GI 3

Question 1

liver cirrhosis definition
__ stage of progressive liver disease in which there is distortion of __ architecture

Answer 1

liver cirrhosis definition
late stage of progressive liver disease in which there is distortion of hepatic architecture

Question 2

liver cirrhosis definition
__ formation of regenerative nodules that lack __ organization

Answer 2

liver cirrhosis definition
diffuse formation of regenerative nodules that lack normal organization

Question 3

liver cirrhosis definition
nodules are surrounded by __

Answer 3

liver cirrhosis definition
nodules are surrounded by fibrous bands

Question 4

development of cirrhosis steps

Answer 4

1. liver cell injury
2. activation of heaptic stellate cells (HSC)
3. expansion of myofibroblasts
4. fibrosis
5. cirrhosis

Question 5

3 mediators of activation of stellate cells and expansion of myofibroblasts

Answer 5

ROS
NO
TGF-beta

Question 6

expansion of myofibroblasts causes increased

Answer 6

collagen
glycoproteins
proteoglycans

Question 7

4 causes of liver cell injury

Answer 7

1. HBV, HCV infection
2. drugs and toxin
3. autoimmune attack
4. other causes

Question 8

liver importance to nutrition (3)

Answer 8

1. glucose homeostasis
2. protein synthesis
3. drug/toxin metabolism

Question 9

impacts of malnutrition in liver disease

Answer 9

1. increasingly recognized complications of ESLD
2. very common (20-50% of patients with cirrhosis)

Question 10

5 observed changes of liver disease and cirrhosis

Answer 10

1. malnutrition
2. direct complication of cirrhosis
3. complications due to other organ systems
4. physical inactivity
5. environmental/organizational factors

Question 11

malnutrition in liver disease and cirrhosis due to

Answer 11

1. reduced oral intake
2. malabsorption
3. increased catabolic state/hypermetabolism

Question 12

3 direct complications of cirrhosis

Answer 12

1. altered catabolic state
2. altered protein metabolism
3. increased ammonia concentration (myotoxic)

Question 13

altered catabolic state leads to

Answer 13

imbalance between energy needs and intake

Question 14

altered protein metabolism causes

Answer 14

accelerated muscle breakdown

Question 15

increased ammonia concentration (myotoxic) causes

Answer 15

destruction of skeletal muscle

Question 16

3 complication due to other organ systems

Answer 16

1. high circulating levels of inflammatory markers
2. low levels of testosterone and changes in growth hormone secretion/sensitivity
3. obesity

Question 17

high circulating inflammatory markers leads to

Answer 17

reduced muscle protein synthesis and increased degradation

Question 18

obesity leads to (3)

Answer 18

1. metabolic dysregulation
2. visceral fat accumulation
3. insulin resistance

Question 19

physical inactivity in cirrhosis

Answer 19

common in patients

Question 20

environmental/organizational factors

Answer 20

1. social determinants of health (health literacy, food insecurity, financial strain (including that on caregivers))
2. lack of time during clinical visits to dedicate to nutrition

Question 21

what is alcohol-associated liver disease
__ entity characterized by __ and __

Answer 21

what is alcohol-associated liver disease
distinct entity characterized by jaundice and liver function

Question 22

prevalence of alcohol-associated liver disease in US

Answer 22

2%

Question 23

morbidity and mortality and alcohol use:
incidence of alcohol-associated liver disease:

Answer 23

morbidity and mortality and alcohol use: increasing worldwide
incidence of alcohol-associated liver disease: increasing since pandemic

Question 24

severe acute alcohol-associated hepatitis has mortality of up to __% at one month

Answer 24

severe acute alcohol-associated hepatitis has mortality of up to 25-40% at one month

Question 25

alcohol is high in

Answer 25

calories

Question 26

calories from alcohol __ other claories and cause reduced __ which leads to __

Answer 26

calories from alcohol **displaces** other claories and cause reduced **intake from more nutritious sources** which leads to **nutritional deficiences**

Question 27

effects of alcohol on GI tract 1. shortening of __ in sm. intestine --> __ 2. alteration of __ 3. reduction in gut metabolism of __ --> impaired absorption of

Answer 27

effects of alcohol on GI tract 1. shortening of **villi** in sm. intestine --> **impaired digestion and absorption** 2. alteration of **gut microbiome** 3. reduction in gut metabolism of **bile acids** --> impaired absorption of **fat and fat-soluble vitamins**

Question 28

alcoholism + coexisting chronic __ --> __ insufficiency --> impaired digestion of __

Answer 28

alcoholism + coexisting chronic **pancreatitis** --> **exocrine** insufficiency --> impaired digestion of **macronutrients**

Question 29

alcohol-associated liver disease deficiencies

Answer 29

folic acid thiamine vit D vit A Mg Zn

Question 30

alcohol-associated liver disease folic acid deficiency can promote __ folic acid deficiency may worsen __

Answer 30

alcohol-associated liver disease folic acid deficiency can promote **oxidative stress** folic acid deficiency may worsen **alcohol-related liver injury**

Question 31

__% hospitalized patients with alcohol use disorder have folic acid deficiency __% of patients with alcohol use disorder have thiamine deficiency __% of patients with cirrhosis and __% with liver disease have vit D deficiency __% of patients with cirrhosis have zinc deficiency

Answer 31

**80**% hospitalized patients with alcohol use disorder have folic acid deficiency **80**% of patients with alcohol use disorder have thiamine deficiency **85**% of patients with cirrhosis and **50**% with liver disease have vit D deficiency **> 80**% of patients with cirrhosis have zinc deficiency

Question 32

why does thiamine deficiency occur in alcohol use disorder and what can it lead to

Answer 32

occurs bc inadequate dietary intake impaired absorption increased release/decreased uptake in liver can lead to Wernicke's encephalopathy or Korsakoff psychosis

Question 33

vit D deficiency exaggerates alcohol-related __ and __

Answer 33

vit D deficiency exaggerates alcohol-related **oxidative stress** and **liver injury**

Question 34

increased severity of liver disease = increased deficiency of __

Answer 34

increased severity of liver disease = increased deficiency of **vitamin A**

Question 35

vit deficiency can cause

Answer 35

night blindness hypogonadism hypogeusia insomnia

Question 36

which vitamin deficiency should not be supplemented? why?

Answer 36

vit A bc it can be hepatotoxic

Question 37

Mg deficiency occurs bc of

Answer 37

malabsorption and high renal excretion

Question 38

Mg deficiency can increase

Answer 38

oxidative stress

Question 39

Mg deficiency is associated with

Answer 39

poor cognition reduced muscle strength

Question 40

symptoms of zinc deficiency

Answer 40

muscle craps taste alteration encephalopathy increased infections

Question 41

how to treat zinc deficiency

Answer 41

some evidence for supplementation (especially with severe encephalopathy)

Question 42

timing of meals for liver disease

Answer 42

benefits on muscle mass early morning breakfast late evening snack small, frequent meals and snacks every 3-4 hours while awake

Question 43

protein guidelines adults with cirrhosis: critically ill adults with cirrhosis: children with chronic liver disease:

Answer 43

protein guidelines adults with cirrhosis: **1.2-1.5 g/kg ideal body weight** critically ill adults with cirrhosis: **1-2 g/kg ideal body weight** children with chronic liver disease: **up to 4g/kg ideal body weight**

Question 44

protein guidelines focus on

Answer 44

diversity of protein sources

Question 45

nutritional supplementation options for liver disease

Answer 45

1. oral nutrition supplementation (NG tube feeds if patient still has issues) 2. enteral nutrition 3. parenteral nutrition (only for decomponsated (advanced) cirrhotic patients)