Applied Nutrition Diseases of the Liver, Gall Bladder, and Pancreas Group 3 Amir Bagheri Shila Lacia Christine Roque
The Liver <ul><li>Anatomical information about the liver: </li></ul><ul><li>- It is the largest gland in the body. </li></...
Our Discussion of the the Liver Will Touch On: <ul><li>1. Its centrality as a metabolic organ </li></ul><ul><li>2. Its fun...
The Liver’s Centrality as a Metabolic Organ <ul><li>The liver metabolizes: </li></ul><ul><li>Carbohydrates </li></ul><ul><...
The Liver’s Role in Carbohydrate Metabolism <ul><li>Glucogenesis, which is conversion of glucose to glycogen, which is a r...
The Liver’s Role in Protein  Metabolism <ul><li>It synthesizes almost all plasma proteins. </li></ul><ul><li>It deaminates...
The Liver’s Function in Lipid & Fat Metabolism <ul><li>1. It synthesizes triacylglycerols from fatty acids and phospholipi...
The Liver’s Function in Relation to Minerals and Vitamins <ul><li>1. It stores iron and copper for hemoglobin synthesis </...
The Liver Manufactures the Following Vital Substances: <ul><li>a. Bile </li></ul><ul><li>b. Prothrombin </li></ul><ul><li>...
The Liver Regulates the Following Bodily Processes: <ul><li>Detoxification (e.g., ammonia to urea) </li></ul><ul><li>Blood...
The Liver Stores the Following: <ul><li>Protein </li></ul><ul><li>Glycogen </li></ul>
Diseases of the Liver <ul><li>Hepatitis is the Latin term for liver inflammation. Types of hepatitis include A, B, C, D, E...
Hepatitis A <ul><li>Is an infectious hepatitis </li></ul><ul><li>Its mode of transmission is fecal-oral </li></ul><ul><li>...
Hepatitis B <ul><li>Is a serum hepatitis. </li></ul><ul><li>Its modes of transmission include blood & other body fluids, s...
Hepatitis C <ul><li>Is a post-transfusion hepatitis </li></ul><ul><li>Its modes of transmission include parenteral-acquisi...
Hepatitis D <ul><li>Is classified as Hepatitis Delta virus. </li></ul><ul><li>Its mode of transmission is similar to Hepat...
Hepatitis E <ul><li>Is an enteric or epidemic hepatitis </li></ul><ul><li>Its mode of transmission is fecal-oral </li></ul...
Hepatitis G <ul><li>Is a flavivirus similar to HCV. </li></ul><ul><li>Its mode of transmission is via contaminated blood a...
Signs and Symptoms <ul><li>Acute hepatitis varies considerably from person to person: </li></ul><ul><li>- It can be asympt...
Dietary Management <ul><li>There is no medical treatment available for acute hepatitis, so nutrition is the key to recover...
Dietary  Management <ul><li>A moderate intake of fat: </li></ul><ul><li>- Provides calorie without bulk </li></ul><ul><li>...
Things To Avoid <ul><li>1. Additives, colorants, and preservatives. </li></ul><ul><li>2. Alcohol: </li></ul><ul><li>- Its ...
Cirrhosis <ul><li>Widespread dysfunction of normal hepatic structure can take place via fibrosis, fatty changes, and the f...
Signs and Symptoms of Cirrhosis <ul><li>GIT disturbances include: </li></ul><ul><li>- Anorexia, nausea, vomiting, RUQ pain...
Complications of Cirrhosis <ul><li>Ascites and edema </li></ul><ul><li>Spontaneous bacterial peritonitis </li></ul><ul><li...
Diet Therapy Guidelines <ul><li>High carbohydrates intake </li></ul><ul><li>High protein intake </li></ul><ul><li>Moderate...
High Carbohydrate Intake <ul><li>Provides calories and spares proteins. </li></ul><ul><li>Supports hepatic function. </li>...
High Protein Intake <ul><li>Helps correct negative nitrogen balance. </li></ul><ul><li>Increases activity of Cytochrome p4...
Moderate Fat Intake <ul><li>Provides calories and spares protein. </li></ul><ul><li>Supports hepatic function. </li></ul><...
High Vitamin Supplements <ul><li>They fortify fatty deposition in the liver. </li></ul><ul><li>They include fat soluble vi...
Sodium & Fiber Restriction <ul><li>Sodium is restricted to 250 to 1000 mg per day to ameliorate ascites and edema. </li></...
Hepatic Coma <ul><li>A complex syndrome characterized by neurological manifestations as a complication of severe hepatitis...
Mechanism of Hepatic Coma <ul><ul><li>Ammonia-laden blood enters the cerebral circulation </li></ul></ul><ul><ul><li>This ...
Signs and Symptoms <ul><li>Signs and symptoms of impending coma include: </li></ul><ul><li>- confusion </li></ul><ul><li>-...
