Intestinal Research

Review

IBD

Asian–Pacific perspectives on the management of very early-onset inflammatory bowel disease: Ichiro Takeuchi, Katsuhiro Arai, Pornthep Tanpowpong, Ming-Wei Lai, Andrew S Day, Way Seah Lee, James Guoxian Huang, Karen Sophia Calixto-Mercado, Rosanna Ming Sum Wong, Muhammad Arshad Alvi, Zubin Grover, Jung Ok Shim, Ujjal Poddar; Intest Res 2025;23(4):405-429. Published online October 28, 2025; DOI: https://doi.org/10.5217/ir.2025.00082

Abstract PDF PubReader ePub: Children diagnosed with inflammatory bowel disease (IBD) before the age of 6 years are considered to have “very early-onset IBD (VEO-IBD),” which is challenging to diagnose and treat. Notably, many children with VEO-IBD have monogenic forms of the disease, meaning that early genetic testing is useful. However, because the prevalence of genetic variants causing VEO-IBD differs globally, the diagnosis and treatment of this disease should be tailored to each region. In the present review paper, the IBD Subcommittee of the Scientific Committee of the Asia-Pacific Society of Pediatric Gastroenterology, Hepatology and Nutrition (APSPGHAN) has summarized the epidemiology, presenting features, diagnosis, and treatment of VEO-IBD in the Asia– Pacific region, with an aim to guide clinicians and researchers who work with VEO-IBD in this area. Our 3 main messages are as follows: endoscopy is essential for VEO-IBD diagnosis; all children diagnosed with VEO-IBD should be suspected of having a monogenic form; and children with suspected monogenic IBD should undergo early genetic testing. Our messages aim to improve the early diagnosis and treatment of VEO-IBD in the Asia–Pacific region, including the early detection of monogenic IBD in this area.

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Original Articles

IBD

Characteristics and long-term outcomes of children with perianal Crohn’s disease: Ching-Chun Lin, Ichiro Takeuchi, Hirotaka Shimizu, Reiko Kyodo, Mitsuru Kubota, Akira Ishiguro, Katsuhiro Arai; Intest Res 2026;24(1):164-173. Published online March 5, 2025; DOI: https://doi.org/10.5217/ir.2024.00154

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Background/Aims
The incidence of perianal lesions (PL) in children with Crohn’s disease (CD) is higher in East Asia than in Western countries. Early intervention for PL is essential to prevent sphincter dysfunction and ostomy placement. In this study, we aimed to investigate the clinical features, treatment, and consequences of pediatric CD with PL.
Methods
We retrospectively reviewed a cohort of children diagnosed with CD from 2010 to 2020 at a Japanese children’s hospital. Demographics, treatments, and outcomes were evaluated and compared among subgroups.
Results
Among 112 pediatric patients with CD, 36 (32.1%) had experienced PL during the observational period. The median ages at diagnosis and follow-up periods were 131 and 70 months, respectively. Six (85.7%) patients in the very early-onset (VEO) group (CD diagnosed before 6 years old) and 24 (82.8%) in the older age group had PL upon diagnosis of CD (P= 0.851). Biologics were given to 94.4% of patients: infliximab (67.7%), adalimumab (58.8%), ustekinumab (44.1%), risankizumab (11.8%), and vedolizumab (5.9%). Biologics were introduced within 1 year in 89.5% and 40.0% of patients diagnosed in 2016–2020 and 2010–2016, respectively (P= 0.002). Seton was frequently used in the older age group (87.5 vs. 42.9%, P= 0.190). Ostomy was frequently required in the VEO group (42.9% vs. 0.0%, P= 0.006).
Conclusions
Patients with VEO-CD and PL had a notably high risk of ostomy placement. The earlier introduction of biologics and surgical interventions reduced corticosteroids use and ostomy placement in pediatric CD patients with PL.

