Nonelemental Diet Research Articles

Risk Factors for Gastrointestinal Symptoms post Enteral Nutrition Initiation via a Gastrostomy Tube

Background: Percutaneous endoscopic gastrostomy (PEG) facilitates long-term enteral nutrition. However, parenteral nutrition prior to PEG tube placement can cause impaired gastrointestinal function. Additionally, upon initiation of enteral feeding via a PEG tube, some patients suffer from gastrointestinal symptoms (e.g., vomiting, diarrhea), which reduce their quality of life and increase the nursing workload.Method: This retrospective study included 155 patients upon whom the author performed PEG as the attending physician. Enteral nutrition was started through the PEG tube on the third day after its placement. The following characteristics were analyzed: age, gender, indications for PEG, preoperative enteral nutrition, administered liquid nutrients, daily dosage of nutrients, serum albumin levels, serum alanine aminotransferase levels, serum creatinine levels, serum hemoglobin levels, and vomiting or diarrhea within seven days after the initiation of PEG feeding. A logistic regression model was used to identify the risk factors contributing to gastrointestinal symptoms, and three variables were sequentially introduced into the model—preoperative non-enteral nutrition, hypoalbuminemia, and administration of non-elemental diets.Results: Vomiting and diarrhea occurred in 10 and 15 patients, respectively. There were significant differences in administered nutrients and serum albumin levels between patients with and without gastrointestinal symptoms. Multivariate analysis revealed that the adjusted odds ratios for administration of non-elemental diets and serum albumin level ≤3.2 g/dL were 8.05 (95% confidence interval (CI): 2.66–24.4; p 0.001) and 3.81 (95% CI: 1.33–10.9; p 0.05), respectively.Conclusion: The administration of non-elemental diets and a serum albumin level ≤3.2 g/dL were significant risk factors.

Enteral nutrition for maintenance of remission in Crohn's disease.

Enteral nutrition for maintenance of remission in Crohn's disease.

Enteral nutritional therapy for induction of remission in Crohn's disease.

Enteral nutritional therapy for induction of remission in Crohn's disease.

Impact of enteral nutrition on energy metabolism in patients with Crohn's disease.

To investigate the impact of enteral nutrition (EN) on the body composition and metabolism in patients with Crohn's disease (CD). Sixty-one patients diagnosed with CD were enrolled in this study. They were given only EN (enteral nutritional suspension, TPF, non-elemental diet) support for 4 wk, without any treatment with corticosteroids, immunosuppressive drugs, infliximab or by surgical operation. Body composition statistics such as weight, body mass index, skeletal muscle mass (SMM), fat mass, protein mass and inflammation indexes such as C-reactive protein (CRP), erythrocyte sedimentation rate (ESR) and CD activity index (CDAI) were recorded before and after EN support. The 61 patients were divided into three groups according to CDAI before and after EN support: A (active phase into remission via EN, n=21), B (remained in active phase before and after EN, n=19) and C (in remission before and after EN, n=21). Patients in group A had a significant increase in SMM (22.11±4.77 kg vs 23.23±4.49 kg, P=0.044), protein mass (8.01±1.57 kg vs 8.44±1.45 kg, P=0.019) and decrease in resting energy expenditure (REE) per kilogram (27.42±5.01 kcal/kg per day vs 22.62±5.45 kcal/kg per day, P<0.05). There was no significant difference between predicted and measured REE in active CD patients according to the Harris-Benedict equation. There was no linear correlation between the measured REE and CRP, ESR or CDAI in active CD patients. EN could decrease the hypermetabolism in active CD patients by reducing the inflammatory response.

