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CHRONIC CIRRHOSIS WITH
ASCITES
SHWETA D. KAMBLI
R.D. INTERN
Name: Mrs. XYZ
Age: 47
Gender: Female
Community: Maharashtrian
State: Maharashtra; Taluka: Yawal; District:
Jalgaon
Residential area: Rural
Economic Status: Lower socio-economic status
Occupation: Farmer
No. of family members: 7
Addictions: None
Dietary pattern: Non-Vegetarian
SGA Score: C
Date of Admission: 25/10/2016
Date of Discharge: 26/11/2016
Length of hospital stay: 32 days
PATIENT PROFILE
CLINICAL ASSESSMENT
Present Complaints: k/c/o Pulmonary hypertension, liver cirrhosis now admitted with c/o severe ascites;
distension of stomach since 4 months; pedal edema, poor appetite, loss of weight, weakness, shortness of
breath and dyspnea on exertion and heaviness of chest present.
Past Medical History: 17 years back patient had a case of fluid accumulation in abdomen during post
pregnancy duration. Patient took ayurvedic medications and it settled down.
Family Medical history: None.
Final Medical Diagnosis: LIVER CIRRHOSIS WITH ASCITES AND DILATED CARDIOMYOPATHY.
LIVER CIRRHOSIS
Cirrhosis is a condition in which the liver slowly deteriorates and is unable to function normally due to
chronic, or long lasting injury.
In the early stages of cirrhosis, the liver continues to function.
However, as cirrhosis gets worse and scar tissue replaces healthier tissue, this blocks the flow of blood
through the liver.
Chronic liver failure, which is also called end-stage liver disease, progresses over months, years, or
even decades. With end-stage liver disease, the liver can no longer perform important functions or
effectively replace damaged cells.
Pulmonary hypertension:
• Liver disease can cause “portal hypertension,” meaning there is an increased
blood pressure in the veins that enter the liver. This increased pressure causes
blood to bypass the liver.
• As a result, the blood vessels of the lungs are exposed to possible toxic
substances and this can damage the small arteries of the lungs, causing
pulmonary arterial hypertension (PAH).
• The pulmonary arteries, which are responsible for transporting the blood from
the right ventricle heart to the lungs, become narrowed and blocked due to the
disease.
• To properly pump the blood, the heart needs to work harder, becoming
enlarged and weakened, increasing the risk of suffering right heart failure.
Dilated cardiomyopathy:
• Cardiomyopathy refers to diseases of the heart muscle.
• In dilated cardiomyopathy, the heart's ability to pump blood is decreased because the heart's main pumping
chamber, the left ventricle, is enlarged, dilated and weak.
• At first, the chambers of the heart respond by stretching to hold more blood to pump through the body.
• With time, the heart muscle walls weaken and are not able to pump as strongly.
Ascites:
• The mechanism by which ascites develops in cirrhosis is multifactorial.
• Severe sinusoidal portal hypertension and hepatic insufficiency are the initial factors. They lead to a
circulatory dysfunction characterized by arterial vasodilation, arterial hypotension, high cardiac output,
hypervolemia and to renal sodium and water retention.
Malnutrition:
• Patients with cirrhosis frequently have either global malnutrition or alterations in specific aspects of
nutritional status, such as micronutrient deficiencies, due to multiple mechanisms, including poor
nutritional intake, poor absorption, and increased losses.
• In addition, one of the most significant nutritional problems in cirrhotic patients is muscle wasting and
sarcopenia.
(McClain, C. J. (2016). Nutrition in Patients with Cirrhosis. Gastroenterology & Hepatology, 12(8), 507–510.)
