4. Management of Vitamin B Complex Deficiencies in IBD Patients and
Nutrition support should be considered as an important element of a multidimensional
management of all IBD patients. Although no specific recommendations exist, clinicians
involved in the management of patients with inflammatory bowel disease should regularly
assess the diet and the nutritional status of these patients. Every effort should be made to
always maintain these patients in a well-balanced diet that is rich in nutrients.
Usually, the nutritional needs can be met by food alone together or not with a
multivitamin supplement. Nutritional support as adjunctive therapy should be employed in
any malnourished patient, in those with complications due to specific nutrient deficiencies
and in those who have difficulty in maintaining a normal nutritional status. Special nutritional
considerations are required for specific groups of patients including children, adolescents,
candidates for surgery and those with: severe active disease, severe disease complications
(fistulas, stenoses), and extensive bowel resection with or without short bowel syndrome.
In regard to the “vitamin B complex”, the major concern is to identify and treat the
vitamin B6, vitamin B12 and folate deficiencies, since they are associated with severe
complications in IBD patients (anemia, thrombosis and colon cancer). The other “vitamin B
complex” members’ deficiencies observed in some studies did not have any specific clinical
impact, although some clinical syndromes due to their deficiency have been rarely described.
Nutritional Issues in Inflammatory Bowel Disease… 71
Treatment of macrocytic anemia in IBD patients does not differ from the general
population (intramuscular injections of hydroxycobalamin in vitamin B12 deficiency or
folinic acid orally in folate deficiency).
Hyperhomocysteinemia may be present in IBD patients and has been associated with
thromboembolic complications. Cattaneo et al. [131] found that hyperhomocysteinemia in
IBD patients could be corrected by the administration of folate, vitamin B12 and vitamin B6.
Many other studies assessing the homocysteine and “vitamin B complex” status in IBD
patients suggested the daily administration of folate, vitamin B12 and vitamin B6 for
prophylaxis against hyperhomocysteinemia and thrombotic complications [17,21,39], since
studies have shown a lowering effect on serum homocysteine levels by daily administration
of “vitamin B complex” supplements [132-135]. It is hoped that lowering homocysteine
towards normal serum levels would reduce the risk for thrombosis, but a recent study, the
VITRO trial [135], showed that homocysteine lowering by “vitamin B complex”
supplementation did not prevent recurrent venous thrombosis.
Finally, previous studies have linked folate deficiency with increased cancer risk in UC
patients [104-106]. Evidence from small clinical studies suggests that folate supplementation
in UC patients may have a protective effect against colorectal cancer since it has been
associated with a dose-dependent reduced risk [106] or with an improvement of surrogate
markers of colorectal cancer (DNA repair defects or rectal cell hyperproliferation) [136,137].
However, folate supplementation for colorectal neoplasia chemoprevention should be
regarded with great caution. Animal studies have shown that the protective effect of folate is
dose and timing related, since folate supplementation reduces the risk of colorectal cancer in
normal colorectal mucosa, whereas folate supplementation has a promoting effect on the
progression of established microscopic neoplasmatic foci in the colorectal mucosa and
colorectal neoplasms [138]. Large prospective studies are needed to clarify the
chemopreventive role of folate against colorectal cancer in ulcerative colitis.
• Nutrition-related issues are important components of the global assessment in the
management of patients with inflammatory bowel disease.
• Several nutrient deficiencies, including the “vitamin B complex” members, are
frequently observed in IBD patients. The aetiology of nutrient deficiencies is
multifactorial and clinicians should be aware of the malnutrition existence and its
clinical consequences in IBD patients.
• Nutritional status and nutrient intake should be regularly assessed in all IBD patients.
Children, adolescents, perioperative patients, patients with severe disease or
complications and patients with extended small bowel resection, need special
72 Petros Zezos and Georgios Kouklakis
• Any specific nutrient deficiency should be corrected together with diet adjustment
and prophylactic polyvitamin supplementation when appropriate.
• “Vitamin B complex” supplements protect against macrocytic anemia,
hyperhomocysteinemia and their complications in IBD patients.
• Folate supplementation may have a protective role against colorectal cancer in IBD
[1] Sartor RB. Current concepts of the etiology and pathogenesis of ulcerative colitis and
Crohn’s disease. Gastroenterol Clin North Am 1995;24:475-505.
[2] Fiocchi C. Inflammatory bowel disease: etiology and pathogenesis. Gastroenterology
[3] Geerling BJ, Stockbrugger RW, Brummer RJ. Nutrition and inflammatory bowel
disease: an update. Scand J Gastroenterol Suppl 1999;230:95-105.
[4] Reif S, Klein I, Lubin F, Farbstein M, Hallak A, Gilat T. Pre-illness dietary factors in
inflammatory bowel disease. Gut 1997;40:754-760.
[5] Geerling BJ, Dagnelie PC, Badart-Smook A, Russel MG, Stockbrugger RW, Brummer
RJ. Diet as a risk factor for the development of ulcerative colitis. Am J Gastroenterol
[6] Zurita VF, Rawls DE, Dyck WP. Nutritional support in inflammatory bowel disease.
