Parenteral nutrition related hepato-biliary disease in adults

Parenteral nutrition is a life-saving therapy in patients with intestinal failure. One of the major causes of morbidity and mortality in patients receiving long-term total parenteral nutrition (TPN) is liver disease. Early on, there is steatosis, which can evolve to steatohepatitis and eventually to cholestasis of varying severity. The etiology of parenteral nutrition related liver disease is multifactorial. Provision of excess calories in the TPN solution, along with lipids administered >1 g/kg are thought to increase the risk of parenteral nutrition related liver disease. Other factors such as nutrient deficiencies and nutrient toxicities may also play a role in the pathogenesis of liver disease, along with sepsis and the lack of enteral stimulation. Non-pharmacological management strategies for TPN-related liver disease include enteral stimulation, optimal TPN composition, and avoidance of excess carbohydrate and lipid calories. Pharmacological therapy with ursodeoxycholic acid and antibiotic therapy to reduce the risk of bacterial translocation and sepsis should be considered. Early referral for transplantation should be considered in patients with evidence of portal hypertension. This review focuses on the clinical aspects, pathogenesis, and management strategies of parenteral nutrition-related liver disease in adult patients.