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Exam 2 Study Guide

Cumulative study guide for exam 2 Haiyan Maier

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Medical Nutrition Therapy (DIE4244)

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Florida State University

Academic year: 2020/2021

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MNT Exam 2 Study Guide Lecture 4: Gallbladder and Pancreatic Disease I. Gallbladder ● Lies underneath the right lobe of the liver ● Main functions: ○ Concentrate, store, and excrete bile ● Bile is made up of cholesterol, bilirubin, and bile salts ○ Excreted into the small intestine (duodenum) with pancreatic juice

II. Cholecystitis ● Inflammation of the gallbladder ● Can be acute or chronic ● Usually caused by gallstones obstructing the bile ducts ● Acute cholecystitis may occur in critically ill patients or if the flow of bile is impaired ● Chronic cholecystitis is caused by repeated, mild attacks of acute cholecystitis ○ Leads to thickening of the walls of the gallbladder ○ Gallbladder shrinks and loses functional ability ○ Aggravated by high fat diet

III. MNT for Cholecystitis ● Acute Cholecystitis ○ Oral feedings are discontinued ○ PN may be indicated ○ When feedings are resumed, a low-fat diet is recommended ■ A hydrolyzed low-fat formula or diet consisting of 30-45 grams of fat per day ● Chronic Cholecystitis ○ Long-term, low-fat diet (25-30% fat) ○ Water-soluble forms of fat-soluble vitamins IV. Cholelithiasis (Gallstones) ● The formation of gallstones (calculi) ○ Composed of cholesterol, bilirubin, and calcium salts ● Three types of stones: ○ Cholesterol-80% cases (contains about 10% cholesterol) ○ Pigment ○ Mixed stones ● Generally asymptomatic and may pass into the common bile duct and remain there indefinitely or may pass into the duodenum ● When stones slip into the bile ducts, they produce obstruction, pain, and cramps (Cholangitis) ● Pathophysiology → the exact cause of this disorder is not known: ○ Increased risk in: ■ High fat diet ■ Obesity, insulin resistance, and diabetes ■ Inflammatory bowel disease ■ Cystic fibrosis

■ Rapid weight loss

V. MNT for Cholelithiasis ● Nutrition implications ○ Gallstones are more prevalent in low-fiber, high-fat, Westernized diet ○ High consumption of refined carbohydrates increase the risk for developing gallstones ○ Vegetarian diets may reduce the risk of cholelithiasis ● MNT ○ Low fat (less than 30%) modest protein ○ Small frequent meals ○ During acute attack ○ NPO → complete bowel rest prior to surgery

VI. Formation of Gallstones ● Causes of gallstones: 1. Too much absorption of water from bile 2. Too much absorption of bile acids from bile 3. Too much cholesterol in bile 4. Inflammation of epithelium VII. Cholangitis ● Overview: ○ Inflammation of the biliary ducts secondary to obstruction of the common bile duct ○ Initial medical management ■ Fluids and broad-spectrum antibodies ● Cholecystectomy ○ Surgical removal of the gallbladder when gallstones are numerous, large, or calcified

VIII. Summary of MNT: ● Cholelithiasis ○ Avoid obesity and fasting; follow a low-fat diet ● Acute cholecystitis ○ Hold feedings or provide PN; then low-fat diet ● Chronic cholecystitis ○ Long-term low-fat diet (25-30% kcal from fat) ● Acute cholangitis ○ Fluids; NPO for 12 hours before surgery ● Cholestasis (reduced or blocked bile flow) ○ Occurs when no enteral feedings; need stimulation of biliary motility and secretions by enteral feedings if NPO

IX. Pancreas ● Elongated, flattened gland that lies in the upper abdomen behind the stomach ● Has endocrine and exocrine functions ● Pancreatic cells produce glucagon and insulin for absorption into the bloodstream (endocrine)

