Nutrition Therapy for Liver

and Gallbladder Diseases

Chapter 20
Functions of Liver and Gallbladder

Liver
Very metabolically active
Processes, stores, and redistributes nutrients
Produces bile that emulsifies fat
Makes proteins that circulate in plasma
Detoxifies drugs and alcohol
Processes excess nitrogen for excretion as urea
Liver disease can profoundly affect health

Image Source: Marieb & Hoehn, Human Anatomy & Physiology, 10 th ed., Pearson
Fatty Liver and Hepatitis Most common liver disorders
Can be mild and reversible
Can progress to serious illness
and damage liver
Liver disease progresses slowly
Primary symptom: fatigue
Often goes unnoticed
Accumulation of fat in liver tissue
Imbalance between fat produced in
liver or picked up from blood and
amount exported to the blood via
VLDL
Many causes
Metabolic defects
Excessive alcohol ingestion or
exposure to drugs and toxins
*Insulin resistance is primary risk factor

https://liverfoundation.org.au
Consequences and Treatment of Fatty Liver

Can be asymptomatic and cause no harm

Can cause inflammation, liver enlargement, and fatigue
May progress to cirrhosis, liver failure, or liver cancer
Treatment
Elimination of factors causing it
Weight reduction
Control of blood glucose levels
Lifestyle modifications not always successful

https://liverfoundation.org.au
 Liver inflammation caused by damage to liver
tissue
Hepatitis Viral hepatitis
-Hepatitis A virus: Spread via fecal-oral
transmission
-Hepatitis B virus: Transmitted by infected
blood or needles, sexual contact, or during
childbirth
-Hepatitis C virus: Spread by infected blood
or needles

https://newsnetwork.mayoclinic.org
 Symptoms and Signs of Hepatitis
Effects depend on cause and severity
of condition
Asymptomatic
Fatigue, nausea, or anorexia
Pain or tenderness in liver area
Jaundice, fever, muscle
weakness, joint pain, and skin
rashes
Elevated levels of liver enzymes
ALT and AST

https://newsnetwork.mayoclinic.org
 Treatment of Hepatitis
Supportive care and appropriate diet
Avoid alcohol, drugs, or dietary
supplements that cause liver
damage
Hepatitis A usually resolves without
medications
Hepatitis B and C infections may
require antiviral agents
Nonviral forms: anti-inflammatory
and immunosuppressant drugs

https://newsnetwork.mayoclinic.org
Fatty Liver and Hepatitis
Hepatitis
• Nutrition Care: Varies with patient’s nutrition status and symptoms
• Malnourished individuals need adequate protein and energy
• Small, frequent meals easier to tolerate for patients with anorexia or
abdominal discomfort
• Fluid and electrolyte replacement necessary in case of vomiting

DeBruyne & Pinna, 2020

 Cirrhosis
Late stage of chronic liver disease
Gradual destruction of liver tissue,
leading to scarring
Liver shrinks in size
Can lead to liver failure
Main causes
Chronic hepatitis C infection
Alcoholic liver disease

https://www.topsante.com/
 Consequences of Cirrhosis, Part 1
Initially mild or asymptomatic
Fatigue, weakness, anorexia, or
weight loss
Later stage symptoms
Anemia, impaired blood
clotting, and increased
susceptibility to infection
Advanced stage
Disrupted kidney, lung, and
brain function

http://testdpc.co/liver-repair-after-alcoholism.html
Cirrhosis Continued 2

Consequences of Cirrhosis
FIGURE 20- 1 Clinical Effects of Liver Cirrhosis

© 2020 Cengage. All rights reserved.

