Nutrition-Related Hepatic Failure

The most common nutrition-related hepatic disorder is total parenteral nutrition (TPN) - associated liver disease. The hepatic response to prolonged parenteral nutrition depends on the age of the patient: a cholestatic response predominates in infants; older children and adults develop steatosis and steato-hepatitis. In either case end-stage liver disease may result. Biliary sludge and cholelithiasis occur in both groups &. The histopathology in infants with TPN-related cholestasis are non specific and highly variable. The pathogenesis of TPN-associated liver disease is unknown, but is most likely multifactorial. Infants receiving prolonged TPN often have several comorbidities. By definition, these infants have variable periods of enteral starvation. Concomitant gastrointestinal lesions predispose mucosal injury, bacterial overgrowth, endotoxin absorption, and bacterial translocation &. Hypoxic and hypothensive insults are common &. Sistemic infections that predispose to cholestasis are also common. Patients are often exposed to hepatotropic viruses through blood transfusions and receive hepatotoxic drugs. The infusate may contain potentially toxic materials or be deficient in specific nutrients &. In infancy, the immaturity of the enterohepatic circulation is a major factor &. 
TPN-related cholestasis may lead to portal fibrosis and cirrhosis &. In these cases liver transplantation may be indicated, even if the outcome depends also on the associated intestinal disease. For this reason, patients with TPN-related end-stage liver disease frequently are treated with combined liver and small bowel transplantation or with multivisceral transplantation.