Enteral nutritional therapy for induction of remission in Crohn's disease

The role of enteral nutrition in Crohn's disease is controversial. Increasing research on the mechanisms by which nutritional therapy improves the clinical well being of patients with Crohn's disease has led to novel formula design and trials comparing two different forms of enteral nutrition. This meta-analysis aims to provide an update on the existing effectiveness data for both corticosteroids versus enteral nutrition and for one form of enteral nutrition versus another for inducing remission of active Crohn's disease. To evaluate the effectiveness of exclusive enteral nutrition (EN) as primary therapy to induce remission in Crohn's disease and to examine the importance of formula composition on effectiveness. Studies were selected using a computer-assisted search of the on-line bibliographic databases MEDLINE (1966-2006) and EMBASE (1984-2006), as well as the Science Citation Index on Web of Science. Additional citations were sought by manual search of references of articles retrieved from the computerized search, abstracts submitted to major gastroenterologic meetings and published in the journals: American Journal of Gastroenterology, Gut, Gastroenterology, Journal of Pediatric Gastroenterology and Nutrition, and Journal of Parenteral and Enteral Nutrition, and from the reviewers' personal files or contact with leaders in the field. All randomized and quasi-randomized controlled trials involving patients with active Crohn's disease defined by a clinical disease activity index were considered for review. Studies evaluating the administration of one type of enteral nutrition to one group of patients and another type of enteral nutrition or conventional corticosteroids to the other group were selected for review. Data were extracted independently by two authors and any discrepancies were resolved by rereading and discussion. For the dichotomous variable, achievement of remission, individual and pooled trial statistics were calculated as odds ratios (OR) with 95% confidence intervals (CI); both fixed and random effect models were used. The results for each analysis were tested for heterogeneity using the chi square statistic. The studies were separated into two groups: A. one form of enteral nutrition compared with another form of enteral nutrition and B. one form of enteral nutrition compared with corticosteroids. Subgroup analyses were conducted on the basis of clinical or disease criteria and formula composition. Sensitivity analyses were conducted on the basis of the inclusion of abstract publications, methodologic quality and by random or fixed effects models. In part A, of the 15 included eligible trials (one abstract) comparing different formulations of EN for the treatment of active CD, 11 compared one (or more) elemental formula to a non-elemental one, three compared enteral diets of similar protein composition but different fat composition, and one compared non-elemental diets differing only in glutamine enrichment. Meta-analysis of ten trials comprising 334 patients demonstrated no difference in the efficacy of elemental versus non-elemental formulas (OR 1.10; 95% CI 0.69 to 1.75). Subgroup analyses performed to evaluate the different types of elemental and non-elemental diets (elemental, semi-elemental and polymeric) showed no statistically significant differences. Further analysis of seven trials including 209 patients treated with EN formulas of differing fat content (low fat: < 20 g/1000 kCal versus high fat: > 20 g/1000 kCal) demonstrated no statistically significant difference in efficacy (OR 1.13; 95% CI 0.63 to 2.01). Similarly, the effect of very low fat content (< 3 g/1000 kCal) or type of fat (long chain triglycerides) were investigated, but did not demonstrate a difference in efficacy in the treatment of active CD, although a non significant trend was demonstrated favoring very low fat and very low long chain triglyceride content. This result should be interpreted with caution due to statistically significant heterogeneity and small sample size. Sensitivity analyses had no significant effects on the results. The role of specific fatty acids or disease characteristics on response to therapy could not be evaluated. In part B, eight trials (including two abstracts) comparing enteral nutrition to steroid therapy met the inclusion criteria for review. Meta-analysis of six trials that included 192 patients treated with enteral nutrition and 160 treated with steroids yielded a pooled OR of 0.33 favouring steroid therapy (95% CI 0.21 to 0.53). A sensitivity analysis including the abstracts resulted in an increase in the number of participants to 212 in the enteral nutrition group and 179 in the steroid group but the meta-analysis yielded a similar result (OR 0.36; 95% CI 0.23 to 0.56). There were inadequate data from full publications to perform further subgroup analyses by age, disease duration and disease location. Corticosteroid therapy is more effective than enteral nutrition for inducing remission of active Crohn's disease as was found in previous systematic reviews. Protein composition does not influence the effectiveness of EN in the treatment of active CD. A non significant trend favouring very low fat and/or very low long chain triglyceride content exists but larger trials are required to explore the significance of this finding.

