© 2004, 2002 Elsevier Inc. All rights reserved.

Medical Nutrition Medical Nutrition Therapy for Liver, Therapy for Liver, Biliary System, and Biliary System, and Exocrine Pancreas Exocrine Pancreas DisordersDisorders

Relationship of Relationship of Organs of the Upper Organs of the Upper AbdomenAbdomen

A, Liver (retracted upward); B, gallbladder; C, esophageal opening of the stomach; D, stomach (shown in dotted outline); E, common bile duct; F, duodenum; G, pancreas and pancreatic duct; H, spleen; I, kidneys.

Courtesy The Cleveland Clinic Foundation, Cleveland, Ohio, 2002.

The LiverThe Liver

Largest gland in the body (about Largest gland in the body (about 1500 g)1500 g)

Essential for life, though survival Essential for life, though survival is possible with 10-20% functionis possible with 10-20% function

Plays major role in macronutrient Plays major role in macronutrient and micronutrient digestion, and micronutrient digestion, metabolism, and storagemetabolism, and storage

Metabolizes steroids, detoxifies Metabolizes steroids, detoxifies drugs, alcohol, ammoniadrugs, alcohol, ammonia

Diseases of the LiverDiseases of the Liver

Acute viral hepatitisAcute viral hepatitis Fulminant hepatitisFulminant hepatitis Chronic hepatitisChronic hepatitis Alcoholic liver disease, alcoholic Alcoholic liver disease, alcoholic

hepatitis, and cirrhosishepatitis, and cirrhosis Non-alcoholic hepatic steatosis Non-alcoholic hepatic steatosis

(NASH)(NASH)

Diseases of the LiverDiseases of the Liver

Cholestatic liver diseasesCholestatic liver diseases

——Primary biliary cirrhosisPrimary biliary cirrhosis

——Sclerosing cholangitisSclerosing cholangitis Inherited disordersInherited disorders Other liver diseasesOther liver diseases

Acute Viral HepatitisAcute Viral Hepatitis Widespread inflammation of the Widespread inflammation of the

liver that is caused by hepatitis liver that is caused by hepatitis viruses A, B, C, D and Eviruses A, B, C, D and E– Hep A: oral-fecal routeHep A: oral-fecal route– Hep B and C: body fluidsHep B and C: body fluids– Hep D: occurs only in pts with Hep Hep D: occurs only in pts with Hep

BB– Hep E: oral-fecal route; seen more Hep E: oral-fecal route; seen more

often in Asia, Africa, Mexico often in Asia, Africa, Mexico Hasse JM et al. ASPEN Nutrition Support Practice Manual, 2nd edition, 2005

Acute Viral HepatitisAcute Viral Hepatitis

Four phases of symptoms:Four phases of symptoms:

1. Prodromal phase1. Prodromal phase

2. Preicteric phase2. Preicteric phase

3. Icteric phase3. Icteric phase

4. Convalescent phase4. Convalescent phase

Risk Factors for Risk Factors for Chronic Viral HepatitisChronic Viral Hepatitis Injection drug useInjection drug use Chronic hemodialysisChronic hemodialysis Blood transfusion or transplantation Blood transfusion or transplantation

prior to 1992 (HCV)prior to 1992 (HCV) Receipt of blood (including Receipt of blood (including

needlestick) from a donor needlestick) from a donor subsequently testing positive for subsequently testing positive for HCVHCV

Risk Factors for Risk Factors for Chronic Viral HepatitisChronic Viral Hepatitis Receipt of clotting factor Receipt of clotting factor

concentrates produced before concentrates produced before 19871987

Asian ancestry (HBV)Asian ancestry (HBV) Unvaccinated health care workersUnvaccinated health care workers Birth to mother with chronic HBV Birth to mother with chronic HBV

or HCVor HCV

Possible Risk FactorsPossible Risk Factors

Body piercing or tattooingBody piercing or tattooing Multiple sexual partners or Multiple sexual partners or

sexually transmitted diseases sexually transmitted diseases Health care workers (HCV)Health care workers (HCV) Contacts of HCV positive personsContacts of HCV positive persons

