Managing Patients with Crohn’s Disease

The information in this section refers particularly to the management of adolescent and adult patients who have Crohn’s disease and who are using enteral nutrition as total nutritional support (Exclusive Enteral Nutrition – EEN) to induce remission. We also discuss the use of supplementary nutrition to support an elimination and food re-introduction diet to prolong remission.

EEN is recommended for the management of Crohn’s disease where drug therapy is contraindicated or where the patient chooses diet in preference to drug therapy (1,2,3). The aim is to explain how to approach the management of Crohn’s disease using EEN, how to deal with any problems encountered and how to monitor patients. The reintroduction of food following treatment is also discussed.

A full copy of the Dietitians Guide can be found here

Nutritional Aims:

  • To maintain or improve nutritional status either as a sole therapy or as a supplement (4,5)
  • To promote growth in adolescents and children (4)

Therapeutic Aims:

  • To provide symptomatic relief and improve quality of life (6)
  • To reduce inflammation and thus induce remission (7)
  • To promote mucosal healing (8,9)
  • To allow reduction or withdrawal of steroids in those with resistant disease (10)
  • To provide supplementary nutritional support while conducting an exclusion diet or food re-introduction diet(4,11)

The whole team involved with the care of Crohn’s patients in your hospital should be aware and in agreement with a protocol that outlines some fundamental principles when using EEN. This will help to ensure the best chance of success for the patient at achieving remission.

Positive Messages

It is important that all team members help instil confidence and motivation in patients who are looking at trialling liquid feeds regardless of personal perceptions around taste. Helping patients feel this is achievable, and giving practical ways to increase palatability and preference is important and necessary.

Free Foods

Additions to the diet should be limited as much as possible because the inclusion of other foods could interfere with the delicate balance in the gut and the diet may not be as effective. It is important that all team members are clear about the restrictions so that the patient is not confused by different messages.

Monitoring and Assessment

When the diet is initiated, frequent contact with the patient is required in person or by telephone. These contacts are necessary to assess the patient’s tolerance to the diet, to ensure that nutritional requirements are being met, to encourage compliance and to provide support. Once the diet is established this contact can be slowly reduced in frequency.

Food Re-introduction

Different views exist on the benefits and approach to food re-introduction. An explanation and example of the LOFFLEX diet is available on this website and although different centres may have different protocols this is the approach that has been trialled alongside Elemental 028 Extra and is therefore the approach of choice for this dietitians guide. To view a PDF of the LOFFLEX diet booklet, click here

Malnourished patients

During the introductory phase of EEN it is common for patients to lose a little weight before nutritional requirements are met. In undernourished patients, care needs to be taken because further weight loss may cause additional complications. It may be necessary to admit very high risk patients with a low BMI or high MUST score for monitoring when commencing EEN and to keep them as an inpatient until requirements are fully met.

Dietary Regimen

EEN can be taken either orally or via a NGT/ PEG tube depending on patient requirements, tolerance and compliance. Ready to use Elemental 028 Extra Liquid is very convenient and is easy to use for oral feeding. However, if a more concentrated feed is required, the powdered feeds can be reconstituted to be more energy dense, depending on patient tolerance. The BDA recommends that a ‘Starter Regimen’ is followed to allow the patient to gain confidence with the diet and to establish tolerance.(12).

Children

A paediatric patient, regardless of the feed type they are taking, will typically be fed for six weeks or longer. The rationale for this is to (a) prevent rapid relapse and (b) promote growth, particularly any ‘catch-up’ growth that is needed after a period of illness. From a practical point-of-view, it is also thought to be a lot easier to implement EEN for longer periods in children because parents can ensure compliance rates that are difficult to match in adults (13).

Alicalm is a powdered polymeric formula that has been designed specifically for paediatric Crohn’s patients. Alicalm like other Crohn’s -specific polymeric feeds, requires reconstitution. Unless there is a co-existing cows’ milk allergy present, Alicalm would be the Nutricia product of choice for children until they have reached their full growth potential. Further information on Alicalm can be found in the Dietitian’s Guide, which you can download here or in the product profiles section.

