S5787 Use the Gut or Lose It: The Feeding Dilemma of an ICU Patient With Complex GI Anatomy

Introduction: Malnutrition in critically ill patients significantly worsens outcomes, independently increasing 28-day intensive care unit (ICU) mortality risk. Guidelines favor enteral nutrition (EN), but when EN fails to meet energy and protein needs, parenteral nutrition (PN) is used. PN is vital for patients with non functioning gastrointestinal (GI) systems, yet prolonged use carries risks, including end-stage liver disease in 15% of cases. Once TPN-associated liver failure is diagnosed, total PN (TPN) is typically discontinued to prevent further liver damage. Case Description/Methods: A 39-year-old woman with a history of Roux-en-Y gastric bypass, complicated by leaks, fistulas, and ischemic bowel requiring hemicolectomy, presented with worsening jaundice and rising bilirubin levels. She had chronic malnutrition, previously managed with TPN, which led to biopsy-confirmed TPN-associated liver failure. At presentation, she relied on maximum tolerable oral intake with supplements but remained malnourished. Increasing oral intake worsened fistula output due to insufficient absorptive bowel capacity. Her hospital course involved infections, blood loss from the fistula, and Klebsiella sepsis requiring vasopressors. Despite aggressive therapy, she developed worsening malnutrition, encephalopathy, liver failure, multi-organ failure, and electrolyte imbalances. Evaluated by bariatric surgery, gastroenterology, transplant surgery, and nutrition teams, she was deemed unfit for liver transplant. With no viable nutritional options, she succumbed to her condition. Discussion: TPN-associated liver failure can emerge within 14 days of starting TPN and is diagnosed by excluding other causes, sometimes with biopsy confirmation. Discontinuing TPN halts progression, but for patients with end-stage liver disease unable to stop TPN, combined intestinal-liver transplant may be considered. This complication is more frequent in infants (40-60%) than adults (15-40%), with better-established pediatric management options like ursodeoxycholic acid and taurine supplements. In adults, however, management strategies remain less defined. Balancing EN and PN is critical, as TPN-associated liver failure worsens malnutrition and limits nutritional options, contributing to poor outcomes, as seen here.