Nutrition and Diet Therapy – Lecture

STUDENT ACTIVITY SHEET BS NURSING / SECOND YEAR

Session # 19

LESSON TITLE: Materials:

▪ Carbohydrate- and Fat-Modified Diets for Pen and notebook
Malabsorption Disorders
▪ Nutrition Therapy for Liver and Gallbladder Diseases

LEARNING OUTCOMES:

At the end of the lesson, you can:

1. Describe some procedures that can help to identify a
malabsorption problem;
2. Discuss the potential causes and consequences of fat
malabsorption and bacterial overgrowth;
3. Identify the causes of lactose intolerance and the current
treatment approaches for this condition;
4. Identify the effects of pancreatitis and cystic fibrosis on
health and nutrition status and the nutrition therapies used
in treatment;
5. Summarize the effects of celiac disease and short bowel
syndrome on health and nutrition status and their nutrition
care;
6. Identify potential causes of fatty liver and hepatitis and the
medical or nutrition care that may be helpful for these
conditions;
7. Discuss the potential causes and consequences of liver
Reference:
cirrhosis describe its medical treatments and nutrition
DeBruyne, L.K., Pinna, K., & Whitney E., (2016).
therapies;
Nutrition and diet therapy: Principles and practice
8. Identify the potential health concerns of patients who
(9th ed.). USA: Cengage Learning.
undergo liver transplantation;
9. Explain why gallstones develop; and,
10. Discuss the major risk factors and treatment approaches
for gallstone disease

LESSON PREVIEW/REVIEW
Let us have a review of what you have learned from the previous lesson. Kindly answer the following questions on the
space provided. You may use the back page of this sheet, if necessary. Have fun!

Instruction: List the indications for modifying fiber intake.

Constipation Inflammatory bowel

Diabetes mellitus diseases (active episodes)
Diverticulosis (prevention) Post-surgical diet
Heart disease (depending on tolerance)
Irritable bowel syndrome Ostomy surgery
Prediabetes or diabetes
Weight management

This document and the information thereon is the property of

PHINMA Education (Department of Nursing) 1 of 14
MAIN LESSON
You will study and read their book, if available, about this lesson.

Malabsorption Syndromes

To digest and absorb nutrients, we depend on normal digestive secretions and healthy intestinal mucosa. Malabsorption
can therefore be caused by pancreatic disorders that cause enzyme or bicarbonate deficiencies, disorders that result in
bile deficiency, and inflammatory diseases or medical treatments that damage intestinal tissue. In some cases, the
treatment of an intestinal disease requires surgical removal of a section (resection) of the small intestine, leaving minimal
absorptive capacity in the portion that remains. In addition, various medications can damage the mucosa and impair the
digestive and absorptive functions of the small intestine.

Malabsorption rarely involves a single nutrient. When malabsorption is caused by pancreatic enzyme deficiencies, all
macronutrients—protein, carbohydrate, and fat— may be affected. When fat is malabsorbed, fat-soluble nutrients and
some minerals are usually malabsorbed as well. Malabsorption disorders and their treatments can tax nutritional status
further by causing complications that alter food intake, raise nutrient needs, or promote additional nutrient losses.

Evaluating Malabsorption. A number of clinical procedures and laboratory tests are used to determine whether an
individual has a malabsorption problem.

Examples include the following:

⎯ Endoscopy or biopsy. Direct examination of the duodenal mucosa with an endoscope may reveal physical
changes characteristic of intestinal diseases that cause malabsorption. A biopsy can be taken during the
procedure for further analysis.

⎯ Stool fat analysis. Fat malabsorption can be determined by placing the patient on a high-fat diet (80 to 100
grams per day), performing a 48- to 72-hour stool collection, and measuring the stool’s fat content. Healthy
individuals generally eliminate less than 7 grams of fat per day under these conditions. Excessive fat in the stools
is known as steatorrhea.

⎯ Hydrogen breath test. When carbohydrate is malabsorbed, colonic bacteria digest the carbohydrate and produce
hydrogen gas, which is absorbed and later can be measured in the breath. The hydrogen breath test is often used
to diagnose lactose intolerance, but it can diagnose malabsorption of other types of carbohydrate as well. This
test is also used to determine the presence of excessive bacteria in the small intestine.

⎯ Xylose absorption. Xylose, a sugar that is readily absorbed but is not well metabolized, can be used to test
whether the small intestine is able to absorb nutrients normally. In the xylose absorption test, the patient is given
an oral dose of xylose, and blood and urine tests determine whether appropriate amounts of xylose were
absorbed.