Ileal perforation in a patient with Crohn’s disease while receiving recombinant human growth hormone therapy

Dear Editor: Crohn’s disease manifests systemically and is commonly followed by a chronic catabolic state. Treatment with glucocorticoids might disguise the catabolic state in the majority of patients, while muscle wasting and osteoporosis can be perceived more easily. Attempts to counteract the metabolic effects and the activity of the disease by the use of proteinor amino acid-based formula and nonelemental diets were partially successful in some patients but are reportedly not as effective as glucocorticoid treatment. Thus, the treatment of wasting in patients with Crohn’s diseases remains a challenge to the clinician. Growth hormone (GH) therapy was suggested to improve body composition and counterbalance wasting. GH is a peptide hormone of the pituitary gland. The GH axis and GH signaling in the liver is impaired through IL1, IL6, and TNF-α and might account for GH deficiency in patients with Crohn’s disease and the observed changes in body composition. GH induces an anabolic state mainly due to its mediator IGF-I. The positive effects of GH on intestinal mucosal function and structure have received increasing attention. Moreover, a study by Slonim et al. (2000) verified suggestions that GH treatment in adult patients with Morbus Crohn has beneficial effects on the Crohn’s Disease Activity Index (CDAI). We report on a patient with fistulizing Crohn’s disease with low body mass index (BMI) and GH deficiency who experienced spontaneous free ileal perforation while receiving recombinant human GH. Crohn’s disease of the terminal ileum was diagnosed in our 22-yearold female patient after 2 weeks of severe diarrhea in June 1999. Erythema nodosa, lactose intolerance, and iron deficiency accompanied the acute inflammation; the last one mentioned is still present. After budesonide and prednisone failure, she received azathioprine 2 years after onset and was in stable remission. Three years after onset, an uncomplicated transsphincteral fistula appeared, which resolved after intermittent administration of metronidazole and ciprofloxacin. Recombinant human GH (Genotropin, Pfizer, Erlangen, Germany) treatment was started because of the persistent low BMI of 16.8 kg/m and her low IGF-I and IGF-binding protein at level three (87 ng/ml, i.e., below 5th percentile and 3,170 ng/ml, i.e., below 25th percentile). The GH therapy was applied in a randomized controlled trial, which was approved by the Ethics committee of Dresden University (EK80052001). The trial was stopped in July 2003 due to insufficient patient recruitment. To minimize any adverse effect, the GH treatment was initiated at a dose of 0.4 U/day (0.13 mg/day). The daily G. W. Wolkersdorfer (*) . S. Miehlke . R. Schneider . G. Ehninger Medical Department I, Faculty of Medicine, Carl Gustav Carus, Technical University of Dresden, Fetscherstrasse 74, 01307 Dresden, Germany e-mail: wolkersdoerfer@mk1.med. tu-dresden.de Tel.: +49-351-4582627 Fax: +49-351-4584394

Soporte nutricional basado en la evidencia en la enfermedad inflamatoria intestinal

Patients with inflammatory bowel disease are at risk for malnutrition. Consequently all patients with inflammatory bowel disease should undergo nutritional screening to identify those who require thorough nutritional evaluation. When nutritional support is indicated, enteral nutrition (oral or through a tube) should be used. There are no significant differences between elemental and non-elemental enteral diets in inducing remission of Crohn's disease (CD). Nevertheless, given that non-elemental diets are better tolerated, most authors prefer polymeric diets. Enteral nutrition should not be used as the primary treatment of choice in patients with CD, since they are less effective in inducing remission than steroid therapy. Although dietary fat (quantity and type of fat) might influence the course of the disease, recommendations cannot be made on the basis of the available studies. Equally, there is insufficient evidence that glutamine is effective in inducing remission in CD. The use of probiotics presents a high level of evidence in maintenance treatment and in the prevention of postoperative pouchitis, although the level of evidence is lower in ulcerative colitis and CD. Further studies are required to investigate several issues such as dose, treatment duration, the separate or combined use of several strains, as well as the concomitant use of prebiotics, symbiotics or antibiotics.

Serum selenoprotein-P levels in patients with inflammatory bowel disease

Objective Selenoprotein-P is a selenium-rich serum protein that carries more than 50% of serum selenium. We evaluated changes in serum selenoprotein-P levels in patients with inflammatory bowel disease. Methods Serum selenoprotein-P levels were measured by enzyme-linked immunosorbent assay. Twenty healthy individuals (controls), 34 patients with ulcerative colitis, and 37 patients with Crohn’s disease (CD) were studied. Results A highly significant correlation was found between the serum selenium and selenoprotein-P levels. There was no significant difference in serum selenoprotein-P levels between healthy controls (average 3.4 ± 0.8 μg/mL, n = 20) and patients with ulcerative colitis (3.0 ± 1.0 μg/mL, n = 34). Serum selenoprotein-P levels were significantly lower in patients with CD (average 1.8 ± 0.5 μg/mL, n = 37). Serum selenoprotein-P levels were significantly lower in the elemental diet group of patients who had CD (average 1.4 ± 0.4 μg/mL, n = 17) than in the non-elemental diet group of patients who had CD (average 2.1 ± 0.3 μg/mL, n = 20). Conclusion We found that the serum selenoprotein-P level is decreased in patients with CD. It may be a useful marker to monitor the systemic selenium status in various disorders.

