The patient s cirrhosis is most likely caused from her Hepatitis C diagnosis.

Transcription

1 Lisa Nguyen Medical Nutrition Therapy March 18, 2013 Cirrhosis of the Liver with Resulting Hepatic Encephalopathy 1. The liver is an extremely complex organ that as a particularly important role in nutrient metabolism. Identify three functions of the liver of each of the follow: 1a. Carbohydrate metabolism Gluconeogenesis occurs in the liver The liver stores glucose as glycogen molecules for energy use Glycogenolysis occurs in the liver 1b. Protein metabolism Transamination Liver is the primary site of the uptake of amino acids following digestion of food Liver synthesizes protein form the uptake of amino acids from the portal blood circulation 1c. Lipid metabolism Synthesis of VLDL s occur in the liver Lipolysis Chylomicron remnants can be converted into bile salts and secreted in the bile to aid with lipid digestion 1d. Vitamin and mineral metabolism Hydroxylation of Vitamin D to D3 Formation of 5-methyl tetrahydrofolic acid Formation of acetyl CoA from pantothenic acid 2. What is cirrhosis? Cirrhosis is any pathological condition where fibrous connective tissue replaces healthy tissue in an organ, usually as a consequence of inflammation or other injury. 3. The most common cause of cirrhosis is alcohol ingestion. What are additional causes of cirrhosis? What is the cause of this patient s cirrhosis? Other causes of Cirrhosis: Hepatitis B, which may be coincident with Hepatitis D Hepatitis C Cystic Fibrosis Cryptogenic causes The patient s cirrhosis is most likely caused from her Hepatitis C diagnosis. 4. Explain the physiological changes that occur as a result of cirrhosis. The blood flow to the liver is damaged as scar tissue replaces normal, healthy tissue and prevents or obstructs the normal flow of blood to the liver. As scar tissue begins to replace more and more of the healthy liver tissue, liver function begins to decrease and liver cells die. Life threatening complications can occur if cirrhosis goes untreated.

2 5. List the signs and symptoms of cirrhosis, and relate each of these to the physiological changes discussed in question 4. Signs and symptoms of cirrhosis include fatigue, weakness, nausea, poor appetite, malaise, jaundice, dark urine, light stool, steatorrhea, itching, abdominal pain, and bloating. The major clinical complications with cirrhosis are portal hypertension, hepatic encephalopathy, ascites, and esophageal varices. 6. After reading this patient s history and physical, identify her signs and symptoms that are consistent with the diagnosis. Mrs. Wilcox s signs and symptoms include a diagnosis of hepatitis C, constant fatigue, poor appetite, nausea and vomiting, rapid weight loss and weakness. 7. Hypoglycemia is a symptom that cirrhotic patients may experience. What is the physiological basis for this? Is this a potential problem? Explain. Hypoglycemia is a common problem associated with cirrhosis. It is advised to follow a diet of small frequent meals that include complex carbohydrates such as breads and rice. This problem occurs in those with cirrhosis as the liver is not able to store enough energy in the form of glycogen. Since the body is able to break down carbohydrates quick and use them for energy, this diet is recommended in order to avoid problems caused by hypoglycemia. 8. What are the current medical treatments for cirrhosis? Preventing damage to the liver Treating the complications of cirrhosis Preventing liver cancer or detecting it early Liver transplant 9. What is hepatic encephalopathy? Identify the stages of encephalopathy and outline the major theories regarding the etiology of this condition. Hepatic encephalopathy is a syndrome of impaired mental status and abnormal neuromuscular function that results from major liver failure. The signs and symptoms vary depending on the stage of hepatic encephalopathy. They include changes in mental status and personality, and neuromuscular changes. The neurological changes are graded, using the four-staged West Haven scale and CHESS scale. West Haven Scale Stage West Haven Criteria Adapted-West Haven Criteria 0 No abnormality detected Alert and attentive without signs or symptoms 1 trivial lack of awareness euphoria or anxiety shortened attention span Alert and attentive, but with at least one of the following signs: dysarthria, ataxia, flaaping tremor, or obvious decrease in speed of mental

