營養(yǎng)與肝膽胰疾病課件

營養(yǎng)與肝膽胰疾病Hepatopancreatobiliary

DiseaseandNutrition

主頁目錄-HomeLIVERisthelargestorganinthebody.Itisfoundhighintherightupperabdomen,behindtheribs.Therearetwolobes:abigoneontherightandasmallleftone.Bloodrunsthroughthelivereverytwominutes.第一節(jié)肝炎肝臟與膽囊、胰腺在營養(yǎng)物質(zhì)的消化、吸收、排泄、生物轉(zhuǎn)化以及代謝中發(fā)揮重要的作用。Togetherwithgallbladderandpancreas,theyplaysignificantrolesinthedigestion,absorption,excretion,bioconversion,metabolismofnutrients.主頁目錄-Home定義Definition肝炎各種原因引起的，以肝實(shí)質(zhì)細(xì)胞變性壞死為主要病變的肝功能損害Hepatitisimpliesinjurytothelivercharacterizedbythepresenceofinflammatorycellsinthetissueoftheorgan.主要病癥Symptoms乏力、食欲減退、厭油膩、肝區(qū)不適、腹脹等Themainsymptomsincludehypodynamia,lossofappetite,nauseaorvomiting,abdominaldiscomfortordistension分類Categorizations根據(jù)病程長短分急性肝炎〔病程不超過半年〕和慢性肝炎〔病程在半年以上〕肝炎以病毒性肝炎〔viralhepatitis〕最常見，也包括由于酒精濫用、藥物使用不當(dāng)、環(huán)境毒物以及遺傳引起的肝炎Acutehepatitis(<halfayear);chronichepatitis(<halfayear)Hepatitisiscausedmostlybyviruses,butotherfactorslikealcohol,drugs,toxinsandhereditymayalsoleadtohepatitis.病毒性肝炎是法定乙類傳染病，傳染性較強(qiáng)、傳播途徑復(fù)雜、流行面廣泛、發(fā)病率高局部乙型、丙型和丁型病毒性肝炎患者可演變成慢性，并可開展為肝硬化和原發(fā)性肝細(xì)胞癌ViralhepatitisisoneoftheClassBnotifiableinfectiousdiseasesandeasilyinfected,withahighprevalence.HepatitisA,CandDmaydevelopintolivercirrhosisorprimarylivercellcancer一、肝炎與營養(yǎng)的關(guān)系

Hepatitis&Diet/Nutrition過度節(jié)食，減肥，營養(yǎng)不良，脂肪和能量攝入過剩肥胖，機(jī)體的抵抗力下降，過量飲酒損害肝臟功能水質(zhì)和食物受到有害的重金屬〔鎘、銅、汞等〕、化合物〔苯、酚等〕、農(nóng)藥〔有機(jī)磷等〕污染后可引起中毒性肝炎Overeat,ondiet,malnutrition,excessiveintakeoffatandenergy,declineinimmunefunctionAndwater/foodcontaminatedwithheavymetals(Cd,Cu,Hg),compounds(benzene,phenol)orpesticide(organophosphorus)maycausehepatitis碳水化合物代謝障礙

DisorderofCarbohydrateMetabolism肝糖原合成減少，加上病人進(jìn)食少而處于饑餓狀態(tài)，易出現(xiàn)低血糖肝臟將乳酸轉(zhuǎn)變?yōu)樘窃墓δ軠p弱，易引起乳酸在體內(nèi)蓄積，四肢酸痛，重者可出現(xiàn)酸中毒DeceasedglycogenformationanddietintakeeasilyleadtohypoglycemiaImpairedfunctionofconvertinglacticacidtohepatincauseslacticacidaccumulation,painfullimbsandevenacidosis蛋白質(zhì)代謝障礙

DisorderofProteinMetabolism肝細(xì)胞合成蛋白質(zhì)障礙，血漿白蛋白水平下降凝血酶原和纖維蛋白原等多種凝血因子合成障礙，重癥者可發(fā)生皮膚和粘膜出血不止鳥氨酸循環(huán)受影響，尿素合成能力下降，使血氨水平增高BlockedproteinsynthesisinlivercellsanddecreasedplasmaalbuminlevelProthrombin,fibrinogenandotherbloodclottingfactorssynthesisobstructed;mucocutaneoushemorrhageOrnithinecycleinterfered,declinedureaformationandelevatedbloodammonialevel脂肪代謝障礙

DisorderofLipidMetabolism肝臟受損，各種脂肪轉(zhuǎn)變?yōu)檠獫{中磷脂，膽固醇、膽固醇脂與脂蛋白的合成過程發(fā)生障礙，脂肪不能釋放出肝臟以供人體組織利用脂肪就淤積于肝內(nèi)而形成脂肪肝肝內(nèi)結(jié)締組織增生而導(dǎo)致肝硬化Damagedliver;lipidsturnintoplasmaphospholipids;thecompositionofcholesterol/cholesterolesterandlipoproteinisimpairedandlipidcannotbeusedbythebodyfromtheliverLipidaccumulationleadstofattyliverHyperplasiaofreticulartissuesinlivercausescirrhosis肝臟在脂質(zhì)代謝中的作用Liverinthemetabolismoflipids

維生素和礦物質(zhì)代謝障礙

DisorderofVitamin/MineralMetabolism肝內(nèi)有胡蘿卜素酶95%的維生素A和大量維生素D貯存于肝內(nèi)礦物質(zhì)如鐵和銅在肝內(nèi)貯存亦甚多Carotenaseinliver95%ofvitaminAandmostvitaminDarestoredinliverMinerals,likeironandcopper,areaboundinliver維生素B族在肝內(nèi)形成輔酶參與新陳代謝；維生素C能促使肝糖原形成、保護(hù)肝內(nèi)酶系統(tǒng)、增加肝細(xì)胞抵抗力及促進(jìn)肝細(xì)胞再生B-complexvitaminsbecomecoenzymesandtakepartinmetabolisminliver;vitaminCfacilitatesglycogenformation,protectstheenzymesinliver,increasestheimmunefunctionoflivercellsandpromoteslivercellsproliferation二、營養(yǎng)防治

