Exclusive Enteral Nutrition Treatment Research Articles

Effect of Exclusive Enteral Nutrition on the Disease Process, Nutrition Status, and Gastrointestinal Microbiota for Chinese Children With Crohn's Disease.

The aim of this study was to prospectively study the effect of exclusive enteral nutrition (EEN) treatment on Chinese pediatric Crohn's disease (CD) patients. Thirty-one newly diagnosed CD patients were enrolled in this study and treated with EEN for 8 weeks. Twelve healthy controls (HCs) donated their fecal samples. Statistical methods were used to compare the differences. According to the Simple Endoscopic Score for CD (SES-CD) at the end of the EEN treatment, 21 patients with SES-CD ≤4 were classified into the remission group (CD-RE), and 10 patients with SES-CD >4 were classified into the nonremission group (CD-NRE). After EEN therapy, there was a significant decrease in the SES-CD, the weighted Pediatric Crohn's Disease Activity Index (wPCDAI), and fecal calprotectin (FCP) in the CD-RE group (all P < .001). The wPCDAI and FCP also decreased in the CD-NRE group (both P < .05). In terms of nutrition improvement, the CD-RE group patients showed more improvement in weight gain, hemoglobin, and serum albumin level than the CD-NRE group patients (all P < .05). For the microbiota, the CD patients had a lower bacterial diversity and different bacterial community compared with HCs. EEN increased overall diversity and was able to shift the dysbiosis in CD patients toward a healthier state. Absence of improvement in wPCDAI and Shannon index at 2 weeks predicts poor response at the end of EEN. EEN can be used in most Chinese pediatric CD patients to induce remission and improve nutrition.

DOP01 Exclusive enteral nutrition for the treatment of adult Crohn’s disease

Abstract Background Crohn’s disease (CD) is a debilitating autoimmune disease affecting &amp;gt;40 000 Australians. Exclusive enteral nutrition (EEN) is an effective, risk-free therapy in children with CD, offering an ~80% success rate. Despite similar efficacy in adults, including the potential to decrease the need for high-risk steroids and surgery, adherence remains an unresolved obstacle for its use, with withdrawal rates of up to 40% (Wall 2013). Lack of dietetic expertise and support for adults on EEN were identified as primary barriers (Wall 2013). This prospective, single-centre, observational study aimed to assess the impact of a 6-week EEN model of care on disease symptoms, nutrition and inflammatory markers. We also assessed if &amp;gt;80% of adults with CD could adhere to EEN. Methods Adults with active CD were treated with oral EEN for six weeks between March 2018 and September 2019 which uniquely included weekly specialist Dietetic support. EEN is the provision of 100% of a patient’s nutritional requirements via a nutritionally complete liquid formula. Paired assessment at baseline and EEN completion occurred for Crohn’s disease activity index (CDAI), calprotectin, C-reaction protein (CRP), platelets, albumin, white cell count, weight and calprotectin using paired t-tests. The primary outcome measure was disease activity using CDAI. Results Twenty-seven eligible CD patients were identified. Most patients (85%, n = 23/27) successfully adhered to EEN treatment (45 ± 13 years, 63% female, 52% had Calprotectin ≥100). The patients were further subdivided as per Montreal classification (L1:n = 12; L2:n = 3; L3:n = 12) and 93% were on medications such as steroids (n = 9/27), immunosuppressives (n = 19/27) and biologics (n = 16/27). After EEN, 74% (n = 20/27) achieved clinical remission (CDAI &amp;lt;150) 19/27 patients (70%) achieved clinical response with &amp;gt;70-point reduction in CDAI score and most (77%) patients achieved greatest improvement in CDAI score in the well-being section. A trend showed that 37% (p = 0.087) more patients with L2 and L3 CD achieved clinical response through CDAI than L1 CD patients. Calprotectin also showed a trend for improvement (-23(-65230-150) µg, p = 0.067, n = 20). No differences were observed in CRP, white cell count, or albumin (p = 0.262–0.433, n = 12–13); however, platelets showed a trend for improvement (-26(-156-46) µl, p = 0.071, n = 12) and weight reduced by −2.4(3.2) kg (p = 0.001). Few (30%, n = 8/27) patients changed medications during EEN treatment. No significant side effects were observed. Conclusion EEN may be achievable for most adults with additional professional support and has merit in assisting patients with clinical improvement of CD.

