Nutritional therapy of hospitalized patients with inflammatory bowel disease

Digestive Diseases and Sciences, Vol. 32, No. 12 (December 1987 Supplement), pp. 89S-94S

Nutritional Therapy of Hospitalized Patients with Inflammatory Bowel Disease

J.S. WHITTAKER, MD, FRCP (C)

The use of total parenteral nutrition and enteral nutrition in inflammatory bowel disease has become commonplace. Except for well-documented improvements in nutritional parameters, the efficacy of these treatments for primary therapy or for complications remains largely unproven.

KEY WORDS: total parenteral nutrition; enteral nutrition; Crohn's disease; ulcerative colitis.

Hospitalized patients with inflammatory bowel disease (IBD) are frequently given nutritional support for complications of their disease. These complications include malnutrition, growth failure, bowel obstruction, fistulas, or short-bowel syndrome. Nu- tritional intervention is widely used as the "primary" treatment for an exacerbation of the disease, even though the efficacy of the practice remains unproven. Because of the nature of the diseases, nutritional intervention is much more often given in Crohn's disease than ulcerative colitis.

Numerous studies dating back over 15 years have showed that total parenteral nutrition (TPN) and enteral nutrition (EN) in IBD improve nutritional status, as determined by body weight, anthropom- etry, nitrogen balance, serum proteins, and total body nitrogen (1-14). In addition, both TPN and EN have improved linear growth in children with growth failure (15-21). Since malnutrition has been associated with increased morbidity (sepsis, im- paired wound healing), it has been suggested that

From the Division of Gastroenterology, Department of Med- icine, University of British Columbia, British Columbia, Canada.

Address for reprint requests: Dr. J.S. Whittaker, Division of Gastroenterology, Department of Medicine, University of Brit- ish Columbia, Room F-137, Koerner Pavilion, Health Sciences Centre Hospital, 2211 Wesbrook Mall, Vancouver, British Co- lumbia, Canada V6T IW5.

renourishment of such patients should result in decreased operative morbidity. A retrospective study found that IBD patients who received TPN preoperatively had less sepsis than those who received little or no TPN, but no randomized prospective controlled trial has examined this ques- tion yet.

Enterocutaneous, colocutaneous, enterovesical, and perianal fistulas have been treated with TPN and EN. Unfortunately, the success of nutritional intervention in healing fistulas is difficult to esti- mate. There have been no randomized trials comparing TPN or EN with standard medical therapy. Furthermore, most studies have reported total fistula healing rate in IBD, regardless of whether the fistulas were de novo or postoperative. It would be anticipated that postoperative fistulas would have a much higher healing rate since the communicating bowel would usually be macroscopically normal with no distal obstruction. Three TPN studies have reported an in-hospital fistula healing rate of 49% (34/70) with a "permanent" healing rate of 35% (24/68) (4, 6, 9). These percentages are remarkably similar to those of the earlier literature reviewed by Driscoll and Rosenberg (22), who found a 43% hospital healing rate and a 30% long-term healing rate. There are only sporadic, anecdotal reports of the treatment of fistulas in Crohn's patients with

Digestive Diseases and Sciences, Vol. 32, No. 12 (December 1987 Supplement) 0163-2116/87/120(~089S$05.00/0 �9 1987 Plenum Publishing Corporation

89S

E N (e l emen ta l d ie t ) , p r ec lud ing a n y mean ingfu l

c o m m e n t . W h e t h e r T P N o r E N ac tua l ly i m p r o v e d

f is tu la hea l ing ra t e s o v e r c o n v e n t i o n a l t h e r a p y is

d e b a t a b l e . T h e d a t a sugges t tha t T P N m a y cause

l o n g - t e r m hea l ing in up to one th i rd o f pa t i en t s .

S h o r t b o w e l s y n d r o m e s e c o n d a r y to mul t ip le

r e s e c t i o n s in C r o h n ' s d i s e a s e can be t r e a t ed in the

l o n g - t e r m wi th h o m e T P N or h o m e E N , bu t this

t op i c is o u t s i d e the s c o p e o f this r ev i ew.

