INVENTED REVIEW

Nutrition Support in Inflammatory Bowel Disease MICHAEL D. SITRIN, MD Clinical Nutrition Research Unit, Section

of Gastroenterology, University of Chicago

ABSTRACT: Many patients with the inflammatory bowel diseases, Crohn’s disease, or ulcerative colitis have significant protein-calorie malnutrition and micronutrient deficiencies. Factors that contribute to these nutritional deficits include inadequate nutrient intake, malabsorption, excessive nutrient secretion across the diseased gastrointestinal tract, drug-nutrient interactions, and increased nutrient requirements. In this review, the use of enteral and parenteral nutrition support as primary therapy for active Crohn’s disease and ulcerative colitis is discussed. Other roles for nutrition support in patients with inflammatory bowel disease, including preoperative nutrition support, nutritional treatment of intestinal fistulas and growth retardation, and home parenteral nutrition for gut failure, are also reviewed.

4. Summarize the

5.

importance of calorie malnutrition in the pathogenesis of growth retardation in children with inflammatory bowel disease, and discuss treatment with various nutrition support regimens. Review the use of home total parenteral nutrition in patients with severe Crohn’s disease and gut failure.

The term inflammatory bowel disease denotes two related, but clinically and pathologically distinct, chronic inflammatory diseases of the gastrointestinal tract. Crohn’s disease can affect any region of the bowel and is characterized by transmural inflammation, which is often granulomatous in character. The chronic transmural inflammation often leads to the formation of fistula and to scarring of the bowel, which can cause intestinal obstruction. A majority of patients with Crohn’s disease will require one or more intestinal resections for these or other complications. Unfortunately, intestinal resection is rarely if ever curative, and recurrence of disease is highly predictable. In contrast, ulcerative colitis is characterized by inflammation limited to the mucosa of the large intestine, and total proctocolectomy is a curative procedure. In both diseases, various medications, including corticosteroids, sulfasalazine, and immunosuppressive drugs, are used to suppress the inflammatory response and to provide symptomatic relief. There is presently no medical cure. Because of the chronic involvement of the gastrointestinal tract, the characteristic worsening of symptoms by eating, the loss of functional mucosal surface by inflammation or resection result-

m

LU CREDIT LEARNING OBJECTIVES 1. Consider the

pathogenetic factors that contribute to malnutrition in patients with inflammatory bowel disease. 2. Discuss the data that support and contradict the use of enteral and parenteral nutrition support as primary therapies for patients with active Crohn’s disease and ulcerative colitis. 3. Review preoperative nutrition support in inflammatory bowel disease and in the nutritional treatment of Crohn’s disease patients with intestinal fistulas.

Address for reprints: Michael D. Sitrin, MD, University of ChiCenter, 5841 S. Maryland, Box 223, Chicago, IL 60637.

cago Medical

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ing in malabsorption and secretion of nutrients across the diseased epithelium, and the multiple drugnutrient interactions, this group of patients has a very high frequency of protein-calorie and micronutrient deficits.1,2 Patients with inflammatory bowel disease, therefore, are commonly treated with enteral and/or parenteral nutrition support. Although it is clear that these nutrition support modalities are highly effective in correcting malnutrition in patients with inflammatory bowel disease, opinions about the appropriate roles of these technologies in managing disease symptoms and complications continue to be controversial. In this review, the mechanisms of nutritional depletion in patients with inflammatory bowel disease will be described and the role of nutrition support in the treatment of various clinical problems encountered in inflammatory bowel disease will be discussed. MECHANISM OF NUTRITIONAL DEPLETION IN INFLAMMATORY BOWEL DISEASE

The major mechanisms of nutritional depletion in patients with inflammatory bowel disease are presented in Table 1.1,2 The most important mechanism is decreased food intake. Abdominal pain, diarrhea, and nausea are often exacerbated by eating, and patients frequently diminish their food intake to avoid such unpleasant gastrointestinal symptoms. In many patients, especially children and adolescents, the reduction in food intake can be quite subtle and can show considerable day-to-day variation, but over time results in inadequate ingestion of calories and nutrients. Patients with inflammatory bowel disease are often on restricted diets to control their gastrointestinal symptoms. Lactose intolerance can be managed by the restriction of lactose-containing dairy products. In patients with Crohn’s disease and stenotic bowel segments that produce partial intestinal obstruction, restriction of dietary fiber can be useful. Patients with Crohn’s disease and fat malabsorption require low-fat diets to control their steatorrhea and diarrhea and to prevent the depletion of fat-soluble vitamins and minerals such as calcium, magnesium, and zinc. Inadequate attention, however, is often placed on documentation of the need for specific food restrictions and on assurance that the diet is adequate in calories, protein, and micronutrients by providing alternatives to eliminated foods or by prescribing specific nutritional sup-

