Crohn’s disease complicated with intestinal fistulas: Exclusive enteral nutrition or Biologics?

Abstract Background Approximately 16% of adult patients with Crohn's disease (CD) are complicated with intestinal fistulas. Both exclusive enteral nutrition (EEN) and biologics have shown potential efficacy. We aimed to compare the efficacy of EEN and biologics in adult CD with intestinal fistulas and to explore the preferred choice for these patients. Methods This single-center, retrospective study involved adult CD patients with active intestinal fistulas who received EEN or biologics induction therapy from January 2014 to May 2024. Exclusion criteria included concurrent abdominal abscesses or symptomatic intestinal obstruction. The primary endpoint was clinical remission. The secondary outcomes encompassed clinical response, radiological response, transmural healing, fistula healing, endoscopic response, endoscopic remission, C-reactive protein (CRP) normalization, and surgery. Results A total of 108 patients (47 biologics and 61 EEN) were enrolled. At baseline, the EEN group exhibited more complex intestinal fistulas, higher inflammatory burden, and poorer nutritional status compared to the biologics group. The EEN group showed higher rates of fistula healing (23% vs. 6.4%, P = 0.019), radiological response (93.4% vs. 68.1%, P = 0.001), CRP normalization (73.8% vs. 55.3%, P = 0.045), and surgery (16.4% vs. 2.1%, P = 0.040). Conclusions EEN and biologics are clinically effective treatments for adult CD patients with intestinal fistulas. Biologics are preferred for patients without tolerance of EEN. EEN is preferred for patients with complex intestinal fistulas, severe activity, and malnutrition.