Saint Joseph Hospital Dora

Internship in nutrition and dietetics

August 30 2010

Gastroeriterology case study

Presented to: Ms. Joelle Dib

Done by : Mathilda Jabbour

Crohn’s disease: Crohn’s disease is an ongoing disorder that causes inflammation of the digestive tract, also referred to as the gastrointestinal (GI) tract. Crohn’s disease can affect any area of the GI tract, from the mouth to the anus, but it most commonly affects the lower part of the small intestine, called the ileum. The swelling extends deep into the lining of the affected organ. The swelling can cause pain and can make the intestines empty frequently, resulting in diarrhea.

Crohn’s disease is an inflammatory bowel disease, the general name for diseases that cause swelling in the intestines. Because the symptoms of Crohn’s disease are similar to other intestinal disorders, such as irritable bowel syndrome and ulcerative colitis, it can be difficult to diagnose. Ulcerative colitis causes inflammation and ulcers in the top layer of the lining of the large intestine. In Crohn’s disease, all layers of the intestine may be involved, and normal healthy bowel can be found between sections of diseased bowel. The inflammation may extend deeply into intestinal tissue and is accompanied by ulcerations, fissures and fistula. Scar tissue thickens and stiffens the intestine, narrowing the lumen. This will lead to abdominal pain, diarrhea and fatigue.

Crohn’s disease affects men and women equally and seems to run in some families. Crohn’s disease may also be called ileitis or enteritis. The exact etiology of Crohn's disease remains unknown. The consensus is that the disease results from a complex interaction between genes, immunity and environmental factors.

Below is a list of foods containing different rates of fiber

High fiber foods (> 7 g/svg) Medium fiber foods (> 3g/svg)

Low fiber foods(<3g/svg)

Avocado, bran cereal, dry oats, raspberries, cooked foods like black beans, broccoli, kale, green peas, lentils, kidney beans, navy beans, lima beans, split peas, cooked artichoke, pinto beans and soy beans.

Apples, almonds, 1 medium banana, sweet corn, dried figs, blue berries, flax seeds, grape fruit, olives, navel oranges, whole wheat pasta, papaya, dried peach, pistachio nuts, pear, baked potato, pumpkin seeds, prunes, sesame seeds, strawberries, winter squash and cooked foods like cauliflower, cabbage, garbanzo beans, green beans, spinach, sweet potato, turnip greens.

Apricots, asparagus, dried apricots, whole wheat bread, cantaloupe cubes, cashews, raw carrots, celery, cranberries, sliced cucumber, raw mushrooms, kiwi fruit, peanuts, raw onions, peach, pineapple, sweet peppers, raisins, plum, roman lettuce, sunflower seeds, walnuts, tomatoes and cooked foods like zucchini, summer squash, mustard greens, eggplant, collard greens and Brussels sprouts

During crisis in Crohn’s disease:

NPO in case food is not tolerated Liquid diet in some cases Soft, low residue, low fiber diet in other cases: minimizes abdominal

pains; is less likely to obstruct an intestinal tract that is narrowed by inflammation; minimizes the consumption of foods that add residue to the stool: raw fruits (especially fibrous), vegetables, and seeds, as well as nuts, and popcorn; along with a restriction of milk, cheese and dairy

After crisis in Crohn’s disease:

Gradual increase of fiber intake, from a low fiber diet to a high fiber diet.

Progress diet with introduction of new food items each at a time to check tolerance

Should provide fluids to rehydrate ( 6-7 cups of water/day) Higher fiber diet during remission

Foods to avoid during recovery phase:

Diet should contain limited amount of dairy products such as milk and cheese. Some people have lactose intolerance. But limiting the intake of dairy products, calcium supplements should be taken in order to avoid calcium deficiency.

Spicy foods, broccoli, cabbage, beans, citrus fruits and raw fruit juices and beverages such as alcoholic drinks and caffeinated beverages can aggravate the symptoms.

If Crohn’s disease affects small intestine, then it causes difficulty in digestion and absorption of fats. This can worsen diarrhea. Therefore, there is a need to avoid high-fat foods such as butter, mayonnaise, margarine, cream, avocados, fried foods and red meat.