Fat Malabsorption.

Fat is the nutrient most frequently malabsorbed because both digestive enzymes and bile must be present for its
digestion. Thus, fat malabsorption often develops when an illness reduces either pancreatic or bile secretions. For
example, both pancreatitis and cystic fibrosis can decrease the secretion of pancreatic lipase, whereas severe liver
disease can cause bile insufficiency. Motility disorders that accelerate gastric emptying or intestinal transit can cause fat
malabsorption because they prevent the normal mixing of dietary fat with lipase and bile. Fat malabsorption can also be
caused by conditions or treatments that damage the intestinal mucosa, such as inflammatory bowel diseases, AIDS, and
radiation treatments for cancer
Consequences of Fat Malabsorption.

Nutrition Therapy for Fat Malabsorption. If steatorrhea does not improve, a fat-restricted diet may be recommended.
The diet may help to relieve intestinal symptoms that are aggravated by fat intake (such as diarrhea and flatulence) and
reduce vitamin and mineral losses. Because fat is a primary energy source, it should not be restricted more than
necessary. Medium-chain triglycerides (MCT), which do not require lipase or bile for digestion and absorption, can be
used as an alternative source of dietary fat, although MCT oil does not provide essential fatty acids.

Bacterial Overgrowth. Ordinarily, the GI tract is protected from bacterial overgrowth by gastric acid, which destroys
bacteria; peristalsis, which flushes bacteria through the small intestine before they multiply; and immunoglobulins
secreted into the GI lumen. When bacterial overgrowth does occur, it can lead to fat malabsorption because the bacteria
dismantle the bile acids needed for fat emulsification. Deficiencies of the fat-soluble vitamins A, D, and E may eventually
develop. The bacteria also produce enzymes and toxins that disturb the intestinal mucosa, destroying some mucosal
enzymes (especially lactase) and possibly reducing the absorptive surface area. Some types of bacteria metabolize
vitamin B12, reducing its absorption and increasing the risk of deficiency. Although symptoms of bacterial overgrowth are
often minor and nonspecific, severe cases may lead to chronic diarrhea, steatorrhea, flatulence, bloating, and weight loss.

Causes of Bacterial Overgrowth. Conditions that impair intestinal motility and allow material to stagnate can greatly
increase susceptibility to bacterial overgrowth. For example, in some types of gastric surgery, a portion of the small
intestine is bypassed, preventing the flow of material in the bypassed region and allowing bacteria to flourish. Intestinal
motility can also be reduced by strictures, obstructions, and diverticula in the small intestine, as well as by some chronic
illnesses, including diabetes mellitus and scleroderma.3 Reduced secretions of gastric acid can also lead to bacterial
overgrowth. Possible causes include atrophic gastritis, acid-suppressing medications, and some gastrectomy procedures.

Treatment for Bacterial Overgrowth. Treatment may include antibiotics to suppress bacterial growth and surgical
correction of the anatomical defects that contribute to a motility disorder. Medications may be given to stimulate
peristalsis, and acid-suppressing medications should be discontinued. A lactose-restricted diet may reduce flatulence and
diarrhea in some individuals. Dietary supplements can correct nutrient deficiencies, especially deficiencies of fat-soluble
vitamins, calcium (which combines with malabsorbed fatty acids), and vitamin B12.

Lactose Intolerance

Approximately 75 percent of people worldwide have some degree of lactose intolerance, which is caused by the loss or
reduction of lactase, the intestinal enzyme that digests the lactose in milk products. Lactose intolerance is especially
prevalent among individuals of certain ethnic groups, including Asians, African Americans, Native Americans, Ashkenazi
Jews, and Latinos. It may also result from GI disorders, medications, or medical treatments that damage the small
intestinal mucosa. The primary symptoms of lactose intolerance are diarrhea and increased intestinal gas.

Lactose intolerance is rarely serious and is easily managed by simple dietary adjustments. Although people with the
condition are sometimes reluctant to consume milk products, clinical studies have found that individuals with lactose
intolerance can tolerate up to 2 cups of milk daily without significant symptoms. In addition, the regular consumption of
milk products increases the amount of lactose metabolized by intestinal bacteria, which improves lactose tolerance.6
People who avoid milk for fear of intestinal discomfort can be urged to gradually increase their consumption of lactose-
containing foods.

People who develop lactose intolerance as a result of intestinal illness are often advised to temporarily restrict milk and
milk products. Foods that contain lactose can be reintroduced in small amounts once the condition improves. Individuals
who restrict milk products should be encouraged to consume alternative food sources of calcium and vitamin D.

