Why Do Enteral Diets Help In Treating Crohn’s Disease?
One of the treatments for Crohn’s disease is enteral nutrition, which has been found to be instrumental in the induction of remission of Crohn’s disease’s activities (Akobeng & Thomas, 2009). Crohn’s disease is part of the inflammatory bowel diseases family that affects the gastrointestinal tract. The disease largely attacks the ileum, causing inflammation extending to the deep linings of the gastrointestinal tract. The inflammation in the bowels is usually painful causing frequent emptying of the bowels (and diarrhea). Enteral feeding has over the recent years been preferred as the way of feeding critically ill patients, as well as an essential means of countering the catabolic state of patients caused by chronic illness, among which is Crohn’s disease (Kreymann et al., 2006). Enteral nutrition offers promise for critically ill patients, particularly those with Crohn’s disease, as it helps in avoidance of steroids, which have potential adverse effects on the patient after prolonged use.
Research into Crohn’s disease indicates that the disease has no cure currently. Therefore, the only available measures are therapies, which aim at reducing the disease’s signs and symptoms, as well as bring long-term remission. Good and regular treatment and intervention measures have the capability of improving the patients’ normal functions (Huang et al., 2011). Crohn’s disease affects any part of the gastrointestinal tract, and its symptoms may vary from one patient to another. The most common symptoms are however related to the gastrointestinal tract and the inflammatory bowel. The disease’s symptoms related to the inflammation of the gastrointestinal tract include persistent diarrhea; constipation; feeling of incomplete removal of bowels; pressing need to move bowels; cramps and abdominal pain and rectal bleeding (Shanahan, 2002). On the other hand, symptoms related to the inflammatory bowel include loss of appetite, high fever, fatigue and weight loss as well as interruption of the normal menstrual cycle.
The symptoms vary from one individual to another, however most patients will have a considerable amount of weight loss resulting from loss of appetite (Shanahan, 2002). Children, on the other hand, may have delayed growth and development, necessitating the need for treatment through enteral feeding to allow for normal growth and development, which the disease normally impedes. Generally, however, patients are likely to experience periods of attacks caused by flaring up of the disease causing recurrence of the symptom, followed by periods of remission with no symptoms at all (D’Haens, et al., 1998). Severe cases of the disease have reported tears to the anus lining, causing pain and bleeding during bowel movement, in addition to the development of a fistula, which calls for immediate medical attention.
Medical examination of the disease indicates that it is a disorder mediated by T lymphocytes, and occurs in individuals with genetic susceptibility caused by a breakdown in the “regulatory constraints on mucosal Immune responses to enteric bacteria” (Shanahan, 2002, p. 62). Examination of the bowels, mostly with the use of bowel ultrasound technology, and the regulation of immune reactivity over the years has been instrumental in the comprehension of the disease’s pathophysiological mechanisms (Maconi et al., 2006; Shanahan, 2002). Currently, the disease affects more than 0.5 million Americans, with both men and women being equally susceptible to the disease. Moreover, the disease can occur at any age, although it is more prevalent among adolescents and young adults. Even with medical examination pointing at heredity as the cause of the disease, the real causes of the disease remain unknown, although there is an understanding that diet and stress may exacerbate the disease, but not necessarily cause it. A combination of three interacting elements that include genetics, enteric microflora priming and injury of the immune mediating tissues complete the intricate pathogenesis of the disease (Shanahan, 2002).
Given the absence of a cure for the disease, treatment largely focuses on the remission of the disease. Steroids and immunosuppressive agents have been known to offer respite to patients, although these have potentially serious adverse effects (Akobeng & Thomas, 2009). According to Akobeng and Thomas (2009), studies in the recent years suggest that that long-term use of enteral nutritional supplements, with a combination of unhampered normal food may indeed lengthen the remission periods of Crohn’s disease patients, and at the same time reduce relapsing of the patients. More studies on enteral nutrition suggest that the intervention is not only effective on patients with Crohn’s disease, but also on patients with pressure ulcers, critically ill patients, patients with severe sepsis and septic shock and lung injury (Gramlich et al., 2004; Pontes-Arruda, Aragao & Albuquerque, 2006; Singer et al., 2006; Stratton et al., 2005).
