Causes and Prognosis of Intestinal Failure in Crohn's Disease: An 18-year Experience From a National Centre

Abstract

Background and aims: Intestinal failure [IF] is a feared complication of Crohn's disease [CD]. Although cumulative loss of small bowel due to bowel resections is thought to be the dominant cause, the causes and outcomes have not been reported.

Methods: Consecutive adult patients referred to a national intestinal failure unit over 2000-2018 with a diagnosis of CD, and subsequently treated with parenteral nutrition during at least 12 months, were included in this longitudinal cohort study. Data were extracted from a prospective institutional clinical database and patient records.

Results: A total of 121 patients were included. Of these, 62 [51%] of patients developed IF as a consequence of abdominal sepsis complicating abdominal surgery; small bowel resection, primary disease activity, and proximal stoma were less common causes [31%, 12%, and 6%, respectively]. Further, 32 had perianastomotic sepsis, and 15 of those had documented risk factors for anastomotic dehiscence. On Kaplan-Meier analysis, 40% of all patients regained nutritional autonomy within 10 years and none did subsequently; 14% of patients developed intestinal failure-associated liver disease. On Kaplan-Meier analysis, projected mean age of death was 74 years.2.

Conclusions: IF is a severe complication of CD, with 60% of patients permanently dependent on parenteral nutrition. The most frequent event leading directly to IF was a septic complication following abdominal surgery, in many cases following intestinal anastomosis in the presence of significant risk factors for anastomotic dehiscence. A reduced need for abdominal surgery, an increased awareness of perioperative risk factors, and structured pre-operative optimisation may reduce the incidence of IF in CD.

Keywords: Intestinal failure; optimisation; parenteral nutrition; surgery.

Figure 1.

Cumulative incidence of nutritional autonomy in 121 patients with intestinal failure and Crohn’s disease who did [red, n = 52] and did not [blue, n = 68][missing data, n = 1] undergo reconstructive surgery; *p <0.0001.

Figure 2.

Cumulative incidence of nutritional autonomy in 121 patients with intestinal failure and Crohn’s disease due to primary disease [n = 14], postoperative abdominal sepsis [n = 62], uncomplicated bowel resection [n = 37], and proximal diversion [n = 7][missing data, n = 1]. Difference between groups, p = 0.26.

Figure 3.

Cumulative survival in 121 patients with intestinal failure and Crohn’s disease.

Figure 4.

Direct causes of intestinal failure in 121 patients with Crohn’s disease during 2000–2010 [n = 60] vs 2011–2018 [n = 61]. Disease, primary disease; sepsis, postoperative abdominal sepsis; resection, uncomplicated resection; stoma, proximal stoma. Chi square test p <0.001.

Figure 5.

Cumulative incidence of nutritional autonomy in 121 patients with intestinal failure and Crohn’s disease comparing patients admitted 2000–2010 [early, n = 60] vs 2011–2018 [late, n = 60][missing data, n = 1]; p = 0.59.