Alcoholic Liver Disease: A Nutrition Focused Approach to Treatment. By Laura Johnson Montana State Dietetic Intern

Transcription

1 Alcoholic Liver Disease: A Nutrition Focused Approach to Treatment By Laura Johnson Montana State Dietetic Intern

2 OBJECTIVES 1. UNDERSTAND HOW MALNUTRITION IS RELATED TO CIRRHOSIS 2. LEARN AT LEAST ONE NUTRITION INTERVENTION THAT COULD BE USED TO TREAT CIRRHOSIS

3 PATIENT MALE ALCOHOL INTAKE SUBJECTIVE DATA 2-12 BEERS 1-2 TIMES/WEEK LAST DRINK NOT DOCUMENTED NO PREVIOUS MEDICAL HISTORY PRIOR TO THIS YEAR

4 MEDICAL HISTORY JANUARY: FIRST ADMITTED FOR ABDOMINAL PAIN, BLOODY URINE DIAGNOSED WITH COLON CANCER COLON RESECTION ASCITES: 2 LITERS OF FLUID REMOVED EXTREMELY CIRRHOTIC AND NODULAR LIVER CAUSE: ALCOHOL

5 CIRRHOSIS OF THE LIVER SECONDARY TO ALCOHOL

6 LIVER S ROLE IN ALCOHOL METABOLISM 1 ADH - liver ADH 1. Ethanol + NAD Acetaldehyde + NADH (cytosol) MEOS other organs 1. Ethanol + NADPH Acetaldehyde +NADP CP450 ALDH 2. Acetaldehyde + NAD Acetate + NADH (mitochondria) *cell and liver damage 3. Acetate Skeletal muscle Kreb Cycle 4. Excess Acetate Excess Acetyl coa Fatty Acid Synthesis altered NAD/NADH ratio inhibited nutrient pathways

7 LIVER S ROLE IN PROTEIN METABOLISM 2 1. SYNTHESIZE BLOOD PROTEINS CLOTTING FACTORS, CARRIER AND TRANSPORT PROTEINS 2. MAKES NON-ESSENTIAL AMINO ACIDS 3. BREAKDOWN PROTEINS FOR GLUCOSE GLUCONEOGENESIS 4. UREA SYNTHESIS EXCRETE TOXIC AMMONIA AN IMPAIRED LIVER ALTERS PROTEIN METABOLISM MALNUTRITION

8 FACTORS FOR MALNUTRITION IN CIRRHOSIS 2 1. DECREASED INTAKE EARLY SATIETY AND ASCITES 2. UNABLE TO STORE AND MAKE ADEQUATE AMOUNTS OF GLYCOGEN GLUCOSE NOT READILY AVAILABLE EARLY FASTING STATE = PROTEIN AND FAT BREAKDOWN 3. INCREASED ACTIVITY OF SYMPATHETIC NERVOUS SYSTEM INCREASE IN HORMONES = HYPERMETABOLIC

9 NUTRITION ASSESSMENT3 STATED HIS LAST FULL MEAL WAS IN DECEMBER 2016 TYPICAL DAILY INTAKE AFTER DECEMBER: 2 SMALL MEALS 2 NUTRITION SUPPLEMENTS ESTIMATED NUTRIENT NEEDS: CALORIES GRAMS OF PROTEIN 5, 6 Nutrition Focused Physical Exam Pocket Guide, Nutrition Care Manual Cirrhosis 5, Oncology 6

10 SYMPTOMS ADMITTED FOR RECTAL BLEEDING AND ASCITES 5 OTHER SYMPTOMS 5, 7 MUSCLE WASTING ABDOMINAL PAIN WEIGHT LOSS LOW APPETITE LOW ENERGY JAUNDICE

11 ANTHROPOMETRICS ADMIT WEIGHT: 65.2 KG USUAL WEIGHT: 70 KG HEIGHT: CM ADMIT BMI: 20.37

12 WEIGHT TRENDS Date Weight (kg) Usual body weight 70.0 January 3 rd 72.3 January 22nd 75.9 January 27th 71.8 February 6 th 65.2 February 8 th 64.4 Percent weight loss in 1 month 4: 8.7%

13 PHYSICAL EXAM 4 SEVERE MUSCLE LOSS IN THE CLAVICLES, PATELLAR REGION, CALVES AND THIGHS SEVERE FAT LOSS IN TRICEPS

14 NUTRITION DIAGNOSIS 3 SEVERE PROTEIN CALORIE MALNUTRITION (CHRONIC) RELATED TO POOR APPETITE SECONDARY TO ALCOHOLIC LIVER CIRRHOSIS AS EVIDENCED BY SEVERE MUSCLE AND FAT LOSS PER PHYSICAL EXAM AND SEVERE WEIGHT LOSS GREATER THAN 5% IN ONE MONTH

15 NUTRITION INTERVENTION 3 1. MEDICAL FOOD SUPPLEMENTS 2 PROTEIN SUPPLEMENTS PER DAY NUTRITION GOAL: DIET TO ADVANCE BY NEXT RD VISIT

