ESPEN Guidelines on Enteral Nutrition: Gastroenterology

doi:10.1016/j.clnu.2006.01.007

Clinical Nutrition

Volume 25, Issue 2, April 2006, Pages 260-274

https://doi.org/10.1016/j.clnu.2006.01.007 Get rights and content

Summary

Undernutrition as well as specific nutrient deficiencies have been described in patients with Crohn's disease (CD), ulcerative colitis (UC) and short bowel syndrome (SBS).

The present guideline gives evidence-based recommendations for the indication, application and type of formula of enteral nutrition (EN) (oral nutritional supplements (ONS) or tube feeding (TF)) in these patients. It was developed in an interdisciplinary consensus-based process in accordance with officially accepted standards and is based on all relevant publications since 1985.

ONS and/or TF in addition to normal food is indicated in undernourished patients with CD or CU to improve nutritional status. In active CD EN is the first line therapy in children and should be used as sole therapy in adults mainly when treatment with corticosteroids is not feasible. No significant differences have been shown in the effects of free amino acid, peptide-based and whole protein formulae for TF. In remission ONS is recommended only in steroid dependent patients in CD. In patients with SBS TF should be introduced in the adaptation phase and should be changed with progressing adaptation to ONS in addition to normal food.

The full version of this article is available at www.espen.org.

Section snippets

What influence does CD exert on nutritional status and on energy and substrate metabolism?

1.1. Acute phase

Undernutrition with weight loss, protein deficiency and specific deficiencies in vitamins, minerals and trace elements are common in the acute phase of CD.

Anorexia, increased intestinal losses and systemic inflammation are the main causes of undernutrition.

In children and adolescents a decrease in growth velocity may occur, secondary to inadequate nutrition and steroid therapy. The relevance and extent of these deficiencies vary according to the site and extent of diseased

What influence does UC have on nutritional status as well as on energy and substrate metabolism?

Global undernutrition, as well as specific deficiencies has been described in active UC. Specific deficits including anaemia due to iron and/or folate deficiency are described even in remission. Specific deficits may also be due to drug treatment (e.g. sulphasalazine).

Comment: The information regarding undernutrition in UC derives mainly from case reports. There are no epidemiological studies that would allow estimation of the prevalence of underweight and weight loss, although weight loss is

Short-bowel syndrome (SBS)

SBS is a complex condition resulting from either loss of intestine and/or an impairment of absorptive capacity of the remaining small bowel. SBS is not defined by a certain length of the remaining bowel but rather by the loss of absorptive function. The main causes of SBS are resections after mesenteric infarctions, extensive resections in CD, trauma, and bowel damage from radiotherapy.

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Cited by (296)

