SlideShare ist ein Scribd-Unternehmen logo
1 von 50
CIRRHOSIS OF LIVER
AND
DIETARY MANAGEMENT
Dev Ram Sunuwar
M.Sc.Nutrition and Dietetics1
OBJECTIVE
At the end of presentation, participants will be able to:
1. Define liver Cirrhosis
2. Enumerate the different types of liver cirrhosis
3. Enumerate the predisposing/ contributing factors
of liver cirrhosis
4. Discuss the pathophysiological changes and
clinical manifestations of patients with liver
cirrhosis.
5. Nutritional assessment in CLD patient
6. Dietary management
2
OUTLINE
 Definition
 Causes and predisposing factor in cirrhosis
of liver
 Pathophysiology
 Type of cirrhosis and clinical manifestation
 Complication
 Nutritional assessment
 Dietary management
 Conclusion
3
DEFINITION OF CIRRHOSIS
Cirrhosis is derived from Greek word
kirros=orange or tawny and osis=condition
-WHO definition: a diffuse process characterized
by liver necrosis and fibrosis and conversion of
normal liver architechture into structurally
abnormal nodules that lack normal lobular
organisation.
4
COMMON CAUSES
1. Chronic alcoholism & NASH
2. Chronic hepatitis B& C
3. Autoimmune diseases: autoimmune hepatitis.
4. Biliary disease
5. Cholestatic liver disease:PBC,PSC
6. Hemochromatosis (Iron overload)
7. Cryptogenic 10%
8. Wilson's disease,
9. Alpha-1 anti-trypsin deficiency.
10. Obesity
11. Inherited diseases
12. Drugs & toxins
5
PREDISPOSING/ PRECIPITATING FACTORS:
 malnutrition
 effects of alcohol abuse
 chronic impairment of bile excretion
– biliary obstruction in the liver and
common bile duct (gallbladder
stones)
 necrosis from hepatotoxins or viral
hepatitis
 Congestive heart failure 6
PATHOPHYSIOLOGY
-modularity(regenerating nodules).
fibrosis(deposition of dense fibrous septa)-fragmentation of sample.
abnormal liver architecture
Hepatocyte abnormalities:pleomorphism,dysplasia,hyperplasia
Gross pathology: irregular surface ,yellowish colour,small,firm
7
CirrhosisNormal
Nodules surrounded
by fibrous tissue 8
HISTOLOGICAL IMAGE OF A NORMAL AND A CIRRHOTIC LIVER
9
10
11
12
CLINICAL MANIFESTATIONS
Sign/Symptoms - early:
 anorexia, nausea, indigestion
 aching or heaviness in right upper quadrant
 weakness & fatigue
13
Assessment:
CLINICAL MANIFESTATIONS
Late signs:
 abnormal liver function tests:
 bilirubin (N=0-0.9mg/dl),
 AST (N=4.8-19U/L)
 ALT (N= 2.4-17U/L)
 Serum alkaline phosphatase (N=30-40U/L)
 Ammonia (plasma) (N= 15-45umol/L)
 AST / ALT ratio > 1
 Low albumin (< 3.8 g/dL)
 Prolonged prothrombin time (INR > 1.3)
 Low platelet count (< 175 x1000/ml)
 intermittent jaundice, pruritus
 edema, ascites, prominent abdominal wall veins
 Ecchymosis, bleeding tendencies
 anemia
 Infection
 Gynecomastia, testicular atrophy
 Neurologic changes
14
CLINICAL MANIFESTATIONS
15
16
DIAGNOSIS OF CIRRHOSIS
 clinical+laboratory+radiologic+liver biopsy
17
20
COMPLICATIONS
 The ultimate mechanism of deaths in most cirrhotic
patients is
 (1) progressive liver failure,
 (2) a complication related to portal
hypertension, or
 (3) the development of hepatocellular
carcinoma.
21
Ascites
Esophageal variceal bleeding
Hepatic encephalopathy
Hepatorenal syndrome
Spontaneous bacterial peritonitis
Portal hypertensive gastropathy
Infection
Liver failure
Hepatocellular carcinoma
Subjective Global Assessment
Anthropometric measurements
Bioelectric impedance analysis
Handgrip strength test
22
23
DIETARY
MANAGEMENT
The measures in dietetic treatment are:
• Assuring the adequate intake of protein and
of the correct types of proteins
• Assuring an adequate supply of energy
• Increased dietary intake of fiber
• Administration of branched-chain amino
acids
• Reduced intake of sodium
• Restriction of fluid
• Increased intake of potassium
A. ENERGY REQUIREMENTS
26
Patients usually need 35-45 kcal/kg/day.
They should supply 60-70% of non nitrogen
calories.
Cirrhosis is a disease of accelerated starvation ,so
patients should avoid long time without feeding.
Patients often do better on multiple small meals
with alate bed-time meal.
B. LIPIDS
27
Around 20- 30% of total calorie intake should
be supplied as fat.
MCT oil are preferred as they are easily
digestible and assimilable
A mixed fuel system improves nitrogen
balance compared to glucose alone.
Even in decompensated cirrhosis, high lipid
containing parenteral mixtures were found to
be well tolerated and improve
encephalopathy.
B. LIPIDS CONT..
28
 Thus lipid restriction has no scientific basisin
patients withcirrhosis.
 Fat should be provided aspolyunsaturated
fatty acids, with less than 50% long chain
triglycerides.
 Fat helps make food tastier. This is important
for people who suffer from a suppressed
appetite due to chronic liverdisease.
B. LIPIDS CONT..
29
 fat need in order to properly absorb the
four fat-soluble vitamins—A, D,E, and
K.
 Without some fat, these vitamins may
become deficient in the body, even if
they are taken in supplemental form.
C. PROTEINS.
30
 Proteins should not be restricted in patients
with liver disease unless they become protein
intolerant due to encephalopathy.
 Protein intakeshould be in the rangeof 1-1.5
g/kg/day.
 Several studies have shown that a daily protein
supply of 1.0-1.2g/kg/day may be sufficient to
prevent negative N2 balance in cirrhosis
 With mild stress, this has to increase to 1.5
