SAS #19: Carbohydrate- and Fat-Modified Diets for Malabsorption Disorders; Nutrition Therapy for Liver and Gallbladder Diseases

Malabsorption

occurs when the body fails to digest and absorb nutrients normally. It can be caused by deficiencies in digestive secretions or damage to the intestinal mucosa.

Potential Causes of Malabsorption

Pancreatic disorders (enzyme or bicarbonate deficiencies), bile deficiency (e.g., severe liver disease), Inflammatory diseases or medical treatments that damage intestinal tissue, Surgical removal (resection) of a section of the small intestine and lastly certain medications.

all macronutrients and fat-soluble nutrients and some minerals as well

Malabsorption rarely involves a single nutrient. When pancreatic enzyme deficiencies cause malabsorption, what are affected? What if If fat is malabsorbed?

Endoscopy or Biopsy

Direct examination of the duodenal mucosa to reveal physical changes characteristic of intestinal diseases; Can be taken for analysis.

Stool Fat Analysis

Measures the fat content in a stool collection.

48 to 72 hour stool collection while the patient is on a high-fat diet (80–100 grams/day)

What is the preferred stool for Stool Fat Analysis?

More than 7g per day

Steatorrhea is diagnosed Stool Fat Analysis, if more than how many grams of fat are eliminated per day in the stool

Hydrogen Breath Test:

Used to diagnose lactose intolerance or malabsorption of other carbohydrates. Colonic bacteria digest unabsorbed carbohydrate and produce hydrogen gas, which is measured in the breath. Also used to determine the presence of excessive bacteria in the small intestine.

Xylose Absorption Test

Measures the small intestine’s ability to absorb nutrients normally using an oral dose of xylose.

Lipase and bile

What are the enzymes needed Fat malabsorption

Fat-restricted diet

If steatorrhea persists, this diet may be recommended to relieve intestinal symptoms (diarrhea, flatulence) and reduce vitamin/mineral losses.

Medium-chain triglycerides (MCT)

can be used as an alternative dietary fat source, as they do not require lipase or bile for digestion and absorption, but they do not provide essential fatty acids.

Bacterial overgrowth / Small Intestinal Bacterial Overgrowth (SIBO)

can occur when mechanisms like gastric acid and peristalsis are impaired.

Bacteria dismantle the bile acids, destroy mucosal enzymes (especially lactase) reducing absorptive surface

Why does Bacterial overgrowth causes malabsorption?

Treatment for SIBO

Antibiotics, surgical correction of anatomical defects, medications to stimulate peristalsis, and a lactose-restricted diet. Supplements are used to correct deficiencies, particularly fat-soluble vitamins, calcium, and B12

Lactose Intolerance

When there is a Loss or reduction of lactase, the enzyme that digests lactose. Approximately 75% of people worldwide have some degree of intolerance.

Diarrhea and increased intestinal gas

Common symptoms of Lactose Intolerance

Pancreatitis and Cystic fibrosis (CF)

Disorders of the Pancreas

Pancreatitis

Inflammatory disease of the pancreas.

Acute Pancreatitis

Typically caused by gallstones or alcohol abuse (70–80% of cases). Digestive enzymes become prematurely activated, destroying pancreatic tissue.

Nutrition Therapy for acute pancreatitis

Initial treatment involves withholding oral food and fluids. In severe cases, continuous tube feedings (sometimes using elemental formulas) may be started within the initial 48 hours. Protein needs are high (1.2–1.5 grams/kg body weight/day) due to inflammation.

Chronic Pancreatitis

Progressive, permanent damage of the pancreas resulting in impaired secretion of digestive enzymes and bicarbonate. About 70–80% of cases result from excessive alcohol consumption. Can lead to insulin and glucagon depletion, causing diabetes in 30–50% of patients.

Nutrition Therapy for chronic pancreatitis

Main treatment for malabsorption symptoms (especially steatorrhea) is pancreatic enzyme replacement. High protein (1.0–1.5 g/kg/day) and high energy (about 35 kcal/kg/day) are needed. Patients must completely avoid alcohol and quit smoking

Irreversible damage to pancreatic tissue leading to impaired enzyme and bicarbonate secretion

What is the hallmark of chronic pancreatitis?

Epigastric pain, steatorrhea, weight loss, and diabetes

What are classic symptoms of chronic pancreatitis?

To aid digestion and reduce steatorrhea due to enzyme deficiency

What is the role of pancreatic enzyme replacement therapy?

Cystic Fibrosis (CF)

The most common life-threatening genetic disorder among Caucasians. A protein mutation alters the viscosity and ion concentration of exocrine secretions.

They obstruct ducts - damaging tissue causing severe malabsorption of fat, protein, and fat-soluble vitamins (pancreas), as well as chronic infection (lungs)

What are the consequences of CF specifically the thickening of secretion for exocrine glands?

Nutrition Status of Patients under CF

hypermetabolic, chronically undernourished, and have difficulty maintaining weight.

Nutrition Therapy for CF

high-kcalorie, high-protein diet, Pancreatic enzyme replacement therapy, Routine multivitamin/mineral supplementation, and liberal salt use to replace sodium lost in sweat.

