Updates in Hospital Medicine: Liver Disease - update 1 - Nutritional emphasis to improve outcomes

Sep 29, 2026

Uploaded by dhado

Hospital Medicine article updates focus on nutrition in liver disease, emphasizing that malnutrition is common and linked to worse outcomes such as morbidity, mortality, longer hospital stays, and higher perioperative transplant complications. It highlights sarcopenia, especially in alcohol-associated liver disease and alcohol-associated hepatitis, driven by inadequate protein intake and inflammatory muscle catabolism. New ACG guidance calls for assessing malnutrition in all patients, promoting early enteral or oral nutrition, avoiding fasting beyond 12 hours, and discouraging protein restriction in cirrhosis.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages5

Reading Time13 min

AccessFree to download

update 1

Nutrition assessment and malnutrition risk

ACG guidance for hospitalized cirrhosis

Protein strategy and encephalopathy considerations

Practical feeding and meal recommendations

update 2

Alcohol-associated hepatitis overview

Corticosteroid tapering and infection risk

Updates in Hospital Medicine Updates in Hospital Medicine: Liver Disease Alessandra Daskalakis, MD1,2, Matthew Clark, DO1,2,3, Lesley B. Gordon, MD, MS1,2,3 1 Internal Medicine Residency, Department of Medicine, MaineHealth Maine Medical Center, 2 Tufts University School of Medicine, 3 Division of Hospital Medicine, Department of Medicine, MaineHealth Maine Medical Center Journal of Brown Hospital Medicine Vol. 5, Issue 1, 2025 Article Information Keywords: Hospital Medicine, Liver Disease, Cirrhosis, Alcohol-associated Hepatitis [https://doi.org/10.56305/001c.154454](https://doi.org/10.56305/001c.154454) Submitted: November 17, 2025 EST Accepted: December 15, 2025 EST Published: January 01, 2026 EST update 1 A call for increased emphasis on nutrition to improve outcomes in patients with liver disease Malnutrition in patients with liver disease is common and associated with worse outcomes, including morbidity, mortality, length of stay and increased perioperative transplant complications.1‑3 Sarcopenia is an important feature of liver disease-related malnutrition, and can coexist with calorie excess or volume overload across a spectrum of malnutrition phenotypes. The risk of malnutrition is greatest in patients with alcohol-associated liver disease and alcohol-associated hepatitis whose muscle loss is driven by inadequate protein intake and inflammatory muscle catabolism.1‑5 Historically, guidance for nutrition in liver disease has been limited by patient complexity anda lack of large, randomized trials, with many active recommendations informed by past research on nutrition in critically ill patients who may not have liver disease. This remains true, although there are ongoing efforts to close these gaps in knowledge. Recent guidelines by the American College of Gastroenterology (ACG) aim to address the unique challenges in managing malnutrition in patients with liver disease, informed by the most recent evidence.6 The new ACG guidelines emphasize the importance of assessing malnutrition in all patients with liver disease.6 The authors, who were selected by ACG given content expertise, propose a series of guideline recommendations based upon literature review (prioritizing systematic reviews and meta-analyses, followed by randomized con- trol trials when available) and key concept statements based on expert opinion. These recommendations span both outpatient and inpatient management, but for the purposes of this review, the focus will be on inpatient. ACG recommends that hospitalized patients with cirrhosis receive early enteral or oral nutrition. Prolonged fasting of more than 12 hours can lead to gluconeogenesis and muscle wasting and should thus be avoided. Latenight snacks should be encouraged. Notably, dietary protein restrictions in patients with cirrhosis are no longer recommended. More recent studies suggest that limiting protein intake may result in increased muscle wasting and relatively greater ammonia production compared to protein-restricted diets, thereby increasing the risk of hepatic encephalopathy (HE). While theACG does not set a protein target, recent American Association for the Study of Liver Diseases (AASLD) guidelines specify that protein goals for critically ill patients with cirrhosis should bethe same as for patients without cirrhosis: 1.2-2.0 grams of protein per kilograms of ideal body weight.7 Furthermore, multidisciplinary collaboration, including early consultation of nutrition teams, improves outcomes.7 When possible, ACG recommends supplementing with vegetarian sources of protein for patients experiencing HE. Vegetarian sources of protein have higher arginine and fiber content, facilitating increased urea production and an acidic colonic environment, respectively. These effects result in lower ammonia levels than in diets high in animal protein. For patients with ascites and diuretic use, there is unclear benefit to sodium restricted diets (ACG could not rec

FAQs

Why is nutrition emphasized in hospitalized patients with liver disease?

Malnutrition is common in liver disease and is associated with worse outcomes, including increased morbidity and mortality, longer length of stay, and higher perioperative transplant complications.

What does ACG recommend regarding fasting and feeding in cirrhosis?

Prolonged fasting over 12 hours should be avoided because it can lead to gluconeogenesis and muscle wasting, and late-night snacks are encouraged. ACG recommends early enteral or oral nutrition.

Does ACG recommend protein restriction for patients with cirrhosis?

No. Dietary protein restrictions in cirrhosis are no longer recommended, and evidence suggests restricting protein may increase muscle wasting and ammonia production, raising the risk of hepatic encephalopathy.

Sep 29, 2026

Uploaded by dhado