrhoea and gastrointestinal tract inflammation are common and sometimes serious side-effects of this type of therapy. Prompt recognition of gastrointestinal toxicity and, in many cases, rapid institution of anti-inflammatory or biologic therapy (or both) is required to reverse these complications. Management of organ-specific complications benefits from multidisciplinary input, including engagement with gastroenterologists for optimal management of immune checkpoint inhibitor-induced enterocolitis. In this British Society of Gastroenterology endorsed guidance document, we have developed a consensus framework for the investigation and management of immune checkpoint inhibitor-induced enterocolitis.

The association of inflammatory bowel disease and immediate postoperative outcomes following lumbar fusion

BACKGROUND CONTEXT

The United States Centers for Disease Control and Prevention estimates the prevalence of inflammatory bowel disease (IBD) at more than 3.1 million people. As diagnostic techniques and treatment options for IBD improve, the prevalence of IBD is expected to increase. For spine surgeons, patients with IBD have a unique complication profile because patients with IBD may present with poor nutritional status and because the medications used to manage IBD have been associated with poor vertebral bone mineralization and immunosuppression. Presently, there are very limited data regarding perioperative outcomes among patients with IBD who undergo spinal surgery. The present study begins to address this knowledge gap by describing trends in patients with IBD undergoing lumbar fusion and by quantifying the association between IBD and immediate postoperative outcomes using a large, national database.

PURPOSE

To advance our understanding of the potential pitfalls and risks associated with lumbar fusion surgery in patients with IBD.

DESIGN/SETTING

Retrospective cross-sectional analysis.

PATIENT SAMPLE

The Nationwide Inpatient Sample (NIS) database was queried from 1998 to 2011 to identify adult patients (18+) who underwent primary lumbar fusion operations using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) coding.

OUTCOME MEASURES

Incidence of lumbar fusion procedures, prevalence of IBD, complication rates, length of stay, and total hospital charges.

METHODS

The annual number of primary lumbar fusion operations performed between 1998 and 2011 was obtained from the NIS database. Patients younger than 18 years of age were excluded. The prevalence of IBD in this population (both Crohn disease and ulcerative colitis) was determined using ICD-9-CM codes. Logistic regression models were estimated to determine the association between IBD and the odds of postoperative medical and surgical complications, while controlling for patient demographics, comorbidity burden, and hospital characteristics. The complex survey design of the NIS was taken into account by clustering on hospitals and assuming an exchangeable working correlation using the discharge weights supplied by the NIS. We accounted for multiple comparisons using the Bonferroni correction and an alpha level for statistical significance of . 0028.

RESULTS

The prevalence of IBD is increasing among patients undergoing lumbar fusion, from 0.21% of all patients undergoing lumbar fusion in 1998 to 0.48% of all patients undergoing lumbar fusion in 2011 (p<.001). The odds of experiencing a postoperative medical or surgical complication were not significantly different when comparing patients with IBD with control patients without IBD after controlling for patient demographics, comorbidity burden, and hospital characteristics (adjusted odds ratio=1.1, 95% confidence interval [CI] 0.99-1.3, p=.08). On multivariable analysis, the presence of IBD in patients undergoing lumbar fusion surgery was associated with longer length of stay and greater hospitalization charges.

CONCLUSIONS

Among patients who underwent lumbar fusion, IBD is a rare comorbidity that is becoming increasingly more common. Importantly, patients with IBD were not at increased risk of postoperative complications. Spine surgeons should be prepared to treat more patients with IBD and should incorporate the present findings into preoperative risk counseling and patient selection.

Knowledge, Attitudes, and Beliefs Regarding the Role of Nutrition in IBD Among Patients and Providers

BACKGROUND

Malnutrition is common in inflammatory bowel disease (IBD). Identifying patients who are malnourished or at risk for malnutrition may lead to early intervention and improve patient outcomes. To date, little is known about the role of nutritional assessment and management in IBD care. We aimed to evaluate knowledge, attitudes, and beliefs regarding nutrition in IBD among patients and providers.

