CASE REPORT Home Hyperalimentation for Inflammatory Bowel Disease JASON H. BODZIN, MD, FACS Nutrition
Support Services, Inflammatory Bowel Disease Institute,
Hospital, and Wayne State University, Detroit
patients generally have widespread, recurrent disease, multiple operations, and a risk of short bowel syn-
ABSTRACT: Total parenteral nutrition (TPN) has become a useful tool in the management of patients with inflammatory bowel disease (IBD). In the past, it was felt that TPN would have a therapeutic role in IBD, but experience has shown that it functions more as an adjunct to other therapeutic interventions. The specific roles of TPN in IBD include: (1) nutritional maintenance in the short bowel syndrome, (2) TPN as adjunctive therapy in jejunoileitis of Crohn’s disease, (3) home TPN (HTPN) in Crohn’s colitis, and (4) preoperative repletion of significantly depleted patients going to surgery. The adaptation of hospital techniques to the home situation has allowed patients to carry out long-term TPN therapy at home. Patients with IBD on HTPN are subject to the same mechanical and metabolic problems as are other patients on HTPN and, in addition, have a higher infection rate. When carried out appropriately, however, HTPN is a valuable technique in the management of patients with IBD and may provide an improved quality of life.
drome. It was our early expectation that gut rest and TPN would provide a new primary therapeutic modality in the management of patients with IBD.’ Our early expectations, however, have been given over to the stark reality that TPN has a more adjunctive role.’ The clinical experience over the past 20+ years has allowed us to more accurately define the role of TPN in the management of patients with IBD. In addition, as techniques for the delivery of inhospital TPN developed during the 1970s, it became apparent that some patients who required long-term TPN could be trained to carry out this procedure at home. The development of long-term Silastic catheters facilitated this process. Patients with Crohn’s disease and other catastrophic gastrointestinal conditions who required long-term TPN were regularly discharged home on TPN after appropriate training and &dquo;certification&dquo; of competency. Home TPN (HTPN) has become a useful technique in the management of patients with IBD. The specific role of TPN and, more specifically, HTPN in these patients is the subject of this report and case studies.
Total parenteral nutrition (TPN) has had a profound effect on the management of patients with Crohn’s disease. Before the 1970s, when in-hospital TPN became available, it was not unusual to see several patients on our gastrointestinal (GI) surgical floor with severe cachexia secondary to inflammatory bowel disease (IBD). Draining fistulas were common, and surgical morbidity and mortality were unacceptably high. With the introduction of TPN into the hospital setting, new hope was given to patients with IBD. This was most gratifying when applied to patients with the jejunoileitis of Crohn’s disease. These
Address for reprints: Jason H. Bodzin, MD, FACS, graph Road, Suite 225, Bingham Farms, MI 48025.
Sinai
TPN IN SHORT BOWEL SYNDROME ASSOCIATED WITH CROHN’S DISEASE
B.E. is a 45-year-old woman with Crohn’s disease who was referred to our HTPN program in October 1990 for preoperative nutritional repletion in preparation for colectomy. She had had her first and only bowel resection in 1974. The patient was told that 4 feet of intestine had been removed. She did well with four to five loose stools daily until the past year when uncontrollable diarrhea with incontinence developed. She exhibited 10 to 20 bowel movements each day, which was attributed to &dquo;colitis.&dquo; This prompted her to seek a surgeon to perform a colectomy and permanent ileostomy. At the time she was referred for &dquo;pre-
31500 Tele-
70 Downloaded from ncp.sagepub.com at UNIV OF CALIFORNIA SANTA CRUZ on April 6, 2015
71
operative nutritional repletion,&dquo; she weighed 82 pounds. An upper GI tract and small bowel x-ray were performed, which revealed a severely shortened small bowel and rapid transit of contrast into the colon. The colon itself was intrinsically normal (Fig 1). Laboratory work-up revealed hemoglobin, 6.7 g/dL; K+, 2.7 mEq/dL; C02, 17.8 mmol/L; blood urea nitrogen, 17 mg/dL; and creatinine, 1.7 mg/dL. She was sent home on TPN including iron.’ One year later, she was receiving HTPN 3 days per week, had gained 11 pounds, was having about six bowel movements per day with good control, and had a markedly improved quality of life. The treatment of short bowel syndrome is the most commonly accepted role of HTPN in IBD. This condition occurs in patients with jejunoileitis of Crohn’s disease after multiple resections or a single massive resection. Patients typically exhibit hypokalemia, hypomagnesemia, anemia, and cachexia. Young patients may also encounter growth failure. The severity of the syndrome is related to the length of functional small bowel remaining after resection.’ Also important in the ultimate outcome is the absorptive capacity of the remaining bowel. The ileum is more important than the jejunum, and preservation of the ileocecal valve positively influences the GII transit time.
