Predictors for Developing Intestinal Failure in Patients With Crohn's Disease

Richard B Gearry; Michael A Kamm; Ailsa L Hart; Paul Bassett; Simon M Gabe; Jeremy M Nightingale

Disclosures

J Gastroenterol Hepatol. 2013;28(5):801-807. 

In This Article

Abstract and Introduction

Abstract

Background and Aim: Intestinal failure (IF) is a rare but devastating complication of Crohn's disease (CD). The clinical and surgical factors that predispose to IF are poorly understood. The aim of this study was to define clinical factors that predispose to IF.

Methods: A retrospective case–control study was performed using consecutive CD patients with IF who were identified from a prospective database. Local population-based controls were selected with which to compare demographic, phenotypic, and clinical outcomes.

Results: Eighty-two CD patients requiring long-term intravenous fluids or nutrition were studied. Diagnosis at age 16 years or less (P = 0.01) and a family history of inflammatory bowel disease (P = 0.02) were associated with a significantly higher risk for developing IF. Among the IF group, 53% had perioperative complications from intestinal resections contributing to long-term IF. Furthermore, these patients had more abdominal surgeries (P = 0.05) and stricturing disease was less common than in patients with primary active CD (P = 0.01). IF due to primary active CD was associated with penetrating behavior (P = 0.02) and early age at first surgery (P = 0.004). The need for intravenous nutrition as opposed to intravenous fluids correlated inversely with small intestine length (P < 0.001).

Conclusions: CD resulting in IF relates to earlier age at diagnosis, family history of inflammatory bowel disease, stricturing disease, younger age at first surgery, and operative complications. These factors deserve consideration when planning therapy for CD patients.

Introduction

Surgery is a common treatment for inflammatory bowel disease (IBD). In the setting of Crohn's disease (CD), up to 80% of patients will require one bowel resection, with many requiring further surgeries.[1,2] Recurrent surgeries are likely to predispose to a short small intestine through resection of active disease and postoperative complications leading to further resections. Once the small intestine is unable to absorb sufficient nutrients, electrolytes, and fluid, then intestinal failure (IF) occurs and parenteral fluid and/or nutrition are required.

IF, with the requirement for parenteral fluid and/or nutrition (IVN), is one of the most devastating complications of CD. While IF is uncommon, CD is one of the more common causes of IF in adults and is associated with significant morbidity, financial cost, and mortality.[3–6] While small bowel transplantation has evolved rapidly, 5-year survival data for all small bowel transplants remain approximately 50%, despite improvements in perioperative survival.[7] The mortality rate for intestinal transplantation remains much higher than for home parenteral nutrition.[8] Furthermore, it is estimated that fewer than 200 small bowel transplants are performed worldwide per year; most centers have limited experience. Given the poor access to transplantation, due to limited transplantation centers and low donor rates, and the relative risk of transplantation compared with intravenous nutritional support, long-term parenteral nutrition remains the mainstay of treatment for IF patients.[7]

There are few data concerning risk factors for the development of IF in the setting of CD. Yet, such information is vital if the development of this complication is to be avoided. A major limitation of identifying such risk factors is the small number of centers that have sufficient CD patients with IF to enable such an analysis. In order to describe the characteristics of CD patients with IF, we aimed to analyze a large consecutive cohort of CD patients with IF. Our specific objectives were to: (i) determine the underlying cause of IF in each CD patient and define the demographic, phenotypic, and clinical characteristics associated with specific IF etiologies; (ii) compare the demographic, phenotypic, and clinical characteristics of CD patients with IF with sex- and age-matched controls; (iii) correlate the specific requirements for IVN with the remaining small intestine length.

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