Cirrhosis of the Liver

Cirrhosis of the LiverKelsey Conrad

Annelise ChmelikSeptember 24, 2013

the Liver• Largest organ in the body• Extremely complex organ• Filters harmful substances from the blood• Makes substances that digests food• Plays an important role in nutrient

metabolism

Cirrhosis of the Liver• Healthy tissue in the liver is replaced by scar

tissue• Blocks the flow of blood through the organ• Results in the loss of liver function• Most common causes

• Chronic HCV• Alcoholism

• Genetic factors can increase susceptibility

Cirrhosis of the Liver• Enlarged liver resulting from fat accumulation

and necrosis of the liver cells• Symptoms

• Fatigue, weakness, nausea, poor appetite, and malaise.

• Jaundice, dark urine, light stools, steatorrhea, itching, abdominal pain, and bloating.

• Protein-energy malnutrition• Inability to consume adequate amounts of food• Impaired nutrient absorption and digestion• Vasodilation and expanded blood volume

Cirrhosis of the Liver• Vitamin and mineral deficiencies

• Related to decreased hematocrit and hemoglobin values

• Hypoglycemia• Liver is the key to glucose homeostasis• Altered liver function limits the ability to

maintain normal glucose homeostasis• Disrupts hepatic glucose output• Can affect nutritional status

Cirrhosis of the Liver• Bruising and bleeding

• Related to decreased vitamin K absorption and ability to synthesize protein clotting factors.

• Complications• Portal hypertension, hepatic encephalopathy,

ascites, hepatorenal syndrome, and esophageal varices

• Treatment• Abstention from alcohol• Treatment of the complications• Nutrition therapy

Cirrhosis of the Liver• MELD Score

• Prognosis Model for End-stage Liver Disease• Clinical tool used to determine prognosis in

patients with cirrhosis. • Based on three blood tests

• INR – International normalized ratio• Bilirubin• Creatinine

• Estimates an individual’s 90-day mortality rate

Cirrhosis of the Liver• Nutrition Therapy

• Calorie recommendations – 35 to 40 kcal/kg per day

• Protein intake – Up to 1.6 g/kg per day• Vegetable and dairy sources recommended for

patients with mild encephalopathy• 30% or less of total calories from fat• Carbohydrate consumed throughout the day• Restrict sodium• Consider enteral and parenteral support• Mechanically soft diet for patients with

esophageal varices

Teresa Wilcox• 26 year old female architecture doctoral

student• Single – Lives with roommate Kevin Gustat• Teaches late morning and late afternoon;

takes classes and conducts research during most evenings.

• Hepatitis C Dx 3 years ago

Teresa Wilcox• Height – 5’8’’• Weight – 125 lbs• BP – 102/65• Reports alcohol use• Complains of fatigue, anorexia, nausea,

vomiting, weakness, and bruising unrelated to injury.

• Has lost 10 lbs since last visit 6 months ago• Noted as a “tired looking young female”.

Medical Diagnosis• CT scan and liver biopsy confirm cirrhosis• MELD score 23 represents a 35% 90-day

mortality rate• INR – 2.2• Bilirubin – 3.7 mg/dL• Creatinine serum – 1.4 mg/dL

• Signs and symptoms consistent with diagnosis• Fatigue, weakness, weight loss, bruising, jaundice,

abdominal distension, light stools cloudy amber-colored urine, lack of appetite, enlarged esophageal veins, and hepatomegaly.

Ms. Wilcox’s Weight• Current weight: 125 pounds (56.8 kg)• Height: 5’8” (1.7 m)

• BMI = 19 normal

• Ideal Body Weight: 140 pounds

Energy & Protein Needs

• Energy Requirements: 35-40 kcal/kg• 1,988-2,272 ~2,000-2,300 kcal per day

• Protein Requirements: 1.6 g/kg• 90-91 grams of protein per day

Factors affecting diet

• Impaired nutrient digestion and absorption due to portal hypertension, decreased pancreatic enzyme production and/or secretion, and villus atrophy

• Increased energy expenditure because of the vasodilation and expanded blood volume

Laboratory ValuesLab Value Reference Range Ms. Wilcox’s

ValueAlbumin 3.5-5 g/dL 2.1 g/dLAlkaline Phosphatase

30-120 275

Ammonia 9-33 33ALT 4-36 62AST 0-35 230Lactate Dehydrogenase

208-378 658

PT 12.4-14.4 18.5Protein 6-8 g/dL 5.4Hemoglobin 12-15 10.9

Medications Medication Classification PurposeSpironolactone (25 mg)

