Cirrhosis of the Liver with Resulting Hepatic Encephalopathy

PRESENTED BY LAUREN HUMPHREY

Learning Objectives
!! Demonstrate understanding of the functions of the

Liver !! Demonstrate understanding of the causes and pathophysiology of Cirrhosis of the Liver !! Demonstrate understanding of consequences and symptoms of Cirrhosis of the Liver !! Identify markers of Liver Disease !! Identify nutrition goals for patients with severe Cirrhosis of the Liver and Hepatic encephalopathy

Pre-Test
!! Things to consider: 1.! What functions occur in the Liver? 2.! What is Cirrhosis of the Liver? 3.! What are the diagnostic parameters for Cirrhosis of the Liver? 4.! What is Hepatic Encephalopathy? 5.! What is the MNT for Cirrhotic patients?

Functions of the Liver

!! Powerhouse of the Body!! !! Carbohydrate, Protein, & Lipid Metabolism !! Vitamin and Mineral metabolism

Cirrhosis
!! Cirrhosis Video !! Advanced Stage of Liver Disease !! Enlarged Liver !! Liver damage, inflammation
"!

!! Causes: !! Alcoholism (21%) !! Hepatitis infections (2%)

"!

Characterized by: "! Fatigue, weakness, malaise, nausea, poor appetite, weight loss, jaundice, abdominal pain

!! !! !! !! !!

Hepatitis B (15%) Obesity Heart disease Drug poisoning Unknown ?

Hepatitis C & alcoholic liver ds. (15%)

Prognosis
!! 12th leading cause of death in U.S. !! Scarring of the liver is irreversible !! Best outcome is selection for a Liver Transplant
"! Most

common reason for needs a transplant

Consequences of Cirrhosis
!! Portal Hypertension:
!!

Elevated BP in the portal vein d/t obstructed blood flow through the liver Distended collateral blood vessels that protrude into the esophagus Can cause massive bleeding if ruptured Edema characterized by the accumulation of fluid, electrolytes and serum proteins in the abdominal cavity "! Hepatic Encephalopathy/ Hepatic Coma "! Venous overflow obstruction "! Chronic right-sided heat failure

!! Esophageal Varicies:
!! !!

!! Ascites
!!

!! Hepatic Encephalopathy/Hepatic Coma !! Venous Overflow obstruction !! Chronic right-sided heart failue !! Tricupsis Regurgitation

Hepatitis C
!! Leading cause of Cirrhosis of the Liver !! Blood-born virus that is transmitted through blood or other body fluids from an infected person. !! Prognosis
"! 75-85%

of acute infections will become chronically infected "! 60 - 70% will develop chronic liver disease "! 5-20% will develop cirrhosis of the liver in 20-30 years "! Cause of 8,000 10,000 deaths each year in U.S.
!! Treatment
"! 24-48

week course of combination of pegylated alpha interferon and ribavirin, an oral antiviral agent

Disorders of the Liver

!!

Fatty Liver Disease (Hepatic Steatosis)

"! Accumulation

of fat cells in hepatocytes "! Early Stage of Liver ds. "! Caused by alcohol abuse, obesity, long-term TPN, PEM, small bowel bypass surgery, exposure to toxic substances, drugs
!!

Hepatitis:
"! Inflammation

of hepatocytes secondary to a virus, bacteria, toxins, obstruction, parasite, drug, or alcohol that causes cell damage "! Hepatitis A causes nausea, dark urine, and jaundice "! Hepatitis B, C causes chronic hepatitis causing further damage to the liver or liver cancer leading to hepatic coma or death

!!

Cirrhosis
"! Advanced

stage of liver disease "! Scar tissue from chronic inflammation replaces hepatocytes and changes the structure of the liver impeding hepatic blood flow. "! Caused by alcoholism, obesity, infections

Pathophysiology
!! Disorders
"! The

of the Liver begin with damage to the hepatocytes.

liver will become enlarged as a result of fat accumulation and necrosis of the liver cells. "! Leads to symptoms of fatigue, weakness, nausea, poor appetite, and malaise and the more liver-specific symptoms of jaundice such as dark urine, light stools, steatorrhea, itching, abdominal pain, and bloating. "! With chronic damage or inflammation scar tissue replaces hepatocytes. "! This replacement causes structural changes and impedes hepatic blood flow.
! Leading to loss of liver function.

