Cirrhosis of the Liver with Resulting Hepatic Encephalopathy

1. by Dustin Moore, Michelle Anderson, Stacey James and Candace Woodbury Cirrhosis of the Liver with Resulting Hepatic Encephalopathy

2. MNT • Good nutrition therapy is essential because malnutrition will have a profound negative impact on prognosis • For assessment, SGA parameters should be considered • History • Weight change • Appetite • Taste changes and early satiety • Dietary recall • Persistent gastrointestinal problems • Physical • Muscle wasting • Fat stores • Ascites or edema • Existing Conditions • Disease state and other problems that could influence nutrition status such as hepatic encephalopathy, GI bleeds, renal insufficiency, infection • Nutritional Rating • Well nourished • Moderately malnourished • Severely malnourished

3. Overall Goals of Nutrition Management • Increase energy intake with small frequent meals • Sodium restriction (2g/d) • Fluid restriction to reduce incidence of hyponatremia (1-1.5L/d) • CHO controlled diets for managing hypo and/or hyperglycemia • Vitamin and mineral supplementation • Supplement with enteral tube feeding as needed (esophageal pain, dysguesia, etc.)

4. Energy Requirements • Highly variable in cirrhotic patients • General recommendations: • In cirrhotic patients without ascites = 120-140% of REE • In cirrhotic patients with ascites, infection, or overall malnutrition = 150-170% of REE • The above mentioned amounts come out to about 30-40 calories/kg of estimated dry body weight. Diet based off of ascites will result in overfeeding

5. Carbohydrates • Glucose metabolism is highly compromised in cirrhotic patients • A single overnight fast in a cirrhotic patient = 2-3 days of starvation in a healthy individual • Both hypo and hyperglycemia can occur • B.G. should be monitored closely • Current recommendation for CHO intake is 5-6 g/kg/d spread evenly throughout the day • Patients should eat about 50 g of CHO right before bed to maintain blood glucose levels and combat catabolism

6. Fats • Lipid oxidation increases in cirrhotic patients, so 25-40% of calories from fat are recommended • Lipid oxidation maxes out at about 1 g/kg/d • ≥ 1 g/kg/d will result in triglyceride deposition • For patients suffering from steatorrhea, provide supplementation with MCT’s

7. Protein • Most controversial nutrient with regards to cirrhosis • Most patients should be started at .8-1 g/kg • In order to promote positive or stable N2 balance, recommendation is a minimum of 1.2 g/kg-1.5 g/kg • Protein restriction is not recommended and PEM can worsen the patient’s status

8. Use of BCAA’s • Some have proposed BCAAs to be beneficial for hepatic encephalopathy • Altered neurotransmitter theory: • With compromised glucose metabolism, BCAAs are used more for energy, causing serum levels to drop • The decreased levels of BCAAs now have to compete for transport at the blood brain barrier with aromatic amino acids, which are now more plentiful. • The amino acid imbalance worsens the state of H.E., so the theory is that providing BCAA’s to the patient will correct the H.E. • While good in theory, a cochrane review showed no significant benefits in patients suffering with H.E. after supplementation with BCAAs

9. Protein cont. • Diet modifications can be made to try and improve the state of hepatic encephalopathy • Main sources of aromatic amino acids • Red meat, chicken, fish, turkey, eggs, milk, cheeses, nuts • Therefore, the majority of the diet should consist of vegetables, grains, and smaller amounts of meat or animal products ( 3oz /day)

10. Compensated and Uncompensated Liver Failure • Uncompensated liver failure • Unstable stage of the liver disease • High ammonia level, deficits in lab values • Signs of jaundice, ascites, GI varices • Severely compromised function • More severe dietary restrictions • < .8 g/kg protein • < 1 gram Na • Enteral supplementation may be necessary because of increased calorie needs • TPN is only used under emergencies, or when the patient will be NPO for 5 days or more • Compensated liver failure • Stabilized stage of the liver disease • Low ammonia levels, close to normal lab values • Lack of jaundice and ascites • Functional capacity • Goal is to prepare a person for a liver transplant • Diet restrictions are less severe: • Modified protein intake beginning at .8-1.0 g/kg • Evenly spread carbs capped at 5-6 g/kg • Sodium and fluid restriction

11. Vitamin Needs • Vitamin deficiencies are fairly common and patients should consider supplement use • Fat malabsorption may lead to the need for fat soluble vitamin supplements (ADEK) • Large doses (100mg/d) of thiamin are recommended in cirrhotic patients if a deficiency is suspected

12. Mineral Needs • The following may either be needed as supplements (in RDA or AI amounts) or are contraindicated: • Iron: Necessary with excessive GI bleeding, but contraindicated in patients with hemochromatosis. • Copper/Manganese: Supplements provided should not include these minerals. Because of reduced bile excretion, toxicity may occur. • Magnesium: Depletion is common in ESLD • Zinc: Depletion is common, especially with diuretic therapy. Supplementation possibly improves glucose tolerance. • Calcium: Supplementation may be needed especially if a vitamin D deficiency exists. • Sodium: Typically restricted to about 2 g/day. Depending on severity of ESLD, as low as 500 mg/d.

13. Case Study

14. Another Look at Teresa Wilcox • Client name: Teresa Wilcox • DOB: 3/5 • Age: 26 • Sex: Female • Education: Doctoral graduate assistant • Occupation: Graduate teaching assistant • Hours of work: Teaches late morning and late afternoon; take classes and conducts research during most evenings

15. Chief Complaint • “It just seems as if I can’t get enough rest. I feel so weak. Sometimes I’m tired I can’t go to campus to teach my classes. Does my skin look yellow to you?”

16. Subjective Global Assessment Parameters for Nutrition Evaluation of Liver Disease Patients • Decrease in weight (10#) • Appetite: Anorexia, taste changes, early satiety • Dietary Recall: Calorie-deficient , low in protein, high sodium • Peristent Gastrointestinal Problems: Nausea, vomiting, difficulty swallowing

17. Physical Findings • Bruising on the lower arms and legs • Mild distension of RUQ, but it isn’t diagnosed as ascites • Splenomegaly w/o heptomegaly • Enlarged esophageal veins

18. Existing Conditions • Hepatitis C about 3 years ago

19. Nutritional Rating • Moderately or suspected of being malnourished

20. Nutrition Assessment • Patient is 26 year old female who complains of fatigue, general weakness, anorexia, N/V, and appears jaundiced. • Ht: 5’9” (175.26 cm); Wt: 125 lbs. (56.8 kg); BMI: 18.5; IBW: 145 lbs. (86%) • Current Meds: YAZ, Allegra

21. Nutrition Diagnosis: PES • Inadequate protein-energy intake related to anorexia secondary to cirrhosis as evidenced by decreased albumin levels and absence of food intake over past two days

22. Nutrition Intervention: MNT • Nutrition education (E-1.4). Will educate the patient on the importance of maintaining a good nutritional status so as to not worsen her prognosis. Will also teach patient overall goals for her condition • Give patient ideas to improve her oral intake

23. Nutrition Monitoring • Will follow up with the patient after her first week to see if intake and food choices have improved