Partial Enteral Nutrition Research Articles

Prospective cohort study on the effectiveness of the Crohn's disease exclusion diet and partial enteral nutrition in induring and maintaining remission in adult patients with Crohn's disease

Prospective cohort study on the effectiveness of the Crohn's disease exclusion diet and partial enteral nutrition in induring and maintaining remission in adult patients with Crohn's disease

Diet as an Optional Treatment in Adults With Inflammatory Bowel Disease: A Systematic Review of the Literature.

While the exact cause of IBD is unknown, there are a number of factors that are thought to contribute to its development, including environmental and genetic factors. While exclusive enteral nutrition (EEN) is a promising therapy for Crohn's disease (CD), it is not yet considered a first-line treatment. Additionally, the efficacy of EEN compared to corticosteroid treatment is still being investigated. EEN is suggested as a first-line therapy by which guidelines and in which age groups, as it may differ in pediatric and adult recommendations. Another finding was that dietary changes involving an increase in anti-inflammatory foods and decreased intake of foods high in inflammatory compounds are linked to a beneficial outcome both metabolically and microbiologically in patients with ulcerative colitis (UC) in remission. For relevant medical literature, we examined PubMed/Medline, the Cochrane Library, and Google Scholar as examples of medical databases. The articles were identified, evaluated, and eligibility applied, and nine publications were found. The finished articles investigated the role of several diet alternatives for patients with IBD. Some others have shown that following a normal low-fat diet may be effective in reducing the occurrence of subclinical colitis. The EEN and partial enteral nutrition (PEN) indicated no significant differences between both regimens, but both had good outcomes during active IBD. Other strict diets, such as the specific carbohydrate diet (SCD) versus the Mediterranean diet (MD), demonstrate excellent outcomes in patients with IBD. Fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) dietary counseling improves gastrointestinal symptoms and quality of life in IBD patients. Based on the above, we concluded that more studies determining which component of the diet is not clear (proteins, carbs balanced) or diet types are required to establish a particular diet employed as a treatment intervention in these individuals.

Novel Use of the Crohn's Disease Exclusion Diet Plus Partial Enteral Nutrition for the Treatment of Crohn's Disease During Pregnancy

ABSTRACT The Crohn's Disease Exclusion Diet (CDED) with partial enteral nutrition (PEN) is an emerging treatment option for Crohn's disease (CD). A 35-year-old pregnant woman presented with newly diagnosed ileal CD. At 14/40 gestation, CDED + PEN was prescribed without drug therapy. Outcomes included Harvey-Bradshaw Index, weight, and bowel wall thickness/Limberg score measured on intestinal ultrasound (IUS). In this patient, CDED + PEN achieved clinical and biochemical remission, improvements on IUS, gestational weight gain, and healthy birth weight without drug therapy. Sustained remission was achieved postpartum. Our case highlights the potential effectiveness of CDED + PEN to induce remission for active CD during pregnancy.

Efficacy of Crohn’s disease exclusion diet in treatment -naïve children and children progressed on biological therapy: a retrospective chart review

BackgroundRecent trials suggested that the Crohn’s disease (CD) exclusion diet (CDED) plus partial enteral nutrition (PEN) is a safe and effective strategy in remission induction of paediatric-onset CD. However, real-world evidence regarding the safety and efficacy of the CDED plus PEN approach is still lacking. The present case-series study reported our experience with the outcomes of CDED plus PEN in the paediatric-onset CD at disease onset and after the loss of response to biologics.MethodsWe conducted a retrospective chart review on children who were treated with CDED plus PEN through the period from July 2019 and December 2020. Clinical and laboratory data were retrieved and compared at baseline, 6, 12, and 24 weeks of treatment. The primary endpoint of the present study was the rate of clinical remission.ResultsThe present study retrieved the data from 15 patients. Of them, nine patients were treatment naïve at the time of initiation of CDED plus PEN (group A) and the remaining patients relapsed on biologics before treatment. All patients in groups A and B exhibited clinical remission in week six, which was sustained until week 12. At the end of the follow-up, the clinical remission rate was 87% and 60% in groups A and B, respectively. No side effects were observed in both groups. In group A, the faecal calprotectin (FC) and albumin improved at week six, week 12, and week 24 (p < 0.05). The erythrocyte sedimentation rate (ESR) improved significantly at week 12 (p = 0.021) and week 24 (p = 0.027). At the same time, the haemoglobin and iron levels showed significant improvement only at week 24. For group B, only FC showed numerical reductions over time that did not reach the level of statistical significance.ConclusionTreatment with CDED plus PEN was well tolerated and achieved an excellent clinical remission rate in treatment-naive patients. However, the benefit of CDED plus PEN was less in patients who initiated the strategy after losing the response to biologics.