Disorders of the Pancreas

Pancreatitis is an inflammatory disease of the pancreas. Although mild cases may subside in a few days, other cases can
persist for weeks or months. Chronic pancreatitis can lead to irreversible damage to pancreatic tissue and permanent loss
of function.

Acute Pancreatitis. In acute pancreatitis, the digestive enzymes within pancreatic cells become prematurely activated,
causing destruction of pancreatic tissue and subsequent inflammation. About 70 to 80 percent of acute cases are caused
by gallstones or alcohol abuse; less frequent causes include elevated blood triglyceride levels or exposure to various
toxins. Common symptoms include severe abdominal pain, nausea and vomiting, and abdominal distention. In most
patients, the condition resolves within a week with no complications. More serious cases may lead to chronic pancreatitis,
infection, the systemic inflammatory response syndrome or multiple organ failure.

Nutrition Therapy for Acute Pancreatitis. The initial treatment for acute pancreatitis is supportive and includes pain
control and intravenous hydration. In cases of mild to-moderate pancreatitis, oral fluids and food are withheld until the
patient is pain free and experiences no nausea or vomiting. Afterward, patients can usually consume a regular diet; a fat-
restricted diet may be helpful for patients with symptoms of fat malabsorption (such as steatorrhea and abdominal pain).
In severe pancreatitis, continuous tube feedings, started within the initial 48 hours of treatment, may lead to improved
outcomes compared with withholding intakes; the use of elemental formulas (formulas that contain hydrolyzed nutrients)
may improve patient tolerance. Protein needs are generally high in pancreatitis patients (between 1.2 and 1.5 grams per
kilogram body weight per day10) due to the catabolic effects of inflammation. Patients should be given
multivitamin/mineral supplements until food intakes can meet their nutritional needs.

Chronic Pancreatitis. Chronic pancreatitis is characterized by progressive, permanent damage to pancreatic tissue,
resulting in the impaired secretion of digestive enzymes and bicarbonate. About 70 to 80 percent of cases are caused by
excessive alcohol consumption. Most patients with chronic pancreatitis experience persistent abdominal pain, which may
worsen with eating and be accompanied by nausea and vomiting. Although all macronutrients are maldigested, the
symptoms of fat malabsorption are typically the most severe. Long-term illness is associated with reduced secretion of
insulin and glucagon, and diabetes eventually develops in 30 to 50 percent of patients.

Nutrition Therapy for Chronic Pancreatitis. The objectives of nutrition therapy are to reduce malabsorption and correct
malnutrition. Pancreatic enzyme replacement is the main treatment for steatorrhea and other symptoms of malabsorption.
Most enzyme preparations are enteric coated to resist the acidity of the stomach and do not dissolve until they reach the
small intestine. If nonenteric-coated preparations are used, acid-suppressing drugs are also required. Fecal fat
concentrations can be monitored to determine if the enzyme treatment has been effective. Patients with chronic
pancreatitis who are hypermetabolic and underweight have high protein and energy requirements; protein needs may
range between 1.0 and 1.5 grams per kilogram body weight per day and energy intakes should be about 35 kcalories per
kilogram daily. Dietary supplements are used to correct nutrient deficiencies, which may be due to malabsorption or to the
alcohol abuse that caused the disease. Patients should avoid alcohol completely and quit smoking cigarettes, as these
substances can exacerbate illness and interfere with healing.

Cystic fibrosis is the most common life-threatening genetic disorder among Caucasians, with an incidence of
approximately 1 in 3000 to 5000 white births. The condition is characterized by a mutation in the protein that regulates
chloride transport across epithelial cell membranes. The abnormality alters the ion concentration and/ or viscosity of
exocrine secretions, causing a broad range of serious complications.

Consequences of Cystic. Fibrosis Cystic fibrosis is characterized by abnormal chloride and sodium levels in exocrine
secretions. These altered secretions ultimately disrupt the functioning of multiple tissues and organs. Common
complications of cystic fibrosis involve the lungs, pancreas, and sweat glands.
⎯ Lungs. Changes in bronchial secretions lead to an impaired ability to clear airway mucus, resulting in chronic
respiratory infections, progressive inflammation, and airway obstruction. The eventual lung damage causes
breathing difficulties, chronic coughing, and lower exercise tolerance. Nutrition status may become impaired due
to hypermetabolism, the greater energy cost of labored breathing, and anorexia (loss of appetite).
⎯ Pancreas. Most patients produce thickened pancreatic secretions that obstruct the pancreatic ducts. The trapped
pancreatic enzymes eventually damage pancreatic tissue, leading to progressive atrophy and scarring. Few
pancreatic enzymes reach the small intestine, resulting in severe malabsorption of protein, fat, and fat-soluble
vitamins.
⎯ Sweat glands. Salt losses in sweat are usually excessive, increasing the risk of dehydration.

