Liver Cirrhosis

Liver cirrhosis is the final stage of liver injury and degeneration. It involves inflammation and death of liver cells and is characterized by abnormal structure and function of the liver. Active tissues of the liver are replaced by inactive tissues and are filled by fibrous tissue and fat and nodules are formed leading to obstruction and liver failure.

Various causes of this condition, such as, Neglected acute/chronic hepatitis, alcoholism associated with malnutrition, virus and toxins, metabolic disorders and altered immune response.

The symptoms of liver cirrhosis are GI disturbances like anorexia, nausea, vomiting, abdominal pain and distension; electrolyte and fluid imbalance; weight loss and muscle wasting; fatty infiltration of the liver; severe jaundice; bleeding tendency; ascitis; osteoporosis; high drug sensitivity; chronic inflammation of the liver; fibrosis and fatty infiltration of the liver; and necrosis (death of cells).

Liver cirrhosis progresses in stages – the first stage being fatty liver or hepatic steatosis in which there is fat infiltration in the liver cells which affects normal functioning of the liver. This stage is reversible by just abstinence from alcohol abuse. The second stage is Alcoholic Hepatitis in which the liver is enlarged and there is abdominal pain, anorexia, nausea, vomiting, weakness, diarrhoea, weight loss and fever. This stage too is reversible. The third stage is Alcoholic Cirrhosis in which complications such as ascitis, gastrointestinal bleeding, Portal hypertension, Hepatic coma etc. are seen.

The dietary management is aimed at maintaining adequate nutrition, preventing breakdown of body tissue, controlling oedema and ascitis and preventing symptoms of encephalopathy. A diet high in Carbohydrate, moderate in Protein and low in fat is advised. The diet should be given in several feedings (6-8 feedings per day) and vitamin and mineral supplementation is very important. The diet needs to progress from liquid to soft to normal depending on the acute stage and recovery. High calorie and protein beverages can be given between meals. Fat has to be low and then gradually increased as per the subject improves. Individualized diets are found to be very helpful.

The role of different nutrients in managing liver cirrhosis is given below:

Nutrients	Notes
Kilocalories	The energy requirements are increased due to a high catabolic state. Hence, a 2000-3000KCal diet is recommended. Calories are required to maintain weight.
Carbohydrates	Carbohydrates are kept adequate so that it has a protein sparing action and promotes the storage of glycogen. It protects and supports liver function. Hence, 300-400 g of Carbohydrates is recommended in a diet.
Protein	Proteins should be high enough to maintain positive nitrogen balance and low enough to prevent hepatic coma. Usually it is 1g/kg/dry body weight and may be increased to 1.2-1.5g/kg daily. In cases of Sepsis, infection, GI bleeding, severe ascitis, atleast 1.5g of protein/kg/day may be needed.
Fat (g)	Moderate fat intake is recommended as steatorrhea may be seen or malabsorption of fat occurs. Medium Chain Triglyceride fats are prescribed. About 25% of total Calories should come from fats.
Vitamins and minerals	Vitamin B and C, Folic acid, calcium, magnesium and zinc have to be supplemented, Iron has to be given to prevent anemia. Serum levels of calcium, magnesium and zinc are low and hence have to be supplemented.
Sodium	Restricted if oedema or ascitis is present. Restriction is upto 500mg/day and maybe increased to 2g/day with diuretics. Serum sodium and potassium levels have to be monitored. Emphasis is on low sodium foods and avoidance of table salt and salt in food preparation
Fluids	May be restricted to correct oedema and ascitis. Fluids upto 1500ml/day is recommended.
Fibre	Restricted to prevent haemorrhage from varices.

Post by Faiz Lahori