ANTHROPOMETRIC ASSESSMENT
MEASUREMENTS VALUES
Height 147cm
Weight 37 Kgs during admission
Dry weight post tapping is 34 Kg)
Dry Body mass index (BMI) 15.73Kg/m2
Ideal Body Weight (IBW) 42Kg
DATE
ABDOMINAL
GIRTH
CHARTING
(cms)
WEIGHT
CHARTING
(Kg)
FLUID INPUT
(ml)
FLUID OUTPUT
(ml)
USG GUIDED
ASCITIC FLUID
TAPPING
(ml)
25/10/2016 72 37 1000 550 2500ml
27/10/2016 70 36 1000 1050 -
29/10/2016 70 35 850 500 -
31/10/2016 67 35 950 770 -
2/11/2016 67 35 1000 590 -
4/11/2016 66 36 1150 830 -
6/11/2016 68 36 1000 610 1100ml
8/11/2016 67 35 950 865 -
10/11/2016 66 35.5 1000 900 -
12/11/2016 66 35.5 1000 930 -
14/11/2016 67 36 900 995 -
16/11/2016 66 36 1025 740 -
18/11/2016 65 36 1000 1050 500ml
20/11/2016 63 35 1000 1250 -
22/11/2016 62 34.5 1000 1400 -
24/11/2016 63 34.5 1250 1250 -
26/11/2016 Discharge
BIOCHEMICAL ASSESSMENT
TEST
RESULT
REFERENCE RANGE
25/10/16 27/10/16 5/11/16 8/11/16 19/11/16 22/11/16
Prothrombin time 14.2 13.50 13.30 13.0 11-14 Seconds
WBC - - 6.04 4.22 4.73 4.75 4-10
10^3/uL
Hemoglobin 7.5 - 8.10 7.5 8 9.1 11.5-16g/dl
Platelets 142 - 107 142 141 144 140-440 10^3/uL
Sodium 142 - 138 138 - - 137-145mmol/L
Potassium 4.10 - 4.2 3.7 - - 3.5-5.1mmol/L
Chloride 103 - 100 100 - - 98-107 mmol/L
Ammonia - - - 9.00 - - 9-33 umol/L
AST/ SGOT 20 19 24 23 26 28 15-46 U/L
ALT/ SGPT 14 12 13 15 18 21 13-69 U/L
Bilirubin total 0.84 0.98 0.86 0.80 0.71 0.80 0.2 – 1.3 mg/dL
Bilirubin Unconjugated (BU) 0.29 0.46 0.34 0.26 0.26 0.36 0-1 mg/dL
Bilirubin Conjugated (BC) 0.00 0.00 0.00 0.00 0.00 0.00 0-0.3 mg/dL
Bilirubin delta 0.55 0.52 0.52 0.54 0.45 0.44 0-0.2 mg/dl
Alkaline phosphatase 55 44 57 52 57 81 38-126 IU/L
Total proteins 7.21 6.48 7.15 6.74 6.54 7.08 6.3-8.2mg/dl
Albumin 3.82 3.61 3.78 3.52 3.47 3.71 3.5 – 5 g/dL
Globulin 3.39 2.87 3.37 3.22 3.07 3.38 2.4 – 3.5 g/dL
Albumin/Globulin ratio 1.12 1.26 1.12 1.09 1.13 1.1 1.1 -2.2
BNP Peptide 958 - - - - - >400 pg/ml- heart failure
probable
Blood sugar Random 93 - - - - - 65-165mg/dl
Blood urea Nitrogen 11 - - - - - 7-17mg/dL
Uric Acid 5.3 - - - - - 2.5-6.2 mg/dL
Serum Creatinine 0.7 - 0.8 - 0.7 - 0.7-1.2mg/dL
Adenosine deaminase activity (ADA)
Sample type- Ascitic fluid 15.80 <30U/L
Blood group A Positive
b. Other Investigations:
Date Time Temperature
(F)
Pulse
(b/min)
Respiration
(b/min)
Blood Pressure
(mmHg)
25/10/2016 10:00am 98 76 20 100/70
27/10/2016 10:00am 98 72 20 100/80
5/11/2016 10:00am 98 71 22 100/60
8/11/1016 10:00am 98 82 18 90/60
19/11/2016 10:00am 97 70 20 90/60
22/11/2016 10:00am 98 70 20 90/60
CT Scan of abdomen: Indicate severe Ascites and Splenomegaly.
Liver biopsy: Sections reveal variably sized nodules separated by fibrotic bands. Granulomas were not
seen.
Microbiological testing of the Ascitic fluid: No pus cells, no organisms seen.
MEDICATION DURING HOSPITAL STAY
MEDICATION DOSAGE
MECHANISM OF ACTION
SIDE- EFFECTS
TAB. ENDOBLOC 10MG 1-0-0 Medicine used for the treatment of pulmonary hypertension. It works by widening the arteries and
reducing the blood pressure.
Peripheral edema, Nasal congestion, Sinus
inflammation, Flushing
TAB. CAVERTA 25MG 1-0-1 (5Days a
week)
Used for the treatment of high blood pressure. It works by relaxing the blood vessels and widening
the blood vessels in the lung.
headache, flushing of the face, and upset stomach.
TAB. LANOXIN 0.25MG 1-0-0 Used to treat various heart conditions such as atrial fibrillation, atrial flutter and heart failure.
nausea, vomiting, loss of appetite; fast, slow, or
uneven heart rate
TAB. LASILACTONE
100MG 1-0-0
Used in the treatment of fluid retention. Works by preventing the body to absorb too much salt,
eliminating unneeded water and sodium from the body into the urine.
