Signs/symptoms
Pathophysiology
Liver Disease/Hepatitis
Hepatitis is inflammation of the liver due to injury to hepatocytes & associated influx of inflammatory cells. May be acute (<6 months) or
chronic (>6 months), self-limiting or progressive to fibrosis & cirrhosis (liver can no longer regenerate). Nonalcoholic fatty liver disease
(NAFLD) involves accumulation of fat droplets in hepatocytes. May progress to nonalcoholic steatohepatitis (NASH) with accumulation
of fibrous tissue in liver & further progression to chronic liver disease & cirrhosis. Alcoholic liver disease results from damage due to
excess hydrogen & acetaldehyde, a toxic byproduct of alcohol metabolism. TCA cycle inefficient. Progresses in three stages: hepatic
steatosis, alcoholic hepatitis, & cirrhosis.
Hepatitis (Early)
 Acute viral - Prodromal phase (fever, arthralgia,
arthritis, rash, angioedema); Preicteric phase (malaise,
fatigue, myalgia, anorexia, N&V, epigastric or right
upper quadrant pain); Icteric phase (jaundice);
Convalescent phase (sx subside)
 Early chronic hepatitis - Sx usually mild, occur
intermittently (fatigue, sleep disorders, difficulty
concentrating, mild right upper quadrant pain)
NAFLD
 Fatty liver (hepatic
steatosis)
 Asymptomatic
NASH
 Fibrous tissue in liver
 May be asymptomatic
or malaise, weakness,
hepatomegaly
Alcoholic liver disease (Early)
 Fatty liver (hepatic steatosis)
 Alcoholic hepatitis - Hepatomegaly,
anemia, abdominal pain, anorexia, N&V,
weakness, diarrhea, weight loss, fever
Alcoholic liver disease (other metabolic
changes) – Steatorrhea, Wernicke-Korsakoff
syndrome, peripheral neuropathy, pellagrous
psychosis, folate, thiamin & niacin deficiency
Hepatitis
 Infections - viruses (hepatitis viruses A, B, C,
D, E), bacteria, fungi, protozoa
 Toxic Damage - alcohol, drugs, chemicals
 Immunologic Damage



