Parenteral Nutrition in IBD: Any indication?

Transcription

1 Parenteral Nutrition in IBD: Any indication? Name: Institution: Marianna Arvanitakis Erasme University Hospital, Brussels, Belgium

2 Clinical case 42 year old male Crohn s disease since he was 16 years old 60Kg Previous small bowel resections and right hemicolectomy 2/15: Admitted in our center for enterocutaneous fistula, abdominal collection and sepsis Malnourished, 58 kg.

3 Clinical case Surgical drainage and ileo colic resection 80 cm of small bowel with anastomosis with the transverse colon Antibiotics Implantable port Home Parenteral nutrition (TPN) Care giver: spouse

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5 Clinical case Since 3/2015: Parenteral nutrition 7 days/7 Azathioprine 150 mg Diarrhoea: Loperamide, PPI, water with high salt concentration (Vichy)

6 Clinical case Outcome: Weight gain: 70 kg Chronic cholestasis: ALP 2xnl 2016: 3 x catheter infections requiring antibiotics and catheter replacement Taurolock (antiseptic lock)

7 Clinical case 21/12/16: Right upper quadrant pain Lab: ALP: 2xnl US: Small gallstones 4/1/17: Recurrent pain, more severe in intensity Lab: CRP: 200 mg/dl, ALP: 2xnl, bili: 3.5 mg/dl, ALT/AST: 2xnl, lipase 10xnl Biliary acute pancreatitis

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9 Clinical case ERCP with BS stone extraction Cholecystectomy with laparotomy Excellent outcome

10 Patients with IBD are at risk for malnutrition and therefore should be screened on a regular basis More common in CD than UC Present in obese patients as well (deficits in lean mass) Validated screening tools Malnutrition increases: ER visits Infection Venous thromboembolism Longer LoS Mortality Forbes et al, Clinical Nutrition 2017 Nguyen et al, Inflamm Bowel Dis 2008 Sandhu et al, JPEN 2016 Clinical Nutrition April 2017 Grade GPP, 100% agreement

11 Patients with IBD are at risk for micronutrient deficiencies and should be checked Iron, zinc, vitamin D, folic acid Multivitamin supplementation and specific screening Iron supplementation is recommended in all IBD patients when iron deficiency anaemia, in order to normalize Hb and iron values Oral supplementation if well tolerated IV if intolerance or Hb<10 gr/dl Clinical Nutrition April 2017 Grade A, 100% agreement Dignass et al, J Crohn Colitis 2015 Filippi et al, Inflamm Bowel Dis 2008 Forbes et al, Clinical Nutrition 2017

12 Clinical Nutrition April 2017 In IBD patients with severe diarrhoea and high stoma output, urine sodium and fluid output should be monitored Grade 0, 93% agreement Parenteral infusions (fluid and electrolytes) can be needed in case of high output stomas Grade 0, 96% agreement Baker et al, Color Dis 2011 Forbes et al, Clinical Nutrition 2017

13 High output stoma : > 2000ml/24h Baker et al, Color Dis 2011

14 Baker et al, Color Dis 2011

15 In case nutritional support is required: Clinical Nutrition April 2017 Oral supplementation +600 kcal/day Enteral nutrition should be preferred to parenteral nutrition Parenteral nutrition is indicated in cases when (1) oral/en is not sufficiently possible (ex short bowel), when (2) there is an obstruction with failure of placing tube feeding beyond the obstruction and when (3) other complications occur as: anastomotic leak or high output intestinal fistula Forbes et al, Clinical Nutrition 2017 Enteral nutrition Parenteral nutrition Grade A, 100% agreement Grade B, 96% agreement

16 Clinical Nutrition April 2017 Patients with CD and a distal and low output fistula can receive all nutritional support via the enteral route Patients with CD and a proximal fistula or/and very high output should receive nutritional support via partial or exclusive PN Grade B, 96% agreement Forbes et al, Clinical Nutrition 2017

17 Use of PN during hospitalization Regarding indication: Only 64% CD and 55% UC patients on PN had a clear indication: malnutrition, fistula, obstruction or surgery Use varies according to area PN linked to higher costs, longer LoS and mortality Nguyen GC et al, APT 2007 Need to establish clear guidelines for PN use in IBD patients

18 Use of PN during hospitalization US study to assess the nationwide frequencies of PN usage in hospitalized IBD patients , outcomes and multivariate analysis for mortality Annual incidence: CD: 4.29/ UC: 3.8/ Longer LoS in UC patients receiving PN Independent factors for mortality: UC, kidney injury, > 50 years, hospital required pneumonia, clostridium colitis, prolonged ileus, pulmonary embolism and malnutrition Nguyen DL et al, JPEN 2016 IBD patients on TPN: CD patients have a higher risk of malnutrition but UC patients seem to have more serious disease and higher mortality

19 Clinical Nutrition April 2017 Specific formulations or substrates (glutamine, omega 3 fatty acids) are not recommended for use in EN or PN for IBD patients Grade B, 96% agreement PN must be adapted according to the needs of every patient Home PN should be viewed as a complementary, non exclusive nutrition, which can be tapered to a minimal level Electrolytic supplementation (Na, Mg) might be required in short bowel patients Dehydration should be avoided to prevent thromboembolism Forbes et al, Clinical Nutrition 2017

20 Clinical Nutrition April 2017 In CD patients in whom nutritional deprivation has extended over many days, standard interventions and precautions to prevent refeeding syndrome are mandatory (phosphate and thiamine!) Grade B, 100% agreement Forbes et al, Clinical Nutrition 2017 Stanga et al, Eur Journ of Clin Nutrition 2008

21 Clinical Nutrition April 2017 Specific formulations or substrates (glutamine, omega 3 fatty acids) are not recommended for use in EN or PN for IBD patients Grade B, 96% agreement PN must be adapted according to the needs of every patient Home PN should be viewed as a complementary, non exclusive nutrition, which can be tapered to a minimal level Electrolytic supplementation (Na, Mg) might be required in short bowel patients Dehydration should be avoided to prevent thromboembolism Forbes et al, Clinical Nutrition 2017

22 Clinical Nutrition April 2017 In case of elective surgery, the procedure should be delayed 7 14 days and artificial nutrition (EN,PN) should be administered In case of emergency surgery (toxic megacolon, uncontrolled bleeding, acute abdomen), artificial nutrition (EN, PN) should be initiated in case of malnutrition or if oral nutrition would be delayed > 7 days after surgery Grade A, 96% agreement Grade B, 88% agreement Forbes et al, Clinical Nutrition 2017

23 Clinical Nutrition April 2017 EN should be preferred to PN in the peri operative periode, and PN should be used as a supplement to EN Grade B, 96% agreement PN should be used as the only intervention if EN is impossible (no access, severe vomiting or diarrhoea) or contra indicated (obstruction, shock, intestinal ischemia) Grade A, 96% agreement Forbes et al, Clinical Nutrition 2017

24 Clinical Nutrition April 2017 In CD patients with prolonged intestinal failure (short bowel), PN is mandatory and life saving, at least in the early stages of intestinal failure Grade B, 92% agreement Forbes et al, Clinical Nutrition 2017

25 Take home message Risk of malnutrition in IBD (CD>UC) Screening and nutritional support if necessary The use of PN has largely been replaced by EN Usually PN as a supplementation to EN PN indications: Severe malnutrition and intolerance to EN Peri operative period, in case of malnutrition, and contra indication to EN Proximal or high output fistula Short bowel (<50 cm small bowel left) Refeeding syndrome!!! Sometimes, hydro electrolytic supplementation is only required (high output stomas)