with Crohn’s disease often lose the ileocecal valve, and the distal ileum is often the first segment to become diseased. The exact length of remaining bowel does not accurately predict the clinical course. We have patients with several feet of small bowel who have a much greater absorption defect than do other patients with a smaller residual length. The role of bacterial overgrowth should also be considered because this condition closely resembles short bowel syndrome. A trial of a broad spectrum antibiotic such as tetracycline or ciprofloxicin is indicated whenever the clinical syndrome is worse than the anatomy would predict. The improvement in diarrhea and clinical sense of well-being may be striking. Patients with short bowel syndrome on HTPN should be prescribed low-fat diets. They may absorb better if they eat without drinking at meals and take fluids between meals. Several small meals are better than a few larger ones. Bulk formers such as Metamucil (Proctor and Gamble, Cincinnati), Konsyl (Lafayette Pharmaceutical, Inc., Fort Worth, TX), Alternagel (Johnson & Johnson-Merck Consumer Pharmaceuticals Co., Fort Washington, PA), and others may be very useful if taken in small doses with minimal fluids a few times each day. Antidiarrheal agents
Unfortunately, patients
may
cause some
improvement, especially loperamide,
which seems to increase fluid absorption. While the therapeutic regimen described above is taking place, the HTPN is gradually tapered. Patients infuse TPN 7 days per week, then six, five, etc, as tolerated. Laboratory values, including blood urea nitrogen, creatinine, serum potassium, magnesium, and
1. X-ray of the upper GI and small bowel, revealing shortened small bowel and an intrinsically normal colon.
Figure a
hemoglobin are useful in assessing the recovery of absorption. Weight loss is also of paramount importance, but a lower weight is perfectly acceptable if it can be maintained without TPN. Unfortunately, patients with Crohn’s disease do not recover as quickly as do patients with short bowel syndrome independent of IBD. HTPN AS ADJUNCTIVE THERAPY IN JEJUNOILEITIS OF CROHN’S DISEASE
M.Z. is a 23-year-old dental student who was diagnosed with Crohn’s disease at the age of 13. He had an ileocecal resection at that time and remained asymptomatic for about 2 years. Thereafter, he had intermittent exacerbations of abdominal pain, nausea, and vomiting until 1988, when at the age of 20, an upper GI series showed significant recurrent disease in the jejunum and a stricture of the neoterminal ileum. The patient’s response to 30 mg of prednisone per day was poor, and he was prescribed gut rest and HTPN with hydrocortisone (150 mg) in the TPN daily. Three months later, he was weaned down to hydrocortisone (100 mg) and was started on small amounts of food. He had a 20-pound weight gain. Over the next 3 months, he was gradually weaned from TPN, and the upper GI series was repeated. There was marked improvement of the jejunoileitis; however, the terminal ileal stricture persisted. The patient underwent a local resection of the neoterminal ileum with primary ileocolostomy. At surgery, the jejunum appeared grossly involved with Crohn’s disease; however, there was no stenosis, and the long length of this segment was such that the decision was made not to
Downloaded from ncp.sagepub.com at UNIV OF CALIFORNIA SANTA CRUZ on April 6, 2015
72 resect it. He
was
kept on
15 mg
of prednisone per day,
and 6-mercaptopurine (6-MP) was started. Over the last 2 years, he has been completely weaned off prednisone and continues on 6-MP. A recent upper GI and small bowel series showed continued improvement in the involved jejunum and no evidence of any progression of disease. Patients with jejunoileitis of Crohn’s disease may have a particularly virulent form of disease. This is characterized by early postoperative recurrence, poor response to medical management, and eventual short bowel syndrome. After multiple surgical interventions, HTPN should be considered in these patients in a variety of situations. These include patients who have already had two or more surgical interventions, a previous &dquo;massive&dquo; resection, multiple long strictures, or no cushingoid features while on therapeutic doses of corticosteroids. In the last group, TPN may help to induce a significant clinical remission without a concomitant increase in steroid dosage. The appearance of cushingoid features after the institution of TPN is a good clinical sign indicating that nutritional repletion is a necessary part of the therapeutic regimen. We generally begin immunosuppressive therapy