Partial enteral nutrition induces clinical and endoscopic remission in active pediatric Crohn's disease: results of a prospective cohort study.

The aim of this study was to evaluate rates of clinical remission, endoscopic remission, and mucosal healing after a 6-week treatment period with partial enteral nutrition (PEN) and to compare them to those obtained by standard exclusive enteral nutrition (EEN) treatment in children with active Crohn's disease (CD). Twenty-five patients with active CD (median age 13.6 years, range 3.6-18.0) were recruited to either PEN (n = 12) or EEN (n = 13) treatment groups. The PEN group received 75% of their dietary needs from a polymeric formula plus one meal per day from an anti-inflammatory diet (AID). Patients were assessed at weeks 0, 1, 3, and 6 using clinical and laboratory parameters. Endoscopic assessment was performed at induction and week 6. On intention to treat analysis, clinical remission (Pediatric CD Activity Index < 10) was achieved in 69.2% and 75.0% of EEN and PEN patients, respectively (p = 0.999). The endoscopic remission (Simple Endoscopic Score for CD (SES-CD) ≤ 2) rates were 45.5% in both groups, while mucosal healing rates (SES-CD = 0) were 45.5% with EEN and 27.3% with PEN (p = 0.659).Conclusion: The results of our prospective pilot study suggest that PEN, allowing one meal from AID, could be as effective as EEN in inducing clinical and endoscopic remission in children with active CD. However, larger randomized controlled studies are warranted to confirm our findings.Trial registration: This clinical trial was registered under the number ClinicalTrials.govidentifier: NCT03176875.What is Known:• Exclusive enteral nutrition is a first-line treatment in active pediatric Crohn's disease; however, patients often find it difficult to adhere to.• Exclusive enteral nutrition is more effective than corticosteroids in achieving mucosal healing.What is New:• This is the first prospective study on partial enteral nutrition in active pediatric Crohn's disease, evaluating not only clinical, but also endoscopic remission.• A novel approach of partial enteral nutrition that allows one meal per day from an anti-inflammatory diet was as effective as exclusive enteral nutrition in inducing clinical and endoscopic remission in active Crohn's disease.

The role of exclusive enteral nutrition in the preoperative optimization of laparoscopic surgery for patients with Crohn's disease: A cohort study

BackgroundGrowing evidence has shown that there are significant advantages associated with the use of laparoscopic surgery for Crohn's disease (CD). However, the impact of preoperative exclusive enteral nutrition (EEN) on postoperative complications and CD recurrence following laparoscopic surgery have not been investigated. MethodsA total of 120 CD patients undergoing bowel resection with laparoscopic surgery were eligible for this study. Patient data were collected from a prospectively maintained database. Before laparoscopic surgery, 45 CD patients received EEN for at least 4 weeks, and 75 CD patients had no EEN. Postoperative complications, and endoscopic and clinical recurrence were subsequently measured and compared after laparoscopic surgery and during follow-up assessments. ResultsPatients who received EEN had significant improvements in their nutritional (albumin, prognostic nutritional index (PNI), and hemoglobin) and inflammatory (C-reactive protein) status after the EEN treatment prior to surgery (P < 0.05). Patients who received EEN also experienced fewer postoperative complications, decreased surgical site infections, and a lower comprehensive complication index (P < 0.05). The endoscopic recurrence rates 6 months after surgery were also decreased significantly in patients who received EEN (P < 0.05). However, the incidence of clinical recurrence was similar in the 2 groups at 1-year follow-up. Endoscopic recurrence was correlated with ileocolonic disease, EEN before surgery, and PNI (P < 0.05). PNI remained independently associated with endoscopic recurrence after surgery. ConclusionsPreoperative EEN for at least 4 weeks improved CD patients’ nutritional and inflammatory status, which in turn reduced postoperative complications following laparoscopic surgery and endoscopic recurrence on follow-up.

