%PDF-1.4 % 12 0 obj <> endobj 60 0 obj <>stream /Artifact <>BDC q 1 i 0 841.89 595.276 -841.89 re 297.645 420.96 m W n .015015 841.89 595.29 -841.89 re W n 1 .1 0 .1 k /GS1 gs .015015 0 595.29 31.48 re f EMC /P <>BDC BT /TT4 1 Tf 38 0 0 38 21.1681 695.062 Tm 1 .89 0 0 k 0 Tc 0 Tw (Liver Biopsy in HPN )Tj ET EMC /P <>BDC BT 38 0 0 38 21.1681 655.8621 Tm (Patients When, how )Tj ET EMC /P <>BDC BT 38 0 0 38 21.1681 616.6623 Tm (and why?)Tj ET EMC /Figure <>BDC Q q 1 i 505.272 788.715 61.953 -47.055 re W n 1 .7294 0 .01961 k /GS1 gs q 1 0 0 1 505.269 752.167 cm 0 0 m 4.9153 0 l 6.7251 .0293 8.7119 -.4416 8.7119 -2.6342 c 8.7119 -3.5764 8.153 -4.3413 7.3288 -4.7541 c 8.4472 -5.0776 9.1389 -6.049 9.1389 -7.2404 c 9.1389 -9.7426 7.2993 -10.508 5.0478 -10.508 c 0 -10.508 l 0 0 l h 2.7371 -4.136 m 4.8564 -4.136 l 5.3272 -4.136 5.9751 -3.8855 5.9751 -3.1348 c 5.9751 -2.3696 5.4302 -2.1191 4.8564 -2.1191 c 2.7371 -2.1191 l 2.7371 -4.136 l h 2.7371 -8.3151 m 4.9297 -8.3151 l 5.7981 -8.3151 6.4018 -8.0063 6.4018 -7.1379 c 6.4018 -6.21 5.7537 -5.9011 4.9297 -5.9011 c 2.7371 -5.9011 l 2.7371 -8.3151 l f Q Q 1 .7294 0 .01961 k /GS1 gs 1 i q 1 0 0 1 521.693 752.167 cm 0 0 m 2.7813 0 l 6.7106 -10.508 l 3.8557 -10.508 l 3.208 -8.624 l -.4562 -8.624 l -1.1183 -10.508 l -3.9294 -10.508 l 0 0 l h .1766 -6.5928 m 2.5607 -6.5928 l 1.3982 -2.9141 l 1.3685 -2.9141 l .1766 -6.5928 l f Q q 1 0 0 1 532.141 752.167 cm 0 0 m 4.9888 0 l 6.9461 0 8.7854 -.8979 8.7854 -3.3847 c 8.7854 -5.9897 7.2993 -7.0054 4.9888 -7.0054 c 2.7371 -7.0054 l 2.7371 -10.508 l 0 -10.508 l 0 0 l h 2.7371 -4.8862 m 4.5767 -4.8862 l 5.4301 -4.8862 6.0483 -4.533 6.0483 -3.5764 c 6.0483 -2.59 5.4156 -2.1933 4.5767 -2.1933 c 2.7371 -2.1933 l 2.7371 -4.8862 l f Q q 1 0 0 1 545.165 752.167 cm 0 0 m 8.3737 0 l 8.3737 -2.1933 l 2.7375 -2.1933 l 2.7375 -4.0324 l 7.8878 -4.0324 l 7.8878 -6.1516 l 2.7375 -6.1516 l 2.7375 -8.1531 l 8.521 -8.1531 l 8.521 -10.508 l 0 -10.508 l 0 0 l f Q q 505.269 788.717 61.955 -47.057 re W n q 1 0 0 1 558.159 752.167 cm 0 0 m 2.8112 0 l 6.4608 -6.4753 l 6.4899 -6.4753 l 6.4899 0 l 9.0654 0 l 9.0654 -10.508 l 6.2546 -10.508 l 2.605 -3.959 l 2.5756 -3.959 l 2.5756 -10.508 l 0 -10.508 l 0 0 l f Q Q 1 .14999 0 0 k q 1 0 0 1 546.342 775.936 cm 0 0 m 0 -5.8643 -4.7535 -10.618 -10.618 -10.618 c -16.482 -10.618 -21.236 -5.8643 -21.236 0 c -21.236 5.8643 -16.482 10.618 -10.618 10.618 c -4.7535 10.618 0 5.8643 0 0 c h -10.618 7.9209 m -14.993 7.9209 -18.539 4.3747 -18.539 0 c -18.539 -4.3744 -14.993 -7.9207 -10.618 -7.9207 c -6.2433 -7.9207 -2.6974 -4.3744 -2.6974 0 c -2.6974 4.3747 -6.2433 7.9209 -10.618 7.9209 c f Q q 505.272 788.715 61.953 -47.055 re W n 1 .7294 0 .01961 k q 1 0 0 1 535.788 756.64 cm 0 0 m -1.3188 4.4313 -6.6429 7.5435 y -8.4014 8.7568 -10.306 10.498 y -13.726 13.452 -13.823 19.465 y -13.921 26.587 -7.815 32.021 y -19.587 31.652 -19.587 19.888 y -19.733 12.239 -12.505 8.4403 y -3.0283 4.3256 -2.3935 1.0552 y -5.5682 4.273 -13.091 7.0157 y -22.42 11.342 -21.867 19.91 y -21.736 27.748 -14.556 32.074 y -27.451 32.285 -27.549 19.677 y -27.346 8.1708 -14.507 5.1694 y -11.234 4.0617 -6.985 2.4265 y -3.2101 .8098 -1.4901 -2.0531 -1.1616 -2.7632 c -.8332 -3.4725 .8639 -3.4022 1.1105 -2.8257 c 1.3567 -2.2493 3.1512 .7844 6.9847 2.4265 c 11.235 4.0617 14.507 5.1694 v 27.346 8.1708 27.549 19.677 v 27.451 32.285 14.556 32.074 v 21.736 27.748 21.867 19.91 v 22.42 11.342 13.091 7.0157 v 5.5685 4.273 2.3936 1.0552 v 3.0287 4.3256 12.505 8.4403 v 19.733 12.239 19.587 19.888 v 19.587 31.652 7.8151 32.021 v 13.921 26.587 13.823 19.465 v 13.726 13.452 10.306 10.498 v 8.4015 8.7568 6.6432 7.5435 v 1.3188 4.4313 0 0 v f Q EMC /Artifact <>BDC Q q 0 841.89 595.276 -841.89 re 297.645 420.96 m W n .015015 841.89 595.29 -841.89 re W n 1 .89 0 0 k q 1 0 0 1 297.525 584.902 cm 0 0 m 272.013 0 l 273.579 0 274.848 -1.2693 274.848 -2.835 c 274.848 -291.875 l 274.848 -293.441 273.579 -294.71 272.013 -294.71 c -272.013 -294.71 l -273.579 -294.71 -274.848 -293.441 -274.848 -291.875 c -274.848 -2.835 l -274.848 -1.2693 -273.579 0 -272.013 0 c h f* Q EMC /P <>BDC BT /TT2 1 Tf 11 0 0 11 46.993 554.9203 Tm 0 0 0 0 k -.0049 Tc -.0368 Tw [(Intestinal failure associated liver disease \(IF)55.2(ALD\) is a major consequence of long-term parenteral nutrition)]TJ ET EMC /P <>BDC BT 11 0 0 11 549.5184 554.9203 Tm 0 Tc 0 Tw ( )Tj ET EMC /P <>BDC BT 11 0 0 11 46.993 538.9203 Tm .01 Tc .1412 Tw (\(PN\) and chronic intestinal failure \(IF\). In paediatric patients and young adults it may