P3.N262: Intestinal Failure Associated With Liver Disease and the use of Fish Oil: A Case Report

Introduction: Children with intestinal failure (IF), who are dependent on parenteral nutrition (PN), may face many complications, such as the risk of interactions between medications and PN, central-line-related bloodstream infections, and others. The long-term use of PN may also be related to intestinal failure-associated liver disease (IFALD), which is common among infants with short bowel syndrome (SBS) after bowel resection and/or preterms, especially those who develop necrotizing enterocolitis. The treatment's most important measure is to begin enteral feeding as soon as possible. New evidence suggests that the use of fish oil-based intravenous lipid emulsion (FO-ILE) other than soybean oil-based lipid emulsion may help to reverse IFALD by reducing proinflammatory mechanisms, but the duration and efficacy of this therapy are still controversial.

Case Description: A case report of a 13-year-old male patient who was born an extreme preterm infant with an extremely low birth weight (915g) and had a 4-month stay at the pediatric intensive care unit in his hometown. He underwent two surgical procedures as a consequence of necrotizing enterocolitis by that time, and at the age of 13, after an obstructive acute abdomen, several other intestinal resections were needed. The patient was admitted to our service at the age of 13, with SBS, for evaluation for a multivisceral transplantation. He was icteric, malnourished, and in continuous use of PN for at least 10 months. Laboratory testing found high direct bilirubin (3.9 mg/dL), as well as high transaminases and canalicular enzymes (Image 1). As the patient had signs and symptoms of IFALD, with no possibility to begin enteral nutrition at that moment, an alternative treatment has been tried with a total 20-day use of 1g/kg/day FO-ILE, split in two short courses, showing clinical and laboratory improvement (Image 1).

Discussion: The use of FO-ILE may help improve patients' recovery from IFALD, although there are still some concerns about its safety and duration, especially when it comes to effects on somatic growth and the possibility of essential fatty acid deficiency. Despite of that, it might be remembered as a possible alternative to reverse intestinal failure-related cholestasis in those children who are in critical care with no other treatment possibilities.

Conclusion: Children who receive long-term PN are at risk of developing IFALD, and cholestasis is considered the strongest predictor of mortality in this population. This case report is intended to show good results with an intermittent short course of FO-ILE, which might be a good alternative to reverse this condition and may bring better outcomes to these patients by reducing mortality and the need for multivisceral transplantation.