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Experts in Elemental Nutrient Formulas
Crohn's Disease Literature Review: Abstracts -
References
The following studies inspired our
efforts and influenced our thinking. There has little progress in managing
Crohn's disease since we first looked at the problem 20 years ago. Old dogma
persists and prevails . We think we have the best solution to the problem We are
not disappointed that we have not been offered the Nobel prize- yet. We
realize that the recognition of important contributions often takes many
decades.
Elemental diet as primary treatment of acute Crohn's disease.
Author
O'Moráin C; Segal AW; Levi AJ
Source
Br Med J (Clin Res Ed), 288: 6434, 1984 Jun 23, 1859-62
Abstract
Acute exacerbations of Crohn's disease are usually treated with
prednisolone or potentially more toxic immunosuppressive drugs or by surgery. In pilot
studies replacing the normal diet by a protein free elemental diet also induced remission.
A controlled trial was therefore conducted in which 21 patients acutely ill with
exacerbations of Crohn's disease were randomised to receive either prednisolone 0.75
mg/kg/day or an elemental diet (Vivonex) for four weeks. Assessment at four and 12 weeks
showed that the patients treated with the elemental diet had improved as much as and by
some criteria more than the steroid treated group. Elemental diet is a safe and effective
treatment for acute Crohn's disease. (See Alpha ENF)
Diet in the management of Crohn's disease.
Author
Workman EM; Alun Jones V; Wilson AJ; Hunter JO
Source
Hum Nutr Appl Nutr, 38: 6, 1984 Dec, 469-73
Abstract
Thirty-three patients with Crohn's Disease were studied to see if their
symptoms were related to food intolerances. Initial treatment to produce remission of
symptoms was total parenteral nutrition (20), elemental diet (2) or elimination diet (11).
Twenty-nine patients reported specific food intolerances, and 21 of these remained in
remission on diet alone, the mean length of remission being 15.2 months. The most
important foods provoking symptoms were wheat and dairy products.
Comparison of nitrogen utilization of two elemental diets in
patients with Crohn's disease.
Author
Vaisman N; Griffiths A; Pencharz PB
Address
Division of Clinical Nutrition, Hospital for Sick Children, Toronto,
Ontario, Canada.
Energy, nitrogen absorption, and nitrogen utilization of two commercial
elemental diets, Vivonex and Vital, were compared in 10 teenage boys and girls with
Crohn's disease. The diets were given in random order as overnight feedings and were the
sole source of nutrients for two consecutive periods of 3 weeks each. Urine and stools
were collected for 48 h at the end of each 3-week period. Energy absorption was slightly
better on Vivonex (p less than 0.05), although 95-100% of energy was absorbed with both
formulas. Nitrogen absorption was not different for the two formulas, but nitrogen
utilization was significantly better on Vital (28.6 +/- 12.9% versus 9.7 +/- 17.7%, p less
than 0.01). This difference may be attributable to the different concentrations of
sulfur-containing and aromatic amino acids in the two formulas.
Controlled trial comparing prednisolone with an elemental diet
plus non-absorbable antibiotics in active Crohn's disease.
Author
Saverymuttu S; Hodgson HJ; Chadwick VS
Source
Gut, 26: 10, 1985 Oct, 994-8
Abstract
In a randomised clinical trial, patients with moderately active Crohn's
disease received either prednisolone 0.5 mg/kg/day plus a normal diet, or an elemental
diet plus oral framycetin, colistin and nystatin. Patients were assessed using the Crohn's
disease activity index (CDAI), ESR, and faecal granulocyte excretion quantified by
111In-autologous leucocytes. Five patients were intolerant of the elemental diet plus
antibiotics and were withdrawn from the trial within 72 hours. Sixteen patients completed
10 days treatment on each regime. Fifteen of 16 patients on elemental diet plus
antibiotics and all 16 patients on prednisolone improved with marked, but statistically
indistinguishable falls in CDAI, ESR, and faecal granulocyte excretion between the two
groups. Thus a regime decreasing the intraluminal concentration of bacteria and complex
food molecules, was associated with rapid improvement in activity of Crohn's disease. This
suggests that these intraluminal factors play a role in maintaining inflammation and that
their removal or alteration offers an approach to management.
Comparison of total parenteral nutrition and elemental diet in
induction of remission of Crohn's disease. Long-term maintenance of remission by
personalized food exclusion diets.
Author
Jones VA
Address
Department of Community Medicine, East Anglian Regional Health Authority,
Cambridge U.K.
Source
Dig Dis Sci, 32: 12 Suppl, 1987 Dec, 100S-107S
Abstract
Total parenteral nutrition or elemental diet can be used to induce
remission of Crohn's disease. A randomized study has been conducted of 36 patients to
assess the relative efficacy of the two techniques used without pharmacologic support;
both were successful, and no significant differences emerged in the number of days to
remission or the mean changes in Crohn's disease activity index, erythrocyte sedimentation
rate, or serum albumin. The elemental diet is cheaper, simpler and safer. Uncontrolled
clinical experience with 77 patients showed that personalized food exclusion diets were
associated with an average annual relapse rate of only 11% for the first five years of
diet alone; there have been six pregnancies and the longest remission is now 75 months.
The use of elemental diet followed by the development of a personal food exclusion diet
appears to be an effective long-term therapeutic strategy for Crohn's disease.
Chronic intermittent elemental diet improves growth failure in
children with Crohn's disease.
Author
Belli DC; Seidman E; Bouthillier L; Weber AM; Roy CC; Pletincx M; Beaulieu M;
Morin CL
Address
Service de Gastroentérologie, Hôpital Sainte-Justine,
Québec, Canada.
Source
Gastroenterology, 94: 3, 1988 Mar, 603-10
Abstract
Growth failure often complicates Crohn's disease in pediatric patients and
is principally due to inadequate caloric intake. To assess whether intermittent courses of
an elemental diet could reestablish growth, 8 children (aged 9.8-14.2 yr) with Crohn's
disease and growth failure entered into a prospective trial. Each patient was studied
during an observation year on standard therapy, then for an experimental year during which
they received enteral elemental diet 1 out of 4 mo. An age- and disease-matched control
group of 4 patients was treated by conventional medical therapy during both years.
