Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic...

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Liver, Gallbladder, Exocrine Pancreas KNH 411

Transcript of Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic...

Page 1: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident

Liver, Gallbladder, Exocrine Pancreas

KNH 411

Page 2: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident
Page 3: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident
Page 4: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident
Page 5: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident
Page 6: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident
Page 7: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident
Page 8: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident

Pathophysiology of the Liver

� Alcoholism

� Chronic consumption of > 80 g of ethanol/day� Alcoholic liver disease (ALD)� Dependency may be evident as tolerance or withdrawal� Ethanol rapidly and completely absorbed even with

malabsorption� Cannot be stored - oxidized

Page 9: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident

Pathophysiology of the Liver

� Fatty Liver - Etiology� Steatohepatitis - inflammation� If alcohol not present – NASH� NAFLD progresses to cirrhosis and hepatic carcinoma

� Strong association with obesity, diabetes, metabolic syndrome� Most common type among adolescents

Page 10: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident
Page 11: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident

Pathophysiology of the Liver

� Malnutrition in the Alcoholic

� Malnutrition caused by displacement of nutrients

� Maldigestion or malabsorption of nutrients d/t GI complications

Page 12: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident

Pathophysiology of the Liver

� Malnutrition in the Alcoholic - GI Complications

� Esophagus – heartburn, reduced LES pressure, esophagitis, stricture, tears from vomiting

� Stomach - gastritis, duodenitis, atrophy of gastric mucosal barrier, hemorrage, PUD, pernicious anemia, stomach cancer

Page 13: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident

Pathophysiology of the Liver

� Malnutrition in the Alcoholic - GI Complications

� Intestine – structural and morphological changes, hemorrhagic lesions of villi tips, decreased motility, increased digestion time, bacterial overgrowth

Page 14: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident
Page 15: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident

Pathophysiology of the Liver

� Alcoholism - Nutrition Implications

� Significant caloric contributions – obesity� Irregular eating habits� Decreased appetite – weight loss� Kcal derived from ethanol

� 0.8 X proof X ounces = kcal

Page 16: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident

Pathophysiology of the Liver

� Alcoholism – Malnutrition

� PEM� Poor dietary intake, malabsorption, hypercatabolic state,

altered energy storage, biochemical changes

� Vitamin deficiency

� Major cause of liver damage and resulting dysfunction

Page 17: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident

Pathophysiology of the Liver� Alcoholism - vitamin and mineral deficiencies

� Folate� Thiamin

� Wet and dry beriberi

� Wernicke-Korsakoff syndrome� Low plasma pyridoxine

� Vitamin C� Vitamin D – impairs osteoblastic activity

Page 18: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident

Pathophysiology of the Liver� Alcoholism - vitamin and mineral deficiencies

� Vitamin K - clotting factors� Vitamin A – night blindness

� Interaction between vitamin A and zinc

� Iron – altered response to infection� Calcium – bone density and bone mass

� Potassium – hypokalemia

� Recommend multivitamin 2X RDA

Page 19: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident

Pathophysiology of the Liver� Alcoholism – nutritional effects

� Imbalanced diet and/or anorexia

� Maldigestion and malabsorption

� Increased catabolism of visceral protein and skeletal muscle

� Increased excretion of vitamins

Page 20: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident

©  2007  Thomson  -­ Wadsworth

Page 21: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident

Pathophysiology of the Liver

� Hepatitis – inflammation of the liver caused by virus, bacteria, toxins, obstruction, parasites or drugs� HAV – via oral-fecal route� HBV – blood transfusions, blood-derived fluids, or

improperly sterilized medical equipment� HCV – exposure of blood or body fluids from

infected person; no vaccine� HDV, HEV

Page 22: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident

Pathophysiology of the Liver

� Hepatitis – clinical manifestations

� Jaundice, dark urine, anorexia, fatigue, headache, nausea, vomiting, fever

� Hepatomegaly and splenomegaly

� Bilirubin, alkaline phosphatase, serum AST elevated

Page 23: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident

Pathophysiology of the Liver

� Hepatitis – Nutrition Therapy

� Spare liver and provide nutrients for regeneration� Adequate rest, fluids, good nutrition, avoidance of further

damage� Increase dietary intake

� 30-35 kcal/kg body weight (≥ 3000 kcal)