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Asian–Pacific perspectives on the management of very early-onset inflammatory bowel disease
Ichiro Takeuchi, Katsuhiro Arai, Pornthep Tanpowpong, Ming-Wei Lai, Andrew S Day, Way Seah Lee, James Guoxian Huang, Karen Sophia Calixto-Mercado, Rosanna Ming Sum Wong, Muhammad Arshad Alvi, Zubin Grover, Jung Ok Shim, Ujjal Poddar
Intestinal Research.2025; 23(4): 405. CrossRef

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Inflammatory bowel diseases

Phenotypic characteristics of pediatric inflammatory bowel disease in Japan: results from a multicenter registry: Katsuhiro Arai, Reiko Kunisaki, Fumihiko Kakuta, Shin-ichiro Hagiwara, Takatsugu Murakoshi, Tadahiro Yanagi, Toshiaki Shimizu, Sawako Kato, Takashi Ishige, Tomoki Aomatsu, Mikihiro Inoue, Takeshi Saito, Itaru Iwama, Hisashi Kawashima, Hideki Kumagai, Hitoshi Tajiri, Naomi Iwata, Takahiro Mochizuki, Atsuko Noguchi, Toshihiko Kashiwabara, Hirotaka Shimizu, Yasuo Suzuki, Yuri Hirano, Takeo Fujiwara; Intest Res 2020;18(4):412-420. Published online August 18, 2020; DOI: https://doi.org/10.5217/ir.2019.00130

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Background/Aims
There are few published registry studies from Asia on pediatric inflammatory bowel disease (IBD). Registry network data enable comparisons among ethnic groups. This study examined the characteristics of IBD in Japanese children and compared them with those in European children.
Methods
This was a cross-sectional multicenter registry study of newly diagnosed Japanese pediatric IBD patients. The Paris classification was used to categorize IBD features, and results were compared with published EUROKIDS data.
Results
A total of 265 pediatric IBD patients were initially registered, with 22 later excluded for having incomplete demographic data. For the analysis, 91 Crohn’s disease (CD), 146 ulcerative colitis (UC), and 6 IBD-unclassified cases were eligible. For age at diagnosis, 20.9% of CD, 21.9% of UC, and 83.3% of IBD-unclassified cases were diagnosed before age 10 years. For CD location, 18.7%, 13.2%, 64.8%, 47.3%, and 20.9% were classified as involving L1 (ileocecum), L2 (colon), L3 (ileocolon), L4a (esophagus/stomach/duodenum), and L4b (jejunum/proximal ileum), respectively. For UC extent, 76% were classified as E4 (pancolitis). For CD behavior, B1 (non-stricturing/non-penetrating), B2 (stricturing), B3 (penetrating), and B2B3 were seen in 83.5%, 11.0%, 3.3%, and 2.2%, respectively. A comparison between Japanese and European children showed less L2 involvement (13.2% vs. 27.3%, P< 0.01) but more L4a (47.3% vs. 29.6%, P< 0.01) and L3 (64.8% vs. 52.7%, P< 0.05) involvement in Japanese CD children. Pediatric perianal CD was more prevalent in Japanese children (34.1% vs. 9.7%, P< 0.01).
Conclusions
Upper gastrointestinal and perianal CD lesions are more common in Japanese children than in European children.