Elemental diet therapy was administered nocturnally, at home, by continuous nasogastric
infusion and increased the daily caloric intake by 25% (p less than 0.01). Anthropometric
measurements demonstrated significant height and weight gains in the elemental diet group
vs. controls (p less than 0.01). Crohn's disease activity index and prednisone intake
decreased significantly in patients receiving elemental diet therapy when compared with
themselves and with controls on conventional medical therapy (p less than 0.05). In
contrast, the rate of pubertal development was similar in both groups irrespective of the
treatment modality. This study demonstrates that chronic intermittent elemental diet
effectively reverses growth arrest, while decreasing prednisone requirements and Crohn's
disease activity index in pediatric Crohn's disease patients prior to puberty.
Elemental diets in the prophylaxis and therapy for intestinal
lesions: an update.
Author
Bounous G
Address
Department of Surgery, Montreal General Hospital, Quebec, Canada.
Source
Surgery, 105: 5, 1989 May, 571-5
Abstract
The recognition of potentially noxious physiologic substances in the
intestinal milieu prompted the use of an "elemental" semihydrolyzed formula diet
in the prophylaxis of experimental acute ischemic enteropathy. Elemental diets have been
used in the management of a variety of digestive diseases. An elemental diet protects the
intestinal mucosa of rodents from radiation injury and facilitates mucosal healing.
Clinical trials have shown the benefits of this form of treatment in the prevention of
acute radiation enteropathy and in the therapy for delayed radiation enteropathy and
Crohn's disease.
Steroids and bowel rest versus elemental diet in the treatment
of patients with Crohn's disease: the effects on protein metabolism and immune function.
Author
O'Keefe SJ; Ogden J; Rund J; Potter P
Address
Gastrointestinal Clinic, Groote Schuur Hospital, South Africa.
Recent studies have shown an elemental diet to be as effective as bowel
rest plus steroids in the management of acute Crohn's disease. In order to investigate the
metabolic and immunological effects of these two therapies, six patients with an acute
inflammatory attack of ileal Crohn's disease were randomly assigned to receive steroids or
elemental diet for 7 days. Immunological and protein metabolic studies were performed
before and after therapy, protein kinetic rates being measured by the method of constant
intravenous infusion of 14C-labeled leucine tracer. Clinical and symptomatic improvement
was noted in all six patients with significant falls in sedimentation rate and platelet
counts and increases in albumin concentrations. Both forms of treatment increased plasma
amino acid flux and oxidation rates, whole body protein turnover and rates of
incorporation of amino acid into albumin. However, the increased rates of protein
metabolism in the patients given steroids were at the expense of body protein stores with
a net (average) loss of 58 g of nitrogen over 7 days. While both forms of therapy were
associated with suppression of lymphocyte subsets, complement and circulating immune
complexes only the steroid regimen was associated with suppression of in vivo IgG
synthesis rates. The results indicated that both forms of therapy were associated with
clinical improvement, increases in protein turnover and evidence of reduced inflammatory
activity. However, the beneficial effects of steroid regimen must be balanced against the
deleterious effects on body protein stores; steroids and bowel rest without nutritional
support should be avoided in malnourished patients.
Improvement of abnormal
lactulose/rhamnose permeability in
active Crohn's disease of the small bowel by an elemental diet.
Author
Sanderson IR; Boulton P; Menzies I; Walker-Smith JA
Address
Department of Child Health, St. Bartholomew's Hospital, London.
Source
Gut, 28: 9, 1987 Sep, 1073-6
Abstract
Intestinal permeability to sugar has been used as an objective measure of
small bowel integrity to assess the efficacy of an elemental diet as the sole treatment or
Crohn's disease of the small bowel. Fourteen children aged 11-17 years with active small
bowel Crohn's disease were given an elemental diet for six weeks. Investigations with
iso-osmolar oral test solutions before and after this treatment showed that all 14
children had abnormally raised lactulose/L-rhamnose permeability ratios, which fell
significantly after the elemental diet. This change coincided with marked clinical
improvement, as assessed by a disease activity index score.
Clinical remission and disappearance of radiologic
manifestations in Crohn's disease after oligopeptide diet treatment.
Author
Pfeil AB; Schuster AT; Kemperdick H
Address
Department of Pediatrics, University of
Düsseldorf, F.R.G.
A 9.6-year-old patient was treated exclusively with an oligopeptide diet at
initial diagnosis and at first relapse of Crohn's ileocolitis. The patient achieved
complete remission in both episodes. Control radiologic examinations 14 months after
diagnosis revealed complete disappearance of radiologic manifestations of Crohn's disease.
Diet counseling modifies nutrient intake of patients with
Crohn's disease.
Author
Imes S; Pinchbeck BR; Thomson AB
Source
J Am Diet Assoc, 87: 4, 1987 Apr, 457-62
Abstract
The nutrient intake of 137 outpatients with Crohn's disease was recorded,
and the effect of diet counseling was assessed. Half the patients received monthly diet
counseling that was individualized and aimed at normalizing nutrient intake; the other
half of the patients received no diet counseling and served as controls. Over the 6-month
study period, the mean nutrient intakes met or exceeded the 1980 U.S. Recommended Dietary
Allowances (RDAs) for all nutrients except folate in the men and iron and folate in the
women. However, at study entry, for each nutrient there was a substantial proportion of
patients whose intake did not meet the full RDA. Less than 50% of the men consumed the
full RDA for energy and folate, and less than 50% of the women consumed the full RDA for
energy, folate, calcium, iron, thiamin, and vitamin B-12. Monthly diet counseling sessions
were associated with increases in the mean intake of most nutrients, whereas similar
improvement was not observed in the control group members, who did not receive counseling.
By 6 months, significantly more counseled than non-counseled patients were consuming the
full RDA for protein, riboflavin, and vitamin C (p less than .05). Thus, diet counseling
was found to be an important tool for improving the nutrient intake of outpatients with
Crohn's disease.
Diet and bowel diseases--past history and future prospects.
Author
Walker AR
Source
S Afr Med J, 68: 3, 1985 Aug 3, 148-52
Abstract
Changes in diet from ancient times until the present are described.