Increased production of urine, dehydration,
decreased blood pressure, weakness, drowsiness
TAB.MULTIVIT GOLD 1-0-0
Used for Maintaining the proper balance of body fluids and body's acid base balance, Neutralizing
the free radicals and participates in vital redox reactions of the body, Raising the level of
glutathione thus prevents cells against peroxidative damage, Works for the healing purpose,
Improving the body's metabolism, Widening the blood vessels, Increasing the effects of insulin,
Promoting the formation of active prothrombin in liver, Helping in bone and collagen synthesis.
Vomiting, dehydration, gastrointestinal
disturbances, fatigue, itching of skin.
TAB. PAN 40MG 1-0-1 Used in the treatment of acidity, heartburn, intestinal ulcers and stomach ulcers. It lowers the acid
production in the stomach.
Nausea, Headache, Abdominal pain, Constipation,
Diarrhea, Flatulence
LASIX 10MG 1-0-1
It is a potent diuretic that is used to eliminate water and salt from the body. It works by blocking
the absorption of sodium, chloride and water from the filtered fluid in the renal tubules, causing a
profound increase in the output of urine.
Dizziness, light headedness, headache,
blurred vision
TAB. ZEVIT 1-0-0 It is a multi-vitamin supplement mainly utilized therapeutically as nutritional support in various
cases of deficiency of vitamin B complex , folic acid and vitamin C.
Bitterness of mouth, Gastrointestinal problems,
Flatulence, Loss of appetite, Bloating, stomach
pain, Nausea, Anxiety, Persistent itchy rashes on
skin.
CALCITROL
GRANULES SACHET
Every 4Th Day It is used for the treatment of vitamin D3 deficiency, rickets and osteomalacia
weakness, fatigue, headache, nausea, vomiting,
constipation, dry mouth, metallic taste, muscle pain,
or bone pain.
HEPA MERZ SACHET 1-0-0
It reduces the accumulation of ammonia in patients with poor liver function thereby relieving
symptoms associated with abnormal ammonia metabolism.
Vomiting, Nausea, Diarrhea, Abdominal pain,
Flatulence
DIETARY ASSESSMENT : 24Hr. Home diet recall
Menu Ingredients Amounts Household
measures Energy (Kcal) CHO (g) Protein (g) Fat (g) Vit C (mg) Fe (mg) Na (mg) K (mg) IF (g) SF (g)
Calcium
(mg)
7:00am - EARLY MORNING
Tea Milk 50ml 1/2 cup 33 2 1.65 2 1 0.1 36.5 70 60
Sugar 5g 1 tsp. 20 5 0 0 0.07
Khari 15g 2no. 90 14.23 1 4.1
10:00am - BREAKFAST
Kande Pohe Rice Flakes 30g 1/2 cup 100 21 2.5 0.5 0 6 3.27 46.2 0.96 0.27 6
Onion 50g 1 small 20 5 0.5 0 1 0.6 2 63.5 20
Oil 5ml 1 tsp. 45 0 0 5
2:00pm - LUNCH
Jowarichi Bhakri Jowar flour 30g 2 tbsp. 100 21 2.5 0.5 0 1.23 2.19 39.3 2.4 0.51 7.5
Shengachi Bhaji Drumstick 50g 1 stick 12.5 3 0.5 0 60 0.09 129.5 2.4 0.5 15
Onion 50g 1 small 20 5 0.5 0 1 0.6 2 63.5 20
Tomato 25g 1/2 no. 6.25 1.5 0.25 0 6.75 0.16 3.23 36.5 12
Oil 5ml 1 tsp. 45 0 0 5
5:00pm - SNACK
Tea Milk 50ml 1/2 cup 33 2 1.65 2 1 0.1 36.5 70 60
Sugar 5g 1 tsp. 20 5 0 0 0.07
Khari 15g 2 no. 90 14.23 1 4.1
9:00pm - DINNER
Vangi bhaat Rice 30g 2 tbsp. 100 21 2.5 0.5 0 0.21 0.96 0.27 3
Brinjal 50g 3no. 12.5 3 0.5 0 6 0.19 1.5 100 2.3 0.85 9
Potato 50g 1/2 no. 50 12 0.5 0 8.5 0.24 5.5 123.5 0.55 0.3 5
Oil 5ml 1 tsp. 45 0 0 5
TOTAL 842 135 16 29 85 10 93 742 10 3 218
CALORIE (Kcal) 540 62 258
PERCENT (%) 64 7 31
25KCal/Kg BW 0.4g/Kg BW
Nutritional calculation of home diet recall
Energy: 842Kcal (25KCal/Kg BW)
Proteins:16g (0.4g/Kg BW)
HBV: 3.3g
Carbohydrate: 135g (64.09% of TC)
Fats: 29g (30.67% of TC)
Calories to Nitrogen ratio: 338:1
Sodium: 92.69mg
Interpretation of home diet recall:
The recall indicates that there are large gaps
between the meals.