[7] Seidman EG. Nutritional management of inflammatory bowel disease. Gastroenterol
Clin North Am 1989;18:129-155.
[8] Dieleman LA, Heizer WD. Nutritional issues in inflammatory bowel disease.
Gastroenterol Clin North Am 1998;27:435-451.
[9] Han PD, Burke A, Baldassano RN, Rombeau JL, Lichtenstein GR. Nutrition and
inflammatory bowel disease. Gastroenterol Clin North Am 1999;28:423-443.
[10] Graham TO, Kandil HM. Nutritional factors in inflammatory bowel disease.
Gastroenterol Clin North Am. 2002 ;31(1):203-218.
[11] Fernandez-Banares F, Abad-Lacruz A, Xiol X, Gine JJ, Dolz C, Cabre E, Esteve M,
Gonzalez-Huix F, Gassull MA. Vitamin status in patients with inflammatory bowel
disease. Am J Gastroenterol 1989;84:744-748.
[12] Kuroki F, Iida M, Tominaga M, Matsumoto T, Hirakawa K, Sugiyama S, Fujishima M.
Multiple vitamin status in Crohn's disease. Correlation with disease activity. Dig Dis
[13] Geerling BJ, Badart-Smook A, Stockbrugger RW, Brummer RJ. Comprehensive
nutritional status in recently diagnosed patients with inflammatory bowel disease
compared with population controls. Eur J Clin Nutr 2000;54:514-521.
[14] Filippi J, Al-Jaouni R, Wiroth JB, Hebuterne X, Schneider SM. Nutritional deficiencies
in patients with Crohn's disease in remission. Inflamm Bowel Di. 2006;12:185-191.
Nutritional Issues in Inflammatory Bowel Disease… 73
[15] Geerling BJ, Badart-Smook A, Stockbrugger RW, Brummer RJ. Comprehensive
nutritional status in patients with long-standing Crohn disease currently in remission.
Am J Clin Nutr 1998;67:919-926.
[16] Magee EA, Edmond LM, Tasker SM, Kong SC, Curno R, Cummings JH. Associations
between diet and disease activity in ulcerative colitis patients using a novel method of
data analysis. Nutr J 2005;4:7.
[17] Saibeni S, Cattaneo M, Vecchi M, Zighetti ML, Lecchi A, Lombardi R, Meucci G,
Spina L, de Franchis R. Low vitamin B(6) plasma levels, a risk factor for thrombosis,
in inflammatory bowel disease: role of inflammation and correlation with acute phase
reactants. Am J Gastroenterol 2003;98:112-117.
[18] Wolters M, Strohle A, Hahn A. Cobalamin: a critical vitamin in the elderly. Prev Med
[19] Chowers Y, Sela BA, Holland R, Fidder H, Simoni FB, Bar-Meir S. Increased levels of
homocysteine in patients with Crohn's disease are related to folate levels. Am J
Gastroenterol 2000;95:3498-3502.
[20] Lambert D, Benhayoun S, Adjalla C, Gelot MA, Renkes P, Felden F, Gerard P,
Belleville F, Gaucher P, Gueant JL, Nicolas JP. Crohn's disease and vitamin B12
metabolism. Dig Dis Sci 1996;41:1417-1422.
[21] Koutroubakis IE, Dilaveraki E, Vlachonikolis IG, Vardas E, Vrentzos G, Ganotakis E,
Mouzas IA, Gravanis A, Emmanouel D, Kouroumalis EA. Hyperhomocysteinemia in
Greek patients with inflammatory bowel disease. Dig Dis Sci 2000;45:2347-2351.
[22] Vasilopoulos S, Saiean K, Emmons J, Berger WL, Abu-Hajir M, Seetharam B, Binion
DG. Terminal ileum resection is associated with higher plasma homocysteine levels in
Crohn's disease. J Clin Gastroenterol 2001;33:132-136.
[23] Thompson WG, Wrathell E. The relation between ileal resection and vitamin B12
absorption. Can J Surg 1977;20:461-464.
[24] Lenz K. The effect of the site of lesion and extent of resection on duodenal bile acid
concentration and vitamin B12 absorption in Crohn's disease. Scand J Gastroenterol
[25] Behrend C, Jeppesen PB, Mortensen PB. Vitamin B12 absorption after ileorectal
anastomosis for Crohn's disease: effect of ileal resection and time span after surgery.
Eur J Gastroenterol Hepatol 1995;7:397-400.
[26] Duerksen DR, Fallows G, Bernstein CN. Vitamin B12 malabsorption in patients with
limited ileal resection. Nutrition 2006;22:1210-1213.
[27] Ooi BC, Barnes GL, Tauro GP. Normalization of vitamin B12 absorption after ileal
resection in children. J Paediatr Child Health 1992;28:168-171.
[28] Nilsson LO, Myrvold HE, Swolin B, Ojerskog B. Vitamin B12 in plasma in patients
with continent ileostomy and long observation time. Scand J Gastroenterol
[29] M'Koma AE, Lindquist K, Liljeqvist L. Biochemical laboratory data in patients before
and after restorative proctocolectomy. A study on 83 patients with a follow-up of 36
months. Ann Chir 1994;48:525-534.