Inflammation associated ethanolamine facilitates infection by Crohn’s disease-linked adherent-invasive Escherichia coli

The predominance of specific bacteria within the Crohn’s disease intestine remains poorly understood with little evidence uncovered to support a selective pressure underlying their presence. Intestinal ethanolamine is readily accessible during periods of intestinal inflammation, and enables pathogens to outcompete the host microbiota under such circumstances. Here we show that the intestinal short chain fatty acid propionic acid stimulates increased ethanolamine degradation by one such Crohn’s disease associated pathogen, adherent-invasive Escherichia coli (AIEC). This degradation occurs within bacterial microcompartments that are subsequently excreted in outer membrane vesicles. Additionally ethanolamine, added extracellularly at concentrations comparable to those in the human intestine, is accessible to intracellular AIEC and stimulates significant increases in growth within macrophages. Finally, expression of the operon for ethanolamine degradation (eut) is increased in children with active Crohn’s disease compared to healthy controls. After clinical remission was seen with exclusive enteral nutrition treatment, Crohn’s disease patient’s exhibit significantly reduced eutexpression. Our data indicates a role for ethanolamine metabolism in facilitating AIEC colonization of the Crohn’s disease intestine and warrants further study of its potential use as an indicator of inflammatory status in Crohn’s disease.

Oral exclusive enteral nutrition induces mucosal and transmural healing in patients with Crohn's disease.

Background and aimsMucosal healing is regarded as a clinical endpoint of Crohn’s disease (CD), and transmural healing is correlated to the concept of deep remission. Current therapies to induce mucosal and transmural healing in CD are not satisfactory. Exclusive enteral nutrition (EEN) is underestimated therapy and its value has not been fully evaluated. Our aim was to investigate the efficacy of oral EEN for inducing mucosal and transmural healing in CD patients.MethodsThis was a prospective, single-center, open-label study including diagnosed CD children and adults conducted between January 2015 and December 2016 in the Sixth Affiliated Hospital of Sun Yat-sen University. All patients were treated with oral EEN and underwent paired assessment at baseline and completion using C-reaction protein, erythrocyte sedimentation rate, platelets, hemoglobin, body mass index, CD activity index, simple endoscopic score for CD and bowel sonography. Azathioprine was combined to prevent relapse.ResultsIn this prospective observational study, 29 CD patients with an average age of 28.9 years were identified. After oral EEN treatment, 23 patients (79%) achieved complete mucosal healing, and the mean time to reach mucosal healing was 123 days (ranged from 50 to 212 days). Although only five patients (17%) achieved transmural healing, a significant reduction was observed in bowel-wall thickness (9.41 ± 3.06 vs 4.97 ± 1.76 mm, P < 0.001) and a significant improvement was observed in complications (including fistulas, abscess, ascites, stricture) assessed by bowel sonography (all P < 0.05).ConclusionsOral EEN therapy is highly effective for inducing mucosal healing in CD patients. Both CD patients at active stage and those at clinical remission show excellent clinical response to oral EEN.

Untargeted Metabolomics of Extracts from Faecal Samples Demonstrates Distinct Differences between Paediatric Crohn's Disease Patients and Healthy Controls but No Significant Changes Resulting from Exclusive Enteral Nutrition Treatment.

Metabolomic profiling using high resolution mass spectrometry with hydrophilic interaction chromatography was applied to 11 faecal extracts from eleven healthy children and to 43 faecal extracts from eleven children undergoing exclusive enteral nutrition for the treatment of active Crohn’s disease (CD) at timepoints before, during (15, 30, and 60 days), and after treatment. Differences between the control and CD samples were identified at each timepoint. An orthogonal partial least square-discriminant analysis (OPLS-DA) model identified eight metabolites that were normally distributed according to Q-Q plots. The OPLS-DA model was able to discriminate the CD samples from the controls at every timepoint, but the model was not able to differentiate the CD samples from one another at the different timepoints during treatment with exclusive enteral nutrition. The differentiated metabolites identified in the CD samples included tyrosine, an ornithine isomer, arachidonic acid, eicosatrienoic acid, docosatetraenoic acid, a sphingomyelin, a ceramide, and dimethylsphinganine. Despite successful treatment, underlying differences remained in the metabolome of the CD patients. These differences dominated the separation of the samples when multivariate methods were applied.

