Clinicians should consider starting a patient with gastrointestinal diseases on enteral nutrition as soon as there is a risk for malnutrition due to inadequate oral intake, according to gastroenterologist Matthew Bechtold, MD, co-chair of the American Society for Parenteral and Enteral Nutrition’s EN committee.
During a recent ASPEN webinar on EN in GI disease, Dr. Bechtold, a professor of clinical medicine, the director of endoscopy and the director of GI ambulatory services at the University of Missouri, in Columbia, focused on three primary GI diseases— inflammatory bowel disease, chronic liver disease and acute pancreatitis—and when to consider EN in each of these disease settings.
In IBD, malnutrition can result from decreased oral intake, increased nutrient requirements, increased GI losses of nutrients and drug–nutrient interactions, Dr. Bechtold said. “Malnutrition tends to be much greater in Crohn’s disease due to Crohn’s disease’s effects on the small bowel,” he said. And it can be exacerbated by surgery, “which removes the small bowel’s absorptive capacity,” he added.
In pediatric patients with Crohn’s disease, increasing nutrients via EN can be the first option for inducing remission, based on a meta-analysis of four randomized controlled trials (Aliment Pharmacol Ther 2007;26[6]:795-806). “This is an approach backed by NASPGHAN [North American Society for Pediatric Gastroenterology, Hepatology & Nutrition], and there are quite a few options,” Dr. Bechtold said.
However, the benefit isn’t as pronounced in adult populations. “In adults with Crohn’s, steroids are much better, by far, at inducing remission, as a Cochrane meta-analysis of seven trials found in 2007 [Cochrane Database Syst Rev 2007;(1):CD000542]. Steroids do get adults feeling better faster,” he said. Nevertheless, he said, a medication–EN combination may be the best treatment plan for some patients with Crohn’s disease. He pointed out another meta-analysis that showed that patients taking infliximab alone fared worse than those taking infliximab plus EN (Therap Adv Gastroenterol 2015;8[4]:168-175). “So EN does still play an important role in these adult patients.”
Dr. Bechtold also shared principles for a stepwise approach to nutritional support in IBD. First, he said, oral nutrition supplements should be considered. “It is important to maximize oral nutrition, with oral nutrition supplements as a first-line adjunct ... to oral feeds,” he said. If that isn’t working, then the focus should shift to EN, he said. “If oral nutrition is not sufficient and there is concern about malnutrition, EN should be pursued as a second-line adjunct, as long as there are no contraindications, such as a dysfunctional GI tract or severe short bowel syndrome, or complications such as an anastomotic leak or high-output intestinal fistulas.”
Liver Disease
In the case of chronic liver disease, people with end-stage liver disease or cirrhosis are at particularly high risk for malnutrition, Dr. Bechtold said. “Hypotheses as to the reasons for that include hypermetabolism, enhanced protein catabolism, fat malabsorption, impaired glucose storage, and altered taste and mental status due to possible hepatic encephalopathy.”
There is a debate on the role of branched-chain amino acid (BCAA) formulas in hepatic encephalopathy, with ASPEN and the European Society for Clinical Nutrition and Metabolism (ESPEN) taking divergent positions. “Impaired metabolism can cause neurocognitive effects, and BCAAs compete with aromatic amino acids in blood–brain transporters and do not rely on hepatic metabolism,” Dr. Bechtold said. “ESPEN guidelines suggest that BCAAs may be a good idea and better than standard whole proteins, while ASPEN says that there is no advantage in patients who are on antibiotics or lactulose first.”
After a deep review of the literature, Dr. Bechtold said the answer to the question of BCAAs in hepatic encephalopathy is “100% maybe. There’s a lot of confusion. There are quite a few studies, but they are confusing to read and the end points difficult to understand.”
He pointed to a 2017 Cochrane meta-analysis of 16 randomized controlled trials comparing outcomes using BCAAs versus standard diet in adults with hepatic encephalopathy (Cochrane Database Syst Rev 2017;5[2]:CD001939). “It concluded that they may help, but so do antibiotics and lactulose. Which do we use? I don’t think we have a good answer. I don’t use BCAAs a whole lot unless lactulose or antibiotics fail, but I can’t blame you if you do or don’t.”
Pancreatitis
The use of EN in pancreatitis has evolved over the last three decades, Dr. Bechtold said. “Although 80% to 90% of pancreatitis cases are mild or moderate, in the past we used to withhold all nutrition in most cases until the condition resolved to ‘rest’ the pancreas. This meant that people could go a week or more with nothing by mouth.”
However, a systematic review published in 2017 found that in mild to moderate acute pancreatitis, early feeding (within 48 hours after hospital admission) with a solid, low-fat diet is safe if pain and inflammatory markers are improving and there is no ileus or nausea/vomiting (Ann Intern Med 2017;166[12]:883-892). “Many studies showed a statistically significant decrease in length of stay if the patient had early nutrition at less than 48 hours,” Dr. Bechtold said. “There’s no need for specific EN support therapy, unless the patient is unable to maintain adequate intake or progresses to severe pancreatitis.”
In severe acute pancreatitis, however, the course of action has been less clear. The potential benefits of EN over total parenteral nutrition (PN) in this population include preservation of the integrity of the epithelial cell junction and prevention of bacterial translocation, which could lead to sepsis and severe multi-organ failure, Dr. Bechtold said. An international consensus guideline from major world organizations including ASPEN, ESPEN, the American College of Gastroenterology and several others states that nutritional support is beneficial for these patients, and EN is preferred over PN (JPEN J Parenter Enteral Nutr 2012;36[3]:284-291).
| Enteral Nutrition Indications in Patients With Gastrointestinal Diseases: ASPEN Recommendations | |
| EN Indication | Considerations |
|---|---|
| GI diseases (IBD, chronic liver disease, acute pancreatitis) when the patient is at risk or has emerging malnutrition due to inadequate oral intake |
|
| CD, as therapeutic option for the induction of remission |
|
| SAP, in preference to PN |
|
| CD, Crohn’s disease; EN, enteral nutrition; PN, parenteral nutrition; SAP, severe acute pancreatitis. | |
Formulas and Delivery
But when and how do you initiate nutrition support in these settings? Dr. Bechtold said that while the timing may matter, choice of nasogastric (NG) or nasojejunal (NJ) may depend on the patient. “Overall, early EN (at <48 hours) is preferred over delayed EN, while NG feeding has been found to be no different than NJ feeding,” he said. “NJ tubes clog easily and often have to be replaced, so it is typically easier to use an NG tube. NJ feeding is only required for those who cannot tolerate NG feedings.”
Session moderator Ainsley Malone, MS, RD, LD, CNSC, a clinical practice specialist for ASPEN, discussed which type of nutritional formula is best to start with in these patient groups. “There has not been much study of this particular question ... and early studies had very small sample sizes,” she said. “There is no clear indication that one should automatically start with a hydrolyzed formula. Perhaps that was the case when we always used PN, but now starting with an intact nutrient makes a good deal of sense. Then, if the patient develops significant distension or other indications of intolerance, it would be reasonable to switch.”
—Gina Shaw
Dr. Bechtold reported financial relationships with Medtrition and the NestlÉ Nutrition Institute. Ms. Malone reported no relevant financial disclosures.
This article is from the November 2023 print issue.