[30] Elsborg L. Vitamin B12 and folic acid in Crohn's disease. Dan Med Bull 1982;29:362-
74 Petros Zezos and Georgios Kouklakis
[31] Kennedy HJ, Callender ST, Truelove SC, Warner GT. Haematological aspects of life
with an ileostomy. Br J Haematol 1982;52:445-454.
[32] Jayaprakash A, Creed T, Stewart L, Colton B, Mountford R, Standen G, Probert C.
Should we monitor vitamin B12 levels in patients who have had end-ileostomy for
inflammatory bowel disease? Int J Colorectal Dis 200419:316-318.
[33] Christl SU, Scheppach W. Metabolic consequences of total colectomy. Scand J
Gastroenterol Suppl 1997;222:20-24.
[34] Bayat M, Brynskov J, Dige Petersen H, et al. Direct and quantitative vitamin B12
absorption measurement in patients with disorders in the distal part of the bowel.
Comparison of stool spot test [SST] with whole body counting in patients with ileal
pelvic reservoir, ileostomy or Crohn’s disease. Int J Colorectal Dis 1994;9:68–72.
[35] M’Koma AE. Follow-up results of hematology data before and after restorative
proctocolectomy. Clinical outcome. Dis Colon Rectum 1994;37:932–937.
[36] M'koma AE. Serum biochemical evaluation of patients with functional pouches ten to
20 years after restorative proctocolectomy. Int J Colorectal Dis 2006;2:711-720.
[37] Kuisma J, Nuutinen H, Luukkonen P, Jarvinen H, Kahri A, Farkkila M. Long term
metabolic consequences of ileal pouch-anal anastomosis for ulcerative colitis. Am J
Gastroenterol 2001;96:3110-3116.
[38] Steger GG, Mader RM, Vogelsang H, Schofl R, Lochs H, Ferenci P. Folate absorption
in Crohn's disease. Digestion 1994;55:234-238.
[39] Zezos P, Papaioannou G, Nikolaidis N, Vasiliadis T, Giouleme O, Evgenidis N.
Hyperhomocysteinemia in ulcerative colitis is related to folate levels. World J
Gastroenterol 2005;11:6038-6042.
[40] Hodges P, Gee M, Grace M, Thomson AB. Vitamin and iron intake in patients with
Crohn's disease. J Am Diet Assoc 1984;84:52-58.
[41] Bambach CP, Hill GL. Long term nutritional effects of extensive resection of the small
intestine. Aust N Z J Surg 1982;52:500-506.
[42] Elsborg L, Larsen L. Folate deficiency in chronic inflammatory bowel diseases. Scand
J Gastroenterol 1979;14:1019-1024.
[43] Hoffbrand AV, Stewart JS, Booth CC, Mollin DL. Folate deficiency in Crohn's disease:
incidence, pathogenesis, and treatment. Br Med J 1968;2:71-75.
[44] Lakatos L, Pandur T, David G, Balogh Z, Kuronya P, Tollas A, Lakatos PL.
Association of extraintestinal manifestations of inflammatory bowel disease in a
province of western Hungary with disease phenotype: results of a 25-year follow-up
study. World J Gastroenterol 2003;9:2300-2307.
[45] Glade MJ. Workshop on Folate, B12, and Choline. Sponsored by the Panel on Folate
and other B vitamins of the Standing Committee on the Scientific Evaluation of Dietary
Reference Intakes, Food and Nutrition Board, Institute of Medicine, Washington, D.C.,
March 3-4, 1997. Nutrition 1999;15:92-96.
[46] Alpers DH. What is new in vitamin B(12)? Curr Opin Gastroenterol 2005;21:183-186.
[47] British Committee for Standards in Haematology. Guidelines on the investigation and
diagnosis of cobalamin and folate deficiency. Clin Lab Haematol 1994;16:101–115.
[48] Portoles J, Romero JR, Gallego E, Llamas F, Sanchez-Tarraga L. Red cell folate: an
appropriate index of folate body stores. Nephron 1997;76:119.
Nutritional Issues in Inflammatory Bowel Disease… 75
[49] Galloway M, Rushworth L. Red cell or serum folate? Results from the National
Pathology Alliance benchmarking review. J Clin Pathol 2003;56:924-926.
[50] Talbot RW, Heppell J, Dozois RR, Beart RW Jr. Vascular complications of
inflammatory bowel disease. Mayo Clin Proc 1986;61:140-145.
[51] Vecchi M, Cattaneo M, de Francis R, Mannucci PM. Risk of thromboembolic
complications in patients with inflammatory bowel disease. Study of hemostasis
measurements. Int J Clin Lab Res 1991;21:165-170.
[52] Graef V, Baggenstoss AH, Sauer WG. Venous thrombosis occurring in non-specific
ulcerative colitis. Arch Intern Med 1965;117:377-382.
[53] Hudson M, Hutton RA, Wakefield AJ, Sawyerr AM, Pounder RE. Evidence for
activation of coagulation in Crohn’s disease. Blood Coagul Fibrinolysis 1992;3:773-
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