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Discussion Points
Executive Summary General Information Social History Medical/Surgical Data
Past Medical History Past Surgical History Admitting Physical Exam Diagnostic Tests Surgical Procedures Since Admission Laboratory Values
Hospital Course
Medical and Nutritional Treatment
Executive Summary
The liver is a 3-pound organ, consisting of a right lobe and left lobe, which the body depends on to provide metabolic and nutritional control. Alcoholic liver disease is a disease resulting from excessive alcohol ingestion. The pathogenesis of alcoholic liver disease progresses in three stages with the final stage being cirrhosis. Treatment of cirrhosis focuses on stopping the development of the scar tissue if possible and treating any complications.
Figure 1: A normal liver (left) showing no signs of scarring and a cirrhotic liver (right). (Source: Mayo Foundation for Medical Education and Research)
General Information
47-year-old Caucasian female with an extensive history of alcohol abuse Admitted with abdominal pain, slurred speech, drowsiness, and yellow-tinted whites of her eyes. Admission height: 5 7 (170 cm) Admission weight, following paracentesis of 6 liters of fluid: 142# (64.4kg); BMI=22.2; IBW 135# Dx: Hepatic Encephalopathy with Significant Ascites, and Alcoholic Liver Cirrhosis Date of admission: Wednesday, November 3, 2010 Date of discharge: Thursday, November 13, 2010
Social History
VM is a single mother of two sons, both serving in the Navy. She lives alone in a townhouse, with frequent visitations from her supportive significant other. Tobacco use is less than a half a pack a day. A distant history of spousal abuse was thought to be the cause of her heavy drinking.
Current amounts were not clearly described
Medical/Surgical Data
Diagnostic Tests
Abdominal x-ray suggestive of a small bowel obstruction (11/4/10) Pelvic ultrasound demonstrating a large amount of ascites (11/4/10) Computed tomography (CT) scan of the patients abdomen and pelvis demonstrating massive abdominal and pelvic ascites (11/6/10 )
Figure 3: CT (left) and Ultrasound (right) of Abdomen with loculated ascites (Source: Loyola University Health System Stritch School of Medicine)
Laboratory Values
sodium = hyponatremia chloride = possible hypochloremia acidosis protein and albumin = hypoalbuminemia - decreased production of albumin contributing to ascites amylase and lipase = possible pancreatic damage ammonia = contributing to hepatic encephalopathy glucose = glucose intolerance WBC = infection hematologic values, specifically RBC, Hgb, Hct, MCV, MCH= macrocytic anemia due to chronic disease and hypovolemia (most likely due to fluid losses or decreased fluid intake) LFTS, specifically AST and Bilirubin (= jaundice) = liver disease
Diet History
Balanced diet with minimal salty foods and sweets.
Canned and pre-packaged foods were purchased for convenience with patient not aware of high sodium content of some food items. Prior to acute onset of symptoms, patients appetite and intake had been good. Reported physician directives in hospital
Allergies? N Intake of vitamins, minerals, oral supplements, and/or health food store alternative supplements? N Cultural attitudes that influence dietary intake? N Past/present dietary/nutritional therapy? N
Nutrition Monitoring
FH-1.1.1.1 Total energy intake. Assessment of food recall given by patient verifying adequacy of intake in the promotion of healthy weight gain Laboratory values. BD-1.2.5 Sodium. Criteria: 135-145 mmol/L BD 1.11.1 Prealbumin. Criteria: 18- 45 mg/dl (to evaluate visceral protein stores and adequacy of intake) May also want to monitor control of symptoms, such the reoccurrence of ascites
Hospital course
Day 1
Paracentesis Hyponatremia and hyperkalemia Ammonia levels Diet: 1800 calorie No Added Salt (NAS) diet (3-4 gm Na/low salt), and given the oral nutritional supplement Ensure Plus B.I.D. Limited intake reported. IV fluids: IV normal saline at 75 cc/hr
Day 2
Folic acid, thiamine, multivitamins IV normal saline was stopped due to concern on its impact on heart rate. Lactulose was held
Day 3
Possible spontaneous bacterial peritonitis Elevated finger sticks Possible acute renal failure/acute kidney injury Possible short bowel obstruction, either an ileus or mechanical obstruction Diet: NPO
Day 5
Diet: NPO except meds and ice chips with eventual transition to a clear liquid diet for evening meal
