HCFN 430 Carine Souza. The liver performs many essential functions for life. These functions include metabolism, synthesis and storage of nutrients.

ALCOHOLIC LIVER

DISEASE

HCFN 430

Carine Souza

ABSTRACT The liver performs many essential functions for life. These functions

include metabolism, synthesis and storage of nutrients. The liver is essential in the metabolism of alcohol. Alcohol is produced through the fermentation of yeast, sugars and starches, and it can be divided in three main categories. Liver damage is a common consequence of chronic alcoholism. Alcoholism is a physical dependence characterized by the excessive intake of alcohol. Malnutrition is often observed among these population because alcohol interferes with nutrients digestion, absorption, storage, utilization and excretion. Acute or chronic alcohol abuse can lead to alcoholic liver disease. The etiology of the disease is related to genetic factors, toxicity of alcohol and personal susceptibility. The effects of alcoholic liver disease varies among individuals depending on the time and quantity of alcohol abuse. Alcoholic liver disease can progress in three stages: fatty liver, hepatitis and cirrhosis. Fatty liver is the most common alcoholic liver disease and it is marked by excessive accumulation of fat in the liver. Alcoholic hepatitis is characterized by inflammation of the liver cells that occur with the consumption of a large quantity of alcohol over a period of time. Alcoholic cirrhosis is the final stage of the disease; and it is characterized by the replacement of healthy tissue for scar tissue. Some of the symptoms of the alcoholic liver disease include accumulation of fluids in the abdomen, liver cancer, enlarged spleen, kidney failure, jaundice and high blood pressure in the liver. Physical recover may be possible with proper nutrition, alcohol abstinence and if adequate exercise is followed.

NORMAL PHYSIOLOGY OF THE LIVER (1)

The liver is the largest gland in the body The cells in the liver are called

hepatocytes Hepatocytes have different

concentration of glycolytic enzymes and enzymes involved in lipid metabolism

Two lobes (right and left) that are enclosed and divided in a common connective tissue

The portal vein an the hepatic artery carries blood that enter the liver

The average flow of blood through the liver is 1,400ml/min

Available at: http://www.clarian.org/ADAM/doc/graphics/images/en/8848.jpg. Accessed on February 13, 2010.

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FUNCTIONS OF THE LIVER (3)

Metabolism of nutrients (carbohydrates, lipid, protein, vitamins, minerals and alcohol)

Stores glucose as glycogen (glycogenesis) and break down glycogen to glucose (glycogenolysis)

Synthesize fatty acids Source of factors necessary for blood coagulation Source of albumin Control the concentration of many nutrients Prepare waste materials to be disposed in the urine Production of bile Vitamin A storage Stores Vitamin D, Vitamin E and a small amount of vitamin

K Stores iron, copper and influence the metabolism of sodium,

potassium, calcium, phosphorus and chloride. The liver is essential in the metabolism of ALCOHOL Detoxication (hormones, toxins, drugs)

ALCOHOL(4,5)

Alcohol can be divided into three categories: beer, wine and distilled liquor

Produced by the fermentation of yeast, starches and sugars

Rapidly absorbed from the stomach and small intestine into the bloodstream

Drink Amount (oz)

Absolute Alcohol (g)

Total Calories

Beer 12 12 144

Wine 5 12 105

Liquor 1.5 12 96

Available at: http://www.infoniac.com/uimg/alcohol-drinks.jpg. Accessed on February 13, 2010.

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ALCOHOL (CONT.) (7)

Chronic alcohol intake influence regulatory factors of appetite and inflammation, which may decrease the amount eaten

Alcohol damages the mucosa of the upper gastrointestinal tract

Alcohol interferes with the nutrition process by affecting digestion, absorption, storage, utilization and excretion of nutrients

It is recommended to drink alcohol in moderation, meaning no more than one drink a day for women and two drinks a day for men.

1g of alcohol provides 7.1kcal

ALCOHOLISM (7,8)

A physical dependence characterized by excessive consumption of alcohol accompanied by alcohol dependence and impaired control

Affects 9 to 11 million people in the United States

Cause acute effects (shortly after intake) or can cause effects with chronic abuse

Have social, economic and physiologic consequences including liver disease

Research suggests that certain genes can increase the risks for alcoholism

Available at: http://3.bp.blogspot.com/_LYoXnaQeh2k/SkrioLVCiFI/AAAAAAAAAaM/Iyay1rK5GYs/s320/alcoholism.jp. Accessed on February 13, 2010.

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ALCOHOLISM (10)

Alcoholics often eat poorly, consequently their supply of essential nutrients are limited which affect body energy supply and maintenance

Malnutrition is often observed in this population because of:

Gastrointestinal problemsReduced nutrient absorptionMetabolic changes Increased excretion of nutrients

EFFECTS OF ALCOHOL

Available at: http://www.nutritioncaremanual.org/content.cfm?ncm_content_id=79921. Accessed on February 13, 2010.

