Disorders of the Accessory Organs

DISORDERS OF THE ACCESSORY ORGANS

Cirrhosis

The liver is of major importance to, and plays many roles in, metabolism. Except for a few of the fatty acids, all nutrients that are absorbed in the intes-tines are transported to the liver. The liver dismantles some of these nutrients, stores others, and uses some to synthesize other substances.

The liver determines where amino acids are needed and synthesizes some proteins, enzymes, and urea. It changes the simple sugars to glycogen, provides glucose to body cells, and synthesizes glucose from amino acids if needed. It converts fats to lipoproteins and synthesizes cholesterol. It stores iron, copper, zinc, and magnesium as well as the fat-soluble vitamins and B vitamins. The liver synthesizes bile and stores it in the gallbladder. It detoxifies many substances such as barbiturates and morphine.

Liver disease may be acute or chronic. Early treatment can usually lead to recovery. Cirrhosis is a general term referring to all types of liverdisease characterized by cell loss. Alcohol abuse is the most common cause of cirrhosis, but it can also be caused by congenital defects, infections, or other toxic chemicals.

Although the liver does regenerate, the replacement during cirrhosis does not match the loss. In addition to the cell loss during cirrhosis, there is fatty infiltration and fibrosis. These developments prevent the liver from functioning normally. Blood flow through the liver is upset, and a form of hypertension, anemia, and hemorrhage in the esophagus can occur. The normal metabolic processes will also be disturbed to such a degree that, in severe cases, death may result.

The dietary treatment of cirrhosis provides at least 25 to 35 calories or more and 0.8 to 1.0 gram of protein per kilogram of weight each day, depending on the client’s condition. If hepatic coma appears imminent, the lower amount is advocated. Supplements of vitamins and minerals are usually needed. In advanced cirrhosis, 50% to 60% of the calories should be from carbohydrates.

In some forms of cirrhosis, clients cannot tolerate fat well, so it is restricted. In another form, protein may not be well tolerated, so it is restricted to 35 to 40 grams a day. Sometimes cirrhosis causes ascites. In such a case, sodium and fluids may be restricted. If there is bleeding in the esophagus, fiber can be restricted to prevent irritation of the tissue. Smaller feedings will be better accepted than larger ones. No alcohol is allowed.

Hepatitis

Hepatitis is an inflammation of the liver. It is caused by viruses or toxic agentssuch as drugs and alcohol. Necrosis occurs, and the liver’s normal metabolic activities are constricted. Hepatitis may be acute or chronic.

Hepatitis A virus (HAV) is contracted through contaminated drinking water, food, and sewage via a fecal-oral route. Hepatitis B virus (HBV) and hepatitis C virus (HCV) are transmitted through blood, blood products, semen, and saliva. Hepatitis B and C can lead to chronic active hepatitis (CAH), which is diagnosed by liver biopsy. Chronic active hepatitis can lead to liver failure and end-stage liver disease (ESLD).

In mild cases, the cells can be replaced. In severe cases, the damage can be so extensive that the necrosis leads to liver failure and death. There can be bile stasis and decreased blood albumin levels. Clients experience nausea, headache, fever, fatigue, tender and enlarged liver, anorexia, and jaundice. Weight loss can be pronounced.

Treatment is usually bed rest, plenty of fluids, and medical nutrition therapy. The diet should provide 35 to 40 calories per kilogram of body weight. Most of the calories should be provided by carbohydrates; there should be moderate amounts of fat and, if the necrosis has not been severe, up to 70 to 80 grams of protein for cell regeneration. If the necrosis has been severe and the proteins cannot be properly metabolized, they must be limited to prevent the accumulation of ammonia in the blood. Clients may prefer frequent, small meals rather than three large ones.

Clients with liver disease require a great deal of encouragement because their anorexia and consequent feelings of general malaise can be severe. Their recovery takes patience, rest, and time.

Cholecystitis and Cholelithiasis

The dual function of the gallbladder is the concentration and storage of bile. After bile is formed in the liver, the gallbladder concentrates it to several times its original strength and stores it until needed. Fat in the duodenum triggers the gallbladder to contract and release bile into the common duct for the digestion of fat in the small intestine. If this flow is hindered, there may be pain.

The precise etiology of gallbladder disease is unknown, but heredity factors may be involved. Women develop gallbladder disease more often than men do. Obesity, total parenteral nutrition (TPN), very low calorie diets for rapid weight loss, the use of estrogen, and various diseases of the small intestine are frequently associated with gallbladder disease.

Cholecystitis (inflammation) and cholelithiasis (gallstones) mayinhibit the flow of bile and cause pain. Cholecystitis can cause changes in the gallbladder tissue, which in turn can affect the cholesterol (a constituent of bile), causing it to harden and form stones. It is also thought that chronic over-indulgence in fats may contribute to gallstones because the fat stimulates the liver to produce more cholesterol for the bile, which is necessary for the diges-tion of fat. In addition to pain, which can be severe, there may be indigestion and vomiting, particularly after the ingestion of fatty foods.

Treatment may include medication to dissolve the stones and diet therapy. If medication does not succeed, surgery to remove the gallbladder (cholecys-tectomy) may be indicated.

Medical nutrition therapy includes abstinence during the acute phase. This is followed by a clear liquid diet and, gradually, a regular but fat-restricted diet. Amounts of fats allowed run from 40 to 45 grams a day. In chronic cases, fat may be restricted on a permanent basis. For obese clients, weight loss is recommended in addition to a fat-restricted diet. Clients with chronic gallbladder conditions may require the water-miscible forms of fat-soluble vitamins.

Pancreatitis

In addition to the hormone insulin, the pancreas produces other hormones and enzymes that are important in the digestion of protein, fats, and carbohydrates. When food reaches the duodenum, the pancreas sends its enzymes to the small intestine to aid in digestion.

Pancreatitis is an inflammation of the pancreas. It may be causedby infections, surgery, alcoholism, biliary tract (includes bile ducts and gall-bladder) disease, or certain drugs. It may be acute or chronic.

Abdominal pain, nausea, and steatorrhea are symptoms. Malabsorp-tion (particularly of fat-soluble vitamins) and weight loss occur, and, in cases in which the islets of Langerhans are destroyed, diabetes mellitus may result.

Diet therapy is intended to reduce pancreatic secretions and bile. Just as fat stimulates the gallbladder to secrete bile, protein and hydrochloric acid stim-ulate the pancreas to secrete its juices and enzymes. During acute pancreatitis, the client is nourished strictly parenterally. Later, when the client can tolerate oral feedings, a liquid diet consisting mainly of carbohydrates is given because, of these three nutrients, carbohydrates have the least stimulatory effect on pancreatic secretions.

As recovery progresses, small, frequent feedings of carbohydrates and protein with little fat or fiber are given. The fat is restricted because of deficiencies of pancreatic lipase. The client is gradually returned to a less restricted diet as tolerated. Vitamin supplements may be given. Alcohol is forbidden in all cases.