g/kg/day, and with acute exacerbations of
hepatitis or decompensation to 2.0g/kg/day
C. PROTEINS. CONT.
31
 Special attention should be paid topatients
on beta-blockers for prevention of variceal
bleeding.
Beta-blockers increase protein oxidation
(an alternative method of protein
metabolism withoutenergy production),
and may increase protein requirement.
patients on propranolol should be placed
on the higherend of the protein intake.
AMINO ACIDS COMMONLY ALTERED
IN LIVER DISEASE
 Aromatic amino acids—serum levels
increased
 —Tyrosine
 —Phenylalanine*
 —Free tryptophan*
 Branched-chain amino acids—serum levels
decreased
 —Valine*
 —Leucine*
 —Isoleucine*
 Other amino acids—serum levels increased
32
Oral BCAAs in cirrhosis with or without chronic
encephalopathy
 BCCAs supplement can only be recommended in
pat. At high risk of encephalopathy.
 branched-chain amino acids, at doses of 12 to
14 grams per day
 BCAA-enriched formulations can be useful in p’twhoare
intolerant to protein and malnourished, which can improve
protein synthesis and reduce post injurycatabolism.
 Leucine is the most active in promoting protein
synthesis and inhibitingprotein breakdown.
 Isoleucine and valine increase nitrogen balance and increase
tissue concentrationof leucine.
33
DIETARY RECOMMENDATION :
Energy and protein :
34
Clinical condition Energy
( kcal/kg/day)
Protein
(gm/kg/day)
Compensated cirrhosis 25 – 35 1.0 – 1.2
Decompensated
cirrhosis
35 - 40 1.2 – 1.5
Hepatic encephalopathy
Grade 1 -2
25 - 35 1.0 – 1.5
Hepatic encephalopathy
Grade 3 -4
25 - 35 1.0 – 1.5
BCAA enriched formula
25% of cirrhotics have small intestinal bacterial overgrowth
Probiotics decrease intestinal pH, inhibiting growth of
pathogenic bacteria
Probiotics with fructo-oligosaccharides equal to lactulose for
hepatic encephalopathy
Generally safe and well
36
Fluid intake 30-40mL/kg/day maintains fluid
balance
Dilutional hyponatremia develops due to decreased
renal blood flow and greater free water
accumulation
Fluid restriction of 1.5L/day only if with ascites and
hyponatremia <120mEq/L
37
Vitamins A, D, E, and K, zinc and selenium
supplementation for all cirrhotics
 If with chronic cholestasis, check serum levels of
vitamin A and 25(OH)-D annually
 B12 levels falsely elevated due to inactive
cobalamin analogues
 Alcoholics need folate and thiamine supplements
38
39
• Strict low sodium diet (1 g of
table salt per day)
• Low sodium diet (3 g of table
salt per day)
• Sodium-reduced diet (6 g of
table salt per day)
(Prof. Dr. Mathias Plauth
and Klinik für Innere
Medizin)
CASE STUDY
Name: lal bdr. Thapa
Age/sex: 58/M
Bed number:- 619A gastroenterology ward
Weight: 68 kg
Height: 5.2”
Address: Butwal
Occupation: farmer
BMI:27 (ascites)
Adjusted body weight- 60.5kg
Abdominal girth: 95cm
INVESTIGATION REPORT
TC- 4800
Hb- 7.7
PCV- 21.7
PT/INR- 1.44
Platelets- 63000
RBS- 9.8
Urea- 16
Creatinine- 612
Total billirubirin- 155
SGPT-15
SGOT-42
Alkaline phosphate- 133
Total protein- 68
LDH-112
Uric acid- 22
Ascitis fluid
TC-110
Protein-1.5
Albumin- 5.6
I/O- 950/1000ml
Diagnosis:- ALD/CLD with HTN with ascites
Total energy requirement= 2100kcal
Serving size:- 26
Nutrient distribution
Protein- 91.5gm(18%)- 1.5gm/kg/BW
Carbohydrate- 320gm(60%)
Fat- 52gm(22%)
Food
group
List Unit Protein Fat CHO
CHO 1 11 22 198
2 2 36
Protein 3 3 27 15
4 3.5 14 17.5 21
5 3.5 21 3.5 45.5
Fat 6 1.5 13.5
Vitamin/mi
nerals
7 1.5 7.5 1.5 19.5
SAMPLE MENU
बिहानको नास्ता(७:००-८:००)
दूध/चिया:-१ चिलास
अन्डा:- १ वटा पुरै + ३ वटा सेतो मात्रै
पाउरोटी:- २ slice वा ४ पपस बिस्कु ट
फलफु ल:१ वटा
बिहानको खाना(१०:००-११:००)
भात:- ३+१/२ चिलास
दाल:- १ चिलास
सब्जी:- १ चिलास
दही/दूध/मासु/:- १/१ चिलास वा ३-४ पपस
हररयो सलाद:- थोरै
मध्यान्ह(१:००)
फलफु ल:१ वटा
अन्डाको सेतो भाि:- २ वटा
दिउँसोको खाजा(३:००-४:००)
िेडािुडी:- १ चिलास
दही:- १ चिलास
पाउरोटी/बिस्कु ट:- १ slice वा ३-४ पपस
िेलुकाको खाना(७:००-८:००)
रोटी:- ३-४ वटा
दाल:- १ चिलास
सािसब्जी:- १ चिलास
दूध/दही/माछा,मासु:- १/१ चिलास/ ३-४ पपस
ग्रीन सलाद:- इच्छाअनुसार
CONCLUSION
 Adequate caloric intake (35 kcal per kg
body weight daily)
 Adequate intake of protein (1.2–1.5 g per kg
body weight daily)
 Adequate intake of vegetable fiber or
roughage
 Regular exercise to maintain muscle mass
 Timely addition of enteral dietary
supplementation
 Timely addition of branched-chain amino
acids
RFERENCE
 https://www.slideshare.net/SNBhattacharya/cirrhosis-of-liver
 https://www.slideshare.net/tozki/liver-cirrhosis
 Prof. Dr.Plauth M.; Klinik für Innere Medizin and Städtisches Klinikum Dessau
“A Guide for Patientswith Liver Diseases including Guidelines for
Nutrition”2006
 www.slideshare.net/dinujustin/liver-cirrhosis-ppt
 Gluud LL, Dam G, Borre M, Les I, Cordoba J et al. Oral BCAAs have a
beneficial effect on manifestations of hepatic encephalopathy in a
systematic review with meta-analyses of RCTs. J Nutr 2013;143:1263-
1268.
 Johnson TM, Overgard EB, Cohen AD, DiBaise JK. Nutrition assessment and
management in advanced liver disease. Nutr in Clin Practice 2013; 28: 15-
29.
 Koretz RL, Avenell A, Lipman TO. Nutritional support for liver disease.
Cochrane Review 2012; issue 5.
 Plauth M, Cabre E, Riggio O, Assis-Camilo M, Pirlich M et al.
ESPEN guidelines on enteral nutrition: liver disease. Clin. Nutr.
2006; 25: 285-294.
49
50

