I.

Theoretical Consideration

a. Disease Condition

Cirrhosis of the liver is a serious disease that results in permanent damage to the

liver. Cirrhosis of the liver critically affects its ability to function normally. It is an

ongoing, chronic disease and can lead to grave, even lethal, complications in other vital

organs and body systems, such as the kidneys, immune system, brain,

circulatory system and digestive system.

The liver is a vital organ, and normal functioning of the liver is crucial to health and

life. In cirrhosis of the liver, an underlying disease or conditions cases scar tissue to form

in the liver. This scar tissue reduces the liver's ability to do its vital job in helping the

body to fight infection, stop bleeding, clear the blood of toxins, store energy, produce

healthy blood, digest food and remove waste.

b. Classifications/Type

1. Alcoholic cirrhosis - a type in alcoholics, due to associated nutritional deficiency

or chronic excessive exposure to alcohol as a hepatotoxin.

2. Atrophic cirrhosis - a type in which the liver is decreased in size, seen in

posthepatic or postnecrotic cirrhosis and in some alcoholics.

3. Biliary cirrhosis - a type due to chronic bile retention after obstruction or

infection of the major extra- or intrahepatic bile ducts (secondary biliary c.), or of

unknown etiology (primary biliary c.), and sometimes occurring after

administration of certain drugs.

4. Cardiac cirrhosis - fibrosis of the liver, probably following central hemorrhagic

necrosis, in association with congestive heart disease.

5. Fatty cirrhosis - a form in which liver cells become infiltrated with fat.

6. Laënnec's cirrhosis - a type associated with alcohol abuse.

7. Macronodular cirrhosis - a type that follows subacute hepatic necrosis due to

toxic or viral hepatitis.

8. Metabolic cirrhosis - a type associated with metabolic diseases, such as

hemochromatosis, Wilson's disease, glycogen storage disease, galactosemia, and

disorders of amino acid metabolism.

9. Portal cirrhosis - Laënnec's c.

10. Posthepatitic cirrhosis - a type (usually macronodular) that is a sequel to acute

hepatitis.
 C. Etiology & Pathology

ALCOHOL

Acetyldehyde
Intestinal Oxidative
Permeability Stress

Immunoligical Damage
Endotoxins (protein adducts)
Lipid
Peroxidation

Kupffer Cells
Necro-inflammation
Cytokines (and/or apoptosis)
(TGF-β1)

Stellate Cells

D. Clinical Manifestations
Fibrosis
Collagen
• Spider angiomata or spider nevi- vascular lesions consisting of a central

arteriole surrounded by many smaller vessels because of an increase in estradiol.

These occur in about 1/3 of cases.

Alcoholic
• Palmar erythema - exaggerations of normal speckled mottling of the palm,
Cirrhosis
because of altered sex hormone metabolism.
• Nail changes

o Muehrcke's lines - paired horizontal bands separated by normal color

resulting from hypoalbuminemia (inadequate production of albumin).

o Terry's nails - proximal two-thirds of the nail plate appears white with

distal one-third red, also due to hypoalbuminemia

o Clubbing - angle between the nail plate and proximal nail fold > 180

degrees

• Hypertrophic osteoarthropathy - chronic proliferative periostitis of the long

bones that can cause considerable pain.

• Dupuytren's contracture - thickening and shortening of palmar fascia that leads

to flexion deformities of the fingers. Thought to be caused by fibroblastic

proliferation and disorderly collagen deposition. It is relatively common (33% of

patients).

• Gynecomastia - benign proliferation of glandular tissue of male breasts

presenting with a rubbery or firm mass extending concentrically from the nipples.

This is caused by increased estradiol and can occur in up to 66% of patients.

• Hypogonadism - manifested as impotence, infertility, loss of sexual drive, and

testicular atrophy because of primary gonadal injury or suppression of

hypothalamic or pituitary function.

• Liver size - can be enlarged, normal, or shrunken.

• Splenomegaly (increase in size of the spleen) - caused by congestion of the red

pulp as a result of portal hypertension.

 • Ascites - accumulation of fluid in the peritoneal cavity giving rise to flank

dullness (needs about 1500 mL to detect flank dullness).

• Caput medusa - in portal hypertension, the umbilical vein may open. Blood from

the portal venous system may be shunted through the periumbilical veins into the

umbilical vein and ultimately to the abdominal wall veins, manifesting as caput

medusa.

• Cruveilhier-Baumgarten murmur - venous hum heard in epigastric region (on

examination by stethoscope) because of collateral connections between portal

system and the remnant of the umbilical vein in portal hypertension.

• Fetor hepaticus - musty odor in breath as a result of increased dimethyl sulfide.

• Jaundice - yellow discoloring of the skin, eye, and mucus membranes because of

increased bilirubin (at least 2–3 mg/dL or 30 mmol/L). Urine may also appear

dark.