Enteral nutritional therapy for inducing remission of Crohn's disease.

The role of enteral nutrition in Crohn's disease is controversial. Increasing research on the mechanisms by which nutritional therapy improves the clinical well being of patients with Crohn's disease has led to novel formula design and trials comparing two different forms of enteral nutrition. This systematic review aims to provide an update on the existing efficacy data for both corticosteroids versus enteral nutrition and for one form of enteral nutrition versus another for inducing remission of active Crohn's disease. To evaluate the efficacy of exclusive enteral nutrition as primary therapy to induce remission in Crohn's disease and to examine the importance of formula composition on efficacy. Studies were selected using a computer-assisted search of the on-line bibliographic databases MEDLINE (1966-2000) and EMBASE (1984-2000), as well as the Science Citation Index on Web of Science. Additional citations were sought by manual search of references of articles retrieved from the computerized search, abstracts submitted to major gastroenterologic meetings and published in the journals: Gut, Gastroenterology, Journal of Pediatric Gastroenterology and Nutrition, and Journal of Parenteral and Enteral Nutrition, and from the reviewers' personal files or contact with leaders in the field. All randomized and quasi-randomized controlled trials involving patients with active Crohn's disease defined by a clinical disease activity index were considered for review. Studies evaluating the administration of one type of enteral nutrition to one group of patients and another type of enteral nutrition or conventional corticosteroids to the other group were selected for review. Data were extracted independently by two reviewers and any discrepancies were resolved by rereading and discussion. For the dichotomous variable, achievement of remission, individual and pooled trial statistics were calculated as odds ratios (OR) with 95% confidence intervals (CI); both fixed and random effect models were used. The results for each analysis were tested for heterogeneity using the chi square statistic. The studies were separated into two groups: A. one form of enteral nutrition compared with another form of enteral nutrition and B. one form of enteral nutrition compared with corticosteroids. Subgroup analyses were conducted on the basis of clinical or disease criteria and formula composition. Sensitivity analyses were conducted on the basis of the inclusion of abstracts of studies not yet fully published, methodologic quality and by random or fixed effects models. In part A, of the 11 trials (one abstract) comparing different formulations of enteral nutrition ten compared one [or more (Middleton (a)1995)] elemental formulas to a non-elemental diet. The eleventh study (Akobeng 2000) compared two non-elemental diets differing only by glutamine enrichment in one group. This study was therefore not included in the primary analysis but was part of the subgroup analyses. Meta-analysis of nine studies which included 170 patients treated with an elemental diet and 128 patients treated with a non-elemental diet for active Crohn's disease demonstrated no significant difference among diet formulations [OR 1.15 (95% CI: 0.64, 2.08)]. Significant heterogeneity was not present [chi-square 9.77 (df=8)]. Subgroup and sensitivity analyses had no significant effect on the results. In part B, six trials (two abstracts) comparing enteral nutrition to steroid therapy met the inclusion criteria for review. Meta-analysis of four trials that included 130 patients treated with enteral nutrition and 123 treated with steroids yielded a pooled OR of 0.30 favouring steroid therapy (95% CI: 0.17, 0.52). Heterogeneity was not demonstrated [chi-square 0.43 (df=3)]. The risk difference calculated from this meta-analysis was 0.26, and the NNT (number of patients needed to treat with steroids rather than enteral nutrition to achieve one remission) was four. The same result was found in a sensitivity analysis that included abstracts. The inclusion of abstracts resulted in an increase in the number of participants to 150 in the enteral nutrition group and 142 in the steroid group but the meta-analysis yielded a similar result [OR 0.34 (95% CI: 0.20, 0.56)]. There were inadequate data from full publications to perform further subgroup analyses by age, disease duration and disease location. Corticosteroid therapy is more effective than enteral nutrition for inducing remission of active Crohn's disease as was found in past meta-analyses. There is no significant difference in the efficacy of elemental and non-elemental diets for induction of remission of Crohn's disease.

