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Patients with intestinal failure (IF) and home parenteral nutrition commonly develop abnormal liver function tests. The presentations of IFassociated liver disease (IFALD) range from mild cholestasis or steatosis to cirrhosis and decompensated liver disease. We describe the reversal of IFALD in an adult patient with IF secondary to severe Crohn's disease and multiple small bowel resections. The patient developed liver dysfunction and pathology consistent with IFALD. Multiple causal factors were implicated, including nutrition-related factors, catheter sepsis and the use of hepatotoxic medications. Multidisciplinary treatment in a tertiary IF referral centre included aggressive sepsis management, discontinuation of hepatotoxic medications and a reduction of parenteral nutrition dependency through optimisation of enteral nutrition via distal enteral tube feeding. Upon this, liver function tests normalised. [ABSTRACT FROM AUTHOR]

Problem In 2010, there was a significant waiting list for admission to the intestinal failure unit (IFU) at the Salford Royal National Health Service (NHS) Foundation Trust. There had been a steady increase in the number of new patients referred to the IFU (89 patients 2005; 152 patients 2012) and the number of established patients requiring home parenteral nutrition (HPN) (135 patients 2005; 206 patients 2012) over the last decade. The impact of the resulting long waiting list for these complex patients was that patient deaths occurred in those awaiting admission. Design Continuous improvement methodology using the model for improvement and sequential plan--do--study--act cycles. Setting Salford Royal NHS Foundation Trust IFU; a large NHS teaching hospital in Northwest England. Key measures for improvement The primary outcome measures were inpatient length of stay and time spent on waiting list prior to admission. Strategies for change Acontinuous improvement programme, supported by a project manager. Results There has been a 21%-reduction in average length of stay on the IFU from 55.7 to 44.0 days and a reduction of 72%in the average length of time new patients spent on the waiting list for admission from 65.7 to 18.5 days. These changes were associated with concomitant reduction in 30-day readmission rate from 12.1% to 4.5%and early suggestions of reduced inpatient and waiting list mortality. Conclusions It is possible to improve the efficiency of a large national service for complex patients using quality improvement methodology, resulting in improved access and reduced waiting list mortality. [ABSTRACT FROM AUTHOR]