Cirrhosis of the Liver with Resulting Hepatic Encephalopathy By: Michelle Hoffman

Patient Dx: Probable cirrhosis secondary to chronic hepatitis Teresa Wilcox Physician: P. Horowitz, MD Education: doctoral graduate student Age: 26-years-old Height: 5’9” (1.7 m) Current Weight: 125 lbs (56.8 kg) Usual Body Weight: 145 lbs BMI:18.5 kg/m^2 Underweight Dx: Probable cirrhosis secondary to chronic hepatitis

Patient History Hepatitis C Dx 3 years ago Complaints of fatigue, anorexia, N/V, weakness Lost 10 lbs since last visit 6 months ago Bruising and yellowish skin Family hx cirrhosis (grandfather)

Physical Exam Tired in appearance Enlarged esophageal veins Warm and dry skin with bruising on lower arms and legs Normal muscular tone and ROM No edema or ascites

Nutrition History Has not an an appetite for last few weeks Has not eaten in the last 2 days Nutrition therapy of small, frequent meals with plenty of liquids 3 years ago Breakfast: calcium-fortified orange juice Lunch: soup and crackers with diet coke Dinner: Chinese or Italian carry-out Fluids: small sips of water, diet coke, or juice Does not consume alcohol Current diet order: Soft, 4-g Na, high-kcal

Abnormal Chemistry Albumin Total protein Bilirubin Normal: 3.5-5 g/dL Ms. Wilcox: 2.1 g/dL Total protein Normal: 6-8 g/dL Ms. Wilcox: 5.4 g/dL Bilirubin Normal: ≤ 0.3 mg/dL Ms. Wilcox 3.7 mg/dL

Abnormal Hematology RBC HGB HCT (hematocrit) Normal: 4.3-5.4 Ms. Wilcox: 4.1x10^6/mm^3 HGB Normal: 12-15 g/dL Ms. Wilcox: 10.9 g/dL HCT (hematocrit) Normal: 37-47% Ms. Wilcox: 35.9%

Abnormal Hematology MCV (mean cell volume) Normal: 80-96 μm^3 Ms. Wilcox: 102 μm^3 Ferritin(protein that stores iron) Normal: 20-120 mg/mL Ms. Wilcox: 18 mg/mL PT (prothrombin time) Normal: 11-16 sec Ms. Wilcox: 18.5 sec

Diagnosis Cirrhosis 12th leading cause of death in the U.S. Ending stage of liver disease Secondary to chronic hepatitis C Replacement of healthy liver tissue with scar tissue Blocks the flow of blood through the liver, causing kidney failure, enlarged liver, thickening of various tissues, portal hypertension, ascites, etc.

Diagnosis

Etiology Common causes of cirrhosis: Alcohol-related liver disease Chronic hepatitis C Chronic hepatitis B Autoimmune hepatitis Nonalcoholic fatty liver disease (NAFLD) Bile duct disorders Hereditary disorders

Symptoms Weakness Fatigue Loss of appetite N/V Weight loss Abdominal pain and bloating Itching

Complications & Warning Signs Edema &Ascites Bruising and bleeding Portal hypertension Esophageal varices Jaundice Hepatic encephalopathy Insulin resistance and type II diabetes

Ascites

Diagnosing Cirrhosis Look at the clinical signs & symptoms Biopsy, CT Scan, and MRI may reveal an enlarged liver, reduced blood flow, and /or ascites Biopsy’s are less common because it it expensive, and usually only confirms a diagnosis

Diagnosing Cirrhosis Blood tests to measure: Liver enzymes: Measures function of the liver Albumin Bilirubin PT (Prothrombin Time) Liver enzymes: Measures injury to the liver ALT AST

Severity MELD Model for end-stage liver disease 6 - 40 score range—6 is a likelihood that patient will survive 90 days Score comes from: Bilirubin count—measures bile pigment in the blood Creatine levels—tests kidney function INR (international normalizes ratio)—tests blood clotting tendency

Treating Cirrhosis Primary medical treatments for cirrhosis: Preventing further damage Treatment of the complications Liver transplant Nutrition therapy

Treating Cirrhosis Preventing further damage: The first thing doctors will recommend is abstaining from alcohol and any drugs that will damage the liver further Consume a balanced diet and a multivitamin may be recommended (D and K especially) Avoid nonsteriodalantinflammatory drugs (NSAIDS) Ibuprofen

