The curious case of EN reversing strictures.

[kiny]

https://journals.lww.com/jcge/Abstr...nteral_Nutritional_Therapy_Can_Relieve.9.aspx

Exclusive Enteral Nutritional Therapy Can Relieve Inflammatory Bowel Stricture in Crohn’s Disease
Hu, Dong MD; Ren, Jianan MD, FACS; Wang, Gefei MD; Li, Guanwei MD; Liu, Song MD; Yan, Dongsheng MD; Gu, Guosheng MD; Zhou, Bo MD; Wu, Xiuwen MD; Chen, Jun MD; Ding, Chao MD; Wu, Yin MD; Wu, Qin MD; Liu, Naicheng MD; Li, Jieshou MD

Goals:

To examine the efficiency of exclusive enteral nutrition (EEN) in relieving inflammatory bowel stricture in patients with Crohn’s disease (CD).

Background:

Patients with CD usually develop bowel strictures due to transmural edema of intestinal wall, which can potentially be managed with conservative medical treatment. Previous studies showed that EEN therapy could induce clinical remission through its anti-inflammation effect.

Methods:

We achieved a prospective observational study. CD patients with inflammatory bowel stricture were preliminarily differentiated from a fibrous one, and further treated with EEN therapy for 12 weeks. Demographics and clinical variables were recorded. Nutritional (body mass index, albumin, pre-albumin, transferrin, etc.), inflammatory (C-reactive protein, erythrocyte sedimentation rate, white blood cell, etc.), and radiologic parameters (bowel wall thickness, luminal diameter, and luminal cross-sectional area) were evaluated at baseline, week 4, and week 12, respectively.

Results:

Between May 2012 and January 2013, 65 patients with CD were preliminarily diagnosed with inflammatory bowel stricture and 6 patients were further excluded. Among the remaining 59 cases, 50 patients (84.7%) finished the whole EEN treatment, whereas the other 9 patients (15.3%) gained progressive bowel obstruction resulting in surgery. Intention-to-treat analyses showed that 48 patients (81.4%) achieved symptomatic remission, 35 patients (53.8%) achieved radiologic remission, and 42 patients (64.6%) achieved clinical remission. Among those patients who complete the whole EEN therapy, inflammatory, nutritional, and radiologic parameters improved significantly compared with baseline. Of note, the average luminal cross-sectional area at the site of stricture increased approximately 331% at week 12 (195.7±18.79 vs. 59.09±10.64 mm2, P<0.001).

Conclusions:

EEN therapy can effectively relieve inflammatory bowel stricture in CD, which replenishes roles of enteral nutrition in the treatment of CD. Further studies are expected to investigate the underlying mechanisms of this effect in the future.

 

[kiny]

There need to be follow up studies done regarding this in the West. Stricturing has currently no straightforward solution, if EN can reverse stricturing, this needs to be tested in more studies.

 

[lukesjr]

Since I started reviewing research studies, I have since learned the kiss of death phrase. "suggest more research..." All of these studies that show success end with basically saying, this worked well, someone needs to do more research. Then I see nothing else in the research pipeline. Frustrating!

Kiny, are you now on EEN? My question on EEN. If your theory is just reducing the bacterial load then that would explain why EEN would work. Wouldn't then a good course of treatment just be a continuous cycle of EEN? Meaning, you show inflammation, you go on EEN. Inflammation subsides, you eat normal. I imagine that would be better than taking a biologic when it comes to risk factors.

The one thing that puzzles me is that does EEN really reduce the bacterial load? Even though its EEN you are still getting sugars, carbs, etc. Its just liquified. Is it a solid liquid thing when it comes to bacterial load?

If it is just bacterial load, why don't 100% of the people achieve remission on EEN. Or is it just as you said, Crohns is a bandage term for several different conditions. Kind of like saying the word cancer. Well, which cancer? To treat "cancer" you have to know which specfic cancer. Maybe crohns is like that? There is chrons A, chrohns B, etc.

 

[kiny]

The one thing that puzzles me is that does EEN really reduce the bacterial load?

yes, dramatically so

Even though its EEN you are still getting sugars, carbs, etc. Its just liquified. Is it a solid liquid thing when it comes to bacterial load?

EN are based on maltodextrins (in Europe they call the maltodextrin glucose syrup). If EN mention they contain complex carbs, they really mean maltodextrin, which in reality is not a complex carb, it is instead similar to glucose with a similar glycemic index (depending on the length of the hydrolysis used to make the maltodextrin).

