Approximately 50% of acute intestinal failure (AIF) patients on short-term parenteral nutrition (PN) have intestinal failure-associated liver disease (IFALD) without effect on hospital length of stay and mortality.

INTRODUCTION: Patients with intestinal failure (IF) are often dependent on PN for provision of calories and nutrients for survival. Similar to chronic intestinal failure (CIF) patients, those who have AIF are also at risk of IFALD, which is a poorly understood but potentially fatal condition. The local incidence of IFALD amongst AIF patients is not known. OBJECTIVES: The primary objective of this study was to determine the incidence of IFALD in AIF patients on short-term PN. Secondary objectives were to analyse patient and PN risk factors of IFALD, and clinical outcomes of length of stay (LOS) and inpatient mortality. DESIGN: This was a retrospective cross-sectional cohort study of hospitalised adult patients with AIF prescribed with short-term PN. All adult patients aged 21 years and above who received PN for at least 5 consecutive days and had normal liver function tests (LFTs) at the time of PN initiation were included in this study. RESULTS: A total of 171 patients were enrolled in this study, with 77 (45%) having deranged LFTs at the end of PN therapy and categorised under the IFLAD group. The patient cohort was predominantly male (92 [54%]) and had a median age of 68 years (IQR 59-76). Patients with IFALD at the end of PN therapy had higher diabetes prevalence (36% vs 26%, p = 0.2) and were on PN for a longer duration (median [IQR]: 12 [8-17] vs 8 [6-15] days, p = 0.003) than those without IFALD. There were no significant differences in patient and PN characteristics between the IFLAD and non-IFALD group. The multivariable models showed that the IFALD cohort had longer hospital stays (HR 0.90, 95% CI 0.65-1.23) and lower odds of inpatient death (OR 0.75, 95% CI 0.12-4.60), though both findings are not statistically significant (p = 0.5, 0.7). CONCLUSION: In this study, IFALD is a common phenomenon in AIF and the incidence was found to be an estimated 50% amongst patients on short-term PN with similar clinical outcomes between the two groups.

Approach to Abnormal Liver Biochemistries in the Primary Care Setting.

Liver biochemistries are commonly ordered in the primary care setting, and they may return abnormal even in an asymptomatic patient. Primary care physicians need to have a systematic way of interpreting any derangement in these tests so that further investigations, referrals, and management can be arranged appropriately. This review dwells into patterns of liver biochemistry derangement, common aetiologies to consider, history and examinations that are required, initial investigations to order, and when to refer urgently to the emergency department.

Long term clinical outcomes of home parenteral nutrition in Singapore.

BACKGROUND AND OBJECTIVES: Home parenteral nutrition (HPN) is a life sustaining therapy for patients with chronic intestinal failure. Reported outcomes for Asian HPN patients are scarce. We aim to review the clinical outcomes of adult and paediatric HPN patients in our cohort which caters for 95% of Singaporean HPN patients. METHODS AND STUDY DESIGN: This is a retrospective review of HPN patients from an adult (2002-2017) and paediatric cohort (2011-2017) from the largest tertiary PN centres in Singapore. Patient demographics and clinical outcomes were reviewed. RESULTS: There were 41 adult and 8 paediatric HPN patients. Mean age was 53.0(±15.1) (adults) and 8(±1.8) years-old (paediatrics). Mean duration of HPN was 2.6(±3.5) and 3.5(±2.5) years. Leading indications for adult HPN were short bowel syndrome (SBS) (n=19,46.3%), mechanical obstruction (n=9,22.0%), and gastrointestinal dysmotility disorders (GID) (n=5,12.2%). Thirteen adult (31.7%) patients had underlying malignancy, with seven (17.3%) receiving palliative HPN. Indications for HPN amongst paediatric patients was GID (n=5,62.5%) and SBS (n=3,37.5%). Central line-associated bloodstream infection (CLABSI)/1000catheter-days was 1.0(±2.1) and 1.8(±1.3). Catheter associated venous thrombosis (CAVT)/1000catheter-days was 0.1(±0.4) and 0.7(±0.8). Biochemical Intestinal Failure Associated Liver Disease (IFALD) was found in 21.9% and 87.5%. For adults, median overall survival was 90-months (4.3,175.7,95%CI), with actuarial survival of 70.7%(1-year) and 39.0%(5-years). Median survival for adult patients with malignancy was 6-months (4.2,7.7,95%CI), actuarial survival of 85.7%(3-months) and 30.7%(1-year). One adult patient died from PN related complications. No paediatric deaths were noted. CONCLUSIONS: Whilst patient numbers were modest, we report comparable complication and survival rates to other international centres in both our adult and paediatric cohorts.