Previously relatively low in energy and animal products yet high in fibre-containing
foods, diets are now high in energy and animal products (particularly fat), yet contain
less fibre. The changing incidences of bowel disorders and diseases are described, with
assessments of the role of diet. Clearly, diet is implicated as regards predisposition to
constipation, appendicitis, colorectal cancer and diverticular disease; however, a
meaningful dietary role in irritable bowel syndrome, ulcerative colitis and Crohn's
disease is doubtful. In South Africa the rarity of bowel diseases in rural blacks compared
with whites affords valuable aetiological information about some bowel diseases. The low
occurrence thereof (except inflammatory bowel disease) in Indian and coloured populations
is not readily explicable. While dietary changes in whites are being widely urged in order
to combat degenerative diseases, the magnitude of changes made is unlikely to reduce the
occurrence of bowel diseases. The progressive westernization of the diets and lifestyles
of less-privileged populations is likely to be associated with increases in the incidences
of these diseases.
Home enteral nutrition with formula diets.
Author
Russell RI
Source
Z Gastroenterol, 23 Suppl:1985 Aug, 94-7
Abstract
Home enteral nutrition can be successfully used on a long-term basis to
maintain nutrition and a reasonably normal lifestyle in patients with chronic intestinal
dysfunction. Patients can be easily taught the methods involved, a nocturnal regime
allowing a more normal lifestyle. The use of a pump-controlled system is recommended.
Side-effects are few, generally transient and not severe. Home enteral nutrition has
advantages over home intravenous feeding with respect to ease of administration and
organisation, fewer and less severe complications, and cost.
Iron, folate, vitamin B-12, zinc, and copper status in
outpatients with Crohn's disease: effect of diet counseling.
Author
Imes S; Pinchbeck BR; Dinwoodie A; Walker K; Thomson AB
Source
J Am Diet Assoc, 87: 7, 1987 Jul, 928-30
Abstract
Iron, folate, and vitamin B-12 status was found to be poor in a substantial
proportion of outpatients with generally inactive Crohn's disease. Diet counseling was
associated with a normalization of TIBC and serum folate over a 6-month period, but no
other consistent benefits were noted despite moderate improvements in intake. The
outpatients appeared to be at low risk of developing a zinc or copper deficiency.
Crohn's disease: maintenance of remission by diet.
Author
Jones VA; Dickinson RJ; Workman E; Wilson
AJ; Freeman AH; Hunter JO
Source
Lancet, 2: 8448, 1985 Jul 27, 177-80
Abstract
20 patients with Crohn's disease took part in a controlled trial in which
remission was maintained by either an unrefined carbohydrate fibre rich diet or a diet
which excluded specific foods to which a patient was intolerant. 7 out of the 10 patients
on the exclusion diet remained in remission for 6 months compared with none out of the 10
on an unrefined carbohydrate fibre rich diet (p less than 0.05, Fisher's exact test). In
an uncontrolled study an exclusion diet allowed 51 out of 77 patients to remain well on
the diet alone for periods of up to 51 months, and with an average annual relapse rate of
less than 10%.
Diet counselling improves the clinical course of patients with
Crohn's disease.
Author
Imes S; Pinchbeck B; Thomson AB
Address
Nutrition and Metabolism Research Group, Faculty of Medicine, University of
Alberta, Edmonton, Canada.
Source
Digestion, 39: 1, 1988, 7-19
Abstract
A prospective study was undertaken to establish the role of individualized
diet counselling in the management of 137 outpatients with Crohn's disease. Individualized
dietary counselling for 6 months was associated with a significant decrease in the Crohn's
disease activity index, an increased incidence of disease remission, a decreased need for
prednisone and Salazopyrin therapy, a reduction in the number of days spent in hospital,
and a reduction in the amount of time lost from work due to Crohn's disease, when compared
with control patients who did not receive dietary counselling but who were seen regularly
in follow-up under similar circumstances. Improvement with diet counselling was more
likely to occur in patients who had not previously been subjected to small bowel
resection, and occurred in patients with active or inactive disease. The effect of
counselling 58 patients was assessed over a further 6 months (for a total 12-month
period); there was a persistently reduced Crohn's disease activity index and a continued
decreased number of lost days of work. The mechanism for these beneficial effects of diet
counselling was not established. It is suggested that individualized diet
counselling,
aimed at optimizing the patient's nutritional status, may play a role in the management of
patients with Crohn's disease.
Vitamin C status in 137 outpatients with Crohn's disease. Effect
of diet counseling.
Author
Imes S; Dinwoodie A; Walker K; Pinchbeck B; Thomson AB
Source
J Clin Gastroenterol, 8: 4, 1986 Aug, 443-6
Abstract
Vitamin C intake, and serum and leukocyte ascorbate levels were assessed
serially over 6 months in 137 outpatients with Crohn's disease. Vitamin C intake was low
in 18% of males and 37% of females. Serum ascorbate levels were suboptimal in 11% of males
and 18% of females. Leukocyte ascorbate levels were low in 26% of males and 49% of
females. Serum ascorbate levels were more frequently below the reference range in patients
who smoked, but neither the serum nor the leukocyte ascorbate levels were affected by
Crohn's disease activity, the use of an oral contraceptive agent, or by taking prednisone
or sulfasalazine. Monthly diet counseling sessions significantly increased vitamin C
intake, led to more patients consuming a normal ascorbate intake, and to a normalization
of serum ascorbate values. We did not establish the importance of these ascorbate
abnormalities on the clinical course of Crohn's disease. We conclude that low serum or
leukocyte ascorbate levels are relatively common in patients with active or inactive
Crohn's disease; these abnormalities are due in part to the reduced intake of dietary
ascorbate; and the ascorbate status in patients with Crohn's disease may be normalized by
improving the dietary intake of vitamin C.
Remission induced by an elemental diet in small bowel Crohn's
disease.
Author
Sanderson IR; Udeen S; Davies PS; Savage MO; Walker-Smith JA
Source
Arch Dis Child, 62: 2, 1987 Feb, 123-7
Abstract
Seventeen children with active Crohn's disease of the small intestine were
entered into a randomised control trial comparing the efficacy of an elemental diet with
that of a high dose steroid regimen. Eight children received an elemental diet
(Flexical)
through a nasogastric tube for six weeks, followed by reintroduction of food over six
weeks during which the Flexical was stopped. Seven children were given intramuscular
adrenocorticotrophic hormone followed by oral prednisolone with
sulphasalazine. Two
children were withdrawn from the trial. The elemental diet was equally effective in
inducing an improvement in Lloyd-Still disease activity index, erythrocyte sedimentation
rate, C reactive protein and albumin concentrations, and body weight as the high dose
steroid regimen. Linear growth, assessed from height velocity over six months, was
significantly greater in the children receiving an elemental diet.