Treating Cirrhosis Treating complications: Ascites Antidiuretics Bleeding from varices Beta-blockers Propanolol Hepatic Encephalopathy Laxatives (lactulose)

Treating Cirrhosis Liver Transplant: Cirrhosis in irreversible, and many patients will eventually need a liver transplant as the only option left 80% of patient live for 5 years after surgery

Nutrition Therapy Recommendation Kcals Protein Fat CHO Sodium Fluid 35-40 kcal/kg Protein 1.6 g/kg/day Fat 30% of calories/day CHO 50-60% of calories/day Sodium No more than 2-g/day Fluid 1.2-1.5 L/day Calcium 1,000-1,500 mg Vitamins May need multivitamin supplement; see doctor

Energy & Protein Ms. Wilcox’s energy needs: Weight: 56.8 kg 35 x 56.8= 1,988 calories 40 x 56.8= 2,272 calories 2,000-2,200 calories/day. Ms. Wilcox’s protein needs: 1.6 x 56.8=90.8 ~ 91 g protein/day

Nutrition Problems Inadequate energy intake: NI-1.4 Inadequate oral intake: NI-2.1 Malnutrition: NI-5.2 Inadequate protein-energy intake: NI-5.3 Underweight: NC-3.1

PES Statements Inadequate energy intake related to decreased appetite, fatigue, and nausea by recent cirrhosis of the liver dx as evidenced and diet recall Underweight related to decreased appetite in past three weeks as evidenced by diet recall, recent 10 lb weight loss, and BMI of 18.5 kg/m^2

Nutrition Intervention & Support Small frequent feedings Encourage oral liquid supplements High kcal and protein diet Restrict sodium intake to ≤ 2-g Abstain from alcohol consumption Provide foods that are easy to chew and swallow Optimize gastric emptying Avoid excessive fiber Control blood glucose Liquids over solids if necessary

Prognosis Depends on stage of the disease Once the liver has scarred over, it cannot be reversed, meaning it cannot return to its normal function Survival is generally 10 years after dx (90%) Complications of ascites, portal hypertension, jaundice, hepatorenal syndrome, hepatic encepalopathy, etc. Liver transplant will most likely be needed as a result of cirrhosis

Prognosis: Stages of Cirrhosis Patients without gastro-esophageal varices or ascites have mortality of ~1% per year Stage 2 Patients with gastro-esophageal varices but no ascites have mortality of ~4% per year Stage 3 Patients without gastro-esophageal varices but have ascites have mortality rate of ~20% per year Stage 4 Patients with GI bleeding from portal hypertension with/without ascites have mortality of ~57% per year

References Nelms, M., Sucher, K. P., Lacey, K., & Roth, S. L. (2011). Nutrition Therapy and Pathophysiology. Belmont, California: Wadsworth, Cengage Learning. "Prognosis." Best Practice. BMJ Group, 14 June 2012. Web. 11 Nov. 2012. <http://bestpractice.bmj.com/best-practice/monograph/278/follow-up/prognosis.html>. Longstreth, George F. "Cirrhosis: MedlinePlus Medical Encyclopedia." Medline Plus. U.S. National Library of Medicine, 16 Oct. 2011. Web. 11 Nov. 2012. <http://www.nlm.nih.gov/medlineplus/ency/article/000255.htm>. Lee, Dennis. "Cirrhosis (Liver) Symptoms, Causes, Treatment - How Is Cirrhosis Treated? on MedicineNet." MedicineNet. N.p., 2012. Web. 11 Nov. 2012.<http://www.medicinenet.com/cirrhosis/page5.htm>. "Cirrhosis." Cirrhosis. University of Maryland Medical Center, 2011. Web. 11 Nov. 2012. <http://www.umm.edu/patiented/articles/what_causes_cirrhosis_000075_2.htm>. "National Digestive Diseases Information Clearinghouse (NDDIC)." Cirrhosis. N.p., Dec. 2008. Web. 11 Nov. 2012. <http://digestive.niddk.nih.gov/ddiseases/pubs/cirrhosis/>. "Learning About Your Health." Cirrhosis of the Liver. CPMC Sutter Health, 2012. Web. 11 Nov. 2012. <http://www.cpmc.org/learning/documents/cirrhosis-ws.html>.