Survey of dietary beliefs and habits of inflammatory bowel disease patients
2023, Clinical Nutrition ESPEN
It is presumed that diet plays a role in the prevention and pathogenesis of inflammatory bowel disease (IBD). Patients with Crohn's disease (CD) and ulcerative colitis (UC) often report a link between their disease and diet. However, studies evaluating patient perceptions on diet in IBD are lacking. This study aimed to assess patient beliefs on the role of diet in IBD and the adequacy of dietary advice they received.
A self-administered questionnaire was offered to consecutive patients attending two IBD centers in Switzerland. Data were collected regarding patient dietary beliefs and behaviors and whether they received medical advice on their diet.
Of 210 questionnaires distributed, 171 were completed. Participants were mainly female (53%), young (median age 38 years) with either CD (66%) or UC (34%). Most patients believed that diet plays a role in their disease (74%), whereas only 15% believed that diet could be the trigger of their disease. Since their IBD diagnosis, more than half of patients (56%) modified their diet, and 39% did not receive dietary advice from their physicians or a dietician. Most patients (91–95%) ingested gluten, lactose, red and white meat. 20% of patients practiced intermittent fasting and only a minority had previously tried a low-FODMAP (9%) diet or probiotics supplementation (16%).
The majority of IBD patients believe that diet plays a role in their disease but have never received dietary advice from their doctor or a dietician. This highlights a need for more information for IBD patients on dietary advice from the medical profession.
ESPEN guideline on Clinical Nutrition in inflammatory bowel disease
2023, Clinical Nutrition
The present guideline is an update and extension of the ESPEN scientific guideline on Clinical Nutrition in Inflammatory Bowel Disease published first in 2017. The guideline has been rearranged according to the ESPEN practical guideline on Clinical Nutrition in Inflammatory Bowel Disease published in 2020. All recommendations have been checked and, if needed, revised based on new literature, before they underwent the ESPEN consensus procedure. Moreover, a new chapter on microbiota modulation as a new option in IBD treatment has been added. The number of recommendations has been increased to 71 recommendations in the guideline update. The guideline is aimed at professionals working in clinical practice, either in hospitals or in outpatient medicine, and treating patients with IBD. General aspects of care in patients with IBD, and speciﬁc aspects during active disease and in remission are addressed. All recommendations are equipped with evidence grades, consensus rates, short commentaries and links to cited literature.
Relationship between nutritional treatment compliance and nutritional status improvements in patients with gastrointestinal impairment taking an oral peptide-based supplement
2022, Nutrition
Compliance in outpatients with gastrointestinal (GI) malabsorption is key in nutritional treatment. The objective of this study was to assess compliance in patients with GI impairment and malnutrition taking a high-calorie, high-protein, peptide-based oral nutritional supplement (ONS-PBD).
A prospective, multicenter, observational study was conducted in 19 medical sites in Spain where ONS-PBD were prescribed as standard of care. Patients consumed ONS-PBD daily for 12 wk. Compliance was calculated as the percentage consumed of the prescribed amount of ONS per day.
A total of 90 adult patients were included in the study, of whom 64 completed the 12-wk regimine. Mean compliance was 78.8% ± 24.5%. Risk of malnutrition decreased in 56.3% of patients at 12 wk, as measured with the malnutrition universal screening tool. A reduction in abdominal pain was observed and stool consistency improved, with a mean of 54.7% and 27.5%, respectively. Improvements in quality of life and a decrease in percentage of patients with severe functional impairment were observed.
These data show that ONS-PBD compliance in malnourished patients with GI symptoms is high, reducing GI symptoms and improving patients’ nutritional status.
Personalized pre-habilitation reduces anastomotic complications compared to up front surgery before ileocolic resection in high-risk patients with Crohn's disease: A single center retrospective study
2022, International Journal of Surgery
Citation Excerpt :
A recent review found differences in practices or definitions between studies [29]: on the type of patients (CD phenotype, nutritional status, sepsis, etc.), on the criteria for defining undernutrition, on the administration of the nutritional support (exclusive enteral nutrition, combined nutrition (enteral and parenteral), parenteral nutrition), on the realization of a multimodal prehabilitation (antibiotic or not, discontinuation of therapies …), and over the duration of the prehabilitation (sometimes ranging from 1 week to 3 months). In IBD patients, exclusive parenteral nutrition has not been shown to be superior to enteral nutrition [30,31]. El Hussuna et al. carried out multimodal optimization to reduce postoperative complications (enteral or parenteral nutrition, antibiotic therapy, stopping corticosteroid treatments and smoking cessation) [32].
The aim of this study was to analyze the effect of a personalized prehabilitation (PP) before ileocolic resection (ICR) on the postoperative anastomotic complications in patients with Crohn's Disease (CD) with high risk of post-operative complications.