Children with cystic fibrosis are chronically undernourished, grow poorly, and have difficulty maintaining normal body
weight. Complications that may develop over time include pancreatitis, glucose intolerance or diabetes (due to destruction
of insulin-producing cells), and gallbladder and liver diseases.

Nutrition Therapy for Cystic Fibrosis. Patients with cystic fibrosis have high energy requirements, which range from
120 to 150 percent of DRI values; however, intakes are often much lower than these levels.18 To achieve normal growth
and appropriate weight, patients are typically encouraged to eat a high-kcalorie, high-protein diet, consume high-fat foods
freely, eat frequent meals and snacks, and supplement meals with milk shakes or oral supplements. Supplemental tube
feedings can help to improve nutrition status if energy intakes are inadequate. Pancreatic enzyme replacement therapy is
a central feature of cystic fibrosis treatment. Supplemental enzymes must be included with every meal or snack. For
young children, the contents of capsules are mixed in small amounts of liquid or a soft food (such as applesauce) and fed
with a spoon. Enzyme dosages may need to be adjusted if malabsorption continues, as evidenced by poor growth or GI
symptoms such as steatorrhea, intestinal gas, or abdominal pain.

The risk of nutrient deficiency depends on the degree of malabsorption; nutrients of greatest concern include the fat-
soluble vitamins, essential fatty acids, calcium, iron, and zinc. Multivitamin/mineral supplements are routinely
recommended. The liberal use of table salt and salty foods is encouraged to make up for sodium losses in sweat.

Disorders of the Small Intestine

Celiac disease is an immune disorder characterized by an abnormal immune response to a protein fraction in wheat
gluten and to related proteins in barley and rye. The reaction to gluten causes severe damage to the intestinal mucosa
and subsequent malabsorption. Celiac disease affects approximately 1 percent of Caucasians, although it is less common
in other ethnic groups.

Symptoms of celiac disease include GI disturbances such as diarrhea, steatorrhea, and flatulence. Because lactase
deficiency can result from the mucosal damage, milk products may exacerbate GI symptoms. Due to nutrient
malabsorption, children with celiac disease often exhibit poor growth, low body weight, muscle wasting, and anemia.
Adults may develop anemia, bone disorders, neurological symptoms, and fertility problems. Some gluten-sensitive
individuals may have few GI symptoms but react to gluten by developing a severe, itchy rash. This condition is called
dermatitis herpetiformis and requires dietary adjustments similar to those for celiac disease

Nutrition Therapy for Celiac Disease. The treatment for celiac disease is lifelong adherence to a gluten-free diet.
Improvement in symptoms often occurs within several weeks, although mucosal healing can sometimes take years. If
lactase deficiency is suspected, patients should avoid lactose-containing foods until the intestine has recovered. The
gluten-free diet eliminates foods that contain wheat, barley, and rye. Because many foods contain ingredients derived
from these grains, foods that are problematic are not always obvious. Gluten sources that may be overlooked include
beer, brewer’s yeast, caramel coloring, coffee substitutes, communion wafers, imitation meats, malt syrup, medications,
salad dressings, and soy sauce. Gluten-free products can be purchased to replace common food items such as bread,
pasta, and cereals.
Patients should also be instructed in food preparation methods that prevent cross contamination from utensils, cutting
boards, and toasters.

Short bowel syndrome is the malabsorption syndrome that results when the absorptive capacity of the remaining
intestine is insufficient for meeting nutritional needs. Without appropriate dietary adjustments, short bowel syndrome can
result in fluid and electrolyte imbalances and multiple nutrient deficiencies. Symptoms include diarrhea, steatorrhea,
dehydration, weight loss, and growth impairment in children.

