Chronic liver diseases refer to progressive destruction and regeneration of the liver leading to cirrhosis and fibrosis. The main causes include chronic hepatitis B and C, alcoholic fatty liver disease, non-alcoholic fatty liver disease, and others. Symptoms include fatigue, nausea, ascites, and hepatic encephalopathy. Investigation includes blood tests of liver function and imaging. Treatment focuses on managing the underlying cause and complications through diet and lifestyle modifications. Cirrhosis and hepatic encephalopathy are severe complications where scar tissue replaces healthy liver tissue and toxins affect brain function respectively.

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2. Chronic Liver
Diseases (CLD)
Presented by: Yusaira Fakhar
Presented to: Mam Shamma
Mam Asma
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3. Introduction
• Chronic liver disease refers to a series of
stages in the liver condition that involves
progressive destruction and regeneration
of the liver parenchyma, thereby leading to
cirrhosis and fibrosis.
• It consists of a wide range of liver
pathologies which include inflammation
(chronic hepatitis), liver cirrhosis, and
hepatocellular carcinoma.
https://www.ncbi.nlm.nih.gov/books/NBK554597/
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4. Etiology
The main risk factors for chronic liver disease
include:
• Chronic viral hepatitis B and C
• Alcoholic fatty liver disease (ALFD)
• Non-alcoholic fatty liver disease (NAFLD)
• Primary biliary cirrhosis
• Wilson's disease
• Hemochromatosis
https://www.ncbi.nlm.nih.gov/books/NBK554597/
Krause 's Food and the Nutrition Care Process
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5. Flow Chart of
CLD
https://doi.org/10.3390/nu13051442
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6. Clinical Manifestation of CLD
• Fatigue and weakness
• Nausea and vomiting
• Portal hypertension (increase blood flow in portal venous system)
• Ascites (accumulation of fluid in abdomen)
• Upper GI bleeding, Melana
• Hepatocellular insufficiency (e.g., jaundice, hepatic encephalopathy)
• Acute variceal bleeding and spontaneous bacterial peritonitis (SBP)
https://www.ncbi.nlm.nih.gov/books/NBK554597/
https://emedicine.medscape.com/article/182098-overview 6

7. Investigation &
Clinical findings
• Blood tests: It can be
used to assess liver
function, including
serum levels of
albumin, bilirubin,
• liver enzymes (ALT, AST)
• CBC
• Serum electrolyte
(hyponatremia)
• Serum creatinine
Krause 's Food and the Nutrition Care Process
Sylvia Escot Stump Nutrition and Diagnosis 7

8. Fatty Liver
• Fatty liver is also known as hepatic
steatosis, with or
without inflammation and fibrosis.
• It happens when fat builds up in the
liver. Having small amounts of fat in
your liver is normal, but too much
can become a health problem.
• There are two main types of fatty
liver disease i.e. non-alcoholic and
alcoholic fatty liver.
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9. Symptoms
• Persistent Fatigue or Weakness
• Abdominal Discomfort
• Unexplained Weight Loss
• Elevated Liver Enzymes
• Enlarged liver
• Dark urine or pale stool
• Jaundice
• Ascites
Picture source: www.goggle.com 9

10. Diagnostic
Test
• Blood tests
• Ultrasound, CT scan or
MRI
• Live function test
• Liver Biopsy
• Physical Examination
(ascites, jaundice, red
palms)
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11. General Dietary Guidelines
of Fatty Liver
• Fruits and vegetables
• High-fibre foods like legumes and whole
grains
• Unsaturated Fatty acids (omega 3,6)
• Reducing intake of certain foods and
beverages including those high in added
sugar, salt, refined carbohydrates, and
saturated fat
• No alcohol
Picture source: www.goggle.com
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12. Alcoholic Fatty Liver
Disease - AFLD
• Drinking a lot of alcohol damages
the liver. Alcoholic fatty liver
disease (AFLD) is the earliest
stage of alcohol-related liver
disease.
• If there’s no inflammation or
other complications, the
condition is known as simple
alcoholic fatty liver.
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13. Risk factors
• Heavy and regular alcohol use
• Genetics
• Obesity
• Smoking
• Gender ( mostly men)
• Not having a balanced diet
• Co-existing liver diseases (hepatitis C history)
Krause's Food and the Nutrition Care Process 13