K-sparing diuretic Prevents your body from absorbing too much salt while keeping potassium levels from getting too low; prescribed to help treat edema

Propranolol (40 mg) Beta-blocker Decreases blood pressure; prescribed to help treat portal hypertension

Nutrition Diagnosis• PES Statement #1 – Inadequate Protein-

Energy Intake• P: Inadequate protein-energy intake (NI – 5.3)

Related to • E: Inability to consume adequate amounts of

food, impaired nutrient absorption and digestion, and increased energy expenditure

As evidenced by• S: 10-pound weight loss in 6 months, lack of

appetite, inadequate intake based on client remarks and diet history, and laboratory results.

Nutrition Diagnosis• PES Statement #2- Unintended Weight Loss

• P: Unintended Weight Loss (NC – 3.2)Related to

• E: Decreased appetite, fatigue, and nausea by recent cirrhosis of the liver diagnosis

As evidenced by• S: Client statements and 10 pound weight loss

in past 6 months.

Nutrition Intervention• Calorie recommendations – 2,000 to 2,300

kcal/day• Protein intake – 90 to 91 g/day• Total calories from fat – No more than 690 kcal• Carbohydrate consumed throughout the day• 2 grams Na/day• Mechanically soft diet with small, frequent meals• Discharged with 2-L fluid restriction, but fluids are

not usually restricted

Nutrition Intervention• Ms. Wilcox asked about using salt-substitutes

• Avoid salt substitutes due to high potassium content• Risk of hyperkalemia• Use Mrs. Dash or other spices

• Compliance with sodium and fluid restriction• Replace juice in the morning with whole fruit or other

solid breakfast item• Drain broth from soup or replace soup with sandwich

or salad• Low-sodium soup (<500mg) with unsalted crackers• Reduce Diet Coke consumption• Limit carry-out to 1-2 nights per week

One month later• Weight = 140 pounds• Her shoes do not fit on her feet. Why could

this be?• Diet Recall:

• Total calories: 2,188• FAT: 113.9 g; 1,007 kcal; 46% total kcal• CHO: 193.6 g; 740 kcal; 34% total kcal• PRO: 108.3 g; 444 kcal; 20% total kcal• Sodium: 2,896.6 g

Resources• Akry, R. A. (1989). Hypoglycemia associated with liver disease and ethanol

[Abstract]. Endocrinol Metabolic Clinic North America, 18(1), 75-90. • Fowler, C. (2009). Critical nursing challenge: patients with end-stage liver

disease. Retrieved from https://web-ded.uta.edu/wconnect/ace/static/onlinecne/CEMay09.pdf

• Hepatorenal syndrome. (2012). U.S. National Library of Medicine. Retrieved from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001519/#adam_000489.disease.causes

• "International Dietetics and Nutritional Terminology (IDNT) Reference Manual: Standard Language for the Nutrition Care Process." International Dietetics and Nutritional Terminology (IDNT) Reference Manual: Standard Language for the Nutrition Care Process. Academy of Nutrition and Dietetics, n.d. Web. 20 Sept. 2013.

• Liver cirrhosis: A toolkit for patients. (2011). Informally published manuscript, University of Michigan Health System. Retrieved from http://www.med.umich.edu/hepatology/images/Cirrhosis%20Patient%20Toolkit.v2.pdf

Resources• Longstreth, G. F. (2011). Hepatic encephalopathy. MedlinePlus.

Retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/000302.htm

• Mayo Clinic (2013). MELD Score and 90-Day Mortality Rate for Alcoholic Hepatitis. Retrieved from http://www.mayoclinic.org/meld/mayomodel7.html

• Nemls, M., Sucher, K. P., Lacey, K., & Roth, S. L. (2011). Diseases of the Liver, Gallbladder, and Exocrine Pancreas. In Y. Cossio (Ed.), Nutrition Therapy & Pathophysiology (pp. 437-470). Belmont, CA: Wadsworth.

• WebMD. (2013). What is portal hypertension? Digestive Disorders Health Center. Retrieved from http://www.webmd.com/digestive-disorders/digestive-diseases-portal

• Yeung, E., & Wong, F. S. (2002). The management of cirrhotic ascites. Medscape General Medicine, 4(4), Retrieved from http://www.medscape.com/viewarticle/442364_3