Citations

Citations to this article as recorded by

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Real-world outcomes of ustekinumab, vedolizumab, and tumor necrosis factor inhibitors in very-early-onset inflammatory bowel disease: a multi-center cohort study
Ryusuke Nambu, Itaru Iwama, Ichiro Takeuchi, Shin-ichiro Hagiwara, Yuri Etani, Emiri Kaji, Atsushi Yoden, Fumihiko Kakuta, Yusuke Hoshi, Naoya Tsumura, Tatsuki Mizuochi, Hideki Kumagai, Koji Yokoyama, Takuya Nishizawa, Masaaki Usami, Yugo Takaki, Ryo Eban
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Predictive Factors for Abnormal Diagnostic Colonoscopy Findings among Pediatric Patients: A Retrospective Cohort Study
Kazuki Honjo, Keita Murakami, Junya Arai, Sozaburo Ihara, Hiroyuki Hisada, Dai Kubota, Ken Kurokawa, Yu Miyakawa, Mayo Tsuboi, Yuko Miura, Daisuke Ohki, Hiroya Mizutani, Chihiro Takeuchi, Seiichi Yakabi, Nobumi Suzuki, Hiroto Kinoshita, Yoku Hayakawa, Nao
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Yoko Yamamoto, Ichiro Takeuchi, Hirotaka Shimizu, Hiroki Fujikawa, Masanori Toda, Eri Miyata, Hiroaki To, Satoru Nagata, Katsuhiro Arai
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Pornthep Tanpowpong, Suporn Treepongkaruna, James Guoxian Huang, Kee Seang Chew, Karen Sophia Calixto Mercado, Almida Reodica, Shaman Rajindrajith, Wathsala Hathagoda, Yoko Kin Yoke Wong, Way Seah Lee, Marion Margaret Aw
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James Guoxian Huang, Kee Seang Chew, Veena Logarajah, Way Seah Lee, Marion Margaret Aw
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Georgia Valentina Tartamus (Tita), Daniela Elena Serban, Marcel Vasile Tantau
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Asian–Pacific perspectives on the management of very early-onset inflammatory bowel disease
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Dianzhen Wu, Qi Huang, Yingbi Xu, Ruiyi Cao, Ming Yang, Jin Xie, Dingkun Zhang
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Yoshikazu Miura, Shin‐ichiro Hagiwara, Keinosuke Hizuka, Ryutaro Saura, Ayaha Hata, Takatoshi Maeyama, Yuri Etani
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Eliana Fanous, Tal Marshanski, Noa Tal, Manar Matar, Yael Weintraub, Raanan Shamir, Dror S. Shouval
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Caracterización clínica y terapéutica de una cohorte multicéntrica de pacientes con enfermedad inflamatoria intestinal en Colombia
Viviana Parra-Izquierdo, Cristian Flórez Sarmiento, Juan Sebastián Frías-Ordoñez, Melquicedec Vargas, Joshua Kock, Natalia Lozano Escobar, Juan Ricardo Márquez
Gastroenterología y Hepatología.2023; 46(8): 585. CrossRef
Potential of Gut Microbe-Derived Extracellular Vesicles to Differentiate Inflammatory Bowel Disease Patients from Healthy Controls
Min Heo, Young Soo Park, Hyuk Yoon, Nam-Eun Kim, Kangjin Kim, Cheol Min Shin, Nayoung Kim, Dong Ho Lee
Gut and Liver.2023; 17(1): 108. CrossRef
Medical management of pediatric inflammatory bowel disease in the Asia‐Pacific region: A position paper by the Asian Pan‐Pacific Society for Pediatric Gastroenterology, Hepatology, and Nutrition (APPSPGHAN) PIBD Working Group
Way Seah Lee, Katsuhiro Arai, George Alex, Suporn Treepongkaruna, Kyung Mo Kim, Chee Liang Choong, Karen S. C. Mercado, Andy Darma, Anshu Srivastava, Marion M. Aw
Journal of Gastroenterology and Hepatology.2023; 38(4): 523. CrossRef
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Ryusuke Nambu, Katsuhiro Arai, Takahiro Kudo, Takatsugu Murakoshi, Reiko Kunisaki, Tatsuki Mizuochi, Sawako Kato, Hideki Kumagai, Mikihiro Inoue, Takashi Ishige, Takeshi Saito, Atsuko Noguchi, Toshifumi Yodoshi, Shin-Ichiro Hagiwara, Naomi Iwata, Shigeo N
Journal of Gastroenterology.2023; 58(5): 472. CrossRef
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Takahiro Kudo, Toshiaki Shimizu
Pediatrics International.2023;[Epub] CrossRef
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Viviana Parra-Izquierdo, Cristian Flórez Sarmiento, Juan Sebastián Frías-Ordoñez, Melquicedec Vargas, Joshua Kock, Natalia Lozano Escobar, Juan Ricardo Márquez
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Sung-Yoon Jo, Kyung-Sook Bang
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Journal of Crohn's and Colitis.2022; 16(2): 207. CrossRef
Long-term Disease Course of Crohn’s Disease: Changes in Disease Location, Phenotype, Activities, and Predictive Factors
Choong Wui Cho, Myung-Won You, Chi Hyuk Oh, Chang Kyun Lee, Sung Kyoung Moon
Gut and Liver.2022; 16(2): 157. CrossRef
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Su Hyun Park, Sang Hyoung Park
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Bilge S. Akkelle, Deniz Ertem, Burcu Volkan, Engin Tutar
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Masaaki Usami, Ichiro Takeuchi, Reiko Kyodo, Yuri Hirano, Kosuke Kashiwagi, Hiroki Fujikawa, Hirotaka Shimizu, Toshinao Kawai, Katsuhiro Arai
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Rishi BOLIA, Akhil Dhanesh GOEL
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Comparison between Pediatric Crohn’s Disease and Ulcerative Colitis at Diagnosis in Korea: Results from a Multicenter, Registry-Based, Inception Cohort Study
Sowon Park, Ben Kang, Seung Kim, Sujin Choi, Hyo Rim Suh, Eun Sil Kim, Ji Hyung Park, Mi Jin Kim, Yon Ho Choe, Yeoun Joo Lee, Jae Hong Park, Eell Ryoo, Hong Koh, Byung-Ho Choe
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Kang-Moon Lee
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Rupa Banerjee, Partha Pal, Zaheer Nabi, Upender Shava, Girish Ganesh, D. Nageshwar Reddy
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Incidentally Detected Asymptomatic Perianal Abscess in an Adolescent during Crohn's Disease Diagnosis: Is Routine Pelvic Imaging Required in Korean Pediatric Patients at Diagnosis?
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Case Report

