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8/9/2019 diet in liver diseases

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Diet treatment in liver cirrhosis

EL-Said Galal EL-Badrawy

Prof. Of Gastroenterology

Tropical Medicine

Zagazig University

By


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NutritionNutrition

Ingestion and absorption of aIngestion and absorption of anutrionally adequate diet arenutrionally adequate diet arenecessary to mentain healthnecessary to mentain health

An imbalance between nutrient intakeAn imbalance between nutrient intakeand requirement can lead toand requirement can lead tomalnutritionmalnutrition manifested bymanifested byalternation in metabolism,organalternation in metabolism,organfunction and body compositionfunction and body composition


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MalnutritionMalnutrition

May beMay be

11)Specific mineral and micronutient deficiency)Specific mineral and micronutient deficiency

))ProteinProtein--energy malnutritionenergy malnutrition22


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PEMPEMcommon in patients with chroniccommon in patients with chronicliver diseasesliver diseasesHowever the criteria used to diagnose PEMHowever the criteria used to diagnose PEMare affected by liver disease itself,so theare affected by liver disease itself,so the

presence and severity of malnutrition ispresence and severity of malnutrition isoften related to clinical stages of liveroften related to clinical stages of liverdiseases i.e malnutrition increases withdiseases i.e malnutrition increases with

worsning of liver functionworsning of liver functionPEM is nearly universal finding in patientsPEM is nearly universal finding in patientsawaiting liver transplantationawaiting liver transplantation


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Although indicators of nutritional status doAlthough indicators of nutritional status donot necessarily reflect adequacy ofnot necessarily reflect adequacy of

nutrient intake,these indicators are can benutrient intake,these indicators are can beusefull prognisticators of clinical outcomeusefull prognisticators of clinical outcomein patients with liver diseasein patients with liver disease


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PEM IN CHRONIC LIVER DISEASESPEM IN CHRONIC LIVER DISEASES

Associated withAssociated with

11)An increased risk of infection which lead to inhibition)An increased risk of infection which lead to inhibitionalbumin synthesis(through the inhibitory effect ofalbumin synthesis(through the inhibitory effect ofinterleukeninterleuken 11&TNF)&TNF)22)multiple organ complications)multiple organ complications

)Esophageal variceal haemorrhage)Esophageal variceal haemorrhage33

Increased mortality before transplantationIncreased mortality before transplantation))44

55)Increased risk of infection,prolonged hospitalisation and)Increased risk of infection,prolonged hospitalisation andmortality after transplantationmortality after transplantation

66)Increase incidence of encephalopathy)Increase incidence of encephalopathy


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adequate detoxifying activityno ascites ,

no bleeding tendency

and

no hepatic encephalopathy

Compensated form

liver cirrhosis

Decompensated form

ascites, edema,loss of muscle mass,

bleeding esophageal

varices, hepatic

encephalopathy,

bleeding tendencyand progressive

deterioration in

laboratory test results


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Causes of malnutrition in cirrhosisCauses of malnutrition in cirrhosis


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The importance of correct diet in cirrhosis of

the liver is unfortunately still underestimated.

A liver-adapted

diet is just as important as medication.


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Dietetic treatment becomes necessary

when there are signs of malnutrition or

adequate nutrition is no longerpossible using ordinary means.

Signs of malnutrition include

Loss of muscle mass

Loss of subcutaneous adipose tissue

Increase in tissue water

Indications for starting dietetic treatment


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Assuring the adequate intake of protein and

correct types of proteins

Assuring an adequate supply ofenergy

Increased dietary intake of fiber

Administration of branched-chain amino

acids. Reduced intake of sodium

Restriction of fluid Increased intake of

potassium

The measures in dietetic treatment are


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The goals of dietetic treatment are

Improving liver functionAvoiding catabolic states increased breakdown

of the bodys own protein which may triggerhepatic encephalopathy

Improving protein metabolism, especially in

patients requiring reduced protein diets, by

providing increased amounts of

Management of the formation of ascites and

edema by a low sodium diet, fluid restriction,

and a plentiful supply of potassium

Preventing or remedying malnutrition

branched chain amino acids


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Daily protein intake should be

about 1.2 g per kg body weight.

As long as the liver fulfils its functions

(compensated type of cirrhosis of the liver),no dietetic treatment is required.

Patients should maintain a healthy diet,preferably taking six small meals distributed

throughout the day, and absolutely avoid alcohol.

