Initiation, Advancement, and Acute Complications of Parenteral Nutrition


Complications Associated With the Gallbladder and Liver


Hepatobiliary disorders can arise with short- or long-term use of PN, although there can be many causes for these complications (eg, infec- tion, alcohol use disorder, medications, metabolic disorders, or under- lying liver disease). Complications range in severity from benign (eg, transient elevations in liver function tests) to life-threatening liver failure. This section reviews how to identify and manage various hepa- tobiliary disorders.


Acute Acalculous Cholecystitis


Acute acalculous cholecystitis (AAC) is relatively rare and is defined as acute inflammation of the gallbladder in the absence of gallstones. AAC is thought to be due to disruption of microcirculation, gallbladder mucosal ischemia, reperfusion injury, and inflammatory mediators. It is associ- ated with a variety of conditions or factors, including critical illness, sepsis, major infections, trauma, PN, mechanical ventilation, diabetes, and burns.46-48


Many patients receiving PN also have other risk factors for


AAC, making the exact cause difficult to pinpoint. The diagnosis of AAC is made using a combination of clinical, labora-


tory, and radiologic criteria (typically an ultrasound of the gallbladder). Clinical symptoms of AAC include the following47


:


ƒ persistent and severe right upper quadrant pain that often radi- ates to the back


ƒ fever ƒ nausea and vomiting ƒ jaundice


Surgical treatment involves cholecystostomy.46 For the patient with


AAC receiving PN, starting oral or enteral nutrient intake can be consid- ered in combination with PN, even if in minimal amounts, to stimulate gallbladder contraction and bile flow. Ursodeoxycholic acid supplemen- tation may also improve bile flow.49


Hyperbilirubinemia and Elevated Liver Function Tests


PN is often blamed for abnormal liver function test results and elevated bilirubin.50


Patients more likely to develop PN-associated liver disease 67


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