Source: NACB Laboratory Guidelines for Screening, Diagnosis, and Monitoring of Hepatic Injury. Dufour, Lott, Nolte, Gretch, Koff, Seeff

Fulminant HepatitisFulminant Hepatitis Syndrome in which severe liver Syndrome in which severe liver

dysfunction is accompanied by hepatic dysfunction is accompanied by hepatic encephalopathy within 8 weeksencephalopathy within 8 weeks

Causes include viral hepatitis (75%), Causes include viral hepatitis (75%), chemical toxicity (acetaminophen, drug chemical toxicity (acetaminophen, drug reactions, poisonous mushrooms, other reactions, poisonous mushrooms, other poisons)poisons)

Complications include cerebral edema, Complications include cerebral edema, coagulopathy, bleeding, cardiovascular coagulopathy, bleeding, cardiovascular complications, renal failure, pancreatitiscomplications, renal failure, pancreatitis

Chronic HepatitisChronic Hepatitis

At least 6-month course of hepatitis At least 6-month course of hepatitis or biochemical and clinical or biochemical and clinical evidence of liver disease with evidence of liver disease with confirmatory biopsy findings of confirmatory biopsy findings of unresolving hepatic inflammationunresolving hepatic inflammation

Can be caused by autoimmune, Can be caused by autoimmune, viral, metabolic, or toxic etiologiesviral, metabolic, or toxic etiologies

Alcoholic Liver Disease: Alcoholic Liver Disease: Most Common Liver Most Common Liver DiseaseDisease Alcohol excess and abuseAlcohol excess and abuse Most common cause of liver Most common cause of liver

disease in the U.S.disease in the U.S. Fourth leading cause of death Fourth leading cause of death

among middle-aged Americansamong middle-aged Americans Alcohol problems are highest Alcohol problems are highest

among young adults, ages 18 to among young adults, ages 18 to 29.29.

Stages of Alcoholic Stages of Alcoholic Liver DiseaseLiver Disease Hepatic steatosisHepatic steatosis Alcoholic hepatitisAlcoholic hepatitis Alcoholic (Leannec’s) cirrhosisAlcoholic (Leannec’s) cirrhosis

© 2004, 2002 Elsevier Inc. All rights reserved.

Toxic Effects of Excess Alcohol Toxic Effects of Excess Alcohol UseUse

Normal Liver vs. Normal Liver vs. Damaged LiverDamaged Liver

© 2004, 2002 Elsevier Inc. All rights reserved.

Microscopic Image of (A) Normal Microscopic Image of (A) Normal Liver; (B) cirrhotic liver)Liver; (B) cirrhotic liver)

(Adapted from Bray GA. Gray DS, Obesity, part 1: Pathogenisis. West J Med 149:429, 1988; and Lew EA, Garfinkle L; Variations in mortality by weight among 750,000 men and women. J Clin Epidemiol 32:563, 1979.)(From Kanel G, Korula J. Atlas of Liver Pathology. W.B. Saunders, 1992.)

© 2004, 2002 Elsevier Inc. All rights reserved.

Clinical Manifestations Clinical Manifestations of Cirrhosisof Cirrhosis

Interpretation of Lab Interpretation of Lab Data Data In Liver DiseaseIn Liver Disease

Liver Test PanelLiver Test Panel Aspartate transaminase (AST)Aspartate transaminase (AST) Alanine aminotransferase (ALT)Alanine aminotransferase (ALT) Alkaline phosphatase (ALP)Alkaline phosphatase (ALP) Total bilirubinTotal bilirubin Direct bilirubinDirect bilirubin PT/PTTPT/PTT CeruloplasminCeruloplasmin Total proteinTotal protein AlbuminAlbumin Viral serologiesViral serologies

Bilirubin Circulation Bilirubin Circulation

Lab Tests in Acute Lab Tests in Acute Liver DiseaseLiver Disease

DiseaseDisease Peak ALT Peak ALT (x URL)*(x URL)*

AST/Alt AST/Alt RatioRatio

Peak Bili Peak Bili (mg/dL)(mg/dL)

