Proc. Nutr. SOC.

(1978), 37,79 79

Nutrition in gastrointestinal disease

Gastroenterology Unit, Royal Infirmary, Glasgm, G4 oSF

By R. I. RUSSELL,

The metabolic consequences of severe disease have been extensively investigated

over some years. More recently, the metabolic and nutritional effects of severe
gastrointestinal disease have been studied, and it is now realized that a wide range
of gastrointestinal diseases may be accompanied by such problems. Recovery from
major gastrointestinal illness may be speeded by nutritional support and indeed
survival may depend upon supplying adequate metabolic aid.

Nutritional aspects of gastrointestinal disease

Most of the original work in relation to metabolic or catabolic responses has
been described in relation to trauma, severe infection or surgery, but the findings
regarding metabolic responses are also relevant to patients with severe
gastrointestinal disease.
Catabolic responses and normal nutritional reserves. Catabolic or metabolic
response of the body to severe or chronic gastrointestinal disease may be as
marked as that following Severe trauma or infection. Much information is now
available about these metabolic responses. The catabolism of body protein exceeds
anabolism and dietary intake is unable to correct this imbalance (Moore, 1959).
Negative nitrogen balance can be partially if not completely reversed by the
administration of a high protein, high energy diet (Troell & Wretlind, 1961).
Under conditions of severe or prolonged stress, injury or disease, metabolic
alterations in the body occur. Features of this metabolic response are a negative N
and potassium balance, retention of sodium and water, and accumulation of acid.
In severe cases a continued catabolic response leads to muscle wasting,
hypoproteinaemic oedema, an increased susceptibility to infection and failure to
repair damaged tissues. The degree of the response is determined by the severity of
the illness.
The normal nutritional reserves present in man are shown in Table I.Reserves
of carbohydrate are 8-12 h, fat 2-25 d and protein 1-15 d. In severe or chronic
gastrointestinal disease the nutritional reserves are likely to have been reduced to
some extent due to the seventy and chronicity of the disease prior to the patient
coming under hospital care.
Table I. Nutritional reserves in normal man
Quantity Duration
(43)
Carbohydrate 0.15-0.20 8-12 h
Fat 1-15 1-25 d
Protein 4 4 10-15 d

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 80 SYMPOSIUM PROCEEDINGS I978
Gastrointestinal diseases which may give rise to nutritional and metabolic
problems. A wide range of gastrointestinal conditions may be associated with
significant nutritional deficiency (Table 2). These deficiency states occur much
more widely than was formerly believed and may not be clinically apparent in
many patients for some time. Their Occurrence depends largely on the severity and
duration of the disease. The early recognition of such problems and their
correction will improve the prognosis of many patients with severe gastrointestinal
diseases.
One gastrointestinal disease which is particularly liable to give rise to severe
nutritional deficiency is Crohn’s disease. This condition is increasing in incidence
and many of the patients have severe malabsorption, diarrhoea associated with
malabsorption of fat, water, electrolytes or bile acids, chronic fistulae, local
infections. They may require surgery for obstructive lesions, often necessitating
the removal of part of the intestine, which may exacerbate the malabsorption and
diarrhoea.

Table 2. Gastrointestinal causes of nutritional deficiency

I. Severe diarrhoeal states 3. Prolonged vomiting
Crohn’s disease Pyloric stenosis
Ulcerative colitis Infections
Gastrointestinal infections Tumours of upper gastrointestinaltract
Tumours of colon and rectum
Chronic pancreatic insufficiency 4. Prolonged poor oral intake
Gastrointestinal fistulae Anorexia nervosa
2. Severe malabsorption states Tumours
Coeliac disease Dy sphagia
Crohn’s disease
Massive small intestinal resection 5. Gastrointestinal surgery

6. Paediatric conditions
Gut atresia
Tracheooesophageal fistula

Assessment of nutritional status .

Before formulating a programme for the nutritional and metabolic support of the
patients with severe gastrointestinal disease, it is necessary to ascertain the
presence and the degree of the nutritional deficiency.
Awareness of the possible presence of nutritional deficiency in any patient with
gastrointestinal disease is clearly an important factor. A simple clinical assessment
is the measurement of body-weight. If possible a comparison with the patient’s
previous weight will provide a measure of severity of the catabolic process. Clinical
assessment may also include the analysis of basal energy expenditure, assessment
of skeletal muscle compartment by measuring triceps skin fold thickness and mid
arm muscle circumference, the measurement of the creatine/height index, serum
albumin, serum transferrin, nitrogen balance and measurement of cell mediated

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 VOl. 37 Nutrition in hospitals 81
immunity (Blackburn, Bistrian, Maini, Schlamm & Smith, 1977).Many of these
methods still require to be fully evaluated and may not be routinely available.

