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Clinical and Therapeutic Nutrition PRACTICAL7 NUTRITIONAL MANAGEMENTINLIVER, GALLBLADDERAND PANCREATICDISEASES Structure 7.1 Introduction 7.2 Liver, Gall Bladder and Pancreatic Diseases: An Overview 7.3 Diseases of the Liver: Pathophysiology and of Dietary Management Principles 7.3.1 Infectious Hepatitis 7.3.2 LiverCirrhosis 7.4 Diseases of Gall Bladder 7.4.1 PrinciplesofDietaryManagementCholelithiasis/Cholecystitis 7.5 Diseases of the Pancreas 7.5.1 PrinciplesofDietaryManagementPancreatitis 7.6 Review Exercises Activity 1: Diet Plan for Hepatitis Activity 2: Diet Plan for Liver Cirrhosis Activity 3: Diet Plan for Choletihiasis/Cholecystitis Activity 4: Diet Plan for Pancreatitis 7.1 INTRODUCTION In the previous practical we learnt about the dietary management of the diseases associatedwiththegastrointestinaltract. Inthis unit wewilldiscuss aboutthediseases of the liver, gall bladder and pancreas. Hepatitis, cirrhosis, cholecystitis/cholelithiasis and pancreatitis are the major diseases which will be discussed in this practical. We willbeginwithabriefonthepathophysiology(impactonnutritionalstatus),characteristic symptomsoftheabovementioneddiseasesandthereafterfocus onthevariousaspects ofdietarymanagement. Theactivitiesincludedinthispracticalwillhelpustounderstand andlearnabouttheappliedaspectsrelatedtoworkingoutaday’sdietfor eachdisease. Beforeyoubegin,wesuggest you lookup theconcepts relatedtothepathophysiology and principles of diet planning related to these disease already covered in the theory course (MFN-005)in Unit 15. Objectives After undertaking this practical, you will be able to: discuss the diseases of the liver, gall bladder and pancreas, describe the various aspects of dietary management of the liver, gall bladder and pancreas diseases, and plandiets for hepatitis, cirrhosis, cholecystitis/cholelithiasis andpancreatitis. 134 Nutritional 7.2 LIVER,GALLBLADDERANDPANCREATIC Management in Liver, Gall Bladder and DISEASES:ANOVERVIEW Pancreatic Diseases Nutritionalsupportplaysamajorroleintheclinicalmanagementofpatientswithliver, pancreas and biliary disease(s). It has widely been recognized that malnutrition adversely affects outcome in both chronic and acute form of diseases of the liver, gall bladder and/or arise in patients with chronic forms of hepatobiliary and pancreatic disorders. Thus, theobjectives of thenutritional support shall be to providenutrient in thecorrectquantityandform,torestoreandmaintainnutritionalstatus,correctspecific deficiencies, treat clinical symptoms and promote regeneration of the lost tissues. Wide spectrums of diseases are associated with the insufficiency and/or dysfunction of liver, gall bladder and pancreas and the most important ones include: Liver Gall Bladder Pancreas Acuteviral hepatitis Cholecystitis Acute pancreatitis Liver cirrhosis Cholelithiasis Chronic pancreatitis Hepatic Encephalopathy Cystic fibrosis or Hepatic Coma Tumors Pancreatic abscesses Fistulas Let us briefly recapitulate the pathophysiology, symptoms and dietary management related to these disorders. 7.3 DISEASESOFTHELIVER: PATHOPHYSIOLOGYANDDIETARY MANAGEMENTPRINCIPLES Liver is a vital organrequiredfor our survival. It is requiredfor theproper metabolism of proteins, carbohydrates and fat. Liver is involved in the storage, activation and transport of manyvitamins andminerals suchas vitaminA, D, B12, zinc, iron, copper, magnesiumetc. Italsoplaysanimportantimmunologicalanddetoxificationfunctions. Diseases of theliver canbeacuteor chronic, inheritedor acquired. Themost common one’s being hepatitis (acute, fulminant, chronic, alcoholic), cirrhosis, hepatic encephalopathy. The major pathological changes associated with liver diseases are atrophy, fatty infiltration, fibrosis and neurosis of the hepatic cells. Jaundice whichis synonymously usedfor hepatitis is actually a symptom common to all liver diseases and is characterized by elevated levels of bilirubin in the blood. Hyperbilirubinemiamaybeduetoabnormalitiesintheformation,transport,metabolism and excretion of bilirubin. Normal plasma bilirubin levels are 2-8 mg/litre. Clinical signs of jaundice generally appear when the plasma concentrations are between 8-20 mg/litre. Wehavealready discussed in Unit 15 (in theTheory Manual) the clinical details and etiologicalfactors for somecommonlyencountereddiseasesoftheliver. Inthissection we will, therefore, recapitulate the pathophysiology and the dietary management principles for the liver diseases. Let us first learn about hepatitis. 7.3.1 Infectious Hepatitis Infectioushepatitis,youmayrecallstudying,isadiseasecharacterizedbyinflammation and degeneration of the liver cells. Hepatitis may occur due to reactions with drugs, toxic agents and various viruses. The most common form of hepatitis is that caused 135 Clinical and byfaecal contamination of food and water with TypeAvirus. Serum hepatitis (Type Therapeutic Nutrition B) is next most frequently occurred form. As for the symptoms, mild constant abdominal pain, malaise, easy fatigability, upper respiratory symptoms, anorexia, nausea, frequent episodes of vomitting along with diarrhoea or constipation may occur during the initial stages. Jaundice occurs in 5-10daysandthereisworseningoftheabovementionedsymptoms.Intheconvalescent phase, increasing sense of well being, return of appetite along with reduction in the severityofjaundice, abdominalpain,tendernessofliver andfatigabilityisexperienced. While the above mentioned symptoms may subside in 2-8 weeks; complete recovery takes a long-time. Majority of the symptoms associated with the term ‘jaundice’ adversely affect the food intake. Further, patient may also experience low grade fever thereby increasing the nutritional demands on the body. Efficient treatment and