Laboratory Tests for Evaluation
of Liver Disease
Laboratory Test Normal Ranges Values in Liver Disease
(serum)
Alanine aminotransferase (ALT) Mate: 10-40 U/L Increased
Female: 7-35 U/L
Albumin 3.4-4.8 g/dt Decreased

Alkaline phosphatase 25-100 U/L Normal or increased

Ammonia 15-45 ug N/dL Increased

Aspartate aminotransferase (AST) 10-30 U/L increased

Bilirubin (total) 0.3-1.2 mg/dL Increased

Blood urea nitrogen (BUN) 6-20 mg/dL Normal or decreased

Gamma-glutamyl transpeptidase Mate: 2-30 U/L Increased

(GGT) Female: 1-24 U/L
Prothrombin timea 11-15 seconds Prolonged

a
The test for prothrombin time evaluates the clotting ability of blood.
Note: U/L = units per liter; dL = deciliter; ug = micrograms; N = nitrogen
Consequences of Cirrhosis, Part 2
Portal hypertension
Scarred tissue of cirrhotic liver
Impedes liver blood flow
Increases pressure in portal vein
Collaterals and gastroesophageal varices
Collateral circulation develops as smaller blood vessels
enlarge
To allow alternative pathway for blood

Image Source: Marieb & Hoehn, Human Anatomy & Physiology, 10 th ed., Pearson
 Consequences of Cirrhosis, Part 3

• Ascites:
• Accumulation of fluid in the abdominal
cavity
• Indicates critical stage of liver damage
• Hepatic encephalopathy: Changes in
personality, mental abilities, and motor
function
• Elevated blood ammonia levels
• Malnutrition and wasting

https://www.youtube.com/watch?v=uMjxDuFFZ00
Clinical Effects of Liver Cirrhosis

Figure 20-4 Esophageal varices

Figure 20-5 Ascites

Treatment of Cirrhosis

Supportive care
Appropriate diet
Avoidance of liver toxins and alcohol
Medications prescribed to treat symptoms and complications

Image Source: Marieb & Hoehn, Human Anatomy & Physiology, 10 th ed., Pearson
Cirrhosis Continued 9
Nutrition Therapy for Cirrhosis
• Avoid substances that cause further liver damage
• Soft diet if esophageal varices are present
• Energy
• Small, frequent meals and oral supplements
• Patients with ascites advised to restrict sodium
• Nutrient supplementation
• Enteral and parenteral nutrition support
Cirrhosis Continue 8

Treatment of Cirrhosis
TABLE 20- 5 Possible Causes of Malnutrition in Liver Disease

© 2020 Cengage. All rights reserved.

Mechanism Examples
Reduced nutrient Abdominal discomfort, altered mental status, altered taste
intake sensation, dietary restrictions, early satiety (due to ascites), effects
of medications (including Gl disturbances and taste changes),
fasting for medical procedures, fatigue, nausea and vomiting
Malabsorption or Diarrhea, effects of medications (including malabsorption and
nutrient losses nutrient losses from diuretic use), fat malabsorption (due to
reduced bile flow), Gl bleeding, vomiting
Altered metabolism Hypermetabolism, impaired protein synthesis, infections or
or increased nutrient inflammation, muscle catabolism, reduced nutrient storage and
needs metabolism in the liver, reduced synthesis of nutrient transport
proteins
Cirrhosis Continued 10
Nutrition Therapy for Cirrhosis
TABLE 20- 5 Nutrition Therapy for Liver Cirrhosis
Factor Needs for Therapy of Liver Cirrhosis
Energy • Energy needs range from 25 to 40 kcal/kg body weight per day; patients with stable cirrhosis

© 2020 Cengage. All rights reserved.

usually require 25 to 35 kcal/kg per day, whereas those with multiple complications or malnutrition
may require 30 to 40 kcal/kg per day.
• In patients with ascites, a value for “dry body weight” should be used for calculating nutrition needs.
• Energy requirements may be higher in patients with hypermetabolism, catabolism, infection,
malabsorption, or recent unintentional weight loss. Energy requirements may be lower in patients
who would benefit from weight loss.
Meal frequency • To improve food intake, patients should consume small meals and snacks four to six times daily. A
bedtime snack may help to reduce muscle catabolism during the night.
Protein • Patients should consume 1.0 to 1.5 g protein/kg dry body weight per day to maintain or improve
nitrogen balance.
• In patients with hepatic encephalopathy, the protein intake should be spread throughout the day;
protein restriction is rarely recommended as it may worsen malnutrition.
Carbohydrate • Carbohydrate and fat recommendations are similar to those for the general population.
and fat • Persons with insulin resistance or diabetes should monitor carbohydrate intakes and consume a
diet that maintains blood glucose control.
• If fat is malabsorbed, patients should restrict fat to 30 percent of total kcalories or as necessary to
control steatorrhea and use medium-chain triglycerides (MCT) to increase kcalories.
Sodium • Patients should restrict sodium as necessary to control ascites; 2000 mg sodium per day is
adequate restriction in most cases.
Vitamins and • Patients may require dietary supplements to obtain adequate amounts of vitamins and minerals.
minerals
Liver Transplantation
Liver failure
Resulting from acute or chronic liver disease
May require transplantation as only treatment option
Post-transplantation concerns
Immediate concerns:
Organ rejection and infection
Immunosuppressive drugs

