1. Liver, Biliary & Pancreas Problems

2. Introduction Liver is the largest organ of the body. Liver is the largest organ of the body. It’s a multifunctional organ plays important role in CHO, fat & protein metabolism. It’s a multifunctional organ plays important role in CHO, fat & protein metabolism.

4. Functions of liver 1. Protein metabolism 2. Carbohydrate metabolism 3. Lipid metabolism 4. Mineral & vitamin metabolism 5. Immunological functions 6. Detoxification

5. Common Etiology 1. Dietary deficiencies: Protein deficiencies as in PEM High fat intake Diabetes, obesity 2. Infective agents: Viruses like type A, B, C, D, E cause hepatitis 3. Toxic agents: Alcohol Drugs and chemicals

6. Pathological changes in the liver Atrophy: Degeneration of hepatic cells Atrophy: Degeneration of hepatic cells Fatty infiltration: Deposition of fat droplets in hepatic cells. Reversible but if severe or long lasting may be followed by necrosis or fibrosis. Fatty infiltration: Deposition of fat droplets in hepatic cells. Reversible but if severe or long lasting may be followed by necrosis or fibrosis. Fibrosis: functional hepatic cells are replaced by connective tissue cells. Fibrosis: functional hepatic cells are replaced by connective tissue cells. Necrosis: Death of hepatic cells Necrosis: Death of hepatic cells

7. Jaundice A common symptom of all liver disease A common symptom of all liver disease Is a result of increased bilirubin level in blood.( it is a breakdown product of RBC) Is a result of increased bilirubin level in blood.( it is a breakdown product of RBC)Symptoms: Yellow coloration of skin, conjunctiva & body tissues Yellow coloration of skin, conjunctiva & body tissues

10. Types of jaundice 1. Hepatocellular jaundice: damage to hepatic cells interfering with uptake of bilirubin. 2. Prehepatic (hemolytic) jaundice: icreased bilirubin level in blood as a result of excessive destruction of RBC. Common in inborn, neonatal jaundice Common in inborn, neonatal jaundice Congenital defects like sickle cell anemia, thalessaemia Congenital defects like sickle cell anemia, thalessaemia

11. Types of jaundice 3. Post hepatic (obstructive) jaundice: obstruction of bile flow between liver & duodenum patients suffering from gallstones or cancer of liver or pancreas patients suffering from gallstones or cancer of liver or pancreas

12. Other symptoms of liver disease Lassitude Lassitude Weakness Weakness Fatigue Fatigue Fever Fever Anorexia Anorexia Weight loss Weight loss Abdominal pain Abdominal pain Flatulence Flatulence Nausea Nausea Vomiting Vomiting Hepatomegaly Hepatomegaly Edema Edema Ascites Ascites

13. Hepatitis Inflammation & degeneration of liver cells. Inflammation & degeneration of liver cells.Types: 1. Viral / infectious hepatitis 2. Drug induced

14. Viral Hepatitis Also known as infectious hepatitis. Also known as infectious hepatitis. Inflammation & degeneration of liver cells. Inflammation & degeneration of liver cells. More common, occur as infectious or serum hepatitis. More common, occur as infectious or serum hepatitis.Types: Infectious / type A: virus transmitted through fecal contamination of food & water. Serum hepatitis / Type B: transmitted only by parental routes through blood contaminated with virus or poor sterilized needles.

15. Hepatitis A Fecal-oral route, outbreaks caused by fecal contaminated food or drinking water. Fecal-oral route, outbreaks caused by fecal contaminated food or drinking water. Crowded conditions, poor sanitation & hygiene, undeveloped countries, shellfish from contaminated water Crowded conditions, poor sanitation & hygiene, undeveloped countries, shellfish from contaminated water Most infectious 2 wks before s/s & 1wk after s/s start. Most infectious 2 wks before s/s & 1wk after s/s start.

16. Hepatitis B Percutaneous, permucosal, or perinatal exposure, sexually transmitted disease. Percutaneous, permucosal, or perinatal exposure, sexually transmitted disease. 100X more infectious than HIV 100X more infectious than HIV Carrier state - antigen HBsAg for 6-12 mo. Carrier state - antigen HBsAg for 6-12 mo. Immunity – antigen anti-HBs-Ag Immunity – antigen anti-HBs-Ag

17. Hepatitis C Transmission- pericutaneous Transmission- pericutaneous At risk: IV drugs, bld transfusion, hemodialysis, tattooing, hi risk sexual behavior, organ transplants, health care workers At risk: IV drugs, bld transfusion, hemodialysis, tattooing, hi risk sexual behavior, organ transplants, health care workers