at the same time. If patients have significant diarrhea in the face of stricture and a reasonably adequate length of small bowel, a broad spectrum antibiotic is also used. With the regimen described above, significant improvement may obviate the need for surgery or provide enough palliation to allow for a more conservative resection’ or a procedure such as strictureplasty. It is this type of surgical attitude that will help to prevent cases of short bowel syndrome, which otherwise would plague the clinician in the future. Patients entering this type of program are kept on clear liquids by mouth with TPN essentially providing all of the nutritional needs for approximately 6 months. The upper GI series with dedicated small bowel follow-through or enteroclysis is performed, and weaning from TPN is instituted as indicated. HTPN IN CROHN’S COLITIS
K.L. is a 33-year-old woman with Crohn’s colitis who was first symptomatic at the age of 23. At that time, she had bloody diarrhea, which was quickly diagnosed as Crohn’s colitis because of significant perianal skin tabs. She had been on intermittent steroids, taking approximately 15 mg of prednisone per day for several years. She was first admitted in May 1990 at the age of 31 complaining of explosive diarrhea, approximately six times each day with occasional blood in the stool. She also had urgency and some incontinence. Examination revealed a pale, ill-appearing female in no acute distress with normal vital signs. A generally tender abdomen with a right lower quadrant mass was also noted. Rectal examination revealed several small finger-like projections arising from the anal mucosa. There was a perianal fistula in the
anterior position, and a rectal/vaginal fistula was also identified. The vaginal vault was not stenotic, but the rectum was somewhat tight, indurated, and tender. Laboratory studies showed a hemoglobin of 7.2 g/dL, a white blood cell count of 6800 mm~, a sedimentation rate of 61, and otherwise, fairly normal multiphasic screening panels. The patient underwent colonoscopy, which showed severe Crohn’s colitis with marked cobblestoning, linear ulcerations, and pseudopolyp formation. The rectosigmoid was the most severely involved, whereas the right colon was relatively stenotic. After admission, the patient was placed on HTPN, prednisone (30 mg/d) and 6-MP. The patient rapidly improved over the ensuing 6 months and was gradually weaned from TPN and steroids. She has been maintained on 6-MP for approximately 1.5 years. Currently, she is working full-time, gives herself a score of 10 on a scale from 1 to 10 regarding her general well-being, and has no signs of any systemic disease. She is having one or two well-formed bowel movements each day. Endoscopy shows largely healed Crohn’s colitis with numerous pseudopolyps but no active ulcerations, bleeding, or gross inflammation. Patients with colitis associated with Crohn’s disease have a poorer outcome than do patients with ulcerative colitis. They do not respond to 5-aminosalicylic acid medications as consistently as do the ulcerative colitis patients, and they are not offered a rectalsparing pull-through operation. If they fail on medical therapy, rectal preservation with the avoidance of a permanent stoma is not likely to succeed unless the rectum is spared and there is minimal perianal disease. Because this is not usually the case, a vigorous medical regimen is used. This consists of gut rest, HTPN, corticosteroids, and immunosuppressive drugs. The immunosuppressive drugs provide steroid sparing with the avoidance of long-term iatrogenic steroid complications. Experience with this type of program has recently been documented by Sitzmann and coworkers from Johns Hopkins University.’ They found that surgery could be avoided in 13 of 16 patients with severe, uncomplicated Crohn’s colitis. In contrast, this program was successful in only 4 of 22 patients with ulcerative colitis. The success of therapy is measured by an improved sense of well-being, a reduction or absence of blood in the bowel movements, and endoscopic improvement. Endoscopy can be misleading, however, because a relatively healthy, healed colon may have a bizarre endoscopic appearance (Fig 2). The clinical findings such as sense of well-being, level of activity, strength, ability to work, and bowel actions, are much more
important. HTPN FOR PREOPERATIVE REPLETION
The use of TPN for preoperative repletion should be considered when a major operation is being contem-
Downloaded from ncp.sagepub.com at UNIV OF CALIFORNIA SANTA CRUZ on April 6, 2015
73
Figure 2. Endoscopy of a healthy, healed colon.
