The role of nutrition therapy in the management of inflammatory bowel disease

In patients with inflammatory bowel disease (IBD) malnutrition could often be present. Weight loss has been reported in 65 – 76% of patient with Crohn's disease (CD) and in 18 – 62% with ulcerative colitis. The severity of malnutrition depends on the duration and the activity of IBD, the extent and remaining functional part of the small bowel. Malnutrition might be present up to 80% of patients with CD. The evaluation and correction of nutritional deficits should be an integral part of therapy in these patients. Enteral nutrition (EN) should be the first choice for all patients having anatomically intact and functionally normal digestive tract. Traditionally, total parenteral nutrition (TPN) is reserved for patients with obstruction, fistula, toxic megacolon, short bowel syndrome, severe malabsorption, and other conditions that make enteral nutrition impossible or inefficient, however TPN makes a significant contribution to the success of treatment of undernourished patients with IBD, especially those who are facing surgery. TPN must be applied by a hospital team of experts having experience in both use of this therapeutic modality and deal with of possible complications. Although indications for using TPN seem to be quite simple and clear, it is sometimes quite difficult to identify the suitable patient with IBD, probably because the clinical manifestations of poor nutrition can occur only after a long period of time, depending on the amount of adipose tissue and protein, the underlying clinical disorder, and the kind of treatment applied. Additionally, complications of TPN were rather overemphasized; however, critical review of the available data suggests that TPN does not cause either mucosal enteric atrophy or microbial translocation in these patients. In a small proportion of patients with CD, such as patients with repeated surgical resections of the small bowel, presence of fistulas, septic situations, stomas of high output, and prolonged incomplete bowel obstruction, it is impossible to restore nutritional status using EN. In this subset of patients the application of home parenteral nutrition (HPN) seems to be the ideal solution. In our experience an additional benefit of HPN was that complete blood cell count normalization could be reached in our patient with CD and short bowel syndrome requiring frequent blood transfusion beforehand.