HPB Flashcards
Acute Pancreatitis Key Facts
Most common acute GI condition requiring hospitalization.
Severe cases can lead to necrosis, organ failure, or death.
Acute Pancreatitis Nutritional Risk
High catabolic rates → risk of malnutrition
Acute Pancreatitis Feeding Strategies
Mild AP: Start oral (PO) feeding early with a low-fat, soft diet once tolerated.
Severe AP: Use enteral nutrition (EN) within 24-72 hours to preserve gut integrity.
Parenteral Nutrition (PN): Reserved for cases where EN is contraindicated (e.g., bowel obstruction).
Acute Pancreatitis Formula Recommendations
Standard Polymeric: First-line for functional GI tracts.
Semi-Elemental: For malabsorption or intolerance to standard formulas.
Acute Pancreatitis Prohibited Substances:
Avoid probiotics in severe AP (no proven benefit, potential harm).
Avoid PERT unless exocrine insufficiency is confirmed.
Acute Pancreatitis Feeding Routes
Nasogastric (NG):
Preferred first-line: Easy placement, less invasive, and cost-effective.
Nasojejunal (NJ):
Indicated for digestive intolerance to NG feeding (e.g., vomiting, delayed gastric emptying).
Chronic Pancreatitis Pathophysiology
Progressive pancreatic inflammation → fibrosis and irreversible loss of function (endocrine & exocrine).
CP symptoms & complications
Symptoms: Severe abdominal pain, steatorrhoea, nausea, vomiting, diarrhoea, weight loss.
Complications: Pseudocysts, duct strictures, malnutrition, pancreatic exocrine insufficiency (PEI), type 3c diabetes (T3cDM).
Nutritional Recommendations in CP
- General Dietary Approach:
Well-nourished: Balanced, varied diet.
Malnourished: HEHP diet with 5-6 small meals/day. - Macronutrients:
Moderate-fat diet with PERT for digestion.
Focus on healthy fats (e.g., omega-3), restrict saturated fats. - Micronutrients:
Supplement fat-soluble vitamins (A, D, E, K), B12, iron, zinc, magnesium, selenium, and calcium. - Oral Nutritional Supplements (ONS):
Use when dietary intake is insufficient. - Bone Health:
Prevent osteoporosis with adequate calcium and vitamin D intake.
Perform DEXA scans every 2 years for at-risk patients.
Pancreatic Enzyme Replacement Therapy
Indications: Confirmed PEI.
Dosage:
Meals: 44,000–50,000 units lipase.
Snacks: 22,000–25,000 units lipase.
Administration Tips:
Take with meals/snacks and cold drinks.
Use PPIs to optimize effectiveness.
Avoid temperatures >25°C for storage.
Specialised Feeding Approaches in CP
Enteral Nutrition:
- Indicated for malnourished patients not responding to oral strategies.
- Use semi-elemental formulas if standard ones are poorly tolerated.
Parenteral Nutrition:
- Reserved for severe complications (e.g., gastric outlet obstruction).
- Administer via central venous access.
Management of T3cDM
Prevalence: 80% lifetime risk in CP patients.
Dietary Advice:
Regular meals with low-GI carbs; minimize sugary foods except for hypoglycaemic events.
Monitoring:
HbA1c every 6 months, regular blood glucose monitoring.
Consider CGMs for severe glycaemic instability.
FU & monitoring in CP
Nutritional Reviews: Regular assessment of weight, sarcopenia, deficiencies.
Biochemical Monitoring: Check fat-soluble vitamins, micronutrients, and markers of malabsorption.
Adjust PERT: Evaluate efficacy and address persistent maldigestion.
Bone Health: Regular DEXA scans for osteoporosis prevention.
CP Myths vs. Facts
Myth: Chronic pancreatitis is always caused by alcohol.
Fact: 20% of cases have non-alcoholic causes (e.g., genetic, autoimmune).
Myth: A low-fat diet is standard for CP.
Fact: Moderate-fat diets with PERT are now the standard.
Myth: Steatorrhoea only occurs with 90% pancreatic function loss.
Fact: Fat maldigestion can occur with less severe pancreatic damage.
Liver disease overview of stages
Compensated vs. Decompensated Cirrhosis:
- Compensated: Early stage; liver maintains function despite damage.
- Decompensated: Advanced stage; complications such as ascites, jaundice, and hepatic encephalopathy (HE) occur.
Cirrhosis: Late-stage scarring (fibrosis) due to liver diseases like hepatitis and chronic alcohol use.
Ascites: Fluid accumulation in the abdominal cavity, common in decompensated liver disease.
Nutritional Requirements in Liver Disease
Elevated Energy and Protein Needs:
Increased REE: 10–40% above predicted BMR.
Protein: 1.2–1.5 g/kg/day.
Energy: 35–40 kcal/kg/day.
HEHP Diet Benefits:
Reduces complications like infections and fluid build-up.
Supports muscle maintenance and liver function.
Includes protein- and energy-rich foods at every meal/snack.
Maintain plant protein > animal protein in HE for better tolerance.
Liver disease symptoms & challenges
Fat Malabsorption:
- Causes steatorrhea and deficiencies in fat-soluble vitamins (A, D, E, K).
- MCTs recommended: 10–20% of daily kcal intake.
Anorexia and Cachexia:
- Anorexia = loss of appetite; Cachexia = severe muscle wasting.
Thiamine Deficiency:
- Requires supplementation, especially in decompensated liver disease (100 mg TDS + multivitamin).