manifest as)Tj ET EMC /P <>BDC BT 11 0 0 11 549.5226 538.9203 Tm 0 Tc 0 Tw ( )Tj ET EMC /P <>BDC BT 11 0 0 11 554.2421 538.9203 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 558.9614 538.9203 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 563.6809 538.9203 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 568.4003 538.9203 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 573.1198 538.9203 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 577.8391 538.9203 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 582.5586 538.9203 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 587.278 538.9203 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 591.9974 538.9203 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 46.993 522.9203 Tm .01 Tc .1238 Tw (predominantly cholestasis, while in adults it is often characterised by steatosis/steatohepatitis or a)Tj ET EMC /P <>BDC BT 11 0 0 11 549.5226 522.9203 Tm 0 Tc 0 Tw ( )Tj ET EMC /P <>BDC BT 11 0 0 11 554.0503 522.9203 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 558.5779 522.9203 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 563.1056 522.9203 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 567.6332 522.9203 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 572.1609 522.9203 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 46.993 506.9203 Tm .0097 Tc .0598 Tw (mixed picture of cholestasis and steatosis. In both, progressive fibrosis leading to cirrhosis can also)Tj ET EMC /P <>BDC BT 11 0 0 11 549.526 506.9203 Tm 0 Tc 0 Tw ( )Tj ET EMC /P <>BDC BT 11 0 0 11 553.3462 506.9203 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 557.1664 506.9203 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 560.9866 506.9203 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 564.8068 506.9203 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 568.627 506.9203 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 572.4472 506.9203 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 46.993 490.9203 Tm .0056 Tc .0639 Tw [(occur)55.2(. One of the goals of intensive intestinal rehabilitation is to prevent progression of IF)55.2(ALD, so all)]TJ ET EMC /P <>BDC BT 11 0 0 11 549.5193 490.9203 Tm 0 Tc 0 Tw ( )Tj ET EMC /P <>BDC BT 11 0 0 11 46.993 474.9203 Tm -.0067 Tc -.035 Tw [(members of the multiprofessional intestinal rehabilitation teams \(MPIR)18.1(T\) should be aware of the diagnosis)]TJ ET EMC /P <>BDC BT 11 0 0 11 549.5217 474.9203 Tm 0 Tc 0 Tw ( )Tj ET EMC /P <>BDC BT 11 0 0 11 46.993 458.9203 Tm (and management of this condition.)Tj ET EMC /P <>BDC BT 11 0 0 11 215.1566 458.9203 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 61.1663 442.9203 Tm .0013 Tc .0682 Tw [(A)55.2( key consideration in managing IF)55.2(ALD is knowing when to refer a patient for intestinal transplant.)]TJ ET EMC /P <>BDC BT 11 0 0 11 549.5234 442.9203 Tm 0 Tc 0 Tw ( )Tj ET EMC /P <>BDC BT 11 0 0 11 46.993 426.9203 Tm -.0058 Tc -.0359 Tw [(Historically)74.3(, this was only considered when a patient developed overt liver failure and required a combined)]TJ ET EMC /P <>BDC BT 11 0 0 11 549.5177 426.9203 Tm 0 Tc 0 Tw ( )Tj ET EMC /P <>BDC BT 11 0 0 11 46.993 410.9203 Tm .0035 Tc .066 Tw (liver/intestinal graft, often with poor outcomes. It has become apparent that transplanting an intestine)Tj ET EMC /P <>BDC BT 11 0 0 11 549.5201 410.9203 Tm 0 Tc 0 Tw ( )Tj ET EMC /P <>BDC BT 11 0 0 11 553.3403 410.9203 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 557.1605 410.9203 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 560.9807 410.9203 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 46.993 394.9203 Tm .0017 Tc .0678 Tw (only and weaning the patient from PN, at earlier stages of fibrosis, results in improvement in the liver)Tj ET EMC /P <>BDC BT 11 0 0 11 549.5201 394.9203 Tm 0 Tc 0 Tw ( )Tj ET EMC /P <>BDC BT 11 0 0 11 553.3403 394.9203 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 557.1605 394.9203 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 560.9807 394.9203 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 564.8009 394.9203 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 568.6212 394.9203 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 572.4413 394.9203 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 576.2615 394.9203 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 46.993 378.9203 Tm -.0006 Tc -.0411 Tw [(disease. Isolated intestinal transplants are technically