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ESPEN Guidelines on Parenteral Nutrition: Gastroenterology

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ESPEN Guidelines on Parenteral Nutrition: Gastroenterology Clinical Nutrition 28 (2009) 415–427 Contents lists available at ScienceDirect Clinical Nutrition journal homepage: http://www.elsevier.com/locate/clnu ESPEN Guidelines on Parenteral Nutrition: Gastroenterology Andre´ Van Gossum a, Eduard Cabre b, Xavier He´buterne c, Palle Jeppesen d, Zeljko Krznaric e, Bernard Messing f, Jeremy Powell-Tuck g, Michael Staun d, Jeremy Nightingale h a Hoˆpital Erasme, Clinic of Intestinal Diseases and Nutrition Support, Brussels, Belgium b Hospital Universitari Germans Trias i Pujol, Department of Gastroenterology, Badalona, Spain c Hoˆpital L’Archet, Service de Gastro-ente´rologie et Nutrition, Nice, France d Rigshopitalet, Department of Gastroenterology, Copenhagen, Denmark e University Hospital Zagreb, Division of Gastroenterology and Clinical Nutrition, Zagreb, Croatia f Hoˆpital Beaujon, Service de Gastro-ente´rologie et Nutrition, Paris, France g The Royal London Hospital, Department of Human Nutrition, London, United Kingdom h St Mark’s Hospital, Department of Gastroenterology, Harrow, United Kingdom article info summary Article history: Undernutrition as well as specific nutrient deficiencies has been described in patients with Crohn’s Received 19 April 2009 disease (CD), ulcerative colitis (UC) and short bowel syndrome. In the latter, water and electrolytes Accepted 29 April 2009 disturbances may be a major problem. The present guidelines provide evidence-based recommendations for the indications, application and Keywords: type of parenteral formula to be used in acute and chronic phases of illness. Guidelines Parenteral nutrition is not recommended as a primary treatment in CD and UC. The use of parenteral Clinical practice nutrition is however reliable when oral/enteral feeding is not possible. Evidence-based Parenteral nutrition There is a lack of data supporting specific nutrients in these conditions. Crohn’s disease Parenteral nutrition is mandatory in case of intestinal failure, at least in the acute period. Ulcerative colitis In patients with short bowel, specific attention should be paid to water and electrolyte supplementation. Short bowel syndrome Currently, the use of growth hormone, glutamine and GLP-2 cannot be recommended in patients with Intestinal failure short bowel. Malnutrition Ó 2009 European Society for Clinical Nutrition and Metabolism. All rights reserved. Undernutrition Summary of statements: Parenteral nutrition in Crohn’s disease Subject Recommendations Grade Number Indication PN is indicated for patients who are malnourished or at risk of becoming malnourished and who have an inadequate or B4.1 unsafe oral intake, a non (or poorly) functioning or perforated gut, or in whom the gut is inaccessible. Specific reasons in patients with CD include an obstructed gut, a short bowel, often with a high intestinal output or an enterocutaneous fistula. Active disease Parenteral nutrition (PN) should not be used as a primary treatment of inflammatory luminal CD. A 3.5 Bowel rest has not been proven to be more efficacious than nutrition per se. Maintenance of In case of persistent intestinal inflammation there is rarely a place for long-term PN. B 3.7 remission The most common indication for long-term PN is the presence of a short bowel. Perioperative Use of PN in the perioperative period in CD patients is similar to that of other surgical procedures. B 3.6 Application When indicated, PN improves nutritional status and reduces the consequences of undernutrition, providing there is not B1 continuing intra-abdominal sepsis Specific deficits (trace elements, vitamins) should be corrected by appropriate supplementation. B 1 The use of PN in patients with CD should follow general recommendations for parenteral nutrition. B 1 (continued on next page) Abbreviations: CD, Crohn’s disease; IBD, inflammatory bowel disease; UC, ulcerative colitis; PN, parenteral nutrition. E-mail address: [email protected]. 0261-5614/$ – see front matter Ó 2009 European Society for Clinical Nutrition and Metabolism. All rights reserved. doi:10.1016/j.clnu.2009.04.022 416 A. Van Gossum et al. / Clinical Nutrition 28 (2009) 415–427 Summary of statements: Parenteral nutrition in Crohn’s disease Subject Recommendations Grade Number Route Parenteral nutrition is usually combined with oral/enteral food unless there is continuing intra-abdominal sepsis or C 3.2 perforation. Central and peripheral routes may be selected according to the expected duration of PN Type of formula Although there are encouraging experimental data, the present clinical studies are insufficient to permit the B 4.3 recommendation of glutamine, n-3 fatty acids or other pharmaconutrients in CD. Undernutrition Parenteral nutrition may improve the quality