High-fiber foods such as fresh vegetables, fruits and whole grains are considered beneficial for digestive health. But, in case of inflammatory bowel disease, high-fiber foods may worsen symptoms such as abdominal pain and diarrhea. However, baking, steaming or stewing of vegetables can make them easily digestible.

Dietary changes balanced with regular exercises and healthy lifestyles have proven beneficial in reducing the painful symptoms of Crohn’s disease and maintaining digestive health.

Use of soy products:Soy products can be introduced since they are a good source of protein. They can be a substitute for milk and cheeses. However, some soy products contain high amounts of fiber, so the intake depends on patient’s tolerance.

Elemental diet: o Current guidelines now recommend that corticosteroids are

more effective than enteral nutrition for treating adults. Enteral nutrition has important growth and developmental benefits and continues to be a recommended therapy for children with Crohn's disease.

o An elemental diet is a diet that proposes the ingestion, or, in more severe cases, use of a gastric feeding tube or intravenous feed of liquidized nutrients, in an easily assimilated form. It is usually composed of amino acids, fats, sugars, vitamins, and minerals. This diet, however, lacks whole or partial protein, due to its ability to cause an allergic reaction in some people.

o This diet is mostly given to patients with Crohn's disease as a dietary therapy, so that their inflamed gastro-intestinal tract does not have to work with digesting food and has time to heal and begin remission.

It aids in:

Reducing inflammation and inducing remission Allowing the fistula to heal, if present Providing the proper amount of nutrients for proper body

functions, while the GI is resting Reducing the amount of steroid intake ( if taken) Improving the quality of life and providing relief for the patient

Ulcerative colitis:The different steps of the disease:

The condition is marked by several steps: diarrhea -- and consequent dehydration; fever when

the inflammatory process is entrenched; arthritis of the medium-sized joints; eye inflammation;

skin lesions; progressively severe bleeding causing anemia; loss of protein and swelling; and

development of a toxic megacolon as the severity of inflammation spreads throughout the

bowel.

Fortunately, medical treatment by an expert can alleviate these discomforts and control their

progress.

Vitamins and minerals supplements:

Beta-carotene and vitamin E: for mucus membrane recovery .

B vitamins (folates, B6 & B12): to reduce the chances of diarrhea

Magnesium: to allay the onset of gastric spasm.

Potassium, zinc and selenium: since diarrhea may aggravate the loss of those minerals.

Recommended Diet for Ulcerative Colitis Patients Avoided Diet for Ulcerative Colitis Patients

Curd, Butter Milk, Cottage Cheese, Soya Milk Milk, Ice Cream, Milk Made Sweets

Cauliflower, Carrot, Potato, Pumpkin, Gourd. Capsicum, Raw Salads, Cabbage

Banana, Papaya, Apple, Water Melon Grapes, Mango, Guava

Filtered /Boiled Water, Tea with Little Milk, Orange Juice, Lemon Water

Alcohol, Coffee, Milk Shake, Cold Drinks

Almonds (Socked / Peeled), Dried Raisin. Cashew Nut, Walnut, Ground Nuts.

Mint Chutney. Coconut Chutney Green Chilies, Vinegar, Tomato Ketchup, All Type Of Pickles.

Boiled Rice, Wheat Flour, Roasted Bread, Corn Flour, Black Gram Flour. Popcorn.

Refined Oil, Coconut Oil, Olive Oil, Butter Mustard Oil.

Boiled Eggs 1-2/ Week, Roasted Chicken. Fish, Meat

Foods to Avoid in active Ulcerative Colitis: foods high in insoluble fiber or in dairy fat.

Foods to avoid: Cabbage/sprouts Cauliflower Broccoli Sweet Corn

Mushrooms High Bran fiber items - such as whole meal bread, and high fiber cereal Tomatoes - especially the seeds Soya Protein Onions - Especially raw onions Cheese/cream (tends to cause excess acid/irritation in the gut)

Low residue diet 2000Kcal:

50% CHO = 250g 20% Prot = 100g 30% Fat = 66g

Breakfast:

½ loaf of bread + 60 grams of double cream

Snack:

1 cup of orange juice + 12 crackers

Lunch:

Exchange CHO Protein Fat CaloriesLean Meat 8 - 56 24

Starch 12 180 36 12Veg. 5 25 10 -

Fruits 3 45 - -Fat 6 - - 30

Total (g) 250 102 65Total (Cal) 1000 408 585 1993

BF Snack Lunch Snack DinnerMeat 2 - 4 - 2Starch 2 2 3 2 3Veg. - - 3 - 2

Fruits - 2 - 1 -Fat - - 3 - 3

1 ¼ chicken breast + 1 cup of rice + 1 ½ cooked vegetables ( carrots and squash) ( 3 fat in the cooking)

Snack:

2 cups of puffed rice + 1 medium banana

Dinner:

1 hamburger slice + ½ cup boiled potato + 1 hamburger bun (without sesame) (3 fat in the cooking)

Cheeses he can take for breakfast: 60-90g/day

Low fat cheeses: sylphide, happy cow light, white cheeses such as halloum light, 3akkawi or double crème which are low in fat.

Diarrhea and constipation:1. Nutritional advices for diarrhea:

The typical dietary treatment plan for diarrhea and gastroenteritis is (1) replenishment of lost fluids and calories, followed by (2) a relatively bland diet (eg. BRAT diet).

Replacement of Lost Fluids : The key aspect of home management of diarrhea and gastroenteritis is the need to administer increased volumes of appropriate fluids. Such fluid intake helps to regulate electrolyte imbalance, and prevent further fluid losses, vital to prevent dehydration which is a serious condition in babies and young children. When diarrhea starts, a commercially available oral-rehydration solution can be given at home.

Bland Diet For Diarrhea : One option is the BRAT diet (bananas, rice, applesauce and toast) which is a traditional short-term diet plan used to manage diarrhea and gastroenteritis, after about 24 hours has passed when vomiting has stopped. BRAT-type foods provide a combination of bland, low dietary fiber foods which provide energy without gastric irritation. Bananas contain potassium, to control the body's fluid balance, boiled rice and toast provide low-fiber carbohydrate that doesn't irritate the bowel.

Applesauce supposedly cleanses the digestive system. Keep your child's diet bland until such time the diarrhea is better.

Diarrhea Diet: Foods to Avoid : Foods to be avoided in the aftermath of diarrhea include foods high in simple sugars, which may worsen the diarrhea by osmotic effects. For example, soft drinks, undiluted apple juice, Jell-O, and presweetened cereals should be avoided. Also, fried or fatty foods may not be tolerated because of their tendency to delay stomach emptying. Lastly, avoid spicy as well as high-fiber foods. Generally speaking, maintain a bland diet until symptoms of diarrhea or gastroenteritis have passed.

Infants With Diarrhea : Breast-fed infants may continue nursing on demand. In the case of bottle-fed infants, regular lactose-free, or lactose-reduced formulas should be administered immediately upon rehydration in amounts sufficient to satisfy energy and nutrient requirements. If lactose intolerance occurs, appropriate therapy includes temporary reduction or removal of lactose from the diet.

Older Children With Diarrhea: Older children who are accustomed to receiving semi-solid or solid foods may continue to eat their usual diet foods during diarrhea, so long as these are bland. Cereal-milk and cereal-legume diets are fine. Other recommended foods include starches (e.g., rice, potatoes, noodles, crackers, and bananas), cereals (eg. rice, wheat, and oat cereals), soup, yogurt, and cooked vegetables or fruits.

2. Nutritional advices for constipation:

 

Foods   to Avoid

carbohydrates unrefined grains, confectionary,

cakes and biscuits. Avoid wheat

especially wheat based

breakfast cereals, wheat bran

and pasta. In severe cases of

constipation eliminating all

gluten grains from the diet for at

least 6 weeks.

Fat Avoid saturated fats from red

meat and dairy products since

these promote fluid secretion by

mucus membranes.

Proteins Avoid protein from red meat,

dairy foods and eggs since these

can contribute to constipation.

Fluids  

Avoid stimulants such as coffee,

tea and sugary carbonated

drinks. Caffeine drinks can have

a dehydrating effect on the body

that can contribute to

constipation.

Foods to Increase

 

Carbohydrates

Increasing wholegrains such as

brown rice, millet, buckwheat

and quinoa are excellent sources

of complex carbohydrates.