The protein content in the diet is very low.
No cereal pulse combination recipes are
included.
180Kcals/842Kcal is achieved from Khari.
No fruit consumption in the diet.
NUTRITION ASSESSMENT SUMMARY
BMI = 15.73Kg/m2 which indicates that the patient is severely underweight.
Classification BMI(kg/m2)
Principal cut-off
points Additional cut-off points
Underweight <18.50 <18.50
Severe thinness <16.00 <16.00
Moderate
thinness 16.00 - 16.99 16.00 - 16.99
Mild thinness 17.00 - 18.49 17.00 - 18.49
Normal range 18.50 - 24.99 18.50 - 22.99
23.00 - 24.99
Lancet, Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies; 2004 Mar
13;363(9412):902.
• SGA Score - C; Presence of mild to moderate edema, severe ascites, poor food
intake, severe loss of functional status, strength and stamina; indicates that the
patient is undernourished.
• Low hemoglobin levels indicating the presence of anemia. Hence, provide optimal
iron through diet and nutrition supplement. Include source of Vitamin C in the diet to
enhance the absorption of Iron.
MEDICAL NUTRITION THERAPY
ENERGY:
• Presence of Ascites has found to increase energy expenditure. Daily caloric recommendations for patients with
liver cirrhosis range from 25 to 40 kcal/kg/day.
• ESPEN: 35-40 kcal/kg/day (M. Plauth et al; ESPEN Guidelines on Enteral Nutrition: Liver disease, January 2006; 25, 285–294.)
• ASPEN:
• With acute encephalopathy: 35 kcal/kg/day
• Without encephalopathy: 25-35 kcal/kg/day
• Stable and malnourished: 30-40 kcal/kg/day
(Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care
Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.; Journal of Parenteral and Enteral Nutrition,
Vol 33, Issue 3, pp. 277 – 316)
PROTEIN:
• Cirrhosis is a catabolic disease with increased protein breakdown, inadequate resynthesis, depleted status,
and muscle wasting.
• Negative nitrogen balance due to protein restriction leads to protein-energy malnutrition and decrease the
survival rate in patients with liver cirrhosis.
(O'Brien A, Williams R (2008) Nutrition in end-stage liver disease: principles and practice. Gastroenterology 134: 1729-1740.)
• ESPEN: 1.0-1.5 g/kg dry weight/day
• ASPEN:
With acute encephalopathy: 0.6-0.8 g/kg dry weight /day
Without encephalopathy: 1.0-1.5 g/kg dry weight /day
• Altered amino acid metabolism is a hallmark of liver disease, characterized by low levels of circulating
BCAAs and elevated levels of circulating aromatic amino acids, and methionine.
• BCAA supplementation appears to be associated with decreased frequency of complications of cirrhosis and
improved nutritional status when prescribed as maintenance therapy.
CARBOHYDRATES:
• Carbohydrates should be the major source of calories in the diet.
• Fasting low blood sugar can occur because of the decreased availability of glucose from glycogen.
Therefore, carbohydrate should provide most of the non-protein calories.
LIPID:
• Several investigations have concluded that excess dietary fat may encourage cirrhosis progression.
• High intakes of total fat, saturated fat, and polyunsaturated fat have been implicated.
• Medium chain triglycerides should be included in the diet for liver cirrhosis as it is better tolerated by
the patients and is absorbed in the absence of bile.
(Corrao G, Ferrari PA, Galatola G (1995) Exploring the role of diet in modifying the effect of known disease determinants:
application to risk factors of liver cirrhosis. Am J Epidemiol 142: 1136-1146.)
ANTIOXIDANTS AND B-VITAMINS:
• Cirrhotic patients have significant reductions in antioxidant enzymes and antioxidant nutrients, such as
carotenoids, selenium, vitamin E, and zinc.
• Deficiency of folate is also found in liver cirrhotic patients and an estimated 50% have increased blood
homocysteine concentrations which cause liver fibrosis and ultimately cirrhosis.