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Preventable disease caused after years of excessive consumption of alcohol

Most common liver disease in the US About 20 million people in the US have

some degree of alcoholic liver disease In 2006, it was reported 13,050 cases of

alcoholic liver disease deaths Alcoholic Liver Disease progress in three

stages:Fatty Liver (also called steatosis)Alcoholic HepatitisAlcoholic Cirrhosis

ALCOHOLIC LIVER DISEASE (ALD)(7)

ETIOLOGY OF ALD (10)

Genetic factors (predisposition for alcohol abuse)

Personal susceptibility to alcohol-induced liver disease (availability to alcohol, social acceptability of alcohol use)

Toxicity of alcohol to the liver

FATTY LIVER (10,12,13,14)

Most common alcoholic liver disease Affects 10 to 24% of the US population Occurs after acute alcohol ingestion Marked by the excessive accumulation of

fat inside the liver cells (mainly triglycerides)

In the presence of ethanol, long-chain fatty acids in diet have a greater tendency than medium-chain fatty acids to promote fatty liver

Reversible with alcohol abstinence

SYMPTOMS OF FATTY LIVER (13,14)

Enlargement of the liver

Abdominal discomfort

Available at: http://www.livers.org.nz/images/LIVER/Fatty_change.jpg. Accessed on February 13, 2010.

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ALCOHOLIC HEPATITIS (7)

Acute form of alcoholic liver disease that occur with the consumption of a large quantity of alcohol over a period of time

Characterized by inflammation and more severe injury of the liver

Destruction of hepatic cells and scarring

Available at: http://atlas.kennesaw.edu/~dmurphy3/imageSRI.JPG. Accessed on February 13, 2010.

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SYMPTOMS OF ALCOHOLIC HEPATITIS (7)

Fever Jaundice Increased white blood cells count Enlarged and tender liver Spider-like veins in the skin Accumulation of fluids in the abdominal

cavity

ALCOHOLIC CIRRHOSIS (16)

The 11th leading cause of death in the US Final stage of alcoholic liver disease Condition in which the liver slowly deteriorate in

consequence of chronic injury Alcoholic Cirrhosis destroys normal liver tissue

producing scar in the liver Scar tissue is formed because of injury or long-term

disease Scar tissue replaces healthy tissue but it cannot work

as properly as healthy tissues Scar tissue block the normal flow of blood through the

liver Scarring from cirrhosis is irreversible Can be life-treating but can also be controlled with

proper treatments About 5% of individuals with cirrhosis will also develop

liver cancer

SYMPTOMS OF CIRRHOSIS (16)

Weakness Fatigue Nausea Vomiting Ascites

Loss of appetite Weight loss Abdominal pain Itching

ALD PROGRESSION

Available at: http://protectyourliver.com/images/liver_damage.gif. Accessed on February 13, 2010. (17)

Available at: http://www.cwu.edu/~bergmane/images/Normal%20Liver,%20Fatty%20Liver,%20and%20Cirrhosis.GIF. Accessed on February 13, 2010.

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SYMPTOMS OF ALD (19)

Enlarged liver Liver cancer Accumulation of fluids in the abdomen Kidney failure Increased white blood cell count High blood pressure in the liver Spider-like veins in the skin Fever Jaundice (yellowing of the skin and eyes) Enlarged spleen Confusion Dry mouth Excessive thirst Development of insulin resistance Induced Wernicke-Korsakoff Induced Beri-beri disease

DIAGNOSING ALD (16)

Lifestyle and medical history related to alcohol

Blood test: INR, bilirubin, creatinine

X rays, magnetic resonance imaging and ultrasound images

Liver biopsy (most accurate)

Available at: http://digestive.niddk.nih.gov/ddiseases/pubs/cirrhosis. Accessed on February 13, 2010. (20)

NUTRITION DIAGNOSIS (12,19,21,22)

NI-1.4 Inadequate energy intake Empty calories from

alcohol reduce appetite and food intake

NI-5.2 Malnutrition Malnutrition and nutrient deficiencies are common among alcoholics because of the decreased dietary intake, malabsorption, alterations in metabolism of nutrients, decreased storage and increased losses of nutrients

NI-5.9.1 Inadequate vitamin intake Folic acid, thiamin and vitamin B6 deficit is common ALD patients because of their inability to absorb these vitamins from foods, which can lead to decreased serum folate and induced-beri beri

NI-5.7.1 Inadequate protein intake Protein energy malnourishment aggravates ALD

NC-1.4 Altered GI function Impaired oxidation of triglycerides

NUTRITION THERAPY (8,10,23)

