This document discusses nutrition for disorders of the liver, gallbladder, and pancreas. It covers diseases like hepatitis, fatty liver, cirrhosis, and hepatic encephalopathy. It discusses protein requirements and sources, as well as medical nutrition therapy for various conditions which includes restricting sodium for ascites, limiting protein for hepatic encephalopathy, and restricting fat and fiber for gallbladder disorders. Overall it provides an overview of the nutritional considerations and diet modifications for diseases affecting the liver, gallbladder, and pancreas.

1. NUTRITION FOR DISORDERS
OF THE
LIVER,GALLBLADDER AND
PANCREAS
ZIA IMRAN
2014 year 1

3. • Diseases Of the Liver
• Hepatitis
• Fatty liver
• Cirrhosis
• Hepatic Encephalopathy

4. BRIEF REVISION OF PROTEINS
BUILDING BLOCK UNITS
AMINO ACIDS:
Essential amino acids: a group of amino acids that
the body cannot produce that must be obtained
from food sources or other means.
Non Essential amino acids: a group of amino acids
that the body can synthesize from other substrates
already in the body.

5. RECOMMENDATIONS FOR PROTEIN IN THE DIET
Percent in the diet (10-20% recommended)
A healthy adult requires 0.8g/kg body weight.
Protein requirements vary :(infants,children,pregnant and
lactating women);
Clients with new tissue/repair concerns(trauma,stress and
burn);
Clients with increased metabolic requirements athletes
and disease state).

6. PROTEIN QUALITY
BIOLOGICAL VALUE is a measurements of proteins in terms
of how usable it is by the body or how easily it converts
from being a food protein to a body protein).
High Biological value protein(HBV):have essential amino
acids present in adequate proportions to meet
minimum body needs.(eggs,fish,poultry,lean meat, and
dairy products).
Low Biological value protein(LBV):do not have adequate
amount of essential amino acids to meet minimum
body needs.(grains,nuts,seeds,and legumes.

7. COMPLETE PROTEINS: are food high in
biological value that provide all essential
amino acids and are of animal origin
(exception is gelatin).
INCOMPLETE PROTEINS: are foods low in
biological value and are usually of plant
origin( exception is gelatin).

8. FOOD SOURCES
Animal sources and eggs: most protein sources are of
high biological value and are of animal origin.

9. Soy Protein constitute a high biological value
protein source and soy products can be
substituted in the diet to meet protein needs
(e.g;vegetarian diets).

10. Nutritional Consideration in Liver Disease.
• Protection of the parenchymal cells.
• A nutritious diet.
• With exception of hepatic coma, generous
amount of high quality protein for tissue
repair.
• A high CHO intake.
• Moderate amounts of fat.
• Generous amount of vitamins.
• Sodium restriction if edema or ascites.

11. • Fatty liver
 Infiltration of the liver by fat
 Possible causes include:
 Alcohol
 obesity
 type 2 diabetes
 hyperlipidaemia
 Sudden rapid weight gain
 Hepatitis C
 TPN

12. • Symptoms
• Often asymptomatic of liver disease at time
of diagnosis.
• Fatigue or feeling of fullness or discomfort on
the right side of abdomen.
• Therapy:
• Absistence from alcohol(if that is the cause)
• Restriction of total dietary fat content<30%of
total calories
• Low CHO intake40-45% of caloric intake.

13. © 2007 Thomson - Wadsworth
Hepatitis
• Liver inflammation
• Results from any factor causing liver
damage
– Viruses A, B, & C
– Excessive alcohol
– Exposure to certain drugs & toxic chemicals
– Some herbal remedies

14. © 2007 Thomson - Wadsworth
Types of Hepatitis
• Hepatitis A
– Extremely contagious
– Most common
– Cause: fecal-oral
• Hepatitis B
– Blood contact
– Sexual contact
– Vaccinations available
• Hepatitis C
– Blood contact
– Major cause of chronic hepatitis

15. © 2007 Thomson - Wadsworth
Hepatitis
• Symptoms
– Mild & chronic may be
asymptomatic
– Acute
• Fatigue, nausea, anorexia
• Pain in liver area
• Enlarged liver & jaundice
• Fever, headache
• Muscle weakness, skin rashes
• Elevated liver enzymes

16. Dietary Measures Used As Treatment of
Hepatitis
• Treatment for all types is almost similar; bed
rest, plenty of fluids and diet therapy (high
calorie, high protein, moderate fat diet).
• During periods of nausea and vomitting,use
hydration via IV fluids as necessary;
otherwise give 2500-3000 ml fluid/day to
accommodate high protein diet.
• Provide a high calorie diet (3000-4000calories
/day); and high quality protein(100-150
g/day or 1.5-2.0 g/kg)as tolerated.