� Small, frequent meals

Page 24: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident

Pathophysiology of the Liver

� Hepatitis – Nutrition Therapy

� Adequate protein� 1-1.2 g/kg body weight

� 30-40% of kcal from fat� May not be well tolerated

� Supplemental vitamin K� Potassium and sodium if vomiting and diarrhea

Page 25: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident

Pathophysiology of the Liver

� Alcoholic hepatitis - toxic liver injury associated with chronic ethanol consumption

� Increased susceptibility to infections

� Fatigue, weakness, anorexia, fever, hepatomegaly

Page 26: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident

Pathophysiology of the Liver

� Alcoholic Hepatitis - Treatment/ Nutrition Therapy� Abstention from alcohol� Treatment of withdrawal symptoms� Correction of nutritional deficiencies� Multivitamin – B12, folate, thiamin, pyridoxine,

vitamins A & D� Multimineral – zinc, magnesium, calcium,

phosphorus� Adequate kcal and protein

Page 27: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident

Pathophysiology of the Liver

� Cirrhosis - chronic liver disease in which healthy tissue is replaced by scar tissue, blocking the flow of blood, resulting in loss of liver function

� Most common causes – chronic alcoholism and HCV

� Steatosis is first stage

Page 28: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident

Pathophysiology of the Liver

� Cirrhosis – etiology� Associated with alcoholism� Scar tissue forms� Conversion of fat to lipoprotein impaired� Accumulation of fat in the liver� Portal hypertension may develop� Esophageal varices� Rupture with hemorrhage

Page 29: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident

Pathophysiology of the Liver� Cirrhosis – clinical manifestations

� Enlarged liver from necrosis � Ascites and edema� SGOT elevated, BSP clearing time reduced� Vitamin deficiencies, depressed hgb, hct� Jaundice, lack of appetite, delirium tremens� Fever, gallstones, ulcers, GERD, gastritis, diarrhea

Page 30: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident

Pathophysiology of the Liver� Cirrhosis – complications

� Portal hypertension

� Ascites

� Hepatic encephalopathy

Page 31: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident

Pathophysiology of the Liver� Cirrhosis – portal hypertension

� Always present with ascites

� Decrease in hepatic vascular bed; obstruction, increased resistance, arteriovenous anastomoses

Page 32: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident
Page 33: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident
Page 34: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident

Pathophysiology of the Liver� Cirrhosis – ascites

� Accumulation of fluid in peritoneal cavity; most common complication

� Hepatic fibrosis, reduced osmotic pressure, increased retention of sodium

Page 35: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident
Page 36: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident

Pathophysiology of the Liver� Cirrhosis – ascites: nutrition therapy

� Encourage oral proteins/ supplements

� Restricting salt to 2 g/d

� Restricting fluid to 1500 cc

� Adequate kcal

� Diuretics

Page 37: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident

Pathophysiology of the Liver� Cirrhosis – hepatic encephalopathy

� Syndrome of impaired mental status and abnormal neuromuscular function

� 2 types graded onto 4 clinical scales; Child-Pugh score

� The Glasgow coma scale

� “Flap” - asterixis

Page 38: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident
Page 39: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident

Pathophysiology of the Liver� Cirrhosis – hepatic encephalopathy

� Pathogenesis unknown; inability to eliminate products toxic to brain

� 4 major hypotheses:� Ammonia

� Synergistic neurotoxin� False neurotransmitter

� GABA benzodiazepine

Page 40: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident

Pathophysiology of the Liver� Cirrhosis – hepatic encephalopathy

� Treatment depends on type, extent of neurological damage, presence of precipitating factors

� Treatments� Dietary protein restriction (minimum 50 g/d), plant sources,

increased fiber, milk and cheese, BCAAs� Monitor serum potassium level

� Correct hypoglycemia, vitamin deficiencies

Page 41: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident
Page 42: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident

Pathophysiology of the Liver

� Liver transplant – considered in cases where effects of disease have higher potential mortality than transplant

� With alcoholism - six months abstinence

� Psychological and nutritional evaluations

Page 43: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident

Pathophysiology of the Liver

� Liver Transplant – Nutrition Therapy

� Individualized

� Pretransplant� Kcal 34-45 kcal/kg; protein 1-1.5 g/kg

� Normalize macro- and micronutrients� Normalize blood sugar, nitrogen balance, relevant labs

Page 44: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident

Pathophysiology of the Liver

� Liver Transplant – Nutrition Therapy

� Posttransplant� Regualr diet – slightly lower kcal and pro.

