How to manage it

1. Nutrition & Diet Therapy, 7th Edition
Nutrition Therapy for Liver
& Gallbladder Diseases
Chapter 20

2. Nutrition & Diet Therapy, 7th Edition
Functions of Liver &
Gallbladder
• Liver—most active organ in body
– Receives & processes nutrients absorbed by
small intestine
– Makes bile for fat emulsification
– Synthesizes most proteins circulating in
plasma
– Detoxifies drugs & alcohols
– Processes excess nitrogen for excretion as
urea
• Liver damage or disease can profoundly
affect health & nutritional status

3. Nutrition & Diet Therapy, 7th Edition
I. Fatty Liver & Hepatitis
• Most common of liver disorders
• Usually mild & reversible, but
can progress to serious illness
& liver damage

4. Nutrition & Diet Therapy, 7th Edition
Fatty Liver
• Accumulation of fat in liver
tissue; represents
imbalance between fat
synthesized from the blood
& the amount exported to
the blood via VLDL
• Causes are unclear, but
associated with:
– Alcoholic liver disease
– Result of exposure to
drugs & toxic materials
– Associated with obesity,
diabetes mellitus, diseases
of malnutrition
– May follow gastrointestinal
bypass surgery or long-
term TPN
• Consequences
– Liver enlargement
(hepatomegaly),
inflammation, fatigue
– Abnormal levels of liver
enzymes
– Increased levels of
triglycerides, cholesterol,
glucose
– Liver damage & failure
• Treatment
– Elimination of factors
causing it
– Weight reduction
– Control of blood glucose
levels

5. Nutrition & Diet Therapy, 7th Edition
Hepatitis
• Inflammation of liver,
resulting from damage
to liver tissue
• Cause often infection
with specific viruses
(A, B, C)
• Usual transmission
– Blood contact with
infected persons
– Ingestion of
contaminated food or
water
– Excessive alcohol intake
or exposure to certain
drugs & toxic chemicals
• Symptoms
– Effects depend on cause
& severity of disease
– Fatigue
– Nausea, anorexia
– Pain in liver area
– Liver enlargement
– Jaundice
– Fever
– Headache, muscle
weakness
– Skin rashes
– Elevation of liver
enzymes (ALT, AST)

6. Nutrition & Diet Therapy, 7th Edition
Hepatitis
• Treatment
– Supportive care; bed rest & appropriate diet
– Avoidance of substances that aggravate liver (alcohol, drugs or dietary
supplements that cause liver damage-chaparral, germander, ma
huang, saw palmetto and jin bu huan)
– Hepatitis A usually resolves without medications
– Hepatitis B & hepatitis C infections may require antiviral agents
– Nonviral forms: treated with anti-inflammatory & immunosuppressant
drugs
• Nutrition therapy
– May require high-kcalorie, high-protein diet to replenish nutrient
stores
– Liquid supplements may improve nutrient intakes
– Small, frequent meals easier to tolerate for patients with anorexia or
GI discomfort
– Fluid & electrolyte replacement necessary in case of vomiting
– Sodium & fat restriction may be recommended

7. Nutrition & Diet Therapy, 7th Edition

8. Nutrition & Diet Therapy, 7th Edition
II. Cirrhosis
• End-stage condition resulting
from chronic liver disease
– Gradual destruction of liver
tissue, leading to scarring
– Progressive disease results in
increased scarring, few areas
of healthy tissue
• Impairs liver function & can
lead to liver failure
• Causes
– Alcohol abuse & hepatitis C
infection most common
causes
– Chronic hepatitis
– Drug-induced
– Inherited disorders
– Bile duct blockages
• Consequences
– Initial disease: mild or
asymptomatic, fatigue,
weakness, anorexia,
weight loss
– Later disease: decline in
liver function, anemia,
impaired blood clotting,
increased susceptibility to
infection, jaundice, fat
malabsorption
– Advanced disease:
disruption of kidney & lung
function
– Altered liver enzymes,
bilirubin levels
– Lowered albumin levels,
extended clotting times
– Elevated blood ammonia
levels

9. Nutrition & Diet Therapy, 7th Edition
Cirrhosis
• Consequences (con’t)
– Portal hypertension
• Scarred tissue of cirrhotic liver
impairs blood flow through liver
• Resistance to blood flow
increases pressure in portal
vein: portal hypertension
– Collaterals & gastroesophageal
varices
• Collateral circulation-smaller
blood vessels enlarge to allow
alternative pathway for blood
flow because (in GI tract & near
abdominal wall)
• As a result, varices form
(collaterals become enlarged &
engorged with blood)
• Ruptured esophageal or gastric
varices can result in massive
bleeding, often fatal
– Ascites
• Accumulation of fluid in the
abdominal cavity; indicates
critical stage of liver
damage
• Thought to be consequence
of portal hypertension,
reduced albumin synthesis
& altered kidney function
– Hepatic encephalopathy:
characterized by abnormal
neurological functioning
• Changes in personality,
mental abilities & motor
function
• Amnesia, seizures
• Hepatic coma
– Elevated blood ammonia
levels
– Malnutrition & wasting

10. Nutrition & Diet Therapy, 7th Edition

11. Nutrition & Diet Therapy, 7th Edition

12. Nutrition & Diet Therapy, 7th Edition
Treatment of Cirrhosis
• Individualized according to disease severity & complications
– Supportive care
– Appropriate diet
– Avoidance of liver toxins
– Abstinence from alcohol
• Drug therapy
– Medications for portal hypertension, varices
– Diuretics
– Appetite stimulants
– Medications to reduce or control blood ammonia levels
• Nutrition therapy
– Customized for each patient’s needs
– Avoidance of substances that can cause further liver damage
– Enteral & Parenteral nutrition support as indicated