Adults

Adult patients can experience remission after just two weeks on an elemental diet (7,11) although occasionally it might be necessary to extend the period to 3 weeks for some difficult cases. Elemental 028 Extra Liquid is available as a refreshing fruit flavoured liquid formula in a convenient ready to use carton, and has been designed with adult patients in mind, though it would be suitable as a sole source of nutrition for children over the age of 5 years if required. Elemental 028 Extra Liquid is convenient and only requires a short treatment period to induce remission and provide symptomatic relief and would therefore be the Nutricia product of choice for adults and older children or adolescents.

Having spoken to experts in the field, there is further reason to opt for elemental feeds in adult Crohn’s disease – a 30 year clinical history of its effective use. Although meta-analyses have failed to detect a difference, some doctors feel that elemental feeds work regardless of the severity of the Crohn’s disease, whereas polymeric feeds are perhaps not as effective in the more severe cases.

Professor John Hunter says the following in his book titled “Inflammatory Bowel Disease – The essential guide to controlling Crohn’s disease, colitis and other IBDs”

“Elemental diet is the most effective treatment currently available for Crohn's disease because 80-90% of patients who are willing to continue with it for two to three weeks will go into remission. No other treatment can match these figures! In my opinion patients with proven CD would be very wise to give the diet method a trial” (14) Further information can be found in the Dietitian’s Guide, which you can download here.

Initiation of Exclusive Enteral Nutrition (EEN) is the most challenging period for the patient. They are allowed no food and have been presented with a large volume of formula to drink. Encouragement and support is vital from the team and the patient’s family and it is essential that everyone is aware of the dietary restrictions so that inappropriate food and drinks can be avoided.

For more in depth information on the most effective way to assist patients in the first few weeks of treatment with EEN, please refer to the Dietitian’s Guide.

Outlined in the Dietitian's Guide are key ways to support patients at various milestones in their journey when commencing EEN especially in:-

  • The first and second weeks to encourage motivation
  • Ongoing monitoring to ensure compliance
  • Getting the most from Elemental 028 Extra
  • Ways to overcome possible side effects

Dietary therapy may play a role in the maintenance of remission. Once remission has been induced, various approaches can be used, including:

  • Elimination/exclusion diets (15)
  • Using the feed as a supplement to normal diet (10)

The exact approach used will vary from centre to centre. Some centres will simply wean the patient back on to normal foods. Others may use medication. As the LOFFLEX food re-introduction diet has been trialled most frequently with Elemental 028 Extra14, this is the dietary information that is available on this website. An explanation of the LOFFLEX diet can be found here

  1. Carter MJ et al on behalf of the BSG. Gut. 2004; 53 (SuppV): v1 –v16.
  2. Lochs H et al on behalf of ESPEN. Clin Nutr. 2006; 25: 260-274.
  3. Dignass A et al for ECCO. Journal of Crohn’s and Colitis. 2010; 4:28-62.
  4. Gassull MA, Cabre E. Curr Opin Clin Nutr Metab Care. 2001; 4(6): 561-9.
  5. Zoli G et al Aliment Pharmacol Ther. 1997; 11(4): 735-40.
  6. Afzal NA et al. Aliment Pharmacol Ther. 2004; 20(2): 167-172.
  7. Teahon K et al. Gastroenterology. 1991; 101(1): 84-9.
  8. Modigliani R et al. Gastroenterology. 1990; 98(4): 811-8.
  9. Borrelli O et al Clin Gastroenterol Hepatol. 2006; 4(6):744-53.
  10. Verma S et al. Dig Liver Dis. 2000; 32(9): 769-774.
  11. Riordan AM et al. Lancet. 1993; 342: 1131-1134.
  12. Lee et al. 5th floor Charles House. Birmingham. BDA Gastroenterology Specialist Group.
  13. Sandhu BK et al. on behalf of BSPGHAN. St Georges Hospital, London. 2008.
  14. Hunter J. Inflammatory Bowel Disease -The essential guide to controlling Crohn’s disease, colitis and other IBDs. London. Vermilion. 2010.
  15. Woolner JT et al. J Hum Nutr Diet. 1998; 11: 1-11.
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