14. Alcoholic steatohepatitis (ASH)
• Alcoholic steatohepatitis (ASH) is a type of AFLD.
• It’s when a buildup of excess fat in the liver is accompanied by
inflammation, which is also known as alcoholic hepatitis.
• Signs:
Excess fat in liver
Inflammation in liver
Increased alcohol use
When left untreated, ASH can cause liver fibrosis. In severe cases, this
can progress to cirrhosis and liver failure.
Krause 's Food and the Nutrition Care Process
Sylvia Escot Stump Nutrition and Diagnosis
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15. Non-Alcoholic Fatty Liver-NAFLD
• NAFLD is caused when fat
builds up in the liver of
people who don’t drink a lot
of alcohol.
• If you have excess fat in
your liver and no history of
heavy alcohol use, you may
receive a diagnosis of
NAFLD.
• If there’s no inflammation
or other complications, the
condition is known as
simple NAFLD.
https://doi.org/10.3390/metabo10070283
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16. Classification
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17. Non-Alcoholic Steatohepatitis
• Non-alcoholic steatohepatitis (NASH) is a type of NAFLD.
• It’s when buildup of excess fat in the liver is accompanied by
inflammation.
Signs:
• Excess fat in liver
• Inflammation in liver
• Have no history of heavy alcohol use
• When left untreated, NASH can cause liver fibrosis. In severe cases,
this can progress to cirrhosis and liver failure.
https://www.ncbi.nlm.nih.gov/books/NBK554597/ 17

18. Risk factors
• Obesity
• Unhealthy diet
• Dyslipidaemia
• Type II diabetes
• Metabolic syndrome
• Certain medications
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19. Nutrition Management
• Carbohydrates should
comprise 40–50% of total
calories
• Fat should comprise ≤ 30%
of total calories (saturated
fatty acids > 7% and <10% of
total calories)
• Protein should comprise
about 20% of total calories
https://www.ncbi.nlm.nih.gov/books/NBK554597/
https://doi.org/10.1111/liv.14360 19

20. Foods to be Added in NASH Diet
• Nuts: The polyphenol content and fatty
acid profile of nuts makes them both
heart healthy and beneficial to the liver.
• Fish: Salmon, sardines, mackerel, trout
and tuna are high in omega-3 fatty acids.
• Green vegetables: Spinach, kale and
broccoli help prevent fatty liver buildup.
• Oatmeal: Whole grains like oatmeal
protect blood sugar levels and help
prevent visceral fat deposits.
https://www.ncbi.nlm.nih.gov/books/NBK554597/ 20

21. Continue...
• Milk and milk
alternatives: Consume whey
protein from milk or soy protein
for vegan liver support.
• Seeds: Sunflower seeds, chia
seeds, flaxseeds and more
provide omega-3s and vitamin E.
• Olive oil: This antioxidant- rich oil
helps control body weight.
• Green Tea: Drink green tea for
general longevity and to block fat
absorption
https://doi.org/10.1186/s12876-
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22. Meal Guidelines
• It is recommended to consume 4–5
meals per day; breaks between
meals should not exceed 2–3 hours.
• Last meal should be consumed at
least 3 hours before sleeping.
• Meals should be consumed slowly.
• It is important to finish eating when
the patient does not feel satiety;
signal of satiety is felt usually 15 min
after the end of consumption.
https://doi.org/10.5114%2Fpg.2014.40845 22

