S2725 Enteral Nutrition in Crohns Disease With Abscess

Abstract

Introduction: Enteral nutrition has emerged as a treatment option for patients with active Crohn’s disease. We report a patient achieving remission with enteral nutrition in conjunction with ustekinumab. Case Description/Methods: A 29-year-old Caucasian male with Crohn’s disease not on therapy presented with abdominal pain, nausea and vomiting. In the past 3 years, he had multiple visits to urgent care for symptoms, each treated with systemic steroids. On presentation, he had an elevated CRP of 143.9 mg/L and MR enterography showed inflammation in the small bowel and terminal ileum. The patient completed a 7-day course of piperacillin-tazobactam and was started on ustekinumab. He was readmitted 10 days later with WBC of 16.9 10*3/ul, CRP of 305.6 mg/L, tachycardia, night sweats and worsening abdominal pain. Imaging showed continued inflammation of small bowel and terminal ileum with a mesenteric abscess connected to the D4 portion of duodenum by a fistulous tract. Piperacillin-tazobactam was started for 14 days along with 5 weeks of exclusive enteral nutrition (EEN) with BOOST, ∼2145 kcals daily. Repeat imaging showed interval decrease in abscess size and then complete resolution. Disease remission was obtained with alleviation of abdominal pain and weight gain of 5 lbs. Labs normalized with CRP < 3 mg/L, at the end of the 5 weeks of EEN. Discussion: EEN is the administration of a polymeric formula as the sole source of nutrition for a limited period (4-8 weeks). In Crohn’s disease, EEN has been shown to help reach remission in 85-90% of patients. It has special consideration in achieving remission in CD patients who have steroid intolerance or contraindications to systemic steroids. The mechanism of EEN in treatment of Crohns disease is not completely understood but is hypothesized to be multifactorial and potentially involve alterations in gut microbiota, decreasing gut permeability, and allowing restoration of epithelial barrier. Limited studies have been conducted on concomitant use of EEN with biologic agents. These studies have primarily been done looking at anti-TNF agents, such as infliximab, and sustained remission rates. Induction therapy with such agents as ustekinumab take time to have clinical effect, 56% of patients have response in 6 weeks. In this patient, initiation of ustekinumab along with EEN was successful in achievement of clinical remission and reduction in inflammatory markers.