Increase cooked vegetables and

vegetable juices.

 

Fats Include fresh nuts and seeds,

cold pressed oils and oily fish to

supply essential fatty acids.

Diverticulitis and diverticulosis:Diverticulosis is the condition of having diverticula: diverticula are sacs or pouches that develop in the weakened areas of the intestinal wall (like bulges in an inner tube of a bike tire where the wall is weak)

low fiber diets and constipation may lead to diverticulosis Divericulitis occurs when bacteria or fecal matter gets trapped in a diverticulum and leads to infection: May experience abdominal pain and distention, alternating episodes of diarrhea and constipation, indigestion, flatus, and fever.

DIVERTICULOSIS DIVERTICULITIS

High fiber dietAddition of bran to food (as psyllium)Alleviating the painAvoid nuts and pop corn and all seeds

AntibioticsPain control medicationLow fiber or liquid diets if mildNpo if accute

Esophageal and gastric disease:

1) Oesoophagitis:1- Oesophagitis: inflammation of the lining of the esophagus. Most cases of

oesophagitis are due to reflux of stomach acid which irritates the inside lining of the oesophagus. It can occur for a variety of reasons such as acid reflux diseases, pregnancy, smoking, alcohol consumption, caffeine or fatty and spicy foods.

Foods to avoid: Spicy foods High fat foods Acidic foods and beverages (tomatoes and tomato-based products,

citrus juices, orange, juices, grapefruits) Hard foods because they can cause pain in the esophagus when

swallowed (nuts, raw vegetables, kernels…) Alcohol

Treatment and lifestyle changes proposed in order to avoid the burning sensation:

Avoid tobacco Eat 5 or 6 smaller meals during the day instead of 3 large ones Take small bites of food and chew thoroughly before swallowing

Eat soft foods such as puddings, applesauce, soups, pureed foods, custard, mashed potatoes, cooked cereals…

Drink beverages through a straw to facilitate the swallowing process If swallowing becomes increasingly tough, try tilting the head upwards

so that the food flows to the back of the throat before swallowing Elevate the head of the bed 8 to 10 inches (20.3-25.4cm) or sleep on a

wedge pillow to help keep stomach contents out of esophagus while sleeping

Fruits like apples, bananas and apple juice are good alternatives to citrus fruits. Vegetables such as broccoli, carrots, cabbage, green beans, peas and potatoes can all be included in the diet, but make sure that they are cooked thoroughly and are soft enough to eat without difficulty

Fiber is a very important part of the ulcerative oesophagitis diet (multigrain breads and cereals, oatmeal, brown rice and vegetable sources)

Desserts and snacks can be enjoyed in moderation and they should be low fat and baked instead of fried

Drink at least eight glasses of water every day

2)Ulcer & Gastritis:Ulcer: peptic ulcer is a lesion or erosion of the cells of the mucosa of the lower esophagus, stomach, or small intestineUlcers may also develop in the mouth, upper esophagus, and large intestine, or on the skin.Causes:

Helicobacter pylori infections Chronic use of certain anti- inflammatory drugs Disorders that cause excessive gastric acid secretion (i.e. Zollinger-Ellison

syndrome which results from a tumor of the pancreas that produces gastrin, which, in turn, stimulates excess production of gastric acid)

Treating Peptic Ulcers :

o Eat a variety of nutritious foods including a high intake of vitamin A, soluble dietary fiber, fruits and vegetables

o Avoid overeating, frequent meals, bedtime snacks, alcohol, aspirin, nonsteroidal anti-inflammatory agents, and cigarette smoking

o Limit foods that cause discomfort and caffeine, black pepper, garlic, cloves, and chili powder

Gastritis o Gastritis is an inflammation of the lining of the stomach that can develop

suddenly (acute gastritis) or over time (chronic gastritis)o Unresolved gastritis can lead to:

ulcers hemorrhage shock obstruction perforation gastric cancer

Symptoms of acute gastritis vary and may include o Anorexia o Nausea and vomitingo Stomach paino Fever

Treatment for acute gastritis implies withholding any food or substance that irritates the gastric mucosa à greasy foods, fatty foods, cola beverages

