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

2. 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

3. 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.)

4. Energy Requirements Highly variable in cirrhotic patients
General recommendations:
In cirrhotic patients without ascites = % of REE
In cirrhotic patients with ascites, infection, or overall malnutrition = % of REE
The above mentioned amounts come out to about calories/kg of estimated dry body weight. Diet based off of ascites will result in overfeeding

5. 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

6. 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

7. 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

8. 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

9. 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)

10. 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 g/kg
Evenly spread carbs capped at 5-6 g/kg
Sodium and fluid restriction

11. 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

12. 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.

13. Case Study

14. 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

15. 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?”

16. 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

17. 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

18. Existing Conditions
Hepatitis C about 3 years ago

19. Nutritional Rating
Moderately or suspected of being malnourished

20. Nutrition Assessment
Patient is 26 year old female who complains of fatigue, general weakness, anorexia, N/V, and appears jaundiced.
Ht: 5’9” ( cm); Wt: 125 lbs. (56.8 kg); BMI: 18.5; IBW: 145 lbs. (86%)
Current Meds: YAZ, Allegra

21. 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

22. 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

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