3 impairment in processing performance of addition 2 lethargy or apathy Awake but inattentive: minimal disorientation disoriented, somnolent, easy for time or place to distract, unable to subtle personality perform east mental tests, change patients speech is easy to inappropriate behavior understand impaired performance of subtraction 3 somnolence to semistupor Marked somnolence or but responsive psychomotor agitation, to verbal stimuli speech of difficult to confusion understand gross disorientation 4 coma Coma- the patient does not speak and does not follow simple commands (such as raising an arm or opening the mouth) 10. Protein- energy malnutrition is commonly associated with cirrhosis. What are the potential causes of malnutrition in cirrhosis? Explain each cause. The majority of cirrhotic patients by coincidence follow a low caloric diet. Loss of appetite is attributed to the presence of tumor necrosis or alcohol- induced anorexia. In addition early satiety due to impaired gastric accommodation and impaired expansion capacity of the stomach due to the presence of clinically evident ascites, which often leads to an inadequate nutrient intake. Another factor in malnutrition is the presence of impaired digestion and nutrient absorption due to portal hypertension. Cholestatic liver disease is another reason for impaired absorption, especially of fat- soluble vitamins such as A, D, E, and K, due to the reduced intraluminal bile salt concentrations. II. Understanding the Nutrition Therapy 11. Outline the nutrition therapy for the following stages of cirrhosis with the rationale for each: Diagnosis Sodium Potassium Protein Micronutrients Fluid Stable Cirrhosis Cirrhosis w/acute encephalopathy Cirrhosis w/ascites and No restriction needed 3g Start at 1.2g 2g 2.5g Restricted 1.2g Multivitamin/mineral supplement Multivitamin/mineral supplement, Vitamin D & K 2g 2g Multivitamin/mineral supplement, Vitamin As needed As needed As needed

4 esophageal varices D & K Nutrition Assessment 12. Measurements used to assess nutritional status may be affected by the disease process and not necessarily be reflected of nutritional status. Are there any components of nutrition assessment that would be affected by cirrhosis? Explain. Urine samples can be tested in order to evaluate the amount of water and salt expelled by the body. These levels can indicate if there is any edema or ascites present in the patient and can identify any additional complications. Protein status would be affected, as liver damage impedes the function of the liver to properly metabolize nutrients, especially protein. Gluconeogenesis is greatly reduced and therefore assessing carbohydrate needs is challenging in patients with cirrhosis. In general, overall nutrient absorption is reduced from the inability of the liver to synthesis, store and catabolize various nutrients properly. intake, weight, weight changes, albumin, skin folds, bioelectrical A. Evaluation of Weight/Body Composition 13. Dr. Horowitz notes Ms. Wilcox has lost 10 pounds since her last exam. Assess and interpret Ms. Wilcox s weight. Ms. Wilcox has severely restricted her diet due to lack of appetite. Prior to her nutrition assessment she had not eaten for 2 days, thus this was a factor in her current weight loss. Her appetite has been very limited and she is not eating much due to this complication that is frequently caused by cirrhosis. 10% body fat change is a difference 14. Identify any nutrition problems using the correct diagnostic term. Inadequate energy intake: NI- 1.4 Inadequate oral intake: NI- 2.1 Malnutrition: NI- 5.2 Inadequate protein- energy intake: NI- 5.3 Underweight: NC- 3.1 B. Calculation of Nutrient Requirement 15. Calculate the patient s energy and protein needs. Calories: 56.8 kg x 35kcal/kg = 1988 kcal 56.8 kg x 40 kcal/kg = 2272 kcal Protein: up to 1.6 g/kg x 56.8 kg = up to 91 g/kg 16. What guidelines did you use and why? I used the recommended kcal/kg per day calorie intake for patients with liver cirrhosis. The recommendation for protein intake was up to 1.6 g/kg per day depending on the degree of malnutrition and other medical complications. C. Intake Domain 17. Evaluate the patient s usual nutritional intake. Ms. Wilcox s usual nutritional intake was altered, as her appetite has decreased. Her diet over the last few days consisted of juice, water, and Diet Coke only. Even when she