16 1. MEDICAL FOOD SUPPLEMENTS 3 DIFFERENT PROTEIN SHAKE 2. MEALS AND SNACKS SMALL, FREQUENT MEALS EARLY SATIETY GLUCOSE READILY AVAILABLE 3. NUTRITION EDUCATION REVIEWED CIRRHOSIS DIET GUIDELINES WITH PATIENT AND FAMILY Snacks NEW GOAL: EAT AT LEAST 50% OF AT LEAST 2 MEALS PER DAY

17 MONITOR AND EVALUATE 3 FOOD AND NUTRIENT INTAKE: AMOUNT, FREQUENCY, TYPE, ADEQUACY NUTRITION FOCUSED PHYSICAL FINDINGS: APPETITE, PAIN BODY COMPOSITION: WEIGHT TRENDS

18 Question: Treat malnutrition or HE? 2013 Review 2 Middle East Journal of Digestive Diseases Ammonia can be present regardless of intake Vegetables low in AAA Dairy protein high in BCAA Hepatic Encephalopathy (HE) Too much ammonia can worsen HE Grams of protein/kg 0.5 = muscle breakdown 8 <1 = increased risk of muscle wasting and negative nitrogen balance = muscle mass was maintained 10

19 PROS TO VEGETABLE PROTEIN FIBER SLOW CARB ABSORPTION = SHORT TIME IN FASTING STATE INCREASES RATE OF NITROGEN EXCRETION POSITIVE NITROGEN BALANCE 2. LOW IN AROMATIC AMINO ACIDS (AAA) EX: TRYPTOPHAN OXYPHENOL 3. LOW IN SULPHATED AMINO ACIDS EX: METHIONINE MERCAPTANS 4. HIGH IN AMINO ACIDS: ORNITHIONE AND ARGININE INCREASE RATE OF UREA SYNTHESIS

20 CONS TO VEGETABLE PROTEIN BULK EARLY SATIETY 2. PALATABILITY NO SALT 3. BIOAVAILABILITY OF PROTEIN AND MINERALS IRON, CALCIUM

21 JOURNAL OF GASTROENTEROLOGY 10 PROTOCOL 1.2 GRAMS OF PROTEIN/KG/DAY FOR 2 WEEKS 4 MEALS/DAY + EVENING SNACK OF COMPLEX CARBS MEASURED BLOOD AMMONIA AND NUMBER CONNECTION TEST (NCT) RESULTS PATIENTS IMPROVED: 79.7% - SS MOST IMPROVEMENT SEEN IN PATIENTS WITH SEVERE HE NOT IMPROVED: 20.3% 0.5 GRAMS OF PROTEIN/KG/DAY + NITROGEN SUPPLEMENTS

22 JOURNAL OF DIGESTIVE DISEASES AND SCIENCES 12 PROTOCOL 3 DIETS: ALL SUBJECTS TRIED EACH FOR 2 WEEKS RESULTS BOTH VEGETABLE GROUPS IMPROVED NCT TIME - SS 80 GRAM GROUP: EEG TEST IMPROVEMENT SS MEASURES BRAIN ACTIVITY

23 Summary Malnutrition is a common complication of cirrhosis Symptoms and treatments to consider: Decreased intake small frequent meals for regular glucose Hypermetabolic state protein and energy needs Protein Intake grams/kg Consider hepatic encephalopathy Treatment with vegetable and dairy protein may be beneficial Our role is important!

24 Resources 1. King, Michael W., PH.D. "Ethanol Metabolism." Ethanol (Alcohol) Metabolism: Acute and Chronic Toxicities. N.p., Jan Web. 23 Jan Eghtead, S. Hossein, P. Malekzadeh, R. Malnutrition in Liver Cirrhosis: The Influence of Protein and Sodium. Middle East Journal of Digestive Diseases Apr; 5(2): Web. 20 Mar International Dietetics & Nutrition Terminology (IDNT) Reference Manual: Standardized Language for the Nutrition Care Process. Academy of Nutrition and Dietetics, nd Mordarski, B. Wolff, J. Nutrition Focused Physical Exam Pocket Guide. Academy of Nutrition and Dietetics, n.d "Cirrhosis." Nutrition Care Manual. Academy of Nutrition and Dietetics, n.d. Web. 10 Feb Oncology. Nutrition Care Manual. Academy of Nutrition and Dietetics, n.d. Web. 15 May "Cirrhosis." MedlinePlus Medical Encyclopedia. U.S National Library of Medicine, 14 Aug Web. 5 Feb Cordoba J, Lopez-Hellin J, Planas M, Sabin P, Sanpedro F, Castro F. et al. Normal protein diet for episodic hepatic encephalopathy: results of a randomized study. J Hepatol. 2004;41: Charlton MR. Protein metabolism and liver disease. Baillieres Clin Endocrinol Metab. 1996;10: Gheorghe L, Iacob R, Vădan R, Iacob S, Gheorghe C Rom J Gastroenterol Sep; 14(3): Amodio, P., Caregaro, L., Pettenó, E., Marcon, M., Delpiccolo, F., & Gatta, A. (2001). Vegetarian diets in hepatic encephalopathy: facts or fantasies? Digestive and Liver Disease, 33(6), doi: /s (01) Uribe M, Marquez MA, Garcia Ramos G, Ramos-Uribe MH, Vargas F, Villalobos A. et al. Treatment of chronic portal-- systemic encephalopathy with vegetable and animal protein diets: A controlled crossover study. Dig Dis Sci. 1982;27:

25 2017