METHODS

Surveys were mailed electronically to patients and providers identified through their membership in the Crohn's & Colitis Foundation of America. In addition, patient and provider focus groups were conducted to explore nutrition-related themes. These surveys and focus groups were designed to evaluate knowledge and perceived importance of nutrition, patient-provider interactions regarding nutrition and use of nutritional resources.

RESULTS

There were 223 provider respondents (65.5% gastroenterologists, 15.2% nurses, and 6.7% dietitians). Forty-one percent of the gastroenterologists rated their knowledge of nutrition in IBD as "very good" compared with 87% of dietitians and 16% of nurses (P < 0.001). Thirty-three percent of the gastroenterologists reported not routinely screening their IBD patients for malnutrition. The patient survey had 567 respondents with 27% rating their knowledge of nutrition in IBD as "very good." In the focus groups, a lack of adequate IBD nutritional resources was evident along with a desire for improved access to nutrition specialists.

CONCLUSIONS

Significant gaps in knowledge relating to nutrition in IBD seem to exist. Targeted educational initiatives and improved access to nutritional experts are warranted. In addition, a standardized process for the assessment of malnutrition among patients with IBD should be developed.

Ingestão alimentar em pacientes com doença inflamatória intestinal

RACIONAL: Pacientes com doença inflamatória intestinal podem apresentar deficiências nutricionais. OBJETIVO: Verificar a adequação da ingestão alimentar de pacientes com doença de Crohn e retocolite ulcerativa inespecífica. MÉTODOS: Para avaliação da ingestão alimentar de 55 pacientes, 28 com doença de Crohn e 27 com retocolite ulcerativa atendidos em ambulatório de gastroenterologia, utilizou-se o Recordatório Alimentar de 24 Horas e o Questionário de Frequência Alimentar. A atividade inflamatória da doença foi avaliada pelos níveis séricos de proteína C reativa e o Índice de Harvey e Bradshaw. Para comparação de médias foi usado o teste t não pareado e, para as médias não paramétricas, o teste de Mann-Whitney, considerando nível de significância valor de p<0,05. RESULTADOS: Os pacientes tinham idade entre 19 e 63 anos e tempo de diagnóstico de 7,9 anos (1 a 22). De acordo com a ingestão alimentar identificou-se deficiência na ingestão de energia, fibras, ferro, potássio, sódio, magnésio, cálcio, menadiona, riboflavina, niacina, folato, ácido pantotênico, tocoferol e colecalciferol na doença de Crohn e na retocolite ulcerativa em atividade ou em remissão. A ingestão de legumes, frutas, laticínios e feijão foi baixa, e a de doces e gorduras foi maior que as recomendações. CONCLUSÃO: Houve deficiência na ingestão alimentar tanto na doença de Crohn como na retocolite ulcerativa, em atividade e em remissão. Essas deficiências podem afetar negativamente o curso da doença e justificam a necessidade de intervenção nutricional com esses pacientes.

Nutritional status in patients with active inflammatory bowel disease: prevalence of malnutrition and methods for routine nutritional assessment

BACKGROUND AND AIM

Malnutrition is a common feature of inflammatory bowel disease (IBD). There are numerous methods for the assessment of nutritional status, but the gold standard has not yet been established. The aims of the study were to estimate the prevalence of undernutrition and to evaluate methods for routine nutritional assessment of active IBD patients.

MATERIAL AND METHODS

Twenty-three patients with active Crohn disease, 53 patients with active ulcerative colitis and 30 controls were included in the study. The nutritional status was assessed by extensive anthropometric measurements, percentage of weight loss in the past 1-6 months and biochemical markers of nutrition.