Exclusive enteral nutrition′s moderating effect on Th17 cell of juvenile rat with inflammatory bowel disease

Objective Through the TNBS-induced inflammatory bowel disease model in young rats, to observe the level of Th17 cell related cytokine IL-17A on the intestinal tissue of IBD young rats model after feeding EEN, Peptisorb, and investigate the enteral nutrition’s regulative effects on Th17 cells. Methods Thirty six four-week healthy male Sprague-Dswley rats were selected and divided into 4 groups, blank control group and EEN control group with 8 rats in each group, IBD group and IBD-EEN group with 10 rats in each group: blank control group and EEN control group were given normal saline enema, then fed with normal diet and enteral nutrition separately; IBD group and IBD-EEN group were given 5% TNBS enema, establish the IBD model, then fed with normal diet and enteral nutrition separately.The weights, defecate characters and occult blood situations of all rats were determined.Also, we carried out the activity index score of disease according to the Cooper score method.On the seventh day, all rats were sacrificed and the colon specimens were collected.We observed mucosal injury by HE staining and expression level of Th17 cell related cytokine IL-17A that were detected by immunohistochemical staining. Results Compared with IBD group, IBD-EEN group was improved significantly in terms of defecate character and occult blood situation.Both IBD group and IBD-EEN group gained their body weights than before, (39.95±2.929)g and(38.40±4.545)g respectively after 7 days(P≥0.05). In IBD group, gross tissue and pathological section displayed significant intestinal inflammation change, showing typical inflammatory bowel disease change; under the microscope, intestinal mucosa showed a large amount of inflammatory cell infiltration, a part of section displayed inflammatory granuloma formation, normal glandular structure was damaged.After EEN treatment, DAI scores werr decreased significantly; intestinal inflammation changes were relieved; intestinal mucosa inflammatory cell infiltration were reduced.Immunohistochemical study showed that the expression of IL-17A cytokine in the intestinal mucosa of IBD group was higher than that of IBD-EEN group(P<0.05). Conclusion The exclusive enteral nutrition treatment possessed the effect of reducing IBD young rat′s intestinal mucosal inflammation, the inner mechanism may be related with the changing expression of Th17-cell cytokines, IL-17A. Key words: Exclusive enteral nutrition; Inflammatory bowel disease; Th17 cell; Rat

Fecal calprotectin is not a clinically useful marker for the prediction of the early nonresponse to exclusive enteral nutrition in pediatric patients with Crohn disease.

Exclusive enteral nutrition (EEN) has been recommended as the first-line therapy in children with active Crohn disease (CD). The primary aim of our study was to determine whether it is possible to use the difference between basal fecal calprotectin (F-CPT) and the value at week 2 of EEN to predict clinical response at week 6. We prospectively collected stool samples for F-CPT analysis and clinical and laboratory parameters during EEN from 38 pediatric patients (28 boys, median age 12.8years) with newly diagnosed active luminal CD. The difference between F-CPT concentrations before EEN and at week 2 did not predict clinical non-response at week 6 (OR 0.9996 95% CI 0.9989-1.0002, p = 0.18); however, it predicted patients who did not achieve clinical remission at week 6 (OR 0.9993, 95% CI 00.9985-0.9998, p = 0.006) with sensitivity of 58%, and specificity of 92% for cut-off of F-CPT increase by 486μg/g.Conclusions: An early decrease in F-CPT levels in children with newly diagnosed active luminal CD did not predict clinical response at week 6 of EEN induction therapy, and clinical remission was predicted with low accuracy. Therefore, F-CPT cannot be used as a predictor to select the patients in whom EEN should be terminated. What is Known: • The fecal calprotectin (F-CPT) is an important marker of intestinal inflammation. • Approximately 25% of pediatric patients with Crohn disease (CD) do not achieve clinical remission, and there is still no sufficient predictor of response to exclusive enteral nutrition (EEN) treatment. What is New: • The difference between the F-CPT concentrations before EEN treatment and at week 2 did not predict clinical response to treatment at week 6, even if it predicted clinical remission, however, with low accuracy. F-CPT is not a suitable predictor to select the patients for discontinuing of EEN induction therapy.