Dietary Management <ul><li>Goals include: </li></ul><ul><li>- Maintenance of adequate nutrition. </li></ul><ul><li>- Preve...
Dietary Therapy <ul><li>1. Calorie intake should be 1500 to 2000 calories – just enough to prevent tissue breakdown, which...
Dietary Therapy <ul><li>3. Carbs and fatty acids are ingested to prevent tissue breakdown. </li></ul><ul><li>4. Fluid inta...
Dietary Therapy <ul><li>Dietary limitations include: </li></ul><ul><li>*Vegetables: high-protein legumes </li></ul><ul><li...
Cholecystitis <ul><li>Is inflammation of the gallbladder arising from a low grade chronic infection in areas of the body s...
Etiology of Cholecystitis <ul><li>Cystic duct obstruction due to a stone normally leads to acute inflammation of the gallb...
Bacterial Inflammation in Cholecystitis <ul><li>*Agents of bacterial inflammation include: </li></ul><ul><li>- Escherichia...
<ul><li>Predisposing factors include: </li></ul><ul><li>- Familial hypercholesterolemia </li></ul><ul><li>- Diabetes Melli...
<ul><li>Precipitating Factors </li></ul><ul><li>- Adenocarcinoma of the gallbladder </li></ul><ul><li>- Cholelithiasis </l...
Clinical Manifestations <ul><li>Signs and Symptoms include: </li></ul><ul><li>Right upper quadrant rebound tenderness. </l...
Triad  of  Onset <ul><li>RUQ rebound tenderness </li></ul><ul><li>Low grade fever </li></ul><ul><li>Leukocytosis </li></ul>
<ul><li>Medical Management </li></ul><ul><li>- The analgesic Meperidine Hydrochloride (Demerol) can be administered to adu...
<ul><li>Surgical Management </li></ul><ul><li>-Cholecystectomy </li></ul>
Dietary   Management <ul><li>-Fat restriction in chronic cholecystitis is called for, because fat simulates  gallbladder c...
GALL STONES <ul><li>Gall stones are crystalline structure formed by concretion or accretion of normal or abnormal bile con...
GALL STONES <ul><li>-Cholelithiasis is the formation of gallstones in the gallbladder. No symptoms may arise, so the patie...
GALL STONES <ul><li>Choledocholiathiasis develops when stones slip into the common bile duct, obstructing bile flow and ca...
<ul><li>Composition of Stones </li></ul><ul><li>Cholesterol and mixed stones are composed of: </li></ul><ul><li>-Bile acid...
<ul><ul><li>Dietary Management </li></ul></ul><ul><li>- Same as cholecystitis </li></ul><ul><li>Surgical Management </li><...
The Pancreas <ul><li>The pancreas is both an exocrine and endocrine organ, but our focus will be limited to its exocrine a...
<ul><li>Pancreatitis </li></ul><ul><li>Pancreatitis is inflammation of the pancreas characterized by edema, cellular exuda...
<ul><li>Etiology:  </li></ul><ul><li>  -Unknown </li></ul><ul><li>Causes: </li></ul><ul><li>-Chronic alcoholism </li></ul>...
<ul><li>-Alcohol causes duodentitis and edema of the papilla of Vater, where the common bile duct opens into duodenum and ...
<ul><li>-It is also possible that alcohol exerts a direct cytotoxic effect on  the pancreas by causing  excessive precipit...
<ul><li>Dietary Management </li></ul><ul><li>-  For acute attack,  cease oral ingestion;  after a few days, if amylase is ...
<ul><li>-A  low fat,  bland diet is recommended.  About 30 to 60 grams of fat per day will be tolerated. Fat soluble vitam...
With chronic pancreatitis, digestion – especially of fat – is permanently impaired.  A special diet is required for the sa...
Dietary Aims: <ul><li>To alleviate pain. </li></ul><ul><li>To prevent further damage to the pancreas. </li></ul><ul><li>To...
<ul><li>Proteins and fats should be avoided; carbohydrates are preferred. </li></ul><ul><li>Specific treatment of pancreat...
Alcohol is prohibited as it acts as an intestinal irritant and encourages recurrence of pancreatitis <ul><li>For acute att...
