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21 years of parenteral nutrition in Northern Ireland: a review of intestinal-failure associated liver disease
Abstracts / Clinical Nutrition ESPEN 22 (2017) 116e147
When asked to rate their patient/carer experiences of BD there were no negative responses and the majority were positive experiences (very good 60%, excellent 26.7%). Amongst those not using BD the most frequently selected reasons were, it wasn't requested by patient/carer (76%), risk of tube blockages (51.7%), unknown nutritional content (42.6%) and infection risk (40.6%). Over 90% of respondent stated that they would like further information regarding BD most notably around nutritional adequacy, risk of blockages and patient experience. BD is being used in the UK. It appears to result in a positive patient experience and can be effective in managing GI disturbances. Despite concerns the use of BD does not appear to have resulted in significant complications. Finally, it's evident through the significant number of respondents requesting further information that dietitians potentially feel that there is a lack of evidence around the implementation of BD in the UK. References [1] Campbell S. An anthology of advances in enteral tube feeding formulations. Nutr Clin Prac 2006;21:411e15. [2] Borghi R, Dutra Araujo T, Airoldi Vieira R I, et al. ILSI Task Force on enteral nutrition; estimated composition and costs of blenderized diets. Nutr Hosp. 2013;28:2033e8. [3] Barkhidarian B, Seyedhamzeh S, Mousavi N, et al. Nutritional and physical qualities of blenderised enteral diets. Clin Nutr Suppl 2011;6:92e3. [4] Sullivan M, Sorreda-Esguerra P, Platon B, et al. Nutritional analysis of blenderized enteral diets in the Philippines. Asia Pac J Clin Nutr 2004;4:385e91. [5] Jalali M, Sabzghabaee A, Badri S, et al. Bacterial contamination of hospital-prepared enteral tube feeding formulas in Isfahan, Iran. J Res Med Sci 2009;14:149e56. [6] Pentiuk S, O'Flaherty T, Santoro K, et al. Pureed by gastrostomy tube diet improves gagging and retching in children with fundoplication. JPEN J Parenter Enteral Nutr 2001;35:375e9. [7] O'Flaherty T. Use of a Pureed by Gastrostomy Tube (PBGT) diet to promote oral intake: review and case study. Support Line 2015;37:21e3. [8] Policy Statement. Use of liquidised food with enteral feeding tubes. British Dietetic Association; 2013. [Accessed June 12, 2016, at https://www. bda.uk.com/improvinghealth/healthprofessionals/policystatement_ liquidisedfood]. OC3 21 YEARS OF PARENTERAL NUTRITION IN NORTHERN IRELAND: A REVIEW OF INTESTINAL-FAILURE ASSOCIATED LIVER DISEASE L. Stratton, E. Murray, G. Rafferty, G.B. Turner. Department of Gastroenterology, Belfast City Hospital, Lisburn Road, Belfast, BT9 7AB, Ireland Intestinal failure associated liver disease (IFALD) is an indication for multivisceral transplantation (MVT). Disturbance of liver function is common, and often multi-factorial, in the complex patients who require long-term home parenteral nutrition (HPN). Little is known about how best to monitor for liver disease in these patients, or who will progress to end stage liver disease. This is a retrospective analysis of all patients who have been on HPN since 1995. The aim was to identify which patients have evidence IFALD, and of those who died, how many had evidence of liver disease at time of death. This analysis used a database of HPN patients that is already established. Hospital electronic data records were used to access laboratory values, histopathology, radiology, and patient clinical letters. 53 females and 38 males have received HPN from 1995 to 2016. The most common aetiologies of underlying disease are inflammatory bowel disease (29), ischaemia (19), cancer-related (12) and surgical complications (11). 22 patients remain on HPN, 32 patients have died, and 37 are alive off HPN. Of the patients currently on HPN, duration has ranged from 2e187 months (mean 72 months). By defining abnormal liver function tests (LFTs) as 1.5 times the upper limit of normal (ULN), we identified that at baseline, 8/22 current patients had abnormal tests. Two of this group have liver transplants e one in childhood as part of a multi-visceral transplant, and one who developed acute liver failure secondary to non-A/non-B hepatitis. This patient became HPN dependent due to surgical complications. Of the current HPN population, 8 patients have abnormal LFTs as defined above, but are not necessarily the same 8 patients with abnormal tests at