● Overview: ○ Chronic, irreversible inflammation leading to fibrosis with tissue calcification ○ Signs and symptoms: ■ Chronic abdominal pain ■ Elevated pancreatic enzyme levels ■ Weight loss, malnutrition, and/or steatorrhea ○ Diabetes in 30-50% of patients ● MNT for Chronic Pancreatitis ○ High risk for protein-energy malnutrition (PEM) ■ 35 kcal/kg/day with 1-1 g/kg protein ○ Antioxidants, MCT ○ Pancreatic enzyme replacements if patient shows signs of fat malabsorption ■ 10,000 IU per snack ■ 40,000-50,000 IU per meal ■ 2000 units lipase per 1 gram of fat ingested ○ Low-fiber diet is recommended XV. Enteral Nutrition for Severe Acute Pancreatitis ● Benefit: ○ Use of the GIT decreases the stress response ○ Has been associated with less infectious complications and decreased length of hospital stay ○ Less expensive ○ Associated with a faster return to an oral diet

Lecture 5: Diseases of the Liver I. Physiology and Function of the Liver ● Largest solid internal organ in the body, about 1 kg, about the size of a football ● Two functional lobes: right and left ● Functional unit: lobule ● Each lobe is made up of thousand of lobules around a central vein ● You cannot survive without a liver, but only 10% to 20% of function is needed to sustain life ● Cells of liver: resilient/regenerate ● 1500 mL of blood/min circulates through the liver ● Performs more than 500 tasks ○ Produces bile ○ Bilirubin elimination ○ Metabolizes hormones and drugs ○ Synthesizes proteins, glucose, and clotting factors ○ Stores vitamins and minerals ○ Changes ammonia to urea ○ Converts fatty acids to ketones ○ Metabolizes macronutrients

II. Common Lab Tests Used to Test for Liver Function

● Blood test ○ Ammonia → increased in cirrhosis, liver failure ● Protein Studies ○ Albumin and total protein → decreased value associated with hepatic disease and inflammatory state ● Enzymes (increased or elevated in hepatic injuries) ○ Alkaline phosphatase (ALP): increased activity occurs in hepatic disease and in chronic obstruction of the biliary duct; increased levels suggest cholestasis ○ Aspartate aminotransferase (AST): less specific enzyme to detect hepatic disease secondary to cellular necrosis ○ Alanine aminotransferase (ALT): most sensitive test to detect hepatocellular injury secondary to exacerbation of infectious hepatitis ○ AST:ALT ratio of 2:1 or higher suggests alcohol injury ● Pigment Studies ○ Serum bilirubin (total): reflects the ability of the liver to conjugate and excrete bilirubin; increased in liver and biliary disease, causing jaundice clinically ■ Jaundice → yellowish tint to body tissues caused by large quantities of bilirubin in extracellular fluid (can be hemolytic, hepatic, or obstructive) III. Bilirubin Elimination IV. Disease of the Liver ● Hepatitis ● Nonalcoholic Fatty Liver Disease ● Alcholic liver disease ● Cirrhosis ○ Portal hypertension/Ascites ○ Hepatic Encephalopathy V. Hepatitis ● Hepatitis A Virus (HAV) ○ Transmitted almost exclusively by the fecal-oral route; contaminated drinking water, food, sewage ● Serum Hepatitis or Hepatitis B (HBV) ○ Transmitted via blood, blood products, semen, and saliva ○ Can be acute or chronic ○ Development of cirrhosis, liver cancer ● Hepatitis C (HCV) ○ Exposure to blood or bodily fluids from an infected person ○ Associated with development of chronic liver disease, cirrhosis, and need for liver transplant ● Hepatitis D and E (HDV; HEV) ○ Uncommon ○ Acute infection ○ Rare in the US ● Nutrition Therapy for Viral Hepatitis

● Nutritional Therapy for Individuals with Alcohol Dependency/Alcoholic Hepatitis ○ Nutritional implications: ■ Imbalance diet and/or anorexia ■ Intestinal maldigestion and malabsorption ○ Nutritional diagnoses: ■ Increased energy expenditure; inadequate energy intake; inadequate oral food/beverage intake; inadequate protein-energy intake; malnutrition; inadequate vitamin/mineral intake; impaired nutrient utilization; underweight; altered nutrition-related laboratory values; food-medication interactions; and involuntary weight loss ● MNT for Alcoholic Liver Disease ○ Abstinence from alcohol ○ Manage malnutrition ○ Manage vitamin deficiency ■ E., thiamin