PTT PTT ProlongaProlongation (s)tion (s)

Viral Viral hepatitishepatitis

10-4010-40 <1<1 <15<15 <3<3

Alcoholic Alcoholic hepatitishepatitis

2-82-8 >2>2 <15<15 1-31-3

Toxic Toxic injuryinjury

>40>40 >1 early>1 early <5<5 >5 >5 transienttransient

Ischemic Ischemic injuryinjury

>40>40 >1 early>1 early <5<5 >5 >5 transienttransient

Source: NACB Laboratory guidelines for screening, diagnosis, and monitoring of hepatic injury. Dufour, Lou, Nolic, Gretch, Koff, Seeff

*upper reference limit

Causes of Elevated ALT Causes of Elevated ALT and/or ASTand/or AST

CauseCause Key FeatureKey Feature Screening Screening testtest

Confirming Confirming testtest

Non-Non-alcoholic alcoholic steato-steato-hepatitis hepatitis (NASH)(NASH)

Most Most common common cause other cause other than viral, than viral, alcoholicalcoholic

NoneNone biopsybiopsy

Hemo-Hemo-chromatosischromatosis

Autosomal Autosomal recessive recessive traittrait

1:200 among 1:200 among northern northern European European ancestryancestry

Transferrin Transferrin saturation saturation >45%>45%

HFE gene HFE gene analysis for analysis for C282Y C282Y mutationmutation

Source: NACB Laboratory guidelines for screening, diagnosis, and monitoring of hepatic injury. Dufour, Lou, Nolic, Gretch, Koff, Seeff

Causes of Elevated ALT Causes of Elevated ALT and/or ASTand/or AST

CauseCause Key FeatureKey Feature Screening Screening testtest

Confirming Confirming testtest

Wilson’s Wilson’s DiseaseDisease

Autosomal Autosomal recessive trait. recessive trait. 1:30,000 1:30,000 individuals; individuals; hemolytic hemolytic anemia, renal anemia, renal injuryinjury

Low Low cerulo-cerulo-plasmin in plasmin in 65-95% 65-95% homozy-homozy-gous; 20% gous; 20% heterozy-heterozy-gotesgotes

Genetic Genetic analysis, analysis, low serum low serum copper, copper, high urine high urine coppercopper

Auto-Auto-immune immune hepatitishepatitis

Up to 18% of Up to 18% of non-viral non-viral hepatitis; hepatitis; mainly young mainly young womenwomen

ANA and ANA and ASMA; ASMA; false false positive positive anti-HCV anti-HCV commoncommon

BiopsyBiopsy

Causes of Elevated ALT Causes of Elevated ALT and/or ASTand/or AST

CauseCause Key FeatureKey Feature Screening Screening testtest

Confirming Confirming testtest

Primary Primary biliary biliary cirrhosiscirrhosis

Middle aged Middle aged women; women; mainly mainly ALP; ALP; often often associated associated with Sjogren’s with Sjogren’s SyndromeSyndrome

Anti-mito-Anti-mito-chondrial chondrial antibodyantibody

BiopsyBiopsy

SchlerosinSchlerosing g cholangiticholangitiss

Young to Young to middle aged middle aged men; mainly men; mainly ALP; often with ALP; often with IBDIBD

Anti Anti neutrophil neutrophil cytoplasmicytoplasmic c antibodies; antibodies; ASMA, ANA ASMA, ANA may be +may be +

Bile duct Bile duct imagingimaging

Interpretation of Nutrition Interpretation of Nutrition Assessment Tests in Patients Assessment Tests in Patients with End-Stage Liver Diseasewith End-Stage Liver Disease

Body weightBody weight Anthropometric Anthropometric

measurementsmeasurements Creatinine-Creatinine-

height indexheight index Nitrogen Nitrogen

balance studiesbalance studies

Visceral protein Visceral protein levelslevels

Immune function Immune function teststests

Malnutrition and Ascites Malnutrition and Ascites in End Stage Liver in End Stage Liver Disease Disease

© 2004, 2002 Elsevier Inc. All rights reserved.

