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Alcohol and the Liver. A Case Study. Leslie Anderson. Patient Background. SH was 42 y.o . Caucasian male, married with 2 children Smoked half a pack a day, drank a fifth of whiskey daily Admitted to LDSH for alcohol detox – 08/11 Family History significant for Polycystic Kidney Disease.

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Alcohol and the liver

Alcohol and the Liver

A Case Study

Leslie Anderson


Patient background
Patient Background

  • SH was 42 y.o. Caucasian male, married with 2 children

  • Smoked half a pack a day, drank a fifth of whiskey daily

    • Admitted to LDSH for alcohol detox – 08/11

  • Family History significant for Polycystic Kidney Disease


Past medical history
Past Medical History

  • Hypertension

  • Dyslipidemia

  • Polycystic kidney disease (recent diagnosis)

  • Lymph node resection

  • Alcohol abuse with previous evidence of alcoholic hepatitis


Hospital events procedures
Hospital Events/Procedures

  • 11/2: SH admitted to ER

  • 11/3: Transferred to ICU; Intubated d/t respiratory distress

  • Plan to admit to psychiatric unit to assist in his alcohol detoxification


Alcohol and the liver1
Alcohol and the Liver

  • The liver detoxifies 90% of ingested alcohol

  • Metabolism of alcohol is the main cause of liver damage

  • Alcoholic Liver Disease (ALD) is the cause of 50% of all liver disease cases

    • SteatosisSteatohepatitis Cirrhosis


Risk factors
Risk Factors

  • Binge/Chronic Drinking

  • Drinking between meals

  • Type of beverage

  • Family history of disease

  • Females > Males


Metabolism of alcohol
Metabolism of Alcohol

  • Alcohol Dehydrogenase (ALD)

    • Metabolizes 80% of ingested alcohol

    • Ethanol AcetaldehydeAcetateAcetyl-CoACo2 +H2O

    • Leads to hepatic steatosis

  • Cytochrome P450 2E1 (CYP2E1)

    • Previously called inducible microsomal ethanol-oxidizing system (MEOS)

    • Used most in chronic alcoholism

  • Catalase enzyme

    • Non-oxidative process

    • Leads to hepatic steatosis


Toxic effect of alcohol
Toxic Effect of Alcohol

  • Ethanol

    • “Leaky gut”

    • Reactive Oxygen Species (ROS)

    • Compromised immunity

  • Acetaldehyde – Key toxin

    • Cellular damage, inflammation, extracellular matrix remodeling and fibrinogenesis

  • Acetate/Acetyl Co-A

    • Increased IL-6, IL-8, TNF-a

  • Effects perpetuate and progress


Nutritional concerns
Nutritional Concerns

  • Malnutrition

    • Alcohol substitution

    • Malabsorption

  • Altered macronutrient metabolism

    • Reduced glucose production, often accompanied by insulin resistance

    • Lipids are malabsorbed and remain in circulation d/t decreased bile secretion

    • Increased protein catabolism with inadequate resynthesis


Vitamin mineral deficiences
Vitamin/Mineral Deficiences

  • Decreased:

    • Intake of nutritious foods

    • Absorption

    • Storage

  • Increased Use:

    • Antioxidants

    • Metabolism of alcohol


Proposed supplements
Proposed Supplements

  • Milk Thistle (Silymaryin)

    • Safe, well-tolerated

    • No benefit noted

  • S-Adenyosylmethionine

    • Precursor to glutathione (antioxidant)

    • No benefit seen

  • Metadoxine

    • Not approved in U.S.

    • Decreased lipid accumulation

  • Phosphatidylcholine

    • Fibrosis-reducing effect

    • More studies needed


Anthropometrics
Anthropometrics

  • Wt: 106.3 kg

  • Ht: 182.9 cm

  • IBW: 80.8 kg

  • % IBW:132

  • BMI: 31.78

  • Adj BW: 90.5 kg


Estimated nutrition needs
Estimated Nutrition Needs

  • 2100-2550 kcals (23-28 kcal/kg)

  • 80-95 g protein (1.0-1.2 g/kg)

  • 2800 ml fluid (35 ml/kg)

  • Adjusted wt used for energy needs

  • IBW used for protein and fluid needs




Clinical data
Clinical Data

  • Febrile – 38.9º C

  • Tremors – r/t alcohol detoxification

  • Questionable ascites

    • Unable to determine d/t body habitus


Medications
Medications

  • Anesthesia/Sedative

    • Propofol – (85 kcal/day)

  • Antianxiety

  • AntiGERD

  • Antiemetic

  • Fluid/Electrolyte/Vitamin replacement



Nutrition assessment
Nutrition Assessment

  • Pt at high nutrition risk r/t inability to take PO, confusion, and intubation. BMI 31.8 indicates obesity. Albumin was wnl upon admit, with lowered labs d/t fluid administration. Altered labs r/t liver disease precipitated by alcohol consumption. Will continue to monitor lipase to determine possibility of PO intake vs. need for NJ past ligament of Trietz upon NPO day 2. Decreased estimated energy requirements d/t intubation. Unable to talk to pt at this time.


Nutrition problem goals
Nutrition Problem & Goals

  • Excessive alcohol intake r/t alcohol or drug addiction AEB elevated alcohol, LFT’s, and lipase lab values.

  • Advance diet as tolerated and as medically able.


Interventions
Interventions

  • MVI, thiamin, folic acid

  • NPO d/t elevated lipase


Recommendations
Recommendations

  • If still NPO by tomorrow, recommend initiation of enteral feeds past the ligament of Trietz. Initiate feeds of Peptamen AF @ 20 ml/hr and monitor labs for refeeding syndrome as Phos is already low. End goal rate for pt is Peptamen AF @ 75 ml/hr = 24 kcal/kg Adj wt and 1.7 g prot/kg.


Prognosis
Prognosis

  • Poor d/t:

    • PKD

    • Alcoholic Hepatitis

      • continued alcohol abuse

    • Need for continued medical care

      • Possible dialysis

      • Possible transplants


References
References

  • Hasse JM, Matarese LE. Medical nutrition therapy for liver, biliary system, and exocrine pancreas disorders. In: Mahan LK, Escott-Stump S, ed. Krause’s Food & Nutrition Therapy. 12 ed. St. Louise, MO: Saunders Elsevier; 2008:707-727.

  • The Merck Manual of Diagnosis and Therapy. 18th  ed.  Whitehouse Station, NJ; 2006:1129-1131.

  • Seth D, Haber PS, Syn WK, Diehl AM, Day CP. Pathogenesis of alcohol-induced liver disease: classical concepts and recent advances. J GastroenterolHepatol. 2011:26;1089-1105.

  • Szabo G, Mandrekar P. Focus on: Alcohol and the liver. Alcohol Res Health. 2010:33;87-96.

  • Griffith CM, Schenker S. The role of nutritional therapy in alcoholic liver disease. Alcohol Res Health. 2006:29(4):296-306.


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