https://www.hopkinsmedicine.org
Liver Transplantation Continued 1
Overview
• Post-transplantation concerns
• Immediate concerns: organ rejection and infection
• Immunosuppressive drugs reduce immune response that causes
rejection, but increase risk of infection
• Immunosuppressive drug effects on nutrition
• GI side effects, altered appetite and taste
• Hyperglycemia or diabetes
• Fluid and electrolyte imbalances
Gallstone Disease
Disorders of biliary system
Gall bladder and Bile ducts
Cause gallstone formation
Types of gallstones
1. Cholesterol gallstones
Most common type
Composed primarily of cholesterol
Precipitates to form stones
2. Pigment gallstones
Composed mainly of calcium salt of bilirubin
Often result of bacterial infection

Image Source: Marieb & Hoehn, Human Anatomy & Physiology, 10 th ed., Pearson
Consequences of Gallstones
Cholecystitis: Inflammation of the gallbladder (Mayo Clinic)
Perintonitis: inflammation of the peritoneum, typically caused by
bacterial infection either via the blood or after rupture of an
abdominal organ. (Google dictionary)

Many asymptomatic
Symptoms usually occur when stone blocks cystic duct
Steady and severe pain
Nausea and vomiting
Complications
Cholecystitis
Peritonitis
Blockage of bile duct or pancreatic duct

https://www.mayoclinic.org
Risk Factors for Gallstones
TPN: Total Parenteral Nutrition
Risk factors
Ethnicity
Age and gender
Pregnancy
Obesity and weight loss
Other risk factors
Long-term TPN
Medications
High blood triglyceride levels

https://www.mayoclinic.org
Treatment for Gallstones

Cholecystectomy
Gallbladder removal
If recurrent gallstones
Non-surgical
Oral intake of ursodeoxycholic acid
Bile acid that slowly dissolves cholesterol crystals
Shock-wave lithotripsy
Used for stones difficult to extract by other means

https://www.mayoclinic.org
Nutrition in Practice
Alcohol in Health and Disease
• Excessive alcohol consumption is a primary cause of
liver disease
• Can result in toxicity to other organs, including brain,
GI tract, and pancreas
• Can lead to nutrient deficiencies
• Moderate alcohol use has some health benefits
Nutrition in Practice Continued 1
Alcohol in Health and Disease
• Dietary Guidelines for Americans
• Limit intake to one (women) or two (men) drinks per day
for adults
• Avoidance of all alcohol
• Pregnant and lactating women
• Women who may become pregnant
• Children and adolescents
• Those taking medications that interact with alcohol
• Individuals who cannot voluntarily restrict intake
• Anyone who is driving
Nutrition in Practice Continued 2
Alcohol in Health and Disease
• Source of food energy
• Provides seven kcalories per gram
• Quickly absorbed, passes readily into cells
• Metabolized in the liver, given priority over other
substances
• Inhibits glycogen storage and availability of glucose
between meals
• Suppresses breakdown of fat for energy
• Increased VLDL
• Inhibits liver protein synthesis
Nutrition in Practice Continued 3
Alcohol in Health and Disease
• Alcohol alters structure of cell membranes
• Interferes with actions of cell membrane proteins
• Can lead to cell death and tissue damage
• Acts as central nervous system depressant
• Causes sedation
• Slows reaction times
• Relieves anxiety
Nutrition in Practice Continue 4
Alcohol in Health and Disease
• Extremely high blood alcohol levels can lead to coma,
respiratory depression, and death
• Chronic heavy drinking can lead to neurological
damage