Kharader General Hospital

School Of Nursing
GENERIC BSN, 1ST YEAR,2ND SEMESTER
APPLIED NUTRITION
1-CREDIT HOUR

Rehan Ahmad
(Generic BSN, B.Ed)

Nursing Instructor
Kharadar General Hospital School of Nursing
UNIT VI: NUTRITION FOR DISORDERS OF THE
LIVER,GALLBLADDER AND PANCREAS
Learning objectives

• Describe the role of diet in the management of gall stone.

• Describe the role of diet management of liver diseases. Especially
hepatitis, cirrhosis. Encephalopathy.
• Discuss current beliefs and practices related to diet in Liver disease in the
community.
• Identify the role of the nurse in dietary management of Liver disease.
 Diseases Of the Liver
•Hepatitis
•Fatty liver
•Cirrhosis
•Hepatic Encephalopathy
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
 Fatty liver

 Infiltration of the liver by fat

 Possible causes include:

 Alcohol
 Obesity
 Type 2 diabetes
 Hyperlipidemia
 Sudden rapid weight gain
 Hepatitis C
 TPN
 Symptoms:
• Often asymptomatic of liver disease at time of
diagnosis.
• Fatigue or feeling of fullness or discomfort on
the
right side of abdomen.

Therapy:
• Abstinence from alcohol (if that is the cause)
• Restriction of total dietary fat content <30% of
total calories.
• Low CHO intake 40-45% of caloric intake.
 HEPATITIS
Inflammation of the liver
HEPATITIS
VIRAL HEPATITS
Symptoms of Hepatitis
 Associated Nutritional Problems

• Patients require adequate calorie intake and a balanced diet in order to

maintain liver function.

• They may suffer from anorexia, nausea, and vomiting, which may prevent
them from maintaining adequate intake.

• Vitamins/minerals deficiencies can occur because of impact on liver.

 Dietary Measures Used As Treatment

• 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 vomiting , 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.
• 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.
Patients suffering from HCV sometimes have increased iron concentration
in the liver; avoid multivitamins with iron, restrict iron rich foods such as
red meat, liver, iron fortified cereals, and avoid cooking with iron coated
cookware.
 CIRRHOSIS

• 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.
 Causes :

• Chronic alcoholism

• Medications

• Autoimmune disease

• Progression of viral hepatitis

 Symptoms of cirrhosis:
• Malaise & lethargy,
• Dyspepsia,
• Bloating,
• Nausea, vomiting and anorexia.
• As disease progresses, complications
develop leading to jaundice,
hepatomegaly, ascites, secondary
infections, and hepatic encephalopathy.
• Abnormal liver function tests ( elevated
liver enzymes), decreased albumin,
elevated NH3 level, and alteration in
coagulation are common findings.
 Complications Of Liver Cirrhosis

• Portal HTN
• Esophageal varices
• Ascites
• Hyper ammonemia
• Hepatic encephalopathy
• Malnutrition
 Associated Nutritional Problems:

• Nutritional status is influenced by the livers role in the

intermediate metabolism of CHOs, proteins, lipids and vitamins.

• Decline in nutritional status can further impair liver function.

• Inadequate metabolism of CHOs can result in low energy and

lethargy.

• Electrolyte imbalance is common because of poor storage of

minerals.
• Vitamin deficiencies are
common: nutrient intake is
poor.
• Esophageal varices may result,
requiring medical
interventions.
 Dietary Treatment of Liver Cirrhosis
• Calories : provide at least 25-35 kcal or
more(2000-3000) kcal or more to
minimize endogenous protein catabolism.

• Proteins : 0.8-1.0 g protein /kg body wt

/day, dependent on the patient’s
condition. If hepatic coma is imminent,
the lower amount is indicated. In some
forms proteins are not tolerated and
restricted to 30-40g/d. Purpose is to
maintain nitrogen balance; and liver
repair.
• CHO: 50-60 % calories should be provided from CHO. Approximately
300-400 gm/day to minimize endogenous protein catabolism.

