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Hepatobiliary abnormalities and parenteral nutrition
1Institute of Pediatric Gastroenterology, SMS Medical College, Jaipur, Rajasthan. tomar-dr@jp1.dot.net.in
Insights
Parenteral nutrition can cause liver problems, especially in newborns. Early oral feeding or choleretic agents may help prevent or manage these hepatobiliary dysfunctions.
Area of Science:
- Hepatology
- Pediatric Gastroenterology
- Clinical Nutrition
Background:
- Parenteral nutrition-associated hepatobiliary dysfunctions (TPN-HBD) are significant causes of morbidity in newborns and infants.
- Cholestasis is a common TPN-HBD, linked to prematurity, low birth weight, and prolonged TPN duration.
- Pathogenesis is multifactorial, involving necrotizing enterocolitis, sepsis, and cardiac issues.
Purpose of the Study:
- To review the occurrence, pathogenesis, diagnosis, and management of TPN-HBD, focusing on cholestasis.
- To highlight the risk factors and histological findings associated with TPN-HBD.
- To discuss preventive strategies and therapeutic interventions for TPN-HBD.
Main Methods:
- Review of existing literature on TPN-HBD.
- Analysis of factors contributing to cholestasis and biliary complications.
- Evaluation of diagnostic criteria and histological features.
- Assessment of preventive and management strategies.
Main Results:
- TPN-HBD, particularly cholestasis, are more severe in younger infants and correlate with TPN duration.
- Risk factors include enteral starvation, defective bile acid transport, and hypercaloric TPN (especially glucose-only).
- Histological findings range from intralobular cholestasis to portal fibrosis and biliary cirrhosis.
- Biliary complications like acalculous cholecystitis and cholelithiasis are linked to bile stasis.
- Even minimal enteral feeding can prevent TPN-HBD.
- Choleretic agents show promise in prevention and management.
Conclusions:
- TPN-HBD, especially cholestasis, pose significant risks to neonates and infants, necessitating careful management.
- Enteral nutrition, even in small amounts, is crucial for preventing TPN-HBD.
- Choleretic agents offer a potential therapeutic avenue for managing TPN-induced liver issues.
Abstract:
Hepatobiliary dysfunctions (TPN-HBD) occur during parenteral nutrition. In older children these are usually reversible whereas in newborns and infants these hepatobiliary abnormalities play a significant role in the morbidity. Cholestasis is a commonly occurring TPN-HBD. It correlates directly with the decreasing gestational age, low birth weight and increasing duration of TPN therapy. The pathogenesis of cholestasis of TPN is multifactorial and predisposed by necrotising enterocolitis, sepsis, cardiac failure, shock, and hypotension. Diagnosis is made with exclusion of other causes of direct hyperbilirubinemia. Most TPN-HBD appear within 4 weeks of starting of TPN but severe complications manifest usually after the 16th week. Histologically there is intralobular cholestasis. In few cases there may be severe portal fibrosis followed by development of micronodular biliary cirrhosis. Enteral starvation, defective bile acid carriers, hypercaloric TPN are the major factors responsible for TPN-HBD, including cholestasis. Biliary complications of TPN-HBD are acalculous, cholecystitis, and cholelithiasis. Bile stasis is a major pathological factor for these. If the calories are provided only by glucose or glucose-containing electrolyte solutions it may lead to cholestasis and other TPN-HBD. Even small oral alimentation (continuous or bolus) during TPN, prevent TPN-HBD. Choleretic agents have been useful in the prevention and management of cholestasis and other parenteral nutrition induced hepatobiliary abnormalities.