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Crohn’s disease is a chronic recurring illness of the gastrointestinal tract. Up to 25% of those diagnosed with Crohn’s are children. While the exact etiology is unknown, Crohn’s involves a combination of exaggerated immune response, genetic predisposition, environmental influences and microflora imbalance. The affected bowel is engorged with inflammatory cells leading to ulceration, with pain and diarrhea that may be associated with heavy bleeding. Extensive inflammation causes swelling that constricts the bowel diameter (inflammatory stricture). Chronic inflammation may lead to fibrous stricture and obstruction. Fistulae are another outcome of prolonged irritation.
Therapies for Crohn’s Disease include nutritional support, immune suppressants, antibiotics, antidiarrheals and commonly, surgical intervention. Recent advancements include the use of targeted therapies and specific cytokines. Anti–tumor necrosis factor (anti-TNF) agents, such as infliximab, adalimumab, certolizumab pegol, and natalizumab, have shown effective therapeutic results.
Originally implemented in the 1970s, a nutritional therapy known as exclusive enteral nutrition (EEN), involves the administration of a liquid protein diet, with exclusion of all solids for the period of treatment, usually 6-8 weeks. EEN is suggested for first line management of Crohn’s flare ups in children and may be under-prescribed in adults. EEN is quite effective for inducing remission when Crohn’s Disease is active, side-steps the adverse effects of steroid treatment, and promotes mucosal healing. Short term EEN has other positive effects in addition to mucosal healing. It reduces stricture caused by inflammation, improves nutrition and improves bone turnover. Six weeks of EEN has been shown to facilitate remission and delay the need for immunosupressants.
Enteral nutrition (EN) supplemental to a solid diet has also shown positive effects in Crohn’s treatment as well. Research has shown EN effectively reduces mucosal inflammation and bowel edema. However, EEN is preferred for its range of therapeutic effects and potential to prolong remission. One of the most promising benefits of EEN therapy is the reduction of bowel stricture.
A recently published article by researchers at Nanjing University studied the effects of 12 weeks of EEN in patients with inflammatory bowel stricture. A diet of Peptisorb Liquid via nasogastric or nasointestinal tube provided elemental peptides for digestibility and ease of absorption. Nutritional, inflammatory and radiologic parameters were assessed at baseline, 4 and 12 weeks. Critical measurements for this study including bowel wall thickness, bowel loop diameter, luminal diameter, and luminal cross-sectional area were all calculated using the Analyze software.
In patients who completed the entire course of EEN, inflammatory, nutritional and radiologic parameters were significantly improved compared to baseline. Symptomatic remission was seen in 81% of patients, 54% of patients achieved radiological remission and 65% demonstrated clinical remission; the latter falls within the range seen in previous studies, 58% to 72%, for clinical remission. Notably, the average luminal cross-sectional diameter at the stricture increased by approximately 331% at Week 12. Concurrently, bowel wall thickness was significantly decreased at both 4 and 12 weeks.
The conditions of this study were, admittedly, highly controlled for a normal outpatient protocol. Most patients would not comply with intubation for 12 weeks. However, with patient compliance, a total enteral diet could significantly improve Crohn’s outcomes. These results emphasize the profoundly positive effects of EEN for the relief of stricture and abatement of clinical Crohn’s disease, and they advance our understanding of therapies for effective remission. Further studies will examine the duration of remission with EEN and its comparative use with other treatments, such as prednisone and anti-TNF agents.
Tags: Crohn's disease, Gastrointestinal