plated for a chronically ill patient with ongoing active disease or significant complications.’ A patient who is cachectic, but not significantly stressed or septic, can withstand most surgical procedures. Postoperative TPN is used if complications occur. Patients who have been deteriorating or who have been going through a significant long-term illness may benefit from preoperative TPN. This concept is controversial but to make
tients on HTPN. They may be particularly susceptible to infectious complications. Data from the Lifeline Foundation Registry indicate that the average IBD patient is hospitalized more frequently for infection than are most other HTPN patients.’ The higher incidence of infection may be related to the increased permeability of the bowel, which promotes bacterial translocation and subsequent seeding of an indwelling, long-term catheter. We have had several IBD patients with a marked increase in catheter sepsis, especially due to an unusually high incidence of enteric bacteria. In patients prone to infection, we no longer place permanent-type catheters, but prefer subclavian catheters, which are changed over a wire every 6 weeks. A positive culture is an indication for a site change. We have used this technique in several IBD patients, some of whom have successfully used these small catheters for several years. In addition to septic problems, these patients are especially prone to metabolic bone disease’ and fatty infiltration of the liver, as well as all of the psychological problems associated with chronic illness. In this article the clinical applications of HTPN in the patient with IBD have been stressed. The technique of HTPN is well established and is not described here. HTPN remains a risky and expensive therapeutic tool and should not be used frivolously. Definite indications should exist, and alternative enteral methods should be used whenever possible. The patient must be well educated and compliant. When performed appropriately, HTPN can provide an improved medical regimen and greatly improved quality of life for patients with IBD.
seems
sense.
A more definitive indication is a patient with an intra-abdominal abscess. These can often be treated by percutaneous drainage, antibiotics, and TPN. When potent oral antibiotics are sufficient, the patient may be sent home on TPN while the abscess cavity collapses and the sepsis resolves. There is significant individual variation in opinion among physicians with regard to the indications for TPN or HTPN in IBD patients. Whether patients should eat while on HTPN may also be controversial. It depends on whether TPN is being used to achieve the primary goal of &dquo;gut rest&dquo; or whether TPN is being used only to provide additional nutrition. There should be considerable doctor-patient dialogue in making these decisions. An estimate of the patient’s ability to carry out the program, comply with medical regimens, and cooperate with the team are all considerations.
COMPLICATIONS OF HTPN
Patients with IBD may encounter any of the usual metabolic or mechanical complications afflicting pa-
REFERENCES 1. Holm I. Benefits of total parenteral nutrition (TPN) in the treatment of Crohn’s disease and ulcerative colitis. Acta Chir
Scand 1981;147:271-6. 2. Shiloni E, Coronado E, Freund H. Role of total parenteral nutrition in the treatment of Crohn’s disease. Am J Surg 1989
1989;157:180-5. 3. Wan K, Tsallas G. Dilute iron dextran formulation for addition to parenteral nutrient solutions. Am J Hosp Pharm 1980;37: 206-10. 4. Purdum P III, Kirby D. Short-bowel syndrome: a review of the role of nutrition support. JPEN 1991;15:93-101. 5. Lashner B, Evans A, Hanauer S. Preoperative total parenteral nutrition for bowel resection in Crohn’s disease. Dig Dis Sci
1989;34:741-6. J, Converse R Jr, Bayless T. Favorable response to parenteral nutrition and medical therapy in Crohn’s colitis. Gastroenterology 1990;99:1647-52. 7. Gouma D, von Meyenfeldt M, Rouglart M, et al. Preoperative total parenteral nutrition (TPN) in severe Crohn’s disease. Surgery 1987;103:648-52. 8. Oasis. Home Nutrition Support Patient Registry, Annual Report, 1988 Data. Albany, NY: Oley Foundation, 1990. 9. Hurley D, McMahon M. Long-term parenteral nutrition and
6. Sitzmann
metabolic bone disease. Endocrinol Metab Clin North Am 1990; 19:113-31.