VIII. Malnutrition in the Alcoholic ● Displacing the intake of adequate calories and nutrients ○ Lighter drinker: alcohol addition ○ Heavy drinker: alcohol substitution ● Energy metabolism of lipids and carbohydrates is compromised ○ Impaired oxidation of triglycerides results in fat deposition in the hepatocytes ● Reduced intake and altercations in absorption, storage of vitamins and minerals ○ E., Vitamin A, Thiamin, and Folate ○ Thiamin deficiency is most common, and is responsible for Wernicke encephalopathy ■ A triad of acute mental confusion, ataxia, and ophthalmoplegia ○ Thiamin deficiency occur in up to 80 percent of alcoholics IX. Oral Nutritional Supplementation Often Give to Chronic Alcoholics X. Cirrhosis ● End stage chronic liver disease ○ May be clinically silent ○ The normal architecture of the liver is replaced by fibrous tissue, blocking the flow of blood through the organ ○ Irreversible ● Causes of Cirrhosis in the US ○ Most common causes of cirrhosis in the United States: ■ Hepatitis C (26%) ■ Alcoholic liver disease (21%) ■ Hepatitis C plus alcoholic liver disease (15%) ■ Cryptogenic causes (18%); can be due to NAFLD ■ Hepatitis B, which may be coincident with hepatitis D (15%) ■ Miscellaneous (5%) ○ Miscellaneous causes of chronic liver disease and cirrhosis: ■ Autoimmune hepatitis

■ Primary biliary cirrhosis ■ Secondary biliary cirrhosis (associated with chronic extrahepatic bile duct obstruction) ● The most common signs and symptoms of cirrhosis are: ○ Fatigue, weakness, nausea, poor appetite ○ Anorexia ○ Weight loss (sometimes masked by ascites) ○ Portal hypertension and liver failure ○ Ascites ■ The accumulation of fluid, serum protein, and electrolytes within the peritoneal cavity caused by increased pressure from portal hypertension and decreased production of albumin ○ Hepatic encephalopathy ● Nutrition Assessment for Cirrhosis ○ Moderate to severe malnutrition is common ○ Causes: ■ Inadequate oral intake caused by anorexia, dysgeusia, early satiety, nausea, and vomiting ■ Dietary restriction ■ Maldigestion and malabsorption ■ Altered metabolism secondary to liver dysfunction ■ Increased energy expenditure ■ Protein losses from paracentesis ● MNT for Cirrhosis ○ Energy ■ 35-40 kcal/kg per day ○ Carbohydrates ■ Glucose alteration: treat like diabetes ○ Fat ■ <30% of total kcal; low fat (40g/day) for significant stool fat loss ■ MCT may be beneficial for fat malabsorption ○ Protein - should not be restricted, even for encephalopathy ■ Up to 1/kg per day depending on the degree of malnutrition ● Nutrient Requirements in Cirrhosis ○ Vitamins and minerals ■ Supplementation is needed in all patients ■ Deficits in Vitamin A, D, E, K, B1, B3, B6, iron, Mg, Phos, Zinc ■ Caused by steatorrhea, alcoholism, diuretics, diarrhea, GI bleeding ■ Sodium restriction in ascites (<2 grams per day) ○ Fluid restriction is normally recommended ○ Common feeding problems: anorexia, nausea, dysgeusia, and other GI symptoms ● Other Aspects of Cirrhosis ○ Portal hypertension ■ PN if needed for at least 5 days

XIV. Four Stages of Hepatic Encephalopathy ● Stage 1: Mild confusion, agitation, irritability, sleep disturbance, decreased attention ● Stage 2: Lethargy, disorientation, inappropriate behavior, drowsiness ● Stage 3: Somnolence but arousable, incomprehensible speech, confusion, aggression when awake ● Stage 4: Coma