Weitere ähnliche Inhalte

Was ist angesagt?

DIABETIC DIET PLAN
DIABETIC DIET PLANDIABETIC DIET PLAN
DIABETIC DIET PLANFaisal Shaan
 
Diabetes Diet.ppt
Diabetes Diet.pptDiabetes Diet.ppt
Diabetes Diet.pptShama
 
Therapeutic cardiac diet
Therapeutic cardiac dietTherapeutic cardiac diet
Therapeutic cardiac dietAmal ALharbi
 
Dietary management for hypertension-DASH diet
Dietary management for hypertension-DASH dietDietary management for hypertension-DASH diet
Dietary management for hypertension-DASH dietFaseeha 1
 
Diet and cardiovascular disease
Diet and cardiovascular disease Diet and cardiovascular disease
Diet and cardiovascular disease mohammead osman
 
Diet and gastrointestinal problems
Diet and gastrointestinal problemsDiet and gastrointestinal problems
Diet and gastrointestinal problemsmohammead osman
 
Nutritional management of renal diseases
Nutritional management of renal diseasesNutritional management of renal diseases
Nutritional management of renal diseasesWajid Rather
 
Diet treatment in liver cirrhosis - di Vincenzo Ostilio Palmieri
Diet treatment in liver cirrhosis - di Vincenzo Ostilio PalmieriDiet treatment in liver cirrhosis - di Vincenzo Ostilio Palmieri
Diet treatment in liver cirrhosis - di Vincenzo Ostilio PalmieriMedOliveOil
 
Therapeutic diets
Therapeutic diets Therapeutic diets
Therapeutic diets Nasreen Gul
 
Chapter 19 Nutrition and Liver Diseases
Chapter 19 Nutrition and Liver Diseases Chapter 19 Nutrition and Liver Diseases
Chapter 19 Nutrition and Liver Diseases KellyGCDET
 
Introduction to clinical nutrition
Introduction to clinical nutritionIntroduction to clinical nutrition
Introduction to clinical nutritionDr Iyan Darmawan
 
Nutritional management of diarrhea
Nutritional management of diarrheaNutritional management of diarrhea
Nutritional management of diarrheaManu Kaushik
 
Chronic Kidney disease Diet Therapy
Chronic Kidney disease Diet TherapyChronic Kidney disease Diet Therapy
Chronic Kidney disease Diet TherapyTimothy Zagada
 
Nutritional assessment in chronic liver disease
Nutritional assessment in chronic liver diseaseNutritional assessment in chronic liver disease
Nutritional assessment in chronic liver diseaseShaimaa Elkholy
 
Therapeutic diet or Types of Diet
Therapeutic diet or Types of DietTherapeutic diet or Types of Diet
Therapeutic diet or Types of DietAstha Patel
 

Was ist angesagt? (20)

DIET IN DIARRHEA
DIET IN DIARRHEADIET IN DIARRHEA
DIET IN DIARRHEA
 
DIABETIC DIET PLAN
DIABETIC DIET PLANDIABETIC DIET PLAN
DIABETIC DIET PLAN
 
Diabetes Diet.ppt
Diabetes Diet.pptDiabetes Diet.ppt
Diabetes Diet.ppt
 
Nutrition in renal dosorders
Nutrition in renal dosordersNutrition in renal dosorders
Nutrition in renal dosorders
 
Therapeutic cardiac diet
Therapeutic cardiac dietTherapeutic cardiac diet
Therapeutic cardiac diet
 
Dietary management for hypertension-DASH diet
Dietary management for hypertension-DASH dietDietary management for hypertension-DASH diet
Dietary management for hypertension-DASH diet
 
Diet and cardiovascular disease
Diet and cardiovascular disease Diet and cardiovascular disease
Diet and cardiovascular disease
 
Diet and gastrointestinal problems
Diet and gastrointestinal problemsDiet and gastrointestinal problems
Diet and gastrointestinal problems
 
Childhood obesity
Childhood obesityChildhood obesity
Childhood obesity
 
Nutritional management of renal diseases
Nutritional management of renal diseasesNutritional management of renal diseases
Nutritional management of renal diseases
 
Diet treatment in liver cirrhosis - di Vincenzo Ostilio Palmieri
Diet treatment in liver cirrhosis - di Vincenzo Ostilio PalmieriDiet treatment in liver cirrhosis - di Vincenzo Ostilio Palmieri
Diet treatment in liver cirrhosis - di Vincenzo Ostilio Palmieri
 
Therapeutic diets
Therapeutic diets Therapeutic diets
Therapeutic diets
 
Chapter 19 Nutrition and Liver Diseases
Chapter 19 Nutrition and Liver Diseases Chapter 19 Nutrition and Liver Diseases
Chapter 19 Nutrition and Liver Diseases
 
Introduction to clinical nutrition
Introduction to clinical nutritionIntroduction to clinical nutrition
Introduction to clinical nutrition
 
Nutritional management of diarrhea
Nutritional management of diarrheaNutritional management of diarrhea
Nutritional management of diarrhea
 
Dietary management in DM
Dietary management in DMDietary management in DM
Dietary management in DM
 
Chronic Kidney disease Diet Therapy
Chronic Kidney disease Diet TherapyChronic Kidney disease Diet Therapy
Chronic Kidney disease Diet Therapy
 
Nutritional assessment in chronic liver disease
Nutritional assessment in chronic liver diseaseNutritional assessment in chronic liver disease
Nutritional assessment in chronic liver disease
 
Therapeutic diet or Types of Diet
Therapeutic diet or Types of DietTherapeutic diet or Types of Diet
Therapeutic diet or Types of Diet
 
Diet and hepatitis
Diet and hepatitisDiet and hepatitis
Diet and hepatitis
 

Ähnlich wie Cirrhosis of liver. final pptx

Nonalcoholic fatty liver disease
Nonalcoholic fatty liver diseaseNonalcoholic fatty liver disease
Nonalcoholic fatty liver diseaseAshish Kumar
 
ALCOHOLIC LIVER DISEASE
ALCOHOLIC LIVER DISEASEALCOHOLIC LIVER DISEASE
ALCOHOLIC LIVER DISEASEMansi Shah
 
Liver Disease Case Study
Liver Disease Case StudyLiver Disease Case Study
Liver Disease Case StudyAlysse Milano
 
NON ALCOHOLIC FATTY LIVER DISEASE
NON ALCOHOLIC FATTY LIVER DISEASENON ALCOHOLIC FATTY LIVER DISEASE
NON ALCOHOLIC FATTY LIVER DISEASEDr. Haritha Sridhar
 