23. Liver Cirrhosis
• Cirrhosis is a late-stage liver disease
in which healthy liver tissue is
replaced with scar tissue and the
liver is permanently damaged.
• Scarring (fibrosis) of the liver
caused by many forms of liver
diseases and conditions, such as
hepatitis and chronic alcoholism.
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24. Krause 's Food and the Nutrition Care Process
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Pathogenesis Symptoms
bile duct injury and obstruction Weakness
Renal losses Fatigue
Micronutrients losses Loss of appetite
Edema, ascites, jaundice Nausea
Abnormal macronutrient energy distribution Vomiting
Steatorrhea (the presence of fat in the stool) Weight loss

25. Dietary requirement in
Cirrhosis
• Carbohydrates (45-55%): Complex CHO for
liver cell regeneration,
improve glucose production)
• Protein: 0.8 g of protein/kg/day (for
nitrogen balance, muscle building by
reducing the risk of malnutrition). In
situations of stress (sepsis, infection,
gastrointestinal bleeding, or severe ascites),
at least 1.2-1.5 g of protein per kg per day
should be provided.
• Fats (30%): PUFA's and MUFA's
recommended to reduce lipolysis and lipid
deposits.
Krause 's Food and the Nutrition Care Process
Sylvia Escot Stump Nutrition and Diagnosis
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26. Conti..
• Milk thistle: Milk thistle is proposed to reduce free
radical production and lipid peroxidation associated with
hepatotoxicity as well as block the binding of toxins to
hepatocytes.
• Low Sodium (2-4g): This increases the risk of ascites
(abdominal fluid), and levels of restriction may vary from
patient to patient.
Krause 's Food and the Nutrition Care Process
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3586829/
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27. DIET MANUAL OF PAKISTAN
KRAUSE'S FOOD & NUTRITION (12TH EDITION) 2008
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Food to allowed Food not allowed
CHO: Oatmeal, whole grains, bran
bread, wheat chapati, rice
Salted porridge, bakery products
(cakes, pastries, biscuits, samosas,
pakoras, naan, Taftan, Shermaal
All fresh fruits/juices/vegetables
(half cup)
Canned vegetables, spinach not
more than one- fourth cup/canned
fruits
Proteins: Egg whites, fish, chicken
(5 ounces-150 gm)
Mutton, beef, other meat items
such as kidney, liver, brain.
Fats: All types of vegetable oils
(used sparingly)
Recommended: olive oil, canola,
corn etc, walnuts
Salted butter, margarine, ghee,
cream

28. Hepatic
Encephalopathy/ PSE
• Portal-systemic encephalopathy is
considered as an temporary
neurological disorder due to
chronic severe liver disease.
• A diseased liver struggles to filter
toxins from the blood affects
brain function and causes cognitive
impairment.
• It occurs often in patient with
cirrhosis but also seen in patient
with hepatitis C.
MANUAL OF CLINICAL NUTRITION MANAGEMENT, MORRISON: 2001
KRAUSE'S FOOD & NUTRITION (12TH EDITION) 2008
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29. Pathophysiology
The damaged liver cells fail to detoxify and convert the ammonia to urea. This
results in accumulation of ammonia.
It increase serum ammonia levels precipitate or aggravate hepatic
encephalopathy (indigestion of dietary and blood proteins)
The brain dysfunction and damage occurs due to this increased ammonia
concentration in the blood which resulting in hepatic encephalopathy and coma.
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30. Causes
• Surgery/trauma
• Excessive diuresis
• Kidney diseases
• Dehydration/ electrolyte imbalance
• Infection
• Upper GI bleeding
• Hypokalaemia/hypoglycaemia
• Liver shunt
2022 Sharma et al. Cureus 14(8): e28016. DOI 10.7759/cureus.28016 30