NutritionPrevention/Treatment合理的膳食結(jié)構(gòu)、少喝酒和清潔的飲用水可減少肝炎的發(fā)生營養(yǎng)治療的目的是防止加重肝臟的負(fù)擔(dān)和損傷，同時(shí)給予充分營養(yǎng)以保護(hù)肝臟、促進(jìn)肝臟細(xì)胞的再生和功能的恢復(fù)Balanceddiet,noalcoholandcleanwatermayreducetheincidenceofhepatitisThegoalofnutritiontherapyistodecreasetheburdenanddamagetoliver,andmeanwhileprovidesufficientnutritiontoprotectandpromotetheregenerationandrecoveroflivercells1．急性期AcutePhase原那么是保證有足夠的蛋白質(zhì)、糖類、多種維生素和礦物質(zhì)，適量的脂肪，即給予低脂肪、易消化、高維生素、高碳水化合物的清淡飲食選用富有營養(yǎng)、易消化吸收的流質(zhì)或半流質(zhì)飲食，少量屢次用餐Adequateprotein,sugar,multi-vitaminsandminerals,moderatefat,,lowfat,highvitamin,highcarbohydrateandeasilyabsorbed-dietLiquidorsemi-liquiddietthatarenutritiousandeasilyabsorbed/digested;eatoftenandlessatonetime2.慢性期Chronic適宜的能量一般成人每天以～兆焦耳〔2000～2500kcal〕為宜；結(jié)合具體情況作相應(yīng)的能量攝入調(diào)整AppropriateenergyintakeGenerally,adultsneeds8.4~10.5MJ(2000~2500kcal)energydaily;adjustthevolumeaccordingly.足量優(yōu)質(zhì)蛋白Adequategoodprotein蛋白質(zhì)是肝細(xì)胞再生、肝功能恢復(fù)所需要的主要原料肝病時(shí)，易出現(xiàn)負(fù)氮平衡Proteinisthemainmaterialthatthelivercellsneededforcellproliferationandfunction-recoveryNegativenitrogenbalanceoftenoccursinliverdiseases蛋白質(zhì)的供給量應(yīng)占總能量的15％，并以質(zhì)優(yōu)、量足、產(chǎn)氨少的蛋白質(zhì)為主每日供給適量的動物性蛋白和蛋氨酸食物，如瘦肉、蛋、魚、豆類及豆制品等Proteinshouldbethe15%oftotalenergy;goodprotein,adequateamount,lessammoniaproductionProvideanimalproteinandmethioninerichfoodeveryday,likeleanmeat,egg,fish,soyorsoyproduct食物選擇應(yīng)富含必需氨基酸，且種類齊全，特別要多供給魚、蝦、鴨、去皮雞肉、牛奶、黃豆、玉米、小米、糯米、菜花、小紅棗等含支鏈氨基酸多的食物少吃帶皮雞肉、豬肉、牛肉、羊肉、兔肉等含芳香族氨基酸包括酪氨酸、苯丙氨酸、色氨酸多的食物Essentialaminoacidrichfood,variouskinds,especiallyfish,shrimp,duck,skinlesschicken,milk,soy,corn,millet,stickyrice,cauliflower,reddateandotherbranchedaminoacidrichfoodChickenwithskin,pork,beef,mutton,rabbitandotheraromaticaminoacid(liketyrosine,phenylalanine,tryptophan)richfoodshouldbeavoided.適量的碳水化合物ModerateCarbohydrate

肝病時(shí)易出現(xiàn)低血糖和乳酸堆積碳水化合物節(jié)約蛋白質(zhì)，增加肝糖原儲藏，維持肝微粒體酶的活性，增強(qiáng)肝細(xì)胞對毒素的抵抗力每日供給量占總能量的60%～70%為宜，主要從米、面、谷類食物中攝取HypoglycemiaandlacticacidaccumulationoftenhappenduringliverdiseasesCarbohydratecansaveprotein,increasetheglycogencontent,maintainhepatomicrosomeenzymeactivity,andincreasetheresistancetotoxinsCarbohydrateshouldprovide60~70%ofthetotalenergy,mainlyfromrice,flourandothergrains不過分限制脂類Don’trestrictfat每天供給50～60g脂肪，脂肪供給量可占總熱量的20%～25%宜采用易消化的植物油限制膽固醇高的食物，如豬油、動物內(nèi)臟、蛋黃、烏賊魚、貝類等，減輕肝臟的負(fù)擔(dān)，改善膽固醇的代謝障礙50~60gfateveryday,20~25%ofthetotalenergyPlantoilthatareeasilydigestedRestricthighcholesterolfood,likelard,animalviscera,eggyolk,cuttlefishandseashell,torelievetheburdenofliver,improvecholesterolmetabolism補(bǔ)充充足維生素AdequateVitamins維生素對肝細(xì)胞的解毒、再生和提高免疫力等方面有特殊意義；一些抗氧化營養(yǎng)素如維生素E、A、C等有保護(hù)肝臟免受損傷的作用Vitaminshavespecialmeaningsforthedetoxification,regeneration,immunityfunctionsoflivercells;someantioxidants,likevitaminE,AandCcanpreventtheliverfromoxidativedamage選食含B1較多的全麥、花生、豆芽和新鮮蔬菜、水果外，必要時(shí)增服合成制劑富含維生素A的食物，主要為胡蘿卜、深綠色菜葉、牛奶、蛋黃和肝臟肝炎病人維生素C的需要量增加，而存量減少，主要來源為新鮮蔬菜Eatmorewholegrains(richvitaminB1),peanut,beansproutandfreshvegetables&fruits;takesupplementswhennecessaryFoodrichinvitaminAincludescarrot,darkgreenvegetables,milk,yolkandliverTheamountofvitaminCshouldbeincreasedinliverdiseasespatients,withmainlyresourcesfromfreshvegetables豐富的膳食纖維和水分