Celiac disease, Short Bowel Syndrome (SBS)

Disorders of the Small Intestine

Celiac Disease

An immune disorder characterized by an abnormal immune response to a protein fraction in wheat gluten and related proteins in barley and rye.

Dermatitis herpetiformis — an itchy, blistering rash

Which skin condition is associated with celiac disease?

Damage to the brush border reduces lactase enzyme activity, leading to lactose intolerance

Why does lactase deficiency occur in mucosal damage?

Lifelong adherence to a gluten-free diet. Patients must avoid ingredients derived from wheat, barley, and rye, which may be overlooked in products like beer, malt syrup, caramel coloring, and soy sauce. Instructions on preventing cross-contamination are essential.

Treatment for Celiac Disease

Short Bowel Syndrome (SBS)

Malabsorption resulting from the insufficient absorptive capacity left after surgical removal (resection) of a substantial portion of the small intestine.

Treatment for CF

Initially, total parenteral nutrition (TPN) is used, gradually transitioning to tube feedings and oral intake to promote intestinal adaptation. Initial oral intake involves sips of clear, sugar-free liquids. A high-kcalorie diet is encouraged, and very small, frequent feedings are used to maximize the remaining intestine's function

The liver

is the most metabolically active organ, central to processing, storing, and redistributing nutrients. It produces bile (stored in the gallbladder), synthesizes plasma proteins (e.g., albumin, clotting factors), and detoxifies drugs and alcohol. It also processes excess nitrogen for excretion as urea.

Fatty Liver (Steatosis)

Accumulation of fat (triglycerides) in liver tissue, resulting from an imbalance between the amount of fat the liver produces/picks up and the amount it exports via VLDL.

insulin resistance

Primary risk factor of Steatosis

Excessive alcohol ingestion

Primary cause of Steatosis

Steatosis

Often asymptomatic, but can lead to inflammation (steatohepatitis), liver enlargement (hepatomegaly), fatigue, and progression to cirrhosis or liver cancer.

Treatment for Steatosis

Eliminate the underlying cause (e.g., discontinuing alcohol or drugs). For obese/diabetic patients, treatment involves weight reduction, increased physical activity, or medications to improve insulin sensitivity. Rapid weight loss should be discouraged

Hepatitis

Liver Inflammation Most often caused by infection with viruses (A, B, C).

Hepatitis A (HAV)

Spread via fecal-oral transmission (contaminated food/beverages); usually resolves within a few months.

Hepatitis B (HBV)

A viral infection that targets the liver that is transmitted by infected blood/needles, sexual contact, or mother-to-infant.

Hepatitis C (HCV)

Spread by infected blood/needles; most cases progress to chronic illness. No vaccine is available for HCV.

Hepatitis

Causes symptoms of Fatigue, malaise, anorexia, pain, liver enlargement, and jaundice (yellowing of skin and eyes).

Nutritional therapy for Hepatitis

Small, frequent meals may be easier to tolerate for those with anorexia. Malnourished individuals require a diet including 1.0 to 1.2 grams of protein per kilogram of body weight each day. Alcohol and liver irritants must be avoided

Cirrhosis

The late stage of chronic liver disease, characterized by gradual destruction and extensive scarring (fibrosis) of liver tissue.

Cirrhosis

Can led ascites, Hepatic Encephalopathy, Malnutrition/Wasting

Ascites

Fluid accumulation in the abdomen caused by elevated pressure in the liver’s blood vessels (portal hypertension) and low levels of serum albumin. Ascites contributes to malnutrition.

Hepatic Encephalopathy

Abnormal neurological function, ranging from changes in personality and behavior to unresponsiveness and hepatic coma.

Malnutrition/Wasting

Anorexia, hormonal disturbances, and uremia contribute to severe protein-energy malnutrition (PEM).

Diuretics

Medications used treat ascites

lactulose or rifaximin

Medications used to treat encephalopathy by reducing ammonia

Gallstone Disease (Cholelithiasis)

Formation of crystalline masses in the biliary system from excessive concentration and crystallization of compounds in bile.

Cholesterol Gallstones

A type of gallstone (about 90% of cases) Solid deposits of cholesterol formed in the gallbladder or bile ducts

Pigment Gallstones

Biliary colic — severe, steady pain in the upper abdomen, often after fatty meals

What is a classic symptom of gallstones caused by temporary cystic duct obstruction?

Eating fatty foods, which stimulate gallbladder contraction and may dislodge a stone

What triggers biliary colic in patients with gallstones?

The Pain of biliary colic present in gallstone disease

Sudden onset of upper abdominal pain that may radiate to the back or shoulder, typically after meals.

Female gender, pregnancy, obesity and weight loss, aging, and ethnicity

Risk Factors / Those at risk for Cholesterol Stones:

Treatment for Gallstone Disease (Cholelithiasis)

Cholecystectomy (gallbladder removal) is the primary treatment for recurrent presence. Shock-wave lithotripsy (fragmentation) may be used for patients with few stones.