plements. Patients with Crohn’s disease can malabsorb nutrients. Those with diffuse small intestinal disease or prior resections can have inadequate mucosal surface for the absorption of nutrients. Patients with large ileal resections have bile salt malabsorption, causing intraluminal bile salt deficiency, which results in the malabsorption of dietary triglycerides, fat-soluble vitamins, and minerals. Ileal resection or disease also

Table 1. Factors that contribute to malnutrition in patients with inflammatory bowel disease

interferes with vitamin B12 bacterial overgrowth can

absorption. Small-bowel in patients with Crohn’s disease, particularly in those with stenotic occur

bowel segments or enteroenteric fistulas that cause stasis of intestinal contents. Small-bowel bacterial overgrowth results in malabsorption through several mechanisms, including bacterial deconjugation of bile salts, bacterial uptake and utilization of nutrients such as vitamin B12 and carbohydrates, and inflammatory small-bowel damage due to deconjugated bile salts and other toxic products of bacterial metabolism.’ Several of the drugs most commonly used in the treatment of inflammatory bowel disease can also result in nutrient malabsorption. Sulfasalazine is a competitive inhibitor of folate absorption and can cause folate deficiency, especially in individuals with limited dietary folate intake.’ The bile acid-binding resin, cholestyramine, is often used to decrease diarrhea in patients with ileal resection, but it can accelerate fat-soluble vitamin depletion.’ Corticosteroids decrease intestinal calcium absorption and thus contribute to the development of steroid-induced osteoporosis.’ Inflammatory bowel disease also causes increased intestinal secretion and the loss of several nutrients. Protein-losing enteropathy is almost universally observed in active inflammatory bowel disease, and in Crohn’s disease, there is a strong relationship between intestinal loss of serum proteins and the Crohn’s disease activity index.’ Protein-losing enteropathy is conveniently assessed by a determination of the intestinal clearance of a-1-antitrypsin, which correlates well with the traditional but cumbersome methods of determining fecal excretion of radiolabeled plasma proteins.8 Intestinal loss of serum albumin can exceed the ability of the liver to synthesize albumin even when protein intake is adequate and can lead to hypoalbuminemia and eventual edema. Patients with inflammatory bowel disease commonly have chronic occult blood loss, which leads to iron depletion and anemia. Minerals and trace elements are often lost in diarrhea fluid, and hypokalemia, hypomagnesemia, and zinc deficiency are common clinical problems. Studies have demonstrated a relationship between the

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55

volume of diarrhea and the intestinal losses of zinc.’ With steatorrhea, there is an excessive loss of divalent cations such as calcium, magnesium, zinc, and copper in the form of fatty acid soaps. In some circumstances, patients with inflammatory bowel disease can have increased nutrient requirements. Patients whose inflammatory bowel disease is complicated by abscesses, infections, and fever have increased caloric requirements. Patients with less severe inflammatory bowel disease, however, have been found to have resting metabolic rates, measured by indirect calorimetry, that are similar to values predicted for normal individuals by the Harris-Benedict equation.10 A recent study used the doubly labeled water method to measure total daily energy expenditure in ambulatory patients with inflammatory bowel disease, and found values similar to those seen in matched healthy controls.ll NUTRITION SUPPORT AS PRIMARY THERAPYENTERAL NUTRITION

Considerable attention has recently been focused the use of enteral nutrition support as a primary therapy for patients with Crohn’s disease. Early uncontrolled studies indicated that enteral nutrition support given orally or as a tube feeding often caused a dramatic resolution of symptoms and the improvement of laboratory, endoscopic, and radiographic measures of the activity and extent of disease.l2° 13 Interpretation of these initial observations was often complicated by coexisting medical therapy that also might have affected outcome. Several recent controlled clinical trials compared treatment with elemental diets with conventional medical therapy with corticostercids. O’Morain et al randomized 21 patients to receive either elemental diet (Vivonex’) or predon

improvement in the three

measures of disease activity between the two groups. Okada et al performed a controlled trial that compared an elemental diet with prednisolone (0.7 mg/kg per day) in the treatment of patients with active Crohn’s disease who had never received specific therapy.16 Ten patients were evaluated in each treatment group, and after 6 weeks, the patients on the elemental diet showed greater improvement in the clinical disease activity index, laboratory measures of inflammation, and radiographic findings of bowel lesions than did those on steroids. Patients who initially received prednisolone for 6 weeks and then were treated with the elemental diet for an additional 4 weeks showed further improve-

ment.