5 recalled her typical daily diet it consisted of three very small meals each day that do not seem to be providing her with the proper nutrients. low in calorie and protein 18. Her appetite and intake have been significantly reduced for the past several days. Describe the factors that may have contributed to this change in her ability to eat. Those who have been diagnosed with cirrhosis of the liver experience abdominal pain, nausea and bloating and are found to have altered gut motility, all of which lead to development of functional dyspepsia. These are known to lead to increased severity of gastrointestinal symptoms associated with recent weight loss. 19. Why was a soft, 4- g Na, high- kcalories diet ordered? Should there be any other modifications? 4g is for patients who don t eat as much, no added salt diet, soft, high calorie diet I would modify the 4- gram Na recommendation because for patients with cirrhosis usually requires a 2- grams sodium per day. I would maintain the high calorie recommendation due to her current weight loss. I would make sure to recommend Ms. Wilcox obtain no more than 30 percent of those calories from fat. Supplements either from food intake or supplement of B-complex vitamins, vitamin C and K, zinc and magnesium are a good idea due to a decrease in nutrient absorption/metabolism. I would recommend an increase in high bioavailable proteins as well. 20. This patient takes multiple dietary supplements. Identify the possible rationale for each and identify any that may pose risk for someone with cirrhosis. Patients that have cirrhosis of the liver experience impaired absorption of many fat- soluble vitamins such as A, D, E, and K due to the reduced intraluminal bile salt concentrations. Ms. Wilcox is taking a supplement that provides her with extra vitamins D and E, which can be beneficial with her recent diagnosis. With her new multivitamin/ mineral supplement recommendation she needs to be sure that she does not exceed her daily-recommended level of K. D. Clinical Domain 21. Examine the patient s chemistry values. Which labs support the diagnosis of cirrhosis? Explain their connection to the diagnosis. It was found that Ms. Wilcox had several abnormal lab tests. Abnormal elevation of liver enzymes in the blood such as ALT and AST can indicate bile duct blockage from cirrhosis. Advanced cirrhosis leads to a reduced levels of albumin and Ms. Wilcox s albumin levels were lower than normal. Bilirubin is one the most important factors indicative of liver damage. In patient s with hepatitis the liver cannot process bilirubin and blood levels of this substances are elevated. albumin, prealbumin, bilirubin, transferrin 22. Examine the patient s hematology values. Which are abnormal, and why? Patients Value Normal Value RBC 4.1 L HGB 10.9 L 12-15

6 HCT 35.9 L Ferritin 18 L MCV 102 H Due to an impaired liver, iron absorption, synthesis, and uptake via liver receptors and mediators is diminished. This leads to a decrease in iron containing compounds. Ferritin is synthesized in the liver and in cirrhosis its synthesis is decreased. Mean Corpuscular Volume represents large RBC. Her high MCV count is from malabsorption/low intake of vitamin B12 which causes megaloblastic macrocytic anemia. 23. Does she have any physical symptoms consistent with your findings? She was seen to have fatigue, anorexia, nausea and vomiting, and weakness, which are all indicators of her abnormal test results. jaundice 24. What signs and/or symptoms would you monitor to determine further liver decomposition? see and feel in nonlabs A main concern would be her anorexia and nausea and vomiting. These are most important because if she continues to have a poor appetite she will lose too much weight and her body will not be able to response to the cirrhosis diagnosis. weight, enlarged liver, edema, personality changes, loss of balance 25. Dr. Horowitz prescribes two medications to assist with the patient s symptoms. What is the rationale for these medications, and what are the pertinent nutritional implications of each? Medication Rational for RX Nutritional Implications Spironolactone Propranolol This medication causes the kidneys to eliminate unneeded water and Na from the body into the urine while reducing the loss of K from the body This is a beta-blocker that is effective in lower pressure in the portal vein and is used to prevent initial bleeding and rebleeding in patients with cirrhosis A reduced Na diet and daily exercise should be followed. K-containing salt substitutes should be avoided while on this medication Beta-blockers work to interfere with the action of adrenaline and helps the heart beat more slowly and less strongly Low na diet, low albumin, nausea, vomitting IV. Nutrition Diagnosis 28. Select two high priority nutrition problems and complete a PES statement for each. PES #1: Inadequate energy intake R/T loss of appetite from cirrhosis as evidenced by diet recall. PES #2: Underweight R/T disordered eating pattern and inadequate energy intake as evidenced by BMI of less than V. Nutrition Monitoring and Evaluation

