Clinical and
           Therapeutic Nutrition             PRACTICAL7 NUTRITIONAL
                                                                             MANAGEMENTINLIVER,
                                                                             GALLBLADDERAND
                                                                             PANCREATICDISEASES
                                             Structure
                                             7.1    Introduction
                                             7.2    Liver, Gall Bladder and Pancreatic Diseases: An Overview
                                             7.3    Diseases of the Liver: Pathophysiology and of Dietary Management Principles
                                                    7.3.1 Infectious Hepatitis
                                                    7.3.2 LiverCirrhosis
                                             7.4    Diseases of Gall Bladder
                                                    7.4.1 PrinciplesofDietaryManagementCholelithiasis/Cholecystitis
                                             7.5    Diseases of the Pancreas
                                                    7.5.1 PrinciplesofDietaryManagementPancreatitis
                                             7.6    Review Exercises
                                             Activity 1: Diet Plan for Hepatitis
                                             Activity 2: Diet Plan for Liver Cirrhosis
                                             Activity 3: Diet Plan for Choletihiasis/Cholecystitis
                                             Activity 4: Diet Plan for Pancreatitis
                                             7.1     INTRODUCTION
                                             In the previous practical we learnt about the dietary management of the diseases
                                             associatedwiththegastrointestinaltract. Inthis unit wewilldiscuss aboutthediseases
                                             of the liver, gall bladder and pancreas. Hepatitis, cirrhosis, cholecystitis/cholelithiasis
                                             and pancreatitis are the major diseases which will be discussed in this practical. We
                                             willbeginwithabriefonthepathophysiology(impactonnutritionalstatus),characteristic
                                             symptomsoftheabovementioneddiseasesandthereafterfocus onthevariousaspects
                                             ofdietarymanagement. Theactivitiesincludedinthispracticalwillhelpustounderstand
                                             andlearnabouttheappliedaspectsrelatedtoworkingoutaday’sdietfor eachdisease.
                                             Beforeyoubegin,wesuggest you lookup theconcepts relatedtothepathophysiology
                                             and principles of diet planning related to these disease already covered in the theory
                                             course (MFN-005)in Unit 15.
                                             Objectives
                                             After undertaking this practical, you will be able to:
                                                 discuss the diseases of the liver, gall bladder and pancreas,
                                                 describe the various aspects of dietary management of the liver, gall bladder and
                                                  pancreas diseases, and
                                                 plandiets for hepatitis, cirrhosis, cholecystitis/cholelithiasis andpancreatitis.
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                                                                                                                     Nutritional
          7.2      LIVER,GALLBLADDERANDPANCREATIC                                                          Management in Liver,
                                                                                                                Gall Bladder and
                   DISEASES:ANOVERVIEW                                                                       Pancreatic Diseases
          Nutritionalsupportplaysamajorroleintheclinicalmanagementofpatientswithliver,
          pancreas and biliary disease(s). It has widely been recognized that malnutrition
          adversely affects outcome in both chronic and acute form of diseases of the liver, gall
          bladder and/or arise in patients with chronic forms of hepatobiliary and pancreatic
          disorders. Thus, theobjectives of thenutritional support shall be to providenutrient in
          thecorrectquantityandform,torestoreandmaintainnutritionalstatus,correctspecific
          deficiencies, treat clinical symptoms and promote regeneration of the lost tissues.
          Wide spectrums of diseases are associated with the insufficiency and/or dysfunction
          of liver, gall bladder and pancreas and the most important ones include:
            Liver                         Gall Bladder               Pancreas
              Acuteviral hepatitis        Cholecystitis            Acute pancreatitis
              Liver cirrhosis             Cholelithiasis           Chronic pancreatitis
              Hepatic Encephalopathy                                 Cystic fibrosis
               or Hepatic Coma                                        Tumors
                                                                       Pancreatic abscesses
                                                                      Fistulas
          Let us briefly recapitulate the pathophysiology, symptoms and dietary management
          related to these disorders.
          7.3      DISEASESOFTHELIVER:
                   PATHOPHYSIOLOGYANDDIETARY
                   MANAGEMENTPRINCIPLES
          Liver is a vital organrequiredfor our survival. It is requiredfor theproper metabolism
          of proteins, carbohydrates and fat. Liver is involved in the storage, activation and
          transport of manyvitamins andminerals suchas vitaminA, D, B12, zinc, iron, copper,
          magnesiumetc. Italsoplaysanimportantimmunologicalanddetoxificationfunctions.
