Introduction

Intestinal stenosis is a common clinical condition affecting nearly one in two patients with Crohn's disease. Despite the association of stenosing Crohn's disease with numerous risk factors for sarcopenia such as chronic inflammation, repeated hospitalizations and surgeries or sub-occlusive symptoms. Muscle mass is not currently a parameter considered in the prognostic evaluation of these patients.

Aims & Methods

The aim of this study was to investigate the influence of muscle mass on the prognosis of patients with small bowel stenosis secondary to Crohn's disease.
All entero-MRIs performed from November 2016 to April 2021 at the Rouen University Hospital in the context of stenosing Crohn's disease in adults were included. A retrospective centralized review allowed the analysis of the anatomical parameters of the stenosis as well as the calculation of the segmental MaRIA score. A semi-automated method based on axial sections at L3 allowing segmentation of the muscle compartment and measurement of the SMI (Skeletal Muscle Index) was used. Sarcopenia was considered if the SMI was less than 38.9 for women and 54.4 for men¹.
Weight and height of the patients were collected prospectively during the entero-MRI. The clinical, biological characteristics and history of hospitalizations and digestive surgeries were collected retrospectively on the basis of the analysis of the medical chart. The multiple logistic regression was constructed to include the most statistically and medically relevant parameters (backward stepwise selection). The goodness-of-fit of the model was checked by a Hosmer-Lemeshow test.

Results

A total of 107 patients were included in this cohort study. At entero-MRI, 75% of the patients had sarcopenia. The mean follow-up time after MRI was 3 years. The rate of surgery or hospitalization related to a complication of the stenosis was 47% at 3 years.
In multivariate analysis, high muscle mass was associated with a lower rate of surgery (OR=0.93 [0.88;0.99]; p=0.02). The SMI cut-off values of 37.5 in men and 35.7 in women were associated with the risk of surgery (sensitivity 56% and 71% respectively; specificity 77% and 69% respectively). Similarly, high muscle mass was associated with a lower risk of hospitalization in multivariate analysis (OR=0.95 [0.90;0.998]; p=0.048).
In addition, a high diameter of upstream bowel distension was an independent predictor of the need for surgery (OR=1.46 [1.08;2.05]; p=0.02).

Conclusion

Sarcopenia is common and an independent prognostic factor for hospitalization and surgery as well as small bowel dilatation in patients with small bowel stenosing Crohn's disease.

References

1. Mourtzakis M, Prado CMM, Lieffers JR, Reiman T, McCargar LJ, Baracos VE. A practical and precise approach to quantification of body composition in cancer patients using computed tomography images acquired during routine care. Appl Physiol Nutr Metab Physiol Appl Nutr Metab. 2008;33(5):997-1006. doi:10.1139/H08-075

Introduction

Exclusive enteral nutrition (EEN) is a well-established first-line treatment for inducing remission in paediatric Crohn's disease, however, its use in adult Crohn’s disease treatment remains limited. In adults, 22% of patients require surgery within the first five years after diagnosis¹, with postoperative complication rates reaching around 25%². This study investigates whether preoperative EEN can reduce postoperative complications in adults with Crohn’s disease undergoing elective surgery.

Aims & Methods

A systematic search was conducted on October 26, 2024, across three databases: PubMed, EMBASE, and the Cochrane Library. Studies were included if they involved at least two weeks of preoperative EEN and reported postoperative outcomes. The primary outcomes were anastomotic leakage, stoma formation, and abscess formation, while the secondary outcome was the length of hospital stay. The odds ratio (OR) and mean differences (MD) with their 95% confidence interval (CI) were calculated using a random-effect model.

Results

A total of 11 studies, including 2112 patients, were included in the analysis. EEN significantly reduced the odds of anastomotic leakage (OR=0.29, CI: 0.19-0.47), stoma formation (OR=0.39, CI: 0.09-1.73), and abscess formation (OR=0.41, CI: 0.23-0.72). However, there was no significant reduction in the length of hospital stay (MD: 0.88 days, CI: -1.85-0.09).

Conclusion

Preoperative EEN significantly reduces the risk of anastomotic leakage, stoma formation, and abscess formation, leading to improved postoperative outcomes. These findings support adding EEN into preoperative management for adult Crohn’s disease patients undergoing elective surgery to enhance recovery and minimize complications.

References

1. Burisch, J., et al.,(2019). Natural disease course of Crohn's disease during the first 5 years after diagnosis in a European population-based inception cohort: an Epi-IBD study. Gut, 68(3), 423–433. https://doi.org/10.1136/gutjnl-2017-315568
2. Luglio, G., et al.,(2022). Post-operative morbidity in Crohn's disease: what is the impact of patient-, disease- and surgery-related factors?. International journal of colorectal disease, 37(2), 411–419. https://doi.org/10.1007/s00384-021-04076-5

Introduction

Sarcopenia is associated with increased morbidity and mortality in IBD. The main objective of thisstudy was to prospectively evaluate sarcopenia by combining morphological and functional criteria inan outpatient IBD population.