7 29. Ms. Wilcox is discharged on a soft, 4- g Na diet with a 2- L fluid restriction. Do you agree with this decision? PES #1: I would recommend that Ms. Wilcox consume less sodium than was suggested. Cirrhosis can lead to a condition known as ascites, an abnormal accumulation of fluid in the abdomen, and the risk of developing this can be reduced with a low sodium diet. I would recommend that she consume at most 2- g Na in her diet each day in order to keep her sodium levels under control. PES #2: I would recommend that she take in no more than 2- L of fluid daily. I would advice that she not go over this recommendation but instead try to limit her intake to around 1.5- L. 30. Ms. Wilcox asks if she can use a salt substitute at home. What would you tell her? I would tell her that salt substitutes should be used with caution. Salt substitutes containing potassium chloride should be avoided because these can raise potassium levels in the body. Elevated levels of potassium can be dangerous to people taking Aldactone. I would recommend that she try using spices to add flavor to foods instead of salt. 31. What suggestions might you make to assist with compliance for the fluid restriction? I would tell her to limit or eliminate any alcohol from her diet. Alcohol use will only worsen her condition of cirrhosis. Reduce coffee intake so she can have more fluids in other foods such as soup or desserts made with skim milk. VI. Evaluation and Monitoring 32. When you see Ms. Wilcox 1 month later, her weight is now 140 lbs. She is wearing flip- flops because she says her shoes do not fit. What condition is she most probably experiencing? How could you confirm this? Ms. Wilcox most likely has developed edema, which is the retention of water and salt that leads to the swelling of ankles and feet. In order to determine if she is experiencing edema a 24- hour urine collection can be performed to test the amount of water and salt in her urine. In order to treat edema a diuretic can be used in order to remove extra fluid through the urine and sodium restriction. 33. Her diet history is as follows: Breakfast: 1 slice toast with 2 Tbsp peanut butter, 1 c. skim milk Lunch: 2 oz. potato chips, grilled cheese sandwich (1 oz. American cheese with 2 slices of whole- wheat bread, grilled with 1 Tbsp margarine), 1 c. skim milk Supper: 8 barbeque chicken wings, french fries- 1 c., 2 c. lemonade What changes might you make to her nutrition therapy? Identify foods that should be eliminated and make suggestions for substitutions. The biggest change I would make with her diet would be to encourage her to consume small amounts of food more often. I would recommend either five or six small meals a day instead of her typical high calorie three meals a day. For her breakfast and lunch, I would recommend whole grain breads. For breakfast, I would limit the use of peanut butter to 1 Tbsp or replace it with

8 100% fruit jelly. For lunch I would change that potato chips to fruit and/or vegetables in order to reduce sodium levels. Also, to reduce her margarine in. I would also advice her to not consume as much fat at dinner from chicken wings and french fries which also contain high amounts of sodium. She could switch out chicken wings to skinless poultry and consume a potato instead of French fries. When choosing replacement foods I would advice Ms. Wilcox to select no or low- sodium products.