Elemental diet administered nasogastrically without starter
regimens to patients with inflammatory bowel disease.
The present study questions the concept of routinely using 'starter
regimens' at the outset of enteral feeding with chemically defined elemental diets. A
hypertonic elemental diet with an osmolality of 630 mOsm/kg was administered by 24-hr
nasogastric infusion to 12 patients with exacerbations of inflammatory bowel disease and
to two patients with short bowel syndrome. Starter regimens were not used. Upper
gastrointestinal symptoms of nausea, abdominal bloating, and colicky pain occurred
transiently in only five of 14 patients. Stool frequency did not increase during
full-strength feeding, and daily stool weights decreased significantly (p less than 0.01).
These findings show that it is safe to administer undiluted hypertonic elemental diets by
constant nasogastric infusion to patients with inflammatory bowel disease. Avoiding
starter regimens leads to increased nutrient intake and improved nitrogen balance.
Controlled trial comparing an elemental diet with prednisolone
in the treatment of active Crohn's disease.
Author
Okada M; Yao T; Yamamoto T; Takenaka K; Imamura K; Maeda K; Fujita K
Address
1st Department of Internal Medicine, School of Medicine, Fukuoka University,
Japan.
Source
Hepatogastroenterology, 37: 1, 1990 Feb, 72-80
Abstract
To determine whether an elemental diet or prednisolone would be more
effective for treating acute Crohn's disease, a controlled trial was conducted on 20
patients with acute Crohn's disease who had never received specific treatment. The first
ten patients were put on an elemental diet and the remaining ten were prescribed
prednisolone for six weeks at an initial dose of 0.7 mg/kg/day. Patients were assessed
using the simple activity index, body weight, erythrocyte sedimentation rate, C-reactive
protein and alpha 2 globulin, serum albumin, and radiographic findings of bowel lesions.
At six weeks, the patients on the elemental diet showed a significantly greater
improvement in the activity index, inflammatory signs such as C-reactive protein and alpha
2 globulin, and radiographic findings of bowel lesions than did those on the steroid.
Patients who were given steroids for six weeks and then treated with the elemental diet
for four weeks showed improvement in the radiographic findings of bowel lesions and
inflammation. The present study strongly suggests that elemental diet is superior to
steroids for treating active Crohn's disease.
Ten years' experience with an elemental diet in the management
of Crohn's disease.
Author
Teahon K; Bjarnason I; Pearson M; Levi AJ
Address
Section of Gastroenterology, MRC Clinical Research
Centre, Harrow,
Middlesex, UK.
Source
Gut, 31: 10, 1990 Oct, 1133-7
Abstract
The immediate and long-term outcome of treating patients with acute Crohn's
disease with an elemental diet was studied retrospectively. Successful diet induced
remission was achieved in 96 of 113 patients (85%) regardless of age, sex, site or
severity of disease, or associated complications of strictures, fistula, or perianal
disease. Treatment was unsuccessful in 17 patients (15%), but there were no features at
the outset of treatment that distinguished these patients from those who had successful
remission. The longterm outcome of treatment was assessed over a five year period by
analysis of life tables and survival curves. Twenty two per cent of the patients relapsed
within six months of treatment and thereafter the annual relapse rate was 8-10%. Patients
with disease complicated by fistula or perianal involvement had early relapse, approaching
100% for the latter. A further retrospective comparison of longterm outcome of diet vs
steroid induced remissions showed no significant difference in the relapse rates between
the two groups at one, three, and five years.
Controlled trial of polymeric versus elemental diet in treatment
of active Crohn's disease
Author
Giaffer MH; North G; Holdsworth CD
Address
Gastroenterology Unit, Royal Hallamshire Hospital, Sheffield.
Source
Lancet, 335: 8693, 1990 Apr 7, 816-9
Abstract
30 patients with active Crohn's disease, mean Crohn's Disease Activity
Index 301 (SE 32), who would otherwise have been treated with steroids, were randomised to
receive for 4 weeks either an elemental diet ('Vivonex') (n = 16) or a polymeric diet
('Fortison') (n = 14). Assessment on days 10 and 28 showed that clinical remission
occurred in 5 (36%) of the 14 patients on fortison compared with 12 (75%) of the 16
patients assigned to vivonex. The difference in remission rate was significant (p less
than 0.03). Dietary treatment resulted in little change in the nutritional state and
various laboratory indices of activity over a 4 week period despite clinical improvement.
Polymeric diets do not seem to offer an effective therapeutic alternative to elemental
diets in patients with acute exacerbations of Crohn's disease.
Feasibility and effectiveness of a defined-formula diet regimen
in treating active Crohn's disease. European Cooperative Crohn's Disease Study III.
Author
Malchow H; Steinhardt HJ; Lorenz-Meyer H; Strohm WD; Rasmussen S; Sommer H;
Jarnum S; Brandes JW; Leonhardt H; Ewe K; et al
Address
Medizinische Klinik II, Staedtisches Krankenhaus
(Dhuennberg), Leverkusen 1, FRG.
Source
Scand J Gastroenterol, 25: 3, 1990 Mar, 235-44
Abstract
In a randomized multicenter trial the efficacy of treatment of active
Crohn's disease by means of a liquid defined formula diet (DFD) was tested and compared
with a combination of 6-methyl-prednisolone and sulfasalazine. A total of 95 patients
participated in the study. By the end of 6 weeks, among 44 patients randomized to drug
treatment, 32 showed improvement of the Crohn's disease activity index (CDAI) as compared
with 21 of 51 patients receiving oral DFD (p less than 0.05). The proportion of
withdrawals in the DFD group (29 of 51) was sevenfold higher than in the drug group (4 of
44). However, most patients (20 of 29) receiving DFD withdrew because of the
unpalatability of the liquid diet. Analysis of patients in each group who finished the
study showed equal effectiveness of DFD and the drug regimen. In these subsets of
patients the CDAI decreased from 280.8 +/- 90.6 to 151.7 +/- 86.5 (DFD) and from 263.7 +/-
86.3 to 129.3 +/- 63.7 (drug), respectively. Improvement of inflammation factors was
similar in both groups at the end of the study, although improvement was delayed in the
DFD group. In conclusion, our data show a superiority of the drug combination over DFD in
the treatment of Crohn's disease under the conditions of this trial. The results do
suggest, however, that DFD offers a therapeutic alternative to prednisolone and
sulfasalazine in a subgroup of patients, which has to be closer characterized in further
studies.