Aims & Methods

In a prospective cohort study, we included all IBD patients admitted to the Day Hospital (DH) of ourdepartment between March 1st and 31st, 2023. Patients with short bowel syndrome were notincluded. Muscle mass was assessed using a Bodystat®1500MDD dual-frequency impedance meter,and muscle function was assessed by measuring handgrip strength, Carym® digital dynamometer. Pre-sarcopenia was defined by a handgrip measurement < 16 to 26, and myopenia was defined by anappendicular muscle mass index (AMMI) < 5.5 to 7 kg/m2 or a fat-free mass index (FFMI) < 15 to 17 inwomen or men. Sarcopenia was defined by the association of pre-sarcopenia and myopenia. Patientswere followed-up at 6 months to measure a composite criterion of disease activity combining one ofthe factors: FC > 250μg/g, endoscopic activity, therapeutic change, hospitalization, or IBD-relatedsurgery

Results

In total, 60 patients were included, median age 37 years (IQR 28-54), 55% women, with CD (52%) orUC (48%) diagnosed 9 years (4-17) ago, mostly in remission (67%, n=40). Patients with CD had ileocolic(48%), ileal (35%), or colonic (16%) involvement. Patients with UC had E1 (7%), E2 (41%), or E3 (52%)involvement. A history of digestive surgery linked to IBD was noted in 30% of cases. The biologicsadministered were infliximab (61%),vedolizumab (25%), or ustekinumab (14%). The BMI was 24 (21-27) and serum albumin was 41g/l (39-44). The prevalence of sarcopenia, pre-sarcopenia and myopeniawas 10%, 11% and 20%, respectively. Sarcopenic patients were significantly older (59 vs. 36 years,p=0.01), with older disease (20 vs. 8 years, p=0.003), and associated joint damage (40% vs. 2%,p=0.002) and tended to involve CD more frequently (80 vs. 49%, p=0.36). There was no significantdifference between biologics, BMI or albuminemia in sarcopenic patients, but vitamin D levels tendedto be lower (15 vs. 43, p=0.27). Myopenia was significantly associated with a history of surgery (67 vs.21%, p=0.004), a lower BMI (21 vs. 24, p=0.001) and a more active disease at M6 according to thecomposite criterion (50 vs. 21%, p=0.04 after adjustment for age, sex, and disease activity at baseline).Myopenia indices were strongly correlated with handgrip values(r=0.7, p<0.001)

Conclusion

In a prospective study of Day Hospital IBD patients, sarcopenia was identified by impedancemetry in11% and myopenia in 20% of cases, and associated with an increase in morbidity

Disclosure

No conflict of interest

Introduction

Inadequate nutritional status is a major complication of chronic gastrointestinal diseases such as Inflammatory Bowel Diseases (IBD), including two main types: Crohn's Disease (CD) and Ulcerative Colitis (UC) [1]. Previously, sarcopenia and myopenia were associated only with ageing, but they also affect patients with chronic diseases, including IBD, regardless of age [2]. Both malnutrition and sarcopenia lead to poorer health outcomes in IBD patients, increasing the risk of hospitalization, disease exacerbation, need for surgery and post-operative complications [3, 4].

Aims & Methods

The aim of this study was to assess the prevalence of sarcopenia, myopenia and malnutrition in Polish patients with IBD using clinical tools available in daily practice. A total of 91 IBD patients (48 CD, 43 UC), aged 18-65 years, with both inactive and active disease (30 and 61, respectively), were included in the study. Sarcopenia was assessed using the Strength, Assistance in walking, Rise from a chair, Climb stairs, and Falls (SARC-F) questionnaire and the 5-times sit-to-stand test, while myopenia was evaluated through the Fat-Free Mass Index (FFMI). Nutritional status was determined using BMI, the Nutritional Risk Screening (NRS-2002), biochemical parameters (albumin and ferritin levels), and body composition analysis.