Exclusive enteral nutrition protects against inflammatory bowel disease by inhibiting NF‑κB activation through regulation of the p38/MSK1 pathway.

Although enteral nutrition therapy for inflammatory bowel disease has been confirmed to be an effective treatment method, the exact mechanism responsible for the effects of enteral nutrition remains unclear. The aim of the present study was to investigate the protective effect of exclusive enteral nutrition (EEN) against colitis, and to elucidate the potential mechanisms by inhibiting p65 activation via regulating the p38/mitogen- and stress-activated protein kinase-1 (MSK1) pathway. Experiments were performed by establishing dextran sulfate sodium (DSS)-mice colitis and picrylsulfonic acid solution (TNBS)-induced rat colitis, and the results demonstrated that EEN treatment attenuated body weight loss, colon length shortening and colonic pathological damage caused by colitis. EEN also inhibited inflammatory cells infiltration and decreased myeloperoxidase and inducible nitric oxide synthase activities. Furthermore, EEN significantly reduced the production of pro-inflammatory mediators in serum and the colon. Mechanically, EEN suppressed activation of p65 by inhibiting the p38/MSK1 pathway. In conclusion, the present study demonstrated that EEN attenuated DSS- and TNBS-induced colitis by inhibiting p65 activation via regulating the p38/MSK1 pathway, thus suggesting that EEN is effective in the treatment of colitis.

Japanese physicians' attitudes towards enteral nutrition treatment for pediatric patients with Crohn's disease: a questionnaire survey.

Background/AimsEnteral nutrition (EN) is recommended for the treatment of pediatric Crohn's disease (CD) in Japan. However, the indications and treatment protocols for EN vary among hospitals. In the present study, we aimed to determine how EN was administered to pediatric patients and whether physicians followed treatment guidelines in their practices.MethodsTwo types of questionnaires were administered to 32 physicians who were involved in the treatment of pediatric CD. The consensus questionnaire evaluated the physicians' attitudes towards EN, whereas the efficacy questionnaire collected data on patients with CD, aged <17 years, who had undergone induction therapy between 2006 and 2011.ResultsA total of 23 physicians responded to the questionnaires. The results of the consensus questionnaire indicated that 82% and 59% of study participants recommended EN treatment for all newly diagnosed pediatric patients with CD and all relapsed patients, respectively. Exclusive EN (EEN) and elemental formula were recommended by 84% and 85% of physicians, respectively. The efficacy questionnaire revealed that 57 of the 58 patients received EN. Elemental formula was used in 39 of 40 patients who were treated with EEN. Of these 40 patients, 27 were treated with EEN alone; of these, 22 (81%) achieved remission without any other treatment. The mean duration of EEN was 15.9 days.ConclusionsEN is widely recommended by physicians treating pediatric CD in Japan. In contrast to Western countries, clinicians used elemental formula more often and with a shorter EEN treatment duration.

Exclusive Enteral Nutrition Induces Remission in Pediatric Crohn's Disease via Modulation of the Gut Microbiota.

Exclusive enteral nutrition (EEN) has been proven to be effective and safe in treating pediatric Crohn's disease (CD). EEN induces pediatric CD remission possibly through three pathways: (1) direct anti-inflammatory effects, (2) improved epithelial barrier function, and (3) modulation of the gut microbiota. Recent studies have demonstrated that modulation of the gut microbiota plays a major role in EEN-induced remission. Variations of microbial components, which directly influence the diversity and metabolic functions of the gut microbiota, are closely associated with the immunological conditions of the gut and the susceptibility to diseases. The reduction of proinflammatory microbial components and harmful microbial metabolites after EEN treatment greatly decreases the inflammatory injuries of the gut.

The Gut Microbiome of Pediatric Crohn's Disease Patients Differs from Healthy Controls in Genes That Can Influence the Balance Between a Healthy and Dysregulated Immune Response.