<ul><li>Thanks For Listening! </li></ul><ul><li>In loving memory of Dr. Nico. </li></ul>
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Applied nutrition 3 rd presentation - diseases of liver, gall bladder, and pancreas

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Applied nutrition 3 rd presentation - diseases of liver, gall bladder, and pancreas

  1. 1. Applied Nutrition Diseases of the Liver, Gall Bladder, and Pancreas Group 3 Amir Bagheri Shila Lacia Christine Roque
  2. 2. The Liver <ul><li>Anatomical information about the liver: </li></ul><ul><li>- It is the largest gland in the body. </li></ul><ul><li>- The normal weight of the liver constitutes about 2% of the body’s weight. </li></ul><ul><li>‧ It has a mass of 1.4 to 1.8 kilograms in males. </li></ul><ul><li>‧ It has a mass of 1.2 to 1.4 kilograms in females. </li></ul><ul><li>‧ The liver has four lobes: </li></ul><ul><li>1. Right lobe </li></ul><ul><li>2. Left lobe </li></ul><ul><li>3. Caudate lobe </li></ul><ul><li>4. Quadrate lobe </li></ul><ul><li>The anatomical division of the liver is based on attachment of the falciform ligament; this is convenient but serves no useful purpose insofar as it follows no embryological separation. </li></ul><ul><li>The physiological division of the liver is a deep lobar fissure posteriorly in line with the fossa for the gall bladder and fossa for the inferior vena cava. </li></ul>
  3. 3. Our Discussion of the the Liver Will Touch On: <ul><li>1. Its centrality as a metabolic organ </li></ul><ul><li>2. Its function in relation to minerals and vitamins </li></ul><ul><li>3. Its role as a manufacturer of vitamins </li></ul><ul><li>4. How it regulates body processes </li></ul><ul><li>5. Its storage function </li></ul>
  4. 4. The Liver’s Centrality as a Metabolic Organ <ul><li>The liver metabolizes: </li></ul><ul><li>Carbohydrates </li></ul><ul><li>Protein </li></ul><ul><li>Lipids and Fats </li></ul><ul><li>Vitamins </li></ul><ul><li>Minerals </li></ul>
  5. 5. The Liver’s Role in Carbohydrate Metabolism <ul><li>Glucogenesis, which is conversion of glucose to glycogen, which is a reserve form of energy. </li></ul><ul><li>Gluconeogenesis, which is conversion of glycogen to non-carbohydrate precursors. </li></ul><ul><li>Glycogenolysis, in which glycogen to glucose conversion takes place between meals to supply glucose to the blood. </li></ul>
  6. 6. The Liver’s Role in Protein Metabolism <ul><li>It synthesizes almost all plasma proteins. </li></ul><ul><li>It deaminates amino acids. </li></ul><ul><li>It synthesizes non-essential amino acids via transmission. </li></ul><ul><li>The product of protein metabolism – ammonia – is detoxified by the liver and excreted by the urine. </li></ul><ul><li>It synthesizes non-protein nitrogen compounds such as purines and pyrimidines . </li></ul>
  7. 7. The Liver’s Function in Lipid & Fat Metabolism <ul><li>1. It synthesizes triacylglycerols from fatty acids and phospholipids, which are incorporated into lipoproteins. </li></ul><ul><li>2. It synthesizes ketone bodies </li></ul><ul><li>3. It oxidizes fatty acids </li></ul><ul><li>4. It synthesizes cholesterol to bile acids and salts </li></ul><ul><li>5. It synthesizes fat from fatty acids, carbohydrates, and deaminized amino acids. </li></ul>
  8. 8. The Liver’s Function in Relation to Minerals and Vitamins <ul><li>1. It stores iron and copper for hemoglobin synthesis </li></ul><ul><li>2. It stores fat soluble vitamins </li></ul><ul><li>- It converts carotenes to vitamin A </li></ul><ul><li>- It converts vitamin K to prothrombin </li></ul><ul><li>- It converts vitamin D to its active form 1,25-dihydroxyvitamin D – A.K.A. 1,25-(OH) 2 or vitamin D 3 </li></ul><ul><li>- It stores B-complex vitamins (e.g., vitamin B12) </li></ul>
  9. 9. The Liver Manufactures the Following Vital Substances: <ul><li>a. Bile </li></ul><ul><li>b. Prothrombin </li></ul><ul><li>c. Fibrinogen </li></ul><ul><li>d. Heparin </li></ul><ul><li>e. Urea </li></ul>
  10. 10. The Liver Regulates the Following Bodily Processes: <ul><li>Detoxification (e.g., ammonia to urea) </li></ul><ul><li>Blood volume </li></ul><ul><li>Blood sugar level </li></ul>
  11. 11. The Liver Stores the Following: <ul><li>Protein </li></ul><ul><li>Glycogen </li></ul>
  12. 12. Diseases of the Liver <ul><li>Hepatitis is the Latin term for liver inflammation. Types of hepatitis include A, B, C, D, E, and G viruses – F is yet unconfirmed, and A, B, and C are the most common. </li></ul><ul><li>Cirrhosis is fibrosis of the liver. </li></ul><ul><li>Hepatic coma is a complex pathophysiological state that is characterized by neurological manifestations. </li></ul>
