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HEPATOLOGY
Copyright 1985 by the American Association for the Study of Liver Diseases
Vol. 5,No. ,pp. 79-84, 1985
Printed in
U.S A
Test
attern and Prognosis
of
Liver Function
Abnormalities During Parenteral Nutrition in
Inflammatory
Bowel
Disease
JOSE . BENGOA,?TEPHEN
.
HANAUER, ICHAEL
.
SITRIN,
ALFRED
L. BAKER
N D
IRWIN . ROSENBERG
Nutritio n Support Service and Liver Stu dy Unit Section of Gastroenterology Department of
Medicine Th e University of Chicago Hosp itals and Clinics Chicago Illinois
60637
The pat tern of liver function
test
abnormalities was examined duri ng total parent era l nutrition
(TPN), using both dextrose and fa t emulsions as caloric sources, in 92 patients with inflammatory
bowel disease. Seventy-two patient s had completely normal tests before TPN while
20
had one
or
more abnormal liver function tests before TPN was started. Serum bilirubin levels were normal
in
all
patients before TPN; w ithin 2 weeks
on
TPN, 25 of patient s had elevated bilirub in levels.
Serum alkaline phosphatase rose to values above normal in 25 of patients with normal sta rti ng
values but did not change in those with abnormal baseline liver function
tests.
Elevations of SGPT
were characteristically more pronounced than were elevation of SGOT. After 2 weeks of TPN,
mean serum SGOT rose from 15 to 26 IU per liter (p c 0.01) in patients with normal baseline
values and from 28 to 50 IU per lit er in those with abnormal baseline values. Elevations of serum
SGPT were most common, affecting 25 of patients with normal baseline. The mean SGPT value
rose from 13 to 38 IU per
liter
(p < 0.01) at week of TPN. In patients with abnormal tests before
TPN, the mean SGPT value rose from 45 to 102 IU per liter (p < 0.06). Liver biopsies performed
in four patients with substantial elevations of aminotransferases revealed only minor nonspecific
changes and no fatt y infiltration. Elevated liver function tests promptly re turn ed to baseline after
TPN was discontinued, and progressive liver disease was not observed in any patient. Although
abnormalities of liver function
tests,
particularly the aminotransferases,
are
common during
balanced TP N in patients w ith inflammatory bowel disease, the favorable prognosis a nd benign
histologic changes argue against th e need to discontinue TPN in the presence of such changes.
Abnormalities of hepatic function and structure have
been frequently recognized during total parenteral nutri-
tion (TPN ) (1,3).Fatty infiltration of the liver has been
observed mainly in patients receiving infusions with
large amounts of dextrose as the only caloric source
1,
2). Cholestasis has been reported in other patients, par-
ticularly premature infants (4-7). We have observed that
patients with inflammatory bowel disease commonly
show marked elevations of aminotransferase during bal-
anced TPN in which both dextrose and fat emulsions
are used as caloric sources. These patients, who often
Received August
5,
1983; accepted Augu st 8, 1984.
t Present address: Hdpital Cantonal Universitaire, Geneva
121
1,
Switzerland.
Th is work was supported in part by grants from the USPHS (NIH
AM26678) Clinical Nutrition R esearch Unit, th e K raft Nu trition Fel-
lowship (J. M. B.) an d the Beatrice Faculty Scholarship (M.
D.
S.).
Address reprint requests to: Irwin H . Rosenberg,M.D.,he Univer-
sity of Chicago, Department of Medicine, 950 East 59th Street,
Box
400, Chicago, Illinois 60637.
have underlying hepatic abnormalities complicating their
inflammatory bowel disease, may represent a patient
group which is particularly susceptible to detrimental
effects of TP N on the liver. The purpose of the present
study was to examine hepatic complications during TPN
in patients with Crohns disease and ulcerative colitis.
MATERIALS AND METHODS
PATIENTOPULATION
We report a consecutive series of 92 patients with
inflammatory bowel disease (43 males and 49 females)
treated with bowel rest and TPN for 10 days or more by
the Nutrition Support Service from July 1, 1979 to
December 31, 1981. Sixty-nine patients had Crohns
disease and 23 had ulcerative colitis as established by
usual clinical and radiological findings and by histologic
material in most patients. No patient had symptoms or
physical findings which suggested the presence
of
liver
disease. During TPN, all patients took nothing
by
mouth
and almost all were on intravenous corticosteroids. Ex-
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BENGOA
Er AL. HEPATOLOGY
cept for antibiotics in occasional patients, no other med-
ications were prescribed.
TPN
TPN was administered through a central vein catheter
and prescribed according to individual requirements fol-
lowing a detailed clinical and nutritional evaluation. In
all cases, the infusions included a combination of carbo-
hydrate (dextrose, 15 to 25% )and lipid emulsions (Int ra-
lipid lo , Cutter Laboratories, Inc., Berkeley, Calif.).
Total calories infused ranged from 30 to
55
kcal per kg
ideal body weight and the percent of calories supplied as
lipid emulsion accounted for about one-fourth of nonpro-
tein calories (range, 10 to
45% ) .
Crystalline amino acids
in a 4.25% solution (Freeamine 11, McGaw Laboratories,
Glendale, Calif. or Travasol, Travenol Laboratories, Inc.,
Deerfield, Ill.) provided a dose of protein ranging from
1.0 to 2.0 gm per kg ideal body weight. Electrolytes and
minerals were included to meet appropriate require-
ments. Vitamins were added in a standard multivitamin
solution (MVI concentrate, USV Laboratories, Tucka-
hoe, NY).
A
trace metal additive including manganese,
copper, chromium and zinc was also used (IMS Ltd.,
South El Monte, Calif.).
LIVER UNCTIONESTS
Routine serum chemistry values and liver function
tests were obtained on all patients prior to TPN and
thereafter once weekly until nutrition support was dis-
continued. A commercial discrete sample analyzer (KDA,
American Monitor, Indianapolis, Ind.) was used to de-
termine total bilirubin, alkaline phosphatase, SGOT and
SGPT. For data analysis, the patients were cansidered
in two groups: (i)
72
patients with completely normal
liver function tests before TP N, and (ii) 20 patients with
one or more liver function tests elevated above the nor-
mal established by the hospital clinical chemistry labo-
ratory before TPN was administered.
STATISTICALNALYSIS
Statistical analysis was performed with the Student's
paired t test, and
p
values less than 0.05 were considered
significant.
RESULTS
There was no significant difference in demographic
characteristics and parenteral nutrition prescription be-
tween patients with normal baseline liver function tests
and patients with one
or
several elevated baseline values
(Table 1) . None of the patients developed symptoms or
signs suggestive of liver disease such as hepatomegaly or
right upper quandrant pain and tenderness during the
period
of
TPN. The liver function test abnormalities
which were observed during TPN did not correlate with
differences in the administered dose of total calories,
protein or lipid emulsion.
TOTAL
ILIRUBINFIGURE)
All 92 patients had normal baseline total serum bili-
rubin levels
( 4 . 2
mg per dl). In the group with normal
baseline liver function tests, total bilirubin values in-
creased from a mean (& S.D.) of 0.40 rt 0.20 mg per dl
before TPN to
0.74 rt 0.91
mg per dl after
2
weeks of
TPN (p