          Diseases of theliver canbeacuteor chronic, inheritedor acquired. Themost common
          one’s being hepatitis (acute, fulminant, chronic, alcoholic), cirrhosis, hepatic
          encephalopathy. The major pathological changes associated with liver diseases are
          atrophy, fatty infiltration, fibrosis and neurosis of the hepatic cells.
          Jaundice whichis synonymously usedfor hepatitis is actually a symptom common to
          all liver diseases and is characterized by elevated levels of bilirubin in the blood.
          Hyperbilirubinemiamaybeduetoabnormalitiesintheformation,transport,metabolism
          and excretion of bilirubin. Normal plasma bilirubin levels are 2-8 mg/litre.
          Clinical signs of jaundice generally appear when the plasma concentrations are
          between 8-20 mg/litre.
          Wehavealready discussed in Unit 15 (in theTheory Manual) the clinical details and
          etiologicalfactors for somecommonlyencountereddiseasesoftheliver. Inthissection
          we will, therefore, recapitulate the pathophysiology and the dietary management
          principles for the liver diseases.
          Let us first learn about hepatitis.
          7.3.1    Infectious Hepatitis
          Infectioushepatitis,youmayrecallstudying,isadiseasecharacterizedbyinflammation
          and degeneration of the liver cells. Hepatitis may occur due to reactions with drugs,
          toxic agents and various viruses. The most common form of hepatitis is that caused                                  135
           Clinical and                      byfaecal contamination of food and water with TypeAvirus. Serum hepatitis (Type
           Therapeutic Nutrition             B) is next most frequently occurred form.
                                             As for the symptoms, mild constant abdominal pain, malaise, easy fatigability,
                                             upper respiratory symptoms, anorexia, nausea, frequent episodes of vomitting along
                                             with diarrhoea or constipation may occur during the initial stages. Jaundice occurs in
                                             5-10daysandthereisworseningoftheabovementionedsymptoms.Intheconvalescent
                                             phase, increasing sense of well being, return of appetite along with reduction in the
                                             severityofjaundice, abdominalpain,tendernessofliver andfatigabilityisexperienced.
                                             While the above mentioned symptoms may subside in 2-8 weeks; complete recovery
                                             takes a long-time. Majority of the symptoms associated with the term ‘jaundice’
                                             adversely affect the food intake.    Further, patient may also experience low grade
                                             fever thereby increasing the nutritional demands on the body. Efficient treatment and
                                             managementofhepatitisisamusttopreventitsprogressiontowardscirrhosis/hepatic
                                             encephalopathy etc. Let us then study about the treatment of hepatitis.
                                             Treatment
                                             The treatment focuses on:
                                                 Dietary management to maintain a good nutritional status.
                                                 Bed rest or avoidance of strenuous physical activity.
                                                 Drugs, if required (non-metabolism).
                                                 Avoidanceof hepatotoxic agents particularly alcohol.
                                             Let us focus on the dietary management of hepatitis next.
                                             Dietary Management of Hepatitis
                                             Irrespective of the cause of hepatitis, regeneration of the lost liver cells is essential to
                                             promote recovery and hence promote proper functioning of the organ. Relapse of
                                             hepatitis or progression of acutehepatitis to a chronic form/cirrhosis occurs many-at-
                                             times duetoimpairednutritionalstatus. Liver beinga storehousefor severalnutrients
                                             (particularly vitamins/minerals), the nutritional reserves may get depleted during
                                             hepatitis. Thus, the major objectives of dietary management include:
                                                 to promote a positive energy and nitrogen balance,
                                                 to promote recovery and prevent progression of the disease,
                                                 to replenish the depleted reserves, and
                                                 toensuresatisfactoryconvalescenceandmaintainanoptimumnutritionalstatus.
                                             Wewill now discuss the nutrient modifications necessary to promote quick recovery
                                             and prevent further degeneration of hepatic cells.       Let us start with the calorie
                                             requirement.
                                             Energy: Majority of the patients experience weight loss and are malnourished due to
                                             reducedfoodintake. Lowgradefever isgenerallypresent duringviralhepatitis which
                                             also imposes increased demands for calories due to an increase in basal metabolic
                                             rate. Adequateenergyintake is also essential to ensure proper utilization of proteins.