Exclusive enteral nutrition (EEN) is a first-line therapy in pediatric Crohn's disease (CD) thought to induce remission through changes in the gut microbiome. With microbiome assessment largely focused on microbial taxonomy and diversity, it remains unclear to what extent EEN induces functional changes that thereby contribute to its therapeutic effect. Fecal samples were collected from 15 pediatric CD patients prior to and after EEN treatment, as well as from 5 healthy controls. Metagenomic data were obtained via next-generation sequencing, and nonhuman reads were mapped to KEGG pathways, where possible. Pathway abundance was compared between CD patients and controls, and between CD patients that sustained remission (SR) and those that did not sustain remission (NSR). Of 132 KEGG pathways identified, 8 pathways differed significantly between baseline CD patients and controls. Examination of these eight pathways showed SR patients had greater similarity to controls than NSR patients in all cases. Pathways fell into one of three groups: 1) no prior connection to IBD, 2) previously reported connection to IBD, and 3) known roles in innate immunity and immunoregulation. The microbiota of CD patients and controls represent alternative ecological states that have broad differences in functional capabilities, including xenobiotic and environmental pollutant degradation, succinate metavolism, and bacterial HtpG, all of which can affect barrier integrity and immune regulation. Moreover, our finding that SR patients were more similar to healthy controls suggests that community microbial function, as inferred from fecal microbiomes, could serve as a valuable diagnostic tool.

Mucosal MicroRNAs Expression Profiles before and after Exclusive Enteral Nutrition Therapy in Adult Patients with Crohn's Disease.

MicroRNAs (miRNAs) have been shown to be important for the pathogenesis of Crohn’s disease (CD). Exclusive enteral nutrition (EEN) is an effective therapy for inducing remission in CD. We aimed to investigate the alteration of miRNAs expression profile in the terminal ileal mucosa of CD patients before and after EEN. Twenty-five patients and ten healthy individuals were included. MiRNAs expression profile was firstly assessed using microarray technology and then validation was performed by qRT-PCR. The correlations between miRNAs and CD activity index (CDAI) score and serum C–reactive protein (CRP) level were also evaluated. Microarray analysis showed that mucosal miRNAs expression profile after EEN therapy was significantly changed compared with inflamed mucosa before treatment, and was most similar to the healthy one among all CD groups. Altered expressions of hsa-miR-192-5p, hsa-miR-423-3p, hsa-miR-99a-5p, hsa-miR-124-3p, hsa-miR-301a-5p, hsa-miR-495-5p, and hsa-let-7b-5p were confirmed by qRT-PCR. hsa-let-7b-5p was significantly correlated with serum CRP levels before and after EEN treatment (r = −0.518, p = 0.008, and r = −0.569, p = 0.003). Our study showed EEN induction therapy was associated with a trend for normalizing of the mucosal miRNAs expression profile, and expression of mucosal hsa-let-7b-5p was correlated with serum CRP level in patients with CD.

Changes in fecal microbiota and metabolomics in a child with juvenile idiopathic arthritis (JIA) responding to two treatment periods with exclusive enteral nutrition (EEN).

The microbiome and immune system of the digestive tract are highly important in both health and disease. Exclusive enteral nutrition (EEN) is a common anti-inflammatory treatment in children with Crohn's disease in the European countries, and the mechanism is most likely linked to changes in the intestinal microbiome. In the present study, EEN was given in two treatment periods several months apart to a patient with very severe, disabling juvenile idiopathic arthritis (JIA), with a remarkable clinical response as the result. The aim of the present study was to study how the EEN treatment influenced the microbiome and metabolome of this patient. Fecal samples from before, during, and between treatments with EEN were studied. The microbiome was analyzed by sequencing of 16S rRNA amplicons using Illumina MiSeq, and the metabolome was analyzed using nuclear magnetic resonance. The microbiome changed markedly from treatment with EEN, with a strong reduction of the Bacteroidetes phylum. Metabolic profiles showed clear differences before, during, and between treatment with EEN, where butyrate, propionate, and acetate followed a cyclic pattern with the lowest levels at the end of each treatment period. This patient with JIA showed remarkable clinical improvement after EEN treatment, and we found corresponding changes in both the fecal microbiome and the metabolome. Further studies are needed to explore the pathophysiological role of the intestinal canal in children with JIA.