Lecture 6: MNT for Pulmonary Diseases

Lecture 7: Neoplastic Disease I. Cancer ● Overview: ○ Disorder of cell growth and regulation ■ No limits for cellular respiration ■ Production of cells that serve no purpose ○ Second leading cause of mortality ● Etiology of Cancer ○ Carcinogenesis: ■ Multifactorial ● Aging; tobacco use; exposure to sunlight, certain chemicals, and other substances; certain hormones; family history; alcohol consumption; poor diet; lack of PA and being overweight ■ Carcinogens ● Chemicals and other substances that can cause cancer ■ Genetics ● Oncogenes: exert effect on tumor growth by controlling cell division ● Tumor-suppressor genes: cause apoptosis, but may lose function if mutated II. Cancer Prevention III. Etiology of Cancer ● Nutritional Risk Factors: ○ Heavy consumption of red meat ○ Food preparation methods such as smoking, salting, and pickling foods and high- temperature cooking of meats ○ Total fat / certain types of fat ○ Alcohol ○ Obesity ● Nutritional Protective Factors: ○ Fruits and vegetables ○ Carotenoids, resveratrol. Quercetin, curcurmin, diallyl disulfide, and etc. ○ Whole grains ○ Fiber ○ Vitamin D ● Biological effects of diet on cancer: ○ Gut dysbiosis

○ Adverse epigenetic events ○ Inflammation and immune function ○ Metabolic and hormonal disturbance ○ Oxidative stress IV. Body Fatness and the Hallmarks of Cancer ● Several exposures are linked to more than one type of cancer ● Greater body fatness has systemic impact: ○ Hyperinsulinemia ○ Increased estradiol ○ Inflammation ● These systemic factors affect a wide range of cellular and molecular processes that can subsequently promote cancer development and progression ● This impacts the hallmarks of cancer via numerous mechanisms V. Strong Evidence Findings

VI. Nutrition Interventions in Cancer Treatment ● Medical Treatment ○ Chemotherapy ■ Systemic treatment that affects the whole body ■ Medication given to eradicate cancer, control size and spread, and/or alleviate symptoms ○ Radiation ■ Alteration in cellular and nuclear material (DNA) from electromagnetic rays and charged particles; continuously proliferating cells most susceptible ■ Toxicity of RT is localized to region being irradiated ■ Administered internally or externally ○ Surgery ■ Dependent on location & size of tumor and health of individual ● Chemotherapy Side Effects ○ Common side effects due to toxicity of rapidly dividing cells: ■ N/V ■ Neutropenia → abnormally low level of neutrophils ■ Thrombocytopenia → deficiency of platelets in the blood ■ Anemia ■ Diarrhea ■ Mucositis ■ Alopecia ■ Others: cardiotoxicity, neurotoxicity, nephrotoxicity ● Radiation Side Effects ○ Delayed wound healing ○ Fatigue, mucositis, dysgeusia, xerostomia, dysphagia, odynophagia, severe esophagitis, dehydration (head and neck) ■ Odynophagia: pain when swallowing

■ High fiber if not early satiety ■ Limit gas-forming foods, carbonated beverages, straws, and chewing gum ○ Pain with eating ■ Avoid high fiber ■ Chew food well ○ Taste changes ■ Rinse mouth often ■ Use plastic utensils if have metallic taste ■ Use tart flavors to enhance flavor ○ Fatigue ■ Physical activity ■ Use easily prepared foods and those that are not difficult to chew and swallow ● Nutrition Intervention for Pancreatic Cancer ○ Nausea and vomiting ■ Eliminate strong odors ■ Dry crackers/toast ■ Avoid overly sweet, greasy/fried, or spicy foods ■ Eat room temperature foods ■ Small, frequent meals and snacks ○ Poor appetite ■ Avoid overly sweet, greasy/fried, or spicy foods ■ Small, frequent meals and snacks ■ Liquid nutritional supplements ■ Light exercise

Lecture 9: The Immune System and Food Allergies I. The Immune System ● Overview: ○ Defends the body from pathogens ■ Ckears the body of foreign substances or antigens such as viruses, bacteria, blood cells, and tissue cells ○ Removes damaged and dead cells ○ Surveillance function: identify and attack tumor cells ○ Two major categories: ■ Innate immunity and acquired immunity ● Cells of the Immune System ○ All cells of the immune system originate from the stem cells of the bone marrow ○ These immune cells, also called white blood cells or leukocytes ■ Monocytes (macrophages) ■ Neutrophils, basophils, and eosinophils ■ Lymphocytes: T cells and B cells ■ Natural killer cells (NK cells) II. Two Major Categories ● Innate or nonspecific immunity → first line of defence against infectious agents