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baseline. Half of this group have less than 50 cm to stoma. Four have had recent liver imaging revealing extensive fatty infiltration, and two have had liver biopsies showing cholestasis, steatohepatitis and one has fibrosis. Of those with normal LFTs, 7 have features of concern such as extensive fatty infiltration on imaging (4/7), 1 biopsy with evidence of bridging fibrosis and features consistent with long term HPN use, and one patient with a high liver stiffness at Fibroscan consistent with cirrhosis. This patient is being assessed for MVT and was detected due to thrombocytopenia and not abnormal liver tests. A further patient has fluctuating bilirubin and thrombocytopenia and awaits further evaluation. All patients alive off HPN currently have normal LFTs, and no parameters to suggest underlying abnormality, such as thrombocytopenia. 31 of these 37 patients were on HPN for two years or less, although one patient required HPN for 8 years before cessation in favour of parenteral fluids and electrolytes. One patient died while awaiting MVT due to underlying primary sclerosing cholangitis (PSC) and cirrhosis. Two further patients died with known abnormal LFTs, histology and imaging e liver disease did not directly cause death but may have played a role. This data would suggest that short term usage of HPN has no significant effect on long term liver function. In our long-term HPN cohort, LFTs are not sensitive to detect those at risk of IFALD and other parameters such as thrombocytopenia may be a better predictor. We suggest that Fibroscan may be useful to non-invasively assess liver stiffness and propose to further evaluate this group of patients by this method. OC4 RANDOMISED CROSSOVER STUDY TO INVESTIGATE WHETHER PATIENTS EAT MORE WHEN FOOD IS SERVED ON A RED PLATE M. Barne a, G. Colopy b, N. Singh c. a Addenbrooke's hospital, Cambridge, CB2 0QQ, UK; b University of Oxford, UK; c St Helier Hospital, Surrey, SM5 1AA, UK Malnutrition is well recognised in elderly patients with hip fractures and is an important challenge [1]. Cognitive impairment and delirium are common in this patient group. Visual acuity and visual contrast sensitivity decline with ageing [2]. These factors put hip fracture patients at significant risk of consuming less than their optimal nutritional intake. Poor nutritional status is associated with a less favourable outcome following hip fracture [3]. Patients on a hip fracture unit with an Abbreviated Mental Test Score (AMTS) < 7 were shown to eat 30% more lunch from a red plate compared to a white plate [4]. Similar results were observed in a small group of patients with advanced Alzheimer's disease living in a care home [5]. 99 post-operative hip fracture patients participated in this 6-day crossover study. Patients were randomised to either red or white plates. In arm 1 of the study (first 3 days), patients in group A were served food on red plates and patients in group B on white plates. In arm 2 (subsequent 3 days) patients were served food on the alternate colour plate. Dietary intake for breakfast, lunch and dinner was measured during the study period. Oral intake was calculated using weighed meal records and energy (kcal) intake was also calculated. There were 80 female and 19 male participants. Both groups: mean age was 83.9 years; mean AMTS was 7. Oral intake from red plates was 12% higher in arm 1 (p<0.05) but not overall significant in arm two, however group B showed an increased intake each consecutive meal once they switched to a red plate (arm 2). In patients with AMTS <7 (n¼32) there was a 14% increase in oral intake from red plates (across both study arms). Total kcals consumed were generally in proportion to changes in weight of food eaten. This study supports previous research that meals served on red plates increase oral intake in patients recovering from surgery for a hip fracture. Increased oral intake was most marked in patients with cognitive impairment. Serving food on red plates offers a practical and inexpensive option to increasing nutritional intake in this vulnerable group. Further studies are needed to see if there are longer term benefits with regards to nutritional status, hospital readmissions and length of stay. References [1] Stratton R, Green C, Elia M. Disease related malnutrition: an evidence based approach to treatment. Oxford: CABI publishing; 2003. [2] Cronin-Golomb A, Corkin S, Rizzo J, Cohen J, Growdon J, Banks K. Visual dysfunction in Alzheimer's disease: relation to normal aging. Ann Neurol 1991;29(1):41e52.
