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 • Biliary ducts Fig. 18-9, Gould next
Blood Supply to Liver • Liver circulation Fig. 22-1 next
Sinusoids • Sinusoids Fig. 13-1 next • Also see Fig. 18-11 in Gould
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 • Cells that line the sinusoids • Phagocytic cells of the immune system
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 Liver • Portal hypertension • Pressure in hepatic vein increases above 0 mm Hg
Metabolic • What are the metabolic functions of the liver?
Detoxification • Kupffer cells • Toxins detoxified • Removal of ammonia & make urea
Digestion • Bile synthesis • Bilirubin • product of breakdown of heme when rbc discarded • excreted in bile
Progression of Liver Disease • Fatty liver • Hepatitis • Cirrhosis • ESLD
Hepatitis • Infectious mononucleosis • Toxic chemicals • Viral infection • Excessive use of alcohol
Viral Hepatitis • Hepatitis A • fecal-oral route • rapid onset • 2 - 6 weeks • acute type
Viral Hepatitis • Hepatitis B and C • contaminated bodily fluids • slower onset • 6 weeks to 6 months • can become chronic
Hepatitis • Symptoms • jaundice can occur • pale stools • easily fatigued
Hepatitis • Symptoms • nausea & anorexia • fever • liver tenderness • liver enlarged
Hepatitis • Why do these clinical manifestations happen? • hypoglycemia • fluid imbalance • bleed more easily • elevated serum bilirubin > 20mg/dl
Prehepatic Jaundice • Fig. 18-12 in Gould • Hemolytic jaundice • Excessive rbc break down • Unconjuaged bilirubin high • Stool dark/normal color
Intrahepatic Jaundice • If unconjugated bilirubin high means liver cell damage • If conjugated bilirubin high, means blockage
Posthepatic Jaundice • Conjugated bilirubin high • Light colored stool
Cirrhosis • Repeated damage, necrosis to liver • What will eventually happen to the liver?
Alcohol Acetaminophen Androgenic steroids Cyclosporine Erythromycin Glucocorticoids Isoniazid Methotrexate Methyldopa NSAIDs Hepatoxic Drugs
Damage Liver • Hepatitis, especially if chronic • Biliary disorders, obstruction • Hemochromatosis • Chronic use hepatotoxic drugs
Portal HTN • Due to damaged liver • Pressure too high on which end?
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 • Less than 25% of liver functions • Portal systemic encephalopathy (PSE)
Stage 1 apathy restlessness reversal of sleep rhythm Stage 1 slowed intellect impaired computational ability impaired handwriting ESLD Stages
Stage 2 lethargy drowsiness disorientation asterixis Stage 3 stupor (arousable) hyperactive reflexes extensor plantar responses ESLD Stages
ESLD Stages • Stage 4 • coma • response to painful stimuli only
ESLD • Excessive ammonia in blood (NH3) • Abnormal amino acid metabolism • BCAA lower • Aromatic AA higher
ESLD • False neurotransmitter hypothesis by Fischer • too many Aromatic AA favored into brain • phe - hinder neuronal transmission
ESLD • False neurotransmitter hypothesis by Fischer • phe & tyr - precursor of epinephrine & norepinephrine • trypothan - precurson of serotonin
ESLD • False neurotransmitter hypothesis by Fischer • high level of phe result in false neurotransmitters & competes with normal neurotransmitters
ESLD • Precepitating factors • GI bleed • increased dietary protein • constipation • infection • less hepatic function
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
SGA • Three elements of physical exam • loss of subcutaneous fat • muscle wasting • presence of edema or ascites