Mo1814 The N- Acyl-Homoserine Lactone 3-oxo-C12, an Inter-Bacterial Signaling Molecule (Involved in Quorum Sensing), Exerts Effects on the Host: Thus Implicating Quorum Sensing in Inflammatory Bowel Disease

Background Exclusive enteral nutrition (EEN) is a first-line induction therapy in pediatric Crohn's disease (CD). Though unclear, the mode of action of EEN is proposed to involve changes in gut microbiome structure and function. Characterization of the microbiome in IBD has largely focused on the assessment of diversity and the identification of protective and disease-associated species. More recently, metagenomic approaches to IBD microbiome investigation have facilitated predictive mapping of microbiome function. Treatment-induced changes to microbiome function may contribute to the strong therapeutic effect of EEN. Our aims were to compare microbial community structure and functional assessments of microbial metabolic pathways in pediatric CD patients before and after induction of remission by EEN treatment. Methods Metagenomic sequences from stool samples obtained from 4 pediatric Crohn's disease patients who underwent EEN treatment were obtained using MiSeq whole-metagenome sequencing. Sequences were searched against the SILVA database to obtain microbial composition profiles based on 16S ribosomal RNA genes. To obtain functional assignment, sequences were searched against 28 representative KEGG (Kyoto Encyclopedia of Genes and Genomes) pathways. Samples collected prior to EEN treatment were compared to samples collected after 8 to 12 weeks of EEN treatment. All participants achieved clinical remission (PCDAI<10) following EEN treatment. Results Changes in CD patient microbial community structure before and after EEN were variable. However, functional profiling of CD patient microbiota before and after EEN treatment revealed a significant increase in metabolic functions related to biodegradation and metabolism of xenobiotics, such as benzoate (p<0.05). Conclusions The microbiome of CD patients is functionally altered by EEN treatment, specifically increasing metabolic potential for xenobiotic biodegradation and metabolism relative to pre-treatment. Further investigations are warranted to investigate the role of altered xenobiotics metabolism in the therapeutic modality of EEN, as well as CD etiopathogenesis.

Exclusive Enteral Nutritional Therapy Can Relieve Inflammatory Bowel Stricture in Crohn’s Disease

To examine the efficiency of exclusive enteral nutrition (EEN) in relieving inflammatory bowel stricture in patients with Crohn's disease (CD). Patients with CD usually develop bowel strictures due to transmural edema of intestinal wall, which can potentially be managed with conservative medical treatment. Previous studies showed that EEN therapy could induce clinical remission through its anti-inflammation effect. We achieved a prospective observational study. CD patients with inflammatory bowel stricture were preliminarily differentiated from a fibrous one, and further treated with EEN therapy for 12 weeks. Demographics and clinical variables were recorded. Nutritional (body mass index, albumin, pre-albumin, transferrin, etc.), inflammatory (C-reactive protein, erythrocyte sedimentation rate, white blood cell, etc.), and radiologic parameters (bowel wall thickness, luminal diameter, and luminal cross-sectional area) were evaluated at baseline, week 4, and week 12, respectively. Between May 2012 and January 2013, 65 patients with CD were preliminarily diagnosed with inflammatory bowel stricture and 6 patients were further excluded. Among the remaining 59 cases, 50 patients (84.7%) finished the whole EEN treatment, whereas the other 9 patients (15.3%) gained progressive bowel obstruction resulting in surgery. Intention-to-treat analyses showed that 48 patients (81.4%) achieved symptomatic remission, 35 patients (53.8%) achieved radiologic remission, and 42 patients (64.6%) achieved clinical remission. Among those patients who complete the whole EEN therapy, inflammatory, nutritional, and radiologic parameters improved significantly compared with baseline. Of note, the average luminal cross-sectional area at the site of stricture increased approximately 331% at week 12 (195.7 ± 18.79 vs. 59.09 ± 10.64 mm, P<0.001). EEN therapy can effectively relieve inflammatory bowel stricture in CD, which replenishes roles of enteral nutrition in the treatment of CD. Further studies are expected to investigate the underlying mechanisms of this effect in the future.