(Halifeoglu I, Gur B, Aydin S, Ozturk A (2004) Plasma trace elements, vitamin B12, folate, and homocysteine levels in cirrhotic
patients compared to healthy controls. Biochemistry (Mosc) 69: 693-696.)
• Hepatic osteodystrophy or osteopenia can develop from vitamin D deficiency. Therefore,
supplementation is necessary.
(McClain, C. J. (2016). Nutrition in Patients with Cirrhosis. Gastroenterology & Hepatology, 12(8), 507–510.)
SODIUM RESTRICTION:
• A diet low in sodium can help to treat ascites and edema as it will minimize the amount of salt
entering the kidney, leaving less sodium available for re-absorption, therefore, less fluid is retained.
(Dolz C, Raurich JM, Ibáñez J, Obrador A, Marsé P, et al. (1991) Ascites increases the resting energy expenditure in liver
cirrhosis. Gastroenterology 100: 738-744.)
• A 2000 mg sodium-restricted diet is effective, when combined with diuretic therapy, for controlling
fluid overload in 90% of patients with cirrhosis and ascites.
(Runyon BA (1998) Management of adult patients with ascites caused by cirrhosis. Hepatology 27: 264-272.)
FLUID:
• It is important to carefully monitor and maintain the electrolyte and fluid balance.
• In liver diseases, the blood vessels ability to retain fluid is diminished because of
decreased protein synthesis in the liver, mainly albumin.
• This causes fluid leaks in your blood vessels, which in turn, causes fluid buildup in other
tissues, or ascites.
• By limiting the amount of salt and fluid in your diet, fluid retention and swelling can be
reduced.
CASE PROGRESSION
Day 1 NBM
Day 2 - Day 17 Soft Hepatic Salt Restricted Diet
Day 18 – Day 31 Full Hepatic Salt Restricted Diet
SHORT TERM GOALS OF MANAGEMENT
To treat symptoms and prevent complications.
To prevent the progression of the complications and manage them.
To administer fluid and sodium restriction to prevent further complications.
To slow the progression of the scar tissue.
To correct nutritional deficiency if any.
To provide adequate nutrition to prevent macronutrient and micronutrient deficiencies.
To provide adequate protein with high biological value to ensure anabolism and to
prevent protein breakdown for energy synthesis.
To provide small frequent soft meals to reduce the patient’s discomfort.
To improve and maintain the nutrition status.
HOSPITAL PRESCRIBED DIET
Nutritional calculation of Hospital diet
(Soft hepatic salt restricted diet- Day 2-Day 17
Type of diet: Soft hepatic salt restricted diet
Frequency of meals: Distributed 8 meals per
day
Consistency of diet: Soft
Energy: 1052Kcal (31KCal/Kg BW)
Proteins: 39g (1.1g/Kg BW)
HBV: 20.25g
Carbohydrate: 165g (62.84% of TC)
Fats: 26g (22.62%)
MCT: 10g (40% of total fat)
Calories to Nitrogen ratio: 168:1
Sodium: 431mg (Sodium restriction of
2000mg/day)
Salt per day: 4 gm/day
Fluid: 1000ml
Menu Ingredients Amounts Energy (Kcal) CHO (g) Protein (g) Fat (g) Vit C (mg) Fe (mg) Na (mg) K (mg) IF (g) SF (g) Calcium (mg)
7:00am - EARLY MORNING
Tea Milk 50ml 14.5 2.3 1.25 0.05 1 0.1 36.5 70 60
Sugar 5g 20 5 0 0 0.07
Threptin biscuit Biscuit 1no. 21.9 2.4 1.5 0.7
8:00am - BREAKFAST
Upma Rawa 30g 100 21 2.5 0.5 0 0.48 6.3 24.9 2.88 0.87 3
Oil 5ml 45 0 0 5
Boiled Egg Egg 50g 90 0 7 7 0 1.05 30
11:00am - MIDMORNING
Fruit Muskmelon 100g 50 10 0 0 26 1.4 104.6 341 0.5 0.3 32
1:00pm - LUNCH
Soft rice Rice 30g 100 21 2.5 0.5 0 0.21 0.96 0.27 3
Boil Dal Moong dal 30g 100 17 7 0.5 0 1.17 8.16 345 1.95 0.51 22.5
Saute potato with jeera
powder Boiled potato 100g 100 24 1 0 17 0.48 11 247 1.1 0.6 10
