LIVER CIRRHOSIS & IT'S NUTRITIONAL CARE

Cirrhosis is the final stage of liver injury and degeneration. It occurs in 15 % of heavy drinkers. Other causes of liver cirrhosis are drug or chemical poisoning, hepatitis B virus, cystic fibrosis, etc. Cirrhosis is characterized by liver necrosis meaning the normal liver tissue is gradually destroyed and replaced by inactive fibrous connective tissue (scar tissue).

NUTRITIONAL MANAGEMENT:

Energy Requirements: Due to extreme weight loss in cirrhosis, energy requirements are increased. A diet with 25-35 Kcal/Kg IBW (Ideal Body Weight) per day is recommended. Small and frequent meals should be given.

Carbohydrate Requirements: The carbohydrate content of the diet should be high in order to provide sufficient calories so that protein is not utilized for energy. Also, the liver may store glycogen. Liver function improves when an adequate store of glycogen is present in hepatocytes (liver cells). Simple carbohydrates should be given, i.e., sugars, fruits juices, Sago, Arrowroot products, etc. About 65-70 % of total calories should be provided by carbohydrates.

Protein Requirements: A liberal protein intake is essential for the repair of hepatic cells. The serum albumin which is exclusively synthesized by the liver cells falls down in cirrhosis as a result of which there is water retention. So, in order to maintain serum levels of albumin, it is necessary to take protein. In case of absence of Hepatic Coma (a condition in which ammonia levels increases leading to brain tissue damage), 1.2 -1.5 gms per kg present body weight can be given. Both animal and plant protein can be given. Vegetable and dairy proteins are better tolerated because of their lower content of Aromatic Amino Acids (Methionine and Glutamine) and higher content of Branched chain Amino Acids (Valine, Leucine, and Isoleucine). If protein requirements cannot be met by diet alone, then protein supplements can also be given. However, if cirrhosis progresses to Hepatic Coma, then protein has to be totally restricted.

Fat Requirements: Cirrhosis is marked by impaired fat metabolism and absorption. Triglycerides which contain Medium Chain Fatty Acids (8-10 CARBON FATTY ACIDS) like Ghee, Butter, etc. can be given. These triglycerides do not require bile for their digestion and absorption. This will help to prevent steatorrhea (fatty stools). As the condition improves, large chain triglycerides can be given to avoid deficiency of essential fatty acids.

Vitamin Requirements: All of the vitamin should be supplied in abundance to fortify the liver against stress and to repair the damage. Since the liver is involved in the synthesis of active forms of any B-complex vitamin and due to lack of proper function, it is advisable to give B-complex vitamin supplements. In the presence of steatorrhea, water soluble forms of vitamin A, D, E, and K should be given. In severe cirrhosis with problems of vitamin storage, metabolism, and transport intramuscular injections of Vitamin A, D, E, and K may be necessary.

Mineral Requirements: Iron intake should be increased to prevent anemia because the liver is unable to store iron in the form of Ferritin. Iron supplements can be given. However, simultaneous increase of vitamin C is also required. Calcium intake should also be increased. Iron intake can be increased by following measures:

* Increase the intake of Green leafy vegetables like Spinach, Mint, Methi, Amaranth etc.
* Also, increase the intake of vitamin C. So, consume lots of fresh fruits like Guava, Sweet Lime, Oranges, Aavla, etc.
* Consume raw freshly sprouted pulses. It can be consumed with salads too.
* Consume Ragi (Nachni), soya bean flours. They can be mixed with wheat flour and chapatis can be made out of it.
* Consume Rice flakes (Poha) as they are good source of iron.
* Use jaggery instead of sugar, as jaggery is a good source of iron.
* Soak 2-3 dates in water at night and then in the morning, consume it with milk or with water.

Sodium and Potassium Requirements: Sodium restriction is prescribed if edema (fluid retention in body) is present. Sodium is restricted to 2 gm per day. At the same time, potassium intake is increased. Some potassium-rich foods are coconut water, water obtained after boiling Moong Dal, Amla, Guava, Sapota, Papaya, Sweet lime, Peaches, Phalsa, Plums, and Gourd vegetables like Lauki, Karela, Turai, etc.

In order to make food palatable even with less salt one should make use of pepper powder, lemon juice, etc. Also, avoid food items like Jam, Canned fruits, Sauces, Pickles, Papads, Salted biscuits, Salted dry fruits, Cheese, Butter, Potato chips, and fruits like Lichi, Pineapple. Due to restriction of salt, the food becomes less palatable and therefore the patient becomes irritable. However, we can make food palatable if we follow the following tips:

* Make the food look attractive, so garnish well. Can use coriander leaves, tomato slices, onions, etc. Use Ratanjot for natural red color. Ratanjot is a herb which gives bright red color. Make vagaar with Ratanjot, it will give bright red color to food. Can add Ratanjot in Dal, sabzi, pulav, etc.
* Always serve food hot. When food is consumed hot, one does not feel that there is less salt in food. So, serve soups, dal, sabzi hot and ask the patient to consume it hot only.
* Squeeze lemon juice from top just before serving food. This will curb the need of salt in food.
* Add jeera powder and/or black pepper and/or mango powder to food. This will make food tasty even with less salt.
* Serve food in attractive vessels.

Fluid Requirement: In case of edema, fluid restriction is necessary. Total fluid intake equals to urinary output + 500 ml per day .

Alcohol Intake: Alcohol intake should be completely restricted. Even a single drop can be deadly.