E N and , e s p e c i a l l y , T P N have b e e n mos t w ide ly

W H I T T A K E R

used in I B D af te r c o n v e n t i o n a l m e d i c a l t r e a t m e n t

has fa i led . U n f o r t u n a t e l y , t h e r e h a v e b e e n v e r y f ew

p r o s p e c t i v e , r a n d o m i z e d , c o n t r o l l e d t r ia ls e x a m i n -

ing the eff icacy o f E N or T P N in I B D . F u r t h e r m o r e ,

the re is no c o n s e n s u s o f w h a t c o n s t i t u t e s m e d i c a l

fa i lure . In m o s t s tud ie s , o t h e r m e d i c a l t r e a t m e n t

was c o n t i n u e d dur ing the p e r i o d o f nu t r i t i ona l ther -

apy , fu r the r c o n f o u n d i n g the i n t e r p r e t a t i o n o f re-

sul ts ob t a ined . F i n a l l y , the def in i t ion o f r e m i s s i o n

h a s b e e n sub j e c t i ve and i m p r e c i s e , bu t o f t en re fe r s

TABLE 1. RESPONSE OF CROHN'S DISEASE TO TOTAL PARENTERAL NUTRITION GIVEN FOR MEDICAL FAILURE*

Clinical response

No. o f Indications for Duration of Hospital Long-term First author (re3') patients TPN TPN (days) remissions remissions

Length of remissions (months)

Retrospective 1973 Anderson (23) 4 medical failure 30 4/4 (100%) 1973 Fischer (24) 7 medical failure 3/7 (43%) 1974 Vogel (1) 8 medical failure 9-50 8/8 (100%) 1974 Eisenberg (25) 9 medical failure 21 (av) 1976 Fazio (26) 18 medical failure, 20 (av) 12/18 (67%)

diffuse disease, short bowel, post-op fistulas

52 planned surgery 20 (av) 12/52 (23%) 1976 Reilly (27) 23 medical failure 33 (av) 14/23 (61%) 1976 Dean (2) 11 medical failure, 14 (av) 4/11 (36%)

fistulas, malnutrition

1978 Mullen (3) 50 medical failure, 26.0 - 3.7 19/50 (38%) fistulas, malnutrition

1980 Bos (28) 86 medical failure 41.1 (av) 24/86 (28%) 1983 Shiloni (29) 9 medical failure 40.5 -+ 14.5 9/9 (100%) 1985 Ostro (9) 76 19 "active" 25.5 --- 1.1 62/76 (82%)

28 mass 29 obstruction

Prospective 1976 Greenberg (30) 43 11 medical 25 33/43 (77%)

failure 14 fistulas 4 obstruction

14 mass 16 medical failure 36 12/16 (75%) 30 medical failure, 21 25/30 (83%)

fistulas, ileus, (42 at bleeding home)

1980 Elson (4) 1983 Muller (6)

Prospective, randomized, controlled 1980 Dickenson (5) 9

1985 Greenberg (31) 51

1/4 (25%) 3

4/8 (50%) 4-48

4/21 (19%)t 27 (av) of total patients who remitted

6/9 (67%) 6-36 57/74 (77%) 3 42/71 (59%) 12

29/42 (69%) 24

7/16 (44%) 10-48 17/30 (57%) 12 8/30 (27%) up to 48

colitis acute (3 18.8 -+ 1.5 CON 3/3 (100%) 0/3 (0%) control, 6 TPN) TPN 4/6 (67%) 1/6 (17%)

medical failure 21 EN 11/19 (58%) 2/19 (11%) (19 EN, 15 PPN + diet, 17 PPN 9/15 (60%) 4/15 (27%) TPN) TPN 12/17 (71%) 8/17 (47%)

12

*Total number of hospital remissions with TPN/total number treated = 211/358 = 59% response rate [excludes the 52 patients in Fazio et a11976 study (26) who had planned surgery, and Greenberg et al 1976 report (30) which probably include s patients reported by Ostro et al (9) in 1985].

tPublished separately by Harford and Fazio in 1978 (32).