17. • Provide 40% calories as CHOs to promote
glycogen synthesis and spare proteins.
• Do not limit fats unless not well tolerated
(steatorrhea);fat imparts taste and supplies a
concentrated form of calories.
• Supplement with multivitamin that includes B
complex esp,thiamine and vitamin B12;because
of decreased absorption; vitamin K to normalize
bleeding tendency; vitamin C and zinc for poor
appetite.

18. CIRRHOSIS and HEPATIC
ENCEPHALOPATHY
Cirrhosis is characterized
by fibrosis of the liver with
clinical manifestations of:
ascites,
portal hypertension, and
variceal bleeding that can
progress to hepatic
encephalopathy.
Cirrhosis of the liver can
progress to irreversible
change.

19. © 2007 Thomson - Wadsworth
Causes of Cirrhosis
• Hepatitis C
• Alcoholic liver disease
• Bile duct blockages
• All untreated types of chronic
hepatitis
• Drug-induced liver injury
• Some inherited metabolic
disorders

20. © 2007 Thomson - Wadsworth
Symptoms of Cirrhosis
• 40% of people are
asymptomatic
• Initial symptoms
– Fatigue
– Weakness
– Anorexia
– Weight loss
• Later symptoms
– Anemia
– Blood clotting
impairment
– Susceptibility to
infection
– Jaundice & fat
malabsorption
– Ascites & varices

21. © 2007 Thomson - Wadsworth
Consequence of Cirrhosis
• Portal Hypertension
– Scar tissue of liver impedes blood flow
– Causes a rise in pressure in the portal vein
– Blood is diverted to collaterals
– Collaterals become enlarged & engorged,
forming varices, & may rupture
• Esophageal
• Gastric

22. © 2007 Thomson - Wadsworth
Portal Hypertension

23. © 2007 Thomson - Wadsworth
Consequence of Cirrhosis
• Ascites
– Accumulation of fluid in the
abdominal cavity
– Due to
• Portal hypertension
• Reduced albumin
• Altered kidney function
– Abdominal discomfort & early
satiety
– Weight gain

24. © 2007 Thomson - Wadsworth
Consequences of Cirrhosis
• Hepatic encephalopathy
– Abnormal neurological
functioning
– Amnesia, seizures,
hepatic coma
• Elevated blood
ammonia level.
-Entrance of nitrogenous compound including
NH3 into the cerebral circulation.
-The concentration of aromatic amino
acid increases because the liver is not
able to break them down.
• Malnutrition & wasting

25. © 2007 Thomson - Wadsworth
Medical Nutrition Therapy
 Energy
Approximately 2000-3000 kcal per day or more to
minimize the endogenous protein catabolism.
 Protein
– High enough to maintain nitrogen balance
– 0.8-1.2 g/kg body wt /d.If hepatic coma is imminent
the lower the amount is indicated.
 Complex CHO
– May need to restrict fat with steatorrhea.MCT
(medium chain triglycerides)oil may be used to
provide calories).

26. © 2007 Thomson - Wadsworth
Medical Nutrition Therapy
• Sodium & Fluid
– With ascites, need to restrict fluid and
sodium.2000 sodium restriction is an
adequate restriction in most cases.
• Vitamins & minerals
– Multivitamin supplementation
– Liquid form if patient has varices
• Enteral & parenteral
– Specialized enteral products high in kcalories
– Parenteral if patient has obstructions,
bleeding, vomiting

27. Fiber Restriction:
reduce roughage in the diet to avoid damage to intestinal
mucosa and prevent GI bleeding if esophageal varices are
present.
A textured modified i.e;soft,low fiber or full liquid may be
needed if a regular diet irritates the esophageal mucosa.
Spices,caffeine,may also irritate esophageal varices.
Withhold hold food if esophageal varices bleed.
MEDICAL NUTRITION THERAPY

28. Dietary Treatment Of Hepatic Encephalopathy:
•Clients who have hepatic
encephalopathy should restrict
proteins because of their inability to
metabolize protein properly as a result
of poor liver function (yielding
increased ammonia level).
•high amounts of proteins result in
increased serum ammonia levels that
may precipitate hepatic
encephalopathy.

