Liver/Gallbladder - Coggle Diagram
Low fat diet IF required (increased pain with fat/steatorrhoea), malnutrition, prevention
Energy: 30-35kcal/kg (126-147kj/kg), caloric intake divided into 4-6meals per day including late evening snack, HPHE supps
Protein: no restriction, 1.2-1.5g/kg BW
BCAA: beneficial effects - hepatic encephalopathy, improved muscle mass, associated with N/D (unpalatable) - utilise normal protein sources as expensive
Fat: no restriction, good energy source (restrict if steatorrhoea till malabsorption improves), in severe cases <30g/d, supplementing with MCT oils
Sodium: 60mmol/d (ESPEN), no added salt diet 2300mg if no ascites/oedema, lower sodium diet not effective in refractory ascites
Enteral feeding: NGT, malnourished = unable to meet requirements orally, use nutrient dense/low volume feeds
Disorders of liver
NAFLD (non alcoholic fatty liver disease)/MAFLD (metabolically associated fatty liver disease) -> NASH (non alcoholic steatohepatitis)
Chronic liver disease (due to NASH, drug use, alcohol abuse, late to early 30s), hepatitis, fulminant hepatic failure (ALF), cholestatic liver disease (autoimmune disease lead to CLD, no cure), hepatocellular carcinoma
: One role of the liver is to release glucose for energy or to store excess that we consume as glycogen. When the liver is not working properly, your body relies on other energy sources such as protein from breaking down muscle as well as from our fat stores. Advanced liver disease is associated with muscle/fat loss which may be masked by fluid gain around stomach or legs. To prevent this, we need to eat a high protein and high energy diet as protein is used to maintain muscles and body tissues.
If excess fluid is built up, we also want to limit salt in our diet as salt acts like a sponge with fluid in the body, reducing the amount of salt can limit amount of fluid that stays in your body
Anthro: ht, wt, wt hx, BMI, mid arm circumference, tricep skinfold, hand grip strength, short physical performance battery
Without ascites: actual body weight, With ascites: ideal body weight according to height
Clinical: complications of CLD (postural HTN, varices, ascites), types/severity of liver disease (child pugh score - A = well compensated, C = decompensated)(MELD - used for liver transplant pts; higher score = worse), medications, NIS, fatigue
Diet: current intake, previous diet advice (compliance, source of dietary advice), herbal supplements
Disorders of Gallbladder
Cholelithiasis (gall stones), cholecystitis (inflammation of gallbladder), cholestasis (bile that is stored within GB becomes stagnant causing inflammation)
Symptoms: pain, steatorrhoea, jaundice
Gallbladder is a small pear-shaped sac on the right side of stomach beneath the liver, it holds bile which is a juice made up of cholesterol, bilirubin and bile salts that is produced by the liver to be used to breakdown the fats that we consume in our diet. The presence of fatty foods triggers the gallbladder to squeeze bile into small intestine to help with digestion.
Gallstones are small stones that are made up of cholesterol, bile pigment and calcium salts caused from crystallisation of excess cholesterol in the bile and failure of gallbladder to completely empty.
Malnutrition in CLD
Associated with: ascites, hepatorenal syndrome, greater LOS, higher mortality/morbidity
Pathology: poor diet intake (early satiety, taste changes, low salt diet, fluid restrictions), malabsorption, low protein synthesis, hypermetabolism, fatigue, medications
Previously NAFLD, progresses to NASH, aim for 7-10% weight loss, exercise mediterranean diet (improves body weight, insulin sensitivity, hepatic steatosis/fibrosis)
Gallbladder Evidence (PEN
Llimiting trans/long chain saturated fats may have benefits in preventing gallbladder disease.
High intake of refined sugar/high GL associated w/ ^ risk of gallstones,.
high fibre diet may be protective against GB disease.
Consumption of nuts (>140g/wk) = reduced risk of GB disease/cholecystectomy.
Consumption of 7+ servings of fruit/veg = reduced risk of gallstone/cholecystectemy.
Caffein consumption may reduce risk of cholecystectomy.
Recommended approach is to consume healthy diet w/ moderate fat (20-35% calories) - diet too low in fat = suboptimal cholecystokinin secretion/inadequate bile production cause stone formation
Liver Evidence (ESPEN)
In overweight/obese NASH pts, intensive lifestyle intervention leading to wt loss/increased PA should be 1st line treatment.
NAFL/NASH pts advised to exercise to reduce hepatic fat content/should follow wt reducing diet to reduce risk of comorbidity/improve liver enzymes (7-10% wt loss improves steatosis/liver biochem and >10% improve fibrosis).
Med diet advised to improve steatosis/insulin sensitivity.
Vit E should be prescribed to non-diabetic adults w/ NASH to improve enzymes.
Obese NAFL/NASH pts w/ intercurrent illness should be given EN/PN w/ energy intake of 25kcal/kg IBW + increased protein of 2-2.5g/kg IBW
Non-malnourished pts w/compensated cirrhosis should have 1.2g/kg Protein
Malnourished/sarcopenic cirrhotic pts should have 1.5g/kg/d
Oral diet of cirrhotic pts w/ malnutrition/muscle depletion should provide 30-35kcal/kg/d and 1.5g/kg protein