The effect of elemental diet on intestinal permeability and
inflammation in Crohn's disease.
Author
Teahon K; Smethurst P; Pearson M; Levi AJ; Bjarnason I
Address
Section of Gastroenterology, Medical Research Council Clinical Research
Centre, Harrow, Middlesex, England.
Source
Gastroenterology, 101: 1, 1991 Jul, 84-9
Abstract
This study examines whether treatment of acute Crohn's disease with an
elemental diet improves intestinal integrity and inflammation as assessed by a
51Cr-labeled ethylenediaminetetraacetatic acid (EDTA) permeability test and the fecal
excretion of 111In-labeled autologous leukocytes, respectively. Thirty-four patients with
active Crohn's disease completed a 4-week treatment course with an elemental diet. Active
disease was characterized by increased intestinal permeability [24-hour urine excretion of
orally administered 51Cr-EDTA, 6.4% +/- 0.6% (mean +/- SE); normal, less than 3.0%] and by
high fecal excretion of 111In-labeled leukocytes (14.2% +/- 1.1%; normal, less than 1.0%).
Twenty-seven (80%) went into clinical remission, usually within a week of starting
treatment. After 4 weeks of treatment, there was a significant decrease in both the urine
excretion of 51Cr-EDTA (to 3.4% +/- 0.5%; P less than 0.01) and the fecal excretion of
111In (to 5.7% +/- 1.0%; P less than 0.001), indicating that such treatment is not just
symptomatic. A framework for the mechanism by which elemental diet works, centering around
the importance of the integrity of the intestinal barrier function, is proposed, and also
appears to provide a logical explanation for some relapses of the disease.
Long-term effects of elemental and exclusion diets for Crohn's
disease.
Author
Giaffer MH; Cann P; Holdsworth CD
Address
Royal Hallamshire Hospital, Sheffield, UK.
Source
Aliment Pharmacol Ther, 5: 2, 1991 Apr, 115-25
Abstract
Previous studies have confirmed the therapeutic value of elemental diets in
promoting remission in active Crohn's disease, but their long-term benefit has not been
established. Twenty-seven patients with established Crohn's disease who attained clinical
remission after four weeks of enteral feeding were followed prospectively for up to 36
months. Twenty of these were willing to be tested for specific food intolerance using a
pre-defined dietary elimination protocol; the others continued on a normal unrestricted
diet. Eighteen patients (67%) have since relapsed; 89% of the relapse occurred within the
first 6 months. Of the 15 patients with colonic involvement, 12 (80%) relapsed by 6
months. In contrast only 3 of 11 with isolated small bowel disease experienced early
relapse. Of the 14 patients who completed the process of dietary testing, 5 could not
identify any trigger foods; the remaining 9 were maintained on exclusion diets, 3 of whom
relapsed early. Of the 11 taking a normal diet, 9 relapsed. Disease duration, previous
intestinal resection or prior steroid therapy did not affect the relapse rate. Eight
patients (31%) obtained a long-term remission, mean 23 months (range 12-36 months),
without any medication. Long-lasting remissions can be obtained in about one-third of
patients with Crohn's disease following treatment with a defined formula diet. Colonic
involvement is associated with a high early relapse rate.
Elemental diet in the management of Crohn's disease during
pregnancy.
Author
Teahon K; Pearson M; Levi AJ; Bjarnason I
Address
Section of Gastroenterology, MRC Clinical Research
Centre, Middlesex.
Source
Gut, 32: 9, 1991 Sep, 1079-81
Abstract
Four patients with Crohn's disease were treated with an elemental diet
during pregnancy. Two had active disease and two also had symptoms of small intestinal
obstruction. All went into a clinical remission within a few days of starting treatment.
Treatment periods varied from two to four weeks, and were followed by elemental diet as a
supplement to normal food in two patients. At term, all delivered a healthy infant. These
patients indicate that elemental diet is a safe form of treatment for Crohn's disease
during pregnancy and may be considered as an alternative to conventional drug treatments
which carry a theoretical risk of teratogenesis.
Elemental diet in steroid-dependent and steroid-refractory
Crohn's disease.
Author
O'Brien CJ; Giaffer MH; Cann PA; Holdsworth CD
Address
Gastroenterology Unit, Royal Hallamshire Hospital, Sheffield, United
Kingdom.
Source
Am J Gastroenterol, 86: 11, 1991 Nov, 1614-8
Abstract
Sixteen patients with Crohn's disease who had symptoms uncontrolled by
high-dose steroids (n = 11) or symptoms invariably appearing on reduction or withdrawal of
immunosuppressive therapy (n = 5) were treated with elemental diet. After 4 wk of dietary
treatment, 10 patients were in remission and off all medication. Seven continued to be
well without treatment for a minimum of 6 months, and four for at least 1 yr. No patient
who subsequently relapsed had further steroid-refractory symptoms. Of the six patients
failing to respond to elemental diet, four with steroid-refractory disease required early
resective surgery for symptom relief, and two continued with steroid therapy, one in much
reduced dosage. Elemental diet can bring about a sustained remission in many patients with
Crohn's disease dependent on or refractory to corticosteroids, and reduce the need for
surgical intervention.
Improved growth and disease activity after intermittent
administration of a defined formula diet in children with Crohn's disease.
Author
Polk DB; Hattner JA; Kerner JA Jr
Address
Department of Pediatrics, Stanford University School of Medicine,
California.
Growth failure is the most common extraintestinal manifestation of Crohn's
disease in childhood, occurring in up to 50% to 88% of affected patients. Previous studies
have shown malnutrition to be the most likely cause of the decrease in height and weight
velocities in these children. The purpose of this study was to determine the effect of an
intermittent defined formula diet on growth and disease activity in children with Crohn's
disease and growth failure. Six Tanner stage I-II patients, mean age 13.6 years with
height less than the 5th percentile or height velocity less than the 3rd percentile were
enrolled in a 1-year prospective study. An isotonic, hydrolyzed whey, medium-chain
triglyceride formula was given by nocturnal nasogastric infusion at a caloric equivalent
of 50th percentile for age, as the exclusive nutrient source 1 out of 4 months during a
1-year period. A 2-week exclusion diet and a 2-week low-residue diet followed the defined
formula diet before resuming the regular diet for 2 months. Patients served as their
individual control based on observations of at least 1 year before the study. Height and
weight velocity significantly increased. Prednisone intake significantly decreased, and
significant improvement was seen in disease activity, albumin, and somatomedin C. The
results indicate that an intermittent defined formula diet can improve growth failure and
significantly decrease disease activity in children with Crohn's disease.