� Other nutrients individualized based on immunosuppressant drug regimen

� May cause hyperglycemia, sodium retention, potassium retention

� Provide DRI for vitamins

Page 45: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident

Pathophysiology of the Liver� Cystic fibrosis-associated liver disease (CFALD) - inherited

disorder of epithelial transport

� Mutated gene codes for defective protein

� Cl is prevented from leaving cell and water cannot exit

� Mucus thickens, cilia cannot function, bacteria collect on the cells

� infections

Page 46: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident

Pathophysiology of the Liver� CF – Nutrition Therapy

� Counseling on risks associated with alcohol and herbal therapies

� Kcal needs increase 20-40%� May need MCT� Do not restrict protein� Assess status of fat-soluble vitamins� Pancreatic enzyme supplements with meals and supplements

Page 47: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident

Pathophysiology of the Liver� CF – Nutrition Therapy

Vitamin A - risk for night blindness and conjunctival xerosis – 2-4X DRI, but avoid hypervitaminosis

� Vitamin E – protection of lungs from oxidative stress 15-25 IU/d

� Vitamin D – 2-4 µg/dL/day

� Vitamin K – 2.5-10 mg/daily

� EFA supplementation

Page 48: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident

The Gallbladder

� Stores, concentrates and secretes bile

� Removal of water and electrolytes – increasing concentration

� Storage

� Control of delivery of bile salts to duodenum

Page 49: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident
Page 50: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident

The Gallbladder

� Cholelithiasis – Nutrition Therapy

� Assess alcohol intake� Increase complex CHO and insoluble fiber� Assess vitamin C intake� ? Low-fat diet� Counsel on lifestyle habits� Plain, simple foods best tolerated

Page 51: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident

The Gallbladder

� Cholelithiasis – Nutrition Therapy

� Acute attack

� NPO and complete bowel rest

� Parenteral nutrition as needed� Advance as tolerated to liquids, low fat

� Limited amounts of fats and solid foods added

� Progress to regular diet

Page 52: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident

The Gallbladder

� Cholelithiasis – Nutrition Therapy

� Chronic condition

� Low fat (25% kcal)

� Weight reduction (gradual)� Adjust pro and CHO for weight

� Water-soluble forms of fat-soluble vitamins

Page 53: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident

The Gallbladder

� Cholelithiasis – Nutrition Therapy

� Postoperative Cholecystectomy

� Oral feedings resumed once bowel sounds return

� Advance as tolerated to regular diet� Increased fiber to manage diarrhea

� Manage digestive symptoms: fatty food intolerances, heartburn, nausea

Page 54: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident
Page 55: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident
Page 56: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident

The Pancreas

� Pancreatitis - nutrition therapy

� Provide minimal stimulation of affected systems

� Severe attacks – oral feedings withheld

� Less severe - clear liquid diet, progress as tolerated; low fat

� Small, frequent meals

Page 57: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident

The Pancreas

� Pancreatitis - Nutrition Support for Acute

� Provide adequate kcal & protein, minimize nitrogen losses, manage imbalances

� Enteral preferred method

� Maintain gut integrity� Reduce septic and metabolic complications� Less costly

Page 58: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident

The Pancreas

� Pancreatitis - Nutrition Support for Acute� Enteral support below ligament of Treitz via nasogastric

tube� Initiate feeding 25 mL/hour, advance to 25 kcal/kg over

24-48 hrs.� Nearly fat-free elemental formulas� Advance to oral diet when amylase and lipase decrease

towards normal

Page 59: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident

The Pancreas

� Pancreatitis - Nutrition Support for Acute

� Parenteral – only considered in pts. for whom enteral access not possible or not tolerated

� Mixed fuel, volume increased slowly to 25 kcal/kg

� Intralipid les than 15-30% of kcal, protein individualized

Page 60: Liver, Gallbladder, Exocrine Pancreas · Pathophysiology of the Liver! Alcoholism! Chronic consumption of > 80 g of ethanol/day! Alcoholic liver disease (ALD)! Dependency may be evident

The Pancreas

� Pancreatitis - Insufficiency� Frequent, small meals moderate to low in fat� Pancreatic enzymes taken with food� Alcohol, coffee, tea, spices, irritant condiments

avoided� MCT may be added� Maintain weight� Monitor fat and water-soluble vitamins� Medical management of pH� Treat with insulin if indicated