18. Hepatitis D Delta virus Delta virus Transmission - percutaneous Transmission - percutaneous Can turn mild or chronic hepB into severe, chronic, progressive, active hepatitis & cirrhosis Can turn mild or chronic hepB into severe, chronic, progressive, active hepatitis & cirrhosis

19. Hepatitis E Transmission – fecal-oral route, esp contaminated drinking water. Transmission – fecal-oral route, esp contaminated drinking water. Occurs in developing countries, epidemics in India, Asia, Mexico, Africa. In US rarely, only after a person traveled. Occurs in developing countries, epidemics in India, Asia, Mexico, Africa. In US rarely, only after a person traveled.

20. Hepatitis G Recently discovered. Recently discovered. Found in blood donors & transmitted by transfusion. Found in blood donors & transmitted by transfusion. Not associated with chronic hepatitis or cirrhosis. Not associated with chronic hepatitis or cirrhosis.

21. Symptoms of hepatitis Initially non specific symptoms Initially non specific symptoms Anorexia Anorexia Fatigue Fatigue Nausea Nausea Vomiting Vomiting Diarrhea Diarrhea Fever Fever Weight loss Weight loss Abdominal discomfort Abdominal discomfort Usually precede by jaundice Usually precede by jaundice

22. Dietary modification Aim: regeneration of liver tissue & prevent further damage. High protein, high CHO & moderate fat diet. Calorie: Initially 1600-2000kcal, gradually increase to 20-30% but as patient is at bed rest normal requirement will meet extra need. Protein: in mild & moderate hepatitis 1.5 -2gm /kg body weight. Fats: makes food more palatable & increase calorie intake. In severe cases 20gm & in moderate 20-30gm. More emulsified fats.

23. Carbohydrate: high carbohydrate diet, 300-400gm in form of simple carbs like glucose, fruits, fruit juices, starches Vitamins & minerals: diet should provide all vitamin & mineral in adequate amounts. More Vit C for tissue healing Avoid: Fried & fatty foods Nuts & oilseeds Strongly flavored vegetables Alcohol

24. Cirrhosis of the Liver Characterized by diffuse degenerative changes, fibrosis & nodular regeneration of remaining liver cells. Irreversible disease Causes: Infectious hepatitis in some Infectious hepatitis in some Chronic alcoholism with malnutrition Chronic alcoholism with malnutrition Metabolic disturbances like wilson’s disease, Metabolic disturbances like wilson’s disease,Hemochromatosis Toxins like hepatotoxins from plants, fungi Toxins like hepatotoxins from plants, fungi

26. Symptoms Onset may be gradual with GIT disturbances such as anorexia, nausea, vomiting, pain. Onset may be gradual with GIT disturbances such as anorexia, nausea, vomiting, pain. As disease progress, jaundice As disease progress, jaundice Ascites, accumulation of abnormal amount of fluid in abdomen. Ascites, accumulation of abnormal amount of fluid in abdomen. Esophageal varices (varicose vein), varices in the esophagus & upper part of stomach Esophageal varices (varicose vein), varices in the esophagus & upper part of stomach Hemorrhage, itself may be fatal or Hemorrhage, itself may be fatal or Blood may provide accumulation of ammonia & subsequent hepatic coma. Blood may provide accumulation of ammonia & subsequent hepatic coma.

28. Dietary modification High protein, high CHO diet, moderate or restricted fat, which help in regeneration of liver & help to prevent ascites. Energy: require high calorie diet because of prolong under nutrition, 2000-2500kcal Energy: require high calorie diet because of prolong under nutrition, 2000-2500kcal Protein: in absence of hepatic coma 1.2gm/kg of BW can be given. Protein diet varies with the symptoms. If patient is in precoma or coma, protein should be stopped. Protein: in absence of hepatic coma 1.2gm/kg of BW can be given. Protein diet varies with the symptoms. If patient is in precoma or coma, protein should be stopped. Fats: about 20gm is given. Fats: about 20gm is given.

29. CHO: should be supplied liberally so that liver can store glycogen.60% calorie should come from CHO CHO: should be supplied liberally so that liver can store glycogen.60% calorie should come from CHO Vitamins & minerals: liver is the major site for storage & conversion of vitamins into their metabolic active form. In cirrhosis, all these functions are impaired. Supplementation is required. Vitamins & minerals: liver is the major site for storage & conversion of vitamins into their metabolic active form. In cirrhosis, all these functions are impaired. Supplementation is required. Sodium is restricted if edema or ascites present. Sodium is restricted if edema or ascites present. Iron supplementaion Iron supplementaion

30. Hepatic coma Complex syndrome ch. by neurological disturbances develop as a complication of severe liver disease. Complex syndrome ch. by neurological disturbances develop as a complication of severe liver disease. Entrance of ammonia in cerebral circulation without being metabolized by liver. Entrance of ammonia in cerebral circulation without being metabolized by liver.