Mezinárodní zkušenosti s dietou pro Crohnovu chorobu založenou na vyloučení konkrétních potravin (CDED) s parciální enterální výživou (PEN)

The role of dietary intervention in the induction of remission of Crohn’s disease (CD) has been confirmed again by the recent ECCO (European Crohn’s and Colitis Organization) and ESPGHAN (European Society for Paediatric Gastroenterology, Hepatology and Nutrition) guidelines. Exclusive enteral nutrition (EEN) should be the method of choice in induction of remission of active luminal CD in children. Steroids should be reserved for situations when intolerance or infectivity of EEN is present. The main limitations of EEN consist of its monotony and palatability. In search for a safe and at least similarly effective diet, Crohn’s disease exclusion diet (CDED) was developed. The number of published data regarding its safety and efficacy has increased significantly since the publication of the first randomized controlled trial in 2019. CDED seems, to be safe and its efficacy is very promising. It seems that CDED could be used in three scenarios: as a monotherapy, as a part of complex treatment and as rescue therapy in cases of loss of response. The use of CDED is promising but further research for evaluation of its efficacy, including the necessity of using partial enteral nutrition, on larger patient cohorts is required. Keywords Crohn’s disease, exclusive enteral nutrition, steroids, Crohn’s Disease Exclusion Diet (CDED), adherence

Repeated and multiple fecal microbiota transplantations plus partial enteral nutrition as the first-line treatment in active pediatric Crohn's disease.

Most studies have reported fecal microbiota transplantation (FMT) as an effective secondary option for Crohn's disease (CD). However, there is little data on FMT as a first-line treatment for CD. In our study we explore the rates of clinical and endoscopic remission and mucosal healing after FMT plus partial enteral nutrition (PEN), as a first-line treatment for active CD in children. We retrospectively enrolled pediatric CD patients who underwent PEN or PEN plus FMT treatment at diagnosis from November 2016 to July 2019 at the Pediatric Department, Tongji Hospital. The two groups were defined as FMT group (repeated and multiple doses of FMT plus PEN) or PEN group (PEN alone). All the patients received PEN intervention. At baseline and week 8- 10, the FMT group was administered multiple doses of FMT to help induce and maintain remission. All patients were evaluated at week 8- 10 and 18-22 via clinical and relevant laboratory parameters and endoscopic results. The clinical and endoscopic remission and mucosal healing rates were compared between the two groups at different time points after the therapy. Twenty-five newly diagnosed active CD patients were included in the study, containing 7 females and 18 males with a median age of 11. 1 ± 2.3 years. 13 and 12 patients were assigned to the PEN and FMT groups, respectively. At week 8-10, clinical remission was obtained in 83.3% and 53.8% of the FMT and PEN groups, respectively (p=0.202). The endoscopic remission rates were 72.7% for FMT and 25.0% for PEN (p=0.039), whereas the mucosal healing rates were 27.2% for FMT and 0% for PEN (p=0.093). At week 18-22, clinical remission was achieved in 72.7% and 20.0% of patients in the FMT and PEN groups, respectively (p=0.03). Theendoscopic remission rates were 66.6% and 12.5% in the FMT and PEN groups, respectively (p=0.05), whereas the mucosal healing rates were 55.5% and 0% in FMT and PEN groups, respectively (p=0.029). This study demonstrate that FMT plus PEN can be used as a first-line treatment for active CD in children.

Microbiota signatures and mucosal healing in the use of enteral nutrition therapy v. corticosteroids for the treatment of children with Crohn's disease: a systematic review and meta-analysis.