In these studies, the duration of disease remission that followed elemental diet therapy has varied considerably. Some investigators reported long-term remissions, whereas others noted frequent early relapses. Comparisons with steroid treatment are difficult because patients commonly receive tapering doses of steroids long after the conclusion of the initial study

period. Other investigators report less favorable results with enteral nutrition support as a primary therapy for Crohn’s disease. Malchow et al. conducted a randomized multicenter study that compared a protein hydrolysate-based defined-formula diet with the combination of 6-methyl-prednisolone and sulfasalazine.&dquo; At the end of 6 weeks, 32 of 44 patients who were

indices, including body weight, serum albumin, and hemoglobin, improved more in the elemental diet group than in the steroid-treated subjects. Saverymuttu et al reported a randomized clinical trial that compared a regimen of elemental diet plus nonabsorbable antibiotics with treatment with prednisolone (0.5 mg/kg per day) in patients with moderately active Crohn’s disease. 15 Disease activity was assessed by the Crohn’s disease activity index, erythrocyte sedimen-

randomized to drug treatment showed improvement in their Crohn’s disease activity indexes as compared with only 21 of 51 patients who received the definedformula diet, a statistically significant difference in outcome. The proportion of withdrawals from treatment in the defined formula group was sevenfold higher than in the drug group, and withdrawal from treatment in the defined-formula group was largely because the liquid diet was unpalatable. An analysis of patients in each treatment group who finished the study, however, showed equal effectiveness of the drug and defined-formula diet regimens. Because the large number of dropouts in the defined-formula diet group may have significantly biased the results, the European Cooperative Crohn’s Disease Study Group conducted an additional trial that compared an oligopeptide diet given by nasogastric or nasoduodenal tube with treatment with a combination of methylprednisolone and sulfasalazine.18 In that study, the enteral nutrition regimen was found to be less effective than drug therapy. Fewer of the patients who were treated

tation rate, and fecal excretion of 111 In -labeled autologous leukocytes. Five patients had to be withdrawn from the elemental diet group after less than 3 days of therapy because of their gastrointestinal symptoms or intolerance of the feeding tube. Sixteen patients completed 10 days of treatment on each regimen, and there were no statistical differences in the rate of

with enteral nutrition were in remission after 6 weeks (defined as a decrease of the initial Crohn’s disease activity index by 40% or at least 100 points), and the mean elapsed time to remission in those who responded was much longer in the diet group. Initial disease activity or disease location did not appear to influence the response to either treatment regimen.

nisolone (0.75 mg/kg per day) for 4 weeks.14 Disease activity as assessed by a clinical score and by the erythrocyte sedimentation rate improved comparably in both groups after 4 weeks of therapy and after an additional 8 weeks of follow-up. Several nutritional

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Patients with higher stool frequency appeared to respond better to drug treatment than to diet, whereas those with lower stool frequency reacted in the opposite way. It should be noted that 53% of the patients on enteral nutrition reached remission, in contrast to less than 30 to 40% of patients who received a placebo in the large American and European drug trials on Crohn’s disease, suggesting, but not proving, that enteral nutrition has some positive effect in acute Crohn’s disease. Various explanations have been given for the substantially different results of these controlled trials. The studies often included only small numbers of patients, and the duration and type of nutritional and drug therapy differed. Various methods were used for the clinical and laboratory assessment of disease activity, each of which have their own limitations and uncertainties. The studies of the European Cooperative Crohn’s Disease Study Group used a formula diet that contained a protein hydrolysate (80% of nitrogen as oligopeptides), 17,18 whereas the controlled trials that reported enteral nutrition as equal or superior to drug therapy tended to use elemental diets.14-16 Several potential mechanisms have been suggested by which elemental diets could benefit patients with Crohn’s disease;19 they include: (1) reduction of the load of intraluminal antigens and immune stimulation of the gut; (2) medical bypass of disease-affected areas in the distal intestine by the provision of nutrients that are almost completely absorbed in the proximal small bowel; with elemental diets, there is little stool output and reduced stimulation of motility and secretion by the distal small intestine and colon; (3) alterations of gut flora;19. 20 (4) change of intestinal permeabilit y; 21 and (5) provision of specific nutrients, such as glutamine, that are specifically required for the maintainance of small-intestine structure and function.22 It is possible that enteral nutrient with a polymeric diet fails to provide one of more of these beneficial effects. To further examine this question, Giaffer et al recently conducted a controlled trial of a polymeric versus an elemental diet in the treatment of active Crohn’s

