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Hepatic. Working knowledge of physiological changes during disease process & effects on nutrition care. Hepatic. Translate nutrition needs into menus. Working knowledge of MNT for hepatic disease. Calculate and define diets for common conditions. Normal Structure.

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hepatic
Hepatic
  • Working knowledge of physiological changes during disease process & effects on nutrition care.
hepatic2
Hepatic
  • Translate nutrition needs into menus.
  • Working knowledge of MNT for hepatic disease.
  • Calculate and define diets for common conditions.
normal structure
Normal Structure
  • Biliary ducts Fig. 18-9, Gould next
blood supply to liver
Blood Supply to Liver
  • Liver circulation Fig. 22-1 next
sinusoids
Sinusoids
  • Sinusoids Fig. 13-1 next
  • Also see Fig. 18-11 in Gould
sinusoids11
Sinusoids
  • Capillary-like structures
  • Blood from both the hepatic artery and portal vein flow in to the sinusoids
  • Blood collects in central vein & then to hepatic vein
kupffer cells
Kupffer cells
  • Cells that line the sinusoids
  • Phagocytic cells of the immune system
pressure in liver
Pressure in Liver
  • Normally very little resistance to blood flow in liver
  • Hepatic vein pressure 0 mm Hg
  • Portal vein pressure is 8 mm Hg
pressure in liver14
Pressure in Liver
  • Portal hypertension
  • Pressure in hepatic vein increases above 0 mm Hg
metabolic
Metabolic
  • What are the metabolic functions of the liver?
detoxification
Detoxification
  • Kupffer cells
  • Toxins detoxified
  • Removal of ammonia & make urea
digestion
Digestion
  • Bile synthesis
  • Bilirubin
    • product of breakdown of heme when rbc discarded
    • excreted in bile
progression of liver disease
Progression of Liver Disease
  • Fatty liver
  • Hepatitis
  • Cirrhosis
  • ESLD
hepatitis
Hepatitis
  • Infectious mononucleosis
  • Toxic chemicals
  • Viral infection
  • Excessive use of alcohol
viral hepatitis
Viral Hepatitis
  • Hepatitis A
    • fecal-oral route
    • rapid onset
    • 2 - 6 weeks
    • acute type
viral hepatitis23
Viral Hepatitis
  • Hepatitis B and C
    • contaminated bodily fluids
    • slower onset
    • 6 weeks to 6 months
    • can become chronic
hepatitis25
Hepatitis
  • Symptoms
    • jaundice can occur
    • pale stools
    • easily fatigued
hepatitis26
Hepatitis
  • Symptoms
    • nausea & anorexia
    • fever
    • liver tenderness
    • liver enlarged
hepatitis27
Hepatitis
  • Why do these clinical manifestations happen?
    • hypoglycemia
    • fluid imbalance
    • bleed more easily
    • elevated serum bilirubin > 20mg/dl
prehepatic jaundice
Prehepatic Jaundice
  • Fig. 18-12 in Gould
  • Hemolytic jaundice
  • Excessive rbc break down
  • Unconjuaged bilirubin high
  • Stool dark/normal color
intrahepatic jaundice
Intrahepatic Jaundice
  • If unconjugated bilirubin high means liver cell damage
  • If conjugated bilirubin high, means blockage
posthepatic jaundice
Posthepatic Jaundice
  • Conjugated bilirubin high
  • Light colored stool
cirrhosis
Cirrhosis
  • Repeated damage, necrosis to liver
  • What will eventually happen to the liver?
hepatoxic drugs
Alcohol