31. Clinical Manifestation of HE
• Cerebral Edema
• Brain herniation
• Permanent neurologic losses
(movement, sensation, or mental state)
• Increased risk of:
Sepsis
Respiratory failure
Cardiovascular collapse
Kidney Failure
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32. Symptoms • People with hepatic encephalopathy
experience impaired brain function.
Symptoms include:
• Difficulty concentrating or short
attention span.
• Mood or personality changes
(Anxiety or irritability)
• Cognitive impairment (confused
thinking or judgment)
• Coordination or balance
problems/Muscle twitches
(myoclonus)
• Reduced alertness/Sleep
problems/Slurred speech
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33. Conti...
• Acute HE: Acute hepatic encephalopathy may occur in the setting of
chronic liver disease due to some precipitating factor it may also
occur suddenly in the absence of previous liver disease.
 It is characterized by development of an acute confusional state,
neuromuscular abnormalities resulting in problems maintaining
posture, and increased rate of breathing.
Patients usually recover when the precipitating factor is removed or
with improvement of liver function.
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34. Continue...
• Chronic hepatic encephalopathy (Chronic HE) can occur as recurrent
episodes of encephalopathy which may be spontaneous, due to
aggravating factors or discontinuation of treatment.
 It is characterized by abrupt onset and resolution of symptoms.
Features of chronic persistent encephalopathy include confusion and
loss of orientation, presence of involuntary abnormal movements
such as tremor, increased muscle tone, difficulty in speech, poor
attention span, and reduced mental alertness and motor activity.
• Fulminant HE: The symptoms begin as an acute encephalopathy
and patient gradually slips into a coma.
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35. Grades of Hepatic Encephalopathy
Krause And Mahan Food and The Nutrition Care Process
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Grade Symptoms
I Mild confusion, agitation, irritability, sleep disturbance, decreased attention
II Lethargy, disorientation, inappropriate behaviour, drowsiness
III Incomprehensible speech, confused, aggressive behaviour when awake
IV Coma

36. Diagnosis
Blood tests can identify
problems such as infections
and bleeding associated with
liver disease.
Other tests include magnetic
resonance imaging (MRI)
Computed tomography (CT)
scans
Electroencephalogram (EEG)
Elevated serum ammonia
measurements
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37. Nutrition
Guidelines in HE
• Optimal daily protein intake should be 1.2-1.5 g/kg ideal
body weight.
• Use of prebiotics and probiotics in form of green
leafy vegetables, fruits and whole grains.
• BCAA supplementation might allow recommended
nitrogen intakes to be attained/maintained in HE
patients.
https://doi.org/10.1002/hep.26370 37

38. Explanation of Diet Modification in HE/PSE
• Carbohydrates: Soluble fibre may be beneficial in managing hepatic
encephalopathy. Soluble fibre is fermented in the colon by the same
mechanism as lactulose, which eliminates ammonia in the form of
ammonium ion and bacterial proteins.
• Fats: PUFAs and MUFAs added to avoid malabsorption which may
occur because of inadequate production of bile salts. This may lead to
steatorrhea, which could lead to deficiencies in fat-soluble vitamin
and calcium levels.
https://www.ncbi.nlm.nih.gov/books/NBK554597/ 38

39. Conti...
• Protein: In hepatic insufficiency, there is
a decrease in hepatic oxidation of
Aromatic Amino Acids (AAAS), leading to
an increase in circulation of AAAS in the
plasma.
Branched chain Amino Acids (BCAAs) are
metabolized primarily by the skeletal
muscle with minimal risk of precipitating
HE.
BCAAs have also been shown to reduce
the level of false neurotransmitters,
which might contribute to symptoms of
HE.
Increase in BCAA oxidation in
the peripheral tissue during stress,
causing a drop in plasma circulation. 39

40. Foods to Eat in HE
 A diet rich in these proteins like eggs,
fish, meat, pulses, vegetables, and fruits
are some of the sources rich in animal
and vegetable proteins.
 Also, the consumption of electrolytes
rich in potassium and magnesium can
help treat hepatic encephalopathy
quicker.
• Food to be avoided in HE:
 White-flour foods like loaves of bread
and other bakery items and sugary
drinks like carbonated drinks should be
avoided at all costs.
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