There are currently limited indications for the use of parenteral nutrition (PN) in IBD. The most common of these is short bowel syndrome, resulting from extensive intestinal resection. This topic is discussed in detail in another chapter in this book. Complications of Crohn's disease, and to a lesser extent ulcerative colitis, can also be responsible for the need for PN. Fistulae arising from diseased areas of the intestine or leaks with or without fistulae resulting from surgical complications may be treated with PN either to treat the fistulae primarily or to temporize the patient until reparative operation can be undertaken. On occasion short-term TPN and bowel rest are also used in extensive stenosing Crohn's disease to limit the extent of resection or to provide nutritional support until drug therapy effectively controls disease. Evans et al. reported experience with 15 patients dismissed from the hospital on home TPN in an attempt to circumvent or delay early surgery for complicated IBD and found that the therapy was deemed successful in 80%, although 8 of those patients ultimately required surgical intervention . All patients preferred receiving the therapy at home and felt that they had either good or excellent quality of life, yet seven of these patients continued to require nursing visits until the TPN was discontinued, and only six were considered to be independent with TPN care after 2 weeks of treatment.
Growth failure in children and adolescents is seen in 50% of those with Crohn's disease, and weight loss is present in up to 90% at presentation . By contrast, in ulcerative colitis, growth failure occurs in only about 5% of affected children . Growth retardation frequently antedates the diagnosis of the disease, often by years. The causes include poor nutritional status, especially from the point of view of protein-calorie malnutrition. However, with more understanding of systemic effects of inflammation, the role in growth failure is beginning to be elucidated. Insulin-like growth factor-I (IGF-I), which is a stimulus for linear growth , has been shown to be low in children with Crohn's disease . Suppression of growth velocity in Crohn's disease was demonstrated by Murch and colleagues to be directly correlated with TNF-a levels . Animal studies have shown that proinflammatory cytokines can suppress IGF-I concentrations [93, 94]. Ballinger, using an experimental rat model of human Crohn's disease, found that, as expected, animals with disease had linear growth that was less than controls, but that pair fed healthy animals had greater growth than the diseased animals . This indicates that another factor, likely inflammation, is responsible for growth failure over and above that due to compromised nutrition.
Fell and coworkers treated 29 pediatric patients with Crohn's disease (18 newly diagnosed) using a casein-based enteral formula that contains transforming growth factor p2 . Clinical remission occurred in 79% of patients after an 8-week course of therapy. With histological healing there was associated down-regulation of mucosal pro-inflammatory cytokine mRNA. Banarjee et al. found that children with moderate to severe active Crohn's disease who were alimented exclusively with enteral feedings had improvement in inflammatory markers, clinical score and growth factor (IGF-I) before nutritional parameters showed improvement . These studies suggest that inflammation is a major factor in growth failure in children with Crohn's disease and that enteral nutrition may play a role in the primary treatment of Crohn's disease and growth failure.
The role of nutrition support in IBD continues to be important. Future therapies are likely to evolve, including diet as an immunomodulator of Crohn's disease and ulcerative colitis.
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WHAT IT IS A three-phase plan that has been likened to the low-carbohydrate Atkins program because during the first two weeks, South Beach eliminates most carbs, including bread, pasta, potatoes, fruit and most dairy products. In PHASE 2, healthy carbs, including most fruits, whole grains and dairy products are gradually reintroduced, but processed carbs such as bagels, cookies, cornflakes, regular pasta and rice cakes remain on the list of foods to avoid or eat rarely.