Acetaminophen

Androgenic steroids

Cyclosporine

Erythromycin

Glucocorticoids

Isoniazid

Methotrexate

Methyldopa

NSAIDs

Hepatoxic Drugs
damage liver
Damage Liver
  • Hepatitis, especially if chronic
  • Biliary disorders, obstruction
  • Hemochromatosis
  • Chronic use hepatotoxic drugs
portal htn
Portal HTN
  • Due to damaged liver
  • Pressure too high on which end?
portal htn ascites
Portal HTN & Ascites
  • Forces plasma out of vessels
  • Is Alb high or low in the blood?
  • Na restricted diet
  • Fluid restricted diet
end stage liver disease
End-stage Liver Disease
  • Less than 25% of liver functions
  • Portal systemic encephalopathy (PSE)
esld stages
Stage 1

apathy

restlessness

reversal of sleep rhythm

Stage 1

slowed intellect

impaired computational ability

impaired handwriting

ESLD Stages
esld stages42
Stage 2

lethargy

drowsiness

disorientation

asterixis

Stage 3

stupor (arousable)

hyperactive reflexes

extensor plantar responses

ESLD Stages
esld stages43
ESLD Stages
  • Stage 4
    • coma
    • response to painful stimuli only
slide44
ESLD
  • Excessive ammonia in blood (NH3)
  • Abnormal amino acid metabolism
    • BCAA lower
    • Aromatic AA higher
slide45
ESLD
  • False neurotransmitter hypothesis by Fischer
    • too many Aromatic AA favored into brain
    • phe - hinder neuronal transmission
slide46
ESLD
  • False neurotransmitter hypothesis by Fischer
    • phe & tyr - precursor of epinephrine & norepinephrine
    • trypothan - precurson of serotonin
slide47
ESLD
  • False neurotransmitter hypothesis by Fischer
    • high level of phe result in false neurotransmitters & competes with normal neurotransmitters
slide48
ESLD
  • Precepitating factors
    • GI bleed
    • increased dietary protein
    • constipation
    • infection
    • less hepatic function
subjective global assessment
Subjective Global Assessment
  • Four elements of pt. Hx
    • Recent loss of body wt
    • Changes in usual diet
    • Presence of significant gastrointestinal symptoms
    • Patient’s functional capacity
slide50
SGA
  • Three elements of physical exam
    • loss of subcutaneous fat
    • muscle wasting
    • presence of edema or ascites
slide51
SGA
  • Deltoid muscle wasted
  • Shoulders look squared off
  • Muscle wasting at quadriceps femoris
  • Anterior thigh
slide52
SGA
  • Significant wt loss
    • >1 to 2% in 1 week
    • >5% in 1 month
    • >7.5% in 3 months
    • >10% in 6 months
    • >40% life threatening
slide53
SGA
  • Significant wt loss
    • unplanned or recent loss of >10%
    • >20% in surgical pt
labs clinical signs
Serum ammonia

H&H

Aklaline phosphostase

BUN

AST

ALT

Bilirubin

K

Blood glucose

TG & FFA

Prolonged prothrombin time

Alb

LDH

Ascites & edema

Labs & Clinical Signs
medications
Lactulose

Neomycin

Steriods

Insulin

Diuretics

IV albumin

Avoid excessive fat soluble vitamins

Medications
slide56
MNT
  • All liver diseases
    • high kcal
    • do not limit cho
    • moderate lipid
    • 25% - 40% of kcal
    • if have to go low fat - 40 g/day
slide57
MNT
  • All liver diseases
    • supplement vit & minerals
    • use water soluble forms
    • ascites - Na restrict
    • I & O
    • monitor blood K
slide58
MNT
  • Uncomplicated hepatitis & stable cirrhosis
    • high protein
    • 1.2 g/kg or 1.5 g/kg
mnt in esld
MNT in ESLD
  • Before coma
    • high protein
    • keep protein high until see problems on next slide
    • then restrict protein
mnt in esld60
MNT in ESLD
  • Coma
    • start 40 g protein
    • BCAA formulas
    • increase protein 10 g until see
      • increase total bilirubin
      • increase prothrombin time
      • coma
mnt in esld61
MNT in ESLD
  • Try to not restrict fluid intake
  • Case study 32 - 1, 2, 3, 4, 5, 6, 7, 12
  • If time 14
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