Ascites and Oedema:
- Fluid retention leads to significant weight gain (“wet weight”).
- Sodium restriction: 2000–2500 mg/day.
- Fluid restriction: ~1.5L/day (based on MDT guidance).
Liver Disease Feeding Strategies
Small Frequent Meals:
Manage anorexia, early satiety (from ascites), and nausea.
Dietary Adjustments for Symptoms:
Fat restriction (<50g/day) for steatorrhea.
Use MCTs as an alternative fat source.
Late-Night Snacks: Prevent fasting-related catabolism.
Liver Disease Specialised Treatments
Branched-Chain Amino Acids (BCAAs):
10–20 g/day for HE; aid ammonia detoxification.
Probiotics: Modulate gut bacteria to reduce ammonia production.
Laxatives (e.g., Lactulose): Prevent HE by promoting daily bowel movements.
Liver Disease Nutritional Prevalence & Impact
Undernutrition Prevalence:
20–30% in compensated liver disease.
60–80% in decompensated liver disease.
HEHP Diet Advantages:
Reduces complications and hospitalizations.
Dietary MNT for Ascites:
Sodium restriction: <2000–2500 mg/day.
Fluid restriction: ~1.5L/day if tense ascites.
L
Liver Disease Monitoring & FU
Regular Assessments
- Monitor weight, sarcopenia, and nutritional deficiencies every 6–12 months. Include DEXA scans for bone health.
Adjustments Based on Symptoms
- Tailor PERT and dietary interventions to control malabsorption and optimize symptom relief.
Alcoholic Steatohepatitis (ASH)
Provide adequate nutrition (30–35 kcal/kg/day and 1.2–1.5 g protein/kg/day). Trace element and vitamin supplementation is crucial.
Diabetes Management (Type 3c)
Individualized meal planning with low GI carbohydrates. Monitor glucose levels regularly and adjust therapy.
Bone Health in Liver Disease
Prevent osteoporosis with calcium (1200–1500 mg/day) and vitamin D (800–1000 IU/day) supplementation.
LD Meal Frequency and Timing
Encourage small, frequent meals (5–6/day) to meet energy needs and minimize metabolic disturbances.
Nutritional Risk in Liver Disease
Liver disease patients have high nutritional risks due to increased resting energy expenditure (REE) and metabolic derangements.
LD Screening Tools
Use tools like NRS-2002, MUST, or the Royal Free Hospital Nutrition Prioritizing Tool to assess malnutrition in liver disease.
Sarcopenia & muscle loss in LD
Assess for sarcopenia via imaging (DXA, CT) or functional tests (e.g., grip strength). Sarcopenia correlates with increased mortality.
LD Energy Requirements
Stable cirrhosis: 1.3 × REE (~32 kcal/kg/day). Adjust for ascites and complications.
Dietary Approach in Cirrhosis
Balanced diet high in energy and protein (1.2–1.5 g/kg/day). Avoid overnight fasting; late-night snacks are recommended.
Fluid and Salt Management:
Restrict sodium (<2g/day) and manage fluid intake in cases of ascites.
Vits & mins:
Monitor and supplement vitamins A, D, E, K, B12, folate, and minerals like zinc, selenium, and magnesium.
ONS:
Use for patients unable to meet nutritional needs through diet alone.
Liver Disease: Special Conditions & MNT - Hepatic Encephalopathy (HE)
Protein restriction not generally recommended. Provide adequate protein (≥1.2 g/kg/day), use branched-chain amino acids (BCAA) in severe cases.
Liver Disease: Special Conditions & MNT - Acute Liver Failure
Early enteral nutrition (EN) preferred; standard formulas are sufficient. Avoid prolonged fasting.
Liver Disease: Special Conditions & MNT - Non-Alcoholic Fatty Liver Disease (NAFLD)/NASH
Focus on weight loss (7–10% for fibrosis improvement), low-calorie Mediterranean diet, and increased physical activity.
Specialised Feeding Strategies in Liver Disease
Enteral Nutrition (EN)
- Use EN in malnourished patients when oral intake is inadequate. NJ feeding for intolerance to NG feeds.
Parenteral Nutrition (PN)
- Reserved for severe complications when EN is contraindicated. Include omega-3 enriched lipid emulsions to reduce liver injury risks.
Protein Recommendations
- Avoid protein restrictions in cirrhosis. Incorporate late-night snacks to minimize fasting-related catabolism.
Nutritional Requirements for Acute Pancreatitis (ESPEN Guidelines)
Energy Requirements: 25–35 kcal/kg/day
Protein Requirements: 1.2–1.5 g/kg/day
Enteral nutrition is preferred over parenteral nutrition due to better preservation of gut integrity.
Nutritional Requirements for Chronic Pancreatitis (ESPEN Guidelines)
Energy Requirements: 30–35 kcal/kg/day to support metabolic demands.
Protein Requirements: 1.2–1.5 g/kg/day for preventing malnutrition and muscle loss.
Micronutrient deficiencies (vitamins D, E, A, K, and trace elements) should be addressed, especially in cases of pancreatic exocrine insufficiency.
Pancreatitis Feeding Guidelines Summary (ESPEN)
Enteral Nutrition (EN):
- Start within 24–72 hours in patients unable to meet oral intake.
- Standard polymeric feeds are first-line; semi-elemental feeds may be used for malabsorption or intolerance.
Parenteral Nutrition (PN):
- Only when EN is not feasible.
- Supplementation with glutamine may benefit immune and metabolic function, especially in catabolic states.