  13. 13. Hepatitis A <ul><li>Is an infectious hepatitis </li></ul><ul><li>Its mode of transmission is fecal-oral </li></ul><ul><li>It occurs mostly in children and young adults </li></ul><ul><li>It is usually mild and asymptomatic with a 99% complete recovery rate </li></ul><ul><li>Fulminant hepatitis occurs in 1 to 3 people per 1000 </li></ul>
  14. 14. Hepatitis B <ul><li>Is a serum hepatitis. </li></ul><ul><li>Its modes of transmission include blood & other body fluids, sexual contact, needle sharing, and perinatal-acquisition. </li></ul><ul><li>15% of cases occur during birth or childhood. </li></ul><ul><li>90 to 94% of cases recover completely and have no long term effects. </li></ul><ul><li>6 to 10% percent of patients will become chronic carriers of HBV and will be at risk of developing cirrhosis or liver cancer. Over time, hepatitis B can destroy the liver (cirrhosis) and can cause liver cancer. </li></ul><ul><li>1% of cases are fulminant. </li></ul>
  15. 15. Hepatitis C <ul><li>Is a post-transfusion hepatitis </li></ul><ul><li>Its modes of transmission include parenteral-acquisiton, perinatal-acquisiton, secretions, or sexual contact. </li></ul><ul><li>Recovery can take place, or it can remain as a persistent infection that leads to chronic hepatitis, resulting in liver failure, cirrhosis, and hepatocellular carcinoma. </li></ul>
  16. 16. Hepatitis D <ul><li>Is classified as Hepatitis Delta virus. </li></ul><ul><li>Its mode of transmission is similar to Hepatitis B virus. </li></ul><ul><li>It replicates and causes disease only in those with active HBV infection </li></ul><ul><li>- There is co-infection with simultaneous infection of HDV and HBV. </li></ul><ul><li>- There is superinfection when an HBV carrier later gets infected with HDV. </li></ul>
  17. 17. Hepatitis E <ul><li>Is an enteric or epidemic hepatitis </li></ul><ul><li>Its mode of transmission is fecal-oral </li></ul><ul><li>Its symptoms and course are similar to HAV </li></ul><ul><li>Its infection in pregnant women results in a 20% mortality rate. </li></ul>
  18. 18. Hepatitis G <ul><li>Is a flavivirus similar to HCV. </li></ul><ul><li>Its mode of transmission is via contaminated blood and sexual contact. </li></ul><ul><li>It has a protective effect by inhibiting HIV replication in co-infected patients. </li></ul>
  19. 19. Signs and Symptoms <ul><li>Acute hepatitis varies considerably from person to person: </li></ul><ul><li>- It can be asymptomatic </li></ul><ul><li>- Children in most cases show mild symptoms </li></ul><ul><li>Early phase signs and symptoms include fatigue, malaise, slight fever, nausea, poor appetite, headache, muscle & joint pain, and rash. </li></ul><ul><li>Jaundice phase signs and symptoms include yellowing of the sclerae, skin, & mucous membranes, dark urine, and light-colored stools. </li></ul><ul><li>The recovery phase fatigue can last weeks. </li></ul>
  20. 20. Dietary Management <ul><li>There is no medical treatment available for acute hepatitis, so nutrition is the key to recovery </li></ul><ul><li>A high calorie is useful for: </li></ul><ul><li>- Meeting the demands of fever and generalized debilitation </li></ul><ul><li>- Optimum utilization of protein for protein synthesis </li></ul><ul><li>- Renewal of strength </li></ul><ul><li>A high protein diet: </li></ul><ul><li>- Corrects negative balance </li></ul><ul><li>- Regenerates affected liver cells </li></ul><ul><li>A high carbohydrate diet: </li></ul><ul><li>- Provides calories and spares proteins </li></ul><ul><li>- Maintains hepatic function </li></ul><ul><li>- Insures glycogen reserves </li></ul>
  21. 21. Dietary Management <ul><li>A moderate intake of fat: </li></ul><ul><li>- Provides calorie without bulk </li></ul><ul><li>- Adds taste to counter anorexia </li></ul><ul><li>- Insures absorption of fat soluble vitamins </li></ul><ul><li>- Provides essential Fatty Acids </li></ul><ul><li>Vitamin supplementation provides coenzymes for proper metabolism </li></ul><ul><li>Low sodium intake prevents edema and ascites </li></ul><ul><li>Small frequent meals, 6 to 7, are good for maximum utilization of nutrients </li></ul>