29. • Although animal proteins have high biological
value than plant proteins, clients tolerate non
animal proteins better than animal proteins
because ammonia is the end product of
metabolism of meat products.
• Omit foods that contains performed ammonia—
(bacon,shami kabab,seekh kabab)and gelatin.
• Dairy protein source may be used in the
preference of meat.

30. • Plant proteins contain fewer aromatic amino
acids and have more branched chain amino
acids.
• About 0.5 gm/day protein may be restricted (a
restriction less than this may result in
endogenous breakdown of proteins and further
nutritional deficiencies).
• Branched chain amino acids enriched parenteral
solution may improve significantly hepatic
encephalopathy.

31. BRANCHED CHAIN AMINO ACID AROMATIC AMINO ACIS
Metabolism independent on
liver function.
Blood levels reduced in
cirrhosis
Useful in
encephalopathy(valine,leucine,i
soleucine)
Metabolism dependent on liver
function.
Blood levels increased in
cirrhosis
Unfavorable in
encephalopathy(phenylalanine,
tyrosine,methionine).

33. GALL BLADDER DISORDERS

34. Bile: solution of bile
salts, cholesterol,
proteins,
phospholipids &
bilirubin
The gallbladder is a pear-
shaped, hollow structure
located under the liver and on
the right side of the
abdomen. Its
primary function is to store
and concentrate bile, a
yellow-brown digestive liquid
produced by the liver. The
gallbladder is part of the
biliary tract.

35. Gallbladder Disorders
A. Cholelithiasis and Cholecystitis
• 1. Definitions
– a. Cholelithiasis: formation of stones (calculi) within the
gallbladder or biliary duct system
– b. Cholecystitis: inflammation of gall bladder
• 2. Pathophysiology
– a.Gallstones form due to
• 1.Abnormal bile composition
• 2.Biliary stasis
• 3.Inflammation of gallbladder

36. Gallbladder Disorders
Risk factors for cholelithiasis
• a. Age
• b. Family history.
• c. Obesity, hyperlipidemia
• d. Females, use of oral contraceptives
• e. Conditions which lead to biliary stasis:
pregnancy, fasting, prolonged parenteral nutrition
• f. Diseases including cirrhosis, , glucose
intolerance

37. • Causes :
Cholesterol (main constituent of bile)
High consumption of dietary fat.
Treatment :
Medications to dissolve the stone and diet
therapy.

38. Diet Therapy:
Absistence during acute phase. This is
followed by clear liquid diet and gradually a
regular but fat restricted diet(40-45 g
fat/day).
 In Chronic phase fat restriction on
permanent basis.
In obese patients weight reduction + fat
restricted diet.

39. PANCREATITIS
Inflammation of the
pancreas caused by
infection,surgery,
alcoholism,bilary
tract disease bile
duct or gall bladder)
or certain drugs.
It may be acute or
chronic

40. Symptoms of Pancreatitis

41. Treatment :
• In Acute Phase -----parenteral nutrition, later as
patient tolerates clear liquid oral diet mainly
CHOs as they have less stimulatory effect on
pancreatic secretion.
• As recovery progresses, small frequent feedings
of CHO and proteins with little fat or fiber is
given.
• The fat is restricted.
• The patient is gradually returned to less
restricted diet as tolerated.

42. For Chronic Pancreatitis the goal of nutrition
therapy are to reduce steatorrhea,to
minimize pain and to avoid attacks by:
• Limiting Fat to the maximum amount the
patient can tolerate without causing
steatorrhea,to or pain---usually 50 g/day or
less.
• Provide liberal quantities of CHOs and
proteins.
THANK YOU

43. Sample Menu For a Patient With Cirrhosis Of Liver
Breakfast
Toasts 2 with jam
Tea
Mid morning
A glass of fruit juice
Lunch
Rice and dal
Vegetable cutlet
Banana
Mid afternoon
Tea with biscuits
Dinner
Chicken soup
Vegetable curry
Chappatti
Jelly