Management of disease-related abdominal abscesses in Crohn's disease

INTRODUCTION

Crohn's disease (CD)-related abdominal abscesses require tailored management strategies taking into consideration the variability in abscess size, location, and underlying CD activity.

AREAS COVERED

This review discusses current approaches to CD-related abscesses. Literature review was performed through the PubMed and Medline databases to identify studies pertinent to the wide-ranging focus of this review.

EXPERT OPINION

Early, individualized treatment combining medical and surgical strategies is crucial for optimizing outcomes in patients with CD-related abdominal abscesses. Antibiotics are effective for smaller abscesses in hemodynamically stable patients; however, recurrence is common, necessitating close monitoring. Percutaneous drainage (PD) provides a less invasive alternative to surgery, offering high initial success rates but variable long-term results, as many patients ultimately need a definitive surgical intervention. For larger or complex abscesses, surgery may be necessary to address both the abscess and underlying CD. Despite its invasiveness, surgery is associated with high success rates and reduced recurrence risk. Biologic therapies, particularly anti-TNF agents, have shown promise in managing CD-associated abscesses, and can reduce abscess recurrence risk without surgery. While biologics may help delay or avoid surgery in select patients, interdisciplinary collaboration is essential to mitigate the risks associated with immunosuppression in the presence of intra-abdominal infections.

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.

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.

Inpatient Management of Inflammatory Bowel Disease-Related Complications

Despite advances in therapeutic options, a sizeable proportion of patients with inflammatory bowel disease require hospitalization or surgery during their lifetime. While current treatment guidelines for the management of ulcerative colitis and Crohn's disease cover the spectrum of disease severity and behavior, management of acute complications of inflammatory bowel disease can present unique challenges that are not always addressed in these guidelines. In this review, the authors provide a comprehensive summary of the existing literature focused on management of patients hospitalized with complications of inflammatory bowel disease. Proposed management algorithms are provided to guide clinicians through common scenarios to determine the most appropriate interventions - escalation of medical therapies, non-surgical therapeutic interventions (drainage of intra-abdominal abscess or endoscopic balloon dilation) or surgery. Prevention of complications is proposed through a multi-disciplinary approach that involves surgeons, dieticians, radiologists, pathologists and infectious disease consultants.

Nutritional approach as therapeutic manipulation in inflammatory bowel disease

Malnutrition is observed more frequently in patients with inflammatory bowel disease (IBD) than in the general population and associated with adverse clinical outcomes. This study aimed to review the current knowledge regarding the efficacy of dietary and nutritional intervention in IBD patients. Exclusive enteral nutrition might be inferior to corticosteroid treatment in adults with active Crohn’s disease (CD) but might even be superior considering the adverse effects of corticosteroid treatment in children. Total parenteral nutrition has no advantage over enteral nutrition, which is considered a more physiologic modality in organ function. Current guidelines do not yet recommend ω3-polyunsaturated fatty acid supplementation for the prevention and maintenance of remission in IBD patients. Dietary fiber supplementation could be effective in the relief of symptoms and maintenance of remission in ulcerative colitis (UC). Although vitamin D may be favorable to clinical course of IBD and bone density. Probiotic supplementation has proven to be effective in preventing and treating pouchitis for UC but is less effective in treating CD. Nutritional interventions not only correct nutritional deficiencies but also improve symptoms and clinical courses of the disease. Hence, nutritional approaches need to be developed to significantly evaluate the effectiveness of dietary interventions used to treat IBD.

Diet as Adjunctive Treatment for Inflammatory Bowel Disease: Review and Update of the Latest Literature

PURPOSE OF REVIEW

Diet plays an integral role in development of inflammatory bowel disease (IBD) and continues to act as a mediator of intestinal inflammation once disease sets in. Most clinicians provide little dietary guidance to IBD patients, in part due to lack of knowledge in nutrition and lack of available nutritional resources. The purpose of this review is to provide clinicians with a brief summary of the latest evidence behind diets popular among IBD patients, to highlight diets with known efficacy, and to provide guidance that may help busy practitioners.

RECENT FINDINGS

The latest studies show that exclusive enteral nutrition (EEN) remains the most effective diet for induction of remission in Crohn's disease (CD), either in the form of elemental, semi-elemental, or polymeric formulas. Recent studies also show that EEN can be useful in complicated CD including in enterocutaneous fistulas closure and to optimize nutrition in the pre-operative setting. Although new studies suggest that partial enteral nutrition supplemented with elimination diets may be beneficial in ulcerative colitis (UC) and CD, larger controlled studies are needed to support their use. The autoimmune diet also shows promise but lacks larger studies. Recent uncontrolled clinical studies evaluating the specific carbohydrate diet (SCD) suggest that this diet may improve biochemical markers of inflammation and induce mucosal healing, although larger studies are needed to support its use, especially because the SCD is very restrictive. Short-term use of the low FODMAP diet is appropriate when in the setting of an acute flare up and/or in stricturing disease, but long-term restriction of FODMAPs is not recommended given long-term changes observed in the microbiome. Recent studies suggest that avoidance of processed foods, packaged with preservatives and emulsifiers, may be important in decreasing intestinal inflammation; many of the recent popular diets share a common concept, avoidance of processed foods. In this review of the latest literature, we highlight that dietary studies are still in a rudimentary stage. Large prospective randomized control studies are underway evaluating head to head comparisons on the efficacy of some of these diets. We offer general guiding principles that may help gastroenterologists in the meantime.

Evolving role of diet in the pathogenesis and treatment of inflammatory bowel diseases

Recent advances in basic and clinical science over the last 3 years have dramatically altered our appreciation of the role of diet in inflammatory bowel diseases (IBD). The marked increase in incidence of these diseases along with the important role of non-genetic susceptibility among patients with IBD has highlighted that these diseases have a strong environmental component. Progress in the field of microbiome and IBD has demonstrated that microbiome appears to play an important role in pathogenesis, and that diet may in turn impact the composition and functionality of the microbiome. Uncontrolled clinical studies have demonstrated that various dietary therapies such as exclusive enteral nutrition and newly developed exclusion diets might be potent tools for induction of remission at disease onset, for patients failing biologic therapy, as a treatment for disease complications and in reducing the need for surgery. We review these advances from bench to bedside, along with the need for better clinical trials to support these interventions.