Cirrhosis of the Liver Kayla Shoaf

Objectives Be able to define Cirrhosis and the etiology Identify symptoms and complications Able to identify between compensated and decompensated cirrhosis Describe appropriate MNT and treatment options for Cirrhosis

What is Cirrhosis? Blood flow is hampered because scarred tissue replaces normal tissue and prevents normal blood flow to liver. As scar tissue begins to replace healthy tissue liver functions decline and liver cells die.

The Progression of Liver Disease Inflammation: In the early stage of any liver disease, your liver may become inflamed Fibrosis: If left untreated, the inflamed liver will start to scar. As excess scar tissue grows, it replaces healthy liver tissue. This process is called fibrosis. Cirrhosis: If still untreated, your liver may become so seriously scarred that it can no longer heal itself. This stage – when the damage cannot be reversed – is called cirrhosis. Liver failure

Prevalence More than 30 million people in the U.S. have liver disease – or 1 in 10 Americans. Up to 25% of Americans may have non-alcoholic fatty liver disease Four million Americans are infected with hepatitis C and more than 1 million Americans are infected with hepatitis B Approximately 15,000 children are hospitalized every year with pediatric liver disease or disorders

Etiology of Cirrhosis Chronic alcohol abuse Hepatitis B or C   Chronic alcohol abuse Hepatitis B or C Fat accumulating in the liver (nonalcoholic fatty liver disease) Destruction of the bile ducts Hardening and scarring of the bile ducts Iron buildup in the body (hemochromatosis) Liver disease caused by your body's immune system (autoimmune hepatitis) Wilson's disease

Compensated Cirrhosis Liver is heavily scarred but can still perform many important bodily functions Minimal symptoms and complications from liver disease Energy needs should be increased by 20-40% Protein: 1-1.3g/kg

Decompensated Cirrhosis Disease is becoming life threatening Experience more symptoms and complications Energy needs should be increased to 50-75% Protein: 1.5g/kg

Cirrhosis often has no signs or symptoms until liver damage is extensive. Fatigue Weakness Bleeding/ bruising easily Itchy Skin Jaundice Loss of appetite/ nausea Weight loss Swollen legs

Complications of cirrhosis can include: Portal hypertension (increase in the pressure within the portal vein) Swelling in the legs and abdomen Infections Bleeding Insulin resistance and type 2 diabetes Malnutrition High levels of toxins in the blood (hepatic encephalopathy) Increased risk of liver cancer

B. A. C.

Ascites Results from portal HTN and low levels of albumin Accumulation of fluid in the abdominal cavity between abdominal organs Developed in decompensated cirrhosis Management of ascites focuses on low sodium diet and diuretics Diuretic therapy: goal of weight loss of 1-3 kg/d Nutrition depletion can occur if left untreated

Diagnosis Liver Enzyme Tests ALT ALP Bilirubin Tests AST Liver Biopsy GGT Liver Protein Test Albumin Globulin Prothrombin

Medical Treatment Diuretic therapy Management of portal hypertension Monitoring of blood glucose Liver Transplant

MNT Guidelines Eat large amounts of carbohydrate foods. Carbohydrates should be the major source of calories in this diet. Eat a moderate intake of fat, as prescribed by the health care provider. The increased carbohydrates and fat help prevent protein breakdown in the liver. Reduce the amount of salt you consume (typically less than 1500 milligrams per day) If tube feeding is needed avoid glutamine enriched formulas, this could increase ammonia levels. Avoid alcohol

MNT Guidelines Con’t Protein rich nutrition at early stage of cirrhosis can help maintain or increase muscular volume. When Plasma aromatic amino acid (AAA) (Phe, Trp, Try) are high, they increase muscle breakdown and decrease synthesis of proteins. Thus making BCAAs imbalanced, this contributes to hepatic encephalopathy. Increase BCAAs to improve cognitive status

Supplements Multivitamin Antioxidants: have significant reductions in antioxidant enzymes and lower blood levels of certain antioxidant nutrients, such as carotenoids, vitamin E, and zinc. This is an important consideration, because oxidative stress contributes significantly to liver damage. Probiotic: An imbalance in gut flora and bacterial translocation in cirrhosis patients contributes significantly to ammonia production, Providing these patients with supplemental combinations of probiotics reduces blood concentrations of ammonia.

PES Statements Altered nutrition related lab values related to liver dysfunction as evidence by elevated ALT, AST, ALP, NH3, albumin. Inadequate energy intake related to anorexia from cirrhosis as evidence by >10% unintentional weight loss in 3 months.

References www.mayoclinic.org/diseases-conditions/cirrhosis/basics/definition/con-20031617 http://www.liverfoundation.org/chapters/lam2010 http://www.nlm.nih.gov/medlineplus/ency/article/002441.htm http://www.liverfoundation.org/abouttheliver/info/liverfunctiontests/ http://www.nutritionmd.org/health_care_providers/gastrointestinal/cirrhosis_nutrition.html http://www.nlm.nih.gov/medlineplus/ency/article/000286.htm Escott-Stump S,. Nutrition and Diagnosis Related Care. 6th ed. Lippincott Williams & Wilkins; 2007. Krause's Food and Nutrition Care Process (13th ed., pp. 665-661).