Diet and inflammatory bowel disease: a case-control study.
Author
Persson PG; Ahlbom A; Hellers G
Address
Department of Epidemiology, Karolinska
Institutet, Stockholm, Sweden.
Source
Epidemiology, 3: 1, 1992 Jan, 47-52
Abstract
We conducted a population-based case-control
study of inflammatory bowel disease and dietary habits in Stockholm during
1984-1987. We obtained retrospective information about food intake 5 years
previously by a postal questionnaire for 152 cases with Crohn's disease, 145
cases with ulcerative colitis, and 305 controls. The relative risk of
Crohn's disease was increased for subjects who had a high (55 gm or more per
day) intake of sucrose (relative risk = 2.6, 95% confidence interval =
1.4-5.0) and was decreased for subjects who had a high (15 gm or more per
day) intake of fiber (relative risk = 0.5, 95% confidence interval =
0.3-0.9). The most striking finding was an increased relative risk of both
Crohn's disease and ulcerative colitis associated with consumption of fast
foods: the relative risk associated with consumption of fast foods at least
two times a week was estimated at 3.4 (95% confidence interval = 1.3-9.3)
for Crohn's disease and 3.9 (95% confidence interval = 1.4-10.6) for
ulcerative colitis.
Initial response and subsequent course of Crohn's disease
treated with elemental diet or prednisolone.
Author
Gorard DA; Hunt JB; Payne-James JJ; Palmer KR; Rees
RG; Clark ML; Farthing MJ; Misiewicz JJ; Silk DB
Address
Department of Gastroenterology, St Bartholomew's Hospital, London.
Source
Gut, 34: 9, 1993 Sep, 1198-202
Abstract
Elemental diet is as effective as corticosteroids in the treatment of
previously untreated Crohn's disease. It is unclear whether a poor nutritional state is a
prerequisite for efficacy of elemental diet, whether previously treated patients respond
as well, or how duration of remission using elemental diet compares with corticosteroid
induced remission. Forty two patients with active Crohn's disease were stratified for
nutritional state and randomised to receive Vivonex TEN 2.1 l/day for four weeks, or 0.75
mg prednisolone/kg/day for two weeks and subsequent reducing doses. Nine of 22 (41%)
patients assigned to nutritional treatment were intolerant of the diet. Thirty patients
completed four weeks treatment. Disease activity decreased on elemental diet from mean
(SEM) 4.8 (0.9) to 1.7 (0.6), p < 0.05, and on prednisolone from 5.3 (0.5) to 1.9
(0.6), p < 0.05. For each treatment, nourished and malnourished patients responded
similarly. Patients with longstanding disease responded as well as newly diagnosed
patients. The probability of maintaining remission at six months was 0.67 after
prednisolone, 0.28 after elemental diet, and at one year was 0.35 after prednisolone and
0.09 after elemental diet, p < 0.05. When tolerated, elemental diet is as effective in
the short term as prednisolone in newly and previously diagnosed Crohn's disease, and its
benefit is independent of nutritional state. The subsequent relapse rate after elemental
diet induced remission, however, is greater than after treatment with
prednisolone.
Comparison of amino acid v peptide based enteral diets in active
Crohn's disease: clinical and nutritional outcome.
Author
Royall D; Jeejeebhoy KN; Baker JP; Allard JP; Habal FM; Cunnane SC; Greenberg
GR.
Division of Gastroenterology, Toronto General Hospital, Canada.
Source Gut, 35: 6, 1994 Jun, 783-7
Abstract
Elemental diets are considered an effective primary treatment for active
Crohn's disease. This study examined the hypothesis that improvement occurs because of the
presence of amino acids or the low fat content, or both. A randomised, controlled trial
was undertaken in 40 patients with active Crohn's disease to evaluate clinical and
nutritional outcomes after an amino acid based diet containing 3% fat was given by a
feeding tube compared with a peptide based diet containing 33% fat. After three weeks'
treatment, clinical remission occurred in 84% of patients who were given the amino acid
diet and 75% of patients who received the peptide diet (p = 0.38). Plasma linoleic acid
concentration was reduced after the amino acid but not the peptide diet. An increase in
total body nitrogen was associated with the magnitude of nutritional depletion before
treatment and at six months' follow up, only patients who showed gains in total body
nitrogen after enteral nutrition had a sustained clinical remission. This study shows that
peptide based high fat diets are as effective as amino acid low fat diets for achieving
clinical remission in active Crohn's disease. Improved total body protein stores but not
essential fatty acid depletion may be an important indicator of a sustained remission.
Treatment of active Crohn's disease by exclusion diet
Author
Riord an AM; Hunter JO; Cowan RE; Crampton JR; Davidson AR; Dickinson RJ;
Dronfield MW; Fellows IW; Hishon S; Kerrigan GN; et al
Address
Department of Gastroenterology, Addenbrooke's Hospital, Cambridge, UK.
Source
Lancet, 342: 8880, 1993 Nov 6, 1131-4
Abstract
Elemental diet is as effective in producing remission of Crohn's disease
(CD) as is corticosteroid treatment, but most patients relapse soon after resumption of a
normal diet. We have investigated the efficacies of dietary modification and oral
corticosteroids in maintaining remission achieved with elemental diet. In a multicentre
trial, 136 patients with active CD were started on elemental diet and other treatment was
withdrawn. 43 (31%) declined to continue elemental diet for 14 days, but 78 (84%) of the
remaining 93 achieved remission and were randomly assigned corticosteroids (38) or diet
(40). Corticosteroid treatment started at 40 mg prednisolone daily, which was tapered and
stopped after 12 weeks; that group received dietary advice on healthy eating. The diet
group received "tapered" placebo and were instructed to introduce one new food
daily, excluding any that precipitated symptoms. Assessment of progress for up to 2 years
was made by physicians unaware of group assignment. Intention-to-treat analysis showed
median lengths of remission of 3.8 (interquartile range 5.0) months in the corticosteroid
group and 7.5 (15.3) months on diet, and relapse rates at 2 years, adjusted for
withdrawals, of 79% and 62%, respectively (p = 0.048). Clinical improvement in the diet
group was associated with significant changes in plasma albumin and alpha
1-antichymotrypsin concentrations and erythrocyte sedimentation rate. Food intolerances
discovered were predominantly to cereals, dairy products, and yeast. Diet provides a
further therapeutic strategy in active Crohn's disease.
