Parenteral and Enteral Nutrition: A Bridge to Healing and Biological Therapy in a Patient With Enterocutaneous Fistula and Sepsis Complicated Crohn's Disease

Abstract

Inflammatory bowel disease (IBD) patients with severe infections, abscess, or sepsis are ineligible for standard treatment using biological and immunosuppressive drug regimens. We report a case of complicated Crohn's disease with ruptured abdominal abscess, presence of enterocutaneous fistula, and sepsis. We also report and discuss patient management with parenteral nutrition (PN) and enteral nutrition (EN) and treatment outcomes. We report a case of a 31‐year‐old female with a 10‐year history of IBD in clinical remission, who, after previous total proctocolectomy with J‐pouch, presented to the clinic with severe abdominal pain of 2 days, unintentional weight loss, fatigue, fever, and abdominal abscess, which ruptured, and her clinical state became complicated by sepsis. PN was initiated using individually prepared admixture according to patient requirements, because of inability to tolerate any oral intake. Following the remittance of ileus symptoms, EN was added using a semielemental formula via a nasojejunal tube. Upon completion of the treatment, the fistula resolved, the wound had healed, and Crohn's Disease Activity Index score showed remission. This qualified the patient for initiation of biological therapy with infliximab. Patients with severe infections, abscesses, or sepsis are ineligible for standard IBD treatment using biological and immunosuppressive drug regimens. Furthermore, usually patients’ nutrition condition prevents them from combating infection and initiating proper healing process. This case demonstrates the importance of considering nutrition therapy—PN and EN—in unstable patients who cannot be treated with standard pharmacological therapy. Nutrition therapy offers a bridge that allows patients to stabilize and heal before starting standard pharmacological treatment with immunosuppressive agents or biological therapy.

Oligomeric Formulas in Surgery: A Delphi and Consensus Study

“…The surgeons also agreed to consider oligomeric formulas in low-debit ileus or colon fistulas. There is no expert consensus regarding the use of semi-elemental formulas when EN is chosen as the medical nutrition therapy in these situations, but data reported in some clinical cases show that this election is a usual practice in enterocutaneous fistula [20,21]. Moreover, interest is growing related to the delivery of nutrients to the distal intestinal limb when a high output proximal enterocutaneous fistula develops.…”

Use of oral diet and nutrition support in management of stricturing and fistulizing Crohn's disease

“…An adult woman with prior diagnosis of UC with prior ileal pouch-anal anastomosis surgery developed new abscess and enterocutaneous small bowel fistula concerning for CD. 57 PN was initially started with subsequent addition of tube feeds with semielemental formula. PN was discontinued after 4 weeks, and after 6 weeks of EEN, the patient transitioned to an oral diet with spontaneous closure of the fistula and resolution of abscess.…”

“…Data surrounding the use of PN for fistulizing disease are very sparse and limited to a singular, low‐quality case report. An adult woman with prior diagnosis of UC with prior ileal pouch–anal anastomosis surgery developed new abscess and enterocutaneous small bowel fistula concerning for CD 57 . PN was initially started with subsequent addition of tube feeds with semielemental formula.…”

Timing of individualized surgical intervention in Crohn’s disease

“…Fistula: Therapy for fistula has always been a complex clinical challenge. Simple enteral fistula without infection and clinical symptoms can be healed by a medical treatment such as enteral nutrition or biological agents[ 32 , 33 ]. For other complex enteral fistulae, including spontaneous enteroenteral or enteroexternal fistula formed after abscess drainage, the possibility of self-healing is low, and surgery should be adopted[ 34 , 35 ].…”