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1、(Enteral)Nutritional Therapyinduction of remission in CD,Yujie Y.,Contents,Background,Crohns Disease,Environmental factors,Host susceptibility,Immune mediated injury,Cofactors,Not Curative,Treatments,A. Induction and maintenance of remission,B. Anticipation and prevention of complications,C. Correct
2、ion of malnutrition and growth failure,D. Improvement of quality of life,Purpose,Background,Drugs,Nutritional Therapy,Surgical interventions,Sulphasalazine/5-ASA,Corticosteroids/budesonide,Antibiotics/antimycobacterial therapy,Azathioprine/6-mercaptopurine,Cyclosporine A,Methotrexate,Anti-TNF agents
3、: thalidomide, infliximab,Treatments,Parenteral Nutrition (PN),Enteral Nutrition (EN),Elemental Diets- Free amino acid,Semi-elemental Diets- Oligopeptides,Polymeric Diets- Whole protein,Specific nutrients- Fish oil, Glutamine,Background,When to Use Nutritional Therapy?,I. For improving nutritional s
4、tatus,II. As primary therapy for active disease,III. For the maintenance of remission,Nutrition Support: could correct malnutrition and growth impairment,A. Corticosteroids are not feasible; B. In childhood small bowel CD,Overview literatures,Improved disease activity and nutritional status reported
5、 in several small uncontrolled studies Multicentre prospective study ( Greenberg, 1988 )TPN alone, partial PN + normal food and a polymeric diet were equally effective Concluded bowel rest not necessary and PN should be supportive, rather than primary therapy,Parenteral Nutrition,Overview literature
6、s,Parenteral Nutrition,May help to achieve remission in patients with strictures or short bowel syndromePerioperative PN results in less small bowel resection but much longer hospital stayMore complications with PN (especially Sepsis),Overview literatures,Elemental Diets,Chemically defined liquid di
7、ets containing amino acids, simple carbohydrates, fats etc.First RCT by OMorain (1984) suggested elemental diets were as effective as steroids at inducing remission of CDSimilar results and improved growth confirmed by Sanderson (1987) in first paediatric RCT,Enteral nutritional therapy for inducing
8、 remission of Crohns disease,Zachos M, Tondeur M, Griffiths AM Cochrane Library 2001,Part A: Meta-analysis 9 RCTs comparing elemental diet (n=170) to non-elemental diet (n=128) showed N.S. difference in remission rate OR 1.15, 95% CI: 0.64-2.08Part B: Meta-analysis 4 RCTs comparing enteral nutrition
9、 (n=130) to steroids (n=123) showed steroids better at inducing remission OR 0.30, 95% CI: 0.17-0.52,Overview literatures,Overview literatures,Supplementary enteral nutrition maintains remission in pediatric Crohns diseaseWilschanski M et al, Gut 1996;38:543-8,Retrospective review of 65 children wit
10、h active Crohns disease treated with enteral nutrition 47 (72%) achieved remission (PCDAI20)20 relapsed by 6 months; 28 replapsed by 12 monthsLonger remission in those continuing nasogastric supplements after resumption of normal diet,Overview literatures,Double-blind RCT of glutamine-enriched polym
11、eric diet in the treatment of active Crohns diseaseAkobeng AK et al, J Pediatr Gastroenterol Nutr 2000;30:78-84,18 children with active CD received for 4/52 a glutamine rich (42% amino acids) or low glutamine (4% amino acids) polymeric diet in DBRCT Diets were isocaloric & isonitrogenous with identi
12、cal essential amino acid profile2 patients in high glutamine group did not tolerate the dietN.S. in remission rates OR 0.64, 95% CI 0.10-4.11,15-50% children with CD have growth failureMalnutrition probably most important causeMacro/micronutrient deficiencies common Inflammatory mediators and IGF-I
13、Improved growth with long-term oral supplements,Enteral nutrition in growth failure,EN Mechanism of Action,improved nutritional status (macro/micro)improved luminal nutritionimproved immune functionreduced antigenic load to gutaltered gut flora inflammatory mediator production (IL-6), IGF-I,Whats Wr
14、ong with Our Strategies,I. No corticosteroids,II. Enteral Nutritional Support,III. Surgical interventions,(skin-grafting, colostomy, surgical drainage),What we Neglected?,I. Concrete evaluation (Weight/Height),II. Ongoing monitoring (Immune function),III. Other Anti-inflamatory therapies,What we hav
15、e done?,Summary,Bowel rest is unnecessary, PN should be supportiveSteroids are significantly better than EN at inducing remission in active Crohns disease (for Adults)The benefits of EN differ between children and adultsEN promotes growth & may help to prolong remissionGlutamine is of no proven bene
16、fit in active CD,Summary,Further data should evaluate disease location and duration on response to nutrional therapyFuture Studies should focus on mechanisms of EN working, and synthesis of present conservative therapies ( Nutrients + Drugs),If the gut works, please use it!,Thank You !,Reading Changes Life!,
