MEDICAL NUTRITION THERAPY

FOR:DISEASES OF THE
ACCESSORY ORGANS
- The three major accessory organs: liver; pancreas; gallbladder
- They play a major role in the production of digestive & absorptive agents
- Basically, the liver & pancreas are capable of producing & storing enzymes for specific nutrients
for future use.
- The gallbladder serves as the concentrating unit &reservoir for bile. Helps in the digestion of fats
A. THE LIVER
- It is the second largest organ of the body, located at the right side of the body in the upper
abdomen
- It is triangular in shape, weighing between 2.4- to 4 lbs.
- It has the following functions: metabolizing, detoxifying, and regenerating ; that is capable of
regenerating itself when part of it is damaged.
- The liver has a major role in nutrition and metabolism.
- - it receives directly from the intestine most of the absorbed nutrients that are products of
digestion.
-
• B. LIVER DISEASES
- Liver disease may arise from toxic damage ( due to alcohol abuse,
chemicals & infections, biliary tract obstructions, heart disease,
congenital disorders, Wilson’s disease etc.
- A liver panel tests are used to detect liver damage or disease.
• The following are different liver panel tests to detect liver disease
1. Alanine aminotransferase ( ALT )– an enzyme mainly found in the
liver; best test to detect hepatitis.
2. Alkaline Phosphatase ( ALP ) – an enzyme related to the bile ducts;
often increased when they are block
3. Aspartate aminotransferase ( AST ) – an enzyme found in the liver &
a few other areas, particularly the heart, & other muscles in the body.
4. Bilirubin – two different tests of bilirubin often used together ( esp.if
person is jaundiced ); total bilirubin measures all the bilirubin in the
blood. Direct bilirubin measures a form made in the liver.
5. Albumin – measures the main CHON made by the liver & tells how
well the liver is producing the CHON.
6. Total CHON – measures albumin & all other CHONs in blood,
including antibodies made to help fight off infections.
Other tests:
a. gamma-glutamyl transferase ( GGT ), lactic acid dehydrogenase
(LDH), & prothrombin time.
- Nutrition therapy of the liver depends largely on the type & severity
of the disease.
• GOALS OF NUTRITION THERAPY:
• 1. To correct pre-existing malnutrition
• 2. To supply adequate calories & CHON to encourage hepatic regeneration
without precipitating hepatic encephalopathy.
B. FUNCTIONS OF THE LIVER:
1. CHO METABOLISM
• Conversion of monosaccharides (galactose & fructose)to glucose
*Production of glycogen ( glycogenesis process ).
*Degradation of glycogen upon demand ( glycogenolysis reaction )
2. Protein Metabolism
*conversion of amino acids into glucose ( oxidative deamination )
*synthesis of albumin, globulin, & transferrin
*synthesis of non-essential amino acids ( transamination )
*synthesis of nitrogen-containing compounds from amino acids
( purines & pyrimidines )
*removal of nitrogenous wastes ( urea synthesis )
• Plasma CHON synthesis including clotting factors
3. FAT METABOLISM
• Synthesis of cholesterol, phospholipids, & lipoproteins
• Production of ketone acids
• Synthesis of endogenous triglycerides
• Oxidation of fatty acids
• Other functions:
• Synthesis of bile salts
• Detoxification of alcohol, drugs, wastes & other foreign substances
• Conversion of carotene to Vit A
• Site for hydroxylation of vit D for renal activation
• Storage for fat soluble vitamins
• Storage of certain minerals ( e.g.iron, copper, zinc, Mg )
• Hematopoietic organ in the fetus
C. DISEASES OF THE LIVER
• 1. Jaundice ( icterus )
- Exists in a variety of liver & biliary disorders
- It is a syndrome with manifestations of hyperbilirubinemia &
deposition of bile pigment resulting to yellowish discoloration of the
skin, mucous membrane, & sclera.
a. Classification of jaundice:
1. pre-hepatic or hemolytic jaundice – originates from a massive
destruction of the RBC or excess bilirubin production.
- It is seen most often in Rh factor sensitization, hemolytic anemia,
sickle cell anemia, massive lung infarctions, & septicemia.
- Patient has classically lemon color of the skin & sclera.
2. Hepatic or Toxic jaundice – is due to damage or immature liver that
cannot convert fat-soluble form required for its removal form the
blood.
- This type of jaundice is seen in prolonged drug use, viral infections, &
metastatic CA.