Enoughfiberandwater培養(yǎng)良好的飲食習(xí)慣少食多餐，每日4～5餐，定時(shí)定量，食物應(yīng)清淡、可口、易消化，原料必須新鮮，嚴(yán)禁暴飲暴食；戒酒

Regulardieteatlessbutmoreoften,4~5mealsperday,atfixedtimeandvolume;thefoodshouldcontainlessfat,easilydigested,fresh;noengorgementandalcohol第二節(jié)脂肪肝FattyLiver脂肪肝系一種多病因引起肝細(xì)胞內(nèi)脂質(zhì)蓄積過多的病理狀態(tài)脂肪肝的發(fā)病率在我國明顯上升，據(jù)不完全統(tǒng)計(jì)脂肪肝的發(fā)病率在10%左右Fattyliverisareversibleconditionwherelargevacuolesoftriglyceridefataccumulateinlivercellsviatheprocessofsteatosis.Theincidenceoffattyliver,whichinChinaisapproximately10%,isincreasingobviously.一、脂肪肝與營養(yǎng)的關(guān)系

FattyLiverandNutrition“酒精性〞脂肪肝酒精對肝細(xì)胞有較強(qiáng)的直接毒害作用，可使轉(zhuǎn)運(yùn)到肝臟的脂肪增加，肝內(nèi)脂肪的分解代謝降低，運(yùn)出減少，脂肪堆積于肝臟AlcoholicFattyLiveralcoholdoesstronganddirectharmtolivercells,increasesthefatcontentinliver,decreasesthemetabolismandtransportoffatandcausesfataccumulation營養(yǎng)不良性脂肪肝過度節(jié)食、長時(shí)間饑餓、神經(jīng)性厭食、腸道病變引起營養(yǎng)素吸收不良、能量供給缺乏、蛋白質(zhì)供給低下都會導(dǎo)致脂肪發(fā)動增加；磷脂合成受影響，脂蛋白生成缺乏。大量游離脂肪釋放到血液中，進(jìn)入肝臟，超過脂蛋白轉(zhuǎn)運(yùn)能力而沉積于肝內(nèi)MalnutritionOverslimming,longtimehunger,anorexianervosa,intestinaltractdiseaseslimittheabsorptionofnutrients,supplyofenergyandprotein,whichallcausehigherfatmobilization,lessphospholipidsandlipoproteinformation.Largeamountoflipidisreleasedtobloodandgoestoliver,andfinallyexceedthelipoproteincapabilityandaccumulatesinliver營養(yǎng)過剩性脂肪肝偏食葷菜、甜食，攝入過多的脂肪和碳水化合物，在引起高血脂的同時(shí)，還使肝內(nèi)脂肪代謝紊亂，造成肝內(nèi)脂肪蓄積Hyperalimentaryfattyliver---preferenceforanimalfood,sweets,andover-intakeoffatandcarbohydratecausehyperlipemia,disorderoflipidmetabolisminliverandeventuallyfataccumulationinliver二、營養(yǎng)防治NutritionalTherapy1．調(diào)整飲食結(jié)構(gòu)，保持營養(yǎng)均衡2．主食不要過于精細(xì)，注意粗細(xì)糧搭配3．每日進(jìn)食一定量的蔬菜和水果，經(jīng)常食用豆制品4．動物性食品以魚類、禽類、兔肉為主，適量食用牛、羊肉，少吃豬肉，尤其是肥肉、豬大腸1.Keepabalanceddietandnutrition2.Eatmorewholegrainfood3.Eatvegetablesandfruitseveryday,andsoyproductsregularly4.Morefish,poultry,rabbit,moderatebeefandmutton,lesspork,nofatandporkintestine5．建立合理的膳食制度，均衡地安排三餐的飲食，少吃零食6．饑飽適當(dāng)，切忌暴飲暴食，不偏食、挑食7．飲酒要適量，不要酗酒5.Keeparegulardietandeatlesssnacks6.Noengorgement,nomonophagiaandpickyinfood7.Moderateifdrinkwines營養(yǎng)治療的目的消除或減輕肝臟脂肪沉積，阻止脂肪肝開展和惡化；改善肝功能，保證機(jī)體營養(yǎng)需要，防止并發(fā)癥Goalsofnutritionaltherapyeliminateoralleviateliverfataccumulation,improveliverfunctions,provideadequatenutrients,andpreventcomplications營養(yǎng)治療原那么Principles1．糾正營養(yǎng)不良對營養(yǎng)不良性脂肪肝患者應(yīng)給予高蛋白飲食及足夠的糖類及脂肪，選用牛奶、雞蛋、魚、蝦、蟹等和富含不飽和脂肪酸的植物油逐步增加攝入量1.Correctmalnutritiondiethighinproteinandenoughcarbohydrateandfat,choosemilk,egg,fish,shrimp,crabandplantoilwithrichpoly-unsaturatedfattyacidIncreasegradually2．控制能量的攝入對從事輕體力活動、體重在正常范圍的脂肪肝患者，能量以126～147kJ〔30～35kcal〕/〔kg·d〕計(jì)算肥胖或超重者以84～105kJ〔20～25kcal〕/〔kg·d〕計(jì)算，使體重降至正常范圍內(nèi)2.ControlenergyintakeEnergyintakeat126～147kJ〔30～35kcal〕/〔kg·d〕forthelightphysicallaborandnormalweightpatients84～105kJ〔20～25kcal〕/〔kg·d〕forthepatientswhoisobesityoroverweightuntiltheirweightgettonormal3．限制脂肪和碳水化合物的攝入脂肪和碳水化合物分別以～〔kg·d〕和2～4g/〔kg·d〕計(jì)算宜選用植物油或含不飽和脂肪酸多的食物，如魚類；少吃或不吃煎炸食品碳水化合物主要由糧谷供給，總量應(yīng)限制3.Limitfatandcarbohydrateintake～〔kg·d〕～〔kg·d〕ofcarbohydrateChooseplantoil/foodrichinPUFA,likefish;little/nofriedfoodCarbohydrateshouldbeprovidedmainlyfromgrains;thetotalamountshouldbelimited4．增加蛋白質(zhì)的攝入蛋白質(zhì)以～〔kg·d〕計(jì)算，每天供給90～120g優(yōu)質(zhì)蛋白質(zhì)應(yīng)占適當(dāng)比例，多項(xiàng)選擇用豆制品、瘦肉、魚、蝦、去脂牛奶或酸奶等4.Increaseproteinintake～〔kg·d〕protein,totally90~120gperdayGoodproteinshouldbemore,eatmoresoyproducts,leanmeat,fish,shrimp,skimmilkoryoghurt5．供給充足的維生素、礦物質(zhì)及膳食纖維供給富含葉酸、膽堿、維生素B6、維生素B12、維生素C、鉀、鋅、鎂的食物飲食不宜過分精細(xì)，主食應(yīng)粗細(xì)搭配，多吃雜糧，保證新鮮蔬菜尤其是綠葉蔬菜的供給，每天食用新鮮蔬菜500g，以保證維生素、礦物質(zhì)及膳食纖維的供給5.Adequatevitamins,mineralsandfibersEatfoodrichinfolicacid,choline,vitaminB6,B12,C,potassium,zinc,magnesianEatmorewholegrainfood,freshgreenvegetables(500gperday),toensuretheadequateintakesofvitamins,mineralsandfiber6．限制食鹽，適量飲水每天食鹽的用量以6g為宜適量飲水可促進(jìn)機(jī)體的代謝及代謝廢物的排泄6.Limitsalt,drinkenoughwaterLessthan6gsaltperdayDrinkenoughwatercanpromotebodymetabolismandexcretionofmetabolicwaste7．增加富含蛋氨酸食物的攝入小米、莜麥面、芝麻、油菜、菠菜、菜花、甜菜頭、海米、干貝、淡菜等食品富含蛋氨酸7.IncreasethefoodrichinmethionineMillet,hullessoat,sesame,rape,cauliflower,sugarbeet,driedshrimps,shellfish,musselandsoon8．飲食宜清淡，忌辛辣和刺激性食物忌姜、辣椒、胡椒、芥末、咖喱，少用肉湯、雞湯、魚湯等含氮浸出物高的食物，絕對禁酒8.Plainfood,nopungentandstimulusNoginger,chillies,pepper,mustard,garlic,curry;lessmeat/chicken/fishsoupthatcontainmuchnitrogen;noalcohol9．選用降脂食物牛奶、兔肉、蘿卜、大蒜、洋蔥、芹菜、黃瓜、蘑菇、海帶、黑木耳、蘋果、紅棗、山楂、大豆制品、燕麥、麥麩、花生、魔芋、玉米以及茶葉均有降脂作用9.Choosefat-reducingfoodMilk,rabbit,radish,garlic,onion,celery,cucumber,mushroom,kelp,Jew’sear,apple,reddate,hawthorn,soyproduct,oat,wheatbran,peanut,konjac,corn,tea…脂肪肝一日食譜舉例