Infection

Whipple disease mimicking inflammatory bowel disease: Maiko Tatsuki, Takashi Ishige, Yoshiko Igarashi, Reiko Hatori, Akira Hokama, Junko Hirato, Aleixo Muise, Takumi Takizawa, Hirokazu Arakawa; Intest Res 2021;19(1):119-125. Published online July 3, 2020; DOI: https://doi.org/10.5217/ir.2019.09177

Abstract PDF PubReader ePub

Whipple disease is a systemic chronic infection caused by Tropheryma whipplei. Although chronic diarrhea is a common gastrointestinal symptom, diagnosis is often difficult because there are no specific endoscopic findings, and the pathogen is not detectable by stool culture. We present a female patient with Whipple disease who developed chronic bloody diarrhea and growth retardation at the age of 4 years. Colonoscopy showed a mildly edematous terminal ileum and marked erythema without vascular patterns throughout the sigmoid colon and rectum. Subsequently, a primary diagnosis of ulcerative colitis was made. Histopathological analysis of the terminal ileum showed the presence of foamy macrophages filled with periodic acidSchiff-positive particles. Polymerase chain reaction using DNA from a terminal ileum biopsy sample amplified a fragment of 16S rRNA from T. whipplei. Antibiotic treatment relieved the patient’s symptoms. There was no evidence of immunodeficiency in the present case. Since Whipple disease worsens after anti-tumor necrosis factor inhibitor therapy, considering this infection in the differential diagnosis may be important in patients with inflammatory bowel disease, especially before initiation of immunotherapy.

Citations

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Through the Looking Glass: A Child With Arthralgia, Malaise and Weight Loss
Aline R. Verhage, Iris D. Nagtegaal, Cathelijne van der Feen, Tom F.W. Wolfs
Pediatric Infectious Disease Journal.2023; 42(7): 629. CrossRef
Enfermedad de Whipple: revisión sistemática de la literatura
Ledmar Jovanny Vargas Rodriguez, Jeinny Lucero Ruiz Muñoz, Paola Andrea Bolivar Córdoba, Monica Dayana Romero Cely, Ervirson Jair Cañon Abril, Zulma Marisol Suarez Correa, María Angélica Mendoza Cáceres
Revista colombiana de Gastroenterología.2023; 38(1): 35. CrossRef
Whipple’s Disease with Colonic Involvement: A Rare Endoscopic Documentation
Verónica Gamelas, Ines Canha, João Pimentel, Sara Santos, Verónica Borges, Carlos Bernardes
GE - Portuguese Journal of Gastroenterology.2022; 29(6): 436. CrossRef
Whipple’s disease with normal duodenal histology diagnosed by ileal biopsy using balloon endoscopy
Hideki Mori, Chiaki Yakabi, Kiwamu Yonahara, Kazunao Hamahiga, Miyu Yoshimura, Masaki Sakihara, Kenji Ishihara, Kinya Azama, Takayuki Chinen, Osamu Zaha
Clinical Journal of Gastroenterology.2022; 15(4): 702. CrossRef

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Original Article

Functional bowel disorders

Is fecal calprotectin always normal in children with irritable bowel syndrome?: You Jin Choi, Su Jin Jeong; Intest Res 2019;17(4):546-553. Published online September 4, 2019; DOI: https://doi.org/10.5217/ir.2019.00009