Corticosteroids (CS) and exclusive and partial enteral nutrition (EEN and PEN) are effective therapies in paediatric Crohn's disease (CD). This systematic review of randomised controlled trials (RCT) and cohort studies analyses the impact of EEN/PEN v. CS on intestinal microbiota, mucosal healing as well as other clinically important outcomes, including clinical remission, relapse, adherence, adverse events and health-related quality of life (HRQL) in paediatric CD. Three RCT (n 76) and sixteen cohort studies (n 1104) compared EEN v. CS. With limited available data (one RCT), the effect on intestinal microbiome indicated a trend towards EEN regarding Shannon diversity. Based on two RCT, EEN achieved higher mucosal healing than CS (risk ratio (RR) 2·36, 95 % CI (1·22, 4·57), low certainty). Compared with CS, patients on EEN were less likely to experience adverse events based on two RCT (RR 0·32, 95 % CI (0·13, 0·80), low certainty). For HRQL, there was a trend in favour of CS based on data from two published abstracts of cohort studies. Based on thirteen cohort studies, EEN achieved higher clinical remission than CS (RR 1·18, 95 % CI (1·02, 1·38), very low certainty). Studies also reported no important differences in relapse and adherence. Compared with CS, EEN may improve mucosal healing with fewer adverse events based on RCT data. While limited data indicate the need for further trials, this is the first systematic review to comprehensively summarise the data on intestinal microbiome, mucosal healing and HRQOL when comparing enteral nutrition and CS in paediatric CD.

Mild Crohn's Disease: Definition and Management.

Crohn's Disease (CD) is a chronic inflammatory disease that can lead to progressive damage to the gastrointestinal tract and significant disability. Early, "top-down" biologic therapy is recommended in moderate-to-severe CD to induce remission and to prevent hospitalization and complications. However, an estimated 20-30% of patients with CD have a mild disease course and may not garner sufficient benefit from expensive, immunosuppressing agents to justify their risks. Herein, we review characteristics of patients with mild CD, the available options for disease treatment and monitoring, and future directions of research. For ambulatory outpatients with low-risk, mild, ileal or ileocolonic CD, induction of remission with budesonide is recommended. For colonic CD, sulfasalazine is a reasonable choice, although other aminosalicylates have no role in the treatment of CD. No large, randomized trial has supported the use of antibiotics or antimycobacterials in the treatment of CD. Partial Enteral Nutrition and Crohn's Disease Exclusion Diets may be appropriate for inducing remission in some adult patients, with trials ongoing. Select patients with mild-to-moderate CD may benefit from maintenance therapy with azathioprines or gut specific biologics, such as vedolizumab. The role of complementary and alternative medicine is not well defined. The identification, risk stratification, and monitoring of patients with mild CD can be a challenging clinical scenario. Some patients with low risk of disease progression may be appropriate for initial induction of remission with budesonide or sulfasalazine, followed by close clinical monitoring. Future research should focus on pre-clinical biomarkers to stratify disease, novel therapies with minimal systemic immune suppression, and validation of rigorous clinical monitoring algorithms.

Personalised azithromycin+metronidazole (PAZAZ), in combination with standard induction therapy, to achieve a faecal microbiome community structure and metagenome changes associated with sustained remission in paediatric Crohn’s disease (CD): protocol of a pilot study

IntroductionEarly relapse in Crohn’s disease (CD) is associated with a more severe disease course. The microbiome plays a crucial role, yet strategies targeting the microbiome are underrepresented in current guidelines....

P700 Perceptions towards established and emerging dietary therapies for Crohn’s disease management among the adult patients: results from a questionnaire survey

Abstract Background Exclusive enteral nutrition (EEN) and partial enteral nutrition (PEN), replacing at least 50% of the energy intake with formula, remain the only evidence-based dietary therapies in the management of Crohn’s disease (CD). Nonetheless, emerging solid food-based dietary therapies are being researched to offer equally effective, but more palatable alternatives. We assessed the perceptions of adults with CD towards EEN, 50% PEN, and novel dietary therapies within a cross-sectional questionnaire survey. Methods The 26-question anonymous survey with a pre-paid return envelope was mailed to 300 adult patients with CD treated with biologics under the care of the NHS Greater Glasgow &amp; Clyde. A reminder was resent three months later. Responses to open-ended questions regarding concerns about 50% PEN use were analysed independently by two researchers using thematic analysis. Results One-hundred and sixty patients (85/160, 53% female) completed and returned the survey (response rate: 53%). Forty-two percent (67/158) had already followed some form of an exclusion diet, with low spice (32/158, 20%) and low fibre (24/158, 15%) diets being the most popular. Although only a quarter of patients believed that EEN or PEN could help with their CD (42/157, 27%), the majority believed that diet could help (84/157, 54%), with another 13% (21/157) reporting already using diet for CD management. Although only around half of the patients were willing to try EEN (80/157, 51%), the majority were willing to try PEN instead (124/157, 79%) (EEN vs. PEN chi-square: P&amp;lt;.001). Most patients preferred to follow an exclusion diet meal plan to prepare at home (65/154, 42%) compared to EEN or PEN (53/153, 34%). Similarly, most patients preferred to follow a meal plan to prepare at home (76/151, 50%) rather than a meal plan with pre-made meals delivered (59/151, 39%). When asked about preferences related to PEN use, most patients reported that they would prefer to follow a flexible meal plan, allowing them to choose meals to replace to fit their lifestyle (92/153, 60%). The most commonly reported concerns about PEN identified within the thematic analysis were taste/palatability (25%, 34/136), satiety/hunger (22%, 30/136), taste fatigue (14%, 19/136), and impact on social life (14%, 19/136). Conclusion Most adult patients would prefer to follow an exclusion diet meal plan rather than EEN or 50% PEN. However, the majority would try 50% PEN which allows for more flexibility and may be easier to comply with than EEN.