• Asterixis - bilateral asynchronous flapping of outstretched, dorsiflexed hands

seen in patients with hepatic encephalopathy.

• Other - weakness, fatigue, anorexia, weight loss.

II. The Patient-General Info

a. Physicians Data :

Name of Patient : Ronald Nolasco

Age : 58 yrs. Old

Sex : Male
 Place of Residence : Marulas, Valenzuela City

Weight : 40kg

Height : 4’8”

Occupation : Jeepney Driver

III. Evaluation and Implications

a. Dietary Computations

1. Determine the following:

a. BMI classification

BMI: 40 kg = 4’8

=60 x 0.0254 = (1.524)2= 2.32

BMI = weight / kg

= 40/2.32

= 17.24

b. DBW

DBW = (ht in cm – 100 ) – 10 %

= (152.4 – 100 ) – 10 %

= 47.16 or 47%

c. Dietary Management Rationale

Calorie -to increase DBW

Carbohydrates - to lessen cholesterol

Protein - to normalize protein in the body

Fats - to decrease fat intake

d. TER determination

TER = 40 x 40 + 500

= 2100 cals

e. CPF Distribution

Compute the CPF of the client whose TER is 2100 cals using 65-15-20

distribution

C = 2100 x .65 / 4 = 350

P = 2100 x .15 / 4 = 80

F = 2100 x .20 / 9 = 50

Diet Rx 2100 C = 350 P = 80 F = 50

f. Sample Meal Plan for One Day

Food list No. of C P F Energy

Exchange
I. Veg A 2 3 1 - 16

Veg B 1 3 1 - 16

II. Fruit 4 40 - - 160

III. Milk (LF) 1 12 8 5 125

VII. Sugar 3 15 - - 60

73

IV Rice 12 276 24 - 1200

34

V. Meat (LF) 3 - 24 3 123

(MF) 2 - 16 12 172

20

VI. Fat 4 - - 20 180

TOTAL 349 74 40 2052

Food No. B AM’s L PM’s D

exchange
Veg. 3 - - 2 - 1
Fruit 4 1 1 1 1 -
Milk 1 1 - - - -
Sugar 4 1 1 1 1 -
Rice 10 3 1 3 - 3
Meat 5 1 1 1 - 2
Fat 4 1 1 1 - 1

BREAKFAST

Fried Chicken

Food No. of exchange Sample menu Size/serving

Fruit 1 Banana 1 pc.
Milk 1 LF milk 1 cup
Sugar 1 Marshmallow 1 pc.
Rice 3 Rice 1 ½ cup
Meat 2 Chicken leg 2 pcs.
Fat 1 Oil 1 tsp.

AM SNACK

Ham Sandwich

Fruit 1 Buko Juice 1 cup

Sugar 1 Sugar 1 tsp.
Fat 1 Vegetable Oil 1 tsp
Meat 1 Ham 1 slice
Rice 1 Pande-Monay 1 piece

LUNCH

Beef Nilaga

-Pechay,Baguio beans 1 cup

Vegetable 2 -Baby Corn 1 cup

Fruit 1 Ripe Mango 1 slice
Sugar 1 Lifesaver candy 1 piece
Rice 3 Rice 1 ½ cup
Meat 1 Beef 1 matchbox slice
Fat 1 Vegetable oil 1 tsp
PM SNACKS

Apple coated with honey

Fruit 1 Apple Half piece

Sugar 1 Honey 1 tsp

DINNER

Misua with Meatballs

Vegetables 1 Patola 1 cup

Rice 3 Misua 3 cup
Meat 2 Ground Pork 2 matchbox

(meatballs)
Fat 2 Cannola Oil 1 tsp

IV. Nutritional Implications

Analysis

After 2 weeks of proper liver disease diet, the patient responded to the diet

therapy well and spontaneous. His appetite increased continuously. The patient gained

weight rapidly. He also showed signs of improved health status.

Recommendation

A liver disease diet provides the right amount of calories, nutrients, and liquids

for you. A liver disease diet may help your liver work better and prevent other health

problems. The dietary changes you will need to make depend on the type of liver disease
and health problems you have. Your dietitian or nutritionist will tell you about the type of

diet that is best for you.

FOOD AVOIDED FOOD ALLOWED

• Tea Raw goat's milk

• Coffee Home-made raw

• Sugar Cottage cheese

• White flour Sprouted seeds

• Flesh food Grains, Raw nuts, Almonds

• Condiments Beets squashes, Bitter gourds

• Pickles Tomatoes, Carrots, Radishes

• Alcoholic beverages Papaya

A case study on Liver Disease

(underweight)
Diaz, Mary Anne H.

Garcia, Ma. Rebecca Angeli S.

Juan, Christopher M.

Manalo, Sarah Jane S.

Quito, Rachel R.

Salazar, Mary Jane M.

BSN 3y3 – 3

Ms. Catherine Bautista RND