Colonic Crohn’s Disease in Children Does Not Respond Well to Treatment with Enteral Nutrition If the Ileum Is Not Involved

Abstract

Data supporting a response to treatment with exclusive enteral nutrition in pediatric colonic Crohn's disease are few. We examined clinical and biochemical responses of ileal, colonic, and ileocolonic Crohn's disease and assessed the endoscopic and histological colonic mucosal response in the colonic and ileocolonic groups. We prospectively enrolled 65 children (age: 8-17 years) with acute intestinal Crohn's disease (Pediatric Crohn's Disease Activity Index [PCDAI] >20). After ileocolonoscopy, gastroscopy, and a barium meal and follow-through, they were distributed into three groups (ileal, n = 12, ileocolonic, n = 39; and colonic, n = 14). All patients received exclusive polymeric feed as treatment, with a repeat endoscopy at completion of treatment. At enrollment the ileal group had significantly less severe disease (P = 0.05) compared to the colonic and ileocolonic groups. However, the colonic disease group showed the least fall in PCDAI scores at completion of treatment with enteral nutrition (P = 0.03), with the lowest remission rate (50%, vs 82.1% in the ileocolonic and 91.7% in the ileal group [chi2 test, P = 0.021]). Endoscopic and histologic colonic mucosal assessment showed a post-treatment improvement in the ileocolonic (P < or = 0.01) but not in the colonic disease group (P = ns). Children with disease in the colon respond better to enteral nutrition if the ileum is also involved. This may be due to different underlying inflammatory mechanisms. Detailed pretreatment assessment in studies of Crohn's disease according to disease distribution with appropriate individualized tailoring of treatment may be important in this regard.

The major pathway by which polymeric formula reduces inflammation in intestinal epithelial cells: a microarray-based analysis

“…Unfortunately, there is no widely accepted cell line that replicates small bowel epithelial cells, and the only wellaccepted model to investigate the intestinal epithelium is colonic epithelial cells. Previous studies delineating EEN activity in disease location-stratified paediatric IBD patients indicate that EEN has greater activity in ileal and ileocolonic disease and less activity in colonic disease (Afzal et al 2005). It is intriguing to speculate that the activity of PF described in the current study may be replicated in the small bowel epithelium of EEN-treated IBD patients, although further investigations are needed to establish whether this activity is replicated in situ.…”

Repeated exclusive enteral nutrition in the treatment of paediatric Crohn's disease: predictors of efficacy and outcome

“…Neither disease location nor route of administration had an effect on the success of exclusive nutrition, again consistent with other studies. 7,13,15,16 Definition of remission varies in published retrospective cohorts and less rigorous outcome parameters (e.g. Physician Global Assessment) might overestimate remission in clinical trials.…”

Enteral Nutrition Should Be Used to Induce Remission in Childhood Crohn’s Disease

“…Children with any macroscopic ileal inflammation were significantly more likely to achieve a clinical remission than those children with colonic involvement alone (75 vs. 50%) [10] . Despite this, many individuals with Crohn's colitis continue to respond extremely well, still making exclusive enteral nutrition the first choice for any child with Crohn's disease, irrespective of their disease distribution.…”

“…Colonic disease appears to respond as well as terminal ileal disease, with a similar reduction in inflammatory markers, disease activity and improved mucosal histology [5] . More recent retrospective data suggests that clinical remission with isolated colonic disease may only be about 50%, compared to about 75-80% in the presence of any macroscopic ileal involvement [10] . Although there is only anecdotal evidence on the response of oral and perianal Crohn's disease to exclusive enteral nutrition [11] , the authors have made use of exclusive enteral nutrition as an adjunct in treating severe perianal Crohn's disease.…”