Patients who cannot eat because of nausea or vomiting, foods may be withheld

for a day or two. Then, the diet progresses from liquids to a bland diet until acute gastritis

resolves

bland diet is a diet that aims to minimize gastric acid secretion and limit gastric irritants

The following is a detailed list of foods to avoid in every food group

Vegetables Raw vegetables, Raw onion, Cabbage, Broccoli, Tomato, corn, Brussels sprouts, Cucumber, Green pepper, Turnips

Fruits Unripe Fruits, Nuts, Lemon, Lemonade, Orange, Cranberries, Grapefruit, Tomato, Tangerine, Pineapple, Berries and Figs

Meat Ground beef, Beef chuck, Chicken nuggets, Buffalo wings, Corned beef, Luncheon meats, Frankfurter, Sausage

Fish Eel, Salmon, Herring, Sardine

Bread and cereals

Starchy grains, Wheat, Wild Rice, Croissant, Biscuit, Bread products with nuts or dried fruits, crackers

Fats and oils Creamy salad dressing, Palm oil, seeds and nuts, fried foods, chips

Dairy products Milk shakes, Sour creams, Cottage cheese, Ice creams, Whole milk, Strong flavored cheeses

Sweets and others

Butter cookies, Chocolate, Cake, Pie, Pastries, Doughnuts, Brownies, Coconut

Beverages Tea, Coffee, Liquor, Carbonated sweet drinks

3) General guidelines: REFLUX

Frequent small meals of bland, low fat foods Avoid large meals to avoid distending the stomach. A distended exerts pressure and

causes reflux. Relax during mealtimes, eat slowly and chew them thoroughly to avoid swallowing

gas and distending the stomach. Limit foods that include fat, alcohol, coffee, chocolate, spearmint peppermint and

any food that causes discomfort. Lose weight, if necessary. Overweight tends to increase abdominal pressure in the

stomach.

Refrain from lying down, bending over, and wearing tight fitting clothes or belts, particularly after eating, to avoid increasing pressure in the stomach.

Elevate the head of the bed by 4 to 6 inches. Keeping the chest higher than the stomach helps prevent reflux.

Refrain from smoking cigarettes During periods of active reflux, avoid foods and beverages that irritate the

esophagus, such as citrus fruits and juices, tomatoes and tomato- based products, pepper, spices, and very hot or very cold foods, according to individual tolerance.

Foods to avoid (irritates the stomach and causes heartburn):

Fried (greasy) foods High fat meats Butter and margarine Mayonnaise Creamy sauces Salad dressings Whole-milk dairy products Chocolate Peppermint Caffeinated beverages (e.g. soft drinks, coffee, tea, cocoa) Carbonated beverages Alcohol Spicy foods Black pepper Chili peppers Citrus fruit and juices (e.g. orange, grapefruit) Tomato juice

4) Gastrectomy: the surgical removal of all or part of the stomach and may affect normal digestion until the remaining pouch has a chance to expand and adapt.

Nutritional care:1-Eat fewer simple sugars: foods high in sugar should be avoided because they pass through your stomach quickly and may cause diarrhea.Instead of ChooseBrown SugarCorn SyrupHoneyMaple SyrupTable Sugar (Sucrose)

Equal®(Nutrasweet® or aspartame)Sweet ‘N’ Low®

Sugar-Free syrupSugar Twin®

Cake/Pie/PastryCandy/ChocolateCookiesIce CreamJello®

Puddings made with sugar

Angel Food CakeGraham Crackers/Vanilla WafersNutrasweet® FlavoredFrozen YogurtSugar-Free GelatinSugar-Free Pudding

Iced TeaLemonade

Diet SodaSugar-Free Mixes:

Koolaid® or PunchRegular Soda or Ginger AleSweetened Cocoa Mixes

Fruit DrinksHot CocoaIced TeaLemonade

Breakfast Cereals withmore than four grams ofsugar (see label)

All other cereals

Fruit canned in heavy syrupJams/Jelly/Preserves

Unsweetened Fruit cannedin juice or waterSugar-Free Jelly

2- Eat more foods high in soluble fiber: foods high in soluble fiber slow stomach emptying and prevent sugar from being absorbed quickly.

