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Learning Objectives
!! Demonstrate understanding of the functions of the
Liver !! Demonstrate understanding of the causes and pathophysiology of Cirrhosis of the Liver !! Demonstrate understanding of consequences and symptoms of Cirrhosis of the Liver !! Identify markers of Liver Disease !! Identify nutrition goals for patients with severe Cirrhosis of the Liver and Hepatic encephalopathy
Pre-Test
!! Things to consider: 1.! What functions occur in the Liver? 2.! What is Cirrhosis of the Liver? 3.! What are the diagnostic parameters for Cirrhosis of the Liver? 4.! What is Hepatic Encephalopathy? 5.! What is the MNT for Cirrhotic patients?
Cirrhosis
!! Cirrhosis Video !! Advanced Stage of Liver Disease !! Enlarged Liver !! Liver damage, inflammation
"!
Characterized by: "! Fatigue, weakness, malaise, nausea, poor appetite, weight loss, jaundice, abdominal pain
!! !! !! !! !!
Prognosis
!! 12th leading cause of death in U.S. !! Scarring of the liver is irreversible !! Best outcome is selection for a Liver Transplant
"! Most
Consequences of Cirrhosis
!! Portal Hypertension:
!!
Elevated BP in the portal vein d/t obstructed blood flow through the liver Distended collateral blood vessels that protrude into the esophagus Can cause massive bleeding if ruptured Edema characterized by the accumulation of fluid, electrolytes and serum proteins in the abdominal cavity "! Hepatic Encephalopathy/ Hepatic Coma "! Venous overflow obstruction "! Chronic right-sided heat failure
!! Esophageal Varicies:
!! !!
!! Ascites
!!
!! Hepatic Encephalopathy/Hepatic Coma !! Venous Overflow obstruction !! Chronic right-sided heart failue !! Tricupsis Regurgitation
Hepatitis C
!! Leading cause of Cirrhosis of the Liver !! Blood-born virus that is transmitted through blood or other body fluids from an infected person. !! Prognosis
"! 75-85%
of acute infections will become chronically infected "! 60 - 70% will develop chronic liver disease "! 5-20% will develop cirrhosis of the liver in 20-30 years "! Cause of 8,000 10,000 deaths each year in U.S.
!! Treatment
"! 24-48
week course of combination of pegylated alpha interferon and ribavirin, an oral antiviral agent
of fat cells in hepatocytes "! Early Stage of Liver ds. "! Caused by alcohol abuse, obesity, long-term TPN, PEM, small bowel bypass surgery, exposure to toxic substances, drugs
!!
Hepatitis:
"! Inflammation
of hepatocytes secondary to a virus, bacteria, toxins, obstruction, parasite, drug, or alcohol that causes cell damage "! Hepatitis A causes nausea, dark urine, and jaundice "! Hepatitis B, C causes chronic hepatitis causing further damage to the liver or liver cancer leading to hepatic coma or death
!!
Cirrhosis
"! Advanced
stage of liver disease "! Scar tissue from chronic inflammation replaces hepatocytes and changes the structure of the liver impeding hepatic blood flow. "! Caused by alcoholism, obesity, infections
Pathophysiology
!! Disorders
"! The
Consequences
!! Jaundice !! A symptom, causing yellowish tint to the bodies tissue and is usually the result of elevated bilirubin concentration in the extracellular fluids !! Portal Hypertension
"! Elevated
blood pressure in the portal vain (the vein in the abdominal cavity that drains blood primarily from the GI tract and spleen.
A syndrome of impaired mental status and abnormal neuromuscular function that results from major liver failure.
!! Healthy
"!
!! Hyperammonia
Urea is a direct cerebral toxin "! Other nitrogenous compounds may contribute as well
Soulsby CT, Morgan MY. Dietary Management of hepatic encephalopathy in cirrhotic patient: survey of current practice in United Kingdom. BMJ. 1999;318:1391.
ESLD without ascites: BEE x 1.2-1.3 Ascites, infection, malabsorption or malnutrition: BEE x 1.5-1.75 (30-35kcal/kg) Watch for fasting hypoglycemia Small, balanced meals Normal amounts (35-40% kcals) unless steatorrhea (MCTs!) Hepatitis/cirrhosis: 0.8-1.0 g/kg dry wt. Repletion: 1.2-1.3 g/kg Stress/decomposition/sepsis: 1.5g/kg + Encephalopathy: restriction?
!! Carbohydrate
!! !!
!! Lipids
!!
!! Protein
!! !! !! !!
damage impedes proper metabolism of protein and other nutrients is reduced due to liver damage making it difficult to assess CHO needs. affects assessment needs in general
!!
Carbohydrate Status
"! Gluconeogenesis
!!
Nutrition needs
"! Malabsorption
!! Medical Treatments !! Prevent further damage !! Treat complication of Cirrhosis !! Prevent liver cancer or detect it early !! Receive Liver transplant
student !! Graduate teaching assistant !! Ht: 59 !! ABW: 125 lbs. !! UBW: 135 lbs. (lost 10 lbs. n 6 months) !! Came in with increasing symptoms of liver ds !! Previous Dx: Acute Hepatitis 31/2 years ago !! Medical Dx: Cirrohsis of the liver secondary to chronic hepatitis C infection.