NON-ALCOHOLIC FATTY LIVER DISESEppt.pptx
NON-ALCOHOLIC FATTY LIVER DISESEppt.pptxNON-ALCOHOLIC FATTY LIVER DISESEppt.pptx
NON-ALCOHOLIC FATTY LIVER DISESEppt.pptxSangram Das
 
TCELL - Case Presentation-2 - Copy.pptx
TCELL - Case Presentation-2 - Copy.pptxTCELL - Case Presentation-2 - Copy.pptx
TCELL - Case Presentation-2 - Copy.pptxDrAijazTalani
 
NON ALCOHOLIC FATTY LIVER DISEASES modify (edited by Kyin).pptx
NON ALCOHOLIC FATTY LIVER DISEASES modify (edited by Kyin).pptxNON ALCOHOLIC FATTY LIVER DISEASES modify (edited by Kyin).pptx
NON ALCOHOLIC FATTY LIVER DISEASES modify (edited by Kyin).pptxKyawMyoHtet10
 
Pancreatitis - etiology, pathophysiology and nutrition
Pancreatitis - etiology, pathophysiology and nutritionPancreatitis - etiology, pathophysiology and nutrition
Pancreatitis - etiology, pathophysiology and nutritionmunniradhika
 
Nutrition in ckd &amp; hd dawly 2017
Nutrition in ckd &amp; hd  dawly 2017Nutrition in ckd &amp; hd  dawly 2017
Nutrition in ckd &amp; hd dawly 2017FarragBahbah
 
Daily minimum nutritional requirements of the critically ill
Daily minimum nutritional requirements of the critically illDaily minimum nutritional requirements of the critically ill
Daily minimum nutritional requirements of the critically illRalekeOkoye
 
Total parenteral nutrition
Total parenteral nutritionTotal parenteral nutrition
Total parenteral nutritionVenkatesh Kolla
 
Hígado graso no alcohólico en niños y adolescentes obesos
Hígado graso no alcohólico en niños y adolescentes obesosHígado graso no alcohólico en niños y adolescentes obesos
Hígado graso no alcohólico en niños y adolescentes obesosCuerpomedicoinsn
 
Enteral and Parenteral Nutrition
Enteral and Parenteral NutritionEnteral and Parenteral Nutrition
Enteral and Parenteral NutritionDr. Kiran Pandey
 

Ähnlich wie Cirrhosis of liver. final pptx (20)

Nonalcoholic fatty liver disease
Nonalcoholic fatty liver diseaseNonalcoholic fatty liver disease
Nonalcoholic fatty liver disease
 
ALCOHOLIC LIVER DISEASE
ALCOHOLIC LIVER DISEASEALCOHOLIC LIVER DISEASE
ALCOHOLIC LIVER DISEASE
 
NAFLD.pptx
NAFLD.pptxNAFLD.pptx
NAFLD.pptx
 
Liver Disease Case Study
Liver Disease Case StudyLiver Disease Case Study
Liver Disease Case Study
 
NAFLD-Metabolic Syndrome- THE LINK
NAFLD-Metabolic Syndrome- THE LINKNAFLD-Metabolic Syndrome- THE LINK
NAFLD-Metabolic Syndrome- THE LINK
 
NAFLD
NAFLDNAFLD
NAFLD
 
NON ALCOHOLIC FATTY LIVER DISEASE
NON ALCOHOLIC FATTY LIVER DISEASENON ALCOHOLIC FATTY LIVER DISEASE
NON ALCOHOLIC FATTY LIVER DISEASE
 
NON-ALCOHOLIC FATTY LIVER DISESEppt.pptx
NON-ALCOHOLIC FATTY LIVER DISESEppt.pptxNON-ALCOHOLIC FATTY LIVER DISESEppt.pptx
NON-ALCOHOLIC FATTY LIVER DISESEppt.pptx
 
TCELL - Case Presentation-2 - Copy.pptx
TCELL - Case Presentation-2 - Copy.pptxTCELL - Case Presentation-2 - Copy.pptx
TCELL - Case Presentation-2 - Copy.pptx
 
NON ALCOHOLIC FATTY LIVER DISEASES modify (edited by Kyin).pptx
NON ALCOHOLIC FATTY LIVER DISEASES modify (edited by Kyin).pptxNON ALCOHOLIC FATTY LIVER DISEASES modify (edited by Kyin).pptx
NON ALCOHOLIC FATTY LIVER DISEASES modify (edited by Kyin).pptx
 
Pancreatitis - etiology, pathophysiology and nutrition
Pancreatitis - etiology, pathophysiology and nutritionPancreatitis - etiology, pathophysiology and nutrition
Pancreatitis - etiology, pathophysiology and nutrition
 
NAFLD, NASH
NAFLD, NASHNAFLD, NASH
NAFLD, NASH
 
Chronic Liver Disease (1).pdf
Chronic Liver Disease (1).pdfChronic Liver Disease (1).pdf
Chronic Liver Disease (1).pdf
 
Nutrition in ckd &amp; hd dawly 2017
Nutrition in ckd &amp; hd  dawly 2017Nutrition in ckd &amp; hd  dawly 2017
Nutrition in ckd &amp; hd dawly 2017
 
Daily minimum nutritional requirements of the critically ill
Daily minimum nutritional requirements of the critically illDaily minimum nutritional requirements of the critically ill
Daily minimum nutritional requirements of the critically ill
 
Total parenteral nutrition
Total parenteral nutritionTotal parenteral nutrition
Total parenteral nutrition
 
Hígado graso no alcohólico en niños y adolescentes obesos
Hígado graso no alcohólico en niños y adolescentes obesosHígado graso no alcohólico en niños y adolescentes obesos
Hígado graso no alcohólico en niños y adolescentes obesos
 
Enteral and Parenteral Nutrition
Enteral and Parenteral NutritionEnteral and Parenteral Nutrition
Enteral and Parenteral Nutrition
 
A case of Recurrent Pancreatitis
A case of Recurrent PancreatitisA case of Recurrent Pancreatitis
A case of Recurrent Pancreatitis
 
3356769.ppt
3356769.ppt3356769.ppt
3356769.ppt
 

Mehr von Dev Ram Sunuwar

Mehr von Dev Ram Sunuwar (6)

Balance
BalanceBalance
Balance
 
Protein energy malnutrition
Protein energy malnutritionProtein energy malnutrition
Protein energy malnutrition
 
Nutrition and fitness
Nutrition and fitnessNutrition and fitness
Nutrition and fitness
 
Food allergies and food intolerances ppt
Food allergies and food intolerances pptFood allergies and food intolerances ppt
Food allergies and food intolerances ppt
 
Cancer and dietary management
Cancer and dietary managementCancer and dietary management
Cancer and dietary management
 