Abstract PDF PubReader ePub

Background/Aims
Fecal calprotectin (FC) is a marker of intraluminal intestinal inflammation. Intestinal inflammation may contribute to the pathophysiology of irritable bowel syndrome (IBS). This study evaluated FC levels in children with IBS and differences in FC levels in children stratified by IBS subtype and healthy controls (HCs).
Methods
A total of 157 children with IBS and 56 HCs aged 4–16 years (119 boys, 94 girls, mean age of 9.48 years) were included in this prospective study. Children with IBS were diagnosed using the Rome III criteria and classified into 4 subtypes: IBS with constipation (IBS-C, n=37), IBS with diarrhea (IBS-D, n=54), IBS with alternating constipation and diarrhea (IBS-M, n=49), and IBS unsubtyped (IBS-U, n=17); postinfectious IBS (PI-IBS) was also considered. The FC concentration in stool samples was analyzed using an enzyme-linked immunosorbent assay. All participants answered a questionnaire regarding several demographic and clinical characteristics.
Results
Children with IBS had significantly higher levels of FC than the HCs (88.71 μg/g vs. 17.77 μg/g). Among the 4 IBS subtypes, the FC concentration was highest in children with IBS-D, followed by those with IBS-M, IBS-C, and IBS-U (169.94 μg/g vs. 45.04, 31.22, and 33.52 μg/g, respectively), and these differences were statistically significant. For PI-IBS, 90% of cases were in the IBS-D group.
Conclusions
The FC level was significantly higher in children with IBS than in HCs and differed depending on the IBS subtype, supporting the notion that IBS is a type of low-grade bowel inflammation.

Citations

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Tasnia Ahmed, Daniel A. Lemberg, Andrew S. Day, Steven T. Leach
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Nutrients.2023; 15(18): 3991. CrossRef
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Nutrients.2023; 15(19): 4174. CrossRef
Association between body mass index and fecal calprotectin levels in children and adolescents with irritable bowel syndrome
Jun Hwan Kim, Dae Yong Yi, Yoo Min Lee, You Jin Choi, Ju Young Kim, Yong Hee Hong, Ji Young Park, Su Yeong Kim, Na Mi Lee, Sin Weon Yun, Soo Ahn Chae, In Seok Lim, Eung Sang Choi, In Sook Jeong
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Review

IBD

An overview of the role of exclusive enteral nutrition for complicated Crohn’s disease: Mustafa Adamji, Andrew S Day; Intest Res 2019;17(2):171-176. Published online December 3, 2018; DOI: https://doi.org/10.5217/ir.2018.00079

Abstract PDF PubReader ePub

The role and efficacy of exclusive enteral nutrition (EEN) in the treatment of luminal Crohn’s disease (CD) has been well established over the last 2 decades. Consequently, in many centers nutritional therapy is now considered first line therapy in the induction of remission of active CD. However, the use of nutritional therapy in complicated CD has yet to be fully determined. This article aimed to review case reports and clinical trials published in the last decade that have considered and evaluated nutritional therapy in the setting of complicated CD in children and adults. Published literature focusing upon the use of nutritional therapy as part of medical therapy in the management of complicated CD were identified and reviewed. Although there continue to be various interventions utilized for complicated CD, the currently available literature demonstrates that nutritional therapies, especially EEN, have important roles in the management of these complex scenarios. Further assessments, involving large numbers of patients managed with consistent approaches, are required to further substantiate these roles.

Citations

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Focused Review

IBD

Recent advance in very early-onset inflammatory bowel disease: Jung Ok Shim; Intest Res 2019;17(1):9-16. Published online November 12, 2018; DOI: https://doi.org/10.5217/ir.2018.00130

Abstract PDF PubReader ePub

Recent studies on pediatric inflammatory bowel disease (IBD) have revealed that early-onset IBD has distinct phenotypic differences compared with adult-onset IBD. In particular, very early-onset IBD (VEO-IBD) differs in many aspects, including the disease type, location of the lesions, disease behavior, and genetically attributable risks. Neonatal or infantile-onset IBD develops in less than 1% of pediatric patients. Children with infantile-onset IBD have high rates of affected first-degree relatives and severe disease course. The suspicion of a monogenic cause of VEO-IBD was first confirmed by the discovery of mutations in the genes encoding the interleukin 10 (IL-10) receptors that cause impaired IL-10 signaling. Patients with such mutations typically presented with perianal fistulae, shows a poor response to medical management, and require early surgical interventions in the first year of life. To date, 60 monogenic defects have been identified in children with IBD-like phenotypes. The majority of monogenic defects presents before 6 years of age, and many present before 1 year of age. Next generation sequencing could become an important diagnostic tool in children with suspected genetic defects especially in children with VEO-IBD with severe disease phenotypes. VEO-IBD is a phenotypically and genetically distinct disease entity from adult-onset or older pediatric IBD.

