Cirrhosis of the Liver

1. Cirrhosis of the Liver Kelsey Conrad AnneliseChmelik September 24, 2013

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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”.

11. 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.

12. 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

13. 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

14. 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

15. Laboratory Values

16. Medications

17. 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.

18. 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.

19. 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

20. 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

21. 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

22. 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

23. 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