13. Nutrition & Diet Therapy, 7th Edition

14. Nutrition & Diet Therapy, 7th Edition
III. Liver Transplantation
• Liver failure (resulting from acute or chronic liver
disease) may require transplantation as only
treatment option
• Most common result of hepatitis C infection or
alcoholic liver disease
• Nutrition status of transplant patients
– Usually associated with malnutrition (common with
advanced liver disease)
– Correction of malnutrition prior to surgery can help
speed recovery
– Associated deficiencies: vitamins B6, B12, C, thiamin,
niacin, folate, fat-soluble vitamins, calcium, magnesium,
phosphorus, potassium, zinc

15. Nutrition & Diet Therapy, 7th Edition
Liver Transplantation
• Post-transplantation concerns
– Immediate concerns: organ rejection & infection
– Immunosuppressive drugs reduce immune response that
causes rejection, but increase risk of infection
– Effects of immunosuppressant drugs on nutrition
• GI side effects (nausea, vomiting, diarrhea, abdominal pain,
mouth sores)
• Alteration in appetite & taste perception
• Hyperglycemia, diabetes
• Fluid & electrolyte imbalances
• Hypertension, hyperlipidemia, protein catabolism, increased
osteoporosis risk
– Increased protein & energy requirements after transplantation
due to stress of surgery; includes snacks and enteral
supplements.
– Vitamin & mineral supplementation
– Food safety concerns to reduce risk of food-borne illnesses

16. Nutrition & Diet Therapy, 7th Edition
IV. Gallbladder Disease
• Gallstones (cholelithiasis)
– Gallbladder stores the bile made
by the liver
– Disorders of gall bladder & bile
ducts result in formation of
gallstones
– Results from excessive
concentration & crystallization
– Two Types
– 1. Cholesterol gallstones:
majority of cases of gallstones;
composed primarily of
cholesterol; precipitation of
cholesterol out of solution
eventually forms stones
– 2. Pigment gallstones:
composed mainly of calcium salt
of bilirubin; often result of
bacterial infection
Bile: solution of bile
salts, cholesterol,
proteins, phospholipids
& bilirubin

17. Nutrition & Diet Therapy, 7th Edition
Gallbladder Disease
• Consequences of gallstones
– Many asymptomatic
– Other symptoms—usually
occur when gallstones block
cystic duct
• Steady & severe pain
• Nausea, vomiting, bloating
• Symptoms mainly occur after
meals, especially fatty foods
• Complications
– Cholecystitis
– Peritonitis
– Blockage of common bile duct
– Infection
• Risk factors for gallstones
– Ethnicity
– Age & gender
– Pregnancy
– Obesity & weight loss
– Other risk factors
• Long-term TPN
• Medications
• High TG levels
• Treatment
– Low fat diet
– Cholecystectomy
– Non-surgical
• Capsule urso-deoxycholic
acid (cholesterol
production; used on small
stones)
• Shock-wave lithotripsy
(used on few and larger
stones)

18. Nutrition & Diet Therapy, 7th Edition
Nutrition in Practice—Alcohol in
Health & Disease
• Excessive alcohol consumption is primary cause of
liver disease
• Can result in toxicity to other organs, including brain,
GI tract, pancreas
• Moderate use, however, shown to reduce deaths from
coronary heart disease in middle-aged & older adults
• Current dietary guidelines (Dietary Guidelines for
Americans 2005)
– Adults should limit intake to 1 drink/day (women) to 2
drinks/day (men)
– Avoidance of all alcohol: pregnant & lactating women,
women who may become pregnant, children &
adolescents, individuals who are taking medications that
may interact with alcohol, individuals who are unable to
voluntarily restrict intake

19. Nutrition & Diet Therapy, 7th Edition
• Alcohol in the body
– Source of food energy (providing
7 kcalories per gram)
– Quickly absorbed in stomach &
small intestine; passes readily into
body cells
– Liver is site of most alcohol
metabolism
• Metabolism in liver takes priority
over metabolism of other
substances
• Interferes with metabolism of
other substances
– Suppresses storage of glycogen &
availability of glucose between
meals, increasing risk of
hypoglycemia
– Suppresses breakdown of fat for
energy, increasing VLDL
– Inhibits protein synthesis
• Cellular toxicity
– Alcohol alters structure of cell
membranes, interferes with
actions of cell membrane
proteins
– Under certain conditions,
exposure to alcohol can
induce cell death
• Effects on brain function
– Acts as central nervous
system depressant
• Causing sedation
• Slowing reaction times
• Relieving anxiety
– Extremely high blood alcohol
levels can lead to coma &
death
– Chronic heavy drinking can
lead to neurological damage

20. Nutrition & Diet Therapy, 7th Edition
• Effects of excessive alcohol consumption
on nutrition status—nutrient deficiencies
– High kcalorie content displaces other energy
sources, including essential nutrients
– Widespread malabsorption occurs as result of
damage to GI mucosa
– Interferes with body processing of nutrients
• Increased destruction of vitamin A
• Reduction of thiamin (vit. B1) absorption & activation
• Reduction of folate absorption
– Disruptive effect on metabolism of medication

21. Nutrition & Diet Therapy, 7th Edition