Methods of providing nutritional and metabolic support in gastrointestinal disease

After the identification of a nutritional and metabolic problem in any patient
with gastrointestinal disease atld the assessment of its severity, a decision must be
taken as to the form of the nutritional support which should be given.
There are four ways of providing nutritional and metabolic support in such
patients. ( I ) Supplementary feeding. ( 2 ) Nasogastric feeding with a liquidized diet.
(3) Elemental diets. (4) Intravenous nutrition.
For the provision of any form of adequate nutritional support, there is a
requirement for trained medical and nursing staff, together with the codperation
of a committed team of dietitians, biochemists and pharmacists. The development
of a metabolic team with adequate backup facilities will certainly achieve better
results.
No rules or regulations can be laid down regarding the use of any one of these
four methods in the management of any particular gastrointestinal problem. Each
patient is an individual whose gastrointestinal disease may differ markedly in
duration, severity and effects on the gastrointestinal tract and on its nutritional
disturbances.
Supplementary feeding. Supplementary feeding with simple and palatable fluids
may be sufficient in a number of patients. Clearly this method will be inadequate
for the management of severe or chronic gastrointestinal problems with marked
diarrhoea, malabsorption or vomiting, but in minor nutritional problems and in
early gastrointestinal disease this method is simple and effective. Suitable
supplementary foods include preparations containing Caloreen (Berlyne, Bruis,
Booth, Mallick & Simons, 1969). Caloreen is a mixture of dextrins with an average
glucose chain-length of 6 units. It is palatable, blends easily with most foods and
readily dissolves in water. Preparations containing Caloreen with coffee and fruit
juices can be made up.
Nasogastric feeding. Some patients may be improved by the use of nasogastric
feeding with suitable liquidized foods. These patients, who are unable to ingest the
required quantities of nutrients, should have a gastrointestinal tract of normal
digestive and absorptive capacity. The diets introduced by means of nasogastric
tube are cheap and easy to prepare. Examples of such diet preparations are shown
in Table 3. Combinations of Complan, Caloreen, vitamins or Caloreen, Albumaid,
vitamins and egg yolk are suitable for such preparations. The use of these feeds is
relatively free from side effects although some diarrhoea may occur. They should
be given in small quantities at regular intervals.
Elemental diets. An elemental or chemically-defined diet is a preformulated diet
containing an elemental or nearly elemental protein source, either amino acids
alone or amino acids and small peptides. Simple fats, glucose, minerals and
vitamins are also present in varying amounts according to the preparation. They
require little or no digestion and have minimal residue (Russell, 1975). Their

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 82 SYMPOSIUM
PROCEEDINGS 1978
Table 3. Nasogastric feeding: Examples of diet preparations

300 g Complan 600 g Calomn

300 g Caloreen 60 g Amumaid
9 g Methylcdulose 8 g Metabolic mineral
mixture
Vitamin syrup Vitamin syrup
z or 3 1 with water z or 3 1 with water
14'4 g N xogN
2500 kcal (Io5ookJ) 240 kcal (roo8okJ)
64 meq Na 40 meq Na
84 meq K 30 meq K
development is still at an early stage and as nutritional support sources they are
expensive compared with nasogastric feeding or supplementary feeding regimes.
The nutritional value of elemental diets is satisfactory for normal requirements,
although additional requirements may be necessary in many chronic
gastrointestinal diseases. They are totally absorbed in the upper small intestine,
leaving only endogenous residue to enter the large bowel. No digestion or micelle
formation is required for their absorption; they contain no indigestible bulk or
fibrous material, and are thus low residue in nature.
There are two principal elemental diets marketed in the UK, namely Vivonex
and Flexical. In addition, the products Aminutrin and Calonutrin together form a
chemically defined diet. There are marked differences in the composition of the
two principal elemental diets Vivonex and Flexical as is shown in Table 4. These
differences in the composition in the various elemental diets and their significance
has recently been reviewed. (Young, Heuler, Russell & Weser, 1975; Russell,
1978)-

Table 4. Composition of Vivunex and Flexical

Vivonex Flexical
Protein Pure a amino acids Hydrolyzed peptides
+
amino acids
70 energy contribution 8.50 9.00
Carbohydrate Glucose Sucrose
oligosaccharides oligosaccharides
7% energy contribution 90.20 61.00
Fat SaHowa oil Soya-bean oil
Medium chain triglycerides
Soya-bean lecithin
% energy contribution 1.30 30.00

Essentially elemental diets may be given in gastrointestinal diseases to supply

nutritional requirements, or specific dietary formulations of individual elemental
diets may be used in the treatment of specific gastrointestinal symptoms in
particular diseases. Elemental diets may be given as a supplement to normal food