Nutrition Therapy for Short Bowel Syndrome. Total parenteral nutrition meets nutritional needs after surgery and is
gradually replaced by tube feedings and/or oral feedings. To promote intestinal adaptation, the feedings may be started
within a week after surgery, after diarrhea subsides somewhat and some bowel function is restored. Initial oral intake may
consist of sips of clear, sugar-free liquids, progressing to larger amounts of liquid formulas and then to solid foods, as
tolerated. Very small, frequent feedings can utilize the remaining intestine most effectively. To compensate for
malabsorption and reduce the need for nutrition support, a high-kcalorie diet may be encouraged
The liver is the most metabolically active organ in the body. It plays a central role in processing, storing, and redistributing
the nutrients provided by the foods we eat. The liver also produces the bile that emulsifies fat during digestion; between
meals, this bile is stored and concentrated in the gallbladder. The liver synthesizes most of the proteins that circulate in
plasma, including albumin, blood clotting proteins, and transport proteins. In addition, the liver detoxifies drugs and alcohol
and processes excess nitrogen so that it can be safely excreted as urea. If damage or disease hinders the liver’s ability to
perform its numerous functions, the effects on health and nutrition status can be profound.

Liver disease progresses slowly. Its primary symptom, fatigue, often goes unnoticed. Other symptoms may be so mild that
complications develop before liver disease is diagnosed. Once liver disease is recognized, health practitioners emphasize
the need to preserve the remaining liver function, as the liver can regenerate some healthy tissue, improving the
prognosis. Preventing additional damage is the principal means of avoiding liver failure or transplantation.

Fatty Liver and Hepatitis

Fatty liver and hepatitis are the two most common disorders affecting the liver. Although both conditions may be mild and
are usually reversible, each may progress to more serious illness and eventually cause liver damage.

Fatty liver is an accumulation of fat in liver tissue. Ordinarily, the liver’s excess triglycerides are packaged into very-low-
density lipoproteins (VLDL) and exported to the bloodstream. Fatty liver represents an imbalance between the amount of
fat produced in the liver or picked up from the blood and the amount the liver uses or exports to the blood via VLDL.
Fatty liver is a clinical finding that is common to many conditions. It may be caused by defects in metabolism, excessive
alcohol ingestion, or exposure to various drugs and toxins. In cases unrelated to alcohol, insulin resistance (reduced
sensitivity to insulin in liver, muscle, and adipose cells) is the primary risk factor; thus, fatty liver frequently accompanies
diabetes mellitus, metabolic syndrome, and obesity. Other causes of fatty liver include protein-energy malnutrition and
long-term total parenteral nutrition

Consequences of Fatty Liver In many individuals, fatty liver is asymptomatic and causes no harm. In other cases, it may
be associated with inflammation (steatohepatitis), liver enlargement (hepatomegaly), and fatigue. If liver damage and
scarring develop, fatty liver may progress to cirrhosis (discussed in a later section), liver failure, or liver cancer.

Treatment of Fatty Liver. The usual treatment for fatty liver is to eliminate the factors that cause it. For example, if fatty
liver is due to alcohol abuse or drug treatment, it may improve after the patient discontinues use of the substance. In
patients with elevated blood lipids, fatty liver may improve after blood lipid levels are lowered.

An appropriate treatment for obese or diabetic patients might be weight reduction, increased physical activity, or
medications that improve insulin sensitivity. Rapid weight loss should be discouraged, however, because it may accelerate
the progression of liver disease. Note that lifestyle modifications are not always successful in reversing fatty liver,
especially in patients who lack the usual risk factors.

Hepatitis. Hepatitis, a condition of liver inflammation, results from damage to liver tissue. Most often, the damage is
caused by infection with specific viruses, designated by the letters A, B, C, D, and E. Other causes include excessive
alcohol intake, fatty liver disease, autoimmune disease, and exposure to some drugs, herbal substances, and toxic
chemicals. Long-term hepatitis can lead to cirrhosis (discussed in a later section) and liver cancer.

Viral Hepatitis Acute hepatitis is most often caused by infection with hepatitis viruses A, B, or C. Specific features of these
viruses include the following:
● Hepatitis A virus (HAV) is primarily spread via fecal-oral transmission, which usually involves the ingestion of
foods or beverages that have been contaminated with fecal material. Outbreaks of HAV infection are often
associated with floods and other natural disasters, when inadequately treated sewage contaminates water
supplies. Vaccinations against HAV are recommended for high-risk individuals, such as international travelers,
food handlers, and newborn infants. HAV infection usually resolves within a few months and does not cause
chronic illness or permanent liver damage.
● Hepatitis B virus (HBV) is transmitted by infected blood or needles, by sexual contact with an infected person, or
from mother to infant during childbirth. A major global health concern, HBV has infected about one-third of the
world population, although chronic illness develops in less than 10 percent of cases. Vaccinations are currently
recommended for newborn infants and children, health-care workers, dialysis patients, recipients of blood
products, sex partners of infected persons, and users of injected drugs.
● Hepatitis C virus (HCV) is spread by infected blood or needles but is not readily spread by sexual contact or
childbirth. Most HCV cases progress to chronic illness. No vaccine is available to protect against HCV infection.
Preventive measures include blood donor screening, viral inactivation of blood products, infection control
practices in health care settings, and risk reduction counseling to high-risk individuals.