- Due to dysfunction of hepatic cells, the uptake, conjugation and
excretion of bilirubin are compromised causing dark urine & pale
stools, as well as anorexia & malaise
3. Post-hepatic or obstructive jaundice – results when the flow of bile
into the duodenum is blocked with stones, tumors, or inflammation of
the mucosa of the ducts.
- If the conjugated bilirubin has no escape route, the stools go pale, &
bilirubin is passed out in the urine making it very dark as a result.
- If obstruction will not be managed, it results to biliary cirrhosis
c. NUTRITION THERAPY FOR JAUNDICE
- Treatment is directed to the cause & not to the symptoms
- To overcome indigestion & malaise, small frequent meals that offer
the patient’s highly preferred foods would be helpful.
- Small frequent feedings of foods tolerated for nausea, anorexia, and
vomiting that accompany jaundice
- In chronic obstructive jaundice, steatorrhea can be controlled by
restricting intake of long chain fatty acids
- The use of medium-chain triglycerides (2 tbsp/1000 kcal) should be
considered in severe steatorrhea.
- Supplementation with fat-soluble vits is recommended; avoid use of
fats & caffeine
2. HEPATITIS
- It is the inflammation of the liver with necrosis of the liver cells
a. Common causes: drugs like acetaminophen, toxins like alcohol,
viruses like rubella, bacteria like leptospirosis, parasites like
amoeba, non-infectious like biliary obstruction
b. Signs & symptoms: fatigue, nausea, right upper quadrant pain, dark
urine, increased ALT.
NUTRITION THERAPY FOR HEPATITIS
*Goals of dietary therapy: Liver regeneration, prevention of further
injury, promote organ rest, prevention & correction of weight loss.
- Nutrition therapy is the key to recovery of the patient
- Explain the importance of proper diet to the patient
- Since patient has anorexia, make sure that foods should be properly
cooked, creative ideas & attractive food service must be emphasized.
- A high calorie, high CHON, high CHO and moderate fat is usually
prescribed
- In acute cases, patient should be provided with an adequate balanced
diet modified to liquid to soft, progressing to a wider choice of foods
with convalescence.
- Small to moderate portions at mealtime with between meal
supplements of high CHON beverages are more acceptable than
larger meals.
- If patient is poorly nourished, & patient is not satisfied, tube feeding
is instituted.
• HIGH CHON – is essential for liver cell regeneration
- Intake of 1-2 gms CHON/kgBW or 100 to 150 gms CHON daily for
adults is considered sufficient
*Adequate CHO – sufficient available glucose must be provided to
ensure sufficient glycogen reserves needed for the maintenance of
hepatic functions & protection of the liver against further injury.
- Large amount of CHO will spare the CHON for liver regeneration &
supply the bulk caloric needs
- An intake of 300-400 g of CHO should be encouraged daily
• Fats – should be moderate, in order to prevent deposition in the liver.
- An adequate amount of fat adds palatability in the diet; carries fat
soluble vits., & well tolerated by patients.
- Weight gain is more rapid & liver function tests revert to normal
sooner when patient receives 30-40% of kcal from fat or up to 150 g
of fat daily.
*High Calorie- from 3000-3500 kcal (allow 30-35 kcal/kgbw or basal
energy expenditure x 1.5) are needed daily to meet energy demands of
the tissue building process, to compensate for losses from fever &
debilitation, to renew strengths & recuperative powers.
• Vitamins & Minerals
- To effectively raised the prothrombin levels, parenteral vit k or oral vit
k must be given.
- Zinc, B-complex vits esp.B1,B12, ascorbic acid, & folate must be given
- Supplemental other vits. Is necessary to fortify liver against stress
- Make sure that patient abstain from alcohol
*food selection: a simple normal diet consisting of simple foods maybe
eaten as desired. No foods are especially contraindicated but, many
patients complain of intolerance to strongly flavored foods, fatty foods,
Sample Diet for Infectious Hepatitis
Food Grp Amount CHO CHON FAT Energy Kcal
veg A 2 Exchanges 3 1g - 16
veg B 2 Exchanges 6 2g - 32
Fruit 3 Exchanges 30 - - 120
Milk evap 2 Exchanges 24 16 20 340
Rice or substitute 10 exch. 230 20 - 1000
Meat or substitute 9 exch - 64 34 562
Fat 8 exch - - 40 360
Sugar 12 exch. 60 - - 240
total 353 103 94 2670
- chocolates, spicy foods and rich desserts. So, it would be better if
such foods will be avoided.
