1. a replication of hepatitis B and can be


     1.   Why does
portal hypertension occur secondary to cirrhosis? What is ascites? Pg. 568


Portal hypertension occurs
secondary to cirrhosis in the human body due to an increase in blood flow. This
condition results in varices, which are swollen veins (1). Ascites are the
accumulation of fluids within the abdominal region and occurs because of liver
disease (1).

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     2.   What are each of these
conditions? Pg. 577, 579



Cholangitis à It is known as the inflammation of the bile ducts
(1). A crucial precaution of observing this condition is that is could result
in sepsis and liver failure, therefore healthcare professionals must assess
and monitor adequately (1).


Cholecystitis à It is known as the inflammation of the gallbladder,
a condition caused by gallstones obstructing the bile ducts (1).


Choledocholithiasisà refers to the presence of gallstones in the bile
duct (1).


Cirrhosis à refers to the scarring and damage of the tissue of
the liver (1).



     3.   What are the different
types of hepatitis you might see in a hospitalized patient? How is each
transmitted and treated? Pg. 564


Hepatitis A à are transmitted via
fecal-oral route, i.e. in contaminated water, food supplies, and sewage (1). Currently,
there is no treatment or “cure” for Hep. A

Hepatitis B and C
àare transmitted via
blood, blood products, semen, and saliva (1). It is treated through a series of
antiviral medications.

Hepatitis D à are transmitted via a
replication of hepatitis B and can be transmitted through contact blood or any
bodily fluids (1). Currently, no effective medication are used to treat Hep D.  

Hepatitis E à is transmitted in
contaminated water via fecal matter and is treated with medication (ribavirin ~
approx. 21 days) (2).


     4.   What is Wernicke’s
encephalopathy and what nutrient deficiency might lead to it? Pg. 574


Wernicke’s encephalopathy
is a serious neurological condition that can result from a vitamin B-1 (thiamin)
deficiency (1) and is more prevalently seen in alcoholics.





     5.   Consumption of what
foods when eaten by a patient with cholecystitis, may cause pain?

Consumption of what foods
when consumed by a patient with chronic pancreatitis, may cause symptoms to
worsen? Pg. 579, pg. 582


Individuals with chronic
cholecystitis are required to follow a long-term and low-fat diet (1) due to
the gallbladder disorder which affects how fat is digested and absorbed. If a
low-fat diet is not monitored patients may feel discomfort and experience flatulence
and or bloating (1).


Consumption of foods high
in fats in patients with chronic pancreatitis may cause the symptoms to worsen
(1). Malabsorption of fats may be seen in a condition called steatorrhea (1). Along
with limiting the consumption of foods high in fat, patients are also required
to abstain from consuming alcohol (1).



6. What do each of these lab tests tell us about the liver? Pg. 561


           a. Serum alkaline phosphatase à increased levels of
this suggest the condition of cholestasis (1).

           b. Direct serum bilirubin à Liver damage is an indicator
of increased direct serum bilirubin (1).

           c. Alanine aminotransferase à is an enzyme located
in the cytosol of the hepatocyte that indicated cell damage (1).

           d. Prothrombin time à This serum protein indicates a vitamin K deficiency,
a consequence of a decrease in this serum increases risks of bleeding (1).


7. What is steatorrhea and why is it seen in a patient with pancreatic


Steatorrhea is defined as
the presence of fat in the stool, most commonly seen in patients with cirrhosis
(1). Steatorrhea is seen in patients with pancreatic insufficiency because of
an injury or obstruction of the bile duct, thus causing fatty stools (1).



8. Why are children with CF often very thin? What can be done to help
them with their weight? Pg. 683-685


Children suffering from CF
are often thin due to the defect in transportation of chloride, sodium, and
bicarbonate (1). Such defect in transportation produces thick and sticky
secretions that may disrupt how nutrients are being absorbed in the pancreas,
liver, and intestines (1). Also, due to the increased susceptibility of chronic
cough, dyspnea, and respiratory complications children suffering from CF will exhibit
a variety of complications such as growth failure, increased caloric/energy
needs and malabsorption (1) leading to a thin complexion. Health care
practitioners will address and correct the malabsorption and maldigestion in
hopes to correct the weight discrepancy (1).


9. What should be avoided in the diet of an individual with Wilson’s
disease? Why?


In the initial stages of
treating Wilson’s disease, meals/ supplements containing copper should be
avoided (1).



10. In liver disease, which factor(s) affect the interpretation of serum
albumin values?


Testing serum albumin levels
are an indicator of assessing plasma oncotic pressure (1). If a patient is assessed
for low serum albumin, it indicative of liver failure such as cirrhosis (1).