All high-risk patients who required ICR with primary anastomosis for CD between January 2010 and March 2020 were retrospectively analyzed. PP included nutritional support, antibiotic therapy or drainage of an abscess, stopping or decreasing corticosteroid treatments. Patients were considered as high risk for complications when they had at least one or more of these 3 risk factors (RF) (hypoalbuminemia <30 g/L or weight loss of >10% over the last 6 months, treatment with corticosteroids before surgery (within 4 weeks before surgery), or presence of preoperative intra-abdominal sepsis (abscess or enteral fistula)) according to ECCO guidelines 2020.
Ninety high-risk patients were included in our cohort and the anastomotic complication rate was 11.1%. Sixty-four (71.1%) had preoperative prehabilitation (median duration of 37 days), and the mean albumin level (34 g/L vs 37 g/L; p < 0.001) and the number of RF (1.21 vs 1.06; p = 0.001) were improved by PP during the preoperative period. The rate of anastomotic complications at 90 days from surgery (6.25% vs 23.1%; p = 0.031) as well as the re-operation rate (3.1% vs 19.2%; p = 0.019) were lower after PP. No difference was found on the rate of readmission and the length of stay in this subgroup analysis. Biological treatment administration within 3 months before surgery was not a risk factor for postoperative complication.
PP reduces the number of preoperative risk factors before ICR in high-risk patients with CD and allows primary anastomosis with a lower complication rate than in upfront operated patients.
Percutaneous endoscopic gastrostomy tube replacement after head and neck surgery: A case report
2022, International Journal of Surgery Case Reports
Percutaneous endoscopic gastrostomy (PEG) has been available since the 1980s. Routine replacement is conducted at bedside with relatively few complications. Two replacement methods have come into practice: the percutaneous method and the endoscopic method. The laparoscopic method has recently become favorable in the pediatric population.
Herein, we describe a situation in which a gastrostomy tube was replaced at bedside on a patient with previous head and neck surgery for lingual cancer. The percutaneous traction method was used, and gastrostomy tube replacement into the gastric lumen could not be confirmed on subsequent imaging. The patient was ultimately taken to surgery for an open procedure where it was discovered that initial PEG placement had traversed the small bowel mesentery en route to the gastric lumen.
The PEG tube is not a permanent device and routine exchange every 6–12 months is recommended. The percutaneous method and endoscopic method for gastrostomy tube replacement have both been used routinely, each with their set of complications. A third technique, laparoscopic placement, is the preferred modality in the pediatric population. Advantages are twofold: direct visualization of the stomach, thus eliminating inadvertent hollow viscus injury, and applicability in infants too small to undergo endoscopy necessary for PEG tube placement.
Consideration for laparoscopic placement or replacement in the head and neck cancer patient population, in which interval endoscopy is impossible, is thus advocated.
Efficacy of nutritional support protocol for patients with pressure ulcer: comparison of before and after the protocol
2022, Nutrition
Citation Excerpt :
According to many previous studies, providing adequate calories and protein is essential for PU healing. High-dose supplements of vitamin C and zinc are also helpful in treating chronic PU [15,17–21]. However, because most clinicians prioritize vital signs or mental status, nutritional support may be delayed or missed.
Because most patients who develop pressure ulcer (PU) are malnourished, additional nutritional support is important for PU improvement. The aim of this study was to investigate the potential benefit of a simple nutritional support protocol in PU improvement.
This study was a comparative before-and-after study, prospectively performed from May to December 2020. Participants were inpatients of Seoul National University Hospital (SNUH), South Korea. Among the patients who developed PU from May to December 2020, those on enteral nutrition were included in the protocol group. Application of the nutritional support protocol was established in May 2020 in SNUH. Serum levels of prealbumin, transferrin, cholesterol, and zinc were measured initially and 2 and 4 wk after protocol application to evaluate clinical course. A tailored regimen that adjusted the amount of protein and trace elements was provided according to consultation with the nutritional support team. Size and Pressure Ulcer Scale for Healing was evaluated every 2 wk by the same nurse in charge of PU. To validate the efficacy of the protocol, patients who developed PU from May to December 2018, were hospitalized for >2 wk, and who received enteral nutrition were selected as a control group.
Sixty-one patients were included in the protocol group and 100 were in the control group. The protocol group had a higher proportion of PU improvement (85.2 versus 50%; P < 0.001), daily protein intake (1.6 ± 3.2 versus 0.9 ± 0.4; P = 0.048), Braden scale (12.9 ± 1.8 versus 12.3 ± 1.8; P = 0.025), and baseline albumin level (3.1 ± 0.5 versus 2.8 ± 0.4; P = 0.001) when compared with the control group. Multivariate analysis showed that implementation of the nutritional support protocol was the most effective factor in improving PU (odds ratio, 0.18; 95% confidence interval, 0.089–0.366; P < 0.001).
A simple nutritional support protocol was easy to develop and its application contributed significantly to the recovery of PU.