The importance of feeding and nutrition for the critically ill patients cannot be overstated. For these patients, nutrition is as part of their necessary general well-being as it is for normal people. Most critically ill patient however have difficulties with normal feeding, and as thus, artificial feeding takes precedence as a way of ensuring nutritional supply to these individuals. As earlier indicated, enteral nutrition provides nutritional supplements to patients, and has been used with lack of controversy (Seres, Valcarcel & Guillaume, 2013). However, proponents of parenteral nutrition have suggested that enteral nutrition delivers calories much less inefficiently than parenteral nutrition (Seres, Valcarcel & Guillaume, 2013). Moreover, the proponents contend that such delivery is deleterious to the patient. The basis of the argument lies on the assumption that food in the gut is less important than the nutritional supplements delivered to the body through parenteral nutrition.
However, there are postulations that parenteral nutrition is less favorable, with studies indicating parenteral as disadvantageous to the patient given that the patient lacks food in the gut, in addition to parenteral nutrition inducing harmful changes in the patients’ physiology (Seres, Valcarcel & Guillaume, 2013). A different study on the other hand, showed that “providing supplementary enteral nutrition (nocturnal nasogastric supplements), without restriction of normal diet, after successful treatment of active Crohn’s disease by exclusive enteral nutrition, was associated with prolongation of remission and improved linear growth in children and adolescents with Crohn’s disease” (Akobeng & Thomas, 2009, p. 2).
The benefits of enteral nutrition transcend Crohn’s disease and have been used in studies to show its benefit in patients with other chronic diseases. Al-Saady, Blackmore and Bennett (1989) in their study showed the effect of a high fat, low carbohydrate enteral feed on patients with acute respiratory failure. Given that carbohydrates and fats form part of the nutritional supplements in enteral nutrition, the study results indicated that feeding of the patients with high fat and carbohydrates resulted in patients spending 62 hours less on the ventilator (Al-Saady, Blackmore & Bennett, 1989). Another study on the use of enteral nutrition showed positive effects on prematurely born infants fed with long-chain polyunsaturated fatty acids. According to O’Connor et al. (2001), the study showed numerous benefits of supplementing formulas for the premature infants. This goes on to show the importance and benefits of enteral medicine in feeding not only the chronically ill, but immature infants as well.
Moreover, given the severe protein-calorie malnutrition for intensive care patients; Jolliet et al. (1998), state of the importance of enteral nutrition to these patients, particularly in their management. For Jolliet et al. (1998), the role of enteral feeding transcends providing calorie nutrition to the patients, to having favorable effects on the digestive tract. Additionally, enteral nutrition not only cost less, but also reduced the rate of complication for the intensive care patients in comparison with parenteral nutrition (Jolliet et al., 1998; Kumar et al., 2006).
Part of the enteral nutrition also includes carbohydrates, albeit in low quantities. Studies on animals with sepsis-induced acute respiratory distress syndrome have shown that feeding of the carbohydrates along with high-fats and antioxidants result in improvement of the microvascular permeability of lungs, oxygenation, cardiopulmonary function, as well as reduction in pro inflammatory eicosanoid synthesis and inflammation of the lungs (Gadek et al., 1999). From the study findings therefore, it is correct to suggest that enteral nutrition, particularly with EPA+GLA and antioxidants go a long way in the reduction of pulmonary inflammation, and could therefore improve oxygenation and medical result of patients with acute respiratory distress syndrome (Gadek et al., 1999).
As with fatty acids reported to be of benefit to cancer patients (Colomer et al., 2007), proteins and vitamins also help improve nutrition among chronically ill patients getting nutritional supplements through enteral nutrition (Grim et al., 2002; Ockenga et al., 2006). The aim of nutritional support, especially for HIV patients is to improve nutritional status and the quality of life, alleviating gastrointestinal symptoms of HIV and improving patients’ tolerance to ARVs (Ockenga et al., 2006).
Comparing enteral and parenteral nutrition presents distinct differences, with most studies supporting enteral over parenteral nutrition (Gramlich et al., 2004; Kumar et al., 2006; Pontes-Arruda, Aragao & Albuquerque, 2006; Singer et al., 2006; Stratton et al., 2005). There are different routes available for use in administering enteral nutrition, which include nasogatric, nasojejunal, orogastric, gastric, post-pyloric tip, fine bore tubes and percutaneous feeding tubes (Akobeng & Thomas, 2009; Kumar et al., 2006; Pearce & Duncan, 2002). Each of these routes has its advantages and disadvantages, although they all perform a similar role. One of the reasons for advocacy towards enteral nutrition is its role in the production of immunoglobulin A. According to Seres, Valcarcel and Guillaume (2013), enteral nutrition helps in the production of pulmonary immunoglobulin A. This gives patients fed through enteral nutrition some nutritional value through the process.