Downloaded from ncp.sagepub.com at UNIV OF CALIFORNIA SANTA CRUZ on April 6, 2015
Support Services, Inflammatory Bowel Disease Institute,
Hospital, and Wayne State University, Detroit
patients generally have widespread, recurrent disease, multiple operations, and a risk of short bowel syn-
ABSTRACT: Total parenteral nutrition (TPN) has become a useful tool in the management of patients with inflammatory bowel disease (IBD). In the past, it was felt that TPN would have a therapeutic role in IBD, but experience has shown that it functions more as an adjunct to other therapeutic interventions. The specific roles of TPN in IBD include: (1) nutritional maintenance in the short bowel syndrome, (2) TPN as adjunctive therapy in jejunoileitis of Crohn’s disease, (3) home TPN (HTPN) in Crohn’s colitis, and (4) preoperative repletion of significantly depleted patients going to surgery. The adaptation of hospital techniques to the home situation has allowed patients to carry out long-term TPN therapy at home. Patients with IBD on HTPN are subject to the same mechanical and metabolic problems as are other patients on HTPN and, in addition, have a higher infection rate. When carried out appropriately, however, HTPN is a valuable technique in the management of patients with IBD and may provide an improved quality of life.
drome. It was our early expectation that gut rest and TPN would provide a new primary therapeutic modality in the management of patients with IBD.’ Our early expectations, however, have been given over to the stark reality that TPN has a more adjunctive role.’ The clinical experience over the past 20+ years has allowed us to more accurately define the role of TPN in the management of patients with IBD. In addition, as techniques for the delivery of inhospital TPN developed during the 1970s, it became apparent that some patients who required long-term TPN could be trained to carry out this procedure at home. The development of long-term Silastic catheters facilitated this process. Patients with Crohn’s disease and other catastrophic gastrointestinal conditions who required long-term TPN were regularly discharged home on TPN after appropriate training and &dquo;certification&dquo; of competency. Home TPN (HTPN) has become a useful technique in the management of patients with IBD. The specific role of TPN and, more specifically, HTPN in these patients is the subject of this report and case studies.
Total parenteral nutrition (TPN) has had a profound effect on the management of patients with Crohn’s disease. Before the 1970s, when in-hospital TPN became available, it was not unusual to see several patients on our gastrointestinal (GI) surgical floor with severe cachexia secondary to inflammatory bowel disease (IBD). Draining fistulas were common, and surgical morbidity and mortality were unacceptably high. With the introduction of TPN into the hospital setting, new hope was given to patients with IBD. This was most gratifying when applied to patients with the jejunoileitis of Crohn’s disease. These
Address for reprints: Jason H. Bodzin, MD, FACS, graph Road, Suite 225, Bingham Farms, MI 48025.
