The hepatobiliary complications of malnutrition and nutritional support in adults

Hepatobiliary complications of hypoalimentation and parenteral nutrition (PN) are widely recognised. Hypoalimentation includes conditions such as anorexia nervosa (AN), obesity malnutrition and liver disease following bariatric surgery. Treatment of the underlying condition causing hypoalimentation can result in an improvement in liver dysfunction. Liver function test abnormalities are also commonly found in patients on PN, with the three main complications being steatosis, cholestasis and biliary system sludge/stones. Patients with intestinal failure receiving PN often have multiple possible aetiologies for liver dysfunction (rather than solely caused by the PN); hence, it is now more commonly referred to as intestinal failure-associated liver disease (IFALD). Liver enzyme abnormalities are very common with long-term PN use and do not always help with monitoring progression of IFALD. A systematic approach is required for investigating liver function abnormalities related to PN. The key management in IFALD is through prevention of sepsis, promoting intestinal health and restoring intestinal continuity where possible. A variety of imaging modalities can be used to investigate, and monitor, the liver disease. Most importantly, patients on PN for more than 28 days should be managed in a large centre with experience in managing intestinal failure to minimise the risk of such complications. Early identification of liver dysfunction is essential and, should it progress despite the above measures, early discussion with an intestinal transplant centre should be encouraged.