Early Mucosal Healing with Exclusive Enteral Nutrition is Associated with Improved Outcomes in Newly Diagnosed Children with Luminal Crohn's disease

Z Grover; C Burgess; R Muir; C Reilly; P J Lewindon

doi:10.1093/ecco-jcc/jjw075

Early Mucosal Healing with Exclusive Enteral Nutrition is Associated with Improved Outcomes in Newly Diagnosed Children with Luminal Crohn's disease

J Crohns Colitis. 2016 Oct;10(10):1159-64. doi: 10.1093/ecco-jcc/jjw075. Epub 2016 Mar 15.

Authors

Z Grover¹, C Burgess², R Muir³, C Reilly³, P J Lewindon⁴

Affiliations

¹ Department of Gastroenterology, Princess Margaret Hospital for Children, Perth, Australia Department of Gastroenterology, Queensland Children Medical Research institute, Brisbane, Australia zubin.grover@health.wa.gov.au.
² Department of Gastroenterology, Lady Cilento Children's Hospital, Brisbane, Australia.
³ Department of Gastroenterology, Wesley Hospital, Brisbane, Australia.
⁴ Department of Gastroenterology, Wesley Hospital, Brisbane, Australia School of Paediatrics and Child Health, University of Queensland, Brisbane, Australia.

PMID: 26980840
DOI: 10.1093/ecco-jcc/jjw075

Abstract

Background: Exclusive Enteral Nutrition (EEN) induction in children with luminal Crohn's disease (CD) gives early mucosal healing (MH), but the long-term benefits of EEN-induced MH are just emerging.

Aims & methods: We prospectively followed an Australian cohort of newly diagnosed children with predominantly luminal CD who completed at least six weeks EEN and with paired clinical Pediatric Crohn's Disease Activity Index (PCDAI), biochemical (C-reactive protein; CRP) and endoscopic assessment at diagnosis and post EEN. All commenced immunomodulators (IMs) early (<3 months from diagnosis) and had a minimum of 1 year follow-up. Complete MH was a simple endoscopic score for Crohn's disease (SES-CD) of 0, and SES-CD≥1 was ascribed to active endoscopic disease (aED) and further divided into near complete MH (SES 1-3), mild active disease (SES-CD 4-10) and moderate to severe disease (SES-CD>10). The primary outcome was long-term supervised sustained remission (SR) on IMs alone without need for corticosteroids, infliximab (IFX) or surgery.

Results: A total of 54 eligible children (33 males) completing EEN induction were analysed. The median duration between pre and post EEN assessments was 60.5 days [interquartile range (IQR), 56-69.5]. Post EEN: clinical remission (PCDAI < 10) was observed in 45/54 (83%), and biochemical remission (PCDAI < 10 and CRP < 5 mg/dl) was observed in 39/54 (72%). Complete MH was observed in 18/54 (33%), near complete in 10/54(19%). SR was superior in those with complete MH vs. aED; 13/18, (72%) vs. 10/36 (28%), p = 0.003 at 1 year, 8/16, (50%) vs. 3/24, (8%), p = 0.008 at 2 years and (8/16, (50%) vs. 1/19, (6%), p = 0.005) at 3 years. Near-complete MH did not lead to superior SR.

Conclusions: Only complete MH post EEN induction predicts more favourable SR for up to 3 years.

Keywords: EEN; mucosal healing; simple endoscopic score for CD.

Publication types

Clinical Trial

MeSH terms

Azathioprine / therapeutic use
Child
Combined Modality Therapy
Crohn Disease / diagnostic imaging
Crohn Disease / pathology
Crohn Disease / therapy*
Enteral Nutrition / methods*
Female
Follow-Up Studies
Humans
Immunosuppressive Agents / therapeutic use
Intestinal Mucosa / diagnostic imaging
Intestinal Mucosa / pathology*
Kaplan-Meier Estimate
Male
Mercaptopurine / therapeutic use
Proportional Hazards Models
Prospective Studies
Remission Induction
Severity of Illness Index
Treatment Outcome
Wound Healing

Substances

Immunosuppressive Agents
Mercaptopurine
Azathioprine

Supplementary concepts

Pediatric Crohn's disease