disease.23 Thirty patients

were

randomly assigned

to

elemental formula via nasogastric tube, and all medications including corticosteroids were gradually withdrawn during the first 14 days of treatment. After both 10 and 28 days of treatment, 5 of 14 patients on the polymeric diet versus 12 of 16 patients on the elemental diet achieved clinical remission, a statistically significant difference. Reviews of this study, however, pointed out some potentially important differences between the two patient groups with respect to disease location, presence of an abdominal mass, and degree of disease activity, all of which could have influenced the outcome of therapy.2¢ Further large clinicial trials are needed to address this important issue, because polymeric diets are less expensive and are often more palatable and likely to be tolerated for several weeks as oral therapy. receive either

a

polymeric

or

NUTRITION SUPPORT AS PRIMARY THERAPYTOTAL PARENTERAL NUTRITION

Total as

parenteral nutrition is frequently employed primary therapy for patients with severe inflam-

matory bowel disease who fail

to

respond

to cortico-

steroids or who are independent on high-dose steroids for disease control. In patients with active Crohn’s disease, various published series reported that 40 to 90% of patients have a significant initial improvement in symptoms.25-30 Although some studies suggested that patients with Crohn’s colitis respond less well to total parenteral nutrition that do those with smallbowel disease or ileocolitis, most large series indicated that symptomatic response is independent of disease location.26.27,29 Many of these series are retrospective uncontrolled studies and are difficult to interpret because many patients continued to receive various medical therapies or had new drug treatments that were initiated during the course of total parenteral nutrition ; these therapies and treatments could also have affected patient outcome. Several groups, however, reported that patients with active Crohn’s disease who received total parenteral nutrition as the sole therapy or who were continued on the same dose of steroids that previously failed to induce remission also demonstrated high response rates. 27.28 Because total parenteral nutrition is a complicated and expensive therapeutic modality, it would only be useful as primary therapy if the improvement of symptoms was relatively sustained. Muller et al reported 30 patients with active Crohn’s disease who received 12 weeks of total parenteral nutrition as their sole therapy.’8 Twentyfive patients achieved improvement of symptoms that permitted them to resume oral diets and return to work. In these patients, however, the relapse rate at 2 years was 60% and after 4 years was 85%. Compared with patients at the same institution who underwent intestinal resection, the relapse rate in the patients treated with total parenteral nutrition was approximately four times higher. Lerebours et a12’ and Kushner et al3o also found high recurrence rates in steroiddependent and steroid-resistant patients with Crohn’s disease who achieved an initial remission of disease with long-term total parenteral nutrition. A small number of patients in these series, however, did have a prolonged response, and in many cases, the recurrence was relatively mild and responsed well to conventional medical therapy. Ostro et al retrospectively evaluated the role of total parenteral nutrition in 100 patients with Crohn’s disease that was refractory to conventional medical treatment.26 In patients with nonfistulous disease, about 75% were still in remission after 3 months and about 60% were still in remission after 1 year. The authors noted that these remission rates are equal to or greater than those reported with various drug therapies in the National Cooperative Crohn’s Disease Study and the Cooperative Crohn’s Disease Study in Sweden, but it should be noted that