3. CIRRHOSIS of the LIVER- is a chronic irreversible liver disease, where
fibrous connective tissue replaces the functioning liver cells following
fatty degeneration of long standing liver cell injury. The large volume of
blood can not flow easily to the mass of scar tissue, so it backs up to
the portal vein resulting to increased in portal pressure.
- As portal pressure increases, plasma leaks into the abdominal cavity
resulting to ascites ( enlargement of the abdomen )
3 TYPES of Cirrhosis:
1. Biliary cirrhosis- is associated with excessive copper storage in the
liver, as well as the kidneys and spleen, impaired bile excretion &
progressive destruction of bile ducts.it is caused by obstruction of
the bile and possibly autoimmune or endocrine disorders are the
possible cause.
- It is manifested by pruritus, prolonged progressive jaundice,
hepatomegaly & portal hypertension.
2. post-necrotic cirrhosis – cause is unknown, but commonly, it is
preceded by hepatitis. Symptoms is similar to hepatitis or may consist
of abdominal pain, ascites, jaundice, and esophageal hemorrhage from
ruptured esophageal varices.
3. Laennec’s cirrhosis – destruction of liver cells from chronic
alcoholism. Patient may manifest fatigue, weakness, jaundice, edema &
ascites.
- If alcohol intake continues, disease progresses, & patient manifests
fever, nausea & vomiting. If condition will not be managed properly,
patient may die in hepatic coma.
• NUTRITION THERAPY FOR LIVER CIRRHOSIS:
*Common problems that would interfere with food intake:
1. Decreased room for food eaten due to ascites
2. Delayed gastric emtying
3. Anorexia
4. Poor nutrient absorption due to decreased bile production
5. Diet restrictions
6. Altered mental status
• The goal of therapy is to support & enhance the healing process of
the damaged liver & to prevent hepatic coma
CALORIC REQUIREMENT: a daily intake of 35-40 kcal/kg of desirable bw
or estimated dry weight ( about 2000-3000 kcal) is recommended to
maintain the person in positive nitrogen balance.
PROTEIN: the diet should supply 1-1.5 g kcal/kg bw so that liver cells
can regenerate. Sufficient CHON is also needed for the formation of
cholic & other bile acids.
- Avoid giving too much of CHON to prevent ammonia build up which
may result later to hepatic coma.
- A high percentage of protein of high biologic value should be the food
of choice.
- Encourage use of branched chain amino acids; dietary sources for
BCAA are red meat & dairy products. However, meat CHON has a high
level of aromatic amino acids.
- Better sources of CHON are plant CHONs from pasta, vegs., rice,
fruits, & lima beans.
*CHO: an increase in dietary CHO (300-400 g) is well tolerated.
- It provides needed calories & aids in recovery.
• FATS: moderate amount of fat is allowed.
- About 25% - 30% of total calories from fat is recommended along
with the use of medium chain triglycerides
- Monitor the use of MCTs, they may cause diarrhea or acidosis.
- Ensure that essential fatty acids are included in the diet.
- Avoid trans fats
• Fluids & NA: a low NA can help decrease water or fluid retention
• w/ ascites, 2-4 g sodium-restricted diet is suggested.
• Avoid overhydration, ( usually 6-8 cups is adequate ( 48-64 oz. )
• Vits & minerals: the use of vit supplements esp vit B-complex & iron is
always indicated because most patients develop poor physical
condition as a result of limited food intake.
• Deficiencies in vit B-complex is manifested by tongue lesions,
presence of polyneuritis and vit k deficiency indicated by
hypoprothrombinemia are common.
• Provide vit C, K, zinc, & Mg-rich foods or supplements.
• Monitor the need for vit A & D
• FOOD SELECTION:
- Great care should be taken to have the patient select his food
preferences whenever possible.
- The distribution of meal from 6-8 small feedings/day is preferred
compared to the 3 large meals.
- Replace salt shaker w/ herb shaker
- Serve fresh unprocessed foods; alcohol is strictly avoided
- Reduction in the fiber content of the diet is necessary to decrease the
danger of hemorrhage.
4. HEPATIC COMA or HEPATIC ENCEPHALOPATHY:
- It is a serious complication of advanced liver disease
- It is a complex syndrome characterized by neurological disturbances
from increased ammonia level in the blood.
- Signs of impending coma: confusion, irritability, mental disturbances
such as change in judgment & mood.