Day 7
Lactulose was decreased, but pt still inconsistent in answers to questions. Diet: NPO
Day 8
Diet: Soft, NAS diet w/ percent intake of meals intake reported at 5%
Day 9
Hepatic encephalopathy was resolved on Rifaximin and Lactulose. Diet: Soft, NAS diet. Patients appetite fair w/ percent intake of meals noted at 25%
Day 10
Paracentesis Clostridium difficile colitis Liver transplant list Diet: Sodium restriction continued on Soft, NAS diet w/ percent intake of meals noted at 75%
Day 11
Patient discharged home Diet: Soft, NAS diet with percent intake of meals 100%
Medical Considerations
Moderate to severe malnutrition is a common finding in patients with liver cirrhosis, and has a severe negative impact on a patients prognosis. Glucose intolerance occurs in almost of patients with cirrhosis, and 10% to 37% of patients will develop overt diabetes. Hepatorenal syndrome is a renal failure associated with severe liver disease without intrinsic kidney abnormalities Hyponatremia often occurs because of decreased ability to excrete water resulting from the persistent release of antidiuretic hormone, sodium losses via paracentesis, or overly sodium restriction. Portal hypertension, hypoalbuminemia, and renal retention of sodium and fluid contribute to fluid retention
Large-volume paracentesis Diuretic therapy: Spironolactone and Furosemide
Ammonia is a direct cerebral toxin. The main source of ammonia is its endogenous production by the gastrointestinal tract from the metabolism of protein, and from the degradation of bacteria and blood from gastrointestinal bleeding.
Lactulose and Rifaximin
Liver transplant
References
Calculations for nutrition assessment Diseases and Conditions of the Liver, Gallbladder, and Pancreas > Cirrhosis. American Dietetic Association Nutrition Care Manual. Source: Manual. http://www.nutritioncaremanual.org/content.cfm?ncm_content_id=81465. Retrieved November 30, 2010. http://www.nutritioncaremanual.org/content.cfm?ncm_content_id=81465. Cirrhosis. Medline Medical Encyclopedia. Source: http://www.nlm.nih.gov/medlineplus/cirrhosis.html http://www.nlm.nih.gov/medlineplus/cirrhosis.html Topic last reviewed: May 07, 2010. Retrieved: November 25, 2010. Cirrhosis - National Digestive Diseases Information Clearinghouse (NDDIC). Source: http://digestive.niddk.nih.gov/ddiseases/pubs/cirrhosis/#treatment. Posted: December 2008. Accessed: December 14, http://digestive.niddk.nih.gov/ddiseases/pubs/cirrhosis/#treatment. 2010. Disease Process Diseases and Conditions of the Liver, Gallbladder, and Pancreas > Cirrhosis. American Dietetic Association Nutrition Care Manual. Source: http://www.nutritioncaremanual.org/content.cfm?ncm_content_id=81451. Retrieved November 30, 2010. http://www.nutritioncaremanual.org/content.cfm?ncm_content_id=81451. Friedman, LS. (2010). Surgery in the Patient with Liver Disease. Trans Am Clin Climatol Assoc. 2010; 121, 121, 192205. Source: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2917124/. Retrieved December 14, 2010. 192 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2917124/. Lindsey, A. (2010). Profound hyponatremia in cirrhosis: a case report. Cases J. 2010; 3: 77. Source: report. 77. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2851673/?tool=pubmed. Published online March 23, 2010. Retrieved http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2851673/?tool=pubmed. December 14, 2010. Mahan, LK., Escott-Stump, S. (2008). Krauses Food & Nutrition Therapy, 12th Edition. St. Louis: EscottKrause Edition. Saunders Elsevier. pgs. 708-726. 708Sanyal, A. Mullen, K. Bass, N. (2010). The Treatment of Hepatic Encephalopathy in the Cirrhotic Patient. Sanyal, Encephalopathy Gastroenterol Hepatol (N Y). 2010 April; 6(4_Suppl): 112. Source: 1 12. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2886485/#__secid3913169. Retrieved: December 14, 2010. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2886485/#__secid3913169. Tabers Cyclopedic Medical Dictionary, 20th Edition. (2001). Philadelphia: F.A. Davis Company. Taber Davis Understanding Cirrhosis of the Liver Patient Center of the American Gastroenterological Association. Source: http://www.gastro.org/patient-center/digestive-conditions/cirrhosis-of-the-liver. Topic Last Reviewed: April 2008. http://www.gastro.org/patient- center/digestive- conditions/cirrhosis- of- theRetrieved November 26, 2010.
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