EDITORIAL Nutrition in Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) is a term used to describe two clinical syndromes, ulcerative colitis and Crohn’s disease, that have no clear causes and uncertain pathophysiologies. At present, the management of ulcerative colitis is essentially straightforward: manage the symptoms until the patient has had the disease for a long time or becomes refractory to therapy, and then remove the colon to prevent the development of malignancy. Nutrition support is usually reserved for the management of complications and is not considered primary therapy. Crohn’s disease, on the other hand, is a triply frustrating syndrome: frustrating to the internist, frustrating to the surgeon, and most importantly, frustrating to the patient. Not surprisingly, all three individuals would give anything for a cure. The patients tend to become complainers, their problems never seem to go away, their medications cause side effects, their surgical procedures are often complicated, and their disease inevitably recurs. When you think about it, these characteristics are not all that different from a number of malignancies, but our attitude and approach to IBD is quite different from our views on malignancy. In malignancy, we accept these problems as part of the inevitable; in inflammatory bowel disease, they become part of the &dquo;aura&dquo; of the disease. Therefore, when early reports suggested that parenteral nutrition and bowel rest could &dquo;cure&dquo; IBD, everyone who treated these patients hoped that a &dquo;magic bullet&dquo; had finally arrived. Soon it became apparent that parenteral nutrition played only a minor role in the management of the patient with ulcerative colitis-having no net effect on the disease process and producing improvement only in nutrition status. Hope continued for nutrition support in Crohn’s disease with continued reports of dramatic success and enthusiasm for long-term home nutrition support, only to be followed by reports of very high rates of recurrence in less than a year.

In recent years, the


in nutrition sup-

port has shifted dramatically from parenteral to enteral nutrition. Protection of the gut, provision of

glutamine, prevention of bacterial overgrowth, alteration of the hormonal milieu, use of cytokines, and prevention of bacterial translocation have all been implicated in the enteral versus parenteral nutrition debates by a series of reports that show that enteral nutrition is preferable to parenteral. Not surprisingly, similar reports have emerged from the experts in IBD. Circumstances in which parenteral support and bowel rest were considered &dquo;essential,&dquo; such as high-grade obstruction or fistulization, now appeared to be treated best by defined-formula enteral nutrition, particularly with dipeptides and tripeptides. With additional study, the role of nutrition support in ulcerative colitis has been confirmed to be only supportive. Early reports of &dquo;cure&dquo; in Crohn’s disease are being replaced by confirmation of a high rate of recurrence. Over time we will identify new therapeutic options, which we will embrace enthusiastically, but it is likely that the solution to these diseases will elude us again. In the process of our continued search for effective treatment modalities, however, we will have significantly improved the nutrition status of most patients, perhaps decreased the complications of therapy in many, and been able to postpone interventional therapy-at least for a short time-in some. In many circumstances, these will be major advances, and our ability to treat the complications of these diseases will be significantly enhanced. In this issue, Dr. Sitrin shares with us a comprehensive overview of nutrition support in IBD. He addresses the early enthusiasm for nutrition support as well as the disappointments of randomized trials. He points out that the cure for IBD continues to elude us, but that nutrition support, both parenteral and enteral, has an adjunctive role in management. He combines optimism for a role of nutrition with the practical reality of complications, cost, and less-thanenthusiastic results. And he points out the need for continued research, additional randomized trials, and a critical appraisal. So what have we accomplished in nutrition support of IBD? Although we may not have traveled far in our journey to understand and treat these diseases, we have had to continuously reset our sights and our 51

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patients do better now than they did 25 our emphasis on nutrition assessment and years ago, and nutrition therapy is a major contributor to that horizons. Our


improve the lives of those unfortunate enough


improvement. We should not stop looking for new methods of treatment just because old ones have not entirely panned out. We should be encouraged that even




these diseases.

inadequacies we can continue to find ways

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Peter J. Fabri, MD

Chief, Surgical Services Hurley, VA Hospital Tampa, Florida

James A.

Nutrition in inflammatory bowel disease.

EDITORIAL Nutrition in Inflammatory Bowel Disease Inflammatory bowel disease (IBD) is a term used to describe two clinical syndromes, ulcerative coli...
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