Asampledietforthefattyliverpatient早餐燕麥片50g，脫脂牛奶200ml，面包〔面粉50g〕，黃瓜100g，奇異果50g午餐大米飯100g〔大米50g〕，芹菜牛肉絲〔芹菜100g、牛肉50g〕，糟溜魚片〔青魚100g，黑木耳25g〕，西紅柿蛋湯〔西紅柿50g、雞蛋50g〕。Breakfastoatmeal50g,skimmilk200ml,bread50g,cucumber100g,kiwifruit50gLunchrice50g,friedcereal100gwithbeef50g,fish100g,Jaw’sear25g,tomato(50g)andegg(50g)soup晚餐大米飯100g〔大米50g〕，青椒炒雞片〔青椒100g、雞胸肉50g，香菇25g〕，腐竹炒西蘭花〔腐竹50g、西蘭花100g〕。全日烹調(diào)用油20g全日攝入能量6972KJ〔1660kcal〕，蛋白質(zhì)104gSuperrice50g,friedgreenpepper(100g)andchicken(50g)withmushroom(25g),frieddriedsoyacream(50g)withbroccoli(100g)totalcookoil20gtotalenergy6972KJ(1660kcal),protein104g第三節(jié)肝硬化LiverCirrhosis肝硬化是由不同病因引起的慢性、進(jìn)行性、彌漫性肝細(xì)胞變性、壞死與再生，并誘發(fā)廣泛纖維組織增生，肝小葉結(jié)構(gòu)破壞的嚴(yán)重肝病Livercirrhosisis

aconsequenceofchronicliver

diseasecharacterizedbyreplacementoflivertissuebyfibrousscartissueaswellasregenerativenodules(lumpsthatoccurasaresultofaprocessinwhichdamagedtissueisregenerated),leadingtoprogressivelossofliverfunction臨床表現(xiàn)Clinicsymptoms臨床上多系統(tǒng)受累，以肝功能損害和門脈高壓為主要表現(xiàn)，并有脾功能亢進(jìn)、胃底靜脈曲張、輕度或中度黃疸，75%以上的病人晚期出現(xiàn)腹水，并有出血傾向和凝血缺陷。Multisystemaffected,liverfunctionsdamaged,portalhypertension,spleenhyperfunction,varicoseveininstomach,jaundice,ascites,bleedingandthromboasthenia早期屬肝功能代償期，以惡心嘔吐、消化不良、右上腹痛、大便不成形等病癥為主病情開展那么出現(xiàn)浮腫、黃疸、發(fā)熱、食管靜脈曲張、消化道出血、明顯營養(yǎng)不良晚期常出現(xiàn)消化道出血、肝性昏迷、繼發(fā)感染等嚴(yán)重并發(fā)癥Earlyphase:nausea,vomit,indigestion,bellyache,abnormalstoolEdema,jaundice,fever,esophagusvaricosity,digestivetractbleeding,malnutritionEnd-stage:digestivetractbleeding,hepaticcomaandcomplications一、肝硬化與營養(yǎng)的關(guān)系