- A typical motor system change is manifested by flapping
tremor(asterixis)
- Breath is characterized by sweet, musty or pungent odor
• 4 stages of hepatic encephalopathy:
1. Stage 1 – mild confusion, agitation, sleep disturbance, dec attention
2. Stage 2 – lethargy, disorientation, inappropriate behavior,
drowsiness
3. Stage 3 – somnolence but arousable, confusion, aggressive
behavior, incomprehensible speech
4. Stage 4 – coma or unconscious
• NUTRITION THERAPY: the fundamental principle in the dietary
management is to reduce complications.
CHON: if not in coma, patient should receive moderate to high levels of
CHON (1.0-1.5 g/KDBW).
- If in comatose condition, CHON intake should be 0.5-0.6 g CHON/Kbw
in the form of tube feeding, ensure higher intake of BCAAs, can be
taken orally if tolerated or by NGT .
- Leucine is the most essential to this type of condition but expensive
- Glutamine enriched products are avoided
- Milk & eggs produces less ammonia than meats.
- Veg.CHONs contain less amino acids that readily form ammonia &
better suggested for use, they contain more fiber, which prevents
constipation.
- Prevention of constipation reduces absorption of ammonia in the
intestines
FOOD SELECTION:
VEGS: All except legumes milk: in allowable amount
Fruits: all fruits rice or substitute; allowable amount
- Meat or substitute: All except nuts, seed, beans in allowable amount
- Fats: cooking fats, butter, margarine, salad oils, dressings
- Desserts: low CHON desserts as plain cornstarch & pudding, nata de
coco, matamis na bao, kondol, sago or kaong w/ syrup, sweetened
kamoteng kahoy
- Sugar & sweets: all
- Misc.: sotanghon, sauces thickened w/ cornstarch, herbs, spices &
condiments in moderation
• Fat delivers calories efficiently & helps make food appealing to a
person with poor appetite.
• The diet should supply 30-35% fat for calories, but preferably the MCT
• CALORIES: Diet should supply 1.3 x resting energy expenditure/day or
about 30 kcal/kg bw to prevent tissue breakdown.
• Vitamins & minerals: supplementation of vits & mineral is needed
esp.fat-soluble vits., niacin, thiamine, folate, zinc, calcium &
magnesium
• Fluids & sodium:
- Fluids & sodium are restricted if abdominal fluid retention is evident
- Level of restriction depends on the severity of ascites
- Sodium requirement may range from 250-2000 mg/day.
- Fluids from 1500-2000 ml/day
- It is important to weigh patient daily to determine if fluids are
retained that is, there is rapid increased in body weight w/c signifiy
retention of fluids ( 2 kg increased is equivalent to 2000 ml of fluid
retained )
• Meal frequency & food selection:
- Encourage small frequent feedings because ascites limits gastric
capacity
*WILSON’S DISEASE- known as hepatolenticular degeneration &
inherited copper toxicosis, a metabolic disorder characterized by the
retention too much copper into bile, the copper retains in the liver.
- This hereditary disease can damage the kidneys, brain, & eyes, & can
lead to severe brain damage, liver failure, & result to death of the
patient.
SAMPLE LIST OF LOW CHON DIET
Food GROUP ALLOWED Restricted/Avoided
Vegetables all except legumes Legumes
Fruits All None
Milk In allowed amts Excess of allowance
Rice or substitute In allowed amts Excess of allowance
Meat or substitute All except nuts, seeds In excess of allowance
beans in allowed amts nuts, seeds, & beans
Fats cooking fats, butter, coconuts/ other nuts
margarine, salad oils & dressings
Food Group Allowed Restricted/Avoided
Sugar & sweets all none
Desserts low CHON desserts as plain those w/ milk, eggs
arrow roots or cornstarch & pudding, cereals, & nuts,
nata de coco, matamis na bao, kundol, such as ice cream
rimas, sago or kaong w/ syrup, custards, pudding
sweetened kamoteng kahoy cakes, cookies,
bibingka etc.
Food Group Allowed Not allowed/restricted
Miscellaneous sotanghon, sauces
thickened w/cornstarch only,
herbs, spices & condiments
in moderation
• Nutrition Therapy:
- A diet low in copper ( 1-2 mg/day) is given to patients .
- Avoid copper-rich foods like cocoa, chocolates, liver, mushrooms,
nuts, organ meats & shellfish.
- Oral vit. B6 & zinc supplementation of about 25 mg of zinc/day may
be necessary.
- Zinc acetate promotes copper binding to essential cells & subsequent
excretion in the stools
• 6. LIVER CA
- Viral infections that cause chronic active hepatitis ( B & C , viruses )
are responsible for most cases causing CA of the liver in the Phils.