Anemia ppt
Anemia pptAnemia ppt
Anemia ppt
 

Kürzlich hochgeladen

The Most Attractive Hyderabad Call Girls Kothapet 𖠋 6297143586 𖠋 Will You Mis...
The Most Attractive Hyderabad Call Girls Kothapet 𖠋 6297143586 𖠋 Will You Mis...The Most Attractive Hyderabad Call Girls Kothapet 𖠋 6297143586 𖠋 Will You Mis...
The Most Attractive Hyderabad Call Girls Kothapet 𖠋 6297143586 𖠋 Will You Mis...chandars293
 
(Low Rate RASHMI ) Rate Of Call Girls Jaipur ❣ 8445551418 ❣ Elite Models & Ce...
(Low Rate RASHMI ) Rate Of Call Girls Jaipur ❣ 8445551418 ❣ Elite Models & Ce...(Low Rate RASHMI ) Rate Of Call Girls Jaipur ❣ 8445551418 ❣ Elite Models & Ce...
(Low Rate RASHMI ) Rate Of Call Girls Jaipur ❣ 8445551418 ❣ Elite Models & Ce...parulsinha
 
Call Girls Tirupati Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Tirupati Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Tirupati Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Tirupati Just Call 9907093804 Top Class Call Girl Service AvailableDipal Arora
 
Call Girls Bangalore Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Bangalore Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Bangalore Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Bangalore Just Call 9907093804 Top Class Call Girl Service AvailableDipal Arora
 
Call Girls Ooty Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Ooty Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Ooty Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Ooty Just Call 9907093804 Top Class Call Girl Service AvailableDipal Arora
 
Call Girls Gwalior Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Gwalior Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Gwalior Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Gwalior Just Call 9907093804 Top Class Call Girl Service AvailableDipal Arora
 
Call Girls Cuttack Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Cuttack Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Cuttack Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Cuttack Just Call 9907093804 Top Class Call Girl Service AvailableDipal Arora
 
Best Rate (Patna ) Call Girls Patna ⟟ 8617370543 ⟟ High Class Call Girl In 5 ...
Best Rate (Patna ) Call Girls Patna ⟟ 8617370543 ⟟ High Class Call Girl In 5 ...Best Rate (Patna ) Call Girls Patna ⟟ 8617370543 ⟟ High Class Call Girl In 5 ...
Best Rate (Patna ) Call Girls Patna ⟟ 8617370543 ⟟ High Class Call Girl In 5 ...Dipal Arora
 
(Rocky) Jaipur Call Girl - 09521753030 Escorts Service 50% Off with Cash ON D...
(Rocky) Jaipur Call Girl - 09521753030 Escorts Service 50% Off with Cash ON D...(Rocky) Jaipur Call Girl - 09521753030 Escorts Service 50% Off with Cash ON D...
(Rocky) Jaipur Call Girl - 09521753030 Escorts Service 50% Off with Cash ON D...indiancallgirl4rent
 
All Time Service Available Call Girls Marine Drive 📳 9820252231 For 18+ VIP C...
All Time Service Available Call Girls Marine Drive 📳 9820252231 For 18+ VIP C...All Time Service Available Call Girls Marine Drive 📳 9820252231 For 18+ VIP C...
All Time Service Available Call Girls Marine Drive 📳 9820252231 For 18+ VIP C...Arohi Goyal
 
Best Rate (Guwahati ) Call Girls Guwahati ⟟ 8617370543 ⟟ High Class Call Girl...
Best Rate (Guwahati ) Call Girls Guwahati ⟟ 8617370543 ⟟ High Class Call Girl...Best Rate (Guwahati ) Call Girls Guwahati ⟟ 8617370543 ⟟ High Class Call Girl...
Best Rate (Guwahati ) Call Girls Guwahati ⟟ 8617370543 ⟟ High Class Call Girl...Dipal Arora
 
Book Paid Powai Call Girls Mumbai 𖠋 9930245274 𖠋Low Budget Full Independent H...
Book Paid Powai Call Girls Mumbai 𖠋 9930245274 𖠋Low Budget Full Independent H...Book Paid Powai Call Girls Mumbai 𖠋 9930245274 𖠋Low Budget Full Independent H...
Book Paid Powai Call Girls Mumbai 𖠋 9930245274 𖠋Low Budget Full Independent H...Call Girls in Nagpur High Profile
 
Premium Bangalore Call Girls Jigani Dail 6378878445 Escort Service For Hot Ma...
Premium Bangalore Call Girls Jigani Dail 6378878445 Escort Service For Hot Ma...Premium Bangalore Call Girls Jigani Dail 6378878445 Escort Service For Hot Ma...
Premium Bangalore Call Girls Jigani Dail 6378878445 Escort Service For Hot Ma...tanya dube
 
Call Girls Visakhapatnam Just Call 9907093804 Top Class Call Girl Service Ava...
Call Girls Visakhapatnam Just Call 9907093804 Top Class Call Girl Service Ava...Call Girls Visakhapatnam Just Call 9907093804 Top Class Call Girl Service Ava...
Call Girls Visakhapatnam Just Call 9907093804 Top Class Call Girl Service Ava...Dipal Arora
 
Call Girls Bhubaneswar Just Call 9907093804 Top Class Call Girl Service Avail...
Call Girls Bhubaneswar Just Call 9907093804 Top Class Call Girl Service Avail...Call Girls Bhubaneswar Just Call 9907093804 Top Class Call Girl Service Avail...
Call Girls Bhubaneswar Just Call 9907093804 Top Class Call Girl Service Avail...Dipal Arora
 
Call Girls Varanasi Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Varanasi Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Varanasi Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Varanasi Just Call 9907093804 Top Class Call Girl Service AvailableDipal Arora
 
Call Girls Gwalior Just Call 8617370543 Top Class Call Girl Service Available
Call Girls Gwalior Just Call 8617370543 Top Class Call Girl Service AvailableCall Girls Gwalior Just Call 8617370543 Top Class Call Girl Service Available
Call Girls Gwalior Just Call 8617370543 Top Class Call Girl Service AvailableDipal Arora
 
VIP Service Call Girls Sindhi Colony 📳 7877925207 For 18+ VIP Call Girl At Th...
VIP Service Call Girls Sindhi Colony 📳 7877925207 For 18+ VIP Call Girl At Th...VIP Service Call Girls Sindhi Colony 📳 7877925207 For 18+ VIP Call Girl At Th...
VIP Service Call Girls Sindhi Colony 📳 7877925207 For 18+ VIP Call Girl At Th...jageshsingh5554
 
Call Girls Ludhiana Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Ludhiana Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Ludhiana Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Ludhiana Just Call 9907093804 Top Class Call Girl Service AvailableDipal Arora
 
Lucknow Call girls - 8800925952 - 24x7 service with hotel room
Lucknow Call girls - 8800925952 - 24x7 service with hotel roomLucknow Call girls - 8800925952 - 24x7 service with hotel room
Lucknow Call girls - 8800925952 - 24x7 service with hotel roomdiscovermytutordmt
 

Kürzlich hochgeladen (20)

The Most Attractive Hyderabad Call Girls Kothapet 𖠋 6297143586 𖠋 Will You Mis...
The Most Attractive Hyderabad Call Girls Kothapet 𖠋 6297143586 𖠋 Will You Mis...The Most Attractive Hyderabad Call Girls Kothapet 𖠋 6297143586 𖠋 Will You Mis...
The Most Attractive Hyderabad Call Girls Kothapet 𖠋 6297143586 𖠋 Will You Mis...
 
