Liver Function Tests Abnormalities in Patients with Inflammatory Bowel Disease Receiving Artificial Nutrition: A Prospective Randomized Study of Total Enteral Nutrition vs Total Parenteral Nutrition

Abstract

Liver and biliary abnormalities are well-known complications of inflammatory bowel disease (IBD). It has been suggested that using total parenteral nutrition (TPN) may further impair liver function in these patients; this seems not to be so with total enteral nutrition (TEN). However, prospective trials comparing the incidence of liver function test (LFT) abnormalities with either TPN or TEN have not been carried out. Twenty-nine IBD inpatients with normal LFT, randomized to receive either TEN with a polymeric diet or isocaloric, isonitrogenous "all-in-one" TPN because of protein-energy malnutrition and/or severe disease, were included in the study. Sixteen patients (five with ulcerative colitis and 11 with Crohn's disease) received TEN, and 13 patients (eight ulcerative colitis and five Crohn's disease) were on TPN. All patients were on systemic steroids, and nine of them were on oral metronidazole. Both groups were homogeneous regarding age, sex, diagnosis, disease activity, nutritional status, daily nutrient supply, and days on artificial nutrition. Serum albumin levels significantly increased with TEN (32 ± 1 to 38.2 ± 1.6 g/liter, p < 0.01), but not with TPN (32.1 ± 2.2 to 33.9 ± 1.4 g/liter, NS). Clinical improvement occurred in both groups of patients as shown by the change in the disease activity indexes. In all cases, measurements of serum alkaline phosphatase, serum bilirubin, aspartate aminotransferase, alanine aminotransferase, and γ-glutamyltransferase were performed weekly. There were no significant differences in the initial LFT between both groups. Eight of 13 patients (61.5%) in the TPN group developed some LFT abnormalities, whereas this only occurred in one of 16 patients (6.2%) in the TEN group (p = 0.002). In most cases, LFT derangement was mild, the most frequent change being an increase of γ-glutamyltransferase. However, TPN had to be withdrawn in one patient because of severe LFT derangement. The mean period of time on TPN between patients developing or not LFT derangement was not significantly different (16.9 ± 1.25 us 18.2 ± 2.97 days). In the TPN group, all patients with Crohn's disease developed LFT abnormalities, whereas this only occurred in three of eight patients with ulcerative colitis ( p = 0.043). Possible causes—other than IBD or nutritional support—for LFT derangement did not significantly differ between TEN and TPN groups. These results confirm that LFT abnormalities are significantly more frequent in patients with IBD on TPN than in those on TEN. The maintenance of the integrity of the intestinal mucosa, promoted by the presence of nutrients in the gut lumen, may be necessary in preventing the development of liver damage. (Journal of Parenteral and Enteral Nutrition 14:618-621, 1990)