Nutrition support is essential for improvement Malnourished alcoholics should be recommended

a high-calorie, well-balanced and nutritious diet, rich in complex carbohydrates, dietary fiber and protein

Calories: 35-40 kcal/kg body weight based on adequate weight rather than current weight

Protein, CHO and fat recommendations:Alcoholic Hepatitis

1.5-2 g protein/kg body weight High carbohydrate 30-35 g/kg body weight Moderate fat

Alcoholic Cirrhosis 1-2 g protein/kg body weight High carbohydrate 30-35 g/kg body weight Moderate fat

Personalized meal plan Eat 4 to 6 small meals a day instead of 3

large ones Adequate fluid intake Vitamin and mineral supplementation

(especially thiamin, folate and vitamin B6) When possible liquid supplements should

be administered orally or via enteral tube feedings

Strict abstinence from alcohol is necessary for the liver to recover

NUTRITION THERAPY (10,23)

NUTRITION THERAPY (CONT) (10)

Recommended Foods/Beverages

NOT Recommended Foods/Beverages

Fresh vegetables and fruits

Whole-wheat grains Lean meat Health snacks: nuts,

cheese, yogurt, whole-grain crackers, sunflower seeds

Drink 8 glasses of fluids each day

Avoid foods that are high in sodium, such as canned soups, canned vegetables, processed meats and cheeses, condiments, and snack foods

Avoid foods that can cause food borne illnesses such as unpasteurized or raw milk, raw or undercooked meat, raw or undercooked eggs , unwashed fresh fruits and vegetables, unpasteurized fruit and vegetable juices and cider and all raw vegetable sprouts

Foods prepared with alcohol Foods and beverages

containing caffeine Foods high in sugar

HIGH-CALORIE/HIGH-PROTEIN SAMPLE MENU (10,24)

Meal Menu

Breakfast ½ cup oatmeal with 1tsp of brown sugar1 cup of soymilk2 slices whole wheat toast with1tsp margarine and 1tsp of strawberry jam1 egg

Morning Snack 6 oz yogurt with 2 tbs granola

Lunch 1 cup low-sodium chicken noodle soup2 slices of whole wheat bread3oz of lean turkey1 tsp of mayonnaise4 baby carrots1 banana1 cup of soymilk

Afternoon Snack 1 cup of liquid high-calorie supplement (such as Boost or Ensure)5 whole wheat, no-salt-added crackers

Dinner 4 oz pork tenderloin1 small baked sweet potato with 2 teaspoons margarine½ cup stir-fried broccoli, pea pods, onion, andmushrooms½ cup mixed fresh fruit

Evening Snack 2 cookies

Available at: http://www.womenfitness.net/wfimgank7/balance_diet.jpg. Accessed on February 13, 2010.

OTHER TREATMENTS (25)

Medications Liver transplant (most alcoholics do not

qualify for transplant) Social support Psychotherapy Exercise

Available at: http://www.providence.org/resources/everett/GroupTherapy.jpg Accessed on February 13, 2010.

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LABORATORY TESTS AND ALD (10)

Liver function tests Prothrombin Test Bilirubin Test Hepatitis markers Blood counts Protein levels Vitamin and mineral levels

LABORATORY VALUES (10)

Hemogram Hemoglobin Hematocrit Platelet count

Liver Enzymes Gamma glutamyl

transferase, gamma glutamyl transpeptidase (GGT)

Serum glutamyic-oxaloacetic transaminase (SGOT), serum glutamic pyruvic transaminase (SGPT)

Toxicology Blood alcohol content

Blood Chemistry Glucose Blood urea

nitrogen (BUN) Creatinine Albumin Total protein Serum folate Triglycerides

Urinalysis Bilirubin Ketones

MEDICATIONS (12)

There is not enough evidence to support the effectiveness of medications in the treatment of ALD

Patients with cirrhosis are more sensitive to medications

Some examples of medications used are: Pentoxifylline Corticosteroid (alcoholic hepatitis) Diuretic edema Oral antibiotics prevent infections Beta-blocker or nitrate portal hypertension

DRUG-NUTRIENT INTERACTION (27)Medication Nutritional Interaction/Monitoring

Recommendation

Pentoxifylline

•No caffeine•Take with food•Fluid needs may increase•Weight and appetite may decrease

Corticosteroid

•Should be consumed with food or milk to decrease GI distress•Sodium intake should decrease•Adequate potassium, protein, Ca, Phos, Zn, Fol, Vits A,B6,C,D should be consumed

Diuretic•Take on an empty stomach or with milk •Some diuretics cause loss of potassium, calcium and magnesium•Monitor glucose levels, weight, blood pressure

Beta-blocker or nitrate

•Take with food•Alcohol should be avoided

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Alcohol and your liver