Clinical Manifestations Clinical Manifestations of Cirrhosisof Cirrhosis

Esophageal VaricesEsophageal Varices

Causes of Malnutrition Causes of Malnutrition in Liver Diseasein Liver Disease AnorexiaAnorexia Early satiety or dysgeusiaEarly satiety or dysgeusia Nausea and vomitingNausea and vomiting Maldigestion or malabsorptionMaldigestion or malabsorption Restricted dietsRestricted diets Altered metabolismAltered metabolism

Malnutrition in Liver Malnutrition in Liver Disease—Disease—PathophysiologyPathophysiology

Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000. Updated by Jeanette M. Hasse and Laura E. Matarese, 2002.

Malnutrition in Liver Disease—Malnutrition in Liver Disease—Medical and Nutritional Medical and Nutritional ManagementManagement

Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000. Updated by Jeanette M. Hasse and Laura E. Matarese, 2002.

Vitamin/Mineral Vitamin/Mineral Deficits* in Severe Deficits* in Severe Hepatic Failure Hepatic Failure Vitamin AVitamin A Vitamin DVitamin D Vitamin EVitamin E Vitamin KVitamin K Vitamin BVitamin B66

Vitamin BVitamin B1212

FolateFolate

NiacinNiacin ThiaminThiamin ZincZinc MagnesiumMagnesium IronIron PotassiumPotassium PhosphorusPhosphorus

* May be related to fat malabsorption, medications, alcoholism (p. 752 Krause)

Four Stages of Hepatic Four Stages of Hepatic EncephalopathyEncephalopathyStageStage SymptomSymptom

II Mild confusion, agitation, Mild confusion, agitation, irritability, sleep disturbance, irritability, sleep disturbance, decreased attention decreased attention

IIII Lethargy, disorientation, Lethargy, disorientation, inappropriate behavior, inappropriate behavior,

drowsinessdrowsinessIIIIIISomnolence but arousable, Somnolence but arousable,

incomprehensible speech, confusion, incomprehensible speech, confusion, aggression when awakeaggression when awake

IVIV ComaComa

Esophageal VaricesEsophageal Varices

Relationship of Relationship of Organs of the Upper Organs of the Upper AbdomenAbdomen

A, Liver (retracted upward); B, gallbladder; C, esophageal opening of the stomach; D, stomach (shown in dotted outline); E, common bile duct; F, duodenum; G, pancreas and pancreatic duct; H, spleen; I, kidneys.

Courtesy The Cleveland Clinic Foundation, Cleveland, Ohio, 2002.

CholedocholithiasisCholedocholithiasis

http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/17038.jpg

PancreatitisPancreatitis

http://www.pennhealth.com/health_info/Surgery/pancreatitis_2.html

Acute Hemorrhagic Acute Hemorrhagic PancreatitisPancreatitis

http://www.pathguy.com/~lulo/lulo0028.htm

Acute PancreatitisAcute Pancreatitis

75% alcohol related75% alcohol related 15% related to gallstones15% related to gallstones 10% trauma, hyperlipidemia, 10% trauma, hyperlipidemia,

hypercalcemia, medications, etc.hypercalcemia, medications, etc.

Mascarenhas et al. ASPEN Nutrition Support Practice Manual, 2nd edition, 2005, p. 211

Whipple ProcedureWhipple Procedure

Source: Johns Hopkins http://www.hopkins-gi.org/pages/latin/templates/ index.cfm?pg=disease3&organ=4&disease =24&lang_id=1&pagetype=12&pagenum=263

MNT in Liver/Biliary MNT in Liver/Biliary DiseaseDisease Disease of the liver/biliary tract has a Disease of the liver/biliary tract has a

profound effect on digestion and profound effect on digestion and absorptionabsorption

Often leads to malnutrition; Often leads to malnutrition; malnutrition exacerbates effect of malnutrition exacerbates effect of diseasedisease

Appropriate nutrition care is key in Appropriate nutrition care is key in reducing associated morbidity and reducing associated morbidity and mortality and improving quality of lifemortality and improving quality of life