(Low Rate RASHMI ) Rate Of Call Girls Jaipur ❣ 8445551418 ❣ Elite Models & Ce...
(Low Rate RASHMI ) Rate Of Call Girls Jaipur ❣ 8445551418 ❣ Elite Models & Ce...(Low Rate RASHMI ) Rate Of Call Girls Jaipur ❣ 8445551418 ❣ Elite Models & Ce...
(Low Rate RASHMI ) Rate Of Call Girls Jaipur ❣ 8445551418 ❣ Elite Models & Ce...
 
Call Girls Tirupati Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Tirupati Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Tirupati Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Tirupati Just Call 9907093804 Top Class Call Girl Service Available
 
Call Girls Bangalore Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Bangalore Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Bangalore Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Bangalore Just Call 9907093804 Top Class Call Girl Service Available
 
Call Girls Ooty Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Ooty Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Ooty Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Ooty Just Call 9907093804 Top Class Call Girl Service Available
 
Call Girls Gwalior Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Gwalior Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Gwalior Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Gwalior Just Call 9907093804 Top Class Call Girl Service Available
 
Call Girls Cuttack Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Cuttack Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Cuttack Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Cuttack Just Call 9907093804 Top Class Call Girl Service Available
 
Best Rate (Patna ) Call Girls Patna ⟟ 8617370543 ⟟ High Class Call Girl In 5 ...
Best Rate (Patna ) Call Girls Patna ⟟ 8617370543 ⟟ High Class Call Girl In 5 ...Best Rate (Patna ) Call Girls Patna ⟟ 8617370543 ⟟ High Class Call Girl In 5 ...
Best Rate (Patna ) Call Girls Patna ⟟ 8617370543 ⟟ High Class Call Girl In 5 ...
 
(Rocky) Jaipur Call Girl - 09521753030 Escorts Service 50% Off with Cash ON D...
(Rocky) Jaipur Call Girl - 09521753030 Escorts Service 50% Off with Cash ON D...(Rocky) Jaipur Call Girl - 09521753030 Escorts Service 50% Off with Cash ON D...
(Rocky) Jaipur Call Girl - 09521753030 Escorts Service 50% Off with Cash ON D...
 
All Time Service Available Call Girls Marine Drive 📳 9820252231 For 18+ VIP C...
All Time Service Available Call Girls Marine Drive 📳 9820252231 For 18+ VIP C...All Time Service Available Call Girls Marine Drive 📳 9820252231 For 18+ VIP C...
All Time Service Available Call Girls Marine Drive 📳 9820252231 For 18+ VIP C...
 
Best Rate (Guwahati ) Call Girls Guwahati ⟟ 8617370543 ⟟ High Class Call Girl...
Best Rate (Guwahati ) Call Girls Guwahati ⟟ 8617370543 ⟟ High Class Call Girl...Best Rate (Guwahati ) Call Girls Guwahati ⟟ 8617370543 ⟟ High Class Call Girl...
Best Rate (Guwahati ) Call Girls Guwahati ⟟ 8617370543 ⟟ High Class Call Girl...
 
Book Paid Powai Call Girls Mumbai 𖠋 9930245274 𖠋Low Budget Full Independent H...
Book Paid Powai Call Girls Mumbai 𖠋 9930245274 𖠋Low Budget Full Independent H...Book Paid Powai Call Girls Mumbai 𖠋 9930245274 𖠋Low Budget Full Independent H...
Book Paid Powai Call Girls Mumbai 𖠋 9930245274 𖠋Low Budget Full Independent H...
 
Premium Bangalore Call Girls Jigani Dail 6378878445 Escort Service For Hot Ma...
Premium Bangalore Call Girls Jigani Dail 6378878445 Escort Service For Hot Ma...Premium Bangalore Call Girls Jigani Dail 6378878445 Escort Service For Hot Ma...
Premium Bangalore Call Girls Jigani Dail 6378878445 Escort Service For Hot Ma...
 
Call Girls Visakhapatnam Just Call 9907093804 Top Class Call Girl Service Ava...
Call Girls Visakhapatnam Just Call 9907093804 Top Class Call Girl Service Ava...Call Girls Visakhapatnam Just Call 9907093804 Top Class Call Girl Service Ava...
Call Girls Visakhapatnam Just Call 9907093804 Top Class Call Girl Service Ava...
 
Call Girls Bhubaneswar Just Call 9907093804 Top Class Call Girl Service Avail...
Call Girls Bhubaneswar Just Call 9907093804 Top Class Call Girl Service Avail...Call Girls Bhubaneswar Just Call 9907093804 Top Class Call Girl Service Avail...
Call Girls Bhubaneswar Just Call 9907093804 Top Class Call Girl Service Avail...
 
Call Girls Varanasi Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Varanasi Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Varanasi Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Varanasi Just Call 9907093804 Top Class Call Girl Service Available
 
Call Girls Gwalior Just Call 8617370543 Top Class Call Girl Service Available
Call Girls Gwalior Just Call 8617370543 Top Class Call Girl Service AvailableCall Girls Gwalior Just Call 8617370543 Top Class Call Girl Service Available
Call Girls Gwalior Just Call 8617370543 Top Class Call Girl Service Available
 
VIP Service Call Girls Sindhi Colony 📳 7877925207 For 18+ VIP Call Girl At Th...
VIP Service Call Girls Sindhi Colony 📳 7877925207 For 18+ VIP Call Girl At Th...VIP Service Call Girls Sindhi Colony 📳 7877925207 For 18+ VIP Call Girl At Th...
VIP Service Call Girls Sindhi Colony 📳 7877925207 For 18+ VIP Call Girl At Th...
 