90S Digestive Diseases and Sciences, Vol. 32, No. 12 (December 1987 Supplement)

NUTRITIONAL THERAPY IN HOSPITALIZED PATIENTS

TABLE 2. RESPONSE OF ULCERATIVE COLITIS TO TOTAL PARENTERAL NUTRITION*

Duration No. of Indications for of TPN Hospital

First author patients TPN (days) remissions

Clinical response

Long-term remissions


Retrospective 1973 Fischer (24) 4 primary therapy 1/4 (25%) 1974 Vogel (1) 1 primary therapy 36 1/1 (100%) 1976 Fazio (26) 5 primary therapy 20 mean 4/5 (80%) 1976 Reilly (27) 11 medical failure 29 (av) 1/11 (9%) 1976 Dean (2) 5 primary therapy 14 (av) 4/5 (80%) 1978 Mullen (3) 24 medical failure 26.0 - 3.7 9/24 (38%)

malnutrition preoperative

Prospective 1980 Elson (4) 10 medical failure 21 (av) 4/10 (40%)

Prospective, randomized, controlled 1980 Dickenson (5) 27 acute colitis (14 23 (av) CON 8/14 (57%)

control, 13 TPN) TPN 6/13 (46%)

1/4 (25%) 0/1 (0%) 3/5 (60%)

4/24 (17%)

1/10 (10%)

5/8 (63%)

4/6 (67%)

6

20--41

6-120

44

12

*Total number of remissions with TPN/total number treated = 30/73 = 41% response rate.

to the ability to avoid surgery when surgery was being contemplated.

Retrospective and uncontrolled prospective studies of TPN in Crohn's disease have reported hospital remission rates of from 23% to 100% of patients given an average of three to six weeks of TPN (Table I). There have been only two prospective, randomized, controlled trials of TPN in Crohn's disease reported in the literature to date. Dickenson et al (5) studied 36 patients with acute colitis due to either Crohn's disease or ulcerative colitis (UC) randomized to receive conventional medical therapy alone or with TPN. Unfortunately, the Crohn's and UC patients were not stratified, with the result

that there were three Crohn's patients in the control group and six in the TPN group. All three patients in the control group went into remission, while four of six in the TPN group went into remission (Table I). One patient in the TPN group had a long-term, 12-month remission. The numbers are clearly too small to draw any conclusions about the efficacy in Crohn's disease patients.

Greenberg et al (31) have recently reported the results of a prospective trial in which Crohn's patients who failed conventional medical management were randomly assigned to receive three weeks of either TPN, a defined formula diet (EN) through a nasogastric tube, or an oral diet with

TABLE 3. RESPONSE OF CROHN'S DISEASE TO ELEMENTAL DIETS*

Duration No. of of EN Hospital

First author patients Indications for EN (days) remissions

Clinical response



Retrospective 1973 Voitk (10) 7 primary therapy, 22 3/7 (43%)

obstruction 1974 Rocchio (11) 25 35.1 (av) 10/25 (40%) 1977 Axelsson (33) 6 medical failure 26 (av) 4/6 (67%)

Prospective 1980 O'Morain (12) 27 primay therapy 28 24/27 (89%) 1984 Lochs (13) 25 primary therapy 32.8 (av) 15/25 (60%)

Prospective, randomized, controlled 1984 O'Morain (14) 21 (10 control primary CON 8/10 (80%)

therapy, 11 EN) EN 9/11 (82%)

3/6 (50%)

18/27 (67%) 12/25 (48%)

7/10 (70%) 8/11 (73%)

22-35

6 3-24

3

*Total number of hospital remissions with EN/total number treated = 65/101 = 64% response rate.

