Lecture 9: Medical Nutrition Therapy in Liver, Pancreas, and Gallbladder Disorders PDF

Lecture 9 – Medical Nutrition Therapy in Liver, Pancreas and Gallbladder diseases Mrs. Kristia Lei A. Reyes, RND, MSCN ND 303-Nutrition Therapy 1  Diseases of the Liver Fatty liver Hepatitis Cirrhosis Hepatic coma  Accumulation of triglycerides in liver 1)...

Lecture 9 – Medical Nutrition Therapy in Liver, Pancreas and Gallbladder diseases Mrs. Kristia Lei A. Reyes, RND, MSCN ND 303-Nutrition Therapy 1  Diseases of the Liver Fatty liver Hepatitis Cirrhosis Hepatic coma  Accumulation of triglycerides in liver 1) Fatty liver Also called “hepatic steatosis” Failure of the liver to metabolize fat due to inflammation, hepatic injury or poor fat transport, insulin resistance, & increased fat synthesis Accounts for an increase of 5-40% of the body weight Insulin resistance and fatty liver  Dietary Management Diet Rationale High protein To synthesize lipotropic factors High kcal for underweight To spare protein Low calorie for the obese To control fat synthesis Control blood glucose if To control insulin resistance related with insulin resistance Lipotropic factors - substances that have the ability to remove and prevent fatty deposits in the body. These nutrients essentially perform the task of breaking down and transporting fat from the liver. Lipotropic factors are important because they can help the liver function better as well as get rid of toxins. Examples are choline, carnitine and inositol.  2) Hepatitis Inflammation of the liver caused by alcohol, infection, parasites, drugs and some supplements Symptoms: – Jaundice – Weight loss – Fatigue – Abdominal pain – Discomfort  Causes of Hepatitis Infectious – Viral, bacterial, fungal, parasitic Noninfectious – Alcohol, drugs, autoimmune, metabolic disease Drugs such as acetaminophen and antidepressants Hepatitis Viruses  Dietary Management Diet Rationale IVF To replenish losses High kcal To provide energy High protein To regenerate liver cells at early stage High carbohydrate To spare protein Low Fat; MCT If there is steatorrhea ADEK supplementation Poor absorption due to low fat diets and poor storage Fe supplementation Inability to store iron Vit. B-complex supplementation For energy metabolism Vit and Min supplementation For replacement of losses, faster wound healing Low sodium In case of ascites Small frequent feeding For better tolerance Progressive diet from clear to normal For better tolerance  3) Liver Cirrhosis Chronic inflammation of the liver replaced with fibrous tissues Complications: – Portal hypertension – increased blood pressure due to obstructed blood flow to the liver – Ascites – accumulation of fluids in the abdominal cavity – Esophageal varices – distended blood vessels due to obstruction – Collateral formation – blood vessels that develop when the blood flow to the liver is obstructed – Hyperammonemia – elevated ammonia in the blood  Liver cirrhosis  Etiology of Liver cirrhosis Alcohol Hepatitis Biliary stasis - condition where bile cannot flow from the liver to the duodenum Toxins  Types of Liver Cirrhosis Postnecrotic – complication of hepatitis Nonalcoholic Laennec’s - if induced by alcohol Biliary cirrhosis – diseases of the bile duct Obstructive cirrhosis – obstruction of the bile duct Cardiac cirrhosis – complication of heart failure Toxic – exposure to chemicals, poisons Inborn error or metabolic – eg. Wilson’s disease, hemochromatosis Idiopathic – when causes are unknown  Diet Rationale High kcal To provide energy High protein To regenerate liver cells, supply lipotropic factors Low protein To prevent nitrogen retention High carbohydrate To spare protein Low Fat; MCT If there is steatorrhea Low sodium, fluid restricted To prevent water retention Low fiber To prevent irritation Liquid diet To prevent irritation of the varices Fe supplementation Inability to store iron Vit. B complex supplementation For energy metabolism Vit and Min Supplementation For replacement of losses, faster wound healing Small frequent feeding For better tolerance Progressive diet from clear to normal For better tolerance  4) Hepatic coma Also called portal systemic encephalopathy Liver malfunction characterized by confusion, apathy and neurological dysfunction, fecal odor of breath, flapping tremor (allows the muscles to flap like wings), anemia and hepatorenal syndrome – The combined symptoms of renal and liver failure; it may develop as a result of severe cirrhosis  Etiology of Hepatic Coma Severe liver damage marked by accumulation of ammonia in blood due to inability of the liver to convert ammonia to urea  Other theories Increased production of gamma amino butyric acid Accumulation of aromatic amino acids, which causes synthesis of more neurotransmitters  Dietary Management Diet Rationale High kcal To provide energy Zero to low protein To prevent accumulation of nitrogenous wastes Branched chain amino acids Not catabolized in the liver (leucine, isoleucine, valine) K supplementation To lessen renal ammonia production  Other info! As a