Teresa
!! Chief Complaint: It just seems as if I cant get enough rest. I feel so
weak. Sometimes Im so tired I cant go to campus to teach my classes. Does my skin look yellow to you?
!! Patient History:
!!
!! Lost 10 lbs. since last visit (6 months ago) !! Meds: Yaz and Allegra
Physical examination
!! !! !! !! !! !! !! !! !! !! !!
Appearance: tired looking young female Vitals: Temp 96.9F, BP 102/65mm Hg, HR 72 bpm, RR 19 bpm Heart: Regulat rate and rhythm Head: Normocephalic Extremeties: Normal muscular tone, normal ROM, no edema; no asterixis notes Skin: Warm and dry; brusiing noted on lower arms and legs; telangiectasias noted on chest Chest/Lungs: Respirations normal; no crackles, rhonchi, wheezes, or rubs noted Throat: enlarged esophageal veins Eyes: Wears contact lenses to correct myopia, PERRLA Nose: Dry mucous membranes w/out lesions Abdomen: Pierced umbilicus, mild distension RUQ, splenomegaly w/out hepatomegaly; no ascites
Anthropometrics
!! Height: 69 !! Weight: 125lbs on admit !! BMI: 18.5 Normal !! IBW: 145 lbs. !! %IBW: 86% Mildly Depleted Energy Stores !! %UBW: 92% !! 8% weight loss in 6 months. Mild Weight Loss
Food Assessment
#! #! #! #! #!
No appetite for past few days Breakfast: Calcium-fortified OJ Lunch: Soup and crackers & diet coke Dinner: Home or Chinese or Italian take-out Usual Dietary Intake:
#! Sips of water, juice and diet coke #! Has not eating in past 2 days Food Allergies: Doesnt like liver or lima beans Takes 400mg Vit E, 600mg Calcium, 400IU Vit D, MV/mineral, 200mg Milk Thistle 2x/day, 3g/ day Chicory, 500mg Ginger 2x/day
#! Diet Order:
#! Soft #! 4 grams of sodium #! High Kcal
Lab!
Albumin! Total Protein! Prealbumin! Glucose! Bilirubin! ALT! AST! Alk Phos!
Normal Range!
3.5 5 g/dL! 6 8 g/dL! 16 35 mg/dL! 70 110 mg/dL! ! 0.3 mg/dL! 4 36 U/L! 0 35 U/L! 30 120 U/L!
Admit!
2.1 L! 5.4 L! 15 L! 115 H! 3.7 H! 62 H! 230 H! 275 H!
Reason!
Parallels the functional status of parenchymal cells. ! Related to malnutrition, weight loss and decreased liver function Indicative of malnutrition, PEM, possibly? Hyperglycemia due to decreased glucose metabolism. Biomarker of Liver Ds. Biomarker of Liver Ds. Most sensitive enzyme secondary to exacerbation of infectious hepatitis Biomarker of Liver Ds. Less specific enzyme that is secondary to cellular necrosis Biomarker of Liver Ds. Increased activity with hepatic ds. & chronic obstruction of biliary tract, not non-specific Indicative of injury or stress to heart, brain or muscle tissue. Increased by alcohol/drugs Related to fatty liver and decreased liver function and FA metabolism Impaired iron absorption, synthesis and uptake. Chronic hepatitis infection Dehydration Related to long-term hepatitis infection Malabsorption and 2 Vit B12 def. Megaloblastic Macrocytic Anemia Related to malnutrition, chronic infection. Precursor to Iron-deficiency anemia Prolonged with hepatic disease
30 135 U/L! 35 135 mg/dL! 4.2 5.4 x 103/mm3! 4.5 6.2 g/dL! 37 47 %! 80 96 "m3 20 120 mg/mL! 11 16 sec!
Normal!
Reason!
Prot! Ubil!
Neg! Neg!
1+! 1+!
Illness Indicative of biliary obstruction or RBC hemolysis Related to decrease in liver function & inhibition of intrahepatic urobilinogen cycle Infection
Urobil!
1.8!
WBCs! RBCs!
0 5/HPF! 0 5/HPF!
3.8! 2.7!
Assessment
!! Energy Needs "! Current Recommendation: 35-40 kcal/kg/day
! 35kcal/56.8kg/day = 1,988kcals/day
!! !!
BEE = 655 + (9.6 x 56.8) + (1.8 x 175) (4.7 x 26) = 1393kcals TEE: 1393 x 1.5 = 2090kcals
!! Protein Needs "! Protein Needs: "! Current Recommendations: 1.6g/kg/day "! Restrict protein with severe forms of Encephalopathy
! PROTEIN: 56.8kg x 1.6g = 91g/kg/day !! (mildly depleted visceral protein stores)
!! Fluid Needs:
"! Restrict
!!
