Abstract and Introduction
Abstract
Study Objective. To evaluate the use of enteral fish oil for the treatment of parenteral nutrition–associated liver disease (PNALD).
Design. Retrospective case series.
Setting. Pediatric academic hospital and outpatient clinic.
Patients. Six parenteral nutrition–dependent infants with short-bowel syndrome and PNALD.
Measurements and Main Results. The six infants received supplementation with enteral fish oil, and treatment was evaluated over a 12-week period. The PNALD, as reflected by elevated total bilirubin levels, completely reversed in four of the six infants within a mean ± SD of 5 ± 2.6 weeks (range 2–8 wks) after initiation of the enteral fish oil supplementation. In addition, improvement in enteral feedings occurred after starting enteral fish oil therapy.
Conclusion. Enteral fish oil may be an effective adjunctive treatment option for infants with PNALD, particularly for those infants with PNALD who are tolerating some amount of enteral nutrition as the result of an adequate amount of small bowel.
Introduction
Parenteral nutrition–associated liver disease (PNALD) is defined as a decrease in bile flow that occurs independent of mechanical obstruction in patients receiving prolonged parenteral nutrition. It is diagnosed by clinical presentation and elevations in direct bilirubin, liver enzyme, and serum bile acid levels. The disease occurs in 25–66% of patients maintained with long-term parenteral nutrition, and the frequency increases in infants with low birth weight, low gestational age, and short-bowel syndrome. The etiology of PNALD is not well understood and is likely multifactorial. If not reversed, PNALD can progress from cholestasis to liver fibrosis, hepatic failure, and death. The disease improves with the initiation of enteral nutrition and discontinuation of parenteral nutrition, but many patients with short-bowel syndrome are dependent on parenteral nutrition.
Several trials have shown that fish oil–based intravenous fat emulsion (IVFE) appears to be a promising therapy in the treatment of PNALD. However, its lack of approval by the United States Food and Drug Administration requires use under an investigational new drug application. Because of the difficulty in obtaining parenteral fish oil, some patients are treated by restricting soybean oil–based IVFE and administering enteral fish oil supplementation. One group of authors reported complete resolution of PNALD with the removal of soybean oil–based IVFE in six patients, four of whom also received enteral fish oil. In contrast, we report the use of enteral fish oil to treat PNALD, with no change in soybean oil–based IVFE. Fish oil products, both enteral and IVFE, are shown in Table 1.