Consequences
!! Jaundice !! A symptom, causing yellowish tint to the bodies tissue and is usually the result of elevated bilirubin concentration in the extracellular fluids !! Portal Hypertension
"! Elevated

blood pressure in the portal vain (the vein in the abdominal cavity that drains blood primarily from the GI tract and spleen.

!! Ascites !! Fluid retention !! Hypoglycemia

Hepatic Encephalopathy/ Hepatic Coma

!!

A syndrome of impaired mental status and abnormal neuromuscular function that results from major liver failure.
!! Healthy
"!

!! Hyperammonia
Urea is a direct cerebral toxin "! Other nitrogenous compounds may contribute as well

liver converts ammonia to urea

!! Psychomotor abnormalities: confusion,

Symptoms "! Asterixis

drowsiness, slurred speech, forgetfulness, flapping tremors in hands

!!
"!

Chronic disturbance in consciousness can lead to coma

!! Serum AA patterns change: BCAA levels fall and

AAA levels rise (Phe, Tyr)

Hepatic Encephalopathy/ Hepatic Coma

!! 3 Hypothesis 1.! Decreased liver function leads to interference in detoxification process of ammonia 2.! Liver failure leads to build up of Neurotoxins 3.! False neurotransmitters in the brain may displace catecholamines from their receptors
"!

Soulsby CT, Morgan MY. Dietary Management of hepatic encephalopathy in cirrhotic patient: survey of current practice in United Kingdom. BMJ. 1999;318:1391.

MEDICAL NUTRITION THERAPY FOR CIRROHSIS

!! Energy
!! !!

ESLD without ascites: BEE x 1.2-1.3 Ascites, infection, malabsorption or malnutrition: BEE x 1.5-1.75 (30-35kcal/kg) Watch for fasting hypoglycemia Small, balanced meals Normal amounts (35-40% kcals) unless steatorrhea (MCTs!) Hepatitis/cirrhosis: 0.8-1.0 g/kg dry wt. Repletion: 1.2-1.3 g/kg Stress/decomposition/sepsis: 1.5g/kg + Encephalopathy: restriction?

!! Carbohydrate
!! !!

!! Lipids
!!

!! Protein
!! !! !! !!

Protein Energy Malnutrition and Cirrhosis

!! PEM is common in cirrhotic patients and those

with esophageal varicies

!!

Related to difficulty eating and swallowing

"! Anorexia "! Dysguesia "! Satiety "! N/V "! Dietary

restrictions such as sodium and decreased energy intake

!! Maldigestion and malabsorption

!! Merli M, et al. Nutritional status: its influence on the outcome of

patients undergoing liver transplantation. Liver International. 2009; 1478-3231.

Effects & Treatments

!! Nutrition Assessment !! Protein Status
"! Liver

damage impedes proper metabolism of protein and other nutrients is reduced due to liver damage making it difficult to assess CHO needs. affects assessment needs in general

!!

Carbohydrate Status
"! Gluconeogenesis

!!

Nutrition needs
"! Malabsorption

!! Medical Treatments !! Prevent further damage !! Treat complication of Cirrhosis !! Prevent liver cancer or detect it early !! Receive Liver transplant

MEDICAL NUTRITION THERAPY FOR CIRRHOSIS

!! Calories: 35-40Kcal/kg/day !! Protein: up to 1.6g/kg/day !! Vitamins and Minerals !! Steatorrhea: fat-sol vitamins (water-miscible form) !! B vitamins: EtOH liver ds. !! Ca, Mg, Zn (d/t steatorrhea) !! Fluids and Electrolytes !! Sodium and fluid restriction with ascites: 2g/day !! Monitor !! Wt, abdominal girth !! Glucose, Electrolytes, ammonia

PATIENT: Teresa Wilcox

!! 26 y/o Female !! Architectural doctoral graduate

student !! Graduate teaching assistant !! Ht: 59 !! ABW: 125 lbs. !! UBW: 135 lbs. (lost 10 lbs. n 6 months) !! Came in with increasing symptoms of liver ds !! Previous Dx: Acute Hepatitis 31/2 years ago !! Medical Dx: Cirrohsis of the liver secondary to chronic hepatitis C infection.