Saltfree
Butter 5g 35 0 0 5
Curd Curd 100ml 29 4.6 2.5 0.1 2 0.2 73 140 120
4:00pm - SNACKS
Tea Milk 50ml 14.5 2.3 1.25 0.05 1 0.1 36.5 70 60
Sugar 5g 20 5 0 0 0.07
Threptin biscuit Biscuit 1no. 21.9 2.4 1.5 0.7
Menu Ingredients Amounts Energy (Kcal) CHO (g) Protein (g) Fat (g) Vit C (mg) Fe (mg) Na (mg) K (mg) IF (g) SF (g) Calcium (mg)
6:00pm - LATE EVENING
Fruit Papaya 100g 50 10 0 0 57 0.5 6 69 1.3 1.3 17
8:00pm - DINNER
Khichdi Rice 15g 50 10.5 1.25 0.25 0 0.21 0.48 0.135 3
Moong dal 15g 50 8.5 3.5 0.25 0 1.17 4.08 172.5 0.975 0.255 11.25
Saltfree
Butter 5g 35 0 0 5
Boiled carrots Boiled carrot 100g 40 10 1 0 3 1.03 35.6 108 3 1.4 80
Curd Curd 100ml 29 4.6 2.5 0.1 2 0.2 73 140 120
10:00pm - BEDTIME
Warm milk Milk 50ml 14.5 2.3 1.25 0.05 1 0.1 36.5 70 60
Threptin biscuit Biscuit 1no. 21.9 2.4 1.5 0.7
TOTAL 1052 165 39 26 110 9 431 1797 13 6 632
CALORIE (Kcal) 661 156 238
PERCENT (%) 63 15
23
31KCal/Kg
BW 1.1g/Kg BW
Nutritional calculation of Hospital diet
(Full hepatic salt restricted diet- Day 18-Day 31
Type of diet: Full hepatic salt restricted diet
Frequency of meals: Distributed 8 meals per
day
Consistency of diet: Full diet
Energy: 1188Kcal (34KCal/Kg BW)
Proteins: 41.2g (1.2g/Kg BW)
HBV: 20.25g
Carbohydrate: 189 g (63.46% of TC)
Fats: 32g (24.05% of TC)
MCT: 10g (30% of total fat)
Calories to Nitrogen ratio: 180:1
Sodium: 339mg (Sodium restriction of
2000mg/day)
Salt per day: 4gm Salt packet
Fluid: 1000ml
Menu Ingredients Amounts Energy (Kcal) CHO (g) Protein (g) Fat (g) Vit C (mg) Fe (mg) Na (mg) K (mg) IF (g) SF (g) Calcium
(mg)
7:00am - EARLY MORNING
Tea Milk 50ml 14.5 2.3 1.25 0.05 1 0.1 36.5 70 60
Sugar 5g 20 5 0 0 0.07
Threptin biscuit Biscuit 1no. 21.9 2.4 1.5 0.7
8:00am - BREAKFAST
Poha Rice flakes 30g 100 21 2.5 0.5 0 6 3.27 46.2 0.48 0.135 6
Onion 50g 20 5 0.5 0 1 0.6 2 63.5 20
Oil 5ml 45 0 0 5
Boiled Egg Egg 50g 90 0 7 7 0 1.05 30
11:00am - MIDMORNING
Fruit Banana 100g 116 27.2 1.2 0.3 7 0.36 36.6 88 1.1 0.7 17
1:00pm - LUNCH
Chapati Wheat flour 30g 100 21 2.5 0.5 0 1.47 6 94.5 2.88 0.87 14.4
Dudhi bhaji Dudhi 75g 18.75 4.5 0.75 0 0 0.345 1.35 65.25 1.275 0.225 15
Onion 50g 20 5 0.5 0 1 0.6 2 63.5 20
Tomato 25g 6.25 1.5 0.25 0 6.75 0.16 3.23 36.5 12
Oil 5ml 45 0 0 5
Boil Dal Moong dal 30g 100 17 7 0.5 0 1.17 8.16 345 1.95 0.51 22.5
Curd Curd 100ml 29 4.6 2.5 0.1 2 0.2 73 140 120
4:00pm - SNACKS
Tea Milk 50ml 14.5 2.3 1.25 0.05 1 0.1 36.5 70 60
Sugar 5g 20 5 0 0 0.07
Threptin biscuit Biscuit 1no. 21.9 2.4 1.5 0.7
Menu Ingredients Amounts Energy (Kcal) CHO (g) Protein (g) Fat (g) Vit C (mg) Fe (mg) Na (mg) K (mg) IF (g) SF (g) Calcium
(mg)
6:00 - LATE EVENING
Fruit Papaya 100g 50 10 0 0 57 0.5 6 69 1.3 1.3 17
8:00pm - DINNER
Khichdi Rice 15g 50 10.5 1.25 0.25 0 0.105 0.48 0.135 1.5
Moong dal 15g 50 8.5 3.5 0.25 0 0.585 4.08 172.5 0.975 0.255 11.25
Saltfree
Butter 10g 70 0 0 10
Boiled potato with jeera
powder Boiled potato 100g 100 24 1 0 17 0.48 11 247 1.1 0.6 10
Curd Curd 100ml 29 4.6 2.5 0.1 2 0.2 73 140 120
10:00pm - BEDTIME
Warm milk Milk 50ml 14.5 2.3 1.25 0.05 1 0.1 36.5 70 60
Threptin biscuit Biscuit 1no. 21.9 2.4 1.5 0.7
TOTAL 1188 189 41 32 97 14 339 1781 12 5 617
CALORIE (Kcal) 754 165 286
PERCENT (%) 63 14 24
34KCal/Kg
BW
1.2g/Kg
BW
NUTRITIONAL COMPLIANCE
Day Type of diet Planned % Compliance Reasons
2 Soft hepatic Salt Restricted diet Energy- 1052Kcal ;Protein- 39g Energy- 71% ;Protein- 76%
• Patient during admission had
severe loss of appetite and was
not willing to eat food.
