Ultra‐short bowel is an independent risk factor for liver fibrosis in adults with home parenteral nutrition

Abstract

Background & Aims: Intestinal failure-associated liver disease is rare in adults and risk fac-

Intestinal failure‐associated liver disease: Risks and regression

“…In this issue of Liver International , Cazals‐Hatem et al reported their study of 32 adults who received PN, per the new ESPEN guidelines, and underwent liver biopsy. In this study, ultra short bowel (<20 cm of residual small intestine) and alcohol consumption are associated with significant liver fibrosis . Previous studies have correlated liver derangement, namely abnormal function and elevated transaminase activity levels, with short residual small intestine, but this is the first study to consistently incorporate histology .…”

“…It remains unclear if the aetiology of intestinal failure is related to the risk of liver disease. In Cazals‐Hatem et al's article, no association was found; however, this result should be considered with caution as few cases represented each aetiology, and only 2 were inflammatory (Crohn's colitis) . Another study has suggested higher risk of liver disease in patients with inflammatory disorder‐related intestinal failure …”

“…There have been a handful of reported cases of patients with significant IF‐ALD (≥stage 2) who received isolated intestinal transplantation and had serial liver biopsies (Table ). In Cazals‐Hatem et al's study, 1 patient, who advanced to stage 3 fibrosis over a period of 54 months, regressed to stage 2 on biopsy performed 12 months post‐transplantation, and had complete regression (stage 0) documented 48 months post‐transplantation . Fiel et al (2008) reported 4 patients who showed decreased portal fibrosis, centrilobular fibrosis and overall stage post small bowel transplantation .…”

“…Thus, many believe that adherence to these guidelines diminishes PN as a risk factor for liver disease. The issue is not entirely resolved, as studies with altered PN lipid composition and/or source have shown frequent biochemical improvement with histologic resolution of inflammation and cholestasis, but variable changes in fibrosis …”

“…Cholestatic disease is commonly encountered in children; however, as illustrated by Cazals‐Hatem et al and others, it does occasionally occur in the adult population . Liver fibrosis may develop rapidly in patients with intestinal failure, with some patients progressing to stage 3 disease within months …”