Case Study Report

Katherine Chen
Epidemiology and Prognosis
Cirrhosis accounted for approximately 49,500 deaths and was the eighth leading cause
of death in the United States in 2010. Cirrhosis represents a late stage of progressive
hepatic fibrosis characterized by distortion of the hepatic architecture and the formation
of regenerative nodules. It is generally considered to be irreversible in its advanced
stages, at which point the only option may be liver transplantation. In earlier stages,
specific treatments aimed at the underlying cause of liver disease may improve or even
reverse cirrhosis.

Pathophysiology, Symptomology, and Medical Treatment

Alcohol abuse may lead to steatosis, steatohepatitis, cirrhosis, and hepatocellular
carcinoma. Not all patients who drink heavily develop alcoholic liver disease. However,
once alcoholic liver disease develops, continued alcohol use typically leads to persistent
and often progressive liver disease

Alcoholic liver disease should be suspected in patients with a history of significant

alcohol consumption who present with:
Abnormal transaminases (particularly if the aspartate aminotransferase [AST] is
greater than the alanine aminotransferase [ALT])
Hepatomegaly
Radiographic imaging suggesting hepatic steatosis or fibrosis/cirrhosis
A liver biopsy showing steatosis or cirrhosis

Physical examination of the patient can show hepatomegaly and signs of chronic liver
disease such as spider angiomata, ascites, splenomegaly, and gynecomastia.
The patient may also have extrahepatic manifestations of alcohol abuse such as
cardiomyopathy, neuropathies, pancreatitis, and skeletal muscle wasting.
Standard laboratory evaluation will look at serum transaminases, bilirubin, alkaline
phosphatase, gamma-glutamyl transaminase), a complete blood count, serum albumin,
and coagulation studies (prothrombin time, INR). An AST to ALT ratio >2 is highly
suggestive of alcoholic liver disease.
Other tests include: Hepatitis B surface antigen, anti-hepatitis B core IgG, Antibodies to
hepatitis C virus , Serum ferritin and transferrin saturation for hemochromatosis, Total
IgG or gamma-globulin level, antinuclear antibody, anti-smooth muscle antibody, anti-
liver/kidney microsomal-1 (anti-LKM-1) antibodies for autoimmune hepatitis. A liver
biopsy may also be performed as indicated.

Management of alcoholic liver disease centers on alcohol abstinence. In patients who

have not yet progressed to cirrhosis, abstinence may allow for reversal of the hepatic
changes induced by alcohol. Some measures to prevent superimposed hepatic injury
include vaccination for hepatitis A and B. Patients who have decompensated liver
disease despite alcohol abstinence should be referred to a liver transplantation center
for evaluation

Nutritional Implications
Alcoholism is associated with nutritional deficiencies including protein calorie
malnutrition and deficiencies of vitamins and trace minerals, including vitamin A,
vitamin D, thiamine, folate, pyridoxine, and zinc. Protein calorie malnutrition increases
the risk of major complications, such as infection, encephalopathy, and ascites.
Nutritional therapy is indicated for patients with alcoholic fatty liver who are
malnourished or who have evidence of vitamin or mineral deficiencies. Protein,
carbohydrate, and lipid metabolism are all affected by liver disease
patients with alcoholic cirrhosis should eat multiple times per day, including breakfast
and a nighttime snack. The diet should consist of higher amounts of protein (1.2 to 1.5
g/kg) and total calories (35 to 40 kcal/kg) than are recommended in a standard healthy
diet

Case Study: Alcoholic Cirrhosis

Initial assessment
JV is a 36 year old male with alcoholic cirrhosis who received a liver transplant. As far
as nutrition goes, he had a history of variable food intake over the past 2 years due to
his consumption of alcohol. He is not sure what his usual body weight is, but his
current body weight is approximately 190lbs, which his girlfriend endorses has been
consistent. Upon presentation, he appeared to be well nourished with visible ascites. He
reports strictly adhering to a 2g Na restricted diet since the beginning of October. He
also states that he has been informed on the importance of maintaining adequate
calories and protein in his diet and has a goal of consuming 2000kcal a day, though it is
not consistently achieved every day. During admission, his family has been bringing
him foods that appear to be complying with the previously indicated and well-
appropriate diet therapy.
Nutrition Assessment
Ideal Body Weight : 81 kg(Converted to: 178.57 lb)
Usual Weight : 86.5 kg(Converted to: 190.70 lb)
Estimated Energy Needs : 2025-2430
Estimated Protein Needs : 121
Estimated Needs Based On : Ideal body weight
Energy Needs Calculation : 25-30
Protein Needs Calculation : 1.5
Nutritional Classification : Overweight (BMI 25-29.9)

Nutrition Diagnosis:
Increased calorie and protein needs related to acute clinical condition as
evidenced by estimated energy needs during stress and surgery compared
to normal estimated needs.