of life in undernourished CD patients. C 3.4 Summary of statements: PN in ulcerative colitis Subject Recommendations Grade Number Indication Parenteral nutrition should only be used in patients with UC who are malnourished or at risk of becoming malnourished B9 before or after surgery if they cannot tolerate food or an enteral feed Active disease There is no place for PN in acute inflammatory UC as means of enabling bowel rest. B 10 Maintenance of Parenteral nutrition is not recommended. B11 remission Application Treat specific deficiencies when oral route is not possible. C 5 Type of formula The value of specific substrates (n-3 fatty acids, glutamine) is not proven. B 10.2 Summary of statements: Short bowel syndrome (intestinal failure) Subject Recommendations Grade Number Indication Maintenance and/or improvement of nutritional status, correction of water and electrolyte balance, improvement in quality B15 of life. Route Post-op period Predictions on the route of nutritional support needed can be made from knowledge of the remaining length of small bowel B17.1 and the presence or absence of the colon. PN is likely to be needed if the remaining small bowel length is very short (e.g., less than 100 cm with a jejunostomy and less than 50 cm with a remaining colon in continuity). With longer lengths parenteral nutrition, water and electrolytes may be needed until oral/enteral intake is adequate to maintain nutrition, water and electrolyte status. Adaptation phase Patients with a jejunostomy have little change in their nutritional/fluid requirements with time. Patients with a colon in B17.2 continuity with the small bowel have an improvement in absorption over 1–3 years and parenteral nutrition can often be reduced or stopped. Dietary counseling is important for those with a retained colon and may facilitate intestinal adaptation. In patients with a jejunostomy and a high output stoma advice on oral fluid intake and drug treatments are vital. Maintenance/ Parenteral nutrition, water and electrolytes (especially sodium and magnesium should be continued when oral/enteral B17.3 Stabilization intake is insufficient to maintain a normal body weight/hydration or when the intestinal/stool output is so great as to severely reduce the patient’s quality of life. Assuming strict compliance with dietary/water and electrolyte advice, after 2 years, dependency on PN is likely to be long-term. Type of formula No specific substrate composition of PN is required per se. B 16 Specific attention should be paid to electrolyte supplementation (especially sodium and magnesium). B 16, 17 Currently, the use of growth hormone, glutamine or GLP-2 cannot be recommended. B 18 1. Crohn’s disease Malnutrition is very common in CD, with an incidence ranging from 25 to 80%.3 There is significant influence of small bowel 1.1. What influence does CD exert on nutritional status and on involvement on body weight in CD, suggesting that individuals energy and substrate metabolism? with small bowel disease have a higher risk of inadequate nutrition, probably because of simultaneous malabsorption, protein losing 1.1.1. Acute phase enteropathy and decreased energy intake.4 CD patients with small bowel resection have lower bone mineral content, lean body mass, Undernutrition or protein–energy malnutrition, which is and BMI compared with those without small bowel resection. A a prominent feature of CD, develops largely as a result of the negative nitrogen balance caused by reduced intake, increased systemic inflammatory response. intestinal losses, and steroid induced catabolism occurs in more Anorexia, inadequate food intake, reduced absorption, than 50% of patients with active CD. increased intestinal loss and altered protein synthesis, all Resting energy expenditure (REE) may vary depending on contribute to a significantly reduced nutritional status. inflammatory activity, disease extent and nutritional status.5 Today Deficiencies of micronutrients (vitamins, minerals and trace it is generally accepted that total energy expenditure is similar to elements) are common especially in the acute phase of CD or after that in healthy subjects, but REE has been found to be increased, extensive surgery. normal or even reduced.2,6 It is slightly increased if calculated in In children and adolescents a decrease in growth velocity may relation to fat free mass (FFM) when this is low.7 Changes in occur as a consequence of systemic inflammatory response, substrate metabolism, with reduced oxidation of carbohydrates nutritional disturbances and due to drugs (e.g., steroids). and increased oxidation of lipids, are similar to the alterations in patients during starvation and are not disease specific.8 They are Comments: A low Body Mass Index (BMI) and recent weight mostly reversible when patients receive adequate nutritional loss in CD reflect poor nutritional status
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