Call Girls Ludhiana Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Ludhiana Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Ludhiana Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Ludhiana Just Call 9907093804 Top Class Call Girl Service Available
 
Lucknow Call girls - 8800925952 - 24x7 service with hotel room
Lucknow Call girls - 8800925952 - 24x7 service with hotel roomLucknow Call girls - 8800925952 - 24x7 service with hotel room
Lucknow Call girls - 8800925952 - 24x7 service with hotel room
 

Cirrhosis of liver. final pptx

  • 1. CIRRHOSIS OF LIVER AND DIETARY MANAGEMENT Dev Ram Sunuwar M.Sc.Nutrition and Dietetics1
  • 2. OBJECTIVE At the end of presentation, participants will be able to: 1. Define liver Cirrhosis 2. Enumerate the different types of liver cirrhosis 3. Enumerate the predisposing/ contributing factors of liver cirrhosis 4. Discuss the pathophysiological changes and clinical manifestations of patients with liver cirrhosis. 5. Nutritional assessment in CLD patient 6. Dietary management 2
  • 3. OUTLINE  Definition  Causes and predisposing factor in cirrhosis of liver  Pathophysiology  Type of cirrhosis and clinical manifestation  Complication  Nutritional assessment  Dietary management  Conclusion 3
  • 4. DEFINITION OF CIRRHOSIS Cirrhosis is derived from Greek word kirros=orange or tawny and osis=condition -WHO definition: a diffuse process characterized by liver necrosis and fibrosis and conversion of normal liver architechture into structurally abnormal nodules that lack normal lobular organisation. 4
  • 5. COMMON CAUSES 1. Chronic alcoholism & NASH 2. Chronic hepatitis B& C 3. Autoimmune diseases: autoimmune hepatitis. 4. Biliary disease 5. Cholestatic liver disease:PBC,PSC 6. Hemochromatosis (Iron overload) 7. Cryptogenic 10% 8. Wilson's disease, 9. Alpha-1 anti-trypsin deficiency. 10. Obesity 11. Inherited diseases 12. Drugs & toxins 5
  • 6. PREDISPOSING/ PRECIPITATING FACTORS:  malnutrition  effects of alcohol abuse  chronic impairment of bile excretion – biliary obstruction in the liver and common bile duct (gallbladder stones)  necrosis from hepatotoxins or viral hepatitis  Congestive heart failure 6
  • 7. PATHOPHYSIOLOGY -modularity(regenerating nodules). fibrosis(deposition of dense fibrous septa)-fragmentation of sample. abnormal liver architecture Hepatocyte abnormalities:pleomorphism,dysplasia,hyperplasia Gross pathology: irregular surface ,yellowish colour,small,firm 7
  • 8. CirrhosisNormal Nodules surrounded by fibrous tissue 8 HISTOLOGICAL IMAGE OF A NORMAL AND A CIRRHOTIC LIVER
  • 9. 9
  • 10. 10
  • 11. 11
  • 12. 12
  • 13. CLINICAL MANIFESTATIONS Sign/Symptoms - early:  anorexia, nausea, indigestion  aching or heaviness in right upper quadrant  weakness & fatigue 13 Assessment:
  • 14. CLINICAL MANIFESTATIONS Late signs:  abnormal liver function tests:  bilirubin (N=0-0.9mg/dl),  AST (N=4.8-19U/L)  ALT (N= 2.4-17U/L)  Serum alkaline phosphatase (N=30-40U/L)  Ammonia (plasma) (N= 15-45umol/L)  AST / ALT ratio > 1  Low albumin (< 3.8 g/dL)  Prolonged prothrombin time (INR > 1.3)  Low platelet count (< 175 x1000/ml)  intermittent jaundice, pruritus  edema, ascites, prominent abdominal wall veins  Ecchymosis, bleeding tendencies  anemia  Infection  Gynecomastia, testicular atrophy  Neurologic changes 14
  • 16. 16
  • 17. DIAGNOSIS OF CIRRHOSIS  clinical+laboratory+radiologic+liver biopsy 17
  • 18.
  • 19.
  • 20. 20
  • 21. COMPLICATIONS  The ultimate mechanism of deaths in most cirrhotic patients is  (1) progressive liver failure,  (2) a complication related to portal hypertension, or  (3) the development of hepatocellular carcinoma. 21 Ascites Esophageal variceal bleeding Hepatic encephalopathy Hepatorenal syndrome Spontaneous bacterial peritonitis Portal hypertensive gastropathy Infection Liver failure Hepatocellular carcinoma
  • 22. Subjective Global Assessment Anthropometric measurements Bioelectric impedance analysis Handgrip strength test 22
  • 23. 23
  • 25. The measures in dietetic treatment are: • Assuring the adequate intake of protein and of the correct types of proteins • Assuring an adequate supply of energy • Increased dietary intake of fiber • Administration of branched-chain amino acids • Reduced intake of sodium • Restriction of fluid • Increased intake of potassium
  • 26. A. ENERGY REQUIREMENTS 26 Patients usually need 35-45 kcal/kg/day. They should supply 60-70% of non nitrogen calories. Cirrhosis is a disease of accelerated starvation ,so patients should avoid long time without feeding. Patients often do better on multiple small meals with alate bed-time meal.
  • 27. B. LIPIDS 27 Around 20- 30% of total calorie intake should be supplied as fat. MCT oil are preferred as they are easily digestible and assimilable A mixed fuel system improves nitrogen balance compared to glucose alone. Even in decompensated cirrhosis, high lipid containing parenteral mixtures were found to be well tolerated and improve encephalopathy.
  • 28. B. LIPIDS CONT.. 28  Thus lipid restriction has no scientific basisin patients withcirrhosis.  Fat should be provided aspolyunsaturated fatty acids, with less than 50% long chain triglycerides.  Fat helps make food tastier. This is important for people who suffer from a suppressed appetite due to chronic liverdisease.
  • 29. B. LIPIDS CONT.. 29  fat need in order to properly absorb the four fat-soluble vitamins—A, D,E, and K.  Without some fat, these vitamins may become deficient in the body, even if they are taken in supplemental form.