P751 Crohn’s Disease Exclusion Diet: A single centre real-life experience

Abstract Background According to ECCO-ESPGHAN consensus guidelines, exclusive enteral nutrition (EEN) is the first line therapy for induction of remission in children with active luminal Crohn’s disease (CD). Steroids may be considered in cases when EEN is not an option. However, adherence to EEN is not ideal. According to various sources it ranges from 50-91 %. This poor adherence is mainly due to palatability and monotony. Many attempts have been made to find an alternative to EEN. One of them is Crohn’s Disease Exclusion Diet (CDED) with partial enteral nutrition (PEN), which shows promising results in efficacy, safety, and adherence. This study evaluates the efficacy of CDED with PEN in a single European centre. Methods Retrospective evaluation of prospectively collected dated of children treated with CDED with PEN between 10/19-11/22. Wellbeing, anthropometric data, and laboratory results were evaluated prior to the commencement of CDED with PEN and at the end of both phases 1 and 2. A mean, median and a standard deviation were calculated were applicable. ANOVA was used for evaluation of presence of statistically significant differences and a P-value ≤ 0.05 was regarded as such. Results CDED with PEN was used in 24 patients. The mean age at diagnosis was 14.6±3.7 years. At the time of evaluation, 21/24 patients have completed phase 1 and 20/24 have completed phase 2. Three patients were still in phase 1 and 1 in phase 2. One patient decided to quit CDED with PEN at the end of phase 1 and 2 more at the end of phase 2. All patients, who started phase 1 completed it, and 95.2% completed phase 2. Non-adherence was recorded in two patients: once in diet composition and twice in PEN volume. At commencement of CDED with PEN, dietary intervention was the only treatment in 16/24 patients. Three patients were on Azathioprine (AZA), 2 5-aminosalicylic acid (5-ASA), 1 Methotrexate (MTX) and another Prednisone. At the end of phase 1, 8 patients were on anti-TNF-α, 8 were using AZA, 2 5-ASA and 1 MTX. At the end of the phase 2, anti-TNF-α was used in 12 patients, AZA in 8, MTX in 3 and both anti-IL12/23 and 5-ASA in 1 patient. CRP and ESR showed a statistically significant decrease (P&amp;lt; 0.01) at the end of phases 1 and 2, Faecal calprotectin (FC) showed so at the end of phase 2 (P&amp;lt; 0.01). Other followed parameters failed to show a significant difference at the end of follow-up. Conclusion These data support that CDED with PEN is both well tolerated and has a very high adherence rate. They also confirm that CRP and ESR decrease significantly at the end of both phases and FC at the end of phase 2. CDED with PEN should be considered as an alternative to EEN and steroids in induction of remission of luminal CD in children.

P680 A real-life experience of Crohn’s Disease Exclusion Diet use at disease onset and as an add-on therapy in pediatric Crohn’s disease