- Other factors: HCV, alcohol abuse, prolonged heavy aflatoxin
exposure.
- The Aspergillus, a mold which is found in foods with aflatoxin like
peanuts, rice, soybeans, corn, & wheat.
- Other studies show that various raw agricultural products & foods,
feeds processed from contaminated products contain high levels of
aflatoxin.
• * PREVENTIVE MEASURES: The Dept.of Health thru The Phil CA
Society specifies primary prevention & detection measures:
1. Hepatitis B infant vaccination
2. Public sanitation & hygiene
3. Avoidance of heavy alcohol intake
NUTRITIONAL THERAPY
• The major challenge for nutritional therapy:
- Improvement of nutritional status which maybe thru: oral, tube
feedings, or intravenous nutrient supplementation
• For oral diet. Provide a diet high in calorie, CHONs, & CHO
- But for Hepatic CA, a low CHON intake is necessary.
- Low CHON is supplemented with amino acids
- Inclusion of vit supplements is important with care be taken to
prevent toxic levels because of poor liver clearance.
END STAGE LIVER DISEASE
• An irreversible condition that leads to the imminent complete failure
of the liver.
• Factors leading to the causation of ESLD: VIRAL Hepatitis, Cirrhosis,
Genetic d/o, Liver CA, Obesity, toxins, some drugs that are
hepatotoxic, Liver Failure
• This patients has low life expectancy except if patient undergoes liver
transplant.
• LIVER TRANSPLANT: it is considered if conventional treatment has
failed to prevent further damage.
• Candidates for transplant: pts w/ biliary cirrhosis, chronic active
hepatitis w/ cirrhosis & other progressive liver disease.
• The best chance for prolonging survival is to undergo orthotopic liver
transplantation.
• Contraindications: sepsis, advance pulmonary or renal disease,
multiple previous abdominal surgeries
Ntritional Therapy
• A. pre-op period: dietary interventions are designed to ameliorate the
symptoms of ESLD & to optimize nutritional status.
• CALORIE: Energy needs are estimated at 35-45 kcal/kg & may range
up to 1.5 g bw or estimate of dry weight.
• CHON: Requirement is estimated to minimal 1-1.2 g/kg & may range
up to 1.5 g/kg bw. Lower intake is given if patient has Hepatic Coma.
• Sodium : patients with ascites will need sodium restricted diet of
2000 mg/day or less.
- In practical terms, pts can usually achieve a sodium intake of 2000 mg
to 4000 mg/day.
*FLUIDS: patients with persistent, significant hyponatremia after
sodium restriction and diuretic therapy may also need fluid restriction
usually 1-1.5 L/day.
*Vits.& minerals: a multivitamin w/ minerals maybe useful to prevent
potential deficiencies associated with poor intake, metabolic
disturbances of liver disease & drug effects.
• Post-operative Period: following surgery, the diet is aimed to provide
appropriate nutrients to promote anabolism & wound healing, to
prevent & treat post-op complications, & to manage effects &
immunosuppressive & other drugs.
• CALORIES: Obesity can occur after transplant due to
immunosuppressive medications. About 30-35 kcal/kg are needed to
maintain/ improve body weight.
- Fat calories should be 25-40% of the total calories
*CHONs: it is estimated to 1.0-1.2 g/kg dry weight. Increased BCAA &
dec sources of aromatic amino acids(tyrosine, tryptophan,phenylalanin
• CHO: A normal CHO is given. Reduce intake of simple CHO when glucose
intolerance is present.( due to steroid therapy).
• Fluids: must be restricted due to intra-op administration of large volumes,
residual ascites, or edema, and/or oliguric renal failure.
- In cases large losses of fluids due to drains or excessive diuresis, increase
administration of fluids maybe necessary.
• elect.& minerals: electrolyte profile should be checked to identify for
deficits. Deficit of electrolytes should be replaced.
• w/recovery from Liver Transplant, nutritional intervention aimed at
prevention of chronic h-problems(DM, obesity, hypertension,
hyperlipidemia. Adjust energy intake to maintain desirable BW.
- Along w/ nutritional care, patient is given antibiotics to reduce
intestinal gastrointestinal fungi & gram negative bacteria.
- A low bacteria diet is prescribed also called neutropenic diet. It begins
from pre-op transplant & continues post-transplant.
*the essentials of such diet are as follows:
1. Avoid all cheese & yogurt products, raw vegs.including salads &
garnish, raw fruits that are not peeled.