• Later, through various
strategies like counselling the
patient, a marked increase in
the food consumption was
seen.
3 Soft hepatic Salt Restricted diet Energy- 1052Kcal ;Protein- 39g Energy- 70% ;Protein- 75%
4 Soft hepatic Salt Restricted diet Energy- 1052Kcal ;Protein- 39g Energy- 71% ;Protein- 76%
5 Soft hepatic Salt Restricted diet Energy- 1052Kcal ;Protein- 39g Energy- 72% ;Protein- 76%
6 Soft hepatic Salt Restricted diet Energy- 1052Kcal ;Protein- 39g Energy- 81% ;Protein- 79%
7 Soft hepatic Salt Restricted diet Energy- 1052Kcal ;Protein- 39g Energy- 80% ;Protein- 78%
8 Soft hepatic Salt Restricted diet Energy- 1052Kcal ;Protein- 39g Energy- 81% ;Protein- 79%
9 Soft hepatic Salt Restricted diet Energy- 1052Kcal ;Protein- 39g Energy- 82% ;Protein- 80%
10 Soft hepatic Salt Restricted diet Energy- 1052Kcal ;Protein- 39g Energy- 80% ;Protein- 79%
11 Soft hepatic Salt Restricted diet Energy- 1052Kcal ;Protein- 39g Energy- 79% ;Protein- 80%
12 Soft hepatic Salt Restricted diet Energy- 1052Kcal ;Protein- 39g Energy- 81% ;Protein- 79%
13 Soft hepatic Salt Restricted diet Energy- 1052Kcal ;Protein- 39g Energy- 80% ;Protein- 78%
14 Soft hepatic Salt Restricted diet Energy- 1052Kcal ;Protein- 39g Energy- 81% ;Protein- 79%
15 Soft hepatic Salt Restricted diet Energy- 1052Kcal ;Protein- 39g Energy- 82% ;Protein- 80%
16 Soft hepatic Salt Restricted diet Energy- 1052Kcal ;Protein- 39g Energy- 81% ;Protein- 79%
17 Soft hepatic Salt Restricted diet Energy- 1052Kcal ;Protein- 39g Energy- 81% ;Protein- 79%
18 Full hepatic Salt Restricted diet Energy- 1188Kcal ;Protein- 41g Energy- 86%; Protein- 96%
19 Full hepatic Salt Restricted diet Energy- 1188Kcal ;Protein- 41g Energy- 87%; Protein- 96%
20 Full hepatic Salt Restricted diet Energy- 1188Kcal ;Protein- 41g Energy- 86%; Protein- 96%
21 Full hepatic Salt Restricted diet Energy- 1188Kcal ;Protein- 41g Energy- 88%; Protein- 97%
22 Full hepatic Salt Restricted diet Energy- 1188Kcal ;Protein- 41g Energy-90%; Protein- 98%
23 Full hepatic Salt Restricted diet Energy- 1188Kcal ;Protein- 41g Energy-90%; Protein- 98%
24 Full hepatic Salt Restricted diet Energy- 1188Kcal ;Protein- 41g Energy-90%; Protein- 98%
25 Full hepatic Salt Restricted diet Energy- 1188Kcal ;Protein- 41g Energy-90%; Protein- 98%
26 Full hepatic Salt Restricted diet Energy- 1188Kcal ;Protein- 41g Energy- 100%; Protein- 100%
27 Full hepatic Salt Restricted diet Energy- 1188Kcal ;Protein- 41g Energy- 100%; Protein- 100%
28 Full hepatic Salt Restricted diet Energy- 1188Kcal ;Protein- 41g Energy- 100%; Protein- 100%
29 Full hepatic Salt Restricted diet Energy- 1188Kcal ;Protein- 41g Energy- 100%; Protein- 100%
30 Full hepatic Salt Restricted diet Energy- 1188Kcal ;Protein- 41g Energy- 100%; Protein- 100%
31 Full hepatic Salt Restricted diet Energy- 1188Kcal ;Protein- 41g Energy- 100%; Protein- 100%
32 Discharge
DISCHARGE DIET
LONG TERM GOALS OF MANAGEMENT
To provide adequate nutrition to prevent macronutrient and micronutrient deficiencies.