Nutrient Needs
Causes/risk
factors
Blood tests: Serum antibodies to viral hepatitis A, B, C, D, or E indicate current or previous infection. Enzyme assays (such as aspartate
aminotransferase, alanine aminotransferase) measure release of liver enzymes in blood, indicating damage to hepatocytes. Liver function
assays (such as serum levels of bilirubin, albumin, prothrombin time) indicate degree of dysfunction. Imaging tests: Liver ultrasound
detects irregularities in shape & consistency of liver. Computed tomography provides detailed view of liver via X-ray. Liver biopsy can
define stage of disease & severity of inflammation.
MNT
Goals
Screening/
Diagnosis
Regardless of cause, common signs/symptoms as disease progresses:
 Advanced chronic hepatitis - Protein calorie malnutrition, portal hypertension with varices, ascites, hepatic encephalopathy, glucose
alterations, fat malabsorption, osteopenia, thrombocytopenia with anemia
 Fulminant hepatitis - Severe liver dysfunction plus hepatic encephalopathy (impaired mentation, neuromuscular disturbances, &
altered consciousness)
 Cirrhosis - Jaundice, muscle wasting, tea-colored urine, edema, GI bleeding, hepatic encephalopathy, palmar erythema, spider
angioma, portal hypertension, ascites
NAFLD/NASH
 Insulin resistance & metabolic syndrome (most common)
 Other acquired metabolic disorders (lipodystrophy,
jejunal ileal bypass, obesity, malnutrition)
 Drugs, TPN, inborn errors of metabolism
Alcoholic liver disease
 Chronic ETOH intake
 Psychosocial issues
 Most common liver
disease
Prevent or reverse associated malnutrition.
Monitor labs regularly to control for additional disease complications.
Provide pt support in enhancing oral intake. Recommend alternative feeding methods when indicated.
Kcal: 25-35 kcal/kg dry wt or REE x AF x IF 1.2-1.5 (depending on degree of malnutrition and acute vs chronic)
Pro: 0.8-1.0 g/kg dry wt: for uncomplicated hepatitis ; 1.2-1.5 g/kg dry wt: to promote positive nitrogen balance; calculations depend on
degree of malnutrition, malabsorption, metabolic stress
CHO: 45-65% kcal (AMDR); nutrient rich sources; monitor for glucose intolerance
Fat: 25-40% kcal (use MCT with steatorrhea)
Fiber: 21-38 g/d (see DRI for age/sex)
Fluids: may need to restrict if hyponatremia, edema, or ascites is present; may be as low as 1-1.5 L/d
● Electrolytes: restrict sodium to <2 g/day with edema or ascites
Prepared by Jeff Gibberman, Kat Kopfler, and Laura Prevo May 2012
Labs
Treatment &
Medications
Supplements/Herbs/
Botanicals
NOTE: coordination of care is recommended for supplements/herbs/botanicals regarding liver disease due to complex metabolic
derangement. Below is a list of common therapeutic supplements/herbs/botanicals
● Milk Thistle - reduces detoxification load of liver, reduces inflammation & supports cell regeneration
● Herbs that stimulate bile flow & removal of fat:
○ Dandelion, greater celandine, ginger, turmeric
● Potentially TOXIC herbs to the liver, stay away from:
○ Chaparral, ephedra, black cohosh, kava kava, comfrey, licorice root (in excess), germander
Vitamins A, D, E, K: increased losses due to malabsorption; may contribute to osteoporosis; use water miscible sources for repletion
Vitamin B6, B12, folate, niacin, thiamin: deficiencies could lead to macrocytic anemia, confusion & ataxia (esp in alcoholic liver disease)
Zinc, calcium, magnesium, iron, potassium, phosphorus: DRI levels recommended; caution with iron
Diet Therapy
Steroids; Diuretics; Anti-virals: Interferons (B&C); Ribavirin (C); Protease inhibitors (C-genotype 1): telaprevir, boceprevir;
Nucleoside analogues (B): entacavir, telbivudine, lamivudine; Nucleotide analogues (B): adefovir, tenofovir; DNI’s & Side effects :
Anorexia, weight loss, N/V/D, muscle wasting, elevated blood glucose, increased thirst, flu-like symptoms, headache, fatigue, abdominal
pain, anemia, dyspepsia, bone marrow suppression, decreased WBC, decreased platelets; herbs may alterCYP450 & other cytochrome
systems that metabolize Rx
Vits &
Mins
Monitor labs frequently to determine what needs to be supported with liver disease.
Hepatic function: total serum bilirubin, direct & indirect bilirubin, ammonia; Cholestasis tests: serum alkaline phosphatase; Hepatic
enzymes: ALT, AST, LDH; Serum proteins: PT, PTT, serum albumin; Markers of specific liver dz’s: serum ferritin, ceruloplasmin, αfetoprotein, α1 -antitrypsin; Viral hepatitis: IgM anti-HAV, anti-HBS, HCV-RNA; Other common labs: hydration status (Na+),protein status
(albumin, pre-albumin but may be inaccurate if severe inflammation), blood clotting (prothrombin time, platelets), blood sugar (FBS),
Hematology (HCT, Hgb, ferritin), blood pressure, bone health (alkaline phosphatase), renal function (BUN, Creatinine, Phosphorus, Na+, K+)
CAM for liver disease:
 Anti-inflammatory diet (primary diet intervention for early
stage) - quantity & quality of fat (↑ω-3 FAs, ↓sat fat/trans fat),
↓ iron intake, colorful f&v, herbs & spices for bioactives
 Ensure adequate (but not excessive) protein is consumed:
0.8-1.2 g pro/kg
 Promote positive N balance - ↑ BCAA’s (in whey, meat,
dairy) which are used more readily & ensure adequate
probiotics which can improve uremia
 Hydration/edema - limit water if necessary, low sodium
 Improve fat metabolism - focus on medium chain
triglycerides (MCT) like butter, coconut oil, palm kernel oil &
adequate methyl donors from liver supportive foods
 Improve endogenous antioxidant status - selenium, NAC (a
form of cysteine), lipoic acid, quercetin & bioactives to support
endogenous AOX system
 Low glycemic load to prevent excess FA synthesis & VLDL
formation in liver
 Moderate fructose, which can upregulate FA synthesis
 Liver supportive foods - artichoke, lemons, beets, bitter
greens, sage, rosemary, oregano, burdock, onion, garlic,
chives, chamomile, Jerusalem artichoke
NASH:
 Calorie reduction for wt loss
 Low glycemic diet
 Low fructose diet
 ↓ Sat fat & w-3:w-6 balance
without excessive total fat intake
 Bioactive compounds to reduce
inflammation
 Physical activity: 30 – 45 min
moderate PA 5 -7 d/wk
 Avoid ETOH
Alcoholic Liver disease:
Early stage
 Remove ETOH
 Vitamin repletion (Thiamin, B
vitamins)
 Manage hypoglycemia
 Manage inflammation & fatty
infiltration
Late stage
 Manage state of liver dysfunction
End Stage Liver disease:
 Energy: 25 - 35 kcal/kg dry weight, REE
x AF x IF 1.2 to 1.5, depending on
degree of malnutrition
 Protein: 1 - 1.5 g/kg dry wt depending
on degree of malnutrition,
malabsorption, metabolic stress
 Try BCAA formulas for >grade 2
encephalopathy
 CHO: nutrient-rich sources – monitor for
glucose intolerance
 Fat: 25% - 40% of kcal, use MCT with
steatorrhea. Fat restriction if severe,
monitor for D
 Vitamin & mineral supplements
generally essential, water miscible fatsoluble vitamins if steatorrhea is present
 Electrolytes: restrict sodium with
edema or ascites (<2 g/day)
 Fluid: restrict fluid if hyponatremia is
present (may be as low as 1-1.5 L/d)
Due to regenerative capacity of liver, liver disease reversible until it reaches cirrhosis.
References:

Hasse JM, Matarese LE. Medical Nutrition Therapy for Hepatobiliary and Pancreatic Disorders. In: Mahan LK, Escott-Stump S, Raymond JL. Krause’s Food &
the Nutrition Care Process. 13th ed. St. Louis, MO: Elsevier; 2012:645-674.

Morrow K. MNT for Hepatic, Pancreatic and Biliary Disorders. Nutrition Assessment & Therapy 2. Lecture conducted from Bastyr University, Kenmore, WA
(April-May, 2012).

Pronsky Z, Crowe J. Food-Medication Interactions. 16th ed. Birchrunville, PA: Food-Medication Interactions;2010.
Prepared by Jeff Gibberman, Kat Kopfler, and Laura Prevo May 2012