  • 30. C. PROTEINS. 30  Proteins should not be restricted in patients with liver disease unless they become protein intolerant due to encephalopathy.  Protein intakeshould be in the rangeof 1-1.5 g/kg/day.  Several studies have shown that a daily protein supply of 1.0-1.2g/kg/day may be sufficient to prevent negative N2 balance in cirrhosis  With mild stress, this has to increase to 1.5 g/kg/day, and with acute exacerbations of hepatitis or decompensation to 2.0g/kg/day
  • 31. C. PROTEINS. CONT. 31  Special attention should be paid topatients on beta-blockers for prevention of variceal bleeding. Beta-blockers increase protein oxidation (an alternative method of protein metabolism withoutenergy production), and may increase protein requirement. patients on propranolol should be placed on the higherend of the protein intake.
  • 32. AMINO ACIDS COMMONLY ALTERED IN LIVER DISEASE  Aromatic amino acids—serum levels increased  —Tyrosine  —Phenylalanine*  —Free tryptophan*  Branched-chain amino acids—serum levels decreased  —Valine*  —Leucine*  —Isoleucine*  Other amino acids—serum levels increased 32
  • 33. Oral BCAAs in cirrhosis with or without chronic encephalopathy  BCCAs supplement can only be recommended in pat. At high risk of encephalopathy.  branched-chain amino acids, at doses of 12 to 14 grams per day  BCAA-enriched formulations can be useful in p’twhoare intolerant to protein and malnourished, which can improve protein synthesis and reduce post injurycatabolism.  Leucine is the most active in promoting protein synthesis and inhibitingprotein breakdown.  Isoleucine and valine increase nitrogen balance and increase tissue concentrationof leucine. 33
  • 34. DIETARY RECOMMENDATION : Energy and protein : 34 Clinical condition Energy ( kcal/kg/day) Protein (gm/kg/day) Compensated cirrhosis 25 – 35 1.0 – 1.2 Decompensated cirrhosis 35 - 40 1.2 – 1.5 Hepatic encephalopathy Grade 1 -2 25 - 35 1.0 – 1.5 Hepatic encephalopathy Grade 3 -4 25 - 35 1.0 – 1.5 BCAA enriched formula
  • 35.
  • 36. 25% of cirrhotics have small intestinal bacterial overgrowth Probiotics decrease intestinal pH, inhibiting growth of pathogenic bacteria Probiotics with fructo-oligosaccharides equal to lactulose for hepatic encephalopathy Generally safe and well 36
  • 37. Fluid intake 30-40mL/kg/day maintains fluid balance Dilutional hyponatremia develops due to decreased renal blood flow and greater free water accumulation Fluid restriction of 1.5L/day only if with ascites and hyponatremia <120mEq/L 37
  • 38. Vitamins A, D, E, and K, zinc and selenium supplementation for all cirrhotics  If with chronic cholestasis, check serum levels of vitamin A and 25(OH)-D annually  B12 levels falsely elevated due to inactive cobalamin analogues  Alcoholics need folate and thiamine supplements 38
  • 39. 39 • Strict low sodium diet (1 g of table salt per day) • Low sodium diet (3 g of table salt per day) • Sodium-reduced diet (6 g of table salt per day)
  • 40.
  • 41. (Prof. Dr. Mathias Plauth and Klinik für Innere Medizin)
  • 42. CASE STUDY Name: lal bdr. Thapa Age/sex: 58/M Bed number:- 619A gastroenterology ward Weight: 68 kg Height: 5.2” Address: Butwal Occupation: farmer BMI:27 (ascites) Adjusted body weight- 60.5kg Abdominal girth: 95cm
  • 43. INVESTIGATION REPORT TC- 4800 Hb- 7.7 PCV- 21.7 PT/INR- 1.44 Platelets- 63000 RBS- 9.8 Urea- 16 Creatinine- 612 Total billirubirin- 155 SGPT-15 SGOT-42 Alkaline phosphate- 133 Total protein- 68 LDH-112 Uric acid- 22 Ascitis fluid TC-110 Protein-1.5 Albumin- 5.6 I/O- 950/1000ml
  • 44. Diagnosis:- ALD/CLD with HTN with ascites Total energy requirement= 2100kcal Serving size:- 26 Nutrient distribution Protein- 91.5gm(18%)- 1.5gm/kg/BW Carbohydrate- 320gm(60%) Fat- 52gm(22%)
  • 45. Food group List Unit Protein Fat CHO CHO 1 11 22 198 2 2 36 Protein 3 3 27 15 4 3.5 14 17.5 21 5 3.5 21 3.5 45.5 Fat 6 1.5 13.5 Vitamin/mi nerals 7 1.5 7.5 1.5 19.5
  • 46. SAMPLE MENU बिहानको नास्ता(७:००-८:००) दूध/चिया:-१ चिलास अन्डा:- १ वटा पुरै + ३ वटा सेतो मात्रै पाउरोटी:- २ slice वा ४ पपस बिस्कु ट फलफु ल:१ वटा बिहानको खाना(१०:००-११:००) भात:- ३+१/२ चिलास दाल:- १ चिलास सब्जी:- १ चिलास दही/दूध/मासु/:- १/१ चिलास वा ३-४ पपस हररयो सलाद:- थोरै मध्यान्ह(१:००) फलफु ल:१ वटा अन्डाको सेतो भाि:- २ वटा
  • 47. दिउँसोको खाजा(३:००-४:००) िेडािुडी:- १ चिलास दही:- १ चिलास पाउरोटी/बिस्कु ट:- १ slice वा ३-४ पपस िेलुकाको खाना(७:००-८:००) रोटी:- ३-४ वटा दाल:- १ चिलास सािसब्जी:- १ चिलास दूध/दही/माछा,मासु:- १/१ चिलास/ ३-४ पपस ग्रीन सलाद:- इच्छाअनुसार
  • 48. CONCLUSION  Adequate caloric intake (35 kcal per kg body weight daily)  Adequate intake of protein (1.2–1.5 g per kg body weight daily)  Adequate intake of vegetable fiber or roughage  Regular exercise to maintain muscle mass  Timely addition of enteral dietary supplementation  Timely addition of branched-chain amino acids
  • 49. RFERENCE  https://www.slideshare.net/SNBhattacharya/cirrhosis-of-liver  https://www.slideshare.net/tozki/liver-cirrhosis  Prof. Dr.Plauth M.; Klinik für Innere Medizin and Städtisches Klinikum Dessau “A Guide for Patientswith Liver Diseases including Guidelines for Nutrition”2006  www.slideshare.net/dinujustin/liver-cirrhosis-ppt  Gluud LL, Dam G, Borre M, Les I, Cordoba J et al. Oral BCAAs have a beneficial effect on manifestations of hepatic encephalopathy in a systematic review with meta-analyses of RCTs. J Nutr 2013;143:1263- 1268.  Johnson TM, Overgard EB, Cohen AD, DiBaise JK. Nutrition assessment and management in advanced liver disease. Nutr in Clin Practice 2013; 28: 15- 29.  Koretz RL, Avenell A, Lipman TO. Nutritional support for liver disease. Cochrane Review 2012; issue 5.  Plauth M, Cabre E, Riggio O, Assis-Camilo M, Pirlich M et al. ESPEN guidelines on enteral nutrition: liver disease. Clin. Nutr. 2006; 25: 285-294. 49
  • 50. 50