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 VOl. 37 Nutrition in hospitals 83
or as the sole source of nutrition. In some situations they may follow on from
initial treatment with intravenous feeding.
In patients with chronic gastrointestinal fistulae, electrolyte imbalance,
intraperitoneal sepsis and severe nutritional deficiency may develop over a period
of time. The low residue nature and high nutritional value of elemental diets may
be helpful in the management of these problems (Bury,Stevens & Randall, 1969).
They have also been shown to be of value in recto-vaginal, gastrointestinal-
cutaneous fistulae, and in the treatment of fistulae associated with Crohn’s disease
(Grundy, 1971). They are not helpful, however, in the management of high output,
upper gastrointestinal fistulae.
Elemental diets have a part to play in the management of some maldigestion and
malabsorption states. As they require little or no digestion in the upper alimentary
tract they may be helpful in the maldigestion associated with chronic pancreatic
insufficiency (Voitk, Brown, Echave, McArdle, Gurd & Thomson, 1973), or in
cystic fibrosis. After massive small intestind resection, patients may develop
severe nutritional deficiency with marked diarrhoea and weight loss. Nutritional
support is generally necessary in these patients. Elemental diets may be valuable
(possibly after an initial course of intravenous nutrition) and have an added
advantage in that they may also speed intestinal adaptation. Clinical improvement
in patients with the short bowel syndrome has also been reported (Voitk, Echave,
Brown & Gurd, 1973).
In severe Crohn’s disease with malabsorption elemental diet therapy may be
helpful. In such patients fistulae may also be a problem and one factor in the
causation of the severe diarrhoea in these patients is bile acid malabsorption
leading to cholerheic diarrhoea. It has been demonstrated that the elemental diet
Vivonex improves diarrhoea of this type and causes a statistically significant
reduction in faecal bile acid excretion (Nelson, Carmichael, Russell & Atherton,
1977). Vivonex has also been shown to give good longterm nutritional support in
patients with Crohn’s disease (Goode, Hawkins, Fegetter & Johnson, 1976).
Elemental diets may also have a place in the preparation of patients for colonic
surgery and in the management of patients who have undergone gastroinstestinal
surgery.
Elemental diets may be given orally, either alone or as a supplement to normal
diet, or be administered by means of an intragastric or intrajejunal tube. The route
of administration depends upon the indications for the use of the diet in any
individual patient. Palatability is a problem, although it can be improved by the
use of flavourings, combination with ‘Rise and Shine’, the use of half-strength
solutions and a liberal intake of water. Careful monitoring of patients on elemental
diet therapy is necessary because of potential untoward effects such as nausea,
vomiting, diarrhoea, the hyperosmolar syndrome, dumping and skin rashes.
Intravenous nutrition. Intravenous nutrition may be considered as an
alternative to oral feeding when the latter is unable to support the patient in
adequate nutritional and metabolic balance. There are a number of gastrointestinal
conditions in which intravenous nutrition will be of immense value in short term

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 84 SYMPOSIUM
PROCEEDINGS I978
regimes and also in long term support programmes. Intravenous nutrition is not
only concerned with supplying energy sources and N, but is also concerned with
the maintenance of electrolyte equilibrium and serum oncotic pressure, and the
replacement of fluid.
Intravenous feeding may be total or supplementary. Thus, in a patient in which
bowel rest may be regarded as important (as in severe Crohn’s disease), then
intravenous nutrition, if indicated, will be the sole source of nutrition. If, however,
bowel rest is not a requirement and the important aspect of a patient is the
recovery of his nutritional state and metabolic balance as quickly as possible then
intravenous nutrition may be given in conjunction with supplementary oral
feeding. A great deal depends upon the indications for nutritional support and the
state of the gastrointestinal tract of the patient.
Intravenous feeding may be helpful in patients with severe Crohn’s disease to
give nutritional support or bowel rest, or both. In some instances, a disease
remission may be achieved. Intermittent courses may be helpful especially in
young patients with Crohn’s disease, in whom body-weight and height may be
improved. Patients with ulcerative colitis, chronic pancreatic disease and
gastrointestinal fistulae may also respond to this form of therapy, and in the initial
stages after massive small intestinal resection, intravenous nutrition may be
essential in maintaining the patient in a g d clinical state before starting an
elemental diet.
In a few cases with severe coeliac disease, and in patients with severe vomiting
and gastrointestinal tumours, intravenous nutrition may be helpful in the short
term in improving the patient.
In planning an intravenous nutrition regime, it is important to appreciate the
daily requirements of energy and nutrients for patients, while bearing in mind that
in patients with disease processes as in many chronic gastrointestinal problems,
increased requirements may be necessary. The requirements of water, energy and
nitrogen sources, carbohydrate, fat, electrolytes, trace elements and vitamins are
shown in Table 5.
Table 5 . Recommended daily nutritional requirements
Requirement
(per kg body-wt)
Water 30-35 ml
Nitrogen 80-95 mg
Total energy 3-35 kcd ( 1 2 6 1 4 7 kJ)
Carbohydrate 2g
Fat 2-3 8
Sodium I.*I.~ mmol
Potassium 0.7-0.9 mmol
Calcium 0.I I mmol
Magnesium 0.04 mmol
Iron 1.00 mmol
Zinc 0.30mmol
Copper 0.07 mmol
Vitamin B 0.50 mg
Vitamin C o.50-1.o mg