When asked to rate their patient/carer experiences of BD there were no negative responses and the majority were positive experiences (very good 60%, excellent 26.7%). Amongst those not using BD the most frequently selected reasons were, it wasn't requested by patient/carer (76%), risk of tube blockages (51.7%), unknown nutritional content (42.6%) and infection risk (40.6%). Over 90% of respondent stated that they would like further information regarding BD most notably around nutritional adequacy, risk of blockages and patient experience. BD is being used in the UK. It appears to result in a positive patient experience and can be effective in managing GI disturbances. Despite concerns the use of BD does not appear to have resulted in significant complications. Finally, it's evident through the significant number of respondents requesting further information that dietitians potentially feel that there is a lack of evidence around the implementation of BD in the UK. References [1] Campbell S. An anthology of advances in enteral tube feeding formulations. Nutr Clin Prac 2006;21:411e15. [2] Borghi R, Dutra Araujo T, Airoldi Vieira R I, et al. ILSI Task Force on enteral nutrition; estimated composition and costs of blenderized diets. Nutr Hosp. 2013;28:2033e8. [3] Barkhidarian B, Seyedhamzeh S, Mousavi N, et al. Nutritional and physical qualities of blenderised enteral diets. Clin Nutr Suppl 2011;6:92e3. [4] Sullivan M, Sorreda-Esguerra P, Platon B, et al. Nutritional analysis of blenderized enteral diets in the Philippines. Asia Pac J Clin Nutr 2004;4:385e91. [5] Jalali M, Sabzghabaee A, Badri S, et al. Bacterial contamination of hospital-prepared enteral tube feeding formulas in Isfahan, Iran. J Res Med Sci 2009;14:149e56. [6] Pentiuk S, O'Flaherty T, Santoro K, et al. Pureed by gastrostomy tube diet improves gagging and retching in children with fundoplication. JPEN J Parenter Enteral Nutr 2001;35:375e9. [7] O'Flaherty T. Use of a Pureed by Gastrostomy Tube (PBGT) diet to promote oral intake: review and case study. Support Line 2015;37:21e3. [8] Policy Statement. Use of liquidised food with enteral feeding tubes. British Dietetic Association; 2013. [Accessed June 12, 2016, at https://www. bda.uk.com/improvinghealth/healthprofessionals/policystatement_ liquidisedfood]. OC3 21 YEARS OF PARENTERAL NUTRITION IN NORTHERN IRELAND: A REVIEW OF INTESTINAL-FAILURE ASSOCIATED LIVER DISEASE L. Stratton, E. Murray, G. Rafferty, G.B. Turner. Department of Gastroenterology, Belfast City Hospital, Lisburn Road, Belfast, BT9 7AB, Ireland Intestinal failure associated liver disease (IFALD) is an indication for multivisceral transplantation (MVT). Disturbance of liver function is common, and often multi-factorial, in the complex patients who require long-term home parenteral nutrition (HPN). Little is known about how best to monitor for liver disease in these patients, or who will progress to end stage liver disease. This is a retrospective analysis of all patients who have been on HPN since 1995. The aim was to identify which patients have evidence IFALD, and of those who died, how many had evidence of liver disease at time of death. This analysis used a database of HPN patients that is already established. Hospital electronic data records were used to access laboratory values, histopathology, radiology, and patient clinical letters. 53 females and 38 males have received HPN from 1995 to 2016. The most common aetiologies of underlying disease are inflammatory bowel disease (29), ischaemia (19), cancer-related (12) and surgical complications (11). 22 patients remain on HPN, 32 patients have died, and 37 are alive off HPN. Of the patients currently on HPN, duration has ranged from 2e187 months (mean 72 months). By defining abnormal liver function tests (LFTs) as 1.5 times the upper limit of normal (ULN), we identified that at baseline, 8/22 current patients had abnormal tests. Two of this group have liver transplants e one in childhood as part of a multi-visceral transplant, and one who developed acute liver failure secondary to non-A/non-B hepatitis. This patient became HPN dependent due to surgical complications. Of the current HPN population, 8 patients have abnormal LFTs as defined above, but are not necessarily the same 8 patients with abnormal tests at
117