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patients treated with total parenteral nutrition also continued to receive some form of drug therapy. Sitzmann et al recently reported their experience with parenteral nutrition combined with medical therapy in Crohn’s colitis.29 Fifteen of 16 patients improved clinically, and only one required surgery during the initial treatment period. Two patients required subsequent surgery at 16 and 24 months, respectively, after the initial period of treatment. The remaining patients continue to do well but have generally required small doses of alternate-day steroids, azathioprine, sulfasalazine, or metronidazole. Greenberg et al reported a multicenter controlled clinical trial that compared different modalities of nutrition support in the management of active Crohn’ss disease.31 In that study, 51 patients with active Crohn’s disease that was unresponsive to medical management were randomized to receive total parenteral nutrition, defined-formula diet by tube feeding, or partial parenteral nutrition and a low-residue diet for 21 days. There were no significant differences in the initial response rates or the remissions at 1 year among the three treatment groups. Similar conclusions were reached in the retrospective study of Cravo et al, 32 except that patients with intestinal obstruction had better immediate responses when they were treated with total parenteral nutrition than when they received a modified diet or enteral nutrition support. In a prospective trial, Wright and Adler reported similar degrees of symptomatic improvement in patients with Crohn’s disease who were treated for 2 weeks with peripheral parenteral nutrition versus elemental feedings.33 Jones also found no differences in the success rate, speed of achieving remission, or changes in laboratory measures of inflammation between patients with Crohn’s disease who received elemental diets versus total parenteral nutrition.34 On the basis of these clinical studies, it appears that although total parenteral nutrition as sole therapy for active Crohn’s disease is reasonably effective in many of the

achieving a short-term remission, the relapse rate is quite high. Therapy with corticosteroids, sulfasalazine, and other medications or treatment with enteral nutrition support would appear to be preferable as initial therapy in most patients. In patients who have failed to improve on conventional medical therapy or who are steroid dependent, consideration should be given to surgical resection of the affected bowel if the patient has limited disease and has not had prior resections producing a short bowel syndrome. Another alternative would be a trial of enteral nutrition supas an adjunct to continuing medical therapy, although further controlled studies are needed to de-

port

fine the response rate to this type of combined treatment. For patients who do not tolerate enteral feedings, such as those with extensive disease, a very short bowel, high-grade obstruction, or high-output fistulas or those who fail to improve with enteral nutrition support, a 3- to 12-week period of total parenteral

nutrition may induce a remission of disease, although the patients will probably continue to require drug therapy to maintain the remission. Patients with active ulcerative colitis generally respond poorly to total parenteral nutrition.2,25 The majority of patients will continue to have active disease in spite of being on total parenteral nutrition and taking nothing by mouth, and they may even have severe complications such as a toxic megacolon and profuse bleeding. For example, Sitzmann et al found that of 22 patients with ulcerative colitis who were

treated with medical therapy and total parenteral nutrition, 16 required surgery during the initial hospitalization, 1 subsequently had surgery, and 1 died after refusing surgery.2’ Thus, only 4 of 22 had acceptable responses to combined medical and nutritional treatment. In a controlled clinical trial, Dickinson et al. found that patients with acute ulcerative colitis who were treated with total parenteral nutrition did no better than did those receiving conventional medical therapy alone.35 In view of the generally poor results with nutritional therapy in refractory ulcerative colitis, these patients should be encouraged to have a curative proctocolectomy. PREOPERATIVE NUTRITION SUPPORT

Malnutrition is clearly a risk factor for many perioperative complications, such as wound and other infections, wound dehiscence, anastamotic leaks, and

prolonged ileus.36. 37 Although there is a lack of controlled clinical trials of perioperative nutrition support in patients with inflammatory bowel disease, retrospective reviews from several groups indicated that a 5- to 10-day period of preoperative total parenteral nutrition is associated with a reduction in septic and total surgical complications.38,39 Prospective, randomized clinical trials in patients undergoing a variety of abdominal surgical procedures have clearly shown that the net benefit of preoperative total parenteral nutrition can only be demonstrated in patients with significant malnutrition, and for those with only mild malnutrition, total parenteral nutrition may be associated with net harm.36.37 These observations emphasize the importance of a careful nutritional assessment to properly select patients who would most likely benefit from preoperative nutrition support. Because patients with inflammatory bowel disease are so frequently malnourished, it is likely that many would be candidates for nutritional repletion before surgery. At the present time, there are few data to support a prolonged period of preoperative nutrition support, and one must always be careful not to delay urgently needed surgery in the hopes of improving the nutritional status of the patient. Although changes in body composition cannot be demonstrated after only a few weeks of total parenteral nutrition, potentially important improvements in serum proteins and in the function of respiratory and other muscles can be detected.4° In a recent case-

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control study, Lashner et al reported that patients with Crohn’s disease who received preoperative nutrition support had somewhat more limited resections than did those who were not nutritionally repleted before surgery.41 No prospective studies are available that compare preoperative enteral versus parenteral nutrition support in patients with inflammatory bowel disease, but it should be noted, however, that enteral formulas can provide both nutritional repletion and an effective bowel preparation in many patients.42 CROHN’S DISEASE AND INTESTINAL FISTULAS