Frühe enterale Ernährung – Grenzen und Möglichkeiten

Enteral nutrition is an economic and effective way for nutritional support in the posttraumatic and postoperative phase. Early enteral nutrition may preserve the nitrogen balance, the structure and function of the gut mucosa as well as the immune competence. However, there is no consensus about the administration of early enteral nutrition, which reduces its use in the clinical routine. Suitable enteral accesses are of critical importance for the concept of early enteral nutrition after trauma or elective abdominal surgery. Different nasoenteral tubes are usable in patients who are not laparotomized. If a laparotomy is performed, nasoenteral tubes as well as intraoperatively placed percutaneous tubes (e. g. needle catheter jejunostomy) can be used for early enteral nutrition. Enteral feeding should start within 12–24 h after trauma or operation, not only to prevent structural damages of the gut mucosa but also to improve the tolerability and practicability of enteral feeding. Further, the motility of the gastrointestinal tract can be improved if enteral nutrition is started early. A delayed start of substrate administration is not beneficial for the homeostasis of patients. Enteral nutrition should be increased gradually in the days foIlowing surgery. Early enteral nutrition can be performed either with a nonelemental diet or by immunonutrition. Elemental diets are usually not indicated. For monitoring of the early enteral nutrition frequent clinical investigations are necessary. If complications like diarrhea or distension occur, feeding should be reduced or, if necessary, temporarily stopped.

A Randomized Prospective Trial Comparing a Defined Formula Diet, Corticosteroids, and a Defined Formula Diet Plus Corticosteroids in Active Crohn's Disease

Although defined formula diets may be useful for initial episodes of Crohn's disease, the effects of these diets on subsequent attacks of Crohn's disease or in conjunction with corticosteroids are unknown. To evaluate these issues, we studied 27 patients in a randomized prospective trial. Ten patients received only prednisone (group I), nine received only a defined formula diet (Vital HN [high nitrogen]) (group II), and eight received a combination of prednisone and Vital HN (group III). At the time of entry into the study, the groups were similar with respect to age, sex, Crohn's Disease Activity Index, previous and current treatments, anatomic site of disease, and nutritional status. After 1 month of treatment, we noted seven successes (70%) and three failures in group I (prednisone only), three successes (33%) and six failures in group II (Vital HN only), and six successes (75%) and two failures in group III (combination therapy). Four patients randomized to receive only Vital HN were unable or unwilling to tolerate the defined formula diet. Of the five patients who were able to take the defined formula diet for 1 month, however, three (60%) were successfully treated. The patients who received prednisone (groups I and III) responded better than did the patients who received only the defined formula diet. These results may be attributable to the use of a nonelemental diet or the treatment of patients who were not experiencing an initial attack of Crohn's disease or who had previously received corticosteroids. The expensive and often poorly tolerated defined formula diets should not be considered as a substitute for standard therapy with corticosteroids in Crohn's disease.

A nonelemental versus an elemental diet for early postoperative enteral feeding by needle catheter jejunostomy

In a prospective randomised study the use of an elemental versus a nonelemental diet for early postoperative enteral feeding by needle catheter jejunostomy was investigated. After extensive gastrointestinal surgery, 25 patients received an elemental and 24 patients a nonelemental diet. The incidence of diarrhoea, the effects of the feeding and the costs were evaluated. The occurrence of diarrhoea was observed more frequently in the elemental diet group ( 14 25 ) compared to the nonelemental diet group ( 7 24 ), although this difference was statistically not significant (p > 0.05). No difference was found between the two groups in postoperative restoration of total protein and serum albumin levels and the extent of the postoperative weight loss. The costs showed a clear difference: the nonelemental diet was three times cheaper than the elemental diet. For early postoperative enteral feeding by needle catheter jejunostomy we therefore recommend the use of a nonelemental diet.