Sinai
TPN IN SHORT BOWEL SYNDROME ASSOCIATED WITH CROHN’S DISEASE
B.E. is a 45-year-old woman with Crohn’s disease who was referred to our HTPN program in October 1990 for preoperative nutritional repletion in preparation for colectomy. She had had her first and only bowel resection in 1974. The patient was told that 4 feet of intestine had been removed. She did well with four to five loose stools daily until the past year when uncontrollable diarrhea with incontinence developed. She exhibited 10 to 20 bowel movements each day, which was attributed to &dquo;colitis.&dquo; This prompted her to seek a surgeon to perform a colectomy and permanent ileostomy. At the time she was referred for &dquo;pre-
31500 Tele-
70 Downloaded from ncp.sagepub.com at UNIV OF CALIFORNIA SANTA CRUZ on April 6, 2015
71
operative nutritional repletion,&dquo; she weighed 82 pounds. An upper GI tract and small bowel x-ray were performed, which revealed a severely shortened small bowel and rapid transit of contrast into the colon. The colon itself was intrinsically normal (Fig 1). Laboratory work-up revealed hemoglobin, 6.7 g/dL; K+, 2.7 mEq/dL; C02, 17.8 mmol/L; blood urea nitrogen, 17 mg/dL; and creatinine, 1.7 mg/dL. She was sent home on TPN including iron.’ One year later, she was receiving HTPN 3 days per week, had gained 11 pounds, was having about six bowel movements per day with good control, and had a markedly improved quality of life. The treatment of short bowel syndrome is the most commonly accepted role of HTPN in IBD. This condition occurs in patients with jejunoileitis of Crohn’s disease after multiple resections or a single massive resection. Patients typically exhibit hypokalemia, hypomagnesemia, anemia, and cachexia. Young patients may also encounter growth failure. The severity of the syndrome is related to the length of functional small bowel remaining after resection.’ Also important in the ultimate outcome is the absorptive capacity of the remaining bowel. The ileum is more important than the jejunum, and preservation of the ileocecal valve positively influences the GII transit time.
with Crohn’s disease often lose the ileocecal valve, and the distal ileum is often the first segment to become diseased. The exact length of remaining bowel does not accurately predict the clinical course. We have patients with several feet of small bowel who have a much greater absorption defect than do other patients with a smaller residual length. The role of bacterial overgrowth should also be considered because this condition closely resembles short bowel syndrome. A trial of a broad spectrum antibiotic such as tetracycline or ciprofloxicin is indicated whenever the clinical syndrome is worse than the anatomy would predict. The improvement in diarrhea and clinical sense of well-being may be striking. Patients with short bowel syndrome on HTPN should be prescribed low-fat diets. They may absorb better if they eat without drinking at meals and take fluids between meals. Several small meals are better than a few larger ones. Bulk formers such as Metamucil (Proctor and Gamble, Cincinnati), Konsyl (Lafayette Pharmaceutical, Inc., Fort Worth, TX), Alternagel (Johnson & Johnson-Merck Consumer Pharmaceuticals Co., Fort Washington, PA), and others may be very useful if taken in small doses with minimal fluids a few times each day. Antidiarrheal agents
Unfortunately, patients
may
cause some
improvement, especially loperamide,
which seems to increase fluid absorption. While the therapeutic regimen described above is taking place, the HTPN is gradually tapered. Patients infuse TPN 7 days per week, then six, five, etc, as tolerated. Laboratory values, including blood urea nitrogen, creatinine, serum potassium, magnesium, and
1. X-ray of the upper GI and small bowel, revealing shortened small bowel and an intrinsically normal colon.
Figure a
hemoglobin are useful in assessing the recovery of absorption. Weight loss is also of paramount importance, but a lower weight is perfectly acceptable if it can be maintained without TPN. Unfortunately, patients with Crohn’s disease do not recover as quickly as do patients with short bowel syndrome independent of IBD. HTPN AS ADJUNCTIVE THERAPY IN JEJUNOILEITIS OF CROHN’S DISEASE
M.Z. is a 23-year-old dental student who was diagnosed with Crohn’s disease at the age of 13. He had an ileocecal resection at that time and remained asymptomatic for about 2 years. Thereafter, he had intermittent exacerbations of abdominal pain, nausea, and vomiting until 1988, when at the age of 20, an upper GI series showed significant recurrent disease in the jejunum and a stricture of the neoterminal ileum. The patient’s response to 30 mg of prednisone per day was poor, and he was prescribed gut rest and HTPN with hydrocortisone (150 mg) in the TPN daily. Three months later, he was weaned down to hydrocortisone (100 mg) and was started on small amounts of food. He had a 20-pound weight gain. Over the next 3 months, he was gradually weaned from TPN, and the upper GI series was repeated. There was marked improvement of the jejunoileitis; however, the terminal ileal stricture persisted. The patient underwent a local resection of the neoterminal ileum with primary ileocolostomy. At surgery, the jejunum appeared grossly involved with Crohn’s disease; however, there was no stenosis, and the long length of this segment was such that the decision was made not to