Fistulas of the

gastrointestinal tract are among the complications of Crohn’s disease. Enteroenteric and enterocutaneous fistulas usually arise from areas of active inflammatory bowel disease, often proximal to a site of obstruction. Perianal fistulas mainly occur in the context of Crohn’s disease most troublesome

of the rectum and are often refractory to conventional medical and surgical treatments. The effect of bowel rest and total parenteral nutrition on the healing of fistulas was examined by several groups, with some who reported excellent responses and others who found that relatively few patients closed their fistulas.2, 25-27, 43-46 These disparate results can be explained, in part, by the inclusion of different types of fistulas in the various studies. Postoperative fistulas that were caused by anastomotic leaks or that occurred at the site of a drainage tube have a high rate of healing with bowel rest and total parenteral nutrition, whereas fistulas from active inflammatory bowel disease and obstruction responded less favorably. Some fistulas from active Crohn’s disease will temporarily close while a patient is receiving total parenteral nutrition will then reopen once oral food intake is resumed.43 Overall, 30% or less of fistulas due to Crohn’s disease demonstrate long-term closure after total parenteral nutrition, and most patients require surgical intervention. 2,25 Because many of the patients with Crohn’s disease and fistulas have severe malnutrition, a period of nutrition support in conjunction with limited surgical procedures to control infection, such as drainage of abscesses and diverting ostomies, may be extremely beneficial before a definitive surgical repair is at-

tempted. The experience reported with enteral nutrition support in the treatment of Crohn’s disease-related fistulas is mainly confined to isolated case reports and small series.47,48 Because elemental diets are almost completely absorbed in the proximal intestine, it is

likely that they would be of considerable benefit in patients with fistulas arising from the distal bowel. In addition, patients with fistulas that originate in the stomach or duodenum can often be effectively managed by the placement of a feeding tube beyond the fistula site. Calam et al. reported that elemental diets caused improvement in four of six patients with

Crohn’s disease and perianal fistulas, although plete healing was achieved in only one. 49

com-

GROWTH RETARDATION

Retardation of linear growth occurs in about 20 to 30% of children with Crohn’s disease and in a smaller number of children with ulcerative colitis.5° The principal cause of growth failure in inflammatory bowel disease is inadequate caloric intake, which in one study averaged only 56% of that recommended for the child’s height, age, and sex.51 In addition, treatment with daily corticosteroids is widely known to suppress growth.5° Various studies reported success in the achievement of improved growth in children with inflammatory bowel disease by treatment with total parenteral nutrition, tube feedings, or oral nutritional supplements. 50-52 The important principle is to have a therapeutic program that provides adequate nutritional intake and permits improvement in disease activity that is sufficient to avoid chronic treatment with daily corticosteroids. Children often do not take enough oral nutritional supplements to correct calorie deficits because of the poor taste of these products. Supplementation of intake with nocturnal tube feedings has been particularly effective in some children to achieve nutritional repletion and to permit normal school and social activities.52 Total parenteral nutrition should be reserved for children who fail a trial of tube feedings and for those with gut failure due to extensive disease or prior bowel resection. HOME TOTAL PARENTERAL NUTRITION

Patients with Crohn’s disease and gut failure from extensive disease or bowel resections represent one of the largest populations who receive prolonged home total parenteral nutrition. 54-56 Galandiuk et al. recently reviewed their experience with 41 patients with Crohn’s disease who were placed on home total parenteral nutrition for a total of 121 patient years primarily for short bowel syndrome or a high stoma output.56 Therapy with home total parenteral nutrition resulted in nutritional repletion, a reduced requirement for steroid treatment, and a general improvement in the quality of life. This therapy, however, was associated with significant morbidity, as 24 patients had one or more home total parenteral nutrition-related complications, such as a catheter blockage, catheter-related sepsis, or dehydration and electrolyte balance. Furthermore, there was no significant difference between the number of operative procedures performed per patient year of Crohn’s disease before or during home total parenteral nutrition. These results and others indicated that although prolonged home total parenteral nutrition is lifesaving for patients with severe Crohn’s disease and gut failure and generally results in substantial nutritional, medical, and social rehabilitation, it is also associated with

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59

significant morbidity and does history of the disease.

not alter the natural

wiz]

23. Giaffer

24.

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