View all citing articles on Scopus

^☆: For further information on methodology see Schütz et al.¹⁴⁷ For further information on definition of terms see Lochs et al.¹⁴⁸

^☆☆: The authors of the DGEM (German Society for Nutritional Medicine) guidelines on enteral nutrition in gastroenterology are acknowledged for their contribution to this article.

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ESPEN GUIDELINESESPEN Guidelines on Enteral Nutrition: Gastroenterology☆

Summary

Section snippets

What influence does CD exert on nutritional status and on energy and substrate metabolism?

What influence does UC have on nutritional status as well as on energy and substrate metabolism?

Short-bowel syndrome (SBS)

Am J Clin Nutr

Am J Clin Nutr

Nutrition

Am J Gastroenterol

J Nutr

J Pediatr

Gastroenterology

Gastroenterology

Gastroenterol Clin North Am

Gastroenterology

Am J Gastroenterol

Metabolism

J Pediatr

Mayo Clin Proc

Gastroenterology

Lancet

Gastroenterology

Gastroenterology

Mayo Clin Proc

IV. Gastroenterology

Clin Nutr

Dig Liver Dis

Am J Gastroenterol

Lancet

Am J Gastroenterol

Gastroenterology

Nutritional support in inflammatory bowel disease

Dig Dis

Nutrition considerations in patients with Crohn's disease

Semin Colon Rectal Surg

Assessment of nutritional status

J Parenter Enteral Nutr

Nutrition assessment in the 1990s: where are we now?

Nutr Clin Prat

Inflammatory bowel disease: nutritional implications and treatment

Proc Nutr Soc

Nutrition in inflammatory bowel disease

An update, Scand J Gastroenterol

Nutrition in inflammatory bowel disease

Curr Opin Clin Nutr Metab Care

Total enteral nutrition support improves body composition of patients with active Crohn's disease

J Parenter Enteral Nutr

Muscle cell electrolytes in ulcerative colitis and Crohn's disease

Digestion

Evaluation of magnesium status in Crohn's disease as assessed by intracellular analysis and intravenous magnesium infusion

Scand J Gastroenterol

Nutritional deficiencies and complications in chronic inflammatory bowel diseases

Med Klin

Enteral supplementation of phosphate does not prevent hypophosphatemia during refeeding of cachectic patients

J Parenter Enteral Nutr

25-hydroxyvitamin D absorption in patients with Crohn's disease and with pancreatic insufficiency

Wien Klin Wochenschr

Low serum and bone vitamin K status in patients with longstanding Crohn's disease: another pathogenetic factor of osteoporosis in Crohn's disease?

Gut

Vitamin B12 absorption after ileorectal anastomosis for Crohn's disease: effect of ileal resection and time span after surgery

Eur J Gastroenterol Hepatol

Vitamin status in patients with inflammatory bowel disease

Am J Gastroenterol

Total energy expenditure in patients with Crohn's disease: measurement by the combined body scan technique

J Parenter Enteral Nutr

Nutritional aspects of inflammatory bowel disease

Annu Rev Nutr

Assessing nutritional state in inflammatory bowel disease

Gut

Nutritional issues in pediatric inflammatory bowel disease

J Pediatr Gastroenterol Nutr

Growth failure in pediatric inflammatory bowel disease

J Pediatr Gastroenterol Nutr

Growth and development in chronic inflammatory bowel disease

Acta Paediatr Scand

Longitudinal growth in children and adolescents with inflammatory bowel disease

J Pediatr Gastroenterol Nutr

Comprehensive nutritional status in recently diagnosed patients with inflammatory bowel disease compared with population controls

Eur J Clin Nutr

ESPEN GUIDELINES
ESPEN Guidelines on Enteral Nutrition: Gastroenterology☆