Teresa
!! Chief Complaint: It just seems as if I cant get enough rest. I feel so

weak. Sometimes Im so tired I cant go to campus to teach my classes. Does my skin look yellow to you?

!! Patient History:
!!

Diagnosed with Hepatitis C 3 yrs ago.

"!

Treated with alpha-interferon and ribavirin

!! Currently experiencing fatigue, anorexia, N/V, and weakness.

!!

Also, bruising of the skin

!! Lost 10 lbs. since last visit (6 months ago) !! Meds: Yaz and Allegra

Physical examination
!! !! !! !! !! !! !! !! !! !! !!

Appearance: tired looking young female Vitals: Temp 96.9F, BP 102/65mm Hg, HR 72 bpm, RR 19 bpm Heart: Regulat rate and rhythm Head: Normocephalic Extremeties: Normal muscular tone, normal ROM, no edema; no asterixis notes Skin: Warm and dry; brusiing noted on lower arms and legs; telangiectasias noted on chest Chest/Lungs: Respirations normal; no crackles, rhonchi, wheezes, or rubs noted Throat: enlarged esophageal veins Eyes: Wears contact lenses to correct myopia, PERRLA Nose: Dry mucous membranes w/out lesions Abdomen: Pierced umbilicus, mild distension RUQ, splenomegaly w/out hepatomegaly; no ascites

Anthropometrics
!! Height: 69 !! Weight: 125lbs on admit !! BMI: 18.5 Normal !! IBW: 145 lbs. !! %IBW: 86% Mildly Depleted Energy Stores !! %UBW: 92% !! 8% weight loss in 6 months. Mild Weight Loss

24-hour Food Recall

Food Assessment

#! #! #! #! #!

No appetite for past few days Breakfast: Calcium-fortified OJ Lunch: Soup and crackers & diet coke Dinner: Home or Chinese or Italian take-out Usual Dietary Intake:
#! Sips of water, juice and diet coke #! Has not eating in past 2 days Food Allergies: Doesnt like liver or lima beans Takes 400mg Vit E, 600mg Calcium, 400IU Vit D, MV/mineral, 200mg Milk Thistle 2x/day, 3g/ day Chicory, 500mg Ginger 2x/day

#! Drinks Alcohol: 1-2 glasses #! Previous MNT:

#! 3 years ago #! Smal, frequent meals, plenty of liquids

#! Diet Order:
#! Soft #! 4 grams of sodium #! High Kcal

Lab!
Albumin! Total Protein! Prealbumin! Glucose! Bilirubin! ALT! AST! Alk Phos!

Normal Range!
3.5 5 g/dL! 6 8 g/dL! 16 35 mg/dL! 70 110 mg/dL! ! 0.3 mg/dL! 4 36 U/L! 0 35 U/L! 30 120 U/L!

Admit!
2.1 L! 5.4 L! 15 L! 115 H! 3.7 H! 62 H! 230 H! 275 H!

Reason!
Parallels the functional status of parenchymal cells. ! Related to malnutrition, weight loss and decreased liver function Indicative of malnutrition, PEM, possibly? Hyperglycemia due to decreased glucose metabolism. Biomarker of Liver Ds. Biomarker of Liver Ds. Most sensitive enzyme secondary to exacerbation of infectious hepatitis Biomarker of Liver Ds. Less specific enzyme that is secondary to cellular necrosis Biomarker of Liver Ds. Increased activity with hepatic ds. & chronic obstruction of biliary tract, not non-specific Indicative of injury or stress to heart, brain or muscle tissue. Increased by alcohol/drugs Related to fatty liver and decreased liver function and FA metabolism Impaired iron absorption, synthesis and uptake. Chronic hepatitis infection Dehydration Related to long-term hepatitis infection Malabsorption and 2 Vit B12 def. Megaloblastic Macrocytic Anemia Related to malnutrition, chronic infection. Precursor to Iron-deficiency anemia Prolonged with hepatic disease

CPK! TG! RBC! HGB! HCT! MCV! Ferritin! PT!

