الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
The liver is among the most complex and important organs in the human body. Its primary function is to control the flow and safety of substances absorbed from the digestive system before distribution of these substances to the systemic circulatory system. The liver cells, hepatocytes, contain thousands of enzymes essential to perform vital metabolic functions. The liver metabolizes both beneficial and harmful substances. It stores nutrients and other useful substances, as well as detoxifying or breaking down harmful compounds. These can be then excreted from the body in bile via the liver; in urine via the kidney, or by other means. Therefore, both acute and chronic liver injuries frequently have nutritional consequences directly proportional to their severity which may progress to hepatic cirrhosis.
Hepatic cirrhosis is a major health problem in Egypt, especially with the high prevalence of hepatitis C virus infection which is the main cause of liver cirrhosis and liver cancerin Egypt. HC has very serious nutritional consequences, including PEM. Malnourished patients with cirrhosis have a higher rate of complications and, overall, an increased mortality rate.Therefore, nutritional assessment should be performed for every patient with chronic liver disease.
Subjective global nutritional assessment (SGA) is a clinical technique which assesses nutritional status based on features of the medical history and physical examination. SGA method is helpful in the evaluation of nutritional status in patients with HC and classifies patients as either: well-nourished; mildly or moderately malnourished; or severely malnourished based on features of the medical history and physical examination.
The aims of the present study were to assess the nutritional status ofpatients with HCusing SGA method, investigate the clinical signs of malnutrition among these patients using SGA andto relate the nutritional status level with the severity ofliver disease.The present study was conducted at Hepatogastroenterology unit in Internal Medicine Department, hospital ofMedical Research Institute.One hundred and twenty five patients who were already diagnosed of having HC from records were selected for the study. All grades of severity of liver cirrhosis were eligible for the study.
Data was collected from patients using a pre-designed structured interviewing questionnaire, subjective global assessment (SGA) method and review of hospital records. The interviewing questionnaire included collection of socio-demographic data, food habits, determination of the degree of severity of liver disease by Child-Pugh score and dietary intake assessment using the 24 hour recall method. SGA method included medical history (weight change, change in dietary intake, presence of gastrointestinal symptoms affecting oral intake and functional capacity) and physical examination which focused on examination of loss of subcutaneous fat, muscle wasting, edema and ascites. Hospital records were reviewed to obtain the diagnosis of patient’s disease, medical history of patients and their laboratory tests (complete bloodcount, serum albumin level, total serum bilirubin level and prothrombin time).
The present study revealed that 61.6% of patients had SGA score B indicating mild to moderate malnutrition, 22.4% of patients had SGA score A indicating well-nutrition and only 16% of patients had SGA score C indicating severe malnutrition.Laboratory investigations of patients revealed thatthe majority of patients (88.8%) were anemic, 60.0% had decreased TLC, 87.2% were hypoalbuminemic,73.6% had increased TSB level and almost all of them (96%) had prolonged PT.45.6% of the patients were Child-Pugh grade C indicating severe liver disease followed by 40.8% of patients were Child-Pugh grade B indicating moderate liver disease and only 13.2% of patients were Child-Pugh grade A indicating mild liver disease. Mean daily energy adequacy of patients with hepatic cirrhosis was 44.6 ± 11.7%, mean daily protein adequacy was 54.1 ± 16.0% while mean daily carbohydrate adequacy was 39.4 ± 14.7%.
SGA score correlated with ageof patients and with some laboratory tests as serum albumin level and TSB level. Moreover, the nutritional status level as classified by SGA score correlated with liver disease severity as classified by Child-Pugh score.
from the results of the present study, the following can be concluded:
• The highest percent of patients with hepatic cirrhosis had mild/moderate malnutrition bySubjective Global Assessment (SGA) rating.
• The highest percent of patients with hepatic cirrhosis had mild/moderate loss of body fat, and mild/moderate loss of muscle mass.
• The highest percent of patients with hepatic cirrhosishad no edema and mild/moderate ascites.
• Most of patients with hepatic cirrhosis had inadequate intake of energy and macronutrients.
• The highest percent of patients with hepatic cirrhosis were classified as Child-Pugh grade C indicating severe liver disease.
• Malnutrition was prevalent among low educational level patients.
• High percent of patients were from rural areas.
• The majority of patients were anemic, hypoalbuminemic, had a low total lymphocytic count (TLC) count, had increased total serum bilirubin (TSB) level and had prolonged prothrombin time (PT) which may be related to liver disease itself, not due to nutritional status.
• There is a significant correlation between the severity of liver disease and the degree of malnutrition in patients with hepatic cirrhosis.
• The majority of the patients experienced moderate weight loss which may be due to decreased caloric intake, constipation, nausea, early satiety and anorexia.
• Other parameters as weight changes, functional capacity and presence of ascites and edema may be due to chronic liver failure, not due to malnutrition.
from the results of the present study, we are able to recommend the following:
• Regular assessment of dietary intake pattern and weight changes ofpatients with hepatic cirrhosis.
• Research studies should be conducted for further investigations of the role of regular nutritional assessment and nutrition management in the prevention and control of different liver diseases.
• Nutritional advice should be given to patients with hepatic cirrhosis by nutrition specialist and special dietary pamphlets should be prepared for each patient describing the healthier foods they should consume.
• Nutrition education programs must be initiated for all liver disease patients at early stage of liver disease.
• Nutrition intervention programs should be directed to rural areas.
• National centers or institutions specialized in liver diseases should be established and supported, in every governorate if possible. Such centers will not only provide treatment but would also be essential for research and training of medical staff and nutritionists to deal with HC patients.
• Special programs and training should be directed to increase nutritional knowledge of physicians.