Exclusive Enteral Nutrition in Adults with Crohn’s Disease: e-Learning Activity
Dearbhaile O'Hanlon, D-ECCO Member
Exclusive enteral nutrition (EEN) is well established as first-line management for children with luminal Crohn’s Disease (CD) . Its use in paediatrics was covered in the 2017 ECCO e-Learning Activity “Use of exclusive enteral nutrition in CD”.
The use of EEN in adults with CD is not as well established. It is often overlooked as a management tool but can be an effective therapy for adults in many scenarios. Catherine Wall and I designed an e-Learning Activity specifically covering EEN in adults with CD, and this was launched on the e-CCO Learning Platform in May 2022. The course was developed for gastroenterologists, surgeons, dietitians, nurses and other interdisciplinary medical experts interested in Inflammatory Bowel Disease(s) (IBD).
The learning outcomes are:
- Achieve a greater understanding of the indications for EEN in adults with CD
- Understand how to implement an EEN feeding regimen
The e-Learning Activity works through a case study of a young female who has an initial presentation of new mild-to-moderate terminal ileal CD. Throughout the case, questions and answers are posed, explaining the actions taken and the rationale. The case explores how EEN can be used at initial presentation when corticosteroids are not acceptable or desired. The e-Learning Activity follows the case through a disease relapse requiring surgery and addresses some of the common issues which arise. The case provides practical information on decision making and highlights considerations when setting up an EEN regimen.
The practical management of adult patients by means of EEN is further detailed by Day et al. , who propose an optimal care pathway in adult patients with active CD. The paper outlines the pre-, peri-, and post-EEN treatment steps, highlights the clinical, nutritional and dietetic assessments that should be done and explains the level of support required.
EEN in adults is often not considered in clinical management guidelines for CD. Its suggested use is typically limited to patients with mild-to-moderate disease who are not amenable to or suitable for corticosteroids . The multiple uses of EEN have not been fully addressed. However, since the launch of the e-Learning Activity, the British Dietetic Association consensus guidelines on the nutritional assessment and dietary management of patients with IBD have been published . Fifty-five 55 IBD experts and patients participated in the consensus voting. These guidelines contain a practical summary that is helpful when considering and implementing EEN. It also outlines five GRADE recommendations specific to EEN and two practice statements. The former include that EEN may induce remission in patients with inflammatory strictures and may lower the risk of post-surgical infectious complications. There is limited evidence that pre-surgical EEN may reduce post-surgical hospitalisation in patients with CD and very limited evidence that fistulating CD may respond to EEN.
The role of EEN in improving surgical outcomes and complications certainly requires further high-quality research, and a large multicentre RCT is underway in the UK. Currently, pre-operative EEN is supported in practice positions in two ECCO Topical Reviews. S-ECCO’s “Roadmap to optimal peri-operative care in IBD” position statement suggests that “pre-operative EEN in patients with stricturing or penetrating CD improves nutritional status and may reduce postoperative complications” , while the 2020 joint D-ECCO/S-ECCO Topical Review “Perioperative dietary therapy” position statement suggests that “EEN has shown promise as a pre-operative optimisation strategy for reducing complications and improving nutritional status in CD patients. The optimal duration and route of administration is best defined by the multidisciplinary team” .
We hope you find this e-Learning Activity useful when considering EEN for your adult patients: https://e-learning.ecco-ibd.eu/mod/page/view.php?id=776
- van Rheenen PF, Aloi M, Assa A, et al. The medical management of paediatric Crohn's Disease: an ECCO-ESPGHAN Guideline Update. J Crohns Colitis. 2021;15:171–94.
- Day A, Wood J, Melton S, Bryant R. Exclusive enteral nutrition: An optimal care pathway in adult patients with active Crohn’s Disease. JGH Open. 2020;4:260–6.
- Lamb CA, Kennedy NA, Raine T, et al. British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults. Gut. 2019;68:s1–s106.
- Lomer MCE, Wilson B, Wall CL. British Dietetic Association consensus guidelines on the nutritional assessment and dietary management of patients with inflammatory bowel disease. J Hum Nutr Diet. 2022;1–42.
- Sebastian S, Segal JP, Hedin C, et al. Roadmap to optimal peri-operative care in IBD. J Crohns Colitis. 2022. https://doi.org/10.1093/ecco-jcc/jjac129. Online ahead of print.
- Adamina M, Gerasimidis K, Sigall-Boneh R, et al. Perioperative dietary therapy in inflammatory bowel disease. J Crohns Colitis. 2020;14:431–44.