Changes in Liver Function Tests in Patients with Inflammatory Bowel Disease on Enteral Nutrition

Abstract

Morphologic and functional hepatic changes occur in inflammatory bowel disease (IBD). Patients with this disease often require the administration of artificial nutritional support. Liver function tests (LFT) derangement is a widely recognized side-effect of total parenteral nutrition (TPN). Therefore, the use of this modality of nutritional support may be an additional factor to cause hepatic damage in IBD patients. However whether or not the same occurs in patients receiving total enteral nutrition (TEN) is not well-established. The aim of the present study was to evaluate the effect of TEN upon LFT in patients with moderate to severe acute attacks of IBD, by means of a prospective, controlled, and nonrandomized design. Forty-nine patients were included; 29 (11 patients with ulcerative colitis and 18 with Crohn's disease) received TEN, and 20 (11 with ulcerative colitis and 9 with Crohn's disease) did not. Both groups were homogeneous regarding age, sex, disease activity index, nutritional status, and length of the study (24.8 ± 1.3 vs 23.9 ± 16.8 days). In all cases, weekly measurements of serum alkaline phosphatase, GOT, and GPT were performed. There were no significant differences in LFT at the beginning of the study between groups. The percentage of patients showing derangement of some LFT during the study did not differ between both groups: six of 29 (20.6%) in TEN group vs three of 20 (15%) in control group. Six out of the nine patients (in both groups) who developed LFT derangement had one or more causes, other than TEN for explaining hepatic dysfunction. Only in three patients (one in the control group and two in the TEN group) could no other cause, apart from TEN and/or IBD itself, be found to explain the impairment in LFT. Nevertheless, this was mild and did not require either the performance of liver biopsy or the suppression of TEN. These results suggest that, in contrast to TPN, TEN does not imply an additional risk for liver damage in IBD patients. Therefore, TEN can only be blamed for producing LFT derangement when other causes linked to IBD, its complications, and its treatment have been carefully ruled-out. (Journal of Parenteral and Enteral Nutrition 13:401-405, 1989)

Get full access to this article

View all access options for this article.

References

Greenstein AJ , Janowitz HD , Sachar DB : The extraintestinal complications of Crohn's disease and ulcerative colitis: A study of 700 patients . Medicine 55:401-412, 1976

Cello JP : Cholestasis in ulcerative colitis. Gastroenterology 73:357-374, 1977

Christophi C. , Hughes ER : Hepatobiliary disorders in inflammatory bowel disease. Surg Gynecol Obstet 160:187-193, 1985

Bengoa JM , Hanauer SB , Sitrin MD , et al: Pattern and prognosis of liver function test abnormalities during parenteral nutrition in inflammatory bowel disease. Hepatology 5:79-84, 1985

Skidmore FD , Tweedle DEF , Gleave EN , et al: Abnormal liver function during nutritional support in postoperative cancer patients. Ann Royal Coll Surg Engl 61:183-188, 1979

Deutschman CS , et al: (abstr) JPEN 9:113, 1985

Bean P. , et al: Proceedings of 7th Congress ESPEN (abstr). p 139, 1985

Van Hees PAM , Van Elteren PH , Van Lier HJJ , et al: An index of inflammatory activity in patients with Crohn's disease. Gut 21:279-289, 1980

Harvey RF , Bradshaw JM : A simple index of Crohn's disease activity. Lancet 1:514, 1980

10.

Alastrue A. , Sitges-Serra A. , Jaurrieta E. , et al: Valoración antropométrica del estado de nutrición: Normas y criterios de desnutrición y obesidad. Med Clin (Barc) 80:691-699, 1983

11.

Shepherd HA , Selby WS , Chapman WG , et al: Ulcerative colitis and persistent liver dysfunction. Q J Med 208:503-513, 1983

12.

Mistillis SP : Pericholangitis and ulcerative colitis. 1. Pathology, etiology and pathogenesis. Ann Intern Med 63:1-16, 1965

13.

Dordal E. , Glagov S. , Kirsner JB : Hepatic lesions in chronic inflammatory bowel disease. Gastroenterology 52:239-253, 1967

14.

Perret AD , Higgins G. , Johnston HH , et al: The liver in ulcerative colitis. Q J Med 40:211-238, 1971

15.

Perret AD , Higgins G. , Johnston HH , et al: The liver in Crohn's disease. Q J Med 40:187-209, 1971

16.

Palmer WL , Kirsner JB , Goldgraber MB , et al: Disease of the liver in chronic ulcerative colitis. Am J Med 36:856-866, 1964

17.