CirrhosisandNutrition1.酒精乙醇可直接損傷肝細(xì)胞及其細(xì)胞器〔特別是內(nèi)質(zhì)網(wǎng)〕，并引起淋巴細(xì)胞反響，產(chǎn)生各種細(xì)胞毒作用于肝細(xì)胞膜，引起肝細(xì)胞損傷1.AlcoholEthanolcandamagelivercellsandorganelle(esp.endoplasmicreticulum)directly,causelymphocytesreaction,bringtoxiceffecttohepatocytemembrane乙醇的中間代謝產(chǎn)物乙醛可引起脂質(zhì)過氧化，刺激中性粒細(xì)胞形成過氧化物，刺激星狀細(xì)胞和細(xì)胞因子使膠原的合成增加，誘發(fā)肝硬化

Aldehyde,intermediatemetaboliteofethanol,stimulatesneutrophilegranulocytetoproduceoxidants,andastrocytesaswellascytokinetoformcollagen,whichcausecirrhosis2.營養(yǎng)失調(diào)動物實(shí)驗(yàn)證明食物中長期缺乏蛋白質(zhì)、維生素B族、維生素E和抗脂肪因子〔主要是膽堿〕等就會導(dǎo)致脂肪肝、肝細(xì)胞壞死，乃至肝硬變2.UnbalancednutritionAnimalstudiesshowthatlackofprotein,vitaminBs,vitaminEandanti-fatfactors(mainlycholine)indietleadtofattyliver,livercellnecrosisandcirrhosis長期營養(yǎng)失調(diào)降低了肝臟對某些毒物和病原體的抵抗力，肝臟在毒性物質(zhì)的作用下壞死，最終開展為肝硬化Longtimemalnutritiondeclinestheimmuneresponseoflivertosometoxinsandpathogens.Theliverbecomenecrosisunderthepresenceoftoxinsandeventuallydevelopsintocirrhosis3.肝硬化時(shí)的代謝障礙

DisorderofmetabolisminCirrhosis肝硬化可引起蛋白質(zhì)、碳水化合物、脂類與膽汁酸和電解質(zhì)的代謝障礙，出現(xiàn)蛋白質(zhì)合成障礙、凝血障礙、氨基酸代謝紊亂，血漿中支鏈氨基酸的水平通常低于正常，而芳香族氨基酸的濃度明顯增高Cirrhosismaycausedisorderofprotein,carbohydrate,lipids,bileacidandelectrolytesmetabolism;proteinsynthesisobstruction,coagulopathy,aminoacidmetabolismdisorder;decreasedbranchaminoacidandincreasedaromaticaminoacidinplasma肝硬化早期，蛋白質(zhì)分解代謝增加。肝臟蛋白質(zhì)的更新速度快，給肝硬化病人補(bǔ)充足夠的食物蛋白滿足肝臟蛋白質(zhì)更新和肝細(xì)胞再生的需要尤為重要Inearlycirrhosis,proteincatabolismincreases.Theturnoverofproteininliverisquick.Adequateproteinisveryimportantforproteinturnoverandlivercellregeneration.肝細(xì)胞損傷時(shí)，合成蛋白質(zhì)的能力降低，而一些功能性蛋白如轉(zhuǎn)氨酶在肝臟的含量比血漿高肝硬化時(shí)門靜脈壓力增高，淋巴回流減少，白蛋白經(jīng)腸道喪失，血漿白蛋白降低得更明顯Whenthelivercellsaredamaged,thecapabilitytosynthesizeproteinisdecreased.Somefunctionalproteins,likeaminotransferasedeclined;lymphaticreturndecreased;albuminlostintheGItractandsubsequentlydecreasedplasmaalbumin肝硬化晚期，處于分解代謝狀態(tài)，表現(xiàn)為肌肉消耗和蛋白質(zhì)轉(zhuǎn)換加速，肝硬化病人整體蛋白質(zhì)更新速率、合成與分解速率均明顯加快，而且蛋白質(zhì)分解速率大于合成速率，處于負(fù)氮平衡狀態(tài)Intheendstageofcirrhosis,thebodyisincatabolismandthemuscle/proteinturnoverisincreased.Thebodyisinnegativenitrogenbalancebecausetheanabolismrateofproteinishigherthanthecatabolismrate.肝硬化患者攝入大于〔kg·d〕的蛋白質(zhì)才能滿足需要。增加蛋白質(zhì)的攝入能有效地提高肝硬化患者的蛋白質(zhì)貯留Proteinintakeshouldbemorethan1.0g/(kg·d)sothattheneedismet.Increasedproteinintakecanefficientlyenhancethestoreofproteinincirrhosispatients.肝硬化患者糖的氧化和貯存能力降低血漿胰島素/高血糖素比值下降，葡萄糖耐量受損Theoxidationandstorageofglucoseisdecreased.Theratioofplasmainsulin/glucagondeclinesandglucosetoleranceisdamaged.空腹血糖濃度增高，嚴(yán)重者患糖尿病肝硬化患者最多可代謝4～5g/〔kg·d〕的葡萄糖Fastingplasmaglucoseincreases,evendiabetescanoccur.Atmost4~g/(kg·d)ofglucosecanbemetabolizedincirrhosispatients.肝硬化使脂肪酸的代謝降低，生酮作用減弱，血漿游離長鏈脂肪酸和短鏈脂肪酸均升高肝硬化時(shí)內(nèi)源性膽固醇的合成減少，膽汁酸合成及排泌障礙，血漿和皮膚中的膽汁酸濃度升高Lipidmetabolismandketogenesisdecreases;plasmafreelong/shortchainfattyacidleveldeclines.Endogenouscholesterolsynthesisdecreases,bilesynthesisandexcretioninterfered,bileacidlevelinbloodandskinelevated.腸道膽汁酸鹽缺乏，出現(xiàn)乳糜瀉及暗適應(yīng)能力下降Bilesaltinintestineshortagecauseceliacdisease;theabilityofdarkadaptionisdecreased.肝細(xì)胞受損影響維生素A的吸收。肝硬化時(shí)貯脂細(xì)胞的維生素A不易釋放，可使血中維生素A降低，出現(xiàn)夜盲