The following foods are high in soluble fiber:Apples Carrots OatsApricots Dates PearsBarley Dried beans PrunesBeets dried Peas RaspberriesBrussels sprouts Figs Spinach

3- Use liberal amounts of fats: foods such as margarine, mayonnaise, gravy and oils, salad dressings, and cream cheese should be used frequently during meals. Fats slow the emptying of the stomach and can help to prevent dumping syndrome or diarrhea from developing.4- Eat smaller, more frequent meals: eating 5 or 6small meals more often will allow you to eat the equivalent of 3 regular meals without feeling full too fast.5- Drink liquids 30–60 minutes after meals instead of with meals.6- If milk causes distress, try a lactose-free milk (Lactaid® or Dairy Ease®).Dumping syndrome: Dumping syndrome sometimes happens after stomach surgery. Dumping syndrome is caused by large amounts of food passing quickly into the small intestine. This causes symptoms like abdominal pain or fullness, nausea, diarrhea, dizziness, weakness, and fatigue.

Tips to help relieve symptoms• Everyone tolerates foods differently. Avoid foods that you know cause you problems.• Eat small, frequent meals (at least six times every day). • Do not drink liquids with your meal. Instead, drink liquids at least a half-hour to an hour after eating solid food.• If you have problems with hypoglycemia (low blood sugar), avoid sugar and sweets such as candy, soda, cakes, and cookies.• Lie down as soon as you finish eating. This reduces the symptoms of dumping syndrome by slowing the emptying of food from the stomach.• Avoid foods that are very hot or very cold. These can trigger symptoms.• Tell your doctor if you lose any weight.

Dumping syndrome diet

Breads, Cereals, Rice,and Pasta

Foods to Choose Foods to Avoid

6-11 servings each dayOne serving equals:1 slice bread1 cup ready-to-eat cereal1/2 cup cooked cereal,rice, or pasta

- all breads, unsweetenedcereals, pasta, potatoes,rice, crackers, and soup(only if taken one hourafter solid foods and at amedium temperature)

- sweet rolls and doughnuts- sweetened cereals- pancakes and waffleswith syrup- soup (taken with solidfoods)

Fruits Foods to Choose Foods to Avoid

2-4 servings each dayOne serving equals:1 medium-size fresh1/2 cup canned3/4 cup juice

- all fresh fruit- drained, unsweetenedcanned fruit- unsweetened frozen fruit- 100 percent pure juice(taken one hour after meals)

- canned fruits in heavysyrup- sweetened frozen fruit- sweetened juices (that is,punch or sports drinks)- candied fruit

Milk and Dairy Products

Foods to Choose Foods to Avoid

Limit to 2 servingseach dayOne serving equals:1 cup milk or yogurt

- plain or unsweetened yogurt- skim, 2 percent, or wholemilk (taken one hour aftermeals)

- milkshakes andchocolate milk- sweetened yogurt

Vegetables Foods to Choose Foods to Avoid

3-5 servings each dayOne serving equals:1 cup raw1/2 cup cooked orchopped

- all vegetables - any not tolerated

Meats, Poultry, Fish,Dry Beans, Peas, Eggs, and Cheese

Foods to Choose Foods to Avoid

2-3 servings or a totalof six ounces dailyOne serving equals:2-3 ounces cooked meat,chicken, or fish (aboutthe size of a deck of cards)— or —1/2 to 3/4 cup cottagecheese or tuna fish— or —One egg, 1/2 cup cookedbeans, two tablespoonspeanut butter, or oneounce of cheeseChoose leaner cuts of beefand meat and limit theamount of high-fat item like eggs and cheese

- all meat, fish, poultry,peanut butter, cheese,eggs, and dried beansor legumes

- any not tolerated

Fats, Condiments,and Beverages

Foods to Avoid Foods to Choose

- sweet pickles or relish- sweetened drinks(regular lemonade,soda)- any others not tolerated

- all butter, margarine,cream, oil, and saladdressings- salt, herbs, spices, andcondiments- any sugar-free beverage(coffee, tea, diet soda,etc., taken one hour aftersolids)

Snacks Sweets, andDesserts

Foods to Choose Foods to Avoid

- sugar-free gelatin- sugar-free pudding- sugar-free candy- sugar substitutes

- sugar- candy and chocolate- cakes and cookies- ice cream and sherbet- honey, syrup, and jelly