It's hard to know how high up the GI tract, but those maltodextrins are taken up very high in the GI tract, EN is very "bioavailable", it is digested very quickly and quickly turns into blood glucose. Since the 1980s, EN were designed to be as bioavailable as possible.

The reason EN lowers bacterial load is very likely because it deprives intestinal bacteria from nutrients. The intestines are getting to the maltodextrin before the bacteria can.

EN do not contain any fibers, and usually no (or extremely little) lactose, EN creates a hostile environment for bacteria, that results in nutrient deprivation. Meanwhile, your own body can easily and quickly take up the maltodextrin and doesn't suffer the same consequences.

 

[kiny]

(EN also contain fats (medium chain triglycerides which are bioavailable fat)

and some form of protein (the protein used depends on the EN but it does not affect how effective EN is)

...but this is really not very relevant to the mechanics of EN, intestinal bacteria really need undigested carbs to survive, EN deprives bacteria of undigested carbs)

 

[kiny]

Crohn's disease does not exist in a sterile environment, we can see this in mouse models. Crohn's is a response to bacterial antigen, without bacterial antigen, crohn's does not exist.

EN brings down bacterial load, which brings down the inflammatory response to bacterial antigen.

There is likely a function for butyrate producing bacteria, so called "good bacteria", but that should be a tiny footnote when discussing crohn's disease, we are much better off reducing bacterial load than introducing "good" bacteria. When a bacteria enters tissue, it is looked upon as an invader by TLR and macrophages. TLR can create tolerance to lumen bacteria, but the moment a bacteria enters tissue, it is now an enemy of the body and will invoke inflammation. This idea of "good bacteria" is really crazy overblown, a lot of so called harmless bacteria like Fusobacterium are now being reclassified as dangerous pathogens.

EN doesn't just deprive pathogens of nutrients, it also kills off so called "good bacteria", it worsens dysbiosis. Yet this doesn't matter, it brings down total bacterial load and reduces inflammation. We can live without those supposedly "good bacteria" just fine.

 

[kiny]

It has become very trendy among researchers to make claims about supposed health benefits of the microbiome. It's impossible to prove or disprove these theories, due to the sheer abundance of different bacterial populations.

Yet many mammals do not have any resident microbes, they sometimes have transient bacteria, but they are not a microbial host. The bacterial load in the intestine of most mammals is much lower than that of the average human subject.

It is an extremely costly task for the human immune system to maintain an abundant microbiome, and we get very little in return for it. It seems highly unlikely to me that this abundance of microbes in the intestine is normal, the cost to maintain it and the potential for harm is just too great. It seems far more likely that today's diets high in indigestible carbs are creating this overabundance and are to blame instead.

 

[lukesjr]

Then why not just derive a treatment to continually wipe out the bacteria in your gut. Say, take a certain pill every time you eat that just sterilizes your intestine as food passes? That doesn't seem to complex, and I guess in one case that is what AMAT therapy is designed to do.

I mean, the theory is supported by a lot of anecdotal evidence. Many people claim periodic short term fasting has helped put them into remission, etc.

I tend to believe that many of these herbal antivirals, diets, and fasting that reduce bacterial load actually do work and that people who try them struggle to commit to them to make them effective. Someone will take wormwood for 2 weeks and then give up, but I think the on off cycle of bacteria require long term use. Same with fasting, I think it requires long term use.

Personally, when I started treating my mild crohns as an infection I have had much better success and eliminated all my symptoms. I try to do things that would be considered to reduce bacterial load (whether supplements, fasting, etc) My last scope showed mild inflammation, but only in a few spots so something I am doing is working . I am also very disciplined, and don't cheat.

 

[kiny]

I try to do things that would be considered to reduce bacterial load (whether supplements, fasting, etc)

Fasting greatly reduces certain pathogenic bacteria like fusobacteria, and it stimulates autophagy which might be helpful to stimulate xenophagy specific control of intracellular bacteria.

It is just really hard to suggest anyone with crohn's disease should fast due to so many people being underweight.

But yes, eating 3 times a day is unnatural and likely unhealthy, intestines need periods of rest. Eating right before bed and letting all the bugs feed on undigested food is probably not a great idea.

 

[lukesjr]

But yes, eating 3 times a day is unnatural and likely unhealthy, intestines need periods of rest. Eating right before bed and letting all the bugs feed on undigested food is probably not a great idea.
[/QUOTE]

This, I can't specifically point to it because I threw the kitchen sink at crohns, lots of lifestyle changes, but I have pushed my family to eater dinner earlier. We now eat around 5 to 5:30. I think that has contributed to me eliminating my symptoms.