  22. 22. Things To Avoid <ul><li>1. Additives, colorants, and preservatives. </li></ul><ul><li>2. Alcohol: </li></ul><ul><li>- Its byproduct, acetaldehyde, can cause liver damage. </li></ul><ul><li>- It interferes with storage of vitamin A. </li></ul><ul><li>3. Caffeine, because it interferes with storage of vitamins A and D. </li></ul><ul><li>4. Trans fatty acids, because they suppress enzymatic cholesterol regulation, and increase triacylglycerol levels. </li></ul><ul><li>5. Sugars, because they are devoid of nutrients. </li></ul><ul><li>6. Drugs, because some drugs cause metabolic problems. </li></ul><ul><li>7. Smoking, because of free radicals in tobacco smoke. </li></ul>
  23. 23. Cirrhosis <ul><li>Widespread dysfunction of normal hepatic structure can take place via fibrosis, fatty changes, and the formation of regenerative nodules, and can be caused by a variety of conditions. </li></ul><ul><li>Chronic liver disease and cirrhosis constitute the tenth leading cause of death in the United States, with over 25,000 deaths annually. </li></ul><ul><li>Causes: </li></ul><ul><li>1. Infectious hepatitis, which is rare in developed countries. </li></ul><ul><li>2. Chronic alcoholism associated with deficiencies in many vitamins because of decreased food ingestion and, in some cases, impaired absorption, metabolism, and utilization . </li></ul><ul><li>3. Chronic alcoholism associated with metabolic disturbances </li></ul><ul><li>4. Chronic alcoholism associated with biliary stasis </li></ul>
  24. 24. Signs and Symptoms of Cirrhosis <ul><li>GIT disturbances include: </li></ul><ul><li>- Anorexia, nausea, vomiting, RUQ pain, and jaundice. </li></ul><ul><li>- Portal hypertension, leading to ascites & peripheral edema, pleural effusion, esophageal varices, and distended abdominal veins, which can lead to hemorrhage. </li></ul><ul><li>- Hepatomegaly is seen in 70% of patients. </li></ul><ul><li>- Splenomegaly is seen in 35 to 50% of patients. </li></ul><ul><li>Skin manifestations include: </li></ul><ul><li>- Spider nevi (occurring in the upper half of the body) </li></ul><ul><li>- Palmar erythema </li></ul><ul><li>*Glossitis and cheilosis are manifestations of vitamin deficiency. </li></ul>
  25. 25. Complications of Cirrhosis <ul><li>Ascites and edema </li></ul><ul><li>Spontaneous bacterial peritonitis </li></ul><ul><li>Hemorrhage </li></ul><ul><li>Hepatorenal/hepatopulmonary syndrome </li></ul><ul><li>Hepatic encephalopathy </li></ul>
  26. 26. Diet Therapy Guidelines <ul><li>High carbohydrates intake </li></ul><ul><li>High protein intake </li></ul><ul><li>Moderate fat intake </li></ul><ul><li>Good vitamin supplementation </li></ul><ul><li>Sodium restriction </li></ul><ul><li>Fiber restriction </li></ul>
  27. 27. High Carbohydrate Intake <ul><li>Provides calories and spares proteins. </li></ul><ul><li>Supports hepatic function. </li></ul><ul><li>Provides fuel via glucose, especially since cirrhosis patients frequently experience hyper- and hypo- glycemia. </li></ul><ul><li>Examples of Carbohydrates include: </li></ul><ul><li>- Breads, cereals, pasta, and rice </li></ul><ul><li>Intake of complex carbs (starches) should surpass that of simple carbs (sugars). </li></ul>
  28. 28. High Protein Intake <ul><li>Helps correct negative nitrogen balance. </li></ul><ul><li>Increases activity of Cytochrome p450, responsible for drug metabolism, so there is less chance for liver injury. </li></ul><ul><li>Repairs regenerative cells. </li></ul><ul><li>Aids in synthesis of bile acid. </li></ul><ul><li>Provides lipotropes, like methionine and choline, to mobilize fats and counteract fatty infiltration. </li></ul><ul><li>A vegetarian protein diet is low in ammonia. </li></ul><ul><li>An animal protein diet is not recommended due to high ammonia, which may lead to encephalopathy and coma. </li></ul>
  29. 29. Moderate Fat Intake <ul><li>Provides calories and spares protein. </li></ul><ul><li>Supports hepatic function. </li></ul><ul><li>Prevents steatorrhea and fatty liver. </li></ul><ul><li>Linoleic acid (an essential fatty acid) prevents dietary deficits. </li></ul><ul><li>Substitution of medium chain triglycerides results in decreased hepatic fat accumulation. </li></ul>
  30. 30. High Vitamin Supplements <ul><li>They fortify fatty deposition in the liver. </li></ul><ul><li>They include fat soluble vitamins ADEK, taken in their water soluble forms. </li></ul><ul><li>They prevent deficient levels of zinc, calcium, and magnesium. </li></ul>
  31. 31. Sodium & Fiber Restriction <ul><li>Sodium is restricted to 250 to 1000 mg per day to ameliorate ascites and edema. </li></ul><ul><li>Fiber restriction is to prevent esophageal varices, which may rupture and hemorrhage. </li></ul>
