Cholecystitis & Cholelithiasis

• The gallbladder is a sac under the liver that concentrates, stores, and excretes bile.
• Bile is an alkaline emulsifier composed of bile acids (bile salts), cholesterol, bilirubin (bile pigments), phospholipids (lecithin), bicarbonate, water, and other components.
• Bile salts, made by liver cells from cholesterol, are essential for the digestion and absorption of fats, fat-soluble vitamins, and some minerals.

Cholecystitis & Cholelithiasis

• Cholecystitis is the inflammation of the gallbladder, often a complication of gallstones (choleliths).
• A high-fiber, low-fat, plant-based diet is recommended to prevent gallbladder contractions.
• Cholelithiasis is the formation of gallstones.
• Risk factors for cholelithiasis include being overweight, over forty, female, fertile (increased estrogen), and having fair skin.
• Complications of cholelithiasis include cholecystitis, cholangitis (inflammation of bile ducts), malabsorption of lipids, light-colored stools, jaundice, liver damage, and pancreatitis.
• Management includes cholecystectomy (removal of gallbladder) or chemically dissolving stones.
• For the acute phase, a low-fat diet (30-45 g/day) is recommended, potentially with PN or a hydrolyzed low-fat formula.
• For the chronic phase, a long-term low-fat diet containing 25-30% of total kcal as fat is advised.
• Replace saturated fats with fish oils and PUFAs.
• Water-soluble forms of fat-soluble vitamins may be necessary.

Alcoholic Liver Disease (ALD)

• ALD causes fatty liver (hepatic steatosis) and can lead to more serious liver conditions like cirrhosis.
• Risk factors include alcohol consumption (duration and intake), genes, gender, drugs, viral infection, obesity, and poor nutrition status.

ALD Stages

• Hepatic steatosis (fatty liver) is reversible with abstinence from alcohol. Symptoms: fatigue, poor appetite, right upper quadrant discomfort, hepatomegaly.
• Alcoholic hepatitis symptoms include abdominal pain, anorexia, NV, weakness, diarrhea, weight loss, fever, jaundice, ascites, hepatomegaly, and encephalopathy.
• Cirrhosis involves scarring of the liver, which interferes with liver functions. Symptoms: GI bleeding, hepatic encephalopathy, portal hypertension, ascites, easy bruising.
• Dietary management goals include initial abstinence from alcohol, treatment of withdrawal symptoms, prevention of malnutrition, and fluid and sodium restrictions to manage ascites. Key vitamin deficiencies often seen in chronic alcoholics include thiamin, folic acid, riboflavin, B6, B12, vitamin C, fat-soluble vitamins (A, D, E, K), iron, magnesium, selenium, and zinc.

Nonalcoholic Fatty Liver Disease (NAFLD)

• NAFLD includes a spectrum of liver diseases from steatosis (NAFLD) to nonalcoholic steatohepatitis (NASH), fibrosis, and cirrhosis.
• Fructose, high fructose corn syrup, high-fat diets, and the gut microbiome are considerations.
• Weight management, physical activity, and avoiding alcohol are recommended.
• A Mediterranean diet (low fat, low sugar, high fiber/prebiotic) is recommended.
• Nutrient supplementation may include vitamin A, vitamin E, vitamin C, zinc, and copper.

Cirrhosis

• Cirrhosis is the build-up of scar tissue and fibrosis of the liver.
• Symptoms include fatigue, weakness, nausea, poor appetite, weight loss, itchy skin, and abdominal pain.
• Also jaundice, dark urine, light stool, steatorrhea, easy bruising, swelling (edema, ascites), internal bleeding (varices) as symptoms.

Risk Factors

• Chronic hepatitis C virus (HCV) and alcoholism are risk factors.

General MNT Considerations

• Prevent further damage and complications, treating underlying causes. Liver transplant may be necessary.
• Manage other chronic conditions like obesity and diabetes.
• Provide adequate energy and nutrient intake, maximizing oral intake and correcting micronutrient deficiencies.
• For the non-overweight: 30-35 kcal/kg, 1.2-1.5 g protein/kg (do not restrict protein).
• For the obese: 25 kcal/kg IBW (moderate calorie restriction), 2-2.5 g/kg protein.
• Micronutrients of consideration include A, D, K, zinc, selenium, thiamin, folate.
• Consider oral nutritional supplements (ONS) or EN/PN as needed.
• Have small, frequent meals, including a late-evening snack, and spread CHO among multiple meals throughout the day.

Major Complications and Nutritional Management of Complications

• Portal hypertension is elevated blood pressure in the portal venous system due to obstruction of blood flow through the liver, potentially causing varices.
• PN is indicated if the patient is NPO for at least 5-7 days.
• Hepatic encephalopathy is a brain disorder caused by chronic liver failure, particularly in alcoholics with cirrhosis, leading to cognitive, psychiatric, and motor impairments.
• Management includes medications to reduce ammonia (lactulose, antibiotics, L-ornithine and L-aspartate), supplements (BCAAs, prebiotics, zinc), and limiting protein intake (1.2-1.5 g protein/kg dry weight).
• Ascites is the accumulation of fluid within the peritoneal cavity, causing swelling of the abdomen, weight gain, a sense of fullness, NV, SOB, and hyponatremia.
• Management involves diuretics, paracentesis, TIPS, and portal hypertension meds.
• Furosemide and spironolactone are diuretics used.
• Paracentesis= withdrawal of fluid from abdomen via a catheter.
• TIPS= transjugular intrahepatic portosystemic shunt (performed by a radiologist).
• Nutrition considerations include fluid and sodium restrictions.