Intensive Enteral Nutrition in Alcoholic Hepatitis: More Food for Thought

Abstract

The Veteran’s Affairs Cooperative Group Studies in the 1990s established that the majority of patients with severe alcoholic hepatitis have protein-calorie malnutrition.1 Protein-calorie malnutrition, assessed using 8 nutritional parameters, is associated with significantly higher 30-day, 6-month, and 12-month mortality rates.2 Preadmission malnutrition is exacerbated by a marked catabolic state in many patients with alcoholic hepatitis.3 Consequently, guidelines published by the American Association for Study of Liver Disease and the European Association for Study of the Liver recommend enteral nutritional therapy.4,5 Enteral nutrition with goal of 35–40 kcal/kg of body weight (BW) and a daily protein intake of 1.2–1.5 g/kg of BW in patients with liver disease is recommended by the European Society for Clinical Nutrition and Metabolism guidelines.6 Existing evidence favors that early enteral nutrition can significantly benefit morbidity and mortality in severe disease state such as critical illness.6 The mechanisms that can confer enteral nutrition benefits include preserving the intestinal barrier and decreasing intestinal permeability, immune modulation, and decreasing risk of infection. In addition, enteral nutrition supplementation can preserve further muscle loss and prevent worsening sarcopenia, promote anabolism, and replete glutathione stores that are often depleted in chronic alcoholics including those with alcoholic hepatitis. Nevertheless, the evidence supporting the use of enteral nutrition is not strong.7