Cirrhosis of the Liver with Resulting Hepatic Encephalopathy

Cirrhosis of the Liver with Resulting Hepatic EncephalopathyBy:Michelle Hoffman

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Patient• 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

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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)

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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

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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

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Abnormal Chemistry• Albumin

– 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

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Abnormal Hematology• RBC

– 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%

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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

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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.

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Diagnosis

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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

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

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Complications & Warning Signs

• Edema &Ascites• Bruising and bleeding• Portal hypertension• Esophageal varices• Jaundice• Hepatic encephalopathy• Insulin resistance and type II

diabetes

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Ascites

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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

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Diagnosing Cirrhosis• Blood tests to measure:

– Measures function of the liver– Albumin– Bilirubin– PT (Prothrombin Time)

• Liver enzymes:– Measures injury to the liver– ALT– AST

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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

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Treating Cirrhosis• Primary medical treatments for

cirrhosis:– Preventing further damage– Treatment of the complications – Liver transplant– Nutrition therapy

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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

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Treating Cirrhosis• Treating complications:

– Ascites• Antidiuretics

– Bleeding from varices• Beta-blockers• Propanolol

– Hepatic Encephalopathy• Laxatives (lactulose)

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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

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Nutrition TherapyRecommendation

Kcals 35-40 kcal/kg Protein 1.6 g/kg/dayFat 30% of calories/dayCHO 50-60% of calories/daySodium No more than 2-g/dayFluid 1.2-1.5 L/dayCalcium 1,000-1,500 mgVitamins May need multivitamin

supplement; see doctor

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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

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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

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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

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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

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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

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Prognosis:Stages of Cirrhosis• Stage 1

– 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

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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>.