Commentary: oral or enteral nutritional supplementation in cirrhosis
Article first published online: 17 APR 2013
© 2013 Blackwell Publishing Ltd
Alimentary Pharmacology & Therapeutics
Volume 37, Issue 10, pages 1022–1023, May 2013
How to Cite
Cardenas, A. (2013), Commentary: oral or enteral nutritional supplementation in cirrhosis. Alimentary Pharmacology & Therapeutics, 37: 1022–1023. doi: 10.1111/apt.12302
- Issue published online: 17 APR 2013
- Article first published online: 17 APR 2013
- Manuscript Received: 14 MAR 2013
- Manuscript Accepted: 14 MAR 2013
Malnutrition in advanced liver disease is common and may affect up to 80–90% of patients with Child C cirrhosis. In addition it may alter the course of patients whilst awaiting liver transplant, as malnourished candidates have a higher rate of complications and an increased mortality rate. The underlying causes are multifactorial and include decreased intake and absorption of nutrients, increased energy expenditure and altered fuel metabolism with an accelerated starvation metabolism.
In fact, nutritional therapy in patients with advanced cirrhosis improves nutritional status, reduces infection rates, and decreases perioperative morbidity. Thus, it is always recommended that patients be evaluated by a nutritionist for evaluation of malnutrition and appropriate education regarding caloric intake. Most patients who do not meet or reach the goals of caloric intake will require oral nutritional supplements and, in some cases, enteral tube feeding.
The recent meta-analysis by Ney et al. tackles the important issue of oral vs. enteral nutrition in patients with cirrhosis. In the study, they analysed six trials with 470 patients. The studies were heterogenous and they found no overall reduction in mortality, but a sub-analysis did reveal that oral supplementation in three of four studies reduced mortality.
In this regard I believe there is no question that oral supplementation should always be encouraged first. However, a significant proportion has delayed gastric emptying, poor appetite and must in addition follow an unpalatable low-salt diet. Thus, enteral nutrition remains a good option in severely malnourished patients. The two studies of enteral supplementation included in the meta-analysis did not reveal a clear benefit, likely because the intervention was carried out in patients that had a prior GI bleed and nutritional therapy was administered for a short period in one of the studies.[5, 6]
Unfortunately, the authors did not include a randomised controlled study of enteral vs. oral nutrition in their analysis. This study revealed that enteral nutrition was beneficial in severely malnourished patients with cirrhosis as it improved serum albumin levels and Child scores and decreased in-hospital mortality rates compared with the standard oral diet. That said, the conclusions of the meta-analysis correctly conclude that the available data in this field suggest that there is benefit without a significant impact on survival.
The bottom line is that improvement of the nutritional status is essential in these patients (be that oral or enteral) because they have decreased intake and absorption of nutrients. Therefore, strategies to improve oral intake must always be implemented. If oral intake cannot be assured, early implementation of enteral feeding should be considered.
Declaration of personal and funding interests: None.