Liver disease

Question 1

What are some clinical signs and symptoms of liver disease?

Answer 1

Muscle wasting

Ascites/ oedema

Jaundice
- Elevated bilirubin
- Itching –> scabs
- Yellowing skins and eyes
- Pale stools

Encephalopathy

Spider nevi
- Red patches on skin
- Red palms
- White half moon extends down nail bed

Micronutrient losses
- Sodium, zinc, thiamine (unable to utilise CHO, exacerbate protein loss), potassium, calcium (bone density)
- Fat soluble vitamins
- Anaemia
- Night blindness
- Poor dentition
- Altered taste

Poor skin condition
- Itching

Bleeding gums and poor wound healing
- Vitamin C deficiency?

Bruising
- Vitamin K deficiency?

Hair loss

Question 2

What biochemistry is associated with liver disease?

Answer 2

ALP + GGT increase
ALT + AST increase
Bilirubin increase (usually with ALP) –> leakage from hepatocytes
Low albumin –> low protein intake
Low sodium –> ? fluid retention, ascites
Prolonged prothrombin time
Increased cholesterol

Question 3

What are the dietary recommendations for liver disease?

Answer 3

NAFLD –> Mediterranean diet (improves steatosis and insulin sensitivity)

• Aim for a BMI below 25kg/m2
• Weight loss >10% –> improves fibrosis
• Weight loss 0.5kg-1kg/wk
• Encourage exercise for 30mins/d
• Aim for 5 a day
• Eat low GI foods
• Avoid refined sugars and saturated fats
• Decrease fructose sweetened soft drinks
• Abstain from alcohol
• Eat little and often (every 2-3 hours)
• Regulate protein intake over day (protein and cho with each meal)
• 50g CHO before bed

Patients with NAFLD require treatment of each aspect of metabolic syndrome if present

Question 4

What are the advised dietary requirements for patients with cirrhosis?

Answer 4

Compensated
- 30-35kcals/kg
- 1.2g/kg protein
ESPEN

Decompensated
- 30-35kcal/kg (ESPEN)
- 22-28g/kg + activity factor (PENG)
- 1.5g/kg protein (malnourished or sarcopenic cirrhotic)

Supplements:
- 800IU of vitamin D + 1000mg of calcium
- Consider B vitamins –> severely malnourished, withdrawal from alcohol, long term alcohol use.

Question 5

What is the dietary advice for ascites?

Answer 5

Salt reducing advice to patients grade 2 (moderate) ascites or above - 4.6-6.9g/d
No added salt to meals
Avoid salty snack such as crisps and soups
Encourage high energy high protein snacks with a 50g CHO snack in the evening

Question 6

What are can help with nausea?

Answer 6

Breath fresh air before eating - mouthwash, brush teeth
Hunger often makes nausea worse so eat little and often
Cold snacks may be better hot
Dry foods
Avoid eating when tired
Sip cold drinks through a straw

Explore what has helped previously
Is there a pattern to the sickness

Question 7

What is Primary Biliary Cholangitis/ Cirrhosis?

Answer 7

A type of liver disease that gradually worsens over time. If left untreated it may lead to liver failure.
The immune system mistakenly attacks the bile ducts - strongly associated disease, particularly thyroid. The bile ducts become damaged and injured, causing bile to build up in the liver. This further damages the liver and may to scarring.

Often symptomatic
- Bone and joint aches
- Fatigue
- Itchy skin
- Dry eyes and mouth
- Pain or discomfort in upper right side of tummy

Treatment
- Urosodeoxycholic acid
- Obeticholic acid

Question 8

What are some complications of Primary Biliary Cholangitis?

Answer 8

Osteoporosis
Portal hypertension –> Increased blood pressure inside the blood vessels in your abdomen
Ascites
Vitamin deficiencies –> e.g. A, D, E and K
Slighting higher risk of developing liver cancer

Question 9

What are some signs of advanced PBC?

Answer 9

Jaundice
Oedema
Ascites
Small fatty deposits on skin around eyes (Xanthelassmata)
Dark urine
Pale stools
Bleed and bruise more easily
Dry mouth –> increase risk of tooth decay
Problems with memory and concentration

Question 10

What is the dietary management of steatorrhea due to PBC and liver disease?

Answer 10

Small frequent meals
- Eat every 2-3 hours + 50g CHO bedtime snack

Fat restriction if steatorrhea is:
- Causing weight loss
- Causing dehydration or electrolyte losses
- Causing significant nausea and indigestion (NOT responding to antiemetics or antacids)
Fat content reduced slowly to tolerance

Use CHO and low fat high protein supplements (fortijuice) as well as MCT oil (bypasses pancreatic malabsorption) or MCT based supplements (liqugen).

Supplementation of fat soluble vitamins - A, D, E, K - may be required, need to monitor to avoid toxicity.

Question 11

What factors in liver disease could influence malnutrition?

Answer 11

• Changes in metabolism –> altered energy expenditure
• Loss of appetite/ early satiety
• Inability to eat –> repeated investigations requiring fasting
• Altered sleep patterns
• Unnecessary dietary restrictions
• Nausea/ vomiting
• High alcohol intake (oesophagitis, gastritis)
• Altered taste
• Weakness and fatigue