Abstract Background We aimed at appraising real-life efficacy of Crohn’s Disease Exclusion Diet (CDED) coupled with partial enteral nutrition (PEN) in inducing clinical and biochemical remission at disease onset and in patients with loss of response to biologics in a tertiary-level center. We also aimed at identifying early responders to this dietary regimen. Methods We gathered clinical, anthropometric and laboratory data of patients aged less then 18 years of age with a diagnosis of CD, who were consecutively treated with CDED coupled with PEN as main treatment for the induction of remission or in the setting of loss of response to other therapies. We collected data of patients who received CDED plus PEN from April 2019 to June 2022 at diagnosis, at the beginning of the dietary treatment, and at the phase 1. Patients who interrupted diet during follow-up were considered as treatment failures on an intent to treat basis. We compared groups using chi-square, Fisher’s exact test, Mann-Whitney U or related-samples Wilcoxon signed rank tests or McNemar’s test as appropriate. Results 47 patients were retrospectively identified. Table 1. summarizes clinical and biochemical characteristics at diagnosis and at CDED with PEN initiation. 24 (51.1%) patients started CDED as induction therapy at disease onset, whereas 23 (48.9%) of them received CDED with PEN as add-on therapy. 32/47 (68%) patients achieved clinical remission (wPCDAI &amp;lt; 12.5) at the end of phase 1, 16/24 patients (66.7%) who started CDED as induction therapy and 16/23 (69.5%) of those who started CDED as add-on, with no statistically significant difference among the two groups (p=1.00). Laboratory parameters significantly improved in both groups (Figure 1.). There were no statistically significant differences in clinical remission rates between patients with mild-to-moderate and severe disease at the end of phase 1 (25/35 vs 7/12, p=0.481). At disease onset, 14 patients added a concomitant treatment (11 patients added anti-TNF alpha, 3 patients added IMM and one patient added anti-TNF alpha + IMM) after a median time of 4 weeks (IQR: 3-5 weeks). 28 patients had clinical data gathered at week 3. Patients who achieved clinical response at week 3 (a change in wPCDAI &amp;gt; 12.5) were more likely to be in clinical remission at the end of phase 1 (17/20 vs 1/8, p&amp;lt;0.01), both in patients who started CDED at disease onset and in the add-on setting. Conclusion CDED with PEN confirmed its efficacy in a real-life setting, both as induction regimen and as add-on therapy, also in patients with clinically severe disease. Early clinical response predicts clinical remission at the end of phase 1, possibly allowing identification of dietary responsive disease. Table 1. Figure 1.

P716 A 2-week course of Exclusive Enteral Nutrition followed by the Crohn Disease Exclusion Diet is effective for Induction and Maintenance of Remission in children with Crohn Disease; the DIETOMICS-CD trial

Abstract Background Exclusive enteral Nutrition (EEN) is considered a first line therapy for children with active Crohn disease (CD). CD Exclusion Diet (CDED)+Partial Enteral Nutrition (PEN) is effective for induction of remission in mild-moderate CD at weeks 6 and 12, with better tolerance than EEN. We assessed whether a 2-week course of EEN, followed by CDED+PEN is superior to 8 weeks of EEN in sustaining clinical remission at week 14, outcomes of CDED up to 24 weeks, and the utility of CDED in mild-severe CD. Methods This international, multicenter, randomized-controlled trial compared 2 weeks of EEN (Modulen, Nestle Health Science) followed by 3 phases of the CDED+PEN to 8 weeks of EEN, followed by PEN with free diet, both up to week 24. Children aged 8-18 with CD&amp;lt;3 years, mild-severe disease [paediatric CD activity index (PCDAI) 15-47.5], and active inflammation [elevated C-reactive protein (CRP) or faecal calprotectin (FCP)] were included. Stable immunomodulator (IM) treatment was allowed. Naïve patients were allowed to start an IM from week 4. Results Of the 63 eligible patients enrolled, 55 were randomized and included in the final intention to treat analysis (target recruitment failed due to COVID); Group 1 (CDED+PEN;29) and group 2 (EEN;26), mean age 12.7±2.4. Steroids-free sustained remission at week 14 was obtained in 20/29(69%) in group 1 and 16/26(61.5%) in group 2, p=0.56. Remission at week 8 was obtained in 22/29(76%) in group 1 and 14/26(54%) in group 2, p=0.08. 16/29(55%) in group 1 and 9/26(34%) in group 2 maintained clinical remission at week 24; p=0.12. Median PCDAI declined from 32.5[20-36.2] to 2.5[0-5.6] and 1.2[0-5.6] in group 1 (p&amp;lt;0.001 for all), and from 22.5[20-29.3] to 0[0-4.3] and 0[0-2.5] in group 2 (p&amp;lt;0.005 for all) at baseline, week 8 and 14 respectively. Median CRP improved in group 1 from 32 mg/L[6-69] to 5[2-16] and 3[2-10.1] (p&amp;lt;0.001 for both) and in group 2 from 10.35 mg/L[5-33] to 3.7[2.2-7.2], p=0.012 and 3.2[2.8-5], p=0.006 at baseline, week 8 and 14 respectively. Median FCP declined in group 1 from 1946 µg/g [862-3304] to 802[196-1312] at week 8 and 241[82-1175] at week 14 (p&amp;lt;0.01 for both), and in group 2 from 1615[605-2692] at baseline to 436[252-1389] at week 8, which then increased to 731[349-1305] at week 14 (p&amp;lt;0.01 for both). At week 14, 12/22(54%) received IM from group 1 and 15/16(93%) from group 2; p= 0.009. Conclusion Two weeks of EEN followed by CDED&amp;PEN and EEN were successful in induction of clinical and biochemical remission in mild-severe paediatric CD, and most CDED+PEN patients-maintained remission to 24 weeks. Sustained clinical remission at week 14 was similar despite higher IM use in the EEN Group, suggesting that CDED might prevents diet-induced inflammation regardless of IM use.

