Dietetic advocacy for long-term use of exclusive enteral nutrition resulted in high-risk surgical avoidance for complicated fibrotic Crohn's disease – A case report

Abstract

Surgery is often the only therapeutic option for the management of fibrotic Crohn's disease (FCD). Exclusive Enteral Nutrition (EEN), a nutritionally complete liquid formula, is an effective, safe, short-term treatment for Crohn's Disease. No cases were found internationally of adults with FCD on long-term EEN. We report on clinical outcomes and self-reported quality of life (QoL) after longer-term EEN provision in a patient with complex FCD. "Billie", a 54-year-old female, was admitted with ileal FCD diagnosed in 1985. Previous treatments were unsuccessful, including multiple bowel resections. Billie was chronically bedbound with pain and depression. CDAI (Crohn's disease activity index) score was 640 (<150) with ∼3-20 liquid stools/day, and recurrent partial bowel obstructions. Radiological findings were so severe surgeons reluctantly considered surgery but "one more resection will result in short bowel syndrome". Billie trialled EEN given her QoL was "non-existent". Unable to tolerate the taste, EEN was administered via nasogastric tube. After two months, EEN was administered ongoing via percutaneous endoscopic gastrostomy given patient preference and dietetic advocacy. After eight weeks on EEN, Billie's pain predominantly resolved, with bowel motions of ∼1-2/day, and nil bowel obstructions. Twelve months after EEN commencement, Billie's CDAI was 52, with 'no indication for surgical intervention' and was self-reporting that "life is good". After 18 months, Billie remains asymptomatic, and in clinical remission. This unique case is a wonderful example of dietetic advocacy and showcases the positive impact long-term EEN may have on surgical avoidance, clinical outcomes and self-reported QoL.