Results

Malnutrition was identified in 22% of patients based on BMI (3 inactive, 17 active IBD) and in 31.9% based on NRS-2002 (1 inactive, 28 active IBD). Based on BMI, 25 patients (27.5%) were classified as excessive body weight, and 44% of these were in the active phase of the disease. Hypoalbuminemia and low ferritin levels were observed in 64% and 38.3% of participants, respectively. Sarcopenia was present in 24.3% of patients (SARC-F) and 17.6% (sit-to-stand test), while myopenia was detected in 36.7%. Sarcopenia and myopenia were more common during active disease phases. A significant association was found between regular physical activity of patients and a reduced incidence of myopenia (OR = 0.24; 95% CI: 0.09 - 0.64) – compared to patients who did not declare such activity. It was observed that patients receiving biological therapy had a significantly lower prevalence of malnutrition according to the NRS - 2002 scale (OR = 0.33; 95% CI: 0.11 - 0.98). Additionally, in this patient group, a trend toward a lower prevalence of sarcopenia, as assessed by the SARC - F questionnaire, was observed. No significant associations were found between the increased prevalence of either sarcopenia or myopenia and disease type, patient gender, or disease duration.

Conclusion

Our study shows that malnutrition and sarcopenia are prevalent in Polish IBD patients, necessitating comprehensive assessment tools. We demonstrated that reliance on BMI alone is insufficient. While BMI identified malnutrition in a lower percentage of patients, the use of additional parameters, such as the NRS - 2002 scale and biochemical markers, provided a more comprehensive assessment. Higher BMI values can obscure malnutrition by masking muscle loss and nutritional deficiencies, making standard BMI assessments insufficient. In addition, we observed that biological therapy can have a beneficial effect on the nutritional status of IBD patients. We have shown that all of the methods we have presented for detecting malnutrition and sarcopenia can be successfully used in patients with IBD. However, further research is needed to identify the preferred method.

References

[1] Massironi S, Viganò C, Palermo A, Pirola L, Mulinacci G, Allocca M, Peyrin-Biroulet L, Danese S. Inflammation and malnutrition in inflammatory bowel disease. Lancet Gastroenterol Hepatol. 2023 Jun;8(6):579-590. doi: 10.1016/S2468-1253(23)00011-0.
[2] Neelam PB, Sharma A, Sharma V. Sarcopenia and frailty in inflammatory bowel disease: Emerging concepts and evidence. JGH Open. 2024 Jan 27;8(1):e13033. doi: 10.1002/jgh3.13033.
[3] Liu S, Ding X, Maggiore G, Pietrobattista A, Satapathy SK, Tian Z, Jing X. Sarcopenia is associated with poor clinical outcomes in patients with inflammatory bowel disease: a prospective cohort study. Ann Transl Med. 2022 Mar;10(6):367. doi: 10.21037/atm-22-1126.
[4] Dhaliwal A, Quinlan JI, Overthrow K, Greig C, Lord JM, Armstrong MJ, Cooper SC. Sarcopenia in Inflammatory Bowel Disease: A Narrative Overview. Nutrients. 2021 Feb 17;13(2):656. doi: 10.3390/nu13020656.

Introduction

Dietary intervention is well recognised as an effective treatment for Crohn’s disease in children, and there is a growing evidence base for its use in adults in inducing and maintaining remission¹. It has a number of advantages over standard therapy including a low side effect profile and being cost effective, but despite this nutrition therapy is underused in practice².

Aims & Methods

To investigate the efficacy of the addition of dietary intervention including elemental formula and a Low Fat/ Fibre Limited Exclusion (LOFFLEX) diet in addition to standard therapy on outcomes in Crohn’s disease, compared to standard therapy alone.
A cohort of patients at MDHB in Palmerston North, New Zealand, with Crohn’s disease who were started on dietary intervention as monotherapy or in addition to standard therapy in non-responsive patients between the beginning of 2019 and the end of 2021 were analysed retrospectively. A cohort of patients treated with standard therapy alone, which includes treatment with 5ASA, immunomodulator and biologic therapy were also retrospectively recruited from a database of IBD patients at MDHB. Baseline data for both groups were collected and standardised using regression model analysis for baseline characteristics including duration of disease, gender, smoking status, location and behaviour of disease, baseline Harvey-Bradshaw Index (HBI) and C-reactive protein (CRP).
Outcomes for both groups were measured using number of flares (defined by course of steroids and/or hospital presentations), biochemical markers including CRP and faecal calprotectin, and a composite marker of symptoms using the Harvey Bradshaw Index.
We fitted a mixed effects model to the response (i.e. HBI, CRP, faecal calprotectin and number of flares) separately with a fixed effects of time (12 and 24 months) for the nutrition and standard groups.

Results

At the 12 month mark, patients on nutrition therapy had a significantly lower HBI (1.9126) compared to those on standard therapy alone (4.3454 with a p-value of 0.0026. There was no significant difference between groups at 24 months. There was no statistically significant difference between the groups for other outcome measures including CRP, faecal calprotectin, and number of flares.

