Cirrhosis of the Liver with Resulting Hepatic Encephalopathy
By: Michelle Hoffman
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Patient Teresa Wilcox Physician: P. Horowitz, MD Education:
doctoral graduate student Age: 26-years-old Height: 59 (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 2
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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) 3
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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 4
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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 5
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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 6
Diagnosis Cirrhosis 12 th 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. 9
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Diagnosis 10
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11
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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 12
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Symptoms Weakness Fatigue Loss of appetite N/V Weight loss
Abdominal pain and bloating Itching 13
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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
14
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Ascites 15
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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 Biopsys are less common because it it
expensive, and usually only confirms a diagnosis 16
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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 17
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Severity MELD Model for end-stage liver disease 6 - 40 score
range6 is a likelihood that patient will survive 90 days Score
comes from: Bilirubin countmeasures bile pigment in the blood
Creatine levelstests kidney function INR (international normalizes
ratio)tests blood clotting tendency 18
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Treating Cirrhosis Primary medical treatments for cirrhosis:
Preventing further damage Treatment of the complications Liver
transplant Nutrition therapy 19
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20 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
22 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 Therapy Recommendation Kcals 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 Calcium1,000-1,500
mg Vitamins May need multivitamin supplement; see doctor 23
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24 Energy & Protein Ms. Wilcoxs 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. Wilcoxs protein needs: 1.6 x 56.8=90.8 ~ 91 g
protein/day
26 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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27 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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28 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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29 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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30 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.. Longstreth,
George F. "Cirrhosis: MedlinePlus Medical Encyclopedia." Medline
Plus. U.S. National Library of Medicine, 16 Oct. 2011. Web. 11 Nov.
2012.. Lee, Dennis. "Cirrhosis (Liver) Symptoms, Causes, Treatment
- How Is Cirrhosis Treated? on MedicineNet." MedicineNet. N.p.,
2012. Web. 11 Nov. 2012.. "Cirrhosis." Cirrhosis. University of
Maryland Medical Center, 2011. Web. 11 Nov. 2012.. "National
Digestive Diseases Information Clearinghouse (NDDIC)." Cirrhosis.
N.p., Dec. 2008. Web. 11 Nov. 2012.. "Learning About Your Health."
Cirrhosis of the Liver. CPMC Sutter Health, 2012. Web. 11 Nov.
2012..