Downloaded from ncp.sagepub.com at UNIV OF CALIFORNIA SANTA CRUZ on April 6, 2015
72 resect it. He
was
kept on
15 mg
of prednisone per day,
and 6-mercaptopurine (6-MP) was started. Over the last 2 years, he has been completely weaned off prednisone and continues on 6-MP. A recent upper GI and small bowel series showed continued improvement in the involved jejunum and no evidence of any progression of disease. Patients with jejunoileitis of Crohn’s disease may have a particularly virulent form of disease. This is characterized by early postoperative recurrence, poor response to medical management, and eventual short bowel syndrome. After multiple surgical interventions, HTPN should be considered in these patients in a variety of situations. These include patients who have already had two or more surgical interventions, a previous &dquo;massive&dquo; resection, multiple long strictures, or no cushingoid features while on therapeutic doses of corticosteroids. In the last group, TPN may help to induce a significant clinical remission without a concomitant increase in steroid dosage. The appearance of cushingoid features after the institution of TPN is a good clinical sign indicating that nutritional repletion is a necessary part of the therapeutic regimen. We generally begin immunosuppressive therapy at the same time. If patients have significant diarrhea in the face of stricture and a reasonably adequate length of small bowel, a broad spectrum antibiotic is also used. With the regimen described above, significant improvement may obviate the need for surgery or provide enough palliation to allow for a more conservative resection’ or a procedure such as strictureplasty. It is this type of surgical attitude that will help to prevent cases of short bowel syndrome, which otherwise would plague the clinician in the future. Patients entering this type of program are kept on clear liquids by mouth with TPN essentially providing all of the nutritional needs for approximately 6 months. The upper GI series with dedicated small bowel follow-through or enteroclysis is performed, and weaning from TPN is instituted as indicated. HTPN IN CROHN’S COLITIS
K.L. is a 33-year-old woman with Crohn’s colitis who was first symptomatic at the age of 23. At that time, she had bloody diarrhea, which was quickly diagnosed as Crohn’s colitis because of significant perianal skin tabs. She had been on intermittent steroids, taking approximately 15 mg of prednisone per day for several years. She was first admitted in May 1990 at the age of 31 complaining of explosive diarrhea, approximately six times each day with occasional blood in the stool. She also had urgency and some incontinence. Examination revealed a pale, ill-appearing female in no acute distress with normal vital signs. A generally tender abdomen with a right lower quadrant mass was also noted. Rectal examination revealed several small finger-like projections arising from the anal mucosa. There was a perianal fistula in the
anterior position, and a rectal/vaginal fistula was also identified. The vaginal vault was not stenotic, but the rectum was somewhat tight, indurated, and tender. Laboratory studies showed a hemoglobin of 7.2 g/dL, a white blood cell count of 6800 mm~, a sedimentation rate of 61, and otherwise, fairly normal multiphasic screening panels. The patient underwent colonoscopy, which showed severe Crohn’s colitis with marked cobblestoning, linear ulcerations, and pseudopolyp formation. The rectosigmoid was the most severely involved, whereas the right colon was relatively stenotic. After admission, the patient was placed on HTPN, prednisone (30 mg/d) and 6-MP. The patient rapidly improved over the ensuing 6 months and was gradually weaned from TPN and steroids. She has been maintained on 6-MP for approximately 1.5 years. Currently, she is working full-time, gives herself a score of 10 on a scale from 1 to 10 regarding her general well-being, and has no signs of any systemic disease. She is having one or two well-formed bowel movements each day. Endoscopy shows largely healed Crohn’s colitis with numerous pseudopolyps but no active ulcerations, bleeding, or gross inflammation. Patients with colitis associated with Crohn’s disease have a poorer outcome than do patients with ulcerative colitis. They do not respond to 5-aminosalicylic acid medications as consistently as do the ulcerative colitis patients, and they are not offered a rectalsparing pull-through operation. If they fail on medical therapy, rectal preservation with the avoidance of a permanent stoma is not likely to succeed unless the rectum is spared and there is minimal perianal disease. Because this is not usually the case, a vigorous medical regimen is used. This consists of gut rest, HTPN, corticosteroids, and immunosuppressive drugs. The immunosuppressive drugs provide steroid sparing with the avoidance of long-term iatrogenic steroid complications. Experience with this type of program has recently been documented by Sitzmann and coworkers from Johns Hopkins University.’ They found that surgery could be avoided in 13 of 16 patients with severe, uncomplicated Crohn’s colitis. In contrast, this program was successful in only 4 of 22 patients with ulcerative colitis. The success of therapy is measured by an improved sense of well-being, a reduction or absence of blood in the bowel movements, and endoscopic improvement. Endoscopy can be misleading, however, because a relatively healthy, healed colon may have a bizarre endoscopic appearance (Fig 2). The clinical findings such as sense of well-being, level of activity, strength, ability to work, and bowel actions, are much more
important. HTPN FOR PREOPERATIVE REPLETION
The use of TPN for preoperative repletion should be considered when a major operation is being contem-
Downloaded from ncp.sagepub.com at UNIV OF CALIFORNIA SANTA CRUZ on April 6, 2015
73
Figure 2. Endoscopy of a healthy, healed colon.
plated for a chronically ill patient with ongoing active disease or significant complications.’ A patient who is cachectic, but not significantly stressed or septic, can withstand most surgical procedures. Postoperative TPN is used if complications occur. Patients who have been deteriorating or who have been going through a significant long-term illness may benefit from preoperative TPN. This concept is controversial but to make
tients on HTPN. They may be particularly susceptible to infectious complications. Data from the Lifeline Foundation Registry indicate that the average IBD patient is hospitalized more frequently for infection than are most other HTPN patients.’ The higher incidence of infection may be related to the increased permeability of the bowel, which promotes bacterial translocation and subsequent seeding of an indwelling, long-term catheter. We have had several IBD patients with a marked increase in catheter sepsis, especially due to an unusually high incidence of enteric bacteria. In patients prone to infection, we no longer place permanent-type catheters, but prefer subclavian catheters, which are changed over a wire every 6 weeks. A positive culture is an indication for a site change. We have used this technique in several IBD patients, some of whom have successfully used these small catheters for several years. In addition to septic problems, these patients are especially prone to metabolic bone disease’ and fatty infiltration of the liver, as well as all of the psychological problems associated with chronic illness. In this article the clinical applications of HTPN in the patient with IBD have been stressed. The technique of HTPN is well established and is not described here. HTPN remains a risky and expensive therapeutic tool and should not be used frivolously. Definite indications should exist, and alternative enteral methods should be used whenever possible. The patient must be well educated and compliant. When performed appropriately, HTPN can provide an improved medical regimen and greatly improved quality of life for patients with IBD.
seems
sense.
A more definitive indication is a patient with an intra-abdominal abscess. These can often be treated by percutaneous drainage, antibiotics, and TPN. When potent oral antibiotics are sufficient, the patient may be sent home on TPN while the abscess cavity collapses and the sepsis resolves. There is significant individual variation in opinion among physicians with regard to the indications for TPN or HTPN in IBD patients. Whether patients should eat while on HTPN may also be controversial. It depends on whether TPN is being used to achieve the primary goal of &dquo;gut rest&dquo; or whether TPN is being used only to provide additional nutrition. There should be considerable doctor-patient dialogue in making these decisions. An estimate of the patient’s ability to carry out the program, comply with medical regimens, and cooperate with the team are all considerations.
COMPLICATIONS OF HTPN
Patients with IBD may encounter any of the usual metabolic or mechanical complications afflicting pa-
REFERENCES 1. Holm I. Benefits of total parenteral nutrition (TPN) in the treatment of Crohn’s disease and ulcerative colitis. Acta Chir
Scand 1981;147:271-6. 2. Shiloni E, Coronado E, Freund H. Role of total parenteral nutrition in the treatment of Crohn’s disease. Am J Surg 1989
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