Alterations in nutritional status and disease activity during
treatment of Crohn's disease with elemental diet.
Author
Teahon K; Pearson M; Smith T; Bjarnason I
Address
Dept. of Clinical Pharmacology, University of Newcastle-upon-Tyne, UK.
Source
Scand J Gastroenterol, 30: 1, 1995 Jan, 54-60
Abstract
BACKGROUND: The mechanisms by which elemental diets induce remission in
patients with Crohn's disease is unknown, but it has been suggested that improvement in
nutritional state may play a part. METHODS: We assessed sequential changes in disease
activity (clinical and laboratory indices and faecal excretion of indium-111-labelled
leucocytes) and nutritional status (anthropometry, body composition variables), hepatic
secretory proteins (albumin, pre-albumin, transferrin), and trace elements (iron,
magnesium, copper, zinc) during treatment of acute Crohn's disease with an elemental diet.
RESULTS: Disease activity indices improved significantly by 2 weeks and were maintained at
4 weeks of treatment. There was a significant increase in pre-albumin at 4 weeks and an
increase in serum iron and a decrease in serum copper during the study period. The changes
occurring in the measures of nutrition did not correlate significantly with the changes in
disease activity. CONCLUSION: The fact that changes in disease activity appear to precede
any detectable changes in nutritional state, it suggests that the beneficial action of
elemental diet in patients with active Crohn's disease is not due to an improvement in
nutritional status.
Remission following an elemental diet or prednisolone in Crohn's
disease.
Author
Papadopoulou A; Rawashdeh MO; Brown GA; McNeish AS; Booth IW
Address
University of Birmingham, Institute of Child Health, UK.
Source
Acta Paediatr, 84: 1, 1995 Jan, 79-83
Abstract
The short- and long-term effects of an elemental diet in children with
acute Crohn's disease were compared with those of prednisolone in historical controls.
Clinical remission was induced in 25 of 30 and in 18 of 28 episodes treated for six weeks
with an elemental diet and prednisolone. Patients with proximal disease had longer
remission after treatment with an elemental diet (p < 0.05) than did patients with
colonic disease after treatment with prednisolone (p < 0.01). Disease activity index
score improved in both groups compared with the pretreatment scores (p < 0.05).
However, the improvement in the elemental diet group was significantly better than in the
prednisolone group (p < 0.001). Changes in linear growth were better after treatment
with an elemental diet compared with steroids (p < 0.001). Serum albumin and
haematocrit concentrations all improved significantly in the children treated with an
elemental diet (p < 0.001) but not in those treated with steroids. Thus an elemental
diet was better than prednisolone in proximal disease and confirmed improved growth and
nutritional status.
Controlled trial of oligopeptide versus amino acid diet in
treatment of active Crohn's disease.
Author
Mansfield JC; Giaffer MH; Holdsworth CD
Address
Gastroenterology Unit, Royal Hallamshire Hospital, Sheffield.
Source
Gut, 36: 1, 1995 Jan, 60-6
Abstract
Elemental diets are effective in inducing remission in active Crohn's
disease, but how they exert this therapeutic effect is unclear. In a previous study a
whole protein containing diet proved less effective than one in which food antigens were
excluded, suggesting that exclusion of food antigens from the gut was a possible
mechanism. This study was designed to test whether an oligopeptide diet of hydrolysed
proteins was as effective as an amino acid based diet. These diets were equally antigen
free but with different nitrogen sources. Forty four patients with active Crohn's disease
were randomised in a controlled trial of amino acid versus oligopeptide diet. The feeds
were given by nasogastric tube in equicaloric quantities and were the sole form of
nutrition. Treatment was continued for four weeks although failure to improve by day 10
resulted in withdrawal. Quantitative leucocyte scintigraphy was used to investigate the
effect of diet treatment on gut inflammation. Clinical and nutritional responses to
treatment were also measured. Sixteen patients entered remission (including withdrawal of
corticosteroids), six patients could not tolerate the nasogastric tube, and 22 patients
failed to respond. The two diets were equally effective. Patients who responded had a
rapid drop in clinical index of disease activity and a major reduction in the bowel uptake
of leucocytes on scintigraphy. The oligopeptide and amino acid based enteral feeds were
equally effective at inducing remission in active Crohn's disease. With both diets
clinical improvement was accompanied by a reduction in intestinal inflammation.
Polymeric enteral diets as primary treatment of active Crohn's
disease: a prospective steroid controlled trial.
Author
González-Huix F; de León R; Fernández-Bañares F; Esteve M; Cabré E;
Acero D; Abad-Lacruz A; Figa M; Guilera M; Planas R; et al
Source
Gut, 34: 6, 1993 Jun, 778-82
Abstract
Thirty two patients with active Crohn's disease were included in a
controlled randomised trial to determine the efficacy and safety of polymeric enteral
nutrition compared with steroids, to achieve and maintain clinical remission. The
polymeric diet was administered through a fine bore nasogastric tube by continuous, pump
assisted infusion (2800 (SEM 120) kcal/day). The steroid group received 1 mg/kg/day of
prednisone. Both treatments were effective in inducing clinical remission: 15 of the 17
patients given steroids and 12 of the 15 patients assigned to the polymeric diet went into
clinical remission (defined by a Van Hees index < 120) within four weeks of treatment.
The percentage reduction of the Van Hees index was 34.8 (4.9)% for steroids and 32.3 (5)%
for enteral nutrition (mean difference 2.5%; 95% CI--11.8% to +16.8%). Mean time elapsed
to achieve remission was similar in both groups (2.0 (1) v 2.4 (1.2) weeks). Tolerance of
the enteral diet was excellent. Four patients in the steroid group had mild complications
attributable to this treatment. Ten patients (66.6%) in the steroid group and five (41.6%)
in the enteral nutrition group relapsed within a year of discharge, but no differences
were found in the cumulative probability of relapse during the follow up period. These
results suggest that polymeric enteral nutrition is as safe and effective as steroids in
inducing short term remission in active Crohn's disease.