30 135 U/L! 35 135 mg/dL! 4.2 5.4 x 103/mm3! 4.5 6.2 g/dL! 37 47 %! 80 96 "m3 20 120 mg/mL! 11 16 sec!

138 H! 256 H! 4.1 L! 10.9 H! 35.9 L ! 102 H! 18 L! 18.6 H!

Lab! Coll meth! Color! Appear!

Normal!

Admit! Random specimen! Dark! Slightly hazy!

Reason!

Due to decrease or absence of urobilinogen.

Prot! Ubil!

Neg! Neg!

1+! 1+!

Illness Indicative of biliary obstruction or RBC hemolysis Related to decrease in liver function & inhibition of intrahepatic urobilinogen cycle Infection

Urobil!

< 1.1 EU/dL!

1.8!

WBCs! RBCs!

0 5/HPF! 0 5/HPF!

3.8! 2.7!

Assessment
!! Energy Needs "! Current Recommendation: 35-40 kcal/kg/day
! 35kcal/56.8kg/day = 1,988kcals/day
!! !!

BEE = 655 + (9.6 x 56.8) + (1.8 x 175) (4.7 x 26) = 1393kcals TEE: 1393 x 1.5 = 2090kcals

!! Protein Needs "! Protein Needs: "! Current Recommendations: 1.6g/kg/day "! Restrict protein with severe forms of Encephalopathy
! PROTEIN: 56.8kg x 1.6g = 91g/kg/day !! (mildly depleted visceral protein stores)

!! Fluid Needs:
"! Restrict
!!

fluids by decreasing to 2L day

General recommendations: Fluid not usually restricted

Prescribed Medications
Rationale for Rx Sprionolactone Given to treat fluid retention from liver failure. It prevents the body from absorbing too much salt and keeps potassium levels from getting too low. Propranolol A beta-blocker; used to prevent the occurrence of high portal blood pressure. Nutritional Implications Alcohol intake should be monitored Low sodium diet is needed Loss of appetite may occur-leading to malnutrition

Nausea/Vomiting, stomach pains may occur. Food intake needs to be assessed fro these possible side effects

Medication
Vasopressin Lactulose

Classification

Mechanism

Drug Nutrient Interactions

High fiber with 1500 2000mL fluid/day t prevent constipation, N.V, belching, cramps, diarrhea, gas

Laxative, antihyperammonemic

Neomycin

Antibiotic

Interferes with bacterial protein synthesis

Impairs absorption (may increase excretion) of a broad variety of nutrients including CHO, fats, Ca, Fe, Magnesium, Nitrogen, potassium, sodium, folic acid, and vitamins A, B12, D, K

Ferrous Sulfate Bisacodyl Docusate Diphenhydramine

Iron Supplement

Increases serum levels of iron

Foods supplement is taken with can alter the amount of iron being utilized
Causes stomach cramps, diarrhea

Laxative, stimulant Increases stimulations of bowel Laxative Increases stimulations of bowels Antihistamine Blocks action of histamine

Causes stomach cramps, diarrhea

Alcohol can increase side effects of this medication

Decision Tree
Is it in our scope of practice to treat and diagnose Paris?

Nutrition Diagnosis
!! PES Statement:
!! Inadequate

oral intake (NI-2.1) related to poor appetite from complications of cirrhosis as evidenced by 8% weight loss in 6 mo, and diet recall. (NC-3.1) related to impaired nutrient intake and utilization as evidenced by BMI of 18.5.

!! Underweight

GOALS FOR TERESA

!! Outcome goals: !! Patient increases energy intake. !! Patient decreases deterioration or further progress of liver damage. !! Patient discontinues weight loss. !! Action goals: !! Patient slowly increases energy intake to 1500kcals in 1 week !! Patient adheres to sodium restriction of 4g/day !! Pateint begins nocturnal supplementaion each night
"!

Plank LD, Gane EJ, Peng S, et al. Nocturnal Nutritional Supplementation improves total body protein status of patients with liver Cirrhosis: A Randomized 12-month trial. Hepatology. 2008; 48:557-566.

!! !!

Patient incorporates BCAA supplement into diet each day

"!

