Exclusive Enteral Nutrition

(EEN) and Surgery

Azar B-Nejad

Senior Dietitian - Gastroenterology, Colorectal

Surgery and Intestinal Failure

Fiona Stanley Hospital

Contents

• What is EEN?

• Who can benefit from EEN?

• When should EEN be used?

• Why should EEN be used?

• How does EEN work?

• What does this mean for my other treatments and

medications?

• A note on “other” diets

What is EEN?

The provision of 100% of a persons nutrition

requirements from a liquid nutrition formula

Can be drank orally or if taste not tolerated, given

via a feeding tube.

The idea is to use as a form of therapy to induce

remission

What is EEN? C’td

Drink only nutrition supplements and water for 6-8 weeks

A Dietitian will calculate the type and number of nutrition

supplements you need to have per day

Can include up to 500ml of clear broth or jelly (not diet).

Boiled lollies or chewing gum (not sugar free).

No other food or fluids other than water

Food reintroduction must be done slowly and under the

supervision of a dietitian. Food reintroduction typically

takes 5-10 days

Most common reasons people refuse EEN are because they

are unwilling to give up food for 6-8 weeks and taste preference

Who can benefit from EEN?

People with crohns disease

Children and adults

People that have been recommended to trial EEN

by their gastroenterologist and are under the

supervision of a dietitian

No evidence for its use in Ulcerative colitis (UC)

When is EEN used?

• Active disease

• Not usually first line therapy in adults

• Help to achieve appropriate weight and BMI

• Pre-operative optimisation

• Obstructive symptoms

• Strictures

• Fistulas

• Malnutrition

Why is EEN used?

• Waist circumference is better linked to

outcomes in IBD than BMI

• Surgical risks associated with BMI too high or too low

• Optimises CRP levels and to some extent Albumin i.e. reduces inflammation

• Eliminates the need for steroids

• Promotes mucosal healing

Why is EEN used? C’td

• Cheap

• Tolerable in most people with dietitian support

• Reduces post-operative:

- anastomotic leaks

- intra abdominal abscess/collections - wound infection and dehiscence

- high output stoma

- recurrence of disease 6 months post op

Heerasing et al., (2017). Aliment Pharmacol Ther45: 660-669

Preoperative optimisation. 35 optimised Vs 32 non-optimised patients

How does EEN work?

Promotes reduced inflammation and healing of the

muscosa by altering the microbiota

Mucosa = The innermost layer of the GI tract

It comes into contact with digested food

How does EEN work?

Microbiota or “GUT flora” = the microbe or bacterium population living in our intestine. • There are 10 billion bacterium cells per tspn of stools. • We have 10 times more bacterium in our GUT than total human body cells Changing the microbiota with EEN causes: o Reduced intestinal permeability o Enhances the GUTs barrier defence o Promotes a reduction in pro-inflammatory proteins

What does this mean for other

treatments and medications? • Often if you are on any steroids, these will be reduced

and stopped

• EEN does not replace other maintenance medications or

medical follow up.

• Often used in conjunction with other medications

Doing a “liquid diet” or “juice diet” does NOT

achieve the same results and often causes harm

Partial EN with a crohns disease exclusion diet • 47 patients (34 children and 13 adults) • Follow up of 12 weeks • 70.6% of patients achieved remission at 6 weeks

(69% of adults and 70.5% of children) • CRP normalised for 70% of patients

A note on “other” diets

Crohns disease exclusion diet

Thank you Questions???