2. Avoid foods that are stored at room temperature or kept warm for
long periods
3. Defrost frozen foods in ref or microwave.
4. Serve foods quickly after preparation
5. Cover & freeze left over foods quickly
6. Use leftover foods within 2 days
7. Maintain clean techniques and immaculate preparation area.
Disorders of the exocrine pancreas
- The pancreas is 14 cm glandular organ located in the upper abdomen
behind the stomach.
A. Functions of the pancreas:
1. Production of the pancreatic juice when stimulated by secretin which
contains bicarbonate, which neutralize acid chyme.
2. Secretion of insulin (from beta cells of the islets of langerhans) &
glucagon ( from alpha cells)
3. Secretion of digestive enzymes(trypsin, lipase, amylase),into the
collecting duct as stimulated by cholecyskinin produced by the
duodenum.
4. Secretion of metabolic/digestive enzymes involved in CHON, CHO, &
Fat metabolism. Pancreatic secretion has gastric, cephalic, & intestinal
phases.
Disorders of the Pancreas:
1. PANCREATITS
- It is the inflammation, edema, & necrosis of the pancreas a result of
autodigestion of the organ tissues by enzymes it normally produces,
principally trypsin.
a. Factors causing pancreatitis:
- Biliary tract disease, surgery ( stomach, biliary tract), alcohol abuse,
the use of drugs like glucocorticoids, sulfonamides, chlorothiazide.
- Etiology is unknown
- Studies show that it may be due to obstruction of the pancreatic duct
due to calculi, spasm of the sphincter of Oddi, opening of the
common bile duct into duodenum, or inflammation accompanying
infection.
Acute Pancreatitis – is an acute inflammatory disease in which
autodigestion occurs from obstruction of the pancreatic duct.
- It is likely outcome from alcohol abuse or secondary from
cholelithiasis, ESRD, biliary tract disease, abdominal trauma, type IV
hyperlipidemia, malignant pancreatic tumor.
- Signs & symptoms: abdominal pain, nausea, vomiting, diarrhea
*NUTRITION THERAPY:
Objective of care: promoting rest to the organ by inhibiting its activity
& secretion of enzymes; rapid provision of adequate nutrition to
preserve nutritional status & maintain intestinal function.
- During acute attack of inflammation, no food is given for 24 hrs. to
avoid organ stimulation.
- Parenteral fluid is given or TPN may be indicated for excessively slow
progression.
*chronic cases – patient should receive a diet with low-to-moderate
fat, high CHO, & moderate CHON (2 g/kg, unless with renal or liver
failure), in such case 1 g/kg is indicated)
- Enzyme replacements are taken w/ meals to aid in the digestion &
absorption of CHON & fat. Complicated chronic pancreatitis requires
high calorie.
- Fluids & electrolytes are given IVTT
- TPN may be indicated if there are edema losses through NGT suction,
malnutrition due to lack of oral food & disruption of fluid intake.
- Upgrade diet to a low-fat diet w/ ( 15-20% or less of total kcal derived
from fat), & finally to regular diet as tolerated.
- Oral meal is better if distributed to 6 small meals rather than the
usual 3 meals.
- Fat soluble vits are given; vit B12 absorption may be reduced so it is
given parenterally. If glucose intolerance is present, pts is treated as
diabetic, w/ modified diet & insulin.
2. CYSTIC FIBROSIS of the PANCREAS
- Cystic fibrosis is an inherited chronic disease that affects the lungs &
digestive system causing the body to produce unusually thick, sticky
mucus that cogs the lungs & leads to life threatening lung infections;
obstructs the pancreas & stops natural enzymes from helping the
body break down & absorb food.
- Common symptoms: salty-tasting skin, persistent coughing w/ phlegm
wheezing or shortness of breath, frequent lung infection, poor
growth/weight gain inspite of good appetite, constipation
• Nutrition Therapy:
- High calorie, high fats diet, therapies to loosen the clogged mucus
from airways, mucus thinning drugs & antibiotics
- The over-all goal is to support normal nutrition & growth for patients
of all ages.
- Good nutritional status results in better growth, maintains better
nutritional reserves, & better lung function than with poor nutrition.
- The basic objective of nutritional therapy is to compensate for the
extensive loss of nutrient, material resulting from the insufficiency of
pancreatic enzymes.
- CALORIES: Provide enough calories to supply energy demands for
growth & to compensate for the malabsorption of nutrients resulting
in fecal losses.
- Extra calories also help to meet the greater energy needed for
breathing.
- Energy needs are about 150% of the RENI.