baseline. Half of this group have less than 50 cm to stoma. Four have had recent liver imaging revealing extensive fatty infiltration, and two have had liver biopsies showing cholestasis, steatohepatitis and one has fibrosis. Of those with normal LFTs, 7 have features of concern such as extensive fatty infiltration on imaging (4/7), 1 biopsy with evidence of bridging fibrosis and features consistent with long term HPN use, and one patient with a high liver stiffness at Fibroscan consistent with cirrhosis. This patient is being assessed for MVT and was detected due to thrombocytopenia and not abnormal liver tests. A further patient has fluctuating bilirubin and thrombocytopenia and awaits further evaluation. All patients alive off HPN currently have normal LFTs, and no parameters to suggest underlying abnormality, such as thrombocytopenia. 31 of these 37 patients were on HPN for two years or less, although one patient required HPN for 8 years before cessation in favour of parenteral fluids and electrolytes. One patient died while awaiting MVT due to underlying primary sclerosing cholangitis (PSC) and cirrhosis. Two further patients died with known abnormal LFTs, histology and imaging e liver disease did not directly cause death but may have played a role. This data would suggest that short term usage of HPN has no significant effect on long term liver function. In our long-term HPN cohort, LFTs are not sensitive to detect those at risk of IFALD and other parameters such as thrombocytopenia may be a better predictor. We suggest that Fibroscan may be useful to non-invasively assess liver stiffness and propose to further evaluate this group of patients by this method. OC4 RANDOMISED CROSSOVER STUDY TO INVESTIGATE WHETHER PATIENTS EAT MORE WHEN FOOD IS SERVED ON A RED PLATE M. Barne a, G. Colopy b, N. Singh c. a Addenbrooke's hospital, Cambridge, CB2 0QQ, UK; b University of Oxford, UK; c St Helier Hospital, Surrey, SM5 1AA, UK Malnutrition is well recognised in elderly patients with hip fractures and is an important challenge [1]. Cognitive impairment and delirium are common in this patient group. Visual acuity and visual contrast sensitivity decline with ageing [2]. These factors put hip fracture patients at significant risk of consuming less than their optimal nutritional intake. Poor nutritional status is associated with a less favourable outcome following hip fracture [3]. Patients on a hip fracture unit with an Abbreviated Mental Test Score (AMTS) < 7 were shown to eat 30% more lunch from a red plate compared to a white plate [4]. Similar results were observed in a small group of patients with advanced Alzheimer's disease living in a care home [5]. 99 post-operative hip fracture patients participated in this 6-day crossover study. Patients were randomised to either red or white plates. In arm 1 of the study (first 3 days), patients in group A were served food on red plates and patients in group B on white plates. In arm 2 (subsequent 3 days) patients were served food on the alternate colour plate. Dietary intake for breakfast, lunch and dinner was measured during the study period. Oral intake was calculated using weighed meal records and energy (kcal) intake was also calculated. There were 80 female and 19 male participants. Both groups: mean age was 83.9 years; mean AMTS was 7. Oral intake from red plates was 12% higher in arm 1 (p<0.05) but not overall significant in arm two, however group B showed an increased intake each consecutive meal once they switched to a red plate (arm 2). In patients with AMTS <7 (n¼32) there was a 14% increase in oral intake from red plates (across both study arms). Total kcals consumed were generally in proportion to changes in weight of food eaten. This study supports previous research that meals served on red plates increase oral intake in patients recovering from surgery for a hip fracture. Increased oral intake was most marked in patients with cognitive impairment. Serving food on red plates offers a practical and inexpensive option to increasing nutritional intake in this vulnerable group. Further studies are needed to see if there are longer term benefits with regards to nutritional status, hospital readmissions and length of stay. References [1] Stratton R, Green C, Elia M. Disease related malnutrition: an evidence based approach to treatment. Oxford: CABI publishing; 2003. [2] Cronin-Golomb A, Corkin S, Rizzo J, Cohen J, Growdon J, Banks K. Visual dysfunction in Alzheimer's disease: relation to normal aging. Ann Neurol 1991;29(1):41e52.