P769 Randomised feasibility study of preoperative medical nutrition therapy in adults undergoing surgery for Crohn’s disease

Abstract Background Preoperatively patients with Crohn’s disease are at high risk of malnutrition. Patients requiring surgery to manage stricturing disease are often advised to follow a low residue/low fibre diet to reduce risk of bowel obstruction. This diet is usually nutritionally inadequate and may negatively affect nutritional status. Research suggests that preoperative exclusive enteral nutrition (EEN) improves nutritional status, reduces intestinal inflammation and consequently improves surgical outcomes. Recently the Crohn’s disease exclusion diet has been shown to reduce intestinal inflammation in adults but its use preoperatively has not been reported. This research aimed to determine whether it is feasible to recruit and retain patients with Crohn’s disease in a single-blinded, multicentre, randomised controlled trial of three preoperative nutritional therapies. Methods Patients undergoing elective surgery to manage Crohn’s disease at three New Zealand tertiary care hospitals (Christchurch, Auckland and Waikato hospitals), aged &amp;gt;18 years old, with body mass index (BMI) &amp;gt; 18.5 kg/m2 and without recent significant weight loss were eligible to participate. Patients were randomised to six weeks of preoperative EEN, partial enteral nutrition with Phase-1 Crohn’s Disease Exclusion Diet (CDED) or standard care. Nutritional and radiological assessment at baseline and preoperatively was completed and surgical outcomes recorded. Descriptive statistical analysis was undertaken. Health and Disability Ethics Committee approval was given (20/NTB/134). Results Over 18 months (September 2020 to March 2022), 48 patients were screened and 17 were randomised. Patient characteristics were: median age 37.9 (range, 28-68) years, 9 (53%) female, 10 (59%) on biologic medication, median BMI 25.7 (range, 19.7-38.6) kg/m2 and 2 (12%) had low fat-free mass index. Medical nutrition therapy was completed by 13/17 (76%) patients (EEN n=4, CDED n=4 and standard care n=5) and four withdrew. BMI and simplified magnetic resonance index of activity (MaRIA) score changed by a median of -0.3 (range, -1.8 to 2.1) kg/m2 and 0.5 (range, -3 to 2) points respectively. At day 30, 10 patients had no surgical complications. Three patients had Clavien Dindo Grade 2 complications; one (standard care group) experienced fever treated with antibiotics, one (standard care group) had postoperative ileus requiring total parenteral nutrition and one (CDED group) required a blood transfusion postoperatively and antibiotics for a wound infection. Conclusion Patients who need elective Crohn’s disease surgery tolerate preoperative EEN or CDED. Use of preoperative nutrition therapies are feasible and the impact on surgical outcomes should be assessed in a larger study.

P589 Effectiveness of partial enteral nutrition to treat adults with Crohn's Disease who lost response to biological therapy

Abstract Background Partial enteral nutrition (PEN) is a consolidated treatment in children with active Crohn’s disease (CD). However, the benefit of PEN is not well-established for adults with CD. Based on the assumption that diet could aid in treating active disease, we aimed to assess the effectiveness of PEN in combination with biological therapy on transmural response/remission and selected clinical outcomes in adults with CD who lost response to biologics Methods We performed a single-centre retrospective observational study by including patients who received PEN due to loss of response to biologics. The primary endpoint was the rate of transmural response/remission at 6 months. We defined transmural remission as a bowel wall thickness ≤3 mm, while transmural response as a decrease in BWT≥25%. Secondary endpoints included clinical remission, defined as Harvey Bradshaw Index&amp;lt;5, and selected clinical outcomes such as surgery, hospitalisations, and change of therapy, including switch and dose/interval escalation at 6 months. Patients were considered adherent when they completed PEN for 6-8 weeks as required for induction of remission, whereas not adherent when they stopped it or if they did not tolerate. Results A total of 42 patients,25 males (59,5%) with mean age of 36,1 ±15,6 yo and a mean duration of disease of 138,0 ±113,1 months were enrolled [Table 1]. Overall, 14 patients completed PEN at 8 weeks, with a rate of adherence of 33,3%. Whilst 16(38.1%) patients stopped the treatment for intolerance and maintained only biological therapy and 12(28.6%) underwent surgery before 6 months follow-up.At 6 months, patients treated with PEN in combination with biologic had a transmural response of 64,9% compared to 25% treated only with biologics (p=0.03). In both groups, no patients achieved transmural remission. Nevertheless, clinical remission was obtained in 9 (64,3%) patients treated with PEN + biologic compared to 4 (25%) with biologic (p=0.03). Overall,3 patients (18.7%) underwent surgery, all of them were intolerant to PEN. Patients who interrupted PEN and maintained biologics had a higher rate 56,2% of dose escalation/interval and 68,7% changed therapy at six months compared to 7,1% and 14,2% respectively treated with PEN+biologic (p&amp;lt;0.05) [Table 2].At multivariate analysis multiple treatment failures were associated with adherence to PEN (OR=1,583; CI=1,06-2,36; p&amp;lt;0.05). Conclusion For patients who lost response to biological therapy, the combination with PEN was associated with transmural response and clinical remission. Multiple failures to biologics were associated with adherence to PEN. Hence, the use of PEN dietary should be considered in difficult-to-treat patients