Nutrition Intervention:
Renal diet 2g Na sodium restriction to manage fluid retention
Small meals throughout the day
Oral supplements with meals or PRN

Monitor/evaluate:
Weight - fluctuations may be related to fluid shifts. Visualize extremities for wasting
PO intake.
I&O's
Nutrition related labs WNL.

Patient #2:
DM is a 28 year old woman who presented in the transplant clinic for evaluation. Her
primary medical history include alcoholic cirrhosis complicated by gastrointestinal
bleeding, ascites, obesity, and presumed hepatorenal syndrome now on hemodialysis.
She reports heavy alcohol consumption (1L daily) for several years. She was diagnosed
with cirrhosis in April (self cessation of alcohol since then) when she started vomiting
blood and after visiting the emergency department, was hospitalized during which
she was found to be jaundiced and required a cholecystectomy, receiving a liver biopsy
which indicated her cirrhosis. After her cholecystectomy, she developed increasing
ascites and edema in her lower extremities. She was discharged with diuresis and
frequent paracentesis. In September, she developed worsening kidney failure and was
started on hemodialysis (3x/week) through a catheter in her right internal jugular vein.
As of her clinic visit, she reports that her kidney function has improved and does not
require dialysis.
Nutrition Hx: Home Diet : The patient follows a low sodium diet at home and
consumes 5-6 small meals throughout the day.

Weight, Highest : 90.9 kg(Converted to: 200 lb)

(Comment: at the worst of her fluid retention. She couldn't walk from it and that is
when she started dialysis
Weight, Lowest : 59.1 kg(Converted to: 130 lb)
Diet Recall :
Breakfast: leftovers from dinner: steamed rice, steamed fish/chicken, vegetables OR
egg, toast
Snacks: grapes, crackers
Lunch: steamed rice, steamed fish/chicken, vegetables
Dinner: chicken soup OR ground beef, corn, steamed rice
Snacks: fresh fruit
Beverages: watered down apple juice, water

Nutrition Assessment
Physical Appearance : Overweight
Ideal Body Weight : 45.5 kg(Converted to: 100.31 lb)
Estimated Energy Needs : 1150-1350 kcal
Estimated Protein Needs : 45-68
Estimated Fluid Needs : as per MD rx
Estimated Needs Based On : Ideal body weight
Energy Needs Calculation : 25-30
Protein Needs Calculation : 1-1.5
Nutritional Classification : Obesity Grade I (BMI 30-34.9)

Body Mass Index Measured : 32.98 kg/m2 (HI)

Usual Weight : 72.7 kg(Converted to: 160.28 lb)
Height : 152 cm(Converted to: 4.99 ft, 59.84 inch(es))

Nutrition Diagnosis:
Overweight/obesity related to excessive energy intake and fluid retention as evidenced
by diet history, nutrition focused physical assessment and need for low sodium diet.

Intervention: Nutrition education on appropriate foods for a low sodium diet

Attenuate catabolism encourage small meals to prevent discomfort related to ascites

Monitor/evaluation:
Nutrition related labs WNL.
24-hour food recall for nutrition therapy compliance
Weights, extremities with visible adequate energy stores
Summary
The patients were both of a relatively young age with alcoholic cirrhosis being the cause
of their need for a liver transplant. The primary difference was their gender and the
different stage of medical management they were in. One patient already received his
tranpslant, and the later patient is still being evaluated to be an approved recipient.
Due to the nature of excessive alcohol consumption, hepatic cirrhosis was an outcome
that resulted in the need for a liver transplant. Both were at a disease stage of
irreversible damage. Even so, prior to the transplant stage, both patients required
nutrition therapy to manage their disease and condition. As we can see, both were
adherent to their diet, which allowed them to be possible candidates for a liver
transplant.

Given the nature of this most advanced form of liver disease, alcoholic cirrhosis is
certainly best treated with a cessation of alcohol consumption. Nutrition therapy is
indeed indicated with the management of the nutritional status of individuals who
develop subsequent malnutrition and wasting secondary to the indirect behavior of
decreased food consumption. Those who consume alcohol consequently replace their
energy intake with this non nutritive substance, thereby contributing to the
development of malnutrition. Additionally, alcohol competes with absorption of
nutrients that happen to be consumed. With a decompensating liver, which is
responsible for the metabolism of nutrients as well, the risk for malnutrition is
increasingly elevated. Due to this undernutrition, nutrition therapy is evermore vital to
mitigate the progressive insults induced by the excessive alcohol intake.

References
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