Case 19.1
Submitted by Kendall Beck, MD
One month later, routine monitoring labs demonstrate an increase in liver enzymes. You trend the labs one month later, and they continue to increase. You perform a thorough work up of the abnormal liver tests, including with abdominal ultrasound. Serologic work up reveals immunity to hepatitis A and B, no evidence of hepatitis C, and normal anti-mitochondrial Ab, anti-smooth muscle Ab, total IgG, iron panel, ceruloplasmin. Abdominal US revealed echogenic liver, normal biliary tree, and no cholelithiasis.
| Test | Baseline | 1 Month | 2 Months |
| Aspartate transaminase (AST) (U/L, nml 5-44) | 30 | 79 | 88 |
| Alanine transaminase (ALT) (U/L, nml 10-61) | 35 | 81 | 96 |
| Alkaline phosphatase (U/L, nml 38-108) | 105 | 234 | 350 |
| Total bilirubin (mg/dL, nml 0.2-1.2) | 1.2 | 2.2 | 3.9 |
Given these results, you diagnose her with parenteral nutrition associated liver disease (PNALD).
What factors are thought to increase the risk of PNALD? Choose all that apply.
Sepsis
Lipid Preparations with fish oil
Small intestinal bacterial overgrowth
Concomitant Enteral Feeding
Excess total calories
Excess carbohydrate administered
Intermittent Parental nutrition infusion
Excess lipid administered
What interventions should you discuss with your dietician to improve the liver injury?
Reassess total calories in TPN, and reduce total number of calories if appropriate.
Make patient strict NPO.
Optimize the dextrose to fat ratio provided in TPN.
Transition parenteral infusions from cycled infusions over 8-12 hours to continuous, 24 hour infusion.
Change lipid formulation from one solely derived from soybeans to one that is rich in omega-3 fatty acids or is derived from a combination of sources.