○ Cellular response: inflammation ● Acquired immunity → specific responses selectively targeted against a particular foreign material ○ Two phases: ■ Recognize the antigen ■ Mount a reaction to it

III. Malnutrition and Immunodeficiency ● Overview: ○ A combination of factors including insufficient protein, energy, and micronutrients ○ Proper nutrition for optimal immune function begins in utero (maternal nutrition) ■ For example → prenatally undernourished adolescents produce lower antibody response to vaccination ○ Causes of under nutrition: ■ Adherence to fad diets ■ Socioeconomic factors

Lecture 10: Nutritional Therapy for Autoimmune Disease I. Autoimmune Disease ● Overview ● Causes ● How many autoimmune diseases are there? II. Immunity III. Rheumatoid Arthritis ● Overview: ○ Disease that attacks the joints ○ (HLA)-DRB1 is considered the primary antigen ○ One of the most common autoimmune diseases ○ Affects women at a much higher rate ● MNT for Rheumatoid Arthritis: ○ Omega-3 supplementation ○ The Mediterranean diet showed significant improvement compared to a Western diet ○ A four-week vegetarian diet, patients saw significant pain reduction that lasted the year following ○ Plant-based and elimination diets also show benefits but are much harder to adhere to for most IV. Systemic Lupus Erythematosus ● Overview: ○ Widespread disease whose symptoms differ based on the individual ○ Most common sign is the butterfly rash on the patient’s face ○ Can lead to inflammation of the lungs and heart, as well as anemia ○ Lack of blood supply can lead to bone tissue death ● MNT for SLE

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Exam 2 Study Guide

Course: Medical Nutrition Therapy (DIE4244)

7 Documents

Students shared 7 documents in this course

University: Florida State University

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MNT Exam 2 Study Guide

Lecture 4: Gallbladder and Pancreatic Disease

I. Gallbladder

● Lies underneath the right lobe of the liver

● Main functions:

○ Concentrate, store, and excrete bile

● Bile is made up of cholesterol, bilirubin, and bile salts

○ Excreted into the small intestine (duodenum) with pancreatic juice

II. Cholecystitis

● Inflammation of the gallbladder

● Can be acute or chronic

● Usually caused by gallstones obstructing the bile ducts

● Acute cholecystitis may occur in critically ill patients or if the flow of bile is impaired

● Chronic cholecystitis is caused by repeated, mild attacks of acute cholecystitis

○ Leads to thickening of the walls of the gallbladder

○ Gallbladder shrinks and loses functional ability

○ Aggravated by high fat diet

III. MNT for Cholecystitis

● Acute Cholecystitis

○ Oral feedings are discontinued

○ PN may be indicated

○ When feedings are resumed, a low-fat diet is recommended

■ A hydrolyzed low-fat formula or diet consisting of 30-45 grams of fat per day

● Chronic Cholecystitis

○ Long-term, low-fat diet (25-30% fat)

○ Water-soluble forms of fat-soluble vitamins

IV. Cholelithiasis (Gallstones)

● The formation of gallstones (calculi)

○ Composed of cholesterol, bilirubin, and calcium salts

● Three types of stones:

○ Cholesterol-80% cases (contains about 10% cholesterol)

○ Pigment

○ Mixed stones

● Generally asymptomatic and may pass into the common bile duct and remain there indefinitely or

may pass into the duodenum

● When stones slip into the bile ducts, they produce obstruction, pain, and cramps (Cholangitis)

●Pathophysiology → the exact cause of this disorder is not known:

○ Increased risk in:

■ High fat diet

■ Obesity, insulin resistance, and diabetes

■ Inflammatory bowel disease

■ Cystic fibrosis

Exam 2 Study Guide

Medical Nutrition Therapy (DIE4244)

Florida State University

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Exam 2 Study Guide

Course: Medical Nutrition Therapy (DIE4244)

University: Florida State University

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