easier)55.2(, associated with shorter lengths of stay)74.2(, less)]TJ ET EMC /P <>BDC BT 11 0 0 11 549.526 378.9203 Tm 0 Tc 0 Tw ( )Tj ET EMC /P <>BDC BT 11 0 0 11 46.993 362.9203 Tm (complications and greatly improved survival compared to combined grafts. )Tj ET EMC /P <>BDC BT 11 0 0 11 411.3842 362.9203 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 61.1663 346.9203 Tm -.0038 Tc -.0379 Tw [(No non-invasive test has been validated for use in IF)55.2(ALD. Hence, liver biopsy for histological diagnosis)]TJ ET EMC /P <>BDC BT 11 0 0 11 549.5199 346.9203 Tm 0 Tc 0 Tw ( )Tj ET EMC /P <>BDC BT 11 0 0 11 46.993 330.9203 Tm .0584 Tw [(and staging are required. )55.2(Appropriate consideration should be given before asking a patient to have a)]TJ ET EMC /P <>BDC BT 11 0 0 11 549.5217 330.9203 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 11 0 0 11 46.993 314.9203 Tm [(biopsy)74.2(, but overall these are safe and well tolerated with a very low complication rate in expert hands.)]TJ ET EMC /P <>BDC BT 11 0 0 11 539.6083 314.9203 Tm ( )Tj ET EMC /P <>BDC BT /TT4 1 Tf 12 0 0 12 22.6771 272.7119 Tm 1 .89 0 0 k (Key points)Tj ET EMC /P <>BDC /GS2 gs BT /TT6 1 Tf 10 0 0 10 84.0189 272.7119 Tm 0 0 0 1 k ( )Tj ET EMC /P <>BDC /GS1 gs BT /TT2 1 Tf 8 0 0 8 22.6771 255.4427 Tm 0 0 0 .8 k (1.)Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 255.4427 Tm (An intra-operative liver biopsy is not routinely recommended for patients )Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 243.8427 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 243.8427 Tm [(undergoing an extensive enterectomy nor is a routine cholecystectomy)74.2(. )]TJ ET EMC /P <>BDC BT 8 0 0 8 24.5131 232.2426 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 232.2426 Tm [(A)55.2( liver biopsy should ideally be discussed as part of the MPIR)18.1(T)18.1( planning )]TJ ET EMC /P <>BDC BT 8 0 0 8 24.5131 220.6427 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 220.6427 Tm [(of IF surgery)74.2(.)]TJ ET EMC /P <>BDC BT 8 0 0 8 80.5469 220.6427 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 22.6771 209.0426 Tm (2.)Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 209.0426 Tm (No non-invasive method for diagnosing liver fibrosis has been )Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 197.4427 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 197.4427 Tm [(demonstrated to be useful in diagnosing or staging IF)55.2(ALD. )]TJ ET EMC /P <>BDC BT 8 0 0 8 242.1446 197.4427 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 22.6771 185.8426 Tm (3.)Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 185.8426 Tm (Consider liver biopsy in all home parenteral nutrition \(HPN\) patients with )Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 174.2426 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 174.2426 Tm (ultrashort bowel \()Tj ET EMC /P <>BDC BT /TT7 1 Tf 8 0 0 8 95.3751 174.2426 Tm <0001>Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 95.3751 174.2426 Tm (20 cm residual small bowel\) who have been on PN for )Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 162.6426 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 162.6426 Tm (a year or longer and may be a candidate for intestinal transplant.)Tj ET EMC /P <>BDC BT 8 0 0 8 262.5977 162.6426 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 22.6771 151.0425 Tm (4.)Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 151.0425 Tm [(Repeat, after MPIR)18.1(T)18.1( discussions, liver biopsy every 2-3 years in patients)]TJ ET EMC /P <>BDC BT 8 0 0 8 291.168 151.0425 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 139.4426 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 139.4426 Tm (with ultrashort bowel who have not already been referred to an intestinal )Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 127.8427 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 127.8427 Tm (transplant centre.)Tj ET EMC /P <>BDC BT 8 0 0 8 95.8282 127.8427 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 22.6771 116.2426 Tm (5.)Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 116.2426 Tm (Consider liver biopsy in all HPN patients with a second liver insult )Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 104.6426 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 104.6426 Tm (\(including but not limited to, known or suspected previous NAFLD, viral )Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 93.0426 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 93.0426 Tm (hepatitis, or excessive alcohol intake\) who have been on PN for 2 years )Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 81.4426 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 81.4426 Tm (or more. )Tj ET EMC /P <>BDC BT 8 0 0 8 66.0235 81.4426 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 22.6771 69.8426 Tm (6.)Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 69.8426 Tm (For any patient with moderate or severe fibrosis, refer urgently to an )Tj ET EMC /P <>BDC BT 8 0 0 8 24.5131 58.2426 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 58.2426 Tm (intestinal transplant centre.)Tj ET EMC /P <>BDC BT 8 0 0 8 129.6252 58.2426 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 303.5263 275.6241 Tm (7.)Tj ET EMC /P <>BDC BT 8 0 0 8 314.865 275.6241 Tm (For any patient with mild fibrosis, consider repeat liver biopsy in 2-5 )Tj ET EMC /P <>BDC BT 8 0 0 8 305.3622 263.6241 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.865 263.6241 Tm [(years, depending on overall risk. )18.1(The decision on surveillance intervals )]TJ ET EMC /P <>BDC BT 8 0 0 8 305.3622 251.6241 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.865 251.6241 Tm (can be made in conjunction with a transplant centre.)Tj ET EMC /P <>BDC BT 8 0 0 8 499.4196 251.6241 Tm ( )Tj ET EMC /P <>BDC BT /TT4 1 Tf 12 0 0 12 303.5263 230.4507 Tm 1 .89 0 0 k (Explanations)Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 378.2099 228.4507 Tm 0 0 0 .8 k ( )Tj ET EMC /P <>BDC BT 8 0 0 8 303.5263 213.6161 Tm -.015 Tc (1.)Tj ET EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 312.7622 213.6161 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 314.865 213.6161 Tm (Although it may be helpful, we do not recommend a routine baseline )Tj ET EMC /P <>BDC BT 8 0 0 8 312.6422 201.6161 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.865 201.6161 Tm (intra-operative liver biopsy \(to stratify future risk\) because of the added )Tj ET EMC /P <>BDC BT 8 0 0 8 312.6422 189.6161 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.865 189.6161 Tm (risks of bleeding from the biopsy and the biopsy itself likely to show non-)Tj ET EMC /P <>BDC BT 8 0 0 8 312.6422 177.6161 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.865 177.6161 Tm (specific changes associated with acute illness/sepsis/shock. Patients )Tj ET EMC /P <>BDC BT 8 0 0 8 312.6422 165.6161 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.865 165.6161 Tm (with intestinal failure are at higher risk of developing gallstones \(often )Tj ET EMC /P <>BDC BT 8 0 0 8 312.6422 153.6161 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.865 153.6161 Tm (pigment type\), with 45% of short bowel patients \(especially men\) having )Tj ET EMC /P <>BDC BT 8 0 0 8 312.6422 141.6161 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.865 141.6161 Tm [(or having had them. )55.2(A)18.1(wareness of this amongst surgeons means some )]TJ ET EMC /P <>BDC BT 8 0 0 8 312.6422 129.6161 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.865 129.6161 Tm (patients undergoing extensive enterectomy have a cholecystectomy at )Tj ET EMC /P <>BDC BT 8 0 0 8 312.6422 117.6161 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.865 117.6161 Tm -.02 Tc [(the index operation. W)18.1(e)0( do not recommend this. However)55.2(, cholecystectomy)]TJ ET EMC /P <>BDC BT 8 0 0 8 570.6046 117.6161 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 312.6422 105.6161 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.865 105.6161 Tm (may be considered alone or as part of an elective operation if gallstones )Tj ET EMC /P <>BDC BT 8 0 0 8 312.6422 93.6161 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.865 93.6161 Tm (are present. For IF patients undergoing cholecystectomy or other )Tj ET EMC /P <>BDC BT 8 0 0 8 312.6422 81.6161 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.865 81.6161 Tm [(abdominal surgery)74.2(, an intra-operative liver biopsy should be considered )]TJ ET EMC /P <>BDC BT 8 0 0 8 312.6422 69.6161 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.865 69.6161 Tm (if technically possible \(unless the surgery is undertaken with the )Tj ET EMC /P <>BDC BT 8 0 0 8 312.6422 57.6161 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.865 57.6161 Tm (expectation of weaning the patient from PN\).)Tj ET EMC /P <>BDC BT 8 0 0 8 472.7321 57.6161 Tm ( )Tj ET EMC /P <>BDC BT /TT4 1 Tf 9 0 0 9 22.6772 814.1643 Tm 1 .15 0 0 k [(THE BRITISH INTESTINAL)18.1( F)55.2(AILURE )37.1(ALLIANCE \(BIF)55.2(A\) T)18.1(O)0(P)18.1( TIPS )37.1(ARTICLE SERIES)]TJ ET EMC /Artifact <>BDC 0 0 0 .6 k .015015 806.78 595.29 1.417 re f EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 22.6772 14.3571 Tm 0 0 0 0 k [(BIF)55.2(A)55.2( is a Specialist Interest Group of ϳԹ )]TJ ET EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 191.2006 14.3571 Tm [(www)37.1(.bapen.org.uk )]TJ ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 22.6772 596.2451 Tm 0 0 0 .8 k [(Lisa Sharkey)74.2(, Jeremy Nightingale and the BIF)55.2(A)55.2( Committee)]TJ ET EMC /P <>BDC BT 6 0 0 6 510.4381 41.029 Tm (Continued over page...)Tj ET EMC Q endstream endobj 61 0 obj <>/ExtGState<>>> endobj 70 0 obj <> endobj 116 0 obj <>stream /Figure <>BDC q 1 i -16 794.836 625.344 -936.03 re 297.645 420.96 m W* n 0 841.89 595.276 -841.89 re 297.645 420.96 m W n .015015 841.89 595.29 -841.89 re W n /GS3 gs q 702.114 106.142 -80.977 535.654 11.868 -89.181 cm /Im1 Do Q EMC /P <>BDC Q q 1 i 0 841.89 595.276 -841.89 re 297.645 420.96 m W n .015015 841.89 595.29 -841.89 re W n /GS1 gs BT /TT2 1 Tf 8 0 0 8 22.6771 777.0668 Tm 0 0 0 .8 k 0 Tc 0 Tw (2. )Tj ET EMC /P <>BDC BT 8 0 0 8 31.7931 777.0668 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 777.0668 Tm (Non-invasive tests for diagnosing liver fibrosis have gained popularity )Tj ET EMC /P <>BDC BT 8 0 0 8 31.7931 764.9668 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 764.9668 Tm (in other aetiologies of liver disease, but none have been validated in )Tj ET EMC /P <>BDC BT 8 0 0 8 31.7931 752.8668 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 752.8668 Tm [(IF)55.2(ALD. )18.1(T)37.1(ransient elastography \(Fibroscan)]TJ ET EMC /P <>BDC BT 4.8 0 0 4.8 181.6407 755.1918 Tm ()Tj ET EMC /P <>BDC BT 8 0 0 8 185.1775 752.8668 Tm (\) in particular seems an )Tj ET EMC /P <>BDC BT 8 0 0 8 31.7931 740.7668 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 740.7668 Tm [(attractive method, but two studies have shown it is not reliable. )55.2(As the )]TJ ET EMC /P <>BDC BT 8 0 0 8 31.7931 728.6667 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 728.6667 Tm (elastography component on Fibroscan)Tj ET EMC /P <>BDC BT 4.8 0 0 4.8 170.0978 730.9918 Tm ()Tj ET EMC /P <>BDC BT 8 0 0 8 173.6345 728.6667 Tm [( relies on liver stif)18.1(fness, which )]TJ ET EMC /P <>BDC BT 8 0 0 8 31.7931 716.5668 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 716.5668 Tm (will be )Tj ET EMC /P <>BDC BT 8 0 0 8 58.6771 716.5668 Tm [(influenced by portal inflow)55.2(, it is perhaps not surprising that it is )]TJ ET EMC /P <>BDC BT 8 0 0 8 31.7931 704.4668 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 704.4668 Tm (unreliable in patients with intestinal failure, who do not have normal )Tj ET EMC /P <>BDC BT 8 0 0 8 31.7931 692.3668 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 692.3668 Tm (mesenteric/portal haemodynamics. )Tj ET EMC /P <>BDC BT 8 0 0 8 160.2931 692.3668 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 31.7931 674.5975 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 674.5975 Tm -.01 Tc (Certain biochemical panels have been proposed as non-invasive methods)Tj ET EMC /P <>BDC BT 8 0 0 8 290.4363 674.5975 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 31.7931 662.4975 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 662.4975 Tm [(to detect fibrosis, including FIB-4, ELF)110.8(, )55.2(APRI. )18.1(The FIB-4 \(Fibrosis-4\) )]TJ ET EMC /P <>BDC BT 8 0 0 8 31.7931 650.3975 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 650.3975 Tm [(index and )55.2(APRI have been shown to correlate with known IF)55.2(ALD risk )]TJ ET EMC /P <>BDC BT 8 0 0 8 31.7931 638.2975 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 638.2975 Tm (factors in very small studies, but no correlation with histology was made.)Tj ET EMC /P <>BDC BT 8 0 0 8 289.6837 638.2975 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 31.7931 626.1975 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 626.1975 Tm [(The only other method to show correlation with IF)55.2(ALD risk factors is the )]TJ ET EMC /P <>BDC BT 8 0 0 8 31.7931 614.0974 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 614.0974 Tm (LiMAX test, a dynamic test that measures metabolism of 13C labelled )Tj ET EMC /P <>BDC BT 8 0 0 8 31.7931 601.9975 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 601.9975 Tm (methacetin, but this measures liver functional