  32. 32. Hepatic Coma <ul><li>A complex syndrome characterized by neurological manifestations as a complication of severe hepatitis and liver cirrhosis. </li></ul><ul><li>It is mainly due to hyperammonemia. </li></ul><ul><li>A normal liver removes ammonia (NH 3 +) by converting it to urea for urinary excretion. </li></ul><ul><li>- A diseased liver cannot do this, so α- ketoglutarate depletion occurs in neurons, leading to coma. </li></ul>
  33. 33. Mechanism of Hepatic Coma <ul><ul><li>Ammonia-laden blood enters the cerebral circulation </li></ul></ul><ul><ul><li>This leads to: </li></ul></ul><ul><ul><li>A depletion of α- ketoglutarate in the neurons. </li></ul></ul><ul><ul><li>α-ketoglutarate is an essential intermediate in the Krebs cycle; it maintains a high rate of energy production. </li></ul></ul><ul><ul><li>Ammonia (NH3+) is toxic to the brain because it interferes with the Krebs cycle, as it removes α- ketoglutarate from the cycle in order to detoxify it; α-ketoglutarate synthesizes glutamic acid, which combines with ammonia to form glutamine. </li></ul></ul><ul><ul><li>α- ketoglutarate depletion in the neurons leads to: </li></ul></ul><ul><ul><li>Decreased ATP & cellular oxidation </li></ul></ul><ul><ul><li>Which causes: </li></ul></ul><ul><ul><li>Neurons to die </li></ul></ul><ul><ul><li>Which leads to: </li></ul></ul><ul><ul><li>Coma </li></ul></ul>
  34. 34. Signs and Symptoms <ul><li>Signs and symptoms of impending coma include: </li></ul><ul><li>- confusion </li></ul><ul><li>- restlessness </li></ul><ul><li>- irritability </li></ul><ul><li>- drowsiness </li></ul><ul><li>- slurred speech </li></ul><ul><li>- absent stare </li></ul><ul><li>- sleep lapses </li></ul><ul><li>- convulsion </li></ul><ul><li>- asterexis – course flapping tremors of the hands </li></ul>
  35. 35. Dietary Management <ul><li>Goals include: </li></ul><ul><li>- Maintenance of adequate nutrition. </li></ul><ul><li>- Prevention protein catabolism. </li></ul><ul><li>- Controlling ascites and edema </li></ul><ul><li>- Ameliorating symptoms of hepatic encephalopathy. </li></ul>
  36. 36. Dietary Therapy <ul><li>1. Calorie intake should be 1500 to 2000 calories – just enough to prevent tissue breakdown, which could be an additional source of ammonia. </li></ul><ul><li>2. A low protein diet of 15 to 30 grams per day is called for. </li></ul><ul><li>- This is to restrict further ammonia buildup. </li></ul><ul><li>- If improvement is evident, increase intake by 10 to 15 gram increments per day for 5 to 7 days until recommended daily allowance is reached. </li></ul><ul><li>- Proteins with high biological value include animal proteins and essential amino acids </li></ul><ul><li>- Lipotropic agents include methionine and choline. </li></ul>
  37. 37. Dietary Therapy <ul><li>3. Carbs and fatty acids are ingested to prevent tissue breakdown. </li></ul><ul><li>4. Fluid intake is monitored so that it stays within 1500 to 2000 ml per day. </li></ul><ul><li>5. Low sodium ingestion of 250 to 2000 mgs per day should be maintained. </li></ul><ul><li>6. There should be liberal consumption of vitamins and minerals. </li></ul><ul><li>7. Poorly absorbable antibiotics are useful to kill ammonia-forming bacteria in the colon (e.g., Neomycin). </li></ul><ul><li>8. Lactulose – a non-absorbable disaccharide which acts as an osmotic laxative – is given at 30 to 45 ml twice a day until diarrhea subsides. </li></ul><ul><li>An increase in hydron (A.K.A. acidic hydrogen or H+) levels is good because hydron combines with ammonia to form ammonium (NH4+), which is less toxic. </li></ul>
  38. 38. Dietary Therapy <ul><li>Dietary limitations include: </li></ul><ul><li>*Vegetables: high-protein legumes </li></ul><ul><li>*Dairy: milk and cheese </li></ul><ul><li>*Eggs </li></ul><ul><li>*Meat, fish, and poultry </li></ul><ul><li>Other foods to be avoided: </li></ul><ul><li>*Meat extractives, soups, broths, bouillon, gravies, and gelatin desserts </li></ul>
  39. 39. Cholecystitis <ul><li>Is inflammation of the gallbladder arising from a low grade chronic infection in areas of the body such as the tonsils, sinuses, teeth, and even appendix. </li></ul><ul><li>Other causative factors of this condition include obesity, pregnancy, malnourishment, constipation, tight clothing, digestive upsets, and bile stains from cystic duct stones. </li></ul>
