Lessons from an audit of exclusive enteral nutrition in adult inpatients and outpatients with active Crohn's disease: a single-centre experience

Abstract

Objective: To evaluate clinical outcomes, patterns of use, tolerance and nutritional outcomes of exclusive enteral nutrition (EEN) in adults with Crohn's disease and to compare initiation in the inpatient compared with ambulatory care setting.

Design/method: Adults with Crohn's disease who received EEN at a single centre over 2.5 years were identified and outcomes assessed via examination of patient records.

Results: EEN was initiated in 60 patients (23 as an outpatient) who had objective evidence of active disease. Of 49 in whom the goal was induction of remission, 28 completed EEN and 24 achieved clinical remission/response. Twenty-one withdrew prematurely, due to intolerance in 15 and disease factors in 6. Of 11 with a planned intervention, 6 fulfilled the goal of downstaging disease while two were intolerant. Completion of the prescribed therapy was associated with self-reported adherence to EEN and with improvements in disease activity scores and biochemical markers. Malnutrition halved (40% to 20%) and intentional weight loss (median 5.1 kg) was achieved in six obese patients. The major reason for intolerance was the inability to accept total avoidance of non-formula food. There were no differences in any outcomes according to the location of initiation of therapy.

Conclusion: Positive outcomes occur in 70% of adult patients with Crohn's disease tolerating EEN and 81% in those who are able to completely adhere to EEN, without compromise of nutritional status. Similar success occurs when initiated as an inpatient or outpatient. Failure to tolerate EEN is the major hurdle to its use.

Keywords: CROHN'S DISEASE; ENTERAL NUTRITION; INFLAMMATORY BOWEL DISEASE.

Figure 1

Outcomes of exclusive enteral nutrition (EEN) in the intention to treat cohort according to indication: (A) EEN for remission induction. Of 21 patients not completing the prescribed course, 15 were intolerant/non-accepting of EEN after median of 18 (IQR 7–25) days, and 6 were withdrawn early from therapy—4 men with long-standing disease (3 isolated colonic disease and 1 ileocolonic disease) after a median 16 days, a woman with ileocolonic disease had emergency resection after 7 days and another woman changed to prednisolone after 12 days at the discretion of the treating gastroenterologist. Of 28 (57%) who completed the prescribed course with a duration of 41 (IQR 33–44) days, clinical remission was achieved in 22 patients (HBI <5 in 21 and physician global assessment in one patient with an ileostomy) and two responded with reduction of HBI from 16 to 5 and 19 to 15. Of the four patients (three female) who failed therapy, one had a new diagnosis, and disease distribution was ileal in two, colonic in one and ileocolonic plus upper gastrointestinal in one patient. (B) EEN for downstage of disease prior to intervention. Of four who did not complete the prescribed course, one was transferred to another Hospital shortly after commencement of EEN with no data available, two were intolerant/non-accepting of EEN and withdrew after 25 and 37 days, and one developed small bowel obstruction requiring parenteral nutrition after 14 days. Of seven patients who completed the prescribed course, two were in endoscopic remission and four had clinically significant improvement on physician global assessment, but one ileocolonic disease had no discernible improvement on intestinal ultrasound. HBI, Harvey Bradshaw Index.

Figure 2

Clinical, biochemical and nutritional results where available pre and post treatment with exclusive enteral nutrition (EEN) in patients completing the prescribed course. Paired results are shown for the Harvey Bradshaw Index (HBI) (n=29; p=0.001; Wilcoxon signed rank test), serum C reactive protein (CRP) (n=25; p=0.003), serum albumin (n=25; p=0.004) and BMI (n=33, p=0.857). Patients initiated as inpatients are shown in blue and as outpatients in red and patients with intentional weight loss are presented with dashed lines. The black bars represent the medians. BMI, body mass index.