April 2000

740FAT COMPOSITION IS THE DIFFERENTIAL FACTOR TO EX­PLAIN THE PRIMARY THERAPEUTIC EFFECT OF ENTERALNUTRITION IN CROHN'S DISEASE. RESULTS OF A DOUBLE·BLIND, RANDOMIZED, MULTICENTER EUROPEAN TRIAL.Miquel A. Gassull, Fernando Fernandez-Banares, Eduard Cabre, MichelPapo, M. H. Giaffer, Jose L. Sanchez-Lornbrana, Juan C. Quer, HelmutMalchow, Ferran Gonzalez-Huix, European Group on Enteral Nutrition inCrohn's Disease, Badalona, SPAIN; European Group on Enteral Nutritionin Crohn's Disease.

Controversy do exist as to whether the source of nitrogen (aminoacids vswhole protein) or the lipid composition of enteral diets can explain theirprimary therapeutic effect in active Crohn's disease (CD). Aim: To assessthe efficacy of two polymeric enteral diets with different fat composition ininducing clinical remission in active CD, as compared to steroids. Meth­ods: 62 patients with active CD (symptoms of flare-up + Van Hees'activity index [VHAI]> 120 + two of the following: CRP>6 mgIL,ESR>30 mmlh, Hb<12 gIL [<11.5 gIL in females])were randomized toreceive for no more than 4 weeks one of these three treatments: 1) Totalenteral nutrition (TEN) using a polymeric diet containing 35 g of lipids per1000 kcal, high in oleate (80%) and low in linoleate (6%) (TEN1), 2)TENusing an identical formula diet except for the type of fat which was high inlinoleate (50%) and low in oleate (28%) (TEN2), or 3) oral prednisone (Img/Kg/day) (STE). Diets were double blindly administered as sip feeding(VHAI < 170) Dr tube feeding (VHAI> 170). STE group received standardward diet. Daily energy requirements were calculated using the Long'sequation for usual body weight. Treatment failure was considered whenclinical remission (i.e. VHAI<120)was not acheived after 4 weeks oftherapy. Clinical activity, biological parameters and VHAI and CDAI weremonitored weekly. A stepwise logistic regression analysis was performedto identify independent predictors of remission. Results: 9 patients withTEN dropped-out during the first 2 weeks of therapy (8 because of patient'srefusal to continue, an I due to poor tolerance), giving 53 evaluablepatients: TENI: 15, TEN2: 19, and STE: 19. Groups were clinicallyhomogeneous at baseline. Overall remission rates were 27% for TENI,63% for TEN2, and 79% for STE (p=0.008, STE and TEN2 vs TEN 1).Multivariate analysis showed that TEN I theraphy (OR: 0.12), VHAI> 170(OR: 0.05) and small bowel disease (OR: 0.15) were unfavourable related,while new onset disease (OR: 3.43) was favourable associated to remis­sion. In fact, remission rates in patients with new onsed CD were: TENI37%, TEN2 80%, and steroids 73%. Conclusions: The composition ofdietary fat seems to have a crucial role in the primary therapeutic effect ofenteral diets in active CD. 2) TEN may be an alternative to STE in specificgroups of patiens. Further research is warranted to define the mechanismsof action of the different types of fat in active CD.

741

ALENDRONATE INCREASES LUMBAR SPINE BONE MINERALDENSITY IN PATIENTS WITH CROHN'S DISEASE. A DOUBLEBLIND CONTROLLED STUDY.Kent V. Haderslev, Lone Tjellesen, Henrik A. Sorensen, Michael Staun,Dept of Gastroenterology, Rigshospitalet, Copenhagen, Denmark; Dept ofEndocrinolgy, Hvidovre, Denmark.

Background: Low bone-mineral density (BMD) is a common complicationof Crohn's disease and may lead to increased morbidity and mortality dueto fractures. We investigated the effect of treatment with the bisphospho­nate alendronate-sodium on bone mass and markers of bone remodeling inpatients with Crohn's disease. Methods: A 12-month double blind, ran­domized, placebo-controlled trial was performed to study the effect ofIO-mg daily of alendronate. A total of 32 patients (9 men, 16 pre-meno­pausal and 7 post-menopausal women) with a bone-mass T-score below ­I of the hip or lumbar spine were studied. Exclusion criteria included activeCrohn's disease (Van Hees index > 150) and previous small bowelresections exceeding 100 em. The main outcome measure was the differ­ence in the mean percent change in bone mineral density of the lumbarspine measured by dual-energy x-ray absorptiometry. Secondary outcomemeasures included changes in bone mineral density of the hip and bio­chemical markers of bone turnover, i.e., s-osteocalcin, urine pyridinolineand urine deoxypyridinoline excretion. Results: The mean (±SE) of thelumbar spine BMD showed an increase of 4.6 ± 1.2 percent in thealendronate group compared with a decrease 0.9 ± 1.0 percent in patientswho received placebo (P < 0.01). BMD of the hip increased by 3.3 ± 1.5percent in patients who received alendronate treatment compared with asmaller increase of 0.7 ± 1.1 percent in the placebo group (P = 0.08).Biochemical markers of bone turnover decreased significantly in the alen­dronate group (P < 0.001). Alendronate was well tolerated and there wasno difference in adverse events between treatment groups. Conclusion:Treatment with alendronate 10 mg daily significantly increased BMD inpatients with Crohn's disease and was safe and well tolerated.