RESULTS

All investigated nutritional parameters were significantly different in IBD patients compared to control subjects, except MCV, tryglicerides and serum total protein level. Serum albumin level and body mass index (BMI) were the most predictive parameters of malnutrition. According to different assessment methods the prevalence of undernutrition and severe undernutrition in patients with active IBD were 25.0%-69.7% and 1.3%-31.6%, respectively, while in the control subjects no abnormalities have been detected. There was no statistically significant difference of nutritional parameters between UC and CD patients except lower mid-arm muscle circumference in UC group.

CONCLUSIONS

Malnutrition is common in IBD patients. BMI and serum albumin are simple and convenient methods for the assessment of the nutritional status in IBD patients. Further studies with larger group of patients are necessary to elucidate the prevalence of malnutrition and the most accurate assessment methods in IBD patients.

Comparison between handgrip strength, subjective global assessment, anthropometry, and biochemical markers in assessing nutritional status of patients with Crohn's disease in clinical remission

INTRODUCTION

Crohn's disease (CD) may lead to protein and calorie malnutrition (PCM) secondary to impaired digestive and absorptive functions of the small intestine and sometimes to the influence of diet taboos. The earlier the PCM is diagnosed, the higher are the odds of reversal. The objective of this study was to compare different methods of nutritional assessment in patients with CD and correlate them with the disease characteristics.

SAMPLE

The sample comprised 75 patients with CD from the Gastroenterology Service at the Hospital de Clínicas de Porto Alegre; 37 were male, with a mean age of 38.2 years old (SD = 13.3). All patients had been in clinical remission (CDAI <150) for over 3 months. They were not receiving enteral or parenteral nutrition. The nutritional assessment was considered: body mass index (BMI), triceps skin fold (TSF), arm circumference (MAC), arm muscle circumference (MAMC), subjective global assessment (SGA), non-dominating handgrip strength (HGS) and food intake inquiries.

RESULTS

When comparing the different nutritional assessment methods, 26.7% of the patients were malnourished according to the MAC, 29.3% according to the MAMC, 18.7% according to the SGA, 6.7% according to the BMI, 37.3% according to the TSF and 73.3% according to the HGS. No statistically significant associations were found for disease location, its behavior, drugs utilized, ESR, CRP, age of patients and disease time with the nutritional state verified by HGS, TSF, MAMC and SGA.

CONCLUSION

The prevalence of malnutrition is significant in patients with CD, even in clinical remission. The BMI should not be used as reference in this population. The HGS detected a high prevalence of nutritional risk in patients with CD in remission. Studies are required that correlate it with more sensitive methods, for the patients' effective nutritional state assessment.

ESPEN Guidelines on Parenteral Nutrition: gastroenterology

Undernutrition as well as specific nutrient deficiencies has been described in patients with Crohn's disease (CD), ulcerative colitis (UC) and short bowel syndrome. In the latter, water and electrolytes disturbances may be a major problem. The present guidelines provide evidence-based recommendations for the indications, application and type of parenteral formula to be used in acute and chronic phases of illness. Parenteral nutrition is not recommended as a primary treatment in CD and UC. The use of parenteral nutrition is however reliable when oral/enteral feeding is not possible. There is a lack of data supporting specific nutrients in these conditions. Parenteral nutrition is mandatory in case of intestinal failure, at least in the acute period. In patients with short bowel, specific attention should be paid to water and electrolyte supplementation. Currently, the use of growth hormone, glutamine and GLP-2 cannot be recommended in patients with short bowel.

Nutrition assessment of patients with inflammatory bowel disease

BACKGROUND

Malnutrition among inflammatory bowel disease (IBD) subjects is well documented in the literature and may arise from factors including inadequate dietary intake, malabsorption, and disease activity. The aims of this present study were to complete a comprehensive nutrition assessment of IBD subjects.

METHODS

One hundred twenty-six consecutive adults with IBD completed anthropometric measures, 4-day food-record assessments, and biochemical markers of nutrition.