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 VOl. 37 Nutrition in hospitals 85
Fluid requirements are important. The current fluid balance status of the patient
must be known and abnormal fluid losses carefully recorded. The clinical condition
of the patient also requires to be taken into account. It is generally accepted that
approximately 200-250 kcal (840-1050 kJ) are required for each g N given, and
that the N provision should be about 95 mg N or 0.7g amino acidsbg (Lee,1974;
Wretlind, 1974).Potassium (5 mmol) and magnesium (I mmol) is required for each
g N, and there should be adequate electrolyte and vitamin supplementation. The
energy sources should be infused concurrently and at least 20% of the energy
should be in the form of carbohydrates. N source solutions which are available
include both protein hydrolysates and synthetic amino acid preparations. The pure
amino acid preparations show the best results on N balance studies but are most
expensive. The cheaper peptide hydrolysates may be suitable for most
requirements in gastrointestinal disease. The most important sources of energy
available are carbohydrate and fat. The principal carbohydrate source of energy is
glucose. The rate of glucose intake, however, should not be greater than 0.5 g/
kg per h but minimum intake of 100 g carbohydrate/d is sufficient to avoid
ketosis and increased protein catabolism. Blood glucose levels must be carefully
monitored and insulin may be required. Fructose can be substituted for glucose in
many situations provided that the infusion rate does not exceed 0.5 g/kg per h.
With fructose there is an increase in the lactic acid level in the liver and a risk of
lactic acidosis if given too rapidly. Ethanol is also a valuable source of energy but
the richest source of energy available are fat solutions. There are two principal
types of fat solutions available; one derived from cotton seed oil (Lypiphysan) and
one from soya-bean oil (Intralipid). The principal advantage of fat emulsions is
that a large amount of energy can be given in a small volume of isotonic fluid.
Linoleic acid (0.I g/kg) is required to prevent the symptoms of essential fatty acid
deficiency in patients on intravenous nutrition, and this is obtained in 15 g of soya-
bean oil.
Intravenous nutrients are best administered directly into a large vein such as the
superior vena cava or subclavian vein. After insertion of the catheter the position
must be checked radiologically. Full aseptic precautions must be adopted. The
success of any intravenous nutrition regime is dependent upon daily care of the
needle site, daily changing of infusion sets and changing of the catheter at least
once every 2 weeks, or more frequently if infection occurs. Antibiotics should be
started immediately if infection develops.
Some complications of intravenous nutrition may occur. These include insertion
complications such as local infection, pneumothorax and septic thrombophlebitis,
and septicaemia must also always be guarded against and treated promptly if it
develops. Metabolic complications may also occur. These include the hyperosmolar
syndrome and metabolic acidosis. The latter may occur with fructose solutions
(Woods & Alberti, 1972),but has also been seen with the use of some L-amino
acid preparations. Other complications include essential fatty acid deficiency
(Richardson & Sgoutas, 1975), trace element deficiency such as hypo-
phosphataemia (Dudrick, MacFadyen, van Buren, Ruberg & Maynard, 1972),

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 86 PROCEEDINGS
SYMPOSIUM I978
and deficiences of zinc and copper. Hepatic complications such as the cholestatic
syndrome and fatty infiltration, may also occur.

Conclusions
Nutritional deficiency and the metabolic complications of severe disease are
common in gastrointestinal diseases of many types and must be considered
positively and identified rapidly. Gastrointestinal diseases which may be
accompanied by such problems are Crohn’s disease, ulcerative colitis, coeliac
disease, pancreatic disease and gastrointestinal tumours.
With the early recognition of nutritional deficiency and metabolic problems, and
its management, the patient with severe gastrointestinal disease will have a much
improved prognosis. Their symptoms may improve and he is more able to
withstand continuing disease, infection and surgery when required. When such
problems are present the most appropriate method of improving nutrition for that
particular patient and for the symptoms of that patient should be selected. Ease of
administration and cost effectiveness should also be considered. Whichever form of
nutritional support is selected for any individual patient, careful and continuous
monitoring is required and the side effects of the particular form of therapy looked
for, treated if present, and avoided if possible.

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