AGAA117

742PREDICTORS OF OSTEOPENIA IN INFLAMMATORY BOWELDISEASE,Sandra D. Henderson, Satvinder S. Dhaliwal, Neville E. Hoffman, SirCharles Gairdner Hosp, Perth, WA, Australia.

SD Henderson':",SS Dhaliwal",NE Hoffman"and RL Prince':". 'Univer­sity of Western Australia, 2Gastroenterology and 3Endocrinology Depart­ments Sir Charles Gairdner Hospital. Perth Australia BACKGROUND:The prevalence of osteoporosis has been reported between 31-59% ininflammatory bowel disease (IBD) patients. The pathogenesis of osteope­nia is uncertain in IBD patients although both corticosteroid use and thedisease itself are thought to be important. AIM: To determine the relativeclinical significance of disease activity and corticosteroid use in predictingosteopenia. METHOD: 63 Crohn's and 52 ulcerative colitis ambulatoryoutpatients were studied. Bone density was measured at the hip and spineusing QDR 4500 technology. Osteopenia was defined as a z score :5-1.Disease activity (DA) was expressed by a combination of overall severity(ranked mild/moderate/severe by the treating Gastroenterologist), monthsof disease activity in the preceding 12 months, number of admissions in thelast 5 years, use of azathioprine and inflammatory markers including ESR,c-reactive protein, platelet count and haemoglobin. Cumulative corticoste­roid consumption in grams was determined by structured patient interview.Data was analysed using stepwise logistic regression SAS 6.12, and wasadjusted for gender, menopause, age, smoking and dietary calcium. RE­SULTS: 44.4% of Crohn's and 53.8% of ulcerative colitis patients hadosteopenia. In both spine and hip in IBD patients indices of DA predictedosteopenia. In Crohn's osteopenia at the spine was predicted by body massindex (p= 0.02 odds ratio (OR) 0.78, 95% confidence interval (CI) 0.63­0.96) and months of disease activity in the preceding 12 months (p= 0.05OR 1.16,95% CI 1.00-1.35). In ulcerative colitis patients admissions in thelast 5 years was significant (p= 0.03 OR 24.28, 95% CI 1.46-402.21).Total corticosteroid consumption >5gm was a significant predictor ofosteopenia at the spine p= 0.05 in univariate analysis but not in multivar­iate analysis. Osteopenia at the hip in Crohn' s was predicted by diseaseseverity (p= 0.05 OR 3.58, 95% CI 0.10-12.86). In ulcerative colitis hiposteopenia was predicted by body mass index(p= 0.03 OR 0.26, 95% CI0.08-0.88) and cumulative corticosteroid use greater than 5gm (p= 0.03OR 79.1, 95% CI 1.49-999). CONCLUSION: An assessment of diseaseactivity using a combination of short term features (months of activity inthe preceding 12 months), and long term features (admissions in a 5 yearperiod and global severity) is a significant predictor of osteopenia.

743COPING AND QUALITY OF LIFE IN PEDIATRIC CROHN'S DIS·EASE.Stacie B. Isenberg, Aimee E. Christian, Robert N. Baldassano, Children'sHosp of Philadelphia, Philadelphia, PA; The Children's Hosp of Philadel­phia, Philadelphia, PA.

Background: Few studies have examined children's ability to cope withchronic illness. Research on chronic disease in adults has found a relation­ship between depressive coping (i.e., self-criticism and blaming others) andpoor quality-of-life. A child's perceptions of herlbis ability to modify astressor, (e.g., pain, physical changes) may influence the coping strategiess/he uses. If ineffective coping strategies are used, one's ability to functionnormally (i.e., quality-of-life) may be negatively affected. Aim: To inves­tigate the coping strategies and quality-of-life of pediatric patients withCD. Methods: Children seen at the outpatient gastroenterology clinic atThe Children's Hospital of Philadelphia between the ages of 8 and 18 yearsof age were included in the study. All subjects had CD documented byendoscopic andlor radiologic methods. All patients completed the Kidcopequestionnaire to be placed into either positive/approach or negative/avoid­ance coping groups. The IMPACT questionnaire was administered with thescore directly relating to the patient's quality-of-life (0 [worst] to 330[best]). Objective measures including the Physicians Global Assessmentand Pediatric Crohn's Disease Activity Index were also done. One-wayANOV A and Student's t-test were performed to examine the relationshipbetween coping strategies, quality-of-life, and disease severity. Results: Allpatients in this study exhibited good quality-of-life (mean = 219.07 ±46.21). There was no significant predisposition to a particular copingstrategy in this population. Also, there was no significant difference be­tween coping style (either positive or negative) and quality-of-life in thispopulation of patients (F=0.8556, df=3, ns). Of the patients who wereplaced in the negative/avoidance coping group, most exhibited avoidancebehaviors such as distraction (88%) or wishful thinking (88%). Positivecoping behaviors that were prevalent among the patients were cognitiverestructuring (76%) and problem-solving (72%). It is important to note thata small percentage of patients exhibited the negative coping behaviors ofself-criticism (8%) or blaming others (16%). Conclusions: Since all of ourpatients enjoy a good quality of life and few exhibit negative copingbehaviors, a developmental component to coping is suggested. Adults'long-term experience with their chronic disease may lead to the develop­ment of ineffective coping strategies. If children can be taught effectivestrategies of coping, their quality-of-life may remain high throughout theadult years.