Franck Arnaud-Battandier

Colonic Crohn’s Disease in Children Does Not Respond Well to Treatment with Enteral Nutrition If the Ileum Is Not Involved

Data supporting a response to treatment with exclusive enteral nutrition in pediatric colonic Crohn’s disease are few. We examined clinical and biochemical responses of ileal, colonic, and ileocolonic Crohn’s disease and assessed the endoscopic and histological colonic mucosal response in the colonic and ileocolonic groups.We prospectively enrolled 65 children (age: 8–17 years) with acute intestinal Crohn’s disease (Pediatric Crohn’s Disease Activity Index [PCDAI] > 20). After ileocolonoscopy, gastroscopy, and a barium meal and follow-through, they were distributed into three groups (ileal, n = 12, ileocolonic, n = 39; and colonic, n = 14). All patients received exclusive polymeric feed as treatment, with a repeat endoscopy at completion of treatment. At enrollment the ileal group had significantly less severe disease (P = 0.05) compared to the colonic and ileocolonic groups. However, the colonic disease group showed the least fall in PCDAI scores at completion of treatment with enteral nutrition (P = 0.03), with the lowest remission rate (50%, vs 82.1% in the ileocolonic and 91.7% in the ileal group [χ2 test, P = 0.021]). Endoscopic and histologic colonic mucosal assessment showed a posttreatment improvement in the ileocolonic (P ≤ 0.01) but not in the colonic disease group (P = ns). Children with disease in the colon respond better to enteral nutrition if the ileum is also involved. This may be due to different underlying inflammatory mechanisms. Detailed pretreatment assessment in studies of Crohn’s disease according to disease distribution with appropriate individualized tailoring of treatment may be important in this regard.

Increasing plasma glutamine in postoperative patients fed an arginine-rich immune-enhancing diet - a pharmacokinetic randomized controlled study.

Objective:Immune-enhancing diets (IEDs) rich in arginine (ARG) reduce morbi-mortality in trauma and surgical patients. Among the pharmaconutrients inducing these effects, ARG may be involved by generating active metabolites such as glutamine (GLN). However, the ability of an ARG-enriched diet to normalize GLN plasma levels in intensive care unit (ICU) patients has never been documented. To analyze plasma GLN and related amino acid (AA) kinetics in response to an ARG-enriched IED in ICU surgical patients. Design:This prospective, randomized, single-blind, comparative study was performed on 22 patients randomized to receive total enteral nutrition for 7 days with either an ARG-enriched IED or a standard formula (rendered isonitrogenous to the IED, S group, n = 11), providing 30 kcal/kg/day and 0.3 g N/kg/day. Measurements:Plasma AA concentrations were measured on day 5 after a 3-hour washout period (basal values = T0) and after 30, 60, 90, 120, 180, and 360 minutes of enteral nutrition. The primary end point was the variation in plasma GLN from T0 to T90. Results:Only the IED-fed patients showed an increase in plasma levels of GLN (differences [T90 − T0]: +40 ± 6 vs. −35 ± 18 &mgr;mol/L, mean ± sem, p < 0.05, two-way analysis of variance), ARG (+35 ± 5 vs.+1 ± 4 &mgr;mol/L, p < 0.05), ornithine (+23 ± 6 vs. −2 ± 2 &mgr;mol/L, p < 0.05), and proline (+36 ± 10 vs. −6 ± 11 &mgr;mol/L, p < 0.05). Conclusion:To our knowledge, this is the first reported pharmacokinetic study on an IED even though these products have been on the market for 20 years. Our main result is that administering an ARG-enriched IED causes a significant increase in plasma GLN probably from de novo GLN synthesis from ARG. This suggests that the ARG present in IED can serve to supply GLN to ICU patients, who are usually depleted in this conditionally essential AA during injury.

Effect of enteral nutrition on antioxidant enzyme systems and inflammation in paediatric Crohn's disease

Crohns disease is characterized by chronic inflammation of the gastrointestinal mucosa, which can be successfully treated with enteral nutrition. In this study, the activities of the antioxidant metalloenzymes copper/zinc‐superoxide dismutase (Cu/Zn‐SOD) and selenium‐glutathione peroxidase (Se‐GPx) were determined in erythrocyte lysates from children with Crohns disease. Both enzymes exhibited significantly lower activities relative to healthy control subjects: 1.55 ±0.33 vs 2.13 ±0.75 SOD Umg‐1 protein (p < 0.025) for Cu/Zn‐SOD, and 61.9 ±17.7 vs 93.6 ±28.7 mUmg‐1 protein (p<0.01) for Se‐GPx. Treatment of patients with a specific polymeric diet, CT3211, for a period of 8 wk did not significantly alter the activities of the enzymes. In contrast, clinically, enteral nutritional therapy induced a remission in 13/14 children, and a significant fall in both median serum C‐reactive protein and mean serum tumour necrosis factor‐a levels.

Remission induced by a new specific oral polymeric diet in children with Crohn's disease.

We have been able to show that CT3211 is an effective oral treatment in children with active Crohns disease. It was well tolerated, and there were minimal side effects. At the mucosal site of disease there was macroscopic and histological improvement, together with evidence of downregulation of the pro-inflammatory cytokines IL-1 beta, IL-8, and IFN-gamma.