Sample menu:

Breakfast 1/2 grapefruit1 slice toast1 egg1 teaspoon margarine1 cup 2 percent milk (60 minutes after meal)

Snack 2 oz. cheese and 6 crackers1/2 banana

Lunch 2 oz. hamburger on a small bunwith lettuce and tomato1/2 cup fresh fruit saladtea (60 minutes after meal)

Snack 1/2 turkey sandwich with mayonnaiseDinner 1/2 chicken breast

1/2 cup brown rice1/2 cup broccoli1 small apple1 cup 2 percent milk (60 minutes after meal)1 to 2 teaspoons margarine

Snack 2 tablespoons peanut butter on grahamcrackers

Cirrhosis and fatty liver:

1- Dietary guidelines for liver disease:

Energy: 25-35 Kcal/kg.

CHO: 60-70% of total energy—primarily complex carbohydrates.

Protein: 20-30%.

Fat: 20- 30% 10-20% PUFA.

Water: 1-2 liters/day.

No alcohol, no processed food.

Caffeine: no more than 1 to 3 cups of caffeine-containing beverages per day.

Provide Vitamin D, Vitamin C and calcium supplement and antioxidant such as vitamin E.

Blood tests indicative for liver disease:

ALT (aspartate aminotransferase or SGOT) and AST (alanine aminotransferase or SGPT) levels, which indicate the degree of inflammation. These enzymes leak into the blood stream when the liver cells are damaged.

Alkaline phosphatase (ALP), an enzyme found mainly in the bile ducts of the liver. Increases in ALP and another liver enzyme called Gamma GT (GGT) can indicate obstructive or cholestatic liver disease, where bile is not properly transported from the liver because of obstruction (blockage) of the bile duct. GGT is tested with ALP to make sure that ALP increases are coming from your liver.

Bilirubin, an increase of bilirubin causes jaundice, a yellowing of the eyes and skin in liver disease.

Albumin, albumin may decrease in chronic liver disease, but may be decreased for other reasons such as a lack (deficiency) of protein, for example malnutrition.

Clotting studies, which may indicate liver disease, especially worsening chronic liver disease if the prothrombin time (clotting ability) is prolonged. When your liver is damaged your blood becomes too ‘thin’ and takes longer to clot.

Diet for hepatic encephalopathy: 40 g PRO, 2 g Na, 2000 kcal: USE 100g duocol (470 kcal 72.7g CHO and 22.3g fat)

2000 kcal: 8 % PROà 40 g PRO

35 % fat à 77 g FATà55 g FAT left

57 % CHOà 285 g CHOà 212 g CHO left

Exchanges CHO PTN FAT BF S L S DMILKSTARCH 6 90 18 6 2 2 2FRUITS 6 90 0 0 1 2 1VEGETABLES

6 30 12 0 2 3 1

MEAT 2 0 14 10 2FAT 8 0 0 40 2 3 1 2TOTAL 210 44 56

Diet :

Breakfast: ½ loaf bread + 2 tsps olive oil +2cucumber + 1 tomato+ 1 apple

Snack: 1 cup of orange juice

Lunch: 60 g meat (6 pieces of barbequed meat) + ½ loaf of bread + 1 cup of lettuce + 1 tbsp of low fat mayonnaise

+ 2 cups of cabbage salad+ 2 tsp olive oil

+ 1 pear

Snack: 1 cup of vegetable salad with 1 tsp olive oil and lemon

Dinner: ½ loaf of bread of 2 tbsp peanut butter

Special formulas to increase calorie intake:

• Maxijul ( 600 kcal in 300 ml à 2 kcal/ml with 12 g ptn) • Ensure ( 1kcal/ml 14.2% PTN 31.8% FAT 54% CHO) • DUOCAL ( 470 kcal/100g 39% CHO and 41% fat) • Scandishake®: 1sachet + water à 250ml contain 500Kcal; 4.7g prot, 65g carbs,

24.7g fat, some vitamins. It can be mixed with water or milk

Fat and sugar addition to increase caloric intake:

Fat addition Sugar additionCirrhosis x

Hepatic encephalopathy

Pancreatitis X Cholecystitis X

Ileostomy x X