general rule for liver disorders, proteins are restricted only to those who are protein sensitive Calcium, magnesium and vit. D deficiencies need to be controlled because of steatorrhea losses and inability to release vit. D for activation. Zinc losses are also associated with liver disease  Diseases of the Pancreas Pancreatitis Cystic fibrosis  1) Pancreatitis Inflammation of the pancreatic tissues due to inadequate supply of blood or obstruction to the flow of pancreatic juices Etiology: – alcohol, biliary obstruction and inflammation Symptoms: – abdominal pain, nausea, vomiting, abdominal distention  Management A. Medical – anti-infective drugs and surgery B. Dietary: Diet Rationale NPO To prevent irritation Enzyme replacement Failure of the pancreas to release digestive juices Low fat In case of bile destruction Avoid stimulants To prevent irritation  2) Cystic fibrosis Rare genetic disease Accumulation of mucus in the bronchi, pancreas, liver and intestines, causing damage and malfunction of the organs and biliary cirrhosis Characteristics – circulatory collapse, excessive perspiratory losses, biliary cirrhosis, pulmonary damage, intestinal obstruction, salt depletion  Dietary Management Diet Rationale High kcal, high protein To meet nutrient requirements Low fat; MCT To favor fat absorption Vit and Min supplementation To replace losses Enzyme replacement To provide deficient enzymes Pancreatin replacement To provide deficient enzymes Sodium or salt supplements May be necessary for electrolyte replacement  Diseases of the Gallbladder Inflammation of gallbladder/ Gallstones Biliary dyskinesia Jaundice  Gallbladder Concentrates and stores bile produced by the liver until the bile is needed for fat digestion Disorders that obstruct the liver’s release of bile can damage the liver. Disorders of the biliary system—the gallbladder and bile ducts—result in the formation of gallstones  Definition Cholecystitis – inflammation of the gallbladder Cholelithiasis – presence or formation of gallstones in the gallbladder or bile ducts Cholecystolithiasis – presence of one or more gallstones in the gallbladder Choledocholithiasis – occurrence of stone in biliary tree (cystic duct, hepatic duct, common bile duct) Cholangitis – inflammation of the bile ducts  Etiology Infection Overweight Pregnancy Constipation Low gallbladder movement Hypocholesterolemic drugs Hemolytic disorders  Characteristics Epigastric pain radiating to the shoulder, impaired fat digestion, jaundice, abdominal distention, and fever  Types of Gallstones 80% of the cases Cholesterol the cholesterol in bile precipitates out of solution and forms small crystals, which eventually combine to form stones Gallstones the bile concentrate thickens and forms a sludge that cannot be easily expelled by gallbladder contraction 10 to 25% of cases primarily made up of the calcium salt of bilirubin (calcium Pigment bilirubinate) result of bacterial infection, which alters bilirubin and causes it to precipitate out of bile and form stones Gallstones Others: result from excessive red blood cell breakdown, leading to an abnormal accumulation of bilirubin soft and easily crushed  Risk Factors of Gallstones Pima Indians are an exceptionally high-risk population; Ethnicity Native Americans in the United States and Canada, Scandinavians, Chileans, and Bolivians. Aging the cholesterol concentration increases while bile acids decrease, Gender estrogen alters cholesterol metabolism and causes an increased secretion of cholesterol into bile in women Due to hormonal changes: higher serum estrogen levels Pregnancy increase the secretion of cholesterol into bile, and higher progesterone levels impair gallbladder motility  Risk Factors of Gallstones Obesity and Weight Loss increased cholesterol synthesis in the liver Long-term total parenteral reduces gallbladder motility, increasing nutrition the development of biliary sludge Some medications Octreotide, clofibrate, (used for heart disease) High triglyceride levels in blood and Hyperinsulinemia, insulin Increase crystallization resistance, and DM  Management A. Medical – surgery, drugs to dissolve stones B. Dietary: Diet Rationale NPO, IVF For better tolerance Progressive diets For better tolerance Low fat To alleviate pain Low calorie if obese To prevent cholesterol secretion and bile excretion Treatment of Gallstones  2) Biliary Dyskinesia Abnormal bile flow due to increased (spastic) or decreased contraction of the gallbladder (atonic) Dietary Management: Diet Rationale Low fat for spastic To rest the organ High fat for atonic To stimulate bile acid secretion  3) Jaundice Yellow discoloration of the eyes and skin due to overflow of bile into general circulation Types: – Hepatic – obstruction – Hemolytic – rapid breakdown of bilirubin – Infectious – impaired excretion Dietary Management for Jaundice If infectious – high protein, kcal adequate to maintain DBW, low fat If obstructive – same as choledocholithiasis If hemolytic – vit. E supplementation, to eliminate the causes of hemolysis Thank you!