capacity rather than the )Tj ET EMC /P <>BDC BT 8 0 0 8 31.7931 589.8974 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 589.8974 Tm [(degree of fibrosis. However)55.2(, it is useful in predicting outcome after liver )]TJ ET EMC /P <>BDC BT 8 0 0 8 31.7931 577.7975 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 577.7975 Tm (resection and may be worth further evaluation. )Tj ET EMC /P <>BDC BT 8 0 0 8 200.7736 577.7975 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 22.6771 559.9881 Tm -.015 Tc (3.)Tj ET EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 31.9131 559.9881 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 34.0157 559.9881 Tm -.005 Tc (Ultrashort bowel is defined as a residual small bowel length of 20 cm or )Tj ET EMC /P <>BDC BT 8 0 0 8 31.8331 547.8481 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 547.8481 Tm -.005 Tc [(less, from the duodeno-jejunal flexure to an end jejunostomy)74.2(. )18.1(These )]TJ ET EMC /P <>BDC BT 8 0 0 8 31.8331 535.7082 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 535.7082 Tm -.005 Tc [(patients are at particularly high risk for the development of IF)55.2(ALD. )18.1(The )]TJ ET EMC /P <>BDC BT 8 0 0 8 31.8331 523.5681 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 523.5681 Tm -.005 Tc (reasons for this are not completely understood, but these patients are )Tj ET EMC /P <>BDC BT 8 0 0 8 31.8331 511.4281 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 511.4281 Tm -.005 Tc (more likely to have high glucose and lipid content in their PN due to )Tj ET EMC /P <>BDC BT 8 0 0 8 31.8331 499.2882 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 499.2882 Tm -.005 Tc [(\(almost\) complete lack of enteral nutrition. )18.1(They also have minimal )]TJ ET EMC /P <>BDC BT 8 0 0 8 31.8331 487.1482 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 487.1482 Tm -.005 Tc [(portal venous inflow to the liver)55.2(, significant alterations/reductions in the )]TJ ET EMC /P <>BDC BT 8 0 0 8 31.8331 475.0082 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 475.0082 Tm -.005 Tc (microbiome and complete disruption of the enterohepatic circulation of )Tj ET EMC /P <>BDC BT 8 0 0 8 31.8331 462.8681 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 34.0157 462.8681 Tm -.005 Tc (bile salts, which may all influence the development of liver disease.)Tj ET EMC /P <>BDC BT 8 0 0 8 268.269 462.8681 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 270.4916 462.8681 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 303.5264 777.0668 Tm -.015 Tc (4.)Tj ET EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 312.7623 777.0668 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 314.865 777.0668 Tm [(Progression of fibrosis in ultrashort bowel can occur very quickly)74.2(. )]TJ ET EMC /P <>BDC BT 8 0 0 8 312.6423 765.4868 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.865 765.4868 Tm (Sequential biopsies can facilitate referral of the patient for intestinal )Tj ET EMC /P <>BDC BT 8 0 0 8 312.6423 753.9067 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.865 753.9067 Tm (transplant at the optimum time. From a purely histological perspective )Tj ET EMC /P <>BDC BT 8 0 0 8 312.6423 742.3268 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.865 742.3268 Tm (the best time to refer is when there is moderate fibrosis \(Ishak 3/4\), )Tj ET EMC /P <>BDC BT 8 0 0 8 312.6423 730.7468 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.865 730.7468 Tm (though there are other medical, surgical and psychological factors that )Tj ET EMC /P <>BDC BT 8 0 0 8 312.6423 719.1667 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.865 719.1667 Tm (must be considered in each individual patient. Early discussion with a )Tj ET EMC /P <>BDC BT 8 0 0 8 312.6423 707.5868 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.865 707.5868 Tm (transplant centre is always recommended. )Tj ET EMC /P <>BDC BT 8 0 0 8 466.9353 707.5868 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 303.5264 689.9175 Tm (5.)Tj ET EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 312.6423 689.9175 Tm ( )Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 314.865 689.9175 Tm [(A)55.2( small proportion of HPN patients will have co-existing liver disease )]TJ ET EMC /P <>BDC BT 8 0 0 8 312.6423 677.9175 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.865 677.9175 Tm [(or significant risk factors for other liver pathologies. )18.1(This may include )]TJ ET EMC /P <>BDC BT 8 0 0 8 312.6423 665.9175 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.865 665.9175 Tm (chronic viral hepatitis, biliary disease \(particularly those with underlying )Tj ET EMC /P <>BDC BT 8 0 0 8 312.6423 653.9175 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.865 653.9175 Tm (inflammatory bowel disease\) or autoimmune/metabolic liver disease. )Tj ET EMC /P <>BDC BT 8 0 0 8 312.6423 641.9175 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.865 641.9175 Tm (An under-recognised group is probably those patients with IF following )Tj ET EMC /P <>BDC BT 8 0 0 8 312.6423 629.9175 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.865 629.9175 Tm [(complications of bariatric surgery)74.2(, who may have a combination of )]TJ ET EMC /P <>BDC BT 8 0 0 8 312.6423 617.9175 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.865 617.9175 Tm [(IF)55.2(ALD and NAFLD. For these patients with a second hit)37.1( to the liver)55.2(, )]TJ ET EMC /P <>BDC BT 8 0 0 8 312.6423 605.9175 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.865 605.9175 Tm [(there should be a lower threshold for liver biopsy)74.2(.)]TJ ET EMC /P <>BDC BT 8 0 0 8 488.5877 605.9175 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 303.5264 588.2482 Tm (6.)Tj ET EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 312.6423 588.2482 Tm ( )Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 314.865 588.2482 Tm [(It has become apparent that for patients with pre-cirrhotic IF)55.2(ALD-related )]TJ ET EMC /P <>BDC BT 8 0 0 8 312.6423 576.2482 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.865 576.2482 Tm (fibrosis, an isolated intestinal transplant can halt progression or even )Tj ET EMC /P <>BDC BT 8 0 0 8 312.6423 564.2482 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.865 564.2482 Tm [(reverse the degree of fibrosis. )18.1(These transplants are technically easier)55.2(, )]TJ ET EMC /P <>BDC BT 8 0 0 8 312.6423 552.2482 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.865 552.2482 Tm [(associated with shorter lengths of stay)74.2(, fewer complications and greatly )]TJ ET EMC /P <>BDC BT 8 0 0 8 312.6423 540.2482 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.865 540.2482 Tm (improved survival compared to combined liver/intestine grafts. If we can )Tj ET EMC /P <>BDC BT 8 0 0 8 312.6423 528.2482 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.865 528.2482 Tm [(diagnose IF)55.2(ALD at these earlier stages, we can also save)37.1( a liver graft )]TJ ET EMC /P <>BDC BT 8 0 0 8 312.6423 516.2482 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.865 516.2482 Tm (for those waiting on the liver transplant list. )Tj ET EMC /P <>BDC BT 8 0 0 8 468.2751 516.2482 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 303.5264 498.579 Tm (7.)Tj ET EMC /P <>BDC BT 8 0 0 8 312.6423 498.579 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.865 498.579 Tm [(If a patient is at risk of IF)55.2(ALD, but initial biopsy shows very early disease )]TJ ET EMC /P <>BDC BT 8 0 0 8 312.6423 486.579 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.865 486.579 Tm (then a balance needs to be struck between too early a referral for )Tj ET EMC /P <>BDC BT 8 0 0 8 312.6423 474.579 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.865 474.579 Tm [(transplant and missing the boat. )18.1(These decisions are perhaps best )]TJ ET EMC /P <>BDC BT 8 0 0 8 312.6423 462.579 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 314.865 462.579 Tm [(made jointly)74.2(, by the IF team and the transplant centre.)]TJ ET EMC /P <>BDC BT /TT4 1 Tf 9 0 0 9 22.6772 814.1656 Tm 1 .15 0 0 k [(THE BRITISH INTESTINAL)18.1( F)55.2(AILURE )37.1(ALLIANCE \(BIF)55.2(A\) T)18.1(O)0(P)18.1( TIPS )37.1(ARTICLE SERIES)]TJ ET EMC /Artifact <>BDC 0 0 0 .6 k .015015 806.781 595.29 1.4171 re f EMC /Artifact <>BDC 1 .1 0 .1 k .015015 0 595.29 31.482 re f EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 22.6772 14.3583 Tm 0 0 0 0 k [(BIF)55.2(A)55.2( is a Specialist Interest Group of ϳԹ )]TJ ET EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 191.2007 14.3583 Tm [(www)37.1(.bapen.org.uk )]TJ ET EMC /Artifact <>BDC 0 0 0 .08 k 22.379 235.028 549.697 214.408 re f EMC /P <>BDC BT 9 0 0 9 37.8488 425.1717 Tm 1 .89 0 0 k (Suggested reading:)Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 145.8488 425.1717 Tm 0 0 0 .8 k ( )Tj ET EMC /P <>BDC BT 8 0 0 8 37.8488 413.1717 Tm ()Tj ET EMC /P <>BDC BT 8 0 0 8 46.3527 413.1717 