Comparison between the bacterial and oligosaccharide content of
ileostomy effluent in subjects taking diets rich in refined or unrefined carbohydrate.
Author
Berghouse L; Hori S; Hill M; Hudson M;
Lennard-Jones JE; Rogers E
Source
Gut, 25: 10, 1984 Oct, 1071-7
Abstract
Dietary surveys have shown that patients with Crohn's disease tend to eat
more sucrose than control subjects and this investigation was undertaken to determine
whether a diet rich in refined carbohydrate affects the bacterial flora of the terminal
ileum. Ileostomy effluent in five patients with Crohn's disease and five with ulcerative
colitis after two weeks on a diet rich in sucrose and refined cereal has been compared
with the same period on a diet low in sucrose and rich in unrefined cereal. Observations
were made hourly for nine hours after equicaloric breakfasts representing the two diets.
The amount of ileostomy effluent was greater on the unrefined carbohydrate diet both in
terms of wet weight (238 +/- 89 g vs 162 +/- 79 g, p less than 0.02) and dry weight (23 X
6 +/- 6.8 g vs 14.9 +/- 6.6 g, p less than 0.01); surprisingly, the amount of glucose and
oligosaccharide was also greater (169 +/- 41 mg vs 82 +/- 26 mg, p less than 0.001) in all
10 volunteers. The bacteriological flora per gram was also higher on the unrefined
carbohydrate diet after the test meal (p less than 0.02 between three and six hours) as a
result of a general increase in all organisms. The relative proportions of the organisms
did not vary between the two diets. No differences were detected between patients with
ulcerative colitis and those with Crohn's disease.
The gut as a lymphoepithelial organ: the role of intestinal epithelial cells in
mucosal immunity.
Mucosal surfaces covered by a layer of epithelial cells represent the
largest and most critical interface between the organism and its environment. The barrier
function of mucosal surfaces is performed by the epithelial layer and immune cells present
in the mucosal compartment. As recently found, epithelial cells, apart from their
participation in absorptive, digestive and secretory processes perform more than a passive
barrier function and are directly involved in immune processes. Besides the well known
role of epithelial cells in the transfer of polymeric immunoglobulins produced by lamina
propria B lymphocytes to the luminal content of mucosals (secretory Igs), these cells were
found to perform various other immunological functions, to interact with other cells of
the immune system and to induce an efficient inflammatory response to microbial invasion:
enzymic processing of dietary antigens, expression of class I and II MHC antigens,
presentation of antigens to lymphocytes, expression of adhesive molecules mediating
interaction with intraepithelial lymphocytes and components of extracellular matrix,
production of cytokines and probable participation in extrathymic T cell development of
intraepithelial lymphocytes. All these functions were suggested to influence substantially
the mucosal immune system and its response. Under immunopathological conditions, e.g.
during infections and inflammatory bowel and celiac diseases, both epithelial cells and
intraepithelial lymphocytes participate substantially in inflammatory reactions. Moreover,
enterocytes could become a target of mucosal immune factors. Mucosal immunosurveillance
function is of crucial importance in various pathological conditions but especially in the
case of the most frequent malignity occurring in the intestinal compartment, i.e.
colorectal carcinoma. Proper understanding of the differentiation processes and functions
of epithelial cells in interaction with other components of the mucosal immune system is
therefore highly desirable.
Antibodies against Mycobacterium paratuberculosis in Crohn's disease.
Author
Walmsley RS; Ibbotson JP; Chahal H; Allan RN
Address
Gastroenterology Unit, Queen Elizabeth Hospital, Birmingham, UK.
Source
QJM, 1996 Mar, 89:3, 217-21
Abstract
Until recently the investigation of serological responses to mycobacteria
in patients with Crohn's disease has been hindered by the considerable degree of
cross-reactivity between antigens of M. paratuberculosis, and other mycobacterial
subspecies. We evaluated the serological response of Crohn's disease patients to a
recently identified species-specific 18 kDa protease-resistant antigen corresponding to M.
paratuberculosis bacterioferritin. The 18 kDa antigen was purified from M.
paratuberculosis as previously described. Serum was obtained from 40 patients with Crohn's
disease, 15 with ulcerative colitis, 25 coeliac patients, and 21 normal blood donors.
Antibody levels were measured by enzyme-linked immunosorbent assay (ELISA), with
anti-human IgA and IgG alkaline phosphatase conjugate. Antibody titres were expressed as
the dilution giving 1/3 of the plateau binding value of a standard positive serum (MT/3).
Disease activity of the Crohn's disease cases was assessed using the Harvey-Bradshaw
index. There was no statistically significant elevation of the mean IgG or IgA MT/3 titres
of Crohn's disease patients over controls. No patients had antibody titres greater than
two standard deviations above the mean control MT/3 titres, and there was no significant
correlation between Crohn's disease activity and level of antibody titres. These findings
make it unlikely that M. paratuberculosis is of primary pathogenic importance in Crohn's
disease.
Milk hypersensitivity--key to poorly defined gastrointestinal symptoms in
adults.
Author Pelto L; Salminen S; Lilius
EM; Nuutila J; Isolauri E
Source Allergy, 1998 Mar, 53:3, 307-10
Abstract Lactose intolerance is a common adverse reaction to milk in adults,
while milk hypersensitivity is a disorder of infancy. We hypothesized that milk
hypersensitivity may cause many unspecific gastrointestinal disorders in adults. Twenty
adults were subjected to double-blind, placebo-controlled milk challenge. Phagocyte
activity, and Fc gamma and complement receptor expression of phagocytes were assayed, and
serum total IgE, milk-specific IgE, and serum reactivity to milk protein were determined.
The challenge increased phagocyte activity and complement receptor expression of
phagocytes in subjects designated milk-hypersensitive, who had gastrointestinal symptoms
from milk ingestion but normal lactose tolerance. The increase was not detected in
lactose-intolerant or control subjects. The milk-hypersensitive group was also
distinguished from the lactose-intolerant group by enhanced serum reactivity to milk
protein. Only two out of nine milk-hypersensitive subjects had detectable milk-specific
serum IgE. It is concluded that milk hypersensitivity in adults, occurring as
gastrointestinal reactions, may be more common than previously thought.
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