Sustained Diet-Induced Remission in Pediatric Crohn's Disease Is Associated With Kynurenine and Serotonin Pathways.

Both the Crohn's disease exclusion diet combined with partial enteral nutrition (CDED+PEN) and exclusive enteral nutrition (EEN) can induce remission in mild-to-moderate pediatric Crohn's disease and are associated with a marked decrease in fecal kynurenine levels. This suggests a link between clinical outcome of dietary therapy and changes in tryptophan metabolism pathways. Here, we characterize the changes in several fecal tryptophan metabolites induced by CDED+PEN or EEN and their association with remission. A total of 21 tryptophan metabolites were quantified in fecal samples from a 12-week prospective randomized trial with CDED+PEN or EEN for induction of remission in mild to moderate pediatric Crohn's disease. Tryptophan metabolites at week 0 (W0), W6, and W12 of 73 samples were quantitatively measured by liquid chromatography coupled with triple quadrupole mass spectrometry, and data were analyzed according to clinical groups of baselines (W0), induced remission at W6, no remission, sustained remission at W12, and nonsustained remission. Reduction in components of the kynurenine pathway, such as kynurenine and quinolinic acid, were strongly associated with induced remission with both CDED+PEN and EEN, which were maintained in sustained remission. Specific serotonin pathway metabolites, such as melatonin, N-acetylserotonin, and 5-OH-tryptophan, were significantly increased in fecal samples from patients maintaining remission at W12 with both CDED+PEN and EEN. Importantly, in samples from patients failing to sustain remission, no changes were observed. Remission induction with EEN differs from CDED+PEN, particularly the moderate effects on indole pathway metabolites. The ratios of kynurenine and melatonin and quinolinic acid and melatonin perform well as markers for sustained remission. The reduction in specific kynurenine pathway compounds and the increase in serotonin pathway compounds are associated with diet-induced and sustained remission. Further studies are warranted to assess causality and the association of these metabolites with specific diet and lifestyle factors, affecting sustained clinical remission.

Role of Nutrition in Gastroesophageal Reflux, Irritable Bowel Syndrome, Celiac Disease, and Inflammatory Bowel Disease.

There remains a paucity of data on the efficacy of nutritional interventions in luminal gastrointestinal disorders. This review appraises the evidence supporting dietary modification in gastroesophageal reflux disease (GERD), irritable bowel syndrome, Celiac disease, and inflammatory bowel disease. Alhough the use of elimination diets; high fat/low carb; low fermentable oligosaccharides, disaccharides, monosaccharides and polyols; and lactose-free diets in GERD have been studied, the evidence supporting their efficacy remains weak and mixed. Patients with GERD should avoid eating within 3 hours of lying recumbent. Studied dietary interventions for disorders of gut-brain interaction include low fermentable oligosaccharides, disaccharides, monosaccharides and polyols and gluten-restricted and lactose-free diets. While all can be effective in carefully, individually selected patients, the evidence for each intervention remains low. In patients with inflammatory bowel disease, enteral nutrition is established in pediatric populations as useful in reducing inflammation and partial enteral nutrition has a growing evidence base for use in adults and children. Specific carbohydrate diets and the Crohn's disease exclusion diet show promising evidence but require further study to validate their efficacy prior to recommendation. Overall, the evidence supporting nutritional therapy across luminal gastrointestinal disorders is mixed and often weak, with few well-designed randomized controlled trials (RCTs) demonstrating consistent efficacy of interventions. RCTs, particularly cross-over RCTs, show potential to compare dietary interventions.

