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Advances in Inflammatory Bowel Diseases 2014
Millie Boettcher, MSN, PPCNPChildren’s Hospital of Philadelphia
Division of Gastroenterology, Hepatology and Nutrition
Pediatric case
• DS presented at 8 months of age with decreased oral intake and bloody diarrhea
• Associated with introduction of solids • Milk and diary was eliminated from the diet
with improvement
Pediatric case
• At 15 months after immunization – he presented with dark red stools and weight gain slowed and had dropped to <5th %ile on WHO curve
• He was having 5 to 7 stools per day, with blood and mucous
• His diet was basically vegetarian with soy milk
Pediatric case
• He underwent a colonoscopy and the histology revealed – focal active ileitis with granuloma, chronic active colitis with architecture changes and granuloma
• Family history is significant for father with papillary thyroid carcinoma and removed at age 25 and mother with Hashimoto’s disease
Pediatric case
• What are the current options for treatment for induction of remission?
steroids mesalamine antibiotics
Pediatric Case
• Parents opted for balsalazide 250mg 2 times per day and metronidazole 15mg/kg day was added
• TMPT was drawn and normal at 32.6 EU• He continued to have bloody stools and
abdominal pain and poor intake
Pediatric case
• Azathiaprine 25 mg daily initiated • 6TG 315 was therapeutic • 6MMP level persistently undetectable • Prednisone started due to blood persisting
and was tapered off over 6 weeks
Pediatric case
• Admitted due to persistent symptoms – ESR 65, CRP 6, Hgb 8.6 and azathiaprine at this time was at 3.5mg/kg and was on steroid taper
• He was having 4 to 6 stools with intermittent blood and his intake was poor
• IV steroids were initiated
Pediatric Case
• What are the treatment options, for this now 3 year old?
• Do the risks outweigh the benefits?
• What are the goals of treatment?
Pediatric Case
• Biologics versus enteral nutrition • Family history of cancer • Goals not only remission, include weight gain
and growth • He began NG tube feedings for
supplementation and Remicade was initiated
Pediatric Case
• After 3 induction doses of inflximab he had no circulating infliximab and no improvement in his symptoms
• Parents opted for 100% exclusive enteral nutrition via a NG tube at night
• He began Soy formula and steroids were tapered over 6 weeks and stools improved
Pediatric Case
• Weight gain improved and up to 34% ile • Growth improved up to 2%ile then 4%ile • Stools decreased to 2 to 3 per day and his
energy level improved
Whitten et al Journal of Digestive Diseases 2012
Enteral Nutrition in IBD
• A therapy that has been used for 4 decades • Involves the use of a specific enteral formula as
nutrition therapy • Formula is most often delivered via an NG tube • Exclusive, 100% of calories, for a defined period of
time • Partial 80-90% of calorie, with the remainder from
normal food
Enteral Nutrition in IBD
Clinical relevance of diet and IBD -CCFA receives more than 14,000 inquiries per year, of which approximately 65% are for dietary advice. -Patients desire therapies which do not suppress the immune system
Enteral Nutrition in IBD
• Diet is associated with new onset IBD – High dietary intake of total fats, PUFAs, omega-6
and meat were associated with an increased risk of CD and UC
– High fiber and fruit intake were associated wit decreased CD risk
– High vegetable intake was associated with decreased UC risk
Enteral Nutrition in IBD
• CHOP Protocol • Semi-elemental formula • 80-90% of total caloric needs from formula• Nocturnal NG feed via pump• Unrestricted diet during the day • Duration – 7 days per week for 8-12 weeks for
induction and 5 days per week for maintenance
• Retrospective review of CHOP ENT protocol• 43 patients with CD treated from 1998-2010• 87% response rate and 65% remission rate• Decreases in ESR and CRP, increase in albumin• Increases in weight and height
Enteral Nutritional Therapy for Crohn Disease
• Induction of remission Yes• Maintenance of remission Yes• Prevent Post-op recurrence Yes• Mucosal healing Yes
Enteral Nutritional Therapy
• Why does it work?
– Change in gut microbiota ?
– Decrease in antigenic load ?
– Effect of certain nutrients ?
Enteral Nutritional Therapy
• Reduction in luminal antigens • Modulation in the gut microbiota -
proteobacteria were more abundant and bacteroidetes were less abundant
• There is some evidence that an increased in fecal short chain fatty acids
Enteral Nutrition Therapy
• A study by Leach and colleagues evaluated the abundance of 5 key groups of bacteria in the stool of patients with CD treated with EN and healthy patients on a regular diet
• The CD pts treated with EN had a significant decrease in the bacterial diversity which was sustained for several months following completion of therapy.
Safety of EN therapy for Crohn’s Disease
• No immunosuppression and beneficial effects on microbiota
• Generally well tolerated
• Most common side effects: Nausea, flatulence, abdominal pain, diarrhea
Akonberg AK. JPGN. 2010.Afzal NA et al. Clin Nutr. 2002.
Enteral Nutrition in IBD
• CHOP Experience 36 complaints by 22 patients
Morning emesis Liquid stools Difficulty placing the NG tube Abdominal pain/bloating Loss of appetite Throat irritation
Gupta K et al In Press
Enteral Nutritional Therapy:Where should this be in our treatment algorithm?
• Should be offered to all newly diagnosed patients with CD who can tolerate nutritional therapy– Special groups
• Malnourished patients• Younger patients• Growth failure• History of cancer• Family history of lymphoma?
• Consider when failing other therapies
Enteral Nutrition IBD
• Special groups – Malnourished patients – Younger patients – Growth failure – History of cancer – Family history of lymphoma – Patients that are failing other therapies or have
had significant side effects
Enteral Nutrition in IBD
• Induction of remission • Maintenance of
remission • Prevent post-op
recurrence • Mucosal healing
• Tolerability • Serious side effects • Immunosuppressant
• yes• yes• yes
• yes
• yes • no• no
Enteral Nutrition in IBD
Potential disadvantage monotony of the diet social implications compliance support for patients and families financial and insurance issues
Thank You
• Special thanks to Dr. Lindsey Albenberg for her assistance in preparing this talk.