Alpha Nutrition, experts in self-managed care. 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
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.
Abstract 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.
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.
Abstract 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.
Abstract 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.
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.
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.
Abstract 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.
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.
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.
Abstract 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.
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.
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.
Abstract 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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