                                             The energy requirements may increase by 15 to 30% depending upon the existing
                                             nutritional status. However, the energy intake should be increased gradually. An
                                             aggressiveincreaseinenergyresults in aggravatinggastrointestinaldisturbance. Due
                                             to severity of jaundice during the early stages it may not be feasible to provide more
                                             than 1200 Kcal per day. However, during the convalescence phase, adequate intake
                                             of energy is feasible and a must to ensure complete recovery. If the patient is grossly
                                             underweight, theenergyintakemaybecalculatedas35Kcal/kgIBWtoensureweight
                                             gain and replenishment of glycogen reserves.
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           Protein:Theproteinintakeshouldbeincreasedby50%to100%inmildandmoderate                                           Nutritional
           cases of hepatitis i.e. the patient should be given 1.5 to 2.0 gm protein per kg IBW per              Management in Liver,
                                                                                                                     Gall Bladder and
           day. However, if hepatitis is severe and there is risk of developing cirrhosis; the                     Pancreatic Diseases
           protein intakeshould not exceed 1.0 g/kgIBW/day i.e. theprotein shouldbe provided
           as per the RDI.
           Fat: Fats should not be severely restricted as they can make the food unpalatable.
           About 20% of the total calories should be from fat. MCTs are preferred as they are
           easily digestible and assimilable (40-50 g). For example, dairy fat cream and butter
           are preferable.
           Carbohydrates:Inmildandmoderatecasesofhepatitis,carbohydratesshouldprovide
           atleast 60% of the total energy. Liberal intake of carbohydrate helps in replenishing
           the glycogen reserves and sparing the proteins for tissue regeneration. However, in
           severe chronic hepatitis determining the carbohydrate needs is often a challenge
           because liver failure reduces glucose production, glucose utilization and there is
           preference for the use of lipids and proteins as alternative sources of protein. In such
           situations thecarbohydrateintakeshouldnotexceed60%ofthetotalenergy. Emphasis
           should be laid on the inclusion of food rich in monosaccharides, disaccharides and
           starches. Dietary fibre intake should be kept minimum. All fibre rich foods should
           preferably be avoided and if given, should be in a soft cooked form. Thus, include
           goodamountsofglucose,dextrose,jaggery,honey,sugar,ago,rice,refinedfour,pastas,
           starchyrootsandtubers(potato,yam,colocasiacetc.),highcarbohydratefruits(banana,
           mango, sapota, raisins etc.)
           Vitamins and Minerals: Impaired liver function and its associated symptoms can
           result in increaseddemandofB-group vitamins,ascorbicacid,vitaminA,K, calcium,
           andiron.Amongallthenutrient,fatmalabsorptionisthegreatest,therefore-carotene
           rich foods should be included in the diet. Include adequate amount of fresh fruits and
           vegetables in soft cooked form such as mashed pureed vegetables, vegetable soup,
           fruit juice, stewed fruit, fruit jellies, fruit jam, milk shakes, etc.
           Fluids:Fluidintakemayneedtobeincreasedifthepatientissufferingfromdiarrhoea
           and/or constipaton. In such cases include good amounts of clear and full-fluids in the
           diet such as:
           a)   Clear fluids: Coconut water, tea/coffee (without milk,) barley water, strained
                vegetable/ pulse/ meat soup, strained fit juices, strained carrot/rice kanji etc.
           b)   Full fluids:  Milk based beverages such as tea, coffee, milk shake, soufflé,
                bakedcustard, soup, juice, egg nog, fruit jellies etc.
           General Considerations
           Theother considerations include:
               Highenergyhighprotein diet should be given to patients suffering from mild to
                moderate hepatitis.
               During acute hepatitis or if vomitting/diarrhoea is severe, a full fluid or a semi-
                soft diet may need to be given.
               Small, frequent, easy to digest bland meals should be served to the patient. The
                meals should particularly be mechanically and chemically bland.
               Sincepatientsexperiencenauseaandanorexia, itisessentialtopreparepalatable
                meals which are attractively served. Inclusion of variety in terms of colour,
                texture, taste, flavour and mouth feel is important to motivate the patient
                (particularly children) to consume food.
               Moistheatmethodsofcookingsuchasboiling,pressurecooking,stewing,steaming
                should be preferred over dry heat methods such as roasting, grilling etc.
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