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Nutritional characteristic of children with inflammatory bowel disease in the nationwide inflammatory bowel disease registry from the Mediterranean region
Zarife Kuloglu, Funda Çetin, Nafiye Urgancı, Zerrin Önal, Sinan Sarı, Hasan Yüksekkaya, Gönül Çaltepe, Günsel Kutluk, Ebru Dumlupinar, Mustafa Akçam, Duran Arslan, Nur Arslan, Reha Artan, Ayşen Uncuoğlu Aydoğan, Necati Balamtekin, Maşallah Baran, Gökhan B
European Journal of Clinical Nutrition.2022; 76(9): 1289. CrossRef
Novel biallelic mutations in the DUOX2 gene underlying very early-onset inflammatory bowel disease: A case report
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Case Report

IBD

Acute pancreatitis associated with indigo naturalis in pediatric severe Crohn’s disease: Hyeon-A Kim, Hyo-rim Suh, Ben Kang, Byung-Ho Choe, on behalf of Crohn’s and Colitis Association in DaeguGyeongbuk (CCAiD); Intest Res 2019;17(1):144-148. Published online October 16, 2018; DOI: https://doi.org/10.5217/ir.2018.00104

Abstract PDF PubReader ePub

The incidence of inflammatory bowel disease (IBD) is rapidly increasing worldwide. Indigo naturalis is known to have an antiinflammatory effect. Indigo naturalis has been traditionally used in the treatment of IBD in China and Japan. Currently, it is used as a primary or adjunctive drug in patients with ulcerative colitis. There are some reports of the effects of indigo naturalis when used in patients with ulcerative colitis. However, its usage has been associated with adverse events, including liver dysfunction, headache, gastrointestinal disturbance, and pulmonary hypertension. Pancreatitis as an adverse event during treatment using indigo naturalis has not yet been reported. We report a case of recurrent events of pancreatitis that occurred briefly after starting medication with indigo naturalis in a child with severe Crohn’s disease. The pancreatitis improved after indigo naturalis was discontinued in 2 events. This is the first case to report the association between pancreatitis and indigo naturalis in the English literature.

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Original Article

Japanese physicians' attitudes towards enteral nutrition treatment for pediatric patients with Crohn's disease: a questionnaire survey: Takashi Ishige, Takeshi Tomomasa, Hitoshi Tajiri, Atsushi Yoden; Intest Res 2017;15(3):345-351. Published online June 12, 2017; DOI: https://doi.org/10.5217/ir.2017.15.3.345

Abstract PDF PubReader ePub

<b>Background/Aims</b><br/>

Enteral nutrition (EN) is recommended for the treatment of pediatric Crohn's disease (CD) in Japan. However, the indications and treatment protocols for EN vary among hospitals. In the present study, we aimed to determine how EN was administered to pediatric patients and whether physicians followed treatment guidelines in their practices.

Methods

Two types of questionnaires were administered to 32 physicians who were involved in the treatment of pediatric CD. The consensus questionnaire evaluated the physicians' attitudes towards EN, whereas the efficacy questionnaire collected data on patients with CD, aged <17 years, who had undergone induction therapy between 2006 and 2011.

Results

A total of 23 physicians responded to the questionnaires. The results of the consensus questionnaire indicated that 82% and 59% of study participants recommended EN treatment for all newly diagnosed pediatric patients with CD and all relapsed patients, respectively. Exclusive EN (EEN) and elemental formula were recommended by 84% and 85% of physicians, respectively. The efficacy questionnaire revealed that 57 of the 58 patients received EN. Elemental formula was used in 39 of 40 patients who were treated with EEN. Of these 40 patients, 27 were treated with EEN alone; of these, 22 (81%) achieved remission without any other treatment. The mean duration of EEN was 15.9 days.

Conclusions

EN is widely recommended by physicians treating pediatric CD in Japan. In contrast to Western countries, clinicians used elemental formula more often and with a shorter EEN treatment duration.

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