TheabsorptionofvitaminAisdecreasedbecauseofthelivercelldamage.ThereleaseofvitaminAstoredinliveradiposecellsisblocked,whichcausesdecreasedvitaminAlevelinbloodandfurthernightblindness.維生素Bl、B6、B12、葉酸和煙酸是肝硬化時(shí)容易缺乏的水溶性維生素，維生素C缺乏在肝硬化患者中也比較普遍VitaminB1,B6,B12,folateandniacinarethewatersolublevitaminsthatareeasilyrunoutofincirrhosis.VitaminCshortageisalsocommon.血鋅和肝鋅均明顯降低血硒和肝硒均降低血銅和肝銅升高血鐵濃度升高PlasmaandliverzincdecreasesgreatlyPlasmaandliverselenium/copperdecreasesBloodferrumincreases二、營養(yǎng)防治

NutritionPrevention&Treatment〔一〕預(yù)防1．每天攝入的蛋白質(zhì)應(yīng)在70g左右，不要經(jīng)常大量攝入蛋白質(zhì)含量高的食物，如雞、鴨、魚、肉、蛋、海鮮、花生、黃豆及豆制品等Prevention1.Dailyproteinintakeshouldbeat70g.DoNOTeatmuchhighproteinfood,likechicken,duck,fish,meat,egg,seafood,peanut,soyproducts.2．生活要有規(guī)律，飲食要按時(shí)、定量3．不酗酒、不吃生魚4．慢性乙型肝炎患者不要大量攝入蛋白質(zhì)，注意動物蛋白質(zhì)和植物蛋白質(zhì)的合理搭配。適當(dāng)多攝入各種新鮮蔬菜2.Regularlifestylesanddiets3.Noalcohol;norawfish4.TheamountofproteinshouldbelimitedinchronichepatitisBpatients;mixanimalandplantproteinwisely;eatmorefreshvegetables.〔二〕治療Treatment營養(yǎng)治療的目的是增進(jìn)食欲，改善肝臟功能，提高免疫力，促進(jìn)肝細(xì)胞的再生和修復(fù)，改善肝臟的纖維變性的狀況，防止脂肪淤滯，糾正營養(yǎng)不良，從而防止病情進(jìn)一步開展，預(yù)防腹水、貧血等并發(fā)癥的發(fā)生。Thegoalofnutritiontreatmentistoincreaseappetite,promotelivefunctionandimmunefunction,enhancelivercellsregeneration/recovery,decreaseliverfibrosis,preventfataccumulation,correctmalnutrition,preventascites,anemiaandothercomplications.采用“三高一適量〞飲食，即高能量、高蛋白質(zhì)、高維生素、適量脂肪的飲食Thedietwithhighenergy,highprotein,highfiberandlowfatshouldbeencouraged.適當(dāng)增加能量供給

Increaseenergyintakemoderately隨著病情的加重，能量消耗增加，葡萄糖氧化降低，蛋白質(zhì)和脂肪氧化增加。每天的總能量為～〔2000～2300kcal〕，并根據(jù)個(gè)體的具體情況如病情、年齡、體力活動強(qiáng)度作適當(dāng)?shù)恼{(diào)整～12.6MJ(2000～2300kcal)perday;andtheamountshouldbeadjustedindividuallyaccordingtospecificdiseases,age,andlaborintensity.適當(dāng)增加優(yōu)質(zhì)蛋白的供給

Increasetheintakeofgoodprotein蛋白質(zhì)的供給量以患者能耐受、能維持氮平衡、可促進(jìn)肝細(xì)胞再生又不誘發(fā)肝性腦病為宜，可供給～2g/(kg·d)，或100～120g/d，但不能低于1.0g/(kg·d)Theamountofproteinintakeshouldbeoptimizedconsideringthefollowingconditions:patienttolerance,nitrogenbalance,livercellregeneration,nohepaticencephalopathy.Theamountmaybe1.5~2g/(kg·d),or100~120g/d,butnolessthan1.0g/(kg·d).高蛋白飲食能糾正低蛋白血癥，有利于腹水和水腫的消退有肝功能衰竭或肝昏迷傾向時(shí)，要限制蛋白質(zhì)的供給，降至25～35g/dDiethighinproteincancorrecthypoproteinemia,whichisgoodforrecoveringfromascitesanddropsy.Theproteinshouldbelimitedto25~35g/difthereisdangertodevelopliverfailureorhepaticcoma.適量脂肪Moderatefatintake脂肪的供給以40～50g/d，占總能量的25%為宜，不宜過多膽汁性肝硬化患者應(yīng)給予低脂肪、低膽固醇飲食40~50g/d,25%ofthetotalenergyBiliarycirrhosisshouldhavelessfatandcholesteroldiets.碳水化合物Carbohydrate碳水化合物的供給以350～450g/d為宜防止含粗糙的、不溶性膳食纖維多的食物，可選用含可溶性膳食纖維多的食物如山楂糕、果醬、果汁凍等350~450g/dofcarbohydrateisrecommendedTrytoavoidroughageorinsolublefiber,eatmoresolublefiberrichfood,likehawjelly,jamandfruitjelly.對半乳糖血癥引起的肝硬化患者應(yīng)限制奶及奶制品，以切斷乳糖的來源，而對于果糖不耐受癥引起的肝硬化患者，蔗糖、含果糖的水果和蔬菜必須從膳食中取消Cirrhosispatientscausedbygalactosemiashouldlimittheintakemilk/milkproduct;fructoseintoleranceshouldavoidfruitandvegetablethatcontainssugar/fructose.豐富的多種維生素

