Dietetics II

Liver

Structure
 The liver is the largest gland in the body, weighing approximately 1500 g.
 The liver has two main lobes: the right and left
 The liver is supplied with blood from two sources:
 the hepatic artery, which supplies approximately one third of the blood from the aorta
 and the portal vein, which supplies the other two thirds and collects blood drained from
the digestive tract.
 Approximately 1500 mL of blood per minute circulates through the liver and exits via the
right and left hepatic veins into the inferior vena cava.
 The liver has a system of blood vessels and a series of bile ducts.
 The blood vessels divide into small capillaries, with each ending in a
lobule.
 Lobules are the functional units of the liver and consist of millions of
cells called hepatocytes.
 Blood is removed from the liver through three hepatic veins
 Bile, which is formed in the liver cells, exits the liver through a series of
bile ducts that increase in size as they approach the common bile duct.
Liver Functions:

 Metabolism – Carbohydrate, Fat & Protein

 Secretory – bile, Bile acids, salts & pigments
 Excretory – Bilirubin, drugs, toxins
 Synthesis – Albumin, coagulation factors
 Storage – Vitamins, carbohydrates, fat etc.
 Detoxification – toxins, ammonia, etc.
 Laboratory Assessment of Liver Function

Screening tests for hepatobiliary disease include

 serum levels of bilirubin
 alkaline phosphatase ALT
 aspartate amino transferase AST
 alanine aminotransferase
 DISEASES OF THE LIVER

Jaundice

 yellow discoloration of the skin, mucous membranes, sclera and body tissues because of
accumulation of bile pigments, in the blood
 It results due to an increase in bilirubin content Of the blood above the normal range (0.2 to 0.8
mg/ 100 dl plasma).
 If the liver is infected or diseased or the flow of bile is obstructed or if excess bile is produced
then it gets accumulated in the blood and eventually causes jaundice.
Hemolytic Jaundice: pre hepatic jaundice
 This relates to excessive destruction of RBC resulting in an increased bilirubin formation and anemia.
 There is an increased unconjugated plasma bilirubin, which is excreted through the urine (pigment known as
urobilinogen).
 A healthy liver can handle a bilirubin load 6 times greater than normal before unconjugated bilirubin
accumulates in plasma.
 Thus, this kind of jaundice is seen normally in individuals with congenital defects like sickle cell anemia,
thalassemia, blood transfusion reactions and septicemia
Hepatic Jaundice:
 In this, there is a normal bilirubin production.
 The liver cannot convert fat soluble bilirubin to the water soluble form. Hence, there is a
decreased conjugation leading to hepatocyte damage
 An excessive amount of bilirubin is seen as a mixture of unconjugated and conjugated
bilirubin
 Failure of about 80% or more of hepatic functions is observed.
 Clinical features include liver disease, increased unconjugated plasma bilirubin and
increased alanine aminotransferase (ALT)/ aspartate transaminase (AST) enzymes.
Obstructive Jaundice: post-hepatic jaundice.
 This results from the interference of normal flow of bile into the duodenum due to stones,
tumors or inflammation of mucosa of the duct.
 This results in a backflow of bile into the blood stream and is circulated in the body
giving a yellow color
Viral Hepatitis

 Hepatitis is a condition of inflammation of liver which can result in damage of the liver
cells.
 A virus causes viral hepatitis, as liver cells are particularly susceptible to such infections.
 It causes damage to the liver cells and interferes with the uptake of bilirubin by the cells,
and its conjugation and excretion.
 It can be either in form of an acute or chronic condition and is caused due to different
strains of viruses such as A, B, C, D and E.
Hepatitis A
 It is commonly called infectious hepatitis caused by a known virus Hepatitis A (HAV).
 It is common among children and young adults.
 It is transmitted through contaminated water, food and sewage and fecal-oral route
Hepatitis B and C :
 It is caused by a virus hepatitis B (HBV) and hepatitis C (HCV).
 It is more severe and prolonged in nature, and can be fatal.
 It is transmitted by blood transfusion from a carrier, improperly sterilized medical instruments, dental drills, skin
puncturing instruments that corne in contact with contaminated blood, and saliva of an infected person.
 Chronic active hepatitis can develop leading to cirrhosis and liver failure.
Hepatitis D :
 Hepatitis D virus (HDV) is dependent on the HBV for survival and propagation in
humans.
Hepatitis E :
 Hepatitis E virus is transmitted via oral fecal route. Contaminated water is the major
factor.
symptoms of hepatitis

 itchy skin
 fatigue and fever
 lack of appetite
 nausea and vomiting
 weight loss
 jaundice
 enlarged liver and spleen
 mood swings
 pain in joints of the body (osteomalacia and osteoporosis)
 autoimmune problems associated with high risk of cancer
Nonalcoholic steatohepatitis