Conclusion

Our study suggests nutrition therapy in Crohn’s disease is effective as monotherapy or when combined with other treatment modalities in non-responsive patients already on pharmacotherapy. At the 12-month duration nutrition therapy was more effective in this group compared to patients on standard therapy based on the Harvey-Bradshaw Index, suggesting a potential alternative treatment approach for adults with mild to moderate Crohn’s disease, and highlighting the need for further research in this area.

References

• Zulkiflee, Nuur Hj, et al. "PTH-28 Elemental formula and LOFFLEX nutrition therapy; an effective but neglected treatment strategy in Crohn’s disease." (2021): A184-A185.
• Woolner, J., et al. "The development and evaluation of a diet for maintaining remission in Crohn's disease." Journal of Human Nutrition and Dietetics 11.1 (1998): 1-11.
• Luo, D., Ganesh, S., & Koolaard, J. (2021). Predictmeans: calculate predicted means for linear models [R package version 1.0.6]. https://CRAN.R-project.org/package=predictmeans.
• Douglas Bates, Martin Maechler, Ben Bolker, Steve Walker (2015). Fitting Linear Mixed-Effects Models Using lme4. Journal of Statistical Software, 67(1), 1-48. doi:10.18637/jss.v067.i01.

Introduction

Advances in medical management of Crohn’s disease (CD) have improved disease outcomes; however, significant gaps remain. Approximately 30% of patients experience primary non-response to induction therapy with biologics, and over 40% will experience loss of response. There is an urgent need to identify new adjunct therapies, including diet, that can alter the disease course. Dietary patterns characterized by increased intakes of fibre, fruit, vegetables and decreased intakes of processed foods, sugar and omega-6 fatty acids are linked to a reduced prevalence of CD and decreased biomarkers of intestinal and systemic inflammation; however, the effects upon mucosal inflammation are unknown in patients who have lost response to usual medical treatments. We developed the CD Therapeutic Dietary Intervention (CD-TDI), a novel dietary approach incorporating best practices and current evidence to determine its therapeutic potential in reducing inflammation in patients with active CD who have lost response to their usual therapies.

Aims & Methods

This 13-week RCT aimed to explore the efficacy of the CD-TDI compared with conventional management (CM) to reduce clinical disease activity (Harvey-Bradshaw Index (HBI) <5) and reduce mucosal inflammation, as measured by fecal calprotectin (FCP) in mild-to-moderately active luminal CD. Patients with mild to moderately active disease, determined by endoscopic, cross-sectional imaging or FCP >100 ug/g, on stable medical therapy 8 weeks prior to recruitment were eligible to participate (n=28). Upon randomization, the CD-TDI group (n=16) met virtually with a registered dietitian trained in the CD-TDI protocol weekly for 13 weeks. Participants assigned to CM (n=12) followed their habitual diet and met with the same registered dietitian as participants in the CD-TDI group at week 0 (W0) and week 13 (W13) to capture their dietary recall. FCP, HBI, and C-reactive protein (CRP) were assessed at W0 and W13.

Results

Twenty-eight participants (53% females, age 40 years (IQR:31-55); BMI 27 kg/m² (IQR:24-31)) were enrolled. Medical therapy did not differ between groups, with 54% (15/28) of participants receiving no drug therapy, 29% (8/28) 5-ASA monotherapy, 21% (6/28) biologic therapy, 11% (3/28) corticosteroids or 14% (4/28) immunomodulators. At W0, the FCP, HBI and CRP did not differ significantly between groups. In the CD-TDI group, FCP decreased significantly from 130 ug/g (IQR: 38-411) at W0 to 72 ug/g (IQR:3-153) at W13 (p= 0.01) and significantly differed between the CM group at W13 (p=0.04). In a sub-group analysis (n=11) of participants with FCP >250 ug/g at W0, at W13 the FCP decreased significantly from 632 ug/g (IQR: 356-1013) to 166 ug/g, (IQR:52-701) (p=0.06) within the CD-TDI group, however, this same trend was not observed in the CM (W0:337 ug/g IQR:324-1013 vs. W13:431 ug/g, IQR:46-1770, p=0.69). At W13, between-group differences in the CRP were found between the CD-TDI group (1.0 mg/L, IQR:0.6-2.4) and the CM group (4.5 mg/L, IQR:2.6-13.0) (p=0.002). The CD-TDI group experienced a significant decrease in HBI from W0 to W13 (W0: 3.0, IQR:1.0-5.3; W13: 2.0, IQR:0-3.0; p=0.05), however, this was not observed in the CM group.

Conclusion

At W13, the CD-TDI significantly decreased clinical and biochemical markers of inflammation in patients with mild-to-moderately active CD. This preliminary analysis suggests that CD-TDI could be a potential adjunct management strategy for reducing inflammation in CD. We hope to confirm these promising results with an adequately powered sample.