11. Why is enteral nutrition is preferred over parenteral nutrition
when treating patients with severe, acute pancreatitis? Pg. 582


Enteral nutrition is
preferred over parenteral nutrition when treating patients with severe acute
pancreatitis because enteral nutrition reduces the incidence of septic
infections and complications (1). Along with lowering morbidity and mortality
associated with septic infections, enteral nutrition also proves to be cost
efficient (1) in terms of length of stay at the hospital (1). For most patients,
enteral nutrition is better tolerated as it is placed as the jejunal feedings
and increases how nutrients are being absorbed (1).


12. What should be included in the nutrition care plan for a patient in
the acute post liver transplant phase? Pg. 575


A major nutrient of
concern after liver transplant is protein and energy needs. Health care
practitioners, especially registered dietitians will advise the patient to eat
small, frequent, and nutrient dense foods (1). A patient in the acute post
liver transplant phase will be required to monitor nitrogen requirements (1).
Along with protein, nitrogen, and energy needs, the health care practitioners
will monitor: protein, fat, CHO, sodium, fluid intake, calcium as a precaution
to lower the risk of problems such as obesity, hyperlipidemia, hypertension,
diabetes mellitus, and osteopenia (1).







13. What is the relationship with BCAA and hepatic encephalopathy? Pg.


The relationship between
BCAA and hepatic encephalopathy is the protein intolerance as branched-chain
amino acids are crucial as they provide thirty percent of energy that is
required for skeletal muscle, heart and brain to function properly (1).  Depending on the release of plasma amino acids
result in how much is released into circulation and taken up by the muscles and
liver (1). Studies demonstrate a correlation in the ratio of branched-chain
amino acids and plasma amino acids and the development of hepatic
encephalopathy (1).



14. Explain Ranson’s
criteria. Pg. 580


Ranson’s criteria is an
assessment to classify the severity of the condition pancreatitis (1). This is consisting
of the following parameters:

–  Age of 55 or older

– White blood cell count

-Blood glucose level >200

-Lactic dehydrogenase >
350 units/L

-Aspartate transaminase >
250 units/l



15. What can be done for a patient with chronic pancreatitis to minimize
steatorrhea? Pg. 582


Health care practitioners
will attempt to lower frequency of steatorrhea through minimizing the stimulation
of CCK levels in pancreas by recommending a lower fat diet (1). This will allow
for proper enzymatic reactions to take place and lower the incidence of malabsorption
of protein and fat (1).



16. These drugs are commonly given following liver transplant. What are
the nutrition-related side effects you might have to deal with as an RD for a
patient using: Pg. 725, 794-795



Azathioprine? à causes
loss of appetite, nausea or vomiting (1)


Cyclosporine? à causes
loss of appetite and nausea (1)


Glucocorticoid? à causes negative
nitrogen balance, hypercalciuria and risks for deficiencies in calcium and
vitamin D (1).


Tacrolimus? à  cause accelerated protein catabolism, hyperlipidemia,
sodium retention, weight gain, osteoporosis, and electrolyte disturbances











17. Seek out some credible information on the herbal supplements Milk
Thistle in relation to liver disease. Would you recommend it to a family member
or close friend? Why or why not? Pg. 574


Milk thistle is used in
relation to liver disease because of its ability to reduce free radical production
(1).  Despite its poplar use, there is
little to no evidence suggesting the effectiveness and benefits on individuals
with liver disease (1). Because there is no solid evidence suggesting the
benefits or contraindications, as a registered dietitian I would not recommend
to a family member or a close friend.


18. A patient wants to try a liver cleanse to treat hepatitis. How do
you respond? Pg. 564


As a healthcare practitioner
I would not advise a patient to try a liver cleanse to treat hepatitis because
of the serious complications that may arise. Depending which type of hepatitis
the patient is suffering from will dictate the treatment (1). I will educate
the patient on the different forms of hepatitis and the treatments for each ones.



19. Describe each of the following: pg. 583, 569, 577


           a. Shunt placement
à is a surgical procedure
that relieves the pressure on the brain cause by fluid accumulating (***)

           b. Whipple procedure à also called pancreaticoduodenectomy,
a surgical procedure that is used when a patient is suffering from pancreatic
carcinoma (1). It refers to the removal of the head of the pancreas and the
duodenum (1).

           c. Paracentesis à refers to
the procedure in which a needle is inserted to remove excess fluids from the peritoneal
cavity (1)

           d. Shock-wave lithotripsy à is a surgical
procedure that destroys kidney stones (1) by sending shock waves to the kidneys.



20. A patient has to get
her gall bladder removed and is worried that she will never be able to eat food
that contains fat again. How do you respond? 


As a registered dietitian I
would emphasize on the importance of avoiding an excess amount of fats in the
diet, however, I would educate the patient that she can consume small and
adequate amounts of fat in her diet and that there is no need to be concerned. As
an RD I will educate the patient on foods to avoid GI tract distress such as bloating,
diarrhea, abdominal cramps, and flatulence. Such foods as spicy and high-fat
and processed food groups as red meats, starchy vegetables like potatoes.