*CHON: A high diet is indicated to compensate for losses; about 4 g/kg
for infants, 3 g/kg for adolescents, & 1.5 g/kg for adults.
*CHO: Starch is less acceptable than sugar during acute periods. If
glucose intolerance develops, limit intakes of simple sugars.
*FATS: Prescribe a liberal fat intake for pts w/ cystic fibrosis who can
tolerate it.
- Extra fat calories are good for fueling normal growth & development.
- Medium chain triglycerides oil can provide additional kcal for persons
who can not tolerate fat.
- Encourage fish intake for sufficient omega-3 fatty acids.
- For infants, breast feeding is recommended, but if it is not possible, a
regular infant formula w/ enzyme replacement is given. Additional
kcal may be provided by adding CHO & fat supplements to the
formula.
• Vits & minerals: fat-soluble vit. Malabsorption is often a problem
- Vit B2 supplement is needed if cheilosis is evident.
- Minerals like calcium, iron, sodium chloride and zinc, are also
essential to maintaining good health through nutrition.
• Fluids: should be liberal unless contraindicated
• Exercise: is important to maintain lung health, esp.to patients w/ CF.
• CA of the Pancreas:
- It is the 14th leading CA in the Phils.
- The Phil CA society of the Phils.suggests that exposure to industrial
irritants & certain chemicals, cigarette smoking, alcohol abuse, &
history of diabetes are among the causative factors.
- Potential dietary risk factors are low intake of citrus fruits, beans &
legumes, & fiber.
- Lycopene is a protective agent
- Manifestations of malignant pancreatic tumor: malaise, anorexia,
epigastric pain, change in bowel habits, classic weight loss
*Nutrition Therapy:
- TPN or tube feeding has a major impact on the post-op period.
- Good nutritional support, adequate high in CHON and fat-soluble
vitamins, essential fatty acids, should be incorporate d in the diet.
- If can tolerate oral food intake, small meals is better tolerated.
- Improve fiber intake gradually & reduce fat intake.
- Onset of diabetes requires CHO controlled diet.
Disorders of the Gallbladder
- The gallbladder is a hollow, pear shaped sac attached to the right side of
the under surface of liver.
- It is about 3 in.long & 1 inch wide at the thickest part.
- Its main role is to concentrate & store bile produced by the liver cells.
- It is essential for absorption of fats, fat soluble vits, & a number of
hormones & metabolic substances, through the enterohepatic circulation
during consumption and digestion of food.
- The liver produces about 600-800 ml of bile daily, flows down from the
liver through he hepatic duct & enters the gallbladder via cystic duct, only
40-70 ml is stored. Sphincter of Oddi regulates the flow of bile into
intestine
- The bile is being conveyed to the duodenum via the common bile
duct
- The entrance of bile fat into the duodenum stimulates secretion of
hormone cholecystokinin by the intestinal mucosa.
- The hormone is carried by way of the CBD, then to the small intestine
where it is needed for the emulsification of fats
- Interference with the flow of bile impairs fat digestion
DISORDERS OF THE GALLBLADDER
1. CHOLECYSTITIS- is the inflammation of the gallbladder usually
resulting from gallstones or chronic infection.
- Bacteria from the tonsils, teeth, sinuses, or even the appendix may
stray & travel via the blood stream to the gallbladder.
- Other factors: obesity, pregnancy, constipation, improper diets, &
digestive upsets.
- Commonly cholecystitis is seen in places where diet is high in fat &
calories.
- Heredity is a factor & occurs commonly in females.
• Nutrition Therapy:
- The foremost goal of dietary management in cholecystitis is to reduce
discomfort.
- Patients w/ the disorder is more comfortable if he eats plain, simple
foods & avoids pastries, nuts & chocolates, fatty, fried & gas-forming
foods.
- High seasoned condiments & high residue foods frequently cause
distention & increased peristalsis, which results in irritation to the gall
bladder;
- Obese individuals should be advised to reduce weight.
- In acute cases, nothing is given for 24 hrs., followed by a low-fat diet (
30g/day).
- Diet progresses to a moderate fat intake( about 50-60 g/day) to
promote the flow of bile & induce drainage of the biliary tract.
- For chronic cholecystitis, provide a moderate fat intake.
- The CHON level is kept 1g/kg bw.
- CHO should be adequate especially fiber such as pectin that binds
excess bile acids.
- Energy is adjusted to achieve & maintain desirable weight.
- Low-fat diet have been traditionally prescribed to people with
gallbladder diseases.