Symptoms and Signs of Hepatitis. The effects of hepatitis depend on the cause and severity of the condition. Individuals
with mild or chronic cases are often asymptomatic. The onset of acute hepatitis may be accompanied by fatigue, malaise,
nausea, anorexia, and pain in the liver area. The liver is often slightly enlarged and tender. Jaundice (yellow discoloration
of tissues) may develop, causing yellowing of the skin, urine, and sclera. Other symptoms of hepatitis may include fever,
muscle weakness, joint pain, and skin rashes. Serum levels of the liver enzymes ALT and AST are typically elevated.
Chronic hepatitis can cause complications that are typical of liver cirrhosis and may lead to liver cancer.

Treatment of Hepatitis. Hepatitis is treated with supportive care, such as bed rest (if necessary) and an appropriate diet.
Hepatitis patients should avoid substances that irritate the liver, such as alcohol, drugs, and dietary supplements that
cause liver damage. Hepatitis A infection usually resolves without the use of medications, whereas antiviral drugs may be
used to treat HBV and HCV infections. Non-viral forms of hepatitis may be treated with anti-inflammatory and
immunosuppressant drugs. Hospitalization is not required for hepatitis unless other medical conditions or complications
hamper recovery.
Nutrition care varies according to a patient’s symptoms and nutrition status. Most individuals require no dietary changes.
Those with anorexia or abdominal discomfort may find small, frequent meals easier to tolerate. Patients with persistent
vomiting may require fluid and electrolyte replacement. Malnourished individuals need to consume adequate protein and
energy to replenish nutrient stores; the diet should include about 1.0 to 1.2 grams of protein per kilogram of body weight
each day. Oral supplements can be helpful for improving nutrient intakes.

Cirrhosis is a late stage of chronic liver disease. Long-term liver disease gradually destroys liver tissue, leading to
scarring (fibrosis) in some regions and small areas of regenerated, healthy tissue in others. As the disease progresses,
the scarring becomes more extensive, leaving fewer areas of healthy tissue. A cirrhotic liver is often shrunken in size and
has an irregular, nodular appearance. Cirrhosis is characterized by impaired liver function and may eventually result in
liver failure.

Causes of Cirrhosis
● Alcoholic liver disease Autoimmune hepatitis
● Bile duct obstructions (Biliary cirrhosis, Cystic fibrosis)
● Drug-induced liver injury Metabolic disorders (Galactosemia, Glycogen storage diseases, Hemochromatosis
(causes excessive liver iron) and Wilson’s disease (causes excessive liver copper)
● Nonalcoholic fatty liver disease (Viral hepatitis, Hepatitis B and Hepatitis C)

Clinical Effects of Liver Cirrhosis:

The elevated pressure within the liver’s small blood vessels (sinusoids) causes fluid to leak into lymphatic vessels and,
ultimately, the abdominal cavity. The movement of water into the abdomen is exacerbated by low levels of serum albumin,
a protein that helps to retain fluid in blood vessels. Ascites can cause abdominal discomfort and early satiety, which
contribute to malnutrition. Because ascites can raise the body’s water weight considerably, weight changes may be
difficult to interpret.
Hepatic Encephalopathy. Advanced liver disease often leads to hepatic encephalopathy, a disorder characterized by
abnormal neurological functioning. Signs of hepatic encephalopathy include adverse changes in personality, behavior,
mood, mental ability, and motor functions. At worst, amnesia, unresponsiveness, and hepatic coma may develop.
Although hepatic encephalopathy is fully reversible with medical treatment, the prognosis is poor when it progresses to the
advanced stages.

Clinical Features of Hepatic Encephalopathy

Possible Causes of Malnutrition in Liver Disease

Treatment of Cirrhosis. Medical treatment for cirrhosis aims to correct the underlying cause of disease and prevent or
treat complications. Supportive care, including an appropriate diet, abstinence from alcohol, and avoidance of liver toxins,
promotes recovery and helps to prevent further damage. Antiviral medications may be prescribed to treat viral infections.
Patients should be screened and treated for life-threatening complications, such as gastroesophageal varices and liver
cancer. Liver transplantation may be necessary in advanced cirrhosis.

