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.