31. Symptoms Precoma Confusion Confusion Restlessness Restlessness Irritability Irritability Inappropriate behavior Inappropriate behavior Drowsiness Drowsiness When extended: incordination & tremors When extended: incordination & tremors Electrolyte imbalance Electrolyte imbalance Patient may go in coma Patient may go in coma Breath has fecal odor Breath has fecal odor

32. Diet treatment Reduce protein intake thus decrease the amount of ammonia produced Calories: about 1500-2000kcal to prevent breakdown of tissue protein for energy & given chiefly in form of CHO & fats. Calories: about 1500-2000kcal to prevent breakdown of tissue protein for energy & given chiefly in form of CHO & fats. Protein: some omit completely for 2-3 days & some allow 20-30 gm. As patient improves gradually it is increased to 1gm/kg BW under observation. 40-50gm protein can be given for long period of time. Protein: some omit completely for 2-3 days & some allow 20-30 gm. As patient improves gradually it is increased to 1gm/kg BW under observation. 40-50gm protein can be given for long period of time.

33. Disease of gall bladder Inflammation of gall bladder is known as cholecystitis. Inflammation of gall bladder is known as cholecystitis. Gall stone formation is known as cholelithiasis occurs when cholesterol, bile pigments, bile salts, calcium & other substances precipitate out of the bile. Gall stone formation is known as cholelithiasis occurs when cholesterol, bile pigments, bile salts, calcium & other substances precipitate out of the bile. Stones lodged in common duct is known as choledocholithiasis Stones lodged in common duct is known as choledocholithiasis

34. Symptoms Mere presence of stone does not produce symptoms Mere presence of stone does not produce symptoms Inflammation & obstruction of duct by stone may cause severe pain whenever gall bladder contracts Inflammation & obstruction of duct by stone may cause severe pain whenever gall bladder contracts Impaired fat digestion Impaired fat digestion Removal of gall bladder is known as cholecystectomy. Removal of gall bladder is known as cholecystectomy.

36. Risk factors Obesity Obesity Diabetes Diabetes Women over 60 Women over 60 Cholesterol lowering drugs Cholesterol lowering drugs

37. Dietary treatment If the patient is obese then weight loss is advisable. If the patient is obese then weight loss is advisable. Fat is main cause of contraction of organ so it must be reduced to 20gm/day. Fat is main cause of contraction of organ so it must be reduced to 20gm/day. Energy should be taken mainly from CHO. Energy should be taken mainly from CHO. Foods included: cereals in soft form, milk, curd, cooked & pureed vegetables, pulses, tender meat, fruits, soft cooked eggs etc Foods included: cereals in soft form, milk, curd, cooked & pureed vegetables, pulses, tender meat, fruits, soft cooked eggs etc

38. Pancreatic disorder Acute pancreatitis: acute inflammatory disease of pancreas Result from interference with blood supply to the organ or obstruction in flow of pancreatic juice. Causes: 1. Alcoholism 2. Biliary tract disorder 3. Or due to trauma, virus infection, tumors, metabolic disorder

39. Symptoms: Severe upper abdominal pain radiating to back Severe upper abdominal pain radiating to back Increased after eating Increased after eating Constipation Constipation Nausea Nausea Vomiting Vomiting Distention Distention

41. Treatment Aim is to keep pancreatic activity at minimum & replace fluid and electrolytes Aim is to keep pancreatic activity at minimum & replace fluid and electrolytes Nothing by mouth during acute attacks Nothing by mouth during acute attacks Progression from clear liquid to soft diet afterwards. Progression from clear liquid to soft diet afterwards.

42. Chronic pancreatitis Recurrent attack of burning epigastric pain especially after meals containing alcohol and fat Recurrent attack of burning epigastric pain especially after meals containing alcohol and fat Other symptoms: 1. Flatulence 2. Anorexia 3. Weight loss 4. Nausea 5. Vomiting

43. 6. Chronic changes lead to destruction of pancreas, fibrosis, pancreatic calcification 7. Steatorrhea

44. Dietary treatment Diet during attack is same as acute pancreatitis After that a soft diet, high in protein and calorie and low in fat should be given Supplement pancreatic enzymes & fat soluble vitamins Six small meals are better tolerated than large ones.