Medications can effectively treat many of the complications that accompany cirrhosis. Individuals with portal hypertension
and varices may be given propranolol (Inderal) or octreotide (Sandostatin), which reduce portal blood pressure and
bleeding risk. Diuretics can help to control portal hypertension and ascites; common examples include spironolactone
(Aldactone) and furosemide (Lasix). Lactulose, a nonabsorbable disaccharide, treats hepatic encephalopathy by reducing
ammonia production and absorption in the colon. The antibiotic rifaximin is an alternative treatment for elevated ammonia
that works by altering bacterial populations. To stimulate the appetite and promote weight gain, megestrol acetate
(Megace) or dronabinol (Marinol) may be prescribed.
Nutrition Therapy for Liver Cirrhosis

Liver Transplantation

Liver transplantation has improved the long-term outlook for patients with advanced liver disease. Transplant patients are
usually malnourished, however, and may have medical problems that affect transplant success.

Due to the potential for organ rejection, immunosuppressive drugs are prescribed following an organ transplant. Use of
these drugs increases the risk of infection, and the drugs have side effects that can impair nutrition status and general
health.

Gallstone Disease
The gallbladder concentrates and stores the bile produced by the liver until the bile is needed for fat digestion. Disorders
that obstruct the liver’s release of bile can damage the liver. More commonly, disorders of the biliary system—the
gallbladder and bile ducts—involve the formation of gallstones.

Types of Gallstone

Gallstone formation, or cholelithiasis, results from the excessive concentration and crystallization of compounds in bile.
Bile is composed of water, bile salts, cholesterol, phospholipids (primarily lecithin), proteins, and bile pigment (bilirubin).
During storage in the gallbladder, bile’s concentration increases approximately 10-fold as its water content is extracted.
The formation of gallstones is favored by factors that increase bile’s cholesterol concentration, promote crystal formation
and development, or reduce gallbladder motility
Cholesterol Gallstones In about 90 percent of cases, gallstones are composed primarily of cholesterol, although they
also contain calcium salts and bilirubin.25 The cholesterol in bile can precipitate out of solution and form small crystals,
which eventually coalesce to form stones. The stones can be as small as a pea or as large as a golf ball. Some people
tend to form many small stones, while others may form only one or two large ones

Pigment Gallstones are the predominant type of gallstone in some Asian countries. Pigment stones are primarily made
up of the calcium salt of bilirubin (calcium bilirubinate). They often develop as a result of bacterial infection, which alters
the structure of bilirubin and causes it to precipitate out of bile and form stones. Other cases result from excessive red
blood cell breakdown, leading to an abnormal accumulation of bilirubin.

Gallstone Symptoms. Gallstone pain (often called biliary colic) usually arises when a gallstone temporarily blocks the
cystic duct, which leads from the gallbladder to the common bile duct. The pain is steady and severe and may last for
several minutes or several hours. Although the pain is usually located in the upper abdomen, it may radiate to the chest,
back, or shoulder. Nausea and vomiting may also be present. Symptoms usually develop after meals, especially after
eating fatty foods. Pain may also occur during the night and awaken a person from sleep

Complications of Gallstones
● Cholecystitis
● perforation of the gallbladder, peritonitis, and fistulas
● Impacted stone within the bile ducts may lead to infection and the condition known as bacterial cholangitis, which
causes severe pain, sepsis, and fever and is often a medical emergency
● Acute Pancreatitis

Risk Factors for Cholesterol Gallstones

● Ethnicity
● Aging
● Gender
● Pregnancy
● Obesity and Weight Loss
● Other

Treatments for gallstones include gallbladder removal cholecystectomy, is the primary treatment for patients with
recurrent gallstones. The standard surgical approach is a laparoscopic method, which relies on narrow surgical telescopes
(laparoscopes) to view and perform the necessary procedures via small incisions in the abdomen. and gallstone
dissolution or fragmentation using shock-wave lithotripsy, a procedure that is also used to fragment kidney stones. This
technique uses high-amplitude sound waves (called shock waves) to break gallstones into pieces that are small enough to
either pass into the intestine without causing symptoms or be dissolved with ursodeoxycholic acid. Shock-wave lithotripsy
can be performed only in patients with few gallstones. Due to high gallstone recurrence rates (up to 80 percent recurrence
after 10 years), the procedure is used mainly to remove bile duct stones that are difficult to extract by other means.

CHECK FOR UNDERSTANDING

You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be given to the
correct answer and another one (1) point for the correct ratio. Superimpositions or erasures in your answer/ratio is not
allowed.