Patient begins zinc supplementation of 600mg/day

Frohlinde-Schulte E, et al. Role of meal carbohydrate content for the imbalance of plasms amino acids in patients with liver cirrhosis. J Gastroenterology and Hepatology. 2007; 22:1241-1248.

Assessment, cont.
!! Miscellaneous Recommendations:
!!

Sodium Restriction
"!

With ascites restrict sodium to 2g/day

!!

Recommend Multivitamin and Mineral supplementations Oral zinc supplementation of 600mg

"! Research

!! Zinc Supplementation
!!

statusb,

suggests that supplementation can improve nutrition liver function, and decrease progression of Encephalopathya

! Bianchi GP, et al. Nutritional Effects of Oral Zinc Supplementation in Cirrhosis. Nutrition Research. 2000; 20(8):1079-1089.

! Marchesini G, Fabri A, Bianchi G, Brizi M, Zoli M. Zinc Supplementation and Amino Acid-Nitrogen Metabolism in Patients with Advanced Cirrhosis. Hepatology. 1996; 23(5):

Nutrition Intervention
!! Food and/or Nutrient Delivery. Meal and snacks

(ND-1):
!!

Modify dietary pattern to mechanically soft diet !! Eat a high protein, low-fat, nutrient dense diet

!! Vitamin and Mineral Supplement. Mineral zinc &

other (ND-3.2.4).
!!

Zinc supplementation of 600mg !! BCAA supplementation

!! Nutrition Education. Nutrition relationship to

health/disease(E-1.4):
!!

Counsel patient on dietary restrictions (Na, fat & alcohol) and need for increased energy intake !! Counsel patient on nocturnal feedings and importance to care of disease

Monitor and Evaluate

!! Monitor patients tolerance for feedings and

nutrients considered. !! Monitor patients energy intake. !! Monitor any changes in weight. !! Monitor lab values
!!

ALT, AST, Als phos, Albumin, Total protein, Prealbumin, Glucose, Bilirubin, Ammonia, Hgb, Hct, MCV, RBC, Ferritin

!! Monitor cognitive status. !! Onset of Hepatic Encephalopathy

Post Test
1.! 2.! 3.!

POST QUIZ

4.!

5.!
1.!

List three functions of the Liver? What are the main consequences of Cirrhosis of the Liver? What are the Biochemical Markers for Diagnosing Cirrhosis of the Liver? What is one possible reason that patients with Cirrhosis end up with Hepatic Encephalopathy? What are the current Nutrition Recommendations for a patient with Cirrhosis of the Liver
Recommendations for alcohol?

!! Bonus Question! 1.! Who is the 44th President of the United States!?! ;)

References
!! !!

!! !!

!! !! !!

!!

Bianchi GP, et al. Nutritional Effects of Oral Zinc Supplementation in Cirrhosis. Nutrition Research. 2000; 20(8):1079-1089. Frohlinde-Schulte E, et al. Role of meal carbohydrate content for the imbalance of plasms amino acids in patients with liver cirrhosis. J Gastroenterology and Hepatology. 2007; 22:1241-1248. Gropper SS., Smith JL., Groff JL. (2009). Advanced Nutrition and Human Metabolism. Fifth Edition. Belmont, CA: Wadsworth. Marchesini G, Fabri A, Bianchi G, Brizi M, Zoli M. Zinc Supplementation and Amino Acid-Nitrogen Metabolism in Patients with Advanced Cirrhosis. Hepatology. 1996; 23(5):1084-1092. Merli M, et al. Nutritional status: its influence on the outcome of patients undergoing liver transplantation. Liver International. 2009; 1478-3231. Nelms M, Sucher KP, Lacey K, Ruth SL. (2011). Nutrition Therapy & Pathophysiology. Second Edition. Belmont, CA: Wadsworth. Plank LD, Gane EJ, Peng S, et al. Nocturnal Nutritional Supplementation improves total body protein status of patients with liver Cirrhosis: A Randomized 12-month trial. Hepatology. 2008; 48:557-566. Soulsby CT, Morgan MY. Dietary Management of hepatic encephalopathy in cirrhotic patient: survey of current practice in United Kingdom. BMJ. 1999;318:1391.