Liver Disease and Total Parenteral Nutrition

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NAFLD and cholestasis are common complications of total parenteral nutrition (TPN) use in adults (Buchman, 2002). Since the advent of TPN four decades ago, it has been difficult to establish the etiology of these disorders with certainty. Patients receiving TPN often have multiple coexisting medical problems, potential hepatotoxic medication use, or altered bowel anatomy. Nonetheless, both choline and essential fatty acids are necessary for lecithin synthesis, a step that must occur in the liver to allow fat transport out of the liver. This essential metabolic step provides one rationale for ensuring that patients receiving

TABLE 116-1. Therapeutic Options for Nonalcoholic Steatohepatitis (NASH)

Insulin Resistance Exercise Weight Loss Diet

Bariatric surgery Block absorption of calories Drugs Thiazolidinediones Metformin Lipid Lowering Agents 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) inhibitors (statins) Fibrates Cytoprotective Agents Vitamin E Betaine

TPN also receive regular fatty acids and choline supplements. There is a concern that too much fat provided with TPN may contribute to the cholestasis that can occur in subjects receiving long-term TPN, especially children. The causes of TPN-induced cholestasis are less certain.

The approaches to NAFLD and cholestasis during TPN administration include ensuring that patients are not receiving too many calories, reducing small bowel overgrowth with antibiotics, or reducing the toxicity of bile with ursodeoxycholic acid. There is a separate chapter on enteral and parenteral nutrition (Chapter 54).

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