Hepatobiliary Disease Flashcards
Biliary system
Main = liver
Other - pancreas, stomach, gallbladder, common bile duct…
Liver functions (4)
Synthesis - proteins, cytokines, TAG, haem, bile salt
Storage - folate, glycogen, Vit A,D,E,K, B12
Metabolism - fat, CHO
Degradation - detoxification, inactivation of hormones, destruction of RBC
Chronic liver disease (3)
Compensated liver disease
Decompensated liver disease
Cirrhosis
Chronic liver disease:
Complications reflect degree of damage
Chronic liver disease:
Compensated
Asymptomatic
Can occur with up to 80% of liver damage
Chronic liver disease:
Decompensated liver disease
Syptomatic
Child-pugh classification system
Symptoms - ascites, jaundice, variceal bleeding, encephalopathy
Chronic liver disease:
Cirrhosis
Irreversible damage to liver
Hepatocyte replaced by fibrosis
Changes flow of blood through liver => portal hypertension -> ascites or varices
Metabolic changes - glucose intolerance, malnutrition
Types of liver disease
Infections Toxic Cholestatic Metabolic Vascular Other (CF related) Acute or chronic
Non-alcoholic fatty liver disease
May progress to CLD
Occurrence linked with - genetics, low P.A, high energy intake, overweight/obesity, insulin resistance
Symptoms - generally those considered harmless, e.g. fatigue, weight loss, weakness
Liver function tests:
Bilirubin
Pigment
Excretory product of haemoglobin
>17mmol/L = greater severity of damage
Liver function tests:
Aminotransferases
ALT/AST
Enzymes sensitive to liver damage
High levels can suggest obstruction or hepatitis
Liver function tests:
ALP
High in cholestatic liver disease
Liver function tests:
GGT
Sensitive marker of liver cell damage
High serum levels due to liver/biliary disease
Interpret with ALP to confirm liver damage
Liver function tests:
INR
Blood clot time
Produces + clears coagulating factors
Increase may be due to
- low serum vit K
- poor vit K utilisation
- increased risk of bleeding
Liver function tests:
Alpha fetoprotein
Malignancy marker
Liver function tests:
Immunoglobins
Liver degraded antigen
Poor liver function = high circulatory antigens
Activated immune response (IgG, IgM, IgA)
CLD:
Symptoms
Spider angiomas Blotchy red skin Easy bruising Very itchy skin Hair loss
CLD - symptoms:
Jaundice
Yellowing of eyes and/or skin
Accumulation of bilirubin
CLD - symptoms
Hepatic encephalopathy
Neuropsychiatric signs of cerebral irritation
Unclear pathogenesis
To treat
- bowel cleansing
- remove precipitants
CLD - symptoms
Steatorrhoea
Faecal matter full of fat
Impaired bile secretion
Decreased lipase action
CLD - symptoms
Ascites
Excessive ECF in peritoneal cavity
80% cases due to liver cirrhosis
Most common cirrhosis complication
Diagnosis - swollen abdo or ultrasound (small vol)
Leads to - SOB, abdo pain, decreased mobility
Nutritional assessment
Require v detailed A - weight, height, MUAC, handgrip B - albumin, transport proteins C - observation, history D - consider reliability
Calculating requirements
Use estimated dry weight if pt fluid overloaded
2 methods
- energy/kg body weight
- Henry equation for BMR + stress factor
Malnutrition
More common in…
Contributing factors…
More common in decompensated
Contributing factors
- clinical symptoms: steatorrhoea, odema
- dietary: restrictions, unpalatable diet
- treatment related: fluid restrictions, altered taste
Dietetic aims
Symptom management
Increasing energy + protein intake improves - liver function, nutritional status, survival
Acute/end stage - minimise protein loss by meeting increased requirements w/o overfeeding
Early stage/post-transplant - recovery phase, increase or maintain bosy stores
Early onset starvation
Cirrhosis prevents storage + release of glycogen
Even induced by 2hr fast
Prevention
- regular meals
- late night snack to shorten nocturnal fasting
- study 2011: 50g CHO eve snack maintains lean muscle stores by sparing N utilisation overnight
Nutritional support
Enteral feeding
Gastrostomy + jejunostomy contraindicated (e.g. impaired coagulation)
Steatorrhoea treatment
Restriction of fat intake only if symptomatic (decrease to tolerance level to limit deficiencies)
Replace with CHO + protein foods (consider supplements)
May need to supplement with fat soluble vitamins
Varices
Dilated veins in lower end of oesophagus
Medical/surgical - NBM until resolves, variceal banding
Dietetic - establish oral intake ASAP, NG tube with fine bore tube is safe
Ascites treatment
Aims
(4)
Aims - 500ml net fluid loss/day + watch for dehydration
Sodium restriction - less Na available to be reabsorbed so less fluid retained, severe may promote malnutrition
Fluid restriction - 750-1500ml, only used when previous treatment ineffective
Diuretic therapy - blocks Na conserving mechanisms in kidney to result in increased urinary Na excretion (monitor for rapid weight loss)
Paracentesis - catheter inserted into peritoneal cavity to drain fluid, increased protein requirements, albumin loss
Liver transplant
Treatment for end stage liver disease
Liver transplant:
Malnutrition
Increased
- infection rates
- mortality
- operative blood loss
Liver transplant:
Obesity
Increased
- wound infection rates
- mortality
Liver transplant:
Post-transplant
Metabolic response to injury
Early (12-14h) post-op feeding beneficial
Complications
- hypertension (62-69% pts)
- hyperlipidaemia (45-85% pts)
- obesity (increased QoL + no restrictions)
- drug-nutrient interactions
- food bourne illness
- bone disease
Gallstones
May arise due to rapid weight loss (limit to 1.5kg loss/wk)
May cause cholecystitis or obstruction (pyrexia, nausea, poor appetite)
No evidence for low fat diet beyond healthy diet
Recommend healthy diet + weight loss if req
Gallstones:
Cholecystectomy
Surgical removal of gallbladder
Diarrhoea may present post op
CHO rich drink prior surgery associated with decreased post op N+V
Gallstones:
Dietary factors
Refined CHO
Dietary fibre
Alcohol (protective)
Gallstones:
Symptoms
Asymptomatic
Pain
Jaundice
Primary biliary cirrhosis (PBC)
Autoimmune disease
Chronic inflammation + destruction of intrahepatic bile ducts
Predominately females affected
Symptoms - jaundice, dark urine, steatorrhoea, increased lethargy
Primary sclerosing cholangitis (PSC)
Inflammation + fibrosis bile ducts -> cirrhosis -> portal hypertension -> liver failure
Treating PBC + PSC
Treat cirrhosis as in CLD Dietary advice for malnutrition May need advice regarding fat malabsorption Lifestyle advice Consider Ca + vit D supplements