Eade MN : Liver disease in ulcerative colitis. I. Analysis of operative liver biopsy in 138 consecutive patients having colectomy. Ann Intern Med 72:475-487, 1970

18.

Dew MJ , Thompson H. , Allen RN : The spectrum of hepatic dysfunction in inflammatory bowel disease . Q J Med 189:113-135, 1979

19.

Nayak NC : Nutritional liver disease. IN Pathology of the Liver . McSween RNM , Anthony PP , Scheuer PJ (eds). Churchill Living-stone, Edinburgh, 1979 pp 221-231

20.

Alpers DH , Sabesin SM : Fatty liver: Biochemical and clinical aspects. IN Diseases of the Liver, 5th ed. Schiff L , Schiff ER (eds). JB Lippincott, Philadelphia, 1982 , pp 813-845

21.

Zimmerman HJ : Jaundice due to bacterial infection. Gastroenterology 77:362-374, 1979

22.

Ribera JM , Estruch R. , Parés A. , et al: Afección hepática en el curso de la sepsis. Med Clin (Barc) 80:398-401, 1983

23.

Seef LB , Wright EC , Zimmerman HJ , et al: VA cooperative study of postransfusion hepatitis, 1969-1974: Incidence and characteristics of hepatitis and responsible risk factors. Am J Med Sci 270:355-362, 1975

24.

Buhac I. , Agrawal AB , Park SK : Jaundice and bridging centrilobular necrosis of liver in circulating failure . NY State J Med 76:678-682, 1976

25.

Dykes MH , Walzer SG : Preoperative and postoperative hepatic dysfunction. Surg Gynecol Obstet 124:747-754, 1967

26.

Brown BR Halothane hepatitis revisited. N Engl J Med 313:1347-1348, 1985

27.

Morgenstern L. : Postoperative jaundice. IN Diseases of the Liver, 5th ed. Schiff L , Schiff ER (eds). JB Lippincott, Philadelphia, 1982, pp 1581-1594

28.

Mullen JL , Hargrove WK , Dudrick SJ , et al: Ten years experience with intravenous hyperalimentation in inflammatory bowel disease. Ann Surg 187:523-529, 1978

29.

Elson CO , Layden TJ , Nemchausky BA , et al: An evaluation of total parenteral nutrition in the management of inflammatory bowel disease. Dig Dis Sci 25:42-48, 1980

30.

Neidich G. , Schissel K. , Sharp HL : Non-invasive outpatient nutritional therapy in inflammatory bowel disease . JPEN 9:350-352, 1985

31.

Grant JP , Cox CE , Kleinman LM , et al: Serum hepatic enzyme and bilirubin elevation during parenteral nutrition. Surg Gynecol Obstet 145:573-580, 1977

32.

Lowry SF , Brennan MF : Abnormal liver function during parenteral nutrition. Relation to infusion excess. J Surg Res 26:300-307, 1979

33.

Lindor KD , Fleming CR , Abrams A. , et al: Liver function values in adults receiving total parenteral nutrition . JAMA 241:2398-2400, 1979

34.

Robertson JFR , Garden OJ , Shenkin A. : Intravenous nutrition and hepatic dysfunction . JPEN 10:172-176, 1986

35.

Sitges-Serra A. , Pallarés R. , Jaurrieta E. , et al: Clinical biochemical and morphological studies of liver function in adult patients on total parenteral nutrition. IN New Aspects of Clinical Nutrition. Kleinberger G , Deutsch E (eds). Karger, Basel, 1983 pp 540-547

36.

Silk DBA : Enteral nutrition: The future. J Clin Nutr Gastroenterol 1:91-96, 1986

37.

Abad A. , Cabré E. , Giné JJ , et al: Total enteral nutrition in hospitalized patients with inflammatory bowel disease. J Clin Nutr Gastroenterol 1:1-8, 1986

38.

Gassull MA , Abad A. , Cabré E. , et al: Enteral nutrition in inflammatory bowel disease. Gut 27(suppl 1):76-80. 1986

39.

King WWK , Boelhouwer RU , Kingshorth AN , et al: Nutritional efficacy and hepatic changes during intragastric, intravenous, and prehepatic feeding in rats. JPEN 7:443-446, 1983

40.

Pallarés R. , Sitges-Serra A. , Fuentes J. , et al: Factores etiopatogénicos posiblemente implicados en la disfunción hepática asociada a la nutrición parenteral: Estudio prospectivo de 104 pacientes adultos. Med Clin (Barc) 83:832-836, 1984

41.

Capron JP , Gineston JL , Hevre MA , et al: Metronidazole in prevention of cholestasis associated with total parenteral nutrition Lancet 1:446-447, 1983