Adequatemultivitamins為了保護(hù)肝細(xì)胞和防止毒素對肝細(xì)胞的損傷，宜供給富含B族維生素〔葉酸、維生素B1、維生素B6等〕及維生素A、D、E、K、C的食物，也可以制劑的形式補(bǔ)給FoodrichinvitaminBs,A,D,E,KandCshouldbetakenmoretopreventthedamagecausedbytoxinstolivercells.Supplementcanalsobetaken.鈉與水Sodium&Water有水腫和輕度腹水的患者應(yīng)食用低鹽飲食，食鹽量不超過2g/d。Patientswithedemaorslightascitesshouldtakelowsaltdiet,andthesaltintakeshouldbelessthan2g/d.嚴(yán)重水腫時(shí)宜食用無鹽飲食，鈉限制在左右，禁用含鈉多的食物，如海產(chǎn)品、火腿、松花蛋、肉松、醬菜等腌制品、味精等長期低鈉飲食會引起低鈉血癥，應(yīng)注意觀察病人的血鈉水平。每天進(jìn)水量應(yīng)限制在1000ml以內(nèi)。Nosaltdietshouldbetakeninsevereedemaandthesaltintakeshoulbelessthan0.5g/d.Nosaltyfood,likeseafood,ham,preservedeggs,friedporkflakes,picklesandmonosodiumglutamate.Bloodsodiumshouldbemonitoredfrequentlyincasehyponatremiaoccurs.Waterintakeshouldbelessthan1000ml.補(bǔ)充鋅、鎂等微量元素

Zinc,Magnesiumandotherminerals肝硬化患者應(yīng)多食用豬瘦肉、牛肉、羊肉、蛋類、魚類等含鋅量較高的食物?；颊叱４嬖阪V離子缺乏，應(yīng)補(bǔ)充含鎂多的食物，如綠葉蔬菜、豌豆、乳制品和谷類等食物L(fēng)eanmeat,beef,mutton,eggs,fish…thesefoodcontainmuchzinc,whicharegoodforcirrhosispatients.Foodrichinmagnesiumshouldbetakenmore,likegreenvegetables,peas,milkproductandgrains.服利尿劑時(shí)，應(yīng)多食用含鉀高的食物，如蕃茄、南瓜、橘子、香蕉等。由于Wilson病患者肝內(nèi)有大量的銅蓄積，應(yīng)禁食富含銅的食物，如巧克力、貝殼類和動物肝臟等Whentakingdiuretic,foodhighinpotassiumshouldbetaken,liketomato,pumpkin,orange,banana…Wilsondiseasepatientsshouldavoidthefoodrichincopper,likechocolate,seashell,animalliver,forthereismuchcopperaccumulationintheliverofWilsonpatients.Wilsondisease:肝豆?fàn)詈俗冃燥嬍潮揪眄氈狣ietPrinciples少食多餐食物應(yīng)新鮮、無霉變烹調(diào)方法應(yīng)多樣化，注意菜肴的色香味形EatoftenbutlesseachtimeThefoodshouldbefreshVariouscookingmethods,deliciousfood細(xì)嚼慢咽，食物以細(xì)軟、易消化、少纖維、少產(chǎn)氣的軟食或半流質(zhì)為主，防止生、硬、大塊、干硬、粗糙的食物，如帶刺的魚、帶碎骨的畜禽肉、油炸和油煎的食物、不易煮軟的蔬菜Chewslowly;thefoodshouldbetender,easilydigestible,lessfiber,lessaerogenicfood,liquidorsemi-liquid,noraw/hard/bulky/dry/roughfood(likefisn/meatwithbones,friedfood,vegetablesthatarenoteasilycooked〕食物的選擇Foodchoice在每日的膳食中應(yīng)輪換供給奶、蛋、魚、瘦肉、豆制品等優(yōu)質(zhì)蛋白質(zhì)食品?？蛇m中選用葡萄糖、蔗糖、蜂蜜、果汁等易于消化的單糖、雙糖以增加肝糖原儲藏Takemilk,egg,fish,leanmeat,soyproductalternativelyineverydaydiet,toprovideenoughhighqualityprotein.Glucose,sugar,honey,fruitjuiceandothereasilydigestiblemonosaccharide/disaccharidetoensuretheglycogenstorage.忌酒精、辛辣及刺激性食品。防止油炸及干硬的食品。少吃或不吃含纖維較多的食品以及產(chǎn)氣多的食品，如芹菜、韭菜、黃豆芽、紅薯、干豆類、汽水、蘿卜等。鮮鯉魚、赤小豆、冬瓜、絲瓜、南瓜對治療肝硬化腹水有效Noalcohol,pungent,rajasicfood.Trytoavoidfried/driedfood.Lesshighfiber/aerogenicfood,likecelery,leek,soybeansprout,sweetpotato,driedbeans,soda,radish…Carp,redbeans,Chinesewatermelon,towelgourd,pumpkinmayhavesomebenefitsintreatingascites.肝硬化一日食譜舉例

Asampledietforthecirrhosispatients早餐大米粥〔大米50g〕，豆沙包〔面粉50g，豆沙25g〕，煮雞蛋〔50g〕加餐牛奶〔鮮牛奶200g〕，蘋果100g午餐大米飯〔大米100g〕，茄汁魚片〔青魚200g，豌豆25g〕，素炒油菜〔油菜150g〕Breakfastricecongee(rice50g),steameddumplingsstuffedwithsweetbeanpaste(wheatflour50g,sweetbeanpaste25g),boiledegg(50g)ExtramealMilk(200g),apple(100g)Lunchrice(100g),steamedfish(fish200g,pea25g),rape(150g)加餐沖藕粉〔藕粉30g，白糖10g〕，香蕉100g晚餐大米飯〔大米100g〕，炒肉片〔豬精肉50g，青椒25g，豆腐干50g〕，冬瓜西紅柿湯〔冬瓜50g，西紅柿100g〕全日烹調(diào)用油25g。以上食譜含能量9506kJ〔2272kcal〕，蛋白質(zhì)107g