In no case should protein intake be restricted,because, in doubtful cases, this will only be

harmful.


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In decompensated liver cirrhosis, it isimportant to assure that the patient is

getting the required amounts of nutrition.

Often, due to poor appetite, rapid satiety(e.g. due to ascites), weakness and fatigue,

dietary intake is inadequate. Also, the poor

taste of hospital food or of a low-sodium

diet may be culpable in patients not takingadequate nutrition.


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This corresponds to an ordinary diet in

healthy persons, with adequate amounts of

fruit, vegetables, salads, whole grain

products, potatoes, rice and pasta.

There should be no automatic decision toput patients on a reduced protein diet even

in decompensated liver cirrhosis.

On the contrary, these patients, who are often

affected by a significant protein and energy

deficit, should actually be taking 1.5 g of

protein per kg each day, or about 100-120 g of

protein per day in most cases


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xperts recommend the following

protein intakes

1.2 g of protein per kg body weight each

day in compensated liver cirrhosis

1.5 g of protein per kg body weight each

day in de compensated liver cirrhosis andmalnutrition


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Physicians are often concerned that an adequate

protein intake may triggerhepatic encephalopathy.

This is the protein dilemma in which adequateprotein is good for malnutrition but bad for

encephalopathy and vice-versa. This dilemma,

however, does not apply in 99% of patients with

liver cirrhosis, in whom other triggers, such asinfection, bleeding, drugs, renal failure, electrolyte

imbalance and constipation, are present


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Beside the amount, thequality

of protein also is important. Thisis especially true for all sick

persons and very especially for

persons with liver disease.


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An imbalance in amino acids does not

occur solely after such bleeding, but

actually occurs in all cirrhosis patients

as a consequence of disturbed liverfunction and the de-tour of portal blood

through the collateral circulation. Patients

with cirrhosis are deficient in branched-

chain amino acids (BCAA), but have anexcess of aromatic amino acids (AAA).


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BCAABCAA AAAAAA

Metabolism independenton liver function

predominantly in the

musculature

Metabolism dependenton liver function

predominantly in the

liver

Blood level reduced

in cirrhosis

Useful in

encephalopathy

Blood level increased

in cirrhosis

Unfavorable in

encephalopathytyrosine, phenylalanine

and methionine

valine, leucine and

isoleucine

The level of waste products of BCAA does not increase as a result of

their being broken down. BCAA also inhibit the breakdown of protein


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BloodMeat/sausage

Fish/egg

Milk/dairy products

Vegetable protein

Poor tolerancePoor tolerance

BranchedBranched--chain amino acidschain amino acids

(BCAA)(BCAA)

Aromatic amino acidsAromatic amino acids

(AAA)(AAA)

Good tolerance


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Energy supply

About 70% of patients with chronic liver

diseases have a faulty diet. The immunesystem of malnourished patients is

weakened. There may also be loss of the

bodys own protein, such as in catabolic

states with breakdown of muscle mass.


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Normal weight

(height in centimeters minus 100) times 35 =

energy requirement in kilocalories per day.

This calculation considers theenergy content

of all foods, including that of dietary protein,which is not primary used as a source of

energy.

Energy requirement


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Carbohydrates

are the main source ofenergy for the

body. Like fat they do not raise thelevels of toxins in the body. 1 g of

carbohydrate provides the body with 4

kilo-calories (kcal). Foods that are rich

in carbohydrate include: sugar, sweets,fruit, bread, foods made with flour,

potatoes, milk and vegetables.


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For patients with cirrhosis of the liver it is of

particular importance that it

binds toxins in the bowel.

Roughage reduces the toxin levelNon-digestible roughage is also classed

among the carbohydrates. Roughage (or

fiber) consists of those parts of vegetable

foodstuffs that cannot be utilized by thehuman body.

Roughage promotes digestion, slows the rise in

blood sugar, reduces the level of cholesterol

and improves the sensation of satiety.


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A high-fiber diet often has sideeffects

(bloating, sensation of fullness

or abdominal pain).


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Fat does not increase toxic levels of ammonia in hepaticencephalopathy. It is used as a source of energy and as an

energy store. The intake of animal fats should not be too

high and the intake of vegetable fats should not be too low.