Enteral nutrition further plays a role in protecting the lungs for patients receiving nutrition through the process. In a study by Kudsk et al. (1996), the researchers found that mice fed through enteral nutrition showed zero viremia on exposure to influenza. The protective effect of enteral nutrition is also suggested on patients that have undergone surgery. Thus, these patients showed better lung protection after surgery on receiving enteral nutrition than those who received nothing. Even more is that patients receiving enteral nutrition post-operation showed a trend towards reduction in pneumonia (Lewis, Egger, Sylvester & Thomas, 2001).
Enteral nutrition additionally provides better nitrogen balance, preservation of weight, as well as lowering plasma stress hormone levels (Saito et al., 1987). This is largely because enteral nutrition supplies food to the gut, which is more functional and beneficial to patients than the absence of food in the gut (Heylan, Drover, Dhaliwal & Greenwood, 2002). Moreover, by confirming that jejunal feeding does not necessarily reduce aspiration in critically ill patients, enteral nutrition provides easier access to patients (Ho, Dobb & Webb, 2006).
The timing for the provision of enteral nutrition is additionally important if critically ill patients are to reap any benefits from the feeding. It is therefore important to provide this nutrition early, upon the admission of the patients. One of the benefits enteral nutrition, and its contribution towards treatment of patients is that it down regulates systemic immune responses, thus reducing patient’s oxidative stress, and consequently improving patient outcomes. Moreover, by adding particular pharmaconutrient agents to enteral nutrition, the feeding has been known to have synergistic effects, thus causing the magnification of the patient’s physiologic response. Thus, failure to provide enteral nutrition has been known to worsen oxidative stress and increase in systemic inflammatory response syndrome.
The benefits of enteral feeding moreover go beyond its use in patients with Crohn’s disease. Research on short bowel syndrome has shown positive attributes of the nutrition. According to Olieman et al. (2010), enteral nutrition administered to patients with short bowel syndrome enables the nutrients delivered to act as luminal factors. Additionally, slow and continuous administration of the nutrition helps in reducing the risks of osmotic diarrhea (Olieman et al., 2010). Further, through enteral feeding, short bowel syndrome patients have shown nutrient retention and weight gain. By beginning enteral nutrition early enough (particularly after surgery) infants are capable of developing tolerance for feeding, which increases their tolerance for oral feeding as well as decreasing the stay in the hospital (Olieman et al., 2010).
Enteral nutrition provides patients with food in the gut, an important functional element for patients. Moreover, enteral nutrition helps in treatment of Crohn’s disease through prolongation of remission and improved linear growth in children and adolescents with the disease. Even more is that enteral nutrition has helped reduce relapsing of Crohn’s disease patients. Therefore, while the disease has no known cure, through enteral nutrition, patients can live longer healthier lives with few relapsing incidences of the disease.
References
Akobeng, A., K. & Thomas, A., G. (2009). Enteral nutrition for maintenance of remission in Crohn’s disease (Review). Wiley
Al-Saady, N., M., Blackmore, C., M. & Bennett, E., D. (1989). High fat, low carbohydrate, enteral feeding lowers PaCO2and reduces the period of ventilation in artificially ventilated patients. Intensive Care Medicine, 15, 290-295
Colomer, R. et al. (2007). n-3 Fatty acids, cancer, and cachexia: a systematic review of the literature. British Journal of Nutrition, 97, 823-831
D’Haens G., R, et al. (1998). Early lesions of recurrent Crohn’s disease caused by infusion of intestinal contents in excluded ileum. Gastroenterology, 114, 262-67
Gadek, J., E. et al. (1999). Effect of enteral feeding with eicosapentaenoic acid, gamma-linolenic acid, and antioxidants in patients with acute respiratory distress syndrome. Critical Care Medicine, 27(8), 1409-1420
Grim, H. et al. (2002). Regulatory potential of n-3 fatty acids in immunological and inflammatory processes. British Journal of Nutrition, 87(1), 59-67
Heyland D., Drover J., Dhaliwal R., Greenwood J. (2002). Optimizing the benefits and minimizing the risks of enteral nutrition in the critically ill: role of small bowel feeding. Journal of Parenteral Enteral Nutrition26 (6 Suppl.), S51–S55
Ho K., Dobb G., Webb S. (2006). A comparison of early gastric and post-pyloric feeding in critically ill patients: a meta-analysis. Intensive Care Med32, 639–64