THE UNIT PROTOCOL SHOULD CLARIFY THE FOLLOWING POINTS:-

1. Choice of diet
This will depend on the underlying bowel disease, the patient's nutritional state and the aim of treatment.

The experience of the unit will dictate whether whole protein, semi-elemental or elemental diet is chosen as first line treatment. Irrespective of which diet is chosen, the protocol should state how to progress both from a therapeutic and nutritional point of view if the patient fails to respond to the first line choice. For example, if a patient fails to respond to semi-elemental diet, should diet then be abandoned as a therapeutic remedy or should the patient be given a trial of an elemental diet?

2. Route of administration

a) Orally
This is the simplest, safest and cheapest method of administration and should be used providing there are no contraindications.

b) Indications for a Nasogastric Tube (NGT)
i Inability to drink the product. This problem can occur when patients are very ill and weak and cannot physically manage the diet. Occasionally, individuals find the drink unpalatable and refuse to drink it .

ii Inadequate volume being consumed orally. This can be due to the patient's high nutritional requirements and who therefore require to consume a very large volume of diet. Gastrointestinal symptoms of nausea, vomiting or abdominal pain can also reduce oral intake.

iii If the patient is managing some feed orally throughout the day but cannot quite meet their requirements, then nocturnal feeding should be considered to correct the deficit.

iv The majority of patients with a NGT can be taught how to pass their own tube and become self caring with the feeding regimen. With careful monitoring there is no reason why these patients cannot be discharged with a NGT

c) Indications for a Percutaneous Endoscopic Gastrostomy (PEG)
There is insufficient information on the use of PEG's in Crohn's disease to be able to recommend them in individuals who require feeding artificially for a prolonged period of time.

In Crohn's disease there is an increased risk of developing fistulae and the insertion of a PEG may increase the risk of a gastro-cutaneous fistula. (However, to our knowledge such an occurrence has never been documented). Also, many patients have had bowel surgery which may pose difficulties in the placement of the PEG.

3. Length of treatment
The aim of treatment will determine the length of treatment. If the aim is to meet a nutritional goal then treatment continues until this goal is achieved. If the aim is to achieve remission, the optimum length of treatment has not been determined. Regimens in current use vary from treating the patient until their symptoms of active disease have disappeared, to treating for 12 weeks. Most units treat for approximately 4 - 6 weeks.

4. Policy for discharge
The unit protocol should describe the procedure for discharge. This will prevent the all too common situation of a patient being discharged at the last minute with no organised supply of diet or preparation for discharge.

5. Initiation of the diet as an out or in-patient
Ideally patients should be admitted to hospital to commence treatment with ED. Discharge should be withheld until they are tolerating the diet and meeting their nutritional requirements. Although is easier to monitor someone as an in-patient, it is not necessary to admit all patients. This will depend on the patient's comprehension of the diet, social conditions and motivation to initiate the diet at home.

The introduction of ED in Tetra Brik® has allowed many patients to commence ED as an outpatient. Daily contact between the dietitian and patient is recommended until the dietitian is satisfied that the patient has full comprehension of the diet.

6. Free foods
Additions to the diet should be limited as much as possible; as soon as other items are included then a true elemental regimen is not being followed. When the ED is being used for other reasons than to induce remission in active Crohn's disease, a more lenient approach may be taken.

It is important that all team members are clear regarding which additional food/drink items are allowed. This prevents confusion and possible excuses for non-compliance.

7. Monitoring and assessment
The protocol must state clearly what the frequency of contact with the patient should be. It should also make clear which member of the team is responsible for contacting the patient and who the patient should contact if in need of help. When the diet is initiated, frequent contact with the patient is required. This will usually be in person if the patient is in hospital. If the patient is at home then contact may be by telephone, hospital visits and home visits. These contacts are necessary to assess the patient's tolerance to the diet, to ensure that nutritional requirements are being met, to encourage compliance and to provide support. Once the patient is established on the diet the time interval between each contact can be extended.

Laboratory measures of disease activity and nutritional status are also important. The frequency of these will vary between patients but an outline of the measurements and identification of the person responsible for obtaining them is an important feature of the unit protocol (see Appendix 1).

8. Food reintrodution
The unit protocol should state clearly the reintroduction regimen so all team members are aware of it and conflicting advice is not given.

9. Malnourished patients
During the introductory period of an ED it is common for patients to lose a little weight before nutritional requirements are fully met. In undernourished patients care needs to be taken because further weight loss may cause additional complications. The unit protocol must have a system that can identify malnourished individuals and state clearly the action to be taken. Patients with a Body Mass Index below 18 would ideally be admitted to hospital to begin treatment and should remain as in-patients until their nutritional requirements are met. In such patients it is often best to begin with nasogastric feeding and consider converting to oral feeds later.

Uncertainty in the management of malnourished patients with Crohn's disease may result in several weeks of inadequate nutrient intake and a resultant reduction in nutritional status.

LIQUID ELEMENTAL DIETS TAKEN ORALLY

* The starter regimen for the liquid ED is only based on volume as the concentration is predetermined.

* The diet needs to be offered in stages, gradually increasing the volume. If the full volume required to meet the patient's nutritional requirements is offered on the first day it may be daunting and result in poor compliance.

* When starting an elemental diet the patient may doubt their capabilities and will probably be a little apprehensive about avoiding food and surviving solely on a liquid. Regular contact is needed to ensure compliance and provide encouragement.

* It is important that the patient knows what is expected of him/her and for them to have daily goals. It is also important to be flexible.

* Initially the patient should be advised to sip the drink regularly throughout the day. Once the feed is tolerated the drink can then be taken in a manner that suits their lifestyle, e.g. having 1-2 cartons every two hours.
* Advice will need to be offered about taking additional fluid to meet their fluid requirements, especially when the diet is first introduced.

* The diet is best consumed cold, straight from the refrigerator, either through a straw from the Tetra Brik® carton or in a glass over ice.

* Individuals with short bowel syndrome or extensive inflammation of the small bowel may notbe able to tolerate large volumes of the diet in a short period. They may need to be advised to consume smaller volumes continually throughout the day.

Taken from www.shsweb.co.uk