Digestive Diseases and Sciences, Vol. 32, No. 12 (December 1987 Supplement) 91S

WHITTAKER

TABLE 4. RESPONSE OF ULCERATIVE COLITIS TO ELEMENTAL DIETS*

Duration No. of of EN Hospital

First author patients Indications for EN ( d a y s ) remissions

Clinical response



Retrospective 1974 Rocchio (11) 9 35.1 (av) 3/9 (33%) 1977 Axelsson (33) 23 3 primary therapy 26 (av) 8/23 (35%)

20 medical failure With further drugs: 13/23 (57%) 6/23 (26%) 7-28

*Total number of remissions with EN/total number treated = 11/32 = 34% response rate.

partial parenteral nutrition (PPN). The three groups did equally well, with hospital remission rates of between 58% and 71%. Since the follow-up periods of the groups were not stated, meaningful compar- ison of the long-term remission rates cannot be made. It would appear from this study that bowel rest is not essential in inducing remission in refrac- tory Crohn's patients. Whether nutritional support p e r s e is important was not addressed by the study. While there are probably substantial differences in the patients reported in the different studies, it is interesting to calculate the "overall" hospital remission rate in patients treated with TPN. This rate turns out to be 59%. The long-term remission rate is not clear, since each study gave a different follow-up period. The long-term rate varied from 17% to 77%, with the patients followed from three to 120 months.

Fewer studies have examined the effect of TPN in ulcerative colitis (Table 2). There are clearly differences in the degree of illness of the patients reported in the various studies; these differences are reflected in the wide range of remission rates: %80% [excluding the solitary patient reported by Vogel et al (1)]. When all of the studies are considered, there is an "overall" remission rate of 41%, a figure of dubious meaning. There is only one controlled trial among those reported, that by Dicken- son et al (5). This study reported no effect of TPN added to conventional medical therapy with acute ulcerative colitis.

Elemental diets given orally or through a nasogastric tube have also been used as a treatment for both Crohn's disease and ulcerative colitis (Tables 3 and 4). In Crohn's disease, O'Morain et al (14) randomized 21 patients to conventional (steroid) therapy or an elemental diet. The patients had equivalent short-term remissions rates. When all of the reported studies are combined, the "overall"

short-term remission rate in Crohn's disease treated with an elemental diet is 64%. This figure is very similar to the overall hospital remission rate for TPN-treated patients of 59%. Whether the TPN patients were more ill in the retrospective studies cannot be answered. The only randomized, controlled trial comparing EN with TPN is the study by Greenberg et al (31) mentioned above. The enteral group was given a nonelemental, defined formula diet (DFD), so strictly speaking the study is not comparable to the above elemental diet studies. Nevertheless, the DFD group had a 58% remission rate, while the TPN group had a 71% remission rate (no statistical difference).

Very few studies have looked at elemental diets in ulcerative colitis (Table 4). The reported hospital remission rate is about 34%, similar to the 41% "overall" rate reported with TPN. However, the disparity in the patients selected for the different studies makes comparisons hazardous and invalid.

In summary, TPN and EN have been used to treat Crohn's and ulcerative colitis patients both as primary therapy modalities and as backups when conventional medical therapy has failed. The ex- pense and complications of TPN and EN necessi- tate the design of trials to prove or disprove the efficacy of these therapies. TPN and EN should now be considered potentially valuable but largely unproven adjuncts to conventional medical therapy.

Recent work has shown that about 10-40% of children with IBD will suffer growth retardation (34). Nutritional, hormonal, and disease-related fac- tors have been implicated in the growth failure. Nutritional intervention with either TPN or EN has resulted in accelerated growth rates in growth- retarded patients, despite evidence of active disease and ongoing use of steroids. These studies mean that physicians must be vigilant in recognizing


NUTRITIONAL THERAPY IN HOSPITALIZED PATIENTS

growth failure in IBD patients, so that early nutritional intervention can be instituted. In many in- stances, it would appear possible to avoid nutritional dwarfism. The reader is referred to a recent comprehensive review of the subject of nutritional management of inflammatory bowel disease in children (34).

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W H I T T A K E R

33. Axelsson C, Jarnum S: Assessment of the therapeutic value of an elemental diet in chronic inflammatory bowel disease. Scand J Gastroenterol 12:89-95, 1977

34. Motil KJ, Grand ILl: Nutritional management of inflammatory bowel disease. Pediatr Clin North Am 32:447-469, 1985


Documents

Nutritional therapy of hospitalized patients with inflammatory bowel disease