Paediatric inflammatory bowel disease: a mechanistic approach to investigate exclusive enteral nutrition treatment.

The inflammatory bowel diseases (IBD) include Crohn's disease (CD) and ulcerative colitis. The disease may present at any age although the peak of presentation is the second and third decades of life. The incidences of these diseases are increasing around the world with the age of presentation getting younger. At present CD is incurable with colectomy being the treatment for severe UC. Although several pharmacological approaches are used to modulate the inflammatory response in IBD, few lead to histological healing and most have side effects. An alternative approach is to use enteral formulae given exclusively (EEN) to treat IBD. EEN requires the consumption of an elemental or polymeric formula, with the exclusion of all other nutrients, for a period of up to 12 weeks. The introduction of EEN as a therapeutic option for IBD was through prudent observation; however, EEN has become an established and reliable option for the treatment of paediatric IBD. Despite this, the mechanisms through which EEN induces disease remission are unknown and remain hypothetical. This review will discuss recent research into EEN both describing clinical features of EEN therapy and discussing the most up-to-date understanding of the mechanisms through which EEN may be reducing intestinal inflammation and inducing disease remission.

Risk factors for relapse and surgery rate in children with Crohn’s disease

The aim of this study was to evaluate risk factors associated with the relapse rate in the first year and the need for surgery in children with Crohn's disease (CD). Data of all children (n = 74) diagnosed with CD from January 2004 to June 2011 were retrospectively analyzed. Multivariate Cox proportional hazards regression model was used to assess whether important clinical variables at diagnosis (age, presence of perianal disease, first induction therapy, first maintenance therapy, levels of Pediatric CD Activity Index (PCDAI), C-reactive protein (CRP), and standard deviation score (SDS) for height for weight) were associated with the risk of clinical recurrence in the first year and need for surgery during follow-up. Relapse occurred in 36 (48.6%) patients in the first year from diagnosis. The only significant parameter associated with negative risk of relapse in the first year was exclusive enteral nutrition (EEN) used as induction therapy (hazard ratio (HR) 0.469, 95% confidence interval (CI) 0.232-0.948). EEN induced remission in 84.2% of patients. The only risk associated with EEN treatment failure was the involvement of the upper gastrointestinal tract. During the follow-up, 25 (33.7%) patients underwent surgery. The multivariate Cox regression model failed to recognize significant risk factor for surgery. This study underlines the importance of early EEN in the treatment of CD; it is not only efficacious in the remission induction but could also prevent relapse in the first year.

Effect of Exclusive Enteral Nutrition on Health‐Related Quality of Life for Adults With Active Crohn's Disease

Exclusive enteral nutrition (EEN) is an effective and safe remission induction treatment for Crohn's disease in adults. Its influence on adults' health-related quality of life remains unknown. The aim of this study was to determine the effect of EEN on health-related quality of life in adults with active Crohn's disease. Patients recruited were treated with a polymeric enteral feed that was taken orally in the daytime and via a self-intubated nasogastric tube at night for 4 weeks. Prospective evaluation of disease activity (Crohn's Disease Activity Index, CDAI) and health-related quality of life (Inflammatory Bowel Disease Questionnaire, IBDQ) were performed at enrollment and after 4 weeks of treatment. Patients' feelings about EEN were also investigated through 2 questions. Thirteen patients were treated with 4-week EEN. They had a significant improvement in total IBDQ score (P < .001) and all IBDQ dimensions: bowel symptoms (P < .001), systemic symptoms (P < .001), social function (P = .003), and emotional status (P < .001), with 11 patients (84.6%) achieving clinical remission after treatment. In addition, 8 patients (61.5%) expressed their willingness to receive this 4-week EEN treatment again to induce remission if the disease relapsed. The IBDQ correlated significantly with the CDAI at 4 weeks. A 4-week treatment of EEN improves health-related quality of life significantly in adults with active Crohn's disease and was acceptable by most patients.