- Recent studies showed that the gallbladder contracts & ejects bile at
the same rate after either a high or low-fat meal.
- The best advice for patients with gallbladder disease is not necessarily
to avoid fat but to consume a well-balanced diet & avoid foods that
cause pain; 50-60 g fats/day may be given but in chronic cholecystitis,
some degree of fat restriction is usually necessary.
2. GALLSTONE DISEASES
- Formation of stones may be due to infection, stagnation of the bile or
changes in the chemical composition of the bile, overeating or poor
eating habits.
- Obesity correlates strongly w/ cholelithiasis
- The prevalence increases with age, & to individuals w/ DM, &
elevated triglyceride level.
- Pregnant women & those taking oral contraceptives on
hormone/estrogen are risk to develop gallstones
- The gallbladder may contain a simple large stone or many smaller
ones.
- A formation of stone with infection is called cholecystolithiasis
- Formation of stone w/o infection is called cholelithiasis
- Choledolithiasis – when stone slips into the common bile duct
producing obstruction & cramps
- 2 types of stones: cholesterol stones & pigment gallstones.
- Cholesterol stones forms when the cholesterol in the bile gets too
concentrated either from excessive cholesterol synthesis or dec bile
synthesis.
- Certain drugs such as estrogens increase the risk for gallstone
formation.
- Brown pigment stones are formed w/in the intrahepatic &
extrahepatic ducts as well as in the GB.
- They formed as a result of stasis & infection w/in the biliary system.
- Parasites have been implicated in the formation of these stones,
common in southeast asia.
- Symptoms: pain is often precipitated by fatty meals last for 1-2 hrs;
- If stone obstruct the CBD , pt may develop jaundice asso.w/pale stool
• Nutrition therapy:
- In an acute gallstone attack, a low-fat diet is given to decrease
gallbladder contraction & lessen the pain.
- Unless fat induces symptoms, a low-fat diet is NOT necessary.
- If the gallbladder is sluggish, a moderate fat intake is desirable to
stimulate its contraction & prevent stagnation of bile.
- A high fiber diet is also beneficial
• Management of Cholelithiasis
- People w/ gallstones must have their gallbladder removed called
Cholecystectomy.
- Pre-op care is the same with patients who undergoes GIT surgery.
- Post-op care is same with surgical intervention who have undergone
major abdominal surgeries; NPO until intestinal peristalsis s evident;
then gradually revised to clear liquid to general liquid diet.
- Once soft solid foods is started, fat is allowed as tolerated.
- CHON requirement: allowed and kept at a minimum
- CHO requirement is maintained at normal but may be decreased or
increased to maintain the pt’s weight at the desired level.
- Increasing the amount of CHO serves as a therapeutic measure in
cases complicated with jaundice.
- A high fiber diet is beneficial
- If weight loss is indicated, calories should be reduced according to
need.
- Patient should be advised to prepare meals by baking, broiling,
roasting, or stewing & to use spices and herbs in moderation.
- The use of fortified skim milk & inclusion of green leafy vegs will help
ensure adequate intake of vit A.
SUGGESTED LOW FAT DIET
• FOOD SELECTION not allowed/
FOOD GROUP ALLOWED Restricted
Vegetables all cooked w/o added fat fried, creamed or
cooked w/ fat
FRUITS All except avocado Avocado
Milk whole or evap.cow’s milk
in allowed amts only. Skim
milk as desired
FOOD GROUP Allowed Restricted
Rice or substitute All except those avoided mami, miki, bread,
w/ added fat
Meat or substitute Lean only, maybe meat & poultry w/
boiled, broiled or baked, visible fats, fish canned in
eggs cooked except fried, oil. Processed in canned
skim milk, cheese, liver, meat, fried eggs, nuts,
heart, kidney, sweet breads peanuts, whole milk or
cream cheese
• food group Allowed not allowed
• Fats any kind in allowed cream, butter, oil,
amts only mayonnaise & other salad
dressing, except as allowed
in food plan, chicharon &
fried foods
sugar & sweets all except those choco bars, cream-filled
avoided sweets
• Desserts Gelatin, fruit juices, pies & pastries, cookies
• sherbets, pudding made all other cakes, butter &
• w/skim milk, meringue cream icing, doughnuts,
• angel cake yema, leche flan, desserts
• w/ coconut milk
Beverages coffee, tea, carbonated soda fountain bev.
beverages as milk shakes, malted
milk, choco drinks
FOOD GROUP ALLOWED NOT ALLOWED
soup clear, fat free cream soups