Liver in Specific Hepatobiliary Disorders Hepatocellular Diseases

Alcoholic liver disease The term 'alcoholic liver disease' refers to a spectrum of types of hepatic injury associated with continuous alcohol ingestion, ranging from alcoholic fatty liver to alcoholic stea-tohepatitis, fibrosis, and cirrhosis. Nutritional disturbances in alcoholics are an important cause of morbidity and mortality; all classes of nutrients are affected. Anorexia leads to decreased food intake and subsequent protein-calorie malnutrition. Maldigestion and malabsorption can occur secondary to chronic alcohol injury to small intestinal mucosa. Alcohol consumption is often associated with chronic pancreatic insufficiency, which results in steatorrhea and decreased absorption of dietary protein, fat, and fat-soluble vitamins. Chronic alcohol ingestion also results in impaired hepatic amino acid uptake and protein synthesis.

In alcoholics, utilization of lipids and carbohydrates is markedly compromised due to an excess of reductive equivalents and impaired oxidation of triglycerides. Alcoholics are often resistant to insulin and exhibit impaired uptake of glucose into muscle cells. Insulin-dependent diabetes is common. Heavy alcohol consumption is frequently associated with deficiencies of a wide variety of micronutrients, including the fat- and water-soluble vitamins, particularly folate, pyridoxal-5'-phosphate, thiamine, and vitamin A.

Table 1 summarizes the five published controlled trials of the effect of oral or enteral nutritional supplements on patients with alcoholic hepatitis. In most, nitrogen balance and/or protein synthesis improved, although no effect on mortality was shown, perhaps because of the small number of patients studied and/or the duration of follow-up. In the largest study, at 1-year follow-up, the experimental group had a significantly better survival: 2/24 (8%) died compared to 10/27 (37%) of the controls. In general, the effects of parenteral nutrition in alcoholic liver disease are similar to those noted the studies of enteral nutritional supplements.

Many studies have examined the effect of oral or enteral nutritional supplementation in patients with alcoholic cirrhosis. Results are summarized in Table 2. Many studies are small and of short duration, so it is not surprising that results are inconclusive. Most studies demonstrated an improvement in nitrogen balance and protein synthesis; only one showed increased survival in the treated group. Taken together, these studies suggest that there are benefits to nutritional supplementation in this population.

A variety of international associations have made nutritional recommendations for patients with various types of alcoholic liver disease. The primary recommendation is of course abstinence, which may be all that is needed in patients with fatty liver. Patients with alcoholic hepatitis should take 40kcal/kg, 1.5-2.0 g protein/kg, 4-5g/kg of carbohydrates, and 1-2g/kg of lipids per day. Those with cirrhosis without malnutrition should take 35kcal/kg, 1.3-1.5 g protein/kg, and carbohydrates and lipids as recommended for patents with alcoholic hepatitis. Those with cirrhosis and malnutrition should take higher amounts of protein (1.5-2.0g/kg) and lipids (2.0-2.5g/kg) and lower amounts of carbohydrates (3-4 g/kg). Fluid should be restricted to 2-2.5 l/day and all eight B vitamins, including folate and thiamine, as well as vitamins C and K should be routinely supplemented. In addition, patients with cholestasis should take 50% of their dietary lipids as medium-chain triglycerides

Table 1 Studies on therapy of alcoholic hepatitis with oral or enteral nutritional supplements

Reference

Design

Patients (No.)

Duration (days)

Experimental treatment (EXP)

Control treatment (CTR)

Mortality

Secondary end points

Galambos et al.

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