In about 40% of the patients suffering from cirrhosis of theliver the digestion of fats is disturbed because of poor fat

utilization and absorption. This may also affect the

absorption of fat-soluble vitamins (A, D, E and K), which

may lead to deficiency and must be supplemented

parenterally in these patients. In steatorrhea, special fat(MCT-fat) can be used. MCT is the abbreviation for medium

chain triglycerides. Ceres MCT Diet Cooking Oil from

Special MCT fats, such as margarines, oil and special

dietetic MCT foods such as soft cheese, hazelnut nougat

crme etc.,

Fats


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Minerals, vitamins and water


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Sodium

All patients with cirrhosis should,

as a rule, be advised to use less saltin order to inhibit the development

of ascites or edema.

Sodium-defined diets:Strict low sodium diet (1 g of table salt per day)

Low sodium diet (3 g of table salt per day)

Sodium-reduced diet (6g of table salt per day)


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PotassiumPotassium

Salt substitutes generally contain potassium in placeSalt substitutes generally contain potassium in placeof sodium compounds. In addition to anof sodium compounds. In addition to animprovement in taste, they have the advantage ofimprovement in taste, they have the advantage ofthe high potassium content. A potassiumthe high potassium content. A potassium--rich dietrich dietis particularly important for patients who takeis particularly important for patients who takediuretics to get rid of fluid, as potassium deficiencydiuretics to get rid of fluid, as potassium deficiencycan otherwise occurcan otherwise occur

Particularly rich in potassium are all types ofvegetables

(particularly cabbage, potatoes, herbs, tomatoes,

spinach, tomato pulp, mushrooms and chanterelles),

fruit


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Patients with cirrhosis of the liver

often show a deficiency in minerals

(zinc, iron, calcium,) and vitamins

)A, D, E, K, folic acid, B1, B2, B6,B12). Because supplementation in

the form of tablets, capsules or

drops is much easier than the

demonstration of a deficiency


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Many patients with cirrhosis of the liversuffer from a marked zinc deficiency.

When zinc is given in tablet form,

hepatic encephalopathy often

improves. Particularly good here arezinc tablets containing organic zinc

compounds such as zinc histidine,

which are more reliably

absorbed from the bowel thaninorganic zinc salts.


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Supply of fluidSupply of fluid

A restriction in the amount of fluid drunk is onlyA restriction in the amount of fluid drunk is onlyrequired if the level of sodium in the blood is toorequired if the level of sodium in the blood is toolow or in case of edema or ascites.low or in case of edema or ascites. The amountThe amount

consumed should be reduced toconsumed should be reduced to 50050010001000 ml. When theml. When thefluid intake is low, onlyfluid intake is low, onlydrinks that quench the thirst should be chosen. Milk,drinks that quench the thirst should be chosen. Milk,mixed drinks, sweetened soft drinks or teas, and highmixed drinks, sweetened soft drinks or teas, and highsodium mineral waters are not appropriate. Mineralsodium mineral waters are not appropriate. Mineralwater, which is also used to supply the calciumwater, which is also used to supply the calciumrequirement, is thirst quenching.requirement, is thirst quenching.


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Soft dietSoft diet

The importance of soft or strained foods inThe importance of soft or strained foods inthe prophylaxis of variceal bleeding has notthe prophylaxis of variceal bleeding has not

been proven. What is certain is thatbeen proven. What is certain is that

sufficiently small, careful chewed and wellsufficiently small, careful chewed and wellmoistened foods are better tolerated andmoistened foods are better tolerated and

more efficient. In all disorders of themore efficient. In all disorders of theesophagus, you should consider theesophagus, you should consider the

temperaturetemperature(lukewarm is best, avoid very hot or very(lukewarm is best, avoid very hot or very

cold) and aggressiveness (acid,cold) and aggressiveness (acid,hot spices) of the food.hot spices) of the food.


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Summary


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There are no absolute restrictions in

diet for patients with liver disease

and in general they should follow the

principles of a balanced, healthydiet. It is essential, however,

that patients with diseases of liver

absolutely avoid alcohol in any form


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Liver patients with advanced disease are

threatened as their disease progresses withmalnutrition, which can be addressed with the

following measures:

Adequate caloric intake (35 kcal per kg body weight daily)Adequate intake of protein (1.21.5 g per kg bodyweight daily)

Adequate intake of vegetable fiber orroughage

Regularexercise to maintain muscle mass

Timely addition ofenteral dietary supplementation

Timely addition of branched-chain amino acid


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at least

3 portions

no alcohol

otherwise moderately

not more than

12 low-fat portion

at least

4 portions

Drink at least 2 liters daily!

Salt moderately!


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