managementofhepatitisisamusttopreventitsprogressiontowardscirrhosis/hepatic encephalopathy etc. Let us then study about the treatment of hepatitis. Treatment The treatment focuses on: Dietary management to maintain a good nutritional status. Bed rest or avoidance of strenuous physical activity. Drugs, if required (non-metabolism). Avoidanceof hepatotoxic agents particularly alcohol. Let us focus on the dietary management of hepatitis next. Dietary Management of Hepatitis Irrespective of the cause of hepatitis, regeneration of the lost liver cells is essential to promote recovery and hence promote proper functioning of the organ. Relapse of hepatitis or progression of acutehepatitis to a chronic form/cirrhosis occurs many-at- times duetoimpairednutritionalstatus. Liver beinga storehousefor severalnutrients (particularly vitamins/minerals), the nutritional reserves may get depleted during hepatitis. Thus, the major objectives of dietary management include: to promote a positive energy and nitrogen balance, to promote recovery and prevent progression of the disease, to replenish the depleted reserves, and toensuresatisfactoryconvalescenceandmaintainanoptimumnutritionalstatus. Wewill now discuss the nutrient modifications necessary to promote quick recovery and prevent further degeneration of hepatic cells. Let us start with the calorie requirement. Energy: Majority of the patients experience weight loss and are malnourished due to reducedfoodintake. Lowgradefever isgenerallypresent duringviralhepatitis which also imposes increased demands for calories due to an increase in basal metabolic rate. Adequateenergyintake is also essential to ensure proper utilization of proteins. The energy requirements may increase by 15 to 30% depending upon the existing nutritional status. However, the energy intake should be increased gradually. An aggressiveincreaseinenergyresults in aggravatinggastrointestinaldisturbance. Due to severity of jaundice during the early stages it may not be feasible to provide more than 1200 Kcal per day. However, during the convalescence phase, adequate intake of energy is feasible and a must to ensure complete recovery. If the patient is grossly underweight, theenergyintakemaybecalculatedas35Kcal/kgIBWtoensureweight gain and replenishment of glycogen reserves. 136 Protein:Theproteinintakeshouldbeincreasedby50%to100%inmildandmoderate Nutritional cases of hepatitis i.e. the patient should be given 1.5 to 2.0 gm protein per kg IBW per Management in Liver, Gall Bladder and day. However, if hepatitis is severe and there is risk of developing cirrhosis; the Pancreatic Diseases protein intakeshould not exceed 1.0 g/kgIBW/day i.e. theprotein shouldbe provided as per the RDI. Fat: Fats should not be severely restricted as they can make the food unpalatable. About 20% of the total calories should be from fat. MCTs are preferred as they are easily digestible and assimilable (40-50 g). For example, dairy fat cream and butter are preferable. Carbohydrates:Inmildandmoderatecasesofhepatitis,carbohydratesshouldprovide atleast 60% of the total energy. Liberal intake of carbohydrate helps in replenishing the glycogen reserves and sparing the proteins for tissue regeneration. However, in severe chronic hepatitis determining the carbohydrate needs is often a challenge because liver failure reduces glucose production, glucose utilization and there is preference for the use of lipids and proteins as alternative sources of protein. In such situations thecarbohydrateintakeshouldnotexceed60%ofthetotalenergy. Emphasis should be laid on the inclusion of food rich in monosaccharides, disaccharides and starches. Dietary fibre intake should be kept minimum. All fibre rich foods should preferably be avoided and if given, should be in a soft cooked form. Thus, include goodamountsofglucose,dextrose,jaggery,honey,sugar,ago,rice,refinedfour,pastas, starchyrootsandtubers(potato,yam,colocasiacetc.),highcarbohydratefruits(banana, mango, sapota, raisins etc.) Vitamins and Minerals: Impaired liver function and its associated symptoms can result in increaseddemandofB-group vitamins,ascorbicacid,vitaminA,K, calcium, andiron.Amongallthenutrient,fatmalabsorptionisthegreatest,therefore-carotene rich foods should be included in the diet. Include adequate amount of fresh fruits and vegetables in soft cooked form such as mashed pureed vegetables, vegetable soup, fruit juice, stewed fruit, fruit jellies, fruit jam, milk shakes, etc. Fluids:Fluidintakemayneedtobeincreasedifthepatientissufferingfromdiarrhoea and/or constipaton. In such cases include good amounts of clear and full-fluids in the diet such as: a) Clear fluids: Coconut water, tea/coffee (without milk,) barley water, strained vegetable/ pulse/ meat soup, strained fit juices, strained carrot/rice kanji etc. b) Full fluids: Milk based beverages such as tea, coffee, milk shake, soufflé, bakedcustard, soup, juice, egg nog, fruit jellies etc. General Considerations Theother considerations include: Highenergyhighprotein diet should be given to patients suffering from mild to moderate hepatitis. During acute hepatitis or if vomitting/diarrhoea is severe, a full fluid or a semi- soft diet may need to be given. Small, frequent, easy to digest bland meals should be served to the patient. The meals should particularly be mechanically and chemically bland. Sincepatientsexperiencenauseaandanorexia, itisessentialtopreparepalatable meals which are attractively served. Inclusion of variety in terms of colour, texture, taste, flavour and mouth feel is important to motivate the patient (particularly children) to consume food. Moistheatmethodsofcookingsuchasboiling,pressurecooking,stewing,steaming should be preferred over dry heat methods such as roasting, grilling etc. 137
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