  40. 40. Etiology of Cholecystitis <ul><li>Cystic duct obstruction due to a stone normally leads to acute inflammation of the gallbladder wall. Three factors can evoke the inflammatory response: (1) mechanical inflammation arising from elevated intraluminal pressure and distention with resultant ischemia of the gallbladder mucosa and wall, (2) chemical inflammation due to the release of lysolecithin (caused by the action of phospholipase on lecithin in bile) and other local tissue factors, and (3) bacterial inflammation , which plays a role in 50 to 85% of patients with acute cholecystitis. </li></ul>
  41. 41. Bacterial Inflammation in Cholecystitis <ul><li>*Agents of bacterial inflammation include: </li></ul><ul><li>- Escherichia coli </li></ul><ul><li>- Klebsiella </li></ul><ul><li>- Group d streptococcus </li></ul><ul><li>- Clostridium </li></ul><ul><li>- Salmonella </li></ul><ul><li>- Leptospira </li></ul>
  42. 42. <ul><li>Predisposing factors include: </li></ul><ul><li>- Familial hypercholesterolemia </li></ul><ul><li>- Diabetes Mellitus </li></ul><ul><li>- Familial disease </li></ul>
  43. 43. <ul><li>Precipitating Factors </li></ul><ul><li>- Adenocarcinoma of the gallbladder </li></ul><ul><li>- Cholelithiasis </li></ul><ul><li>- Cholecystolithiasis </li></ul><ul><li>- Choledocholithiasis </li></ul>
  44. 44. Clinical Manifestations <ul><li>Signs and Symptoms include: </li></ul><ul><li>Right upper quadrant rebound tenderness. </li></ul><ul><li>Nausea and vomiting. </li></ul><ul><li>Right upper quadrant pain radiating to the interscapular area or shoulder </li></ul><ul><li>Low grade fever (37.7 to 39.4 ℃) </li></ul><ul><li>Charcot’s fever (40.5 ℃) </li></ul><ul><li>Anorexia </li></ul><ul><li>A positive Murphy’s sign (that is, inspiratory arrest) </li></ul>
  45. 45. Triad of Onset <ul><li>RUQ rebound tenderness </li></ul><ul><li>Low grade fever </li></ul><ul><li>Leukocytosis </li></ul>
  46. 46. <ul><li>Medical Management </li></ul><ul><li>- The analgesic Meperidine Hydrochloride (Demerol) can be administered to adults at a dosage of 50 to150 mg orally, intravascularly, intramuscularly, or subcutaneously every 3 to 4 hours as needed. Children are administered 1.8 mg per kg orally, intravascularly, intramusculalry, or subcutaneously every three to four hours as needed; their dosage should not exceed that of adults. </li></ul><ul><li>-The antibiotic fluoroquinolone Ciprofloxacin (Cipro) is only to be administered to those 18 years of age and older at a dosage of 400 mg intravascularly every 12 hours. </li></ul><ul><li>-The antiemetic promethazine can be administered orally, intravascularly, intramuscularly, or rectally every 4 hours as needed, at a dosage of 12.5 to 25 mg for adults, and 0.25 to 1 mg per kg for those 2 years of age and older. </li></ul>
  47. 47. <ul><li>Surgical Management </li></ul><ul><li>-Cholecystectomy </li></ul>
  48. 48. Dietary Management <ul><li>-Fat restriction in chronic cholecystitis is called for, because fat simulates gallbladder contraction via the cholecystokinin secretion of the duodenum. </li></ul><ul><li>-If tolerated, 30 to 60 grams of fat per day should be ingested. </li></ul><ul><li>-Foods rich in condiments and residue are to be avoided as they cause distention and peristalsis. </li></ul><ul><li>-In acute attack, a liquid diet of 2 to 3 liters per day and parenteral nutrition may be required. </li></ul><ul><li>-30 to 40 grams of protein should be ingested per day. </li></ul><ul><li>-200 to 300 grams of carbohydrates should be ingested per day. </li></ul><ul><li>-There should be an avoidance of pastries, nuts, chocolates, and fatty foods, as well as gas-forming foods. </li></ul><ul><li>-Patients are advised to prepare meals by baking, boiling, or stewing, and to use only trimmed or lean meat. </li></ul>
  49. 49. GALL STONES <ul><li>Gall stones are crystalline structure formed by concretion or accretion of normal or abnormal bile constituents: </li></ul>
  50. 50. GALL STONES <ul><li>-Cholelithiasis is the formation of gallstones in the gallbladder. No symptoms may arise, so the patient may not realize that a stone is present. </li></ul>
  51. 51. GALL STONES <ul><li>Choledocholiathiasis develops when stones slip into the common bile duct, obstructing bile flow and causing jaundice. Cramps, as well as agonizing colicky pain of the righter upper quadrant (due to spasm of the common bile duct) arise. Fat digestion and absorption is impaired, and the absence of bile pigments leads to light discoloration of stools. If left untreated, backed up bile can cause liver damage, biliary cirrhosis, and pancreatitis. </li></ul>