Global attitudes on and the status of enteral nutrition therapy for pediatric inflammatory bowel disease.

Enteral nutrition (EN) is a diet-remission therapy for inflammatory bowel disease (IBD) that plays a more important role in children than adults. EN includes exclusive enteral nutrition (EEN), partial enteral nutrition (PEN), and maintenance enteral nutrition (MEN). However, EEN remains an unstandardized treatment for pediatric IBD. The types and methods of EN differ around the world. The current study reviewed the EN literature on children with IBD. A total of 12 survey studies were identified that analyzed the current state of EN use, including clinical opinions, implementation methods, treatment course, EEN formula, IBD classification, progress, dietary reintroduction, and patient feedback. The findings revealed that EEN has a strong effect on mild to moderate Crohn's disease (CD). The usage rates of this treatment in different sites were ileum/colon (Paris classification L3) > ileum (L1) > upper digestive tract (L4) > colon (L2) > perianal disease (P) > ulcerative colitis (UC) > extraintestinal lesions. The polymeric formula was the most used EN formulation. New EN diets include a CD exclusion diet (CDED), a specific carbohydrate diet (SCD), and a CD treatment-with-eating (CD-TREAT) diet. Children with IBD responded similarly to EEN administered orally or using a feeding tube. Most guidelines recommended 6-8 weeks of EEN treatment to induce remission. Many clinicians preferred to combine drug medications during EEN and recommended that MEN accounts for at least 25-35% of daily caloric intake. EN remains an unstandardized therapy that requires teamwork across disciplines.

Selected Aspects of Nutrition in the Prevention and Treatment of Inflammatory Bowel Disease

Inflammatory bowel disease has become a global health problem at the turn of the 21st century. The pathogenesis of this disorder has not been fully explained. In addition to non-modifiable genetic factors, a number of modifiable factors such as diet or gut microbiota have been identified. In this paper, the authors focus on the role of nutrition in the prevention of inflammatory bowel disease as well as on the available options to induce disease remission by means of dietary interventions such as exclusive and partial enteral nutrition in Crohn's disease, the efficacy of which is reported to be comparable to that of steroid therapy. Diet is also important in patients with inflammatory bowel disease in the remission stage, during which some patients report irritable bowel disease-like symptoms. In these patients, the effectiveness of diets restricting the intake of oligo-, di-, monosaccharides, and polyols is reported.

Successful Dietary Therapy in Paediatric Crohn's Disease is Associated with Shifts in Bacterial Dysbiosis and Inflammatory Metabotype Towards Healthy Controls.

Nutritional therapy with the Crohn's Disease Exclusion Diet + Partial Enteral Nutrition [CDED+PEN] or Exclusive Enteral Nutrition [EEN] induces remission and reduces inflammation in mild-to-moderate paediatric Crohn's disease [CD]. We aimed to assess if reaching remission with nutritional therapy is mediated by correcting compositional or functional dysbiosis. We assessed metagenome sequences, short chain fatty acids [SCFA] and bile acids [BA] in 54 paediatric CD patients reaching remission after nutritional therapy [with CDED + PEN or EEN] [NCT01728870], compared to 26 paediatric healthy controls. Successful dietary therapy decreased the relative abundance of Proteobacteria and increased Firmicutes towards healthy controls. CD patients possessed a mixture of two metabotypes [M1 and M2], whereas all healthy controls had metabotype M1. M1 was characterised by high Bacteroidetes and Firmicutes, low Proteobacteria, and higher SCFA synthesis pathways, and M2 was associated with high Proteobacteria and genes involved in SCFA degradation. M1 contribution increased during diet: 48%, 63%, up to 74% [Weeks 0, 6, 12, respectively.]. By Week 12, genera from Proteobacteria reached relative abundance levels of healthy controls with the exception of E. coli. Despite an increase in SCFA synthesis pathways, remission was not associated with increased SCFAs. Primary BA decreased with EEN but not with CDED+PEN, and secondary BA did not change during diet. Successful dietary therapy induced correction of both compositional and functional dysbiosis. However, 12 weeks of diet was not enough to achieve complete correction of dysbiosis. Our data suggests that composition and metabotype are important and change quickly during the early clinical response to dietary intervention. Correction of dysbiosis may therefore be an important future treatment goal for CD.