1.Possible causes of malabsorption include all of the following except:

a. inflammatory bowel disease.
b. pancreatic dysfunction.
c. liver disease.
d. flatulence
ANSWER: D
RATIO: Possible causes of malabsorption include all of the following except flatulence

2. Nutrition problems that may result from fat malabsorption include all of the following
except:
a. weight loss.
b. essential amino acid deficiencies.
c. bone loss.
d. oxalate kidney stones.
ANSWER: B
RATIO: Nutrition problems that may result from fat malabsorption include all of the following except essential amino acid deficiencies
3. Lactose intolerance is a direct consequence of:
a. insufficient lactase.
b. milk allergy.
c. fluid imbalance.
d. pancreatic dysfunction.
ANSWER: A
RATIO: Lactose intolerance is a direct consequence of insufficient lactase.

4. The majority of chronic pancreatitis cases can be attributed to:

a. bacterial and viral infections.
b. gallstones.
c. alcohol abuse.
d. elevated triglyceride
levels ANSWER: C
RATIO: The majority of chronic pancreatitis cases can be attributed to alcohol abuse.

5. A person on a gluten-free diet must avoid products containing:

a. wheat, barley, and rye.
b. lactose.
c. excessive fat.
d. corn, rice, and millet
ANSWER: A
RATIO: A person on a gluten-free diet must avoid products containing wheat, barley, and rye.

6. In cases of fatty liver that are unrelated to excessive alcohol intakes, the primary risk factor is:
a. following a high-protein diet.
b. use of illicit drugs.
c. following a high-fat diet.
d. insulin resistance.
ANSWER: D
RATIO: In cases of fatty liver that are unrelated to excessive alcohol intakes, the primary risk factor is insulin resistance.

7. Which of the following statements about hepatitis is true?

a. Chronic hepatitis can progress to cirrhosis.
b. Whatever the cause of hepatitis, symptoms are typically severe.
c. Vaccines are available to protect against hepatitis A, B, and C viruses.
d. HCV infection can be spread through contaminated foods and water.
ANSWER: A
RATIO: Chronic hepatitis can progress to cirrhosis.

8. Esophageal varices are a dangerous complication of liver disease primarily because they:
a. interferes with food intake.
b. can lead to massive bleeding.
c. diverts blood flow from the GI tract.
d. contributes to hepatic
encephalopathy. ANSWER: B
RATIO: Esophageal varices are a dangerous complication of liver disease primarily because they can lead to massive bleeding.

9. A complication of cirrhosis that contributes to the development of ascites is:

a. portal hypertension.
b. elevated serum ammonia levels.
c. bile obstruction.
d. insulin resistance.
ANSWER: A
RATIO: A complication of cirrhosis that contributes to the development of ascites is portal hypertension.

10. Regarding the major risk factors for gallstone disease:

a. prevalence is much higher in men than in women.
b. gallstone risk is increased during pregnancy.
c. rapid weight loss can temporarily shrink gallstones.
d. risk is generally similar among ethnic groups.
ANSWER: A
RATIO: Regarding the major risk factors for gallstone disease prevalence is much higher in men than in women.

RATIONALIZATION ACTIVITY

The instructor will now provide you the rationalization to these questions. You can now ask questions and debate among
yourselves. Write the correct answer and correct/additional ratio in the space provided.

1. ANSWER:
RATIO:

2. ANSWER:
RATIO:

3. ANSWER:
RATIO:

4. ANSWER:
RATIO:

5. ANSWER:
RATIO:

6. ANSWER:
RATIO:

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 8. ANSWER:
RATIO:

9. ANSWER:
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10. ANSWER:
RATIO:

LESSON WRAP-UP

You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.

You are done with the session! Let’s track your progress.

AL Activity: GUIDED DISCOVERY

This strategy leads you through practices that will help you develop deeper understanding and mastery. By posing one
question, you have the free will to answer it based on your own understanding in the Main Lesson. The more you dig
deeper, the more comprehensive the information you will relay. Here’s the question and enjoy! You can use the back page
of this sheet.

How would you describe the nutrition status of clients with malabsorption and liver diseases?

Patients with alcoholic liver disease are more likely to be deficient in folate, vitamin C, and thiamine, while patients with cirrhosis of any kind,
especially those with cholestatic liver disease, are more likely to be deficient in fat soluble vitamins. Alcohol reduces the production of
digestive enzymes from the pancreas, which slows the breakdown of nutrients into useable molecules. Alcohol reduces nutrient absorption
through harming the cells lining the stomach and intestines, as well as preventing some nutrients from being transported into the
bloodstream.