Prescribed Medications
Rationale for Rx Sprionolactone Given to treat fluid retention from liver failure. It prevents the body from absorbing too much salt and keeps potassium levels from getting too low. Propranolol A beta-blocker; used to prevent the occurrence of high portal blood pressure. Nutritional Implications Alcohol intake should be monitored Low sodium diet is needed Loss of appetite may occur-leading to malnutrition
Nausea/Vomiting, stomach pains may occur. Food intake needs to be assessed fro these possible side effects
Medication
Vasopressin Lactulose
Classification
Mechanism
Laxative, antihyperammonemic
Neomycin
Antibiotic
Impairs absorption (may increase excretion) of a broad variety of nutrients including CHO, fats, Ca, Fe, Magnesium, Nitrogen, potassium, sodium, folic acid, and vitamins A, B12, D, K
Iron Supplement
Foods supplement is taken with can alter the amount of iron being utilized
Causes stomach cramps, diarrhea
Laxative, stimulant Increases stimulations of bowel Laxative Increases stimulations of bowels Antihistamine Blocks action of histamine
Decision Tree
Is it in our scope of practice to treat and diagnose Paris?
Nutrition Diagnosis
!! PES Statement:
!! Inadequate
oral intake (NI-2.1) related to poor appetite from complications of cirrhosis as evidenced by 8% weight loss in 6 mo, and diet recall. (NC-3.1) related to impaired nutrient intake and utilization as evidenced by BMI of 18.5.
!! Underweight
Plank LD, Gane EJ, Peng S, et al. Nocturnal Nutritional Supplementation improves total body protein status of patients with liver Cirrhosis: A Randomized 12-month trial. Hepatology. 2008; 48:557-566.
!! !!
Frohlinde-Schulte E, et al. Role of meal carbohydrate content for the imbalance of plasms amino acids in patients with liver cirrhosis. J Gastroenterology and Hepatology. 2007; 22:1241-1248.
Assessment, cont.
!! Miscellaneous Recommendations:
!!
Sodium Restriction
"!
!!
!! Zinc Supplementation
!!
statusb,
suggests that supplementation can improve nutrition liver function, and decrease progression of Encephalopathya
! Bianchi GP, et al. Nutritional Effects of Oral Zinc Supplementation in Cirrhosis. Nutrition Research. 2000; 20(8):1079-1089.
! Marchesini G, Fabri A, Bianchi G, Brizi M, Zoli M. Zinc Supplementation and Amino Acid-Nitrogen Metabolism in Patients with Advanced Cirrhosis. Hepatology. 1996; 23(5):
Nutrition Intervention
!! Food and/or Nutrient Delivery. Meal and snacks
(ND-1):
!!
Modify dietary pattern to mechanically soft diet !! Eat a high protein, low-fat, nutrient dense diet
other (ND-3.2.4).
!!
health/disease(E-1.4):
!!
Counsel patient on dietary restrictions (Na, fat & alcohol) and need for increased energy intake !! Counsel patient on nocturnal feedings and importance to care of disease
nutrients considered. !! Monitor patients energy intake. !! Monitor any changes in weight. !! Monitor lab values
!!
ALT, AST, Als phos, Albumin, Total protein, Prealbumin, Glucose, Bilirubin, Ammonia, Hgb, Hct, MCV, RBC, Ferritin
Post Test
1.! 2.! 3.!
POST QUIZ
4.!
5.!
1.!
List three functions of the Liver? What are the main consequences of Cirrhosis of the Liver? What are the Biochemical Markers for Diagnosing Cirrhosis of the Liver? What is one possible reason that patients with Cirrhosis end up with Hepatic Encephalopathy? What are the current Nutrition Recommendations for a patient with Cirrhosis of the Liver
Recommendations for alcohol?
!! Bonus Question! 1.! Who is the 44th President of the United States!?! ;)
References
!! !!
!! !!
!! !! !!
!!
Bianchi GP, et al. Nutritional Effects of Oral Zinc Supplementation in Cirrhosis. Nutrition Research. 2000; 20(8):1079-1089. Frohlinde-Schulte E, et al. Role of meal carbohydrate content for the imbalance of plasms amino acids in patients with liver cirrhosis. J Gastroenterology and Hepatology. 2007; 22:1241-1248. Gropper SS., Smith JL., Groff JL. (2009). Advanced Nutrition and Human Metabolism. Fifth Edition. Belmont, CA: Wadsworth. Marchesini G, Fabri A, Bianchi G, Brizi M, Zoli M. Zinc Supplementation and Amino Acid-Nitrogen Metabolism in Patients with Advanced Cirrhosis. Hepatology. 1996; 23(5):1084-1092. Merli M, et al. Nutritional status: its influence on the outcome of patients undergoing liver transplantation. Liver International. 2009; 1478-3231. Nelms M, Sucher KP, Lacey K, Ruth SL. (2011). Nutrition Therapy & Pathophysiology. Second Edition. Belmont, CA: Wadsworth. Plank LD, Gane EJ, Peng S, et al. Nocturnal Nutritional Supplementation improves total body protein status of patients with liver Cirrhosis: A Randomized 12-month trial. Hepatology. 2008; 48:557-566. Soulsby CT, Morgan MY. Dietary Management of hepatic encephalopathy in cirrhotic patient: survey of current practice in United Kingdom. BMJ. 1999;318:1391.