Tm (Abu-Elmagd KM, Costa G, Bond GJ, et al. Five hundred intestinal and multivisceral transplantations at a single center: major ad)Tj 56.417 0 TD (vances with new )Tj ET EMC /P <>BDC BT 8 0 0 8 46.3527 401.1717 Tm [(challenges. )55.2(Ann Surg. 2009; 250\(4\): 567-581. )]TJ ET EMC /P <>BDC BT 8 0 0 8 210.0245 401.1717 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 37.8488 389.1717 Tm ()Tj ET EMC /P <>BDC BT 8 0 0 8 46.3527 389.1717 Tm (Appleton ND, Lal S, Carlson GL, et al. Cholelithiasis and Related Morbidity in Chronic Intestinal Failure: a Longitudinal Cohor)Tj 55.1957 0 TD (t Study from a )Tj ET EMC /P <>BDC BT 8 0 0 8 46.3527 377.1717 Tm (National Specialized Centre. J Gastrointest Surg. 2019; 23\(10\): 2002-2006.)Tj ET EMC /P <>BDC BT 8 0 0 8 312.7316 377.1717 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 37.8488 365.1717 Tm ()Tj ET EMC /P <>BDC BT 8 0 0 8 46.3527 365.1717 Tm [(Boyd )55.2(A, Cain O, Chauhan )55.2(A, W)18.1(ebb GJ. Medical liver biopsy: background, indications, procedure and histopathology)74.2(. Frontline Gast)]TJ 57.8843 0 TD (roenterol. )Tj ET EMC /P <>BDC BT 8 0 0 8 46.3527 353.1717 Tm [(2020; 1)74.2(1\(1\): 40-47. )]TJ ET EMC /P <>BDC BT 8 0 0 8 116.0284 353.1717 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 37.8488 341.1717 Tm ()Tj ET EMC /P <>BDC BT 8 0 0 8 46.3527 341.1717 Tm (Cazals-Hatem D, Billiauws L, Rautou P-E, et al. Ultra-short bowel is an independent risk factor for liver fibrosis in adults wi)Tj 53.9106 0 TD (th home parenteral )Tj ET EMC /P <>BDC BT 8 0 0 8 46.3527 329.1717 Tm (nutrition. Liver Int. 2018; 38\(1\): 174-182. )Tj ET EMC /P <>BDC BT 8 0 0 8 191.3292 329.1717 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 37.8488 317.1717 Tm ()Tj ET EMC /P <>BDC BT 8 0 0 8 46.3527 317.1717 Tm [(Nightingale JMD, Lennard-Jones JE, Gertner DJ, et al. Colonic preservation reduces the need for parenteral therapy)74.2(, increases t)]TJ 56.733 0 TD (he incidence of )Tj ET EMC /P <>BDC BT 8 0 0 8 46.3527 305.1717 Tm (renal stones but does not change the high prevalence of gallstones in patients with a short bowel. Gut 1992; 33: 1493-1497.)Tj ET EMC /P <>BDC BT 8 0 0 8 484.4268 305.1717 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 37.8488 293.1717 Tm ()Tj ET EMC /P <>BDC BT 8 0 0 8 46.3527 293.1717 Tm [(W)18.1(ong D and the BIF)55.2(A)55.2( Committee. )18.1(T)110.8(op )18.1(T)37.1(ips for Managing )55.2(Abnormal Liver Function )18.1(T)110.8(ests in Patients Receiving Parenteral Nutrition. )]TJ 57.8071 0 TD (2018; )Tj ET EMC /P <>BDC BT 8 0 0 8 46.3527 281.1717 Tm [(www)55.2(.bapen.org.uk/pdfs/bifa/bifa-top-tips-series-3.pdf)]TJ ET EMC /P <>BDC BT 8 0 0 8 233.1144 281.1717 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 37.8488 269.1717 Tm ()Tj ET EMC /P <>BDC BT 8 0 0 8 46.3527 269.1717 Tm [(W)18.1(oodward JM, Massey D, Sharkey L. )18.1(The Long and Short of IT)110.8(: intestinal failure-associated liver disease \(IF)55.2(ALD\) in adults rec)]TJ 56.6563 0 TD (ommendations )Tj ET EMC /P <>BDC BT 8 0 0 8 46.3527 257.1717 Tm [(for early diagnosis and intestinal transplantation. Frontline Gastroenterol. 2020; 1)74.2(1: 34-39.)]TJ ET EMC /P <>BDC BT 8 0 0 8 363.7278 257.1717 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 535.3522 14.3583 Tm 0 0 0 0 k (April 2021)Tj ET EMC Q endstream endobj 117 0 obj <>/XObject<>/ExtGState<>>> endobj 6 0 obj <> endobj 5 0 obj <> endobj 118 0 obj <>stream Adobed         #"""#''''''''''     !! !!''''''''''Z""  s!1AQa"q2B#R3b$r%C4Scs5D'6Tdt& EFVU(eufv7GWgw8HXhx)9IYiy*:JZjzm!1AQa"q2#BRbr3$4CS%cs5DT &6E'dtU7()󄔤euFVfvGWgw8HXhx9IYiy*:JZjz? a8թ8S@z@}x9$pT7ڥS?vlٛ؏g0hcL2׀1ٳZE~\[%>39>!V3ǖwwl乔i9)ӿ+?0@ V,MB 8#tTQTbi]^.NˏU<'͞X{K!er$v7 C$OԽ<Bf{;e_f?sp1k8d{u[TavhË?iAuqnuByMw:Y`)/1K004!iF}4i~,kM Ȟ`}V}gYw9TQce9[ڽ΋#'͏q\v&I8P:mw.-E #E|wgFr2"I>g6lٳfȫf͛6lثf͛6lثf͛6lثf͛6lثf͛6lثf͛6lثf͛6lثf͛6lثf͛6lثf͛6lثf͛6lثf͛6lثf͛6lثf͛6lثf͛6lثf͛6lثf͛6lثf͛6lثf͛6lثf͛6lثf͛6lثf͛6lثf͋Zmn"TŜHۉG2礿.ð%ck۠!AN'SOfj-p)4 DZ;ٚ-FO\Y!2CzC|fny&-%}:pO¸[q y0vVbr~0*ϺiIBkv>h:zkv&{եfKKWh.2 q>`Ȏxf3)/8㇔S $ ToR(O|!iTy['+7G=)O~b{<[ep-_*Pv*~y˳`OFYc7hbxuG9O$L%d8d*6j6lٳdٳf͛6lUٳf͛6lUٳf͛6lUٳf͛>U\ٳf͛(uvlٲd~m>H.Xਪ/O>"_ffY.wWJ)mٛN$Ҽ;I,^Iff5,I9{ 7M@C|q>Sc0^mJ][[kveTtHl;g˓,,s&R#̒ylٳf͛+Wf͛6lٱWf͛6ls*7?Uto\P;i_DOpϒ8cYaG#r͛, 6.K6H FFUsWq>^p37S=#Gt?->Zc?wC$݉?qzCy +YiLgH0heL|a58`|ϪϬ3;>q f˗&\˖Fs))JG'$f͛6lZ6lٳf͊6lٳf͊6lٳf͊6lٳf͊6lٳf͊6lٳf͊6lٳf͊6lٳf͊6lٳf͊6lٳf͊6lٳf͊6lٳf͊6lٳf͊6lٳf͊6lٳf͊6lٳf͊6lٳf͊6lٳf͊6lٳf͊6lٳf͊6lٳf͊6lٳf͊6lٳf͊6lٳf͊6l;GQմnqJ T; 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