 Nonalcoholic steatohepatitis (NASH) is associated with hepatocyte injury with or

without fibrous tissue in the liver.
 Inflammation of liver occur
 NASH can develop into chronic liver disease and NASH cirrhosis
 The progression to cirrhosis is variable depending on age and the presence of obesity and
type 2 diabetes, which contribute to a worsening prognosis
 The treatment recommendations for NAFLD from the American Association for the
Study of Liver Diseases (AASLD) include:
 weight loss
 insulin-sensitizing drugs such as thiazolidinediones
 Vitamin E (800 IU/ day of alpha-tocopherol) is considered first-line treatment for NASH
in patients without diabetes
Alcoholic Liver Disease

 Acetaldehyde is a toxic byproduct of alcohol metabolism that causes damage to

mitochondrial membrane structure and function.
 Acetaldehyde is produced by multiple metabolic pathways, one of which involves
alcohol dehydrogenase
The pathogenesis of alcoholic liver disease progresses in three stages:
 hepatic steatosis
 alcoholic hepatitis,
 cirrhosis
Fatty infiltration, known as hepatic steatosis or fatty liver, is caused by these metabolic
disturbances:
 an increase in the mobilization of fatty acids from adipose tissue
 an increase in hepatic synthesis of fatty acids
 a decrease in fatty acid oxidation
 an increase in triglyceride production
 a trapping of triglycerides in the liver
 Hepatic steatosis is reversible with abstinence from alcohol.
 Conversely, if alcohol abuse continues, cirrhosis can develop
Fatty liver
 Often causes no symptoms
 Build-up of fat inside the liver cells enlarges the liver, causing upper abdominal (belly) discomfort on the right side
 Tiredness and weakness
 Weight loss
Alcoholic hepatitis is characterized by
 Hepatomegaly
 Modest elevation of serum transaminase levels
 Increased serum bilirubin concentrations,
 Normal or depressed serum albumin concentrations,
 Anemia
Alcoholic hepatitis (symptoms)
 Pain over the liver
 Fever
 Weakness
 Nausea and vomiting
 Appetite loss
 Yellowing of the skin and eyes (jaundice)
If patients discontinue alcohol intake, hepatitis may resolve; however, the condition often progresses to the third
stage
Liver Cirrhosis

 Cirrhosis is a complication of many liver diseases that is characterized by abnormal

structure and function of the liver
 It is the final stage of liver injury and degeneration
 neglected chronic hepatitis can progress to liver cirrhosis
 In this the liver cells get inflamed
 fibrous septa get develop and the liver cells die and finally nodules develop which lead to
obstructions and liver failure
 The active liver tissue is replaced by inactive tissue incapable of normal functioning.
 Cells get filled with fibrous tissue and fat.
 Cirrhosis develops when the repair that is associated with the dying liver cells causes scar
tissue to form.
 The liver cells that do not die multiply in an attempt to replace the cells that have died.
This results in clusters of newly formed liver cells (regenerative nodules) within the scar
tissue.
Symptoms

 GI disturbances (anorexia, nausea, vomiting, abdominal pain and

 distension)
 Electrolyte and fluid imbalance
 Weight loss and muscle wasting
 Abnormal serum amino acid levels
 Fatty infiltration of the liver
 Severe jaundice
 Hepatic encephalopathy (mental problems ranging from mild confusion to coma)
 Bleeding tendency
 Ascites (accumulation of fluid in the abdominal cavity)
 Osteomalacia and osteoporosis
 High drug sensitivity
 Chronic inflammation of the liver
 Necrosis (death of cells
 Etiology

The etiology of cirrhosis can be enumerated as under:

 Neglected acute/chronic hepatitis
 Alcoholism associated with malnutrition
 Virus and toxins
 Metabolic disorders
 Prolonged biliary stasis.
 Altered immune response
Complications
 Ascites (accumulation of water in abdomen)
 Upper gastrointestinal bleeding (esophageal varices)
 Hepatic coma or Hepatic Encephalopathy
Ascites:
It is a characteristic symptom of advanced stage of liver cirrhosis.
 It relates to the accumulation of massive quantities of fluid in the peritoneal cavity of the abdomen
This may be due to:
 Portal hypertension (obstruction of portal blood vessels that increase intra hepatic pressure)
 Hypoalbuminemia (a fall in colloidal osmotic pressure due to inadequacy of serum albumin
 Renal dysfunction (increased renal tubular sodium resorption; and water retention).
Esophageal varices:
 It relates to a state of varicose (distended or dilated) veins in the esophagus and upper part of the stomach, which
develops as a consequence of portal hypertension.
 Upper GI tract bleeding may be the risk associated with this state
Hepatic Coma:
 It relates to a state Of confusion, apathy, tremor of the hands
Hepatic Encephalopathy (HE)