• FAT: Fat intake may vary according to clinical manifestation. Fat

intake is only restricted if the patient experiences steatorrhea.
MCT(medium chain triglyceride ) oil may be used for calories;
however, it does not contain the essential fatty acids.
• Vitamins : A necessary part of a diet
therapy. Provide a multivitamin
supplement daily. Diet containing 50 g
proteins or less may be deficient in
thiamine, riboflavin, calcium, niacin,
phosphorous and iron.

• Sodium : May need to be restricted to

2000mg if edema or ascites is present.
Sometimes it is necessary to restrict
sodium as little as 1000mg/d for
patients whose edema and ascites are
resistant to diuretic therapy.
• Fluids : given in relation to input and output records,
daily weights, and electrolyte values. Fluid
restrictions are often necessary to prevent or
decrease ascites formation. Fluid restriction usually
begins at 1500ml/d and may decrease to 1200ml/d
on the patients response.

• 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 and caffeine may also irritate
esophageal varices. Withhold hold food if esophageal
varices bleed.
 Nutritional Monitoring:

• Monitor catabolic stress factors such as infection, trauma, surgery or

steatorrhea in order to make adjustments in protein requirements.
• Monitor clients response to fluid restriction ordered to prevent or
decrease ascites)to maintain weight loss objective(0.5 to 1.0 kg/d).
• Monitor renal function because potassium may need to be
restricted if renal function is inadequate. Potassium
supplementation may be needed if K+ wasting diuretics are used.
 HEPATIC ENCEPHALOPATHY
║
HEPATIC COMA

• Hepatic encephalopathy or coma is a potential and serious

complication of advanced liver disease.
 Symptoms :

• Confusion
• Restlessness
• Irritability
• Inappropriate Behavior
• Drowsiness
• Fecal odor of breath
• Electrolyte imbalance
 Causes Of Hepatic Coma:
• Elevated blood ammonia level
• Entrance of nitrogenous compound including NH3 into the cerebral circulation.
• The concentration of aromatic amino acid ( phenylalanine, tyrosine and
tryptophan) increases because the liver is not able to break them down.
• High than normal insulin levels increase the uptake of branched chain amino
acid( valine, leucine, isoleucine) into the muscle cells so that the concentration
of these amino acids decreases.
• The increase concentration of aromatic amino acids to branched chain amino
acids may interfere with the formation of certain neurotransmitters(dopamine,
norepinephrine)and causes the formation of substances that may contribute to
hepatic coma.
Dietary Treatment Of Hepatic
Encephalopathy:
• Patients 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.
• 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 kebab, seekh kebab) and
gelatin.

• Dairy protein source may be used in the

preference of meat.
• 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.
GALL BLADDER DISORDERS
The most common gallbladder disorders are:

• Cholecystitis : Inflammation of the gall bladder associated with pain,

tenderness and fever.
• Cholethiasis : Presence of stones in the gall bladder.
• Choledocolithiasis: Gall stones in the common bile duct.
Suggested Risk Factors in Gall bladder
Disease:

• Advanced age
• Gender (female)
• Obesity with high fat intake
• Hormonal imbalance(estrogen, progestrin,insulin)
• Certain drugs oral contraceptives)
• Enzyme defects
 Causes :

• Cholesterol (main constituent of bile)

• High consumption of dietary fat.
• Treatment :
• Medications to dissolve the stone and
diet therapy.
 Diet Therapy:
• Abstinence 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.
 PANCREATITIS

• Inflammation of the pancreas caused

by infection, surgery, alcoholism,
biliary tract disease bile duct or gall
bladder) or certain drugs.

• It may be acute or chronic.

 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 because of Lipase deficiency.
• The patient is gradually returned to less restricted
diet as tolerated.
• 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.
• Eliminating individual intolerances and gastric acid stimulants.
 Foods & seasonings that stimulate Gastric Acid Secretion:

• Coffee ( regular, decaffeinated)

• Black pepper
• Caffeine
• Chilli powder
• Cloves
• Garlic
• Peppermint and spearmint oils
 References

1. Ruth A. Roth (2011).Nutrition and Diet Therapy (10th edition): Maxwell

drive Clifton park USA.
2. S.R. Mudambi, M.V. Raja Gopal (2006). Fundamental of Food, Nutrition
and Diet Therapy (fifth edition): New age international Publisher India.