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

MNT 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 Good nutrition therapy is essential because malnutrition will have a profound negative impact on prognosis For assessment, SGA parameters should be considered

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.)

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

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

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

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

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

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)

Compensated and 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

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

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.

Case Study

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

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?”

Appetite: Anorexia, taste changes, early satiety 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

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

Existing Conditions Hepatitis C about 3 years ago

Nutritional Rating Moderately or suspected of being malnourished

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

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

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

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