Current management of bowel failure due to Crohn's disease in Spain: Results of the GETECCU survey

Short bowel syndrome was initially defined as a disorder occurring in patients with insufficient length of bowel to enable adequate absorption of nutrients and/or fluids and electrolytes. However, it is now generally defined in anatomical terms, referring to patients who have undergone one or multiple surgical resections resulting in a remaining small bowel shorter than 200 cm (the length of intestine necessary to maintain nutritional autonomy varies).1

A broader concept based on functional criteria is currently used, that of intestinal failure.2 This includes patients with short bowel criteria and those with other causes of intestinal malabsorption. Intestinal failure is therefore defined as situations where, as a result of surgical resection, congenital defect or disease-related loss of absorption, intravenous supplementation is required to maintain optimal macronutrient, micronutrient and fluid and electrolyte balances.2, 3

The actual prevalence of chronic intestinal failure in our setting is variable, although some European studies5 put it in the range of 5–20/106 population (including patients with parenteral nutrition beyond 90 days). However, the incidence of short bowel syndrome (mainly that not requiring prolonged parenteral nutrition) is not clearly established, probably because of the variability in outcomes and even in the definition.

In adults, the most common cause is short bowel syndrome related to extensive surgical resections resulting from mesenteric ischaemia, Crohn's disease (CD) or mesenteric (desmoid) tumours. In children, there can also be other causes, such as motor disorders (for example Hirschsprung's disease) or congenital disorders of the intestinal epithelium.3, 4, 6

It is estimated that CD may be the cause of around 5% of cases of intestinal failure, as the result of extensive or multiple bowel resections.7, 8 However, the published series are old.9, 10 These days, resection surgery is more conservative and less frequent in these patients (due to better clinical control of the disease and drug development), so we might expect short bowel syndrome to be less common.

A recent review11 established that the incidence of intestinal failure in patients with CD is 0.8% at 5 years, 3.6% at 10 years and 8.5% at 20 years (with a mean of 3.3 bowel resections among the patients included), and that it could affect up to a third of patients who have several bowel resection operations.

The aim of treatment in patients with intestinal failure is ultimately to help them achieve an adaptive mechanism through an intestinal rehabilitation programme.

Among the pharmacological measures available are teduglutide, a human glucagon-like peptide-2 (GLP-2) analogue, which acts as a specific trophic therapy,12, 13, 14 and which has proven to be a useful and safe treatment in this scenario, even in patients in whom the cause of the intestinal failure is CD.14

The aim of this study was to find out how patients with intestinal failure are managed in different hospitals in Spain, although in limited form, referring only to patients in whom the cause of the malabsorptive syndrome is CD. There is also a lack of quality and up-to-date scientific evidence on the actual prevalence of CD-related intestinal failure in our setting in the context of the use of biological drugs and close monitoring strategies for the disease.

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