Prolonged enteral nutrition in malnourished patients with nonelemental feeding: Reappraisal of surgical technique, safety, and costs

In a 2 year period, 60 consecutive feeding enterostomies were placed in malnourished patients. The major complication rate was 1.6 percent. Total complications were 8 percent. Thirty day mortality was 13 percent. Nearly all patients were given isosmotic nonelemental diets. The incidence of diarrhea was 2 percent with this regimen. Four of five patients given elemental diets had diarrhea. Serum albumin levels increased significantly from a preoperative mean of 2.75 to 3.03 g/dl. Best overall results were achieved in patients undergoing upper gastrointestinal surgery or pancreatobilary procedures for nonmalignant lesions. More than $60,000 was saved in 2 years by substituting isosmotic formulas for elemental ones. It appears that many patients are given elemental formulas who do not actually require them. Since isosmotic solutions will not infuse through needle catheters, we advocate placing 12 F. catheters and have documented the safety of this change. By using these larger catheters, the surgeon will not lose the option of using isosmotic preparations. We have shown these preparations to be nutritionally effective with a marked lessening of diarrhea and a cost approximately a sixth of that of elemental products.

Fluoroscopic placement of nasojejunal feeding tubes with immediate feeding using a nonelemental diet.

A method for fluoroscopic placement of an Erythrothane (8 French) feeding nasojejunostomy tube with a wire stylet is described. Two hundred thirty-eight feeding tubes were passed successfully to or beyond the Ligament of Treitz in 141 patients with an average fluoroscopy time of 5.3 min/patient. A nonelemental diet was administered without difficulty through the tubes by continuous infusion immediately after placement. This technique was found useful in avoiding total parenteral nutrition in patients with poor gastric emptying in situations such as the immediate postoperative period, drug-induced nausea, and in the presence of an altered mental status.

Rational Use of Elemental and Nonelemental Diets in Hospitalized Patients

Study A included 30 patients who received immediate postoperative enteral feeding with a nonelemental diet. The nonelemental diet was well tolerated. Study patients rapidly achieved nitrogen equilibrium and had a cumulative nitrogen balance of −11.1 g versus −46.7 g for the control group. In part B, 16 patients with varying degrees of bowel dysfunction received elemental and nonelemental diets in a crossover design. Patients with moderate small bowel impairment tolerated nonelemental better than the elemental diets. In those patients with more severe bowel impairment, the elemental diet was better tolerated. Nitrogen balance for both types of diet was similar in both groups of patients. It is concluded that nonelemental diets are better tolerated in most patients with moderate degrees of small bowel abnormality. In patients with severe bowel abnormality, elemental diets may be better tolerated, but nonelemental diets should still be the initial formula.

Rational use of elemental and nonelemental diets in hospitalized patients.

Study A included 30 patients who received immediate postoperative enteral feeding with a nonelemental diet. The nonelemental diet was well tolerated. Study patients rapidly achieved nitrogen equilibrium and had a cumulative nitrogen balance of -11.1 g verus -46.7 g for the control group. In part B, 16 patients with varying degrees of bowel dysfunction received elemental and nonelemental diets in a crossover design. Patients with moderate small bowel impairment tolerated nonelemental better than the elemental diets. In those patients with more severe bowel impairment, the elemental diet was better tolerated. Nitrogen balance for both types of diet was similar in both groups of patients. It is concluded that nonelemental diets are better tolerated in most patients with moderate degrees of small bowel abnormality. In patients with severe bowel abnormality, elemental diets may be better tolerated, but nonelemental diets should still be the initial formula.

Immediate postoperative enteral nutrition with a nonelemental diet

Immediate postoperative enteral nutrition with a nonelemental diet

Absorption of elemental and complex nutritional solutions during a continuous jejunal perfusion in man.

The jejunal absorption of either an elemental solution (amino acids, glucose and glucose oligosaccharides), or of nonelemental diet (chicken meat, egg-yolk power, soya flour, glucose, saccharose, maltose and dextrin maltose, corn and wheat oils) were compared in 25 healthy subjects by the technique of intestinal perfusion with a three-lumen tube. The test solutions were perfused just beyond the ligament of Treitz. The samples were collected 35, 70 and 105 cm below the infusion point. In a small segment of jejunum, the absorption increased the nutritional imbalance of the element diet 1 m below the infusion point, the flow rate in the lumen was similar for the two solutions and higher than the initial flow rate; the absorption, in terms of calories, is similar for the two solutions.