 Hepatic encephalopathy is brain and nervous system damage that occurs as a

complication of liver disorders that reduce liver functioning (as in hepatitis or cirrhosis).
 It is a complex syndrome characterized by neurological disturbances
There are four clinical stages of hepatic encephalopathy.
Stage I — Mild confusion, depression, decreased attention,
agitation, irritability, sleep disturbance, slowing of ability to perform
mental tasks.
Stage II — Lethargy, disorientation, inappropriate behavior, irritability
in performing mental tasks.
Stage III —incomprehensible speech ,confused aggressive behaviour when awake.
Stage IV — Coma.
Etiology

cause of encephalopathy is unknown, but there are three proposed mechanisms leading to it.
These include:
 Accumulation of increased toxins due to impaired liver functions.
 Excess ammonia being the major toxin.
 Altered plasma amino acid composition.
 Decreased ratio of BCAA (leucine, isoleucine, and valine) to AAA, which leads to false
neurotransmitter impulses in the brain and hence neurological symptoms.
 increased gamma-amino butyric acid (GABA) level( neurotransmitter that blocks
impulses between nerve cells in the brain)
Dietary regime tips for successful liver cleanse
and good liver health

 Drink plenty of water to flush out the toxins from the liver.
 Eat high fibber diet which acts as a cleaner for the digestive system and enable the
feeling of fullness. A low fat diet with plenty of olive oil will help heal the fatty liver.
 Add plenty of fruit, vegetables, nuts, and seeds. Add lean animal protein like chicken
and fish.
 Proper prescribed exercises enhance the metabolism which can improve insulin
resistance and reduce fatty liver.
 Herbs like Milk Thistle (Silymarin)a powerful antioxidant will help the liver to repair
and heal.
 Have fresh fruit such as a banana or grapefruit ,Citrus fruits are the healthiest for the liver.
 Grapefruit is rich in vitamin C and antioxidants, both of which promote healthy liver
cleanse. It boosts detoxification enzymes in the liver and has flavonoid compound known as
naringenin which causes the liver to burn fat rather than store it.
 Eat apples, apple juice and or apple cider vinegar since apples contain malic acid an active
ingredient that can breakdown and dissolve liver stones and gallstones.
 Healthy fats are found in olive oil, oily fish, coconut oil, flaxseeds, hemp seeds, chia seeds
and raw nuts and seeds.
 Raw vegetable juices should be consumed 2 to 3 times a week and 250 mL to 300 mL (8 to
10 ounces) is adequate
 Green tea is rich in catechins, a type of plant antioxidant that boosts liver function and
helps reduce fat storage in the liver.
 Walnuts have high levels of l-argentine (an amino acid) glutathione, and omega-3 fatty
acids which help to cleanse the liver of disease causing ammonia.
 Garlic has sulphur-containing compounds that activate liver enzymes that work to flush
out any toxins that might be in the system. Allicin and selenium, two nutrients in the
garlic protect the liver from damages caused by toxins. And also aid in the detoxification
process.
 turmeric to the diet boosts the liver’s ability to produce bile, a key part of the liver-
cleansing process. It has also been known to help regenerate damaged liver cells.
 Magnesium promotes bile production, which in turn promotes the cleansing of the liver
 Magnesium supplements increase liver health.
 Another way to get magnesium is by dissolving a tablespoon of Epsom salt in warm water
and drinking this mixture once or twice a month. Epsom salt contains a high amount of
magnesium.
Foods to be avoided or reduced:

 Limit the amount of salt in the diet as it causes to hold liquids leading to swelling in the
body so that totally
 high sodium containing foods like, bacon, sausage, and deli meats, Packaged snack foods
like potato chips ,soups, canned vegetables and vegetable juice, frozen dinners, and table
salt.
 If there is any swelling in the body, liquid taking to be reduced to the possible extent
 Keep away from all deep fried foods, sugar, alcohol junk food, foods with preservatives,
hormones, muffins, cookies, donuts, artificial flavours, smoking, coffee, etc.
 A high intake of carbohydrate rich foods more than body’s requirement can support fatty
liver, as the liver converts any excess amount of carbohydrate into fat