  52. 52. <ul><li>Composition of Stones </li></ul><ul><li>Cholesterol and mixed stones are composed of: </li></ul><ul><li>-Bile acid (cholic and chenodesoxycholic acid) </li></ul><ul><li>-Protein </li></ul><ul><li>-Phospholipids </li></ul><ul><li>-Fatty acid </li></ul><ul><li>Pigment stone are composed of: </li></ul><ul><li>- Calcium bilirubinate </li></ul>
  53. 53. <ul><ul><li>Dietary Management </li></ul></ul><ul><li>- Same as cholecystitis </li></ul><ul><li>Surgical Management </li></ul><ul><li>- Cholecystectomy </li></ul>
  54. 54. The Pancreas <ul><li>The pancreas is both an exocrine and endocrine organ, but our focus will be limited to its exocrine aspect. </li></ul>
  55. 55. <ul><li>Pancreatitis </li></ul><ul><li>Pancreatitis is inflammation of the pancreas characterized by edema, cellular exudate, and fat necrosis. </li></ul><ul><li>It can be mild and self-limiting or severe, with necrosis of pancreatic tissue. </li></ul><ul><li>It can be acute and chronic, with pancreatic destruction so extensive that exocrine or endocrine pancreatic function is lost, and steatorrhea or diabetes arise. </li></ul>
  56. 56. <ul><li>Etiology: </li></ul><ul><li> -Unknown </li></ul><ul><li>Causes: </li></ul><ul><li>-Chronic alcoholism </li></ul><ul><li>-Biliary tract disease </li></ul><ul><li>-Ingestion of certain drugs </li></ul><ul><li>-Trauma and hypercalcemia </li></ul>
  57. 57. <ul><li>-Alcohol causes duodentitis and edema of the papilla of Vater, where the common bile duct opens into duodenum and obstructs pancreatic and bile flow, which backs up bile and activates the pancreatic enzymes that cause digestion of the organ, causing acute pain. </li></ul>
  58. 58. <ul><li>-It is also possible that alcohol exerts a direct cytotoxic effect on the pancreas by causing excessive precipitation of protein in the pancreatic ductules, which blocks the release of pancreatic juice. </li></ul>
  59. 59. <ul><li>Dietary Management </li></ul><ul><li>- For acute attack, cease oral ingestion; after a few days, if amylase is still elevated, tissue destruction is still going on. In such an event, place the patient in the Intensive Care Unit. After stabilization, progression from clear liquid to a soft or bland diet is made as tolerated. </li></ul>
  60. 60. <ul><li>-A low fat, bland diet is recommended. About 30 to 60 grams of fat per day will be tolerated. Fat soluble vitamins are given in supplement form for persistent steatorrhea. Vitamin B12 may be reduced, so injection of vitamin B12 may be required. </li></ul>
  61. 61. With chronic pancreatitis, digestion – especially of fat – is permanently impaired. A special diet is required for the sake of: <ul><li>-Maintaining optimal nutritional status. </li></ul><ul><li>-Reducing steatorrhea if present. </li></ul><ul><li>-Minimizing pain if necessary. </li></ul><ul><li>-Avoiding subsequent attacks of pancreatitis. </li></ul>
  62. 62. Dietary Aims: <ul><li>To alleviate pain. </li></ul><ul><li>To prevent further damage to the pancreas. </li></ul><ul><li>To abate further attacks of acute inflammation. </li></ul><ul><li>To correct malnutrition. </li></ul><ul><li>To replace fluids and electrolytes. </li></ul>
  63. 63. <ul><li>Proteins and fats should be avoided; carbohydrates are preferred. </li></ul><ul><li>Specific treatment of pancreatic maldigestion consists of manipulation of the diet and enzyme replacement with meals, to aid in the digestion and absorption of proteins and fats. </li></ul><ul><li>Pancreatin may be given orally after every meal to facilitate digestion of foodstuffs. </li></ul><ul><li>Substitution of dietary fat with medium chain triglycerides in patients with pancreatic insufficiency may relieve steatorrhea and result in weight gain. </li></ul>
  64. 64. Alcohol is prohibited as it acts as an intestinal irritant and encourages recurrence of pancreatitis <ul><li>For acute attacks, oral ingestion is ceased so that the gastrointestinal tract can rest. </li></ul><ul><li>A low fat diet controls steatorrhea and prevents stimulation of bile. </li></ul><ul><li>Moderate carbohydrates and proteins prevent hypoglycemia. </li></ul><ul><li>Enzyme supplements enhance digestion of food nutrients. </li></ul><ul><li>Six small feedings are taken to avoid distention and stimulation. </li></ul><ul><li>Clay colored stools occur when there is obstruction of the common bile duct. </li></ul>
  65. 65. <ul><li>Thanks For Listening! </li></ul><ul><li>In loving memory of Dr. Nico. </li></ul>

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