Hepatobiliary complications in adults receiving nutrition support

Hepatobiliary dysfunction in patients receiving nutrition support is frequent. Other reasons for elevated enzyme levels including drugs, recent anesthesia and surgery or sepsis often coexist. Liver test abnormalities in adults are usually milder than in children and frequently self-limited and are 10 times more likely to occur with total parenteral nutrition (TPN) than tube enteral nutrition. Patients on short-term TPN usually have mild-to-moderate elevations in transaminase and alkaline phosphatase levels and steatosis or portal triaditis on biopsy. Patients who are infected while on TPN are at greater risk of developing steatosis and intrahepatic cholestasis. Strategies to correct abnormalities include alteration of the caloric mix in the TPN, cyclic infusions, metronidazole, enteral nutrition and inclusion of L-glutamine in the TPN formula. Patients on long-term home parenteral nutrition may develop persistent elevations in liver tests and steatohepatitis. Both acalculus and calculus cholecystitis occur with increased frequency in patients on long-term TPN. Biliary sludge precedes calcium bilirubinate stones: predisclosing factors include nil per os, prior ileal resection and use of narcotics or anticholinergics.