advances in inflammatory bowel diseases 2014 millie boettcher, msn, ppcnp children’s hospital of...

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.