RESULTS

A high prevalence of inadequate nutrient consumption was observed: vitamin E (63%), vitamin D (36%), vitamin A (26%), calcium (23%), folate (19%), iron (13%), and vitamin C (11%). Several biochemical deficiencies were also observed. The prevalence of subnormal serum levels was hemoglobin (40%), ferritin (39.2%), vitamin B(6) (29%), carotene (23.4%), vitamin B(12) (18.4%), vitamin D (17.6%), albumin (17.6%), and zinc (15.2%). Dietary intake was not correlated with serum levels in all instances; there was a highly significant correlation between diet and serum values of vitamin B(12), folate, and vitamin B(6) for all IBD subjects, independent of disease activity, and for vitamin D among all IBD subjects in remission.

CONCLUSIONS

Subjects with IBD have a high rate of iron deficiency and anemia, which are most likely not secondary to diet. Supplementing with iron should be warranted only if a true iron deficiency exists. The routine evaluation of serum vitamin B(6) and vitamin D levels is recommended. Routine multivitamin supplementation is warranted in IBD in view of numerous dietary and biochemical deficiencies observed among adult IBD subjects. Even if subjects with IBD seem to be well nourished, they may harbor vitamin/mineral deficiencies.

ESPEN Guidelines on Enteral Nutrition: Gastroenterology

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

Serum n3 polyunsaturated fatty acids are depleted in Crohn's disease

To determine fatty acid patterns in Crohn's disease, we measured various serum fatty acids by gas chromatography in 20 patients with the disease and compared them with those in 18 healthy controls. All the patients had been free from any nutritional supplementation during preceding six months or had no history of intestinal resection. Eight of the patients were affected in the small bowel only, three in the large bowel only, and the remaining nine in both the small and large bowel. Both serum concentrations and percentages of C20:4n6, C20:5n3, C22:0, C22:6n3, total n3 polyunsaturated fatty acids, and total polyunsaturated fatty acids were lower in the patients than in the controls. Both essential fatty acids (C18:2n6, C18:3n3) and C20:3n9 levels were not different between the two groups. Among nine fatty acids that correlated with the Crohn's disease activity index, C20:5n3 and total n3 polyunsaturated fatty acids showed the most significant negative correlations. These findings suggest that essential fatty acid deficiency rarely occurs in Crohn's disease and also that n3 polyunsaturated fatty acids may be relevant to the activity of the disease.

Cytokines and food intake: the relevance of the immune system to the student of ingestive behavior

The aims of this paper are to provide a selective review of the literature relating immune system mediators, especially cytokines, to the control of eating and to indicate why this literature is particularly relevant to the student of ingestive behavior. Four reasons are given. Firstly, many immune system mediators influence eating, providing excellent examples of neuroimmunological controls of behaviour. Secondly, the immune system appears to be involved in the profound eating pathology associated with several clinical conditions. Thirdly, cytokines affect both energy intake and energy expenditure. Fourthly, the anorexia typically associated with activation of the immune system provides an informative model for the analysis of gut-brain communication in the control of eating.

Multiple vitamin status in Crohn's disease. Correlation with disease activity

We measured serum, blood, or red cell concentrations of various vitamins in 24 patients with Crohn's disease who had been free from any nutritional treatment, and compared them with those in 24 healthy controls. Twelve of the patients were affected in the small bowel only, two in the large bowel only, and the remaining 10 in both the small and large bowel. The fat-soluble vitamins A and E were significantly decreased in patients with Crohn's disease compared to controls. Among the water-soluble vitamins, vitamins B1, B2 and B6 and folic acid were more depleted in patients with Crohn's disease than in the controls, whereas vitamins B12 and C, nicotinic acid, and biotin were not different between the two groups, and pantothenic acid was increased in patients with Crohn's disease. In addition, vitamin B2 and nicotinic acid showed a negative correlation with the Crohn's disease activity index. These findings suggest that there is a variety of vitamin deficiencies in Crohn's disease prior to treatment and also that concentrations of some vitamins, such as vitamin B2 and nicotinic acid, may reflect the severity of the disease.

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

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

Inflammatory bowel disease: nutritional implications and treatment

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