Cirrhosis of the Liver with Resulting Hepatic Encephalopathyby Dustin Moore, Michelle Anderson, Stacey James and Candace Woodbury
MNT
Good nutrition therapy is essential because malnutrition will have a profound negative impact on prognosis
For assessment, SGA parameters should be considered
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
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.)
Energy Requirements Highly variable in cirrhotic patients General recommendations:
In cirrhotic patients without ascites = 120-140% of REE
In cirrhotic patients with ascites, infection, or overall malnutrition = 150-170% of REE
The above mentioned amounts come out to about 30-40 calories/kg of estimated dry body weight. Diet based off of ascites will result in overfeeding
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
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
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
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
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)
Compensated and Uncompensated Liver Failure
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 .8-1.0 g/kg▪ Evenly spread carbs capped at 5-6 g/kg▪ Sodium and fluid restriction
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
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.
Case Study
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
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?”
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
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
Existing Conditions
Hepatitis C about 3 years ago
Nutritional Rating
Moderately or suspected of being malnourished
Nutrition Assessment Patient is 26 year old female who
complains of fatigue, general weakness, anorexia, N/V, and appears jaundiced.
Ht: 5’9” (175.26 cm); Wt: 125 lbs. (56.8 kg); BMI: 18.5; IBW: 145 lbs. (86%)
Current Meds: YAZ, Allegra
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
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
Nutrition Monitoring
Will follow up with the patient after her first week to see if intake and food choices have improved