ExtramealLotusroodstarch(30g,sugar10g),banana100gSuperrice100g,friedmeat(pork50g,greenpepper25g,driedbeancurd50g,soup(Chinesewatermelon50g,tomato100g)Totalcookingoil25gTotalenergy9506KJ(2272kcal),protein107g三、營養(yǎng)支持NutritionSupport營養(yǎng)支持目的是：提供適量的能量和營養(yǎng)素，維持和改善患者的營養(yǎng)狀況；提供適量的蛋白質(zhì)和氮，維持和恢復(fù)正常的血漿氨基酸譜；預(yù)防肝性腦病防止肝功能進(jìn)一步惡化；糾正和防止水、電解質(zhì)和酸堿失衡Goalofnutritionsupport:provideadequateenergyandnutrients,maintain/improvenutritionstatus;provideadequateprotein/nitrogen,maintain/improveplasmaaminoacidpatterns;preventhepaticencephalopathy;preventfurtherdamage;correct/treatwater,electrolyte,acid/alkalinebalance.1．腸內(nèi)營養(yǎng)腸內(nèi)營養(yǎng)液可刺激IgA的分泌，有助于保持腸道防御屏障的完整性，防止感染的發(fā)生1.EnteralNutritionEnteralnutritionsolutionstimulatesthesecretionofIgA,whichisgoodfortheintegrityofgutbarrierandcomplicationprevention2.腸外營養(yǎng)肝硬化患者出現(xiàn)水和電解質(zhì)異常、肝性腦病、腹水、消化道出血等多種并發(fā)癥時(shí)，患者胃腸道呈無功能狀態(tài)而不能耐受腸內(nèi)營養(yǎng)，或者腸內(nèi)營養(yǎng)支持難以滿足患者的需要，有必要采用腸外營養(yǎng)2.ParenteralNutritionWhenwaterandelectrolytesdisorder,hepaticencephalopathy,ascites,GItractbleedinghappen,enteralnutritionisnottoleratedorcannotprovideenoughnutrients,thusparenteralnutritionisneeded.第四節(jié)肝性腦病

HepaticEncephalopathy(HE)肝性腦病是指各種嚴(yán)重的肝臟疾病引起的以代謝紊亂為根底，以神經(jīng)、精神病癥為主要表現(xiàn)的一系列中樞神經(jīng)系統(tǒng)功能障礙癥侯群。又稱肝功能衰竭或肝昏迷HEisapotentially-reversibleneuropsychiatricabnormalityinthesettingofliverfailure,whetherchronic(asincirrhosis),oracutely.Itcanbediagnosedonlyafterexclusionofotherneurological,psychiatric,infectious,andmetabolicetiologies.一、肝性腦病與營養(yǎng)的關(guān)系

HE&Nutrition肝性腦病的發(fā)生主要原因是中樞和周圍神經(jīng)系統(tǒng)傳導(dǎo)介質(zhì)代謝障礙，特別是胺類遞質(zhì)代謝障礙。由于肝功能嚴(yán)重?fù)p害，不能將血中有毒代謝產(chǎn)物解毒，或門靜脈分流術(shù)后，自然形成的側(cè)支循環(huán)使門靜脈中的有毒物質(zhì)繞過肝臟，未經(jīng)肝臟解毒而直接進(jìn)入體循環(huán)，引起中樞神經(jīng)系統(tǒng)代謝混亂Withsevereliverimpairment,toxicsubstancesnormallyremovedbytheliveraccumulateinthebloodandimpairthefunctionofbraincells.Ifthereisalsoportalhypertension,andsubsequentbypassingoftheliverfiltrationsystemofbloodflowinginfromtheintestines,thesetoxicsubstancescantraveldirectlytothebrain,withoutbeingmodifiedorpurified.Signscanincludeimpairedcognition,aflappingtremor(asterixis),andadecreasedlevelofconsciousnessincludingcoma(hepaticcomaorcomahepaticum),cerebraledema,and,ultimately,death.發(fā)病機(jī)制Pathogenesis1.氨中毒學(xué)說2.假性神經(jīng)遞質(zhì)的形成3.氨基酸代謝失衡4.其他毒素1.Ammoniapoisoning2.Falseneurotransmitterformation3.Disorderofaminoacidmetabolism4.Othertoxins二、營養(yǎng)防治

NutritionPrevention&Treatment〔一〕預(yù)防重型肝炎和嚴(yán)重肝硬化病人應(yīng)禁酒，以免加重肝細(xì)胞的損害；不吃油炸、干硬的食物，盡量吃軟食和半流質(zhì)，防止食道胃靜脈曲張破裂引起消化道出血，誘發(fā)肝性腦病。有肝性腦病先兆者不吃高蛋白食物；攝入足夠的能量；多吃新鮮蔬菜，但含粗纖維較多的蔬菜，如芹菜、毛筍等宜少吃PreventionSeverehepatitisandcirrhosisshouldhavenoalcoholtopreventthefurtherdamagetolivercells;Nofriedorroughfood;semi-liquidandsoftfoodispreferred;preventthestomachvaricealbleeding.ThosewhohaveauratodevelopHEmustn’teathighproteinfoodandeatenoughenergyandfreshvegetables,butvegetableslikeceleryandbambooshootshouldbeavoided,becausetheyhavetoomuchcrudefiber〔二〕治療飲食治療的目的在于控制總能量和蛋白質(zhì)，以減少體內(nèi)氨的生成，防止肝昏迷的發(fā)生及向危重方向開展。提高碳水化合物的比例。同時(shí)，供給充足的微量營養(yǎng)素。TreatmentThegoalofdietarytherapyistocontrolthetotalenergyandproteinintake,sothattheammoniaproducedinhumanbodycanbedecreased,whichpreventsHEhappening.Thepercentofcarbohydrateshouldbeincreased.Meanwhile,adequatemicronutrientsshouldbetaken.對亞臨床肝性腦病患者給予限制蛋白質(zhì)飲食，應(yīng)用乳果糖〔半乳糖甙果糖〕、乳梨醇〔拉克替醇〕和支鏈氨基酸等治療可減輕或消除智能檢查出現(xiàn)的異常Forsubclinicalpatients,proteinintakeshouldbelimited,andlactulose,lactitolandbranchaminoacidshou