To prevent the progression of the complications and manage them.
To slow the progression of the scar tissue.
To administer fluid and Sodium restriction to prevent further complications.
To prevent nutritional deficiency.
To provide nutrition education to the patient and the care giver.
To improve quality of life.
Nutritional calculation of Discharge diet
(Full hepatic salt restricted diet)
Type of diet: Full hepatic salt restricted diet
Frequency of meals: Distributed 8 meals per
day
Consistency of diet: Full diet
Energy: 1349.7Kcal (39KCal/Kg BW)
Proteins: 43.41g (1.2g/Kg BW)
HBV: 14g
Carbohydrate: 219.65g (65.10% of TC)
Fats: 31.72g (21.15% of TC)
MCT: 10g (32% of total fat)
Calories to Nitrogen ratio: 194:1
Sodium: 194.91mg (Sodium restriction of
2000mg/day)
Salt per day: 4gm Salt packet
Fluid: 1200ml
EXCHANGE LIST OF THE PRESCRIBED MNT
Food group Exchange Amounts Energy (Kcal) CHO (g) Protein (g) Fat (g)
Cereal 5 150g 500 105 12.5 2.5
Pulse 2 60g 200 34 14 1
Milk & Milk products 2 200ml 60 8 6.65 0
Egg 1 50g 90 0 7 7
Veg A 1 100g 25 6 1 0
Veg B 1/2 50g 20 5 0.5 0
Veg C 1/2 50g 50 12 0.5 0
Fruits 1 100g 50 10 0 0
Sugar/Jaggery 1 20g 80 19.2 0 0
Glucon D 1/2 20g 72 18 0 0
Oil 2 20ml 180 0 0 20
Garden cress seeds 1/4 5g 22.7 1.65 1.26 1.22
TOTAL 1350 217 43 32
CALORIE (Kcal) 869 174 285
PERCENT (%) 64 13 21
39KCal/Kg BW 1.2g/Kg BW
MEAL DISTRIBUTION
Food Group Early
morning Breakfast Midmorning Lunch Snack
Late
Evening Dinner Bedtime
Total
Exchanges
Cereal 1 1 1 1 1 5
Pulse 1/2 1/2 1 2
Milk & Milk
products 1/2 1 1/2 2
Egg 1 1
Veg A 1/4 3/4 1
Veg B 1/4 1/4 1/2
Veg C 1/2 1/2
Fruits 1 1
Sugar/Jaggery 1/4 1/4 1/4 1/4 1
Glucon D 1/2 1/2
Oil 1/2 1/2 1 2
Garden cress seeds 1/4 1/4
Total Calories
(Kcal) 120 280 50 281 85 120 319 95 1350
DETAILED PRESCRIBED MENU
Menu Ingredient
s Amounts
Household
measures Energy (Kcal) CHO (g) Protein (g) Fat (g) Vit C (mg) Fe (mg) Na (mg) K (mg) IF (g) SF (g)
Calcium
(mg)
8:00am - EARLY MORNING
Naachni satva Naachni 30g 2 tbsp. 100 21 2.5 0.5 0 1.17 3.3 122.4 2.97 0.48 103.2
Jaggery 5g 1 tsp. 20 5 0 0 0.132 4
10:00am - BREAKFAST
Tea Milk 50ml 1/2 cup 15 2 1.66 0 1 0.1 36.5 70 60
Sugar 5g 1 tsp. 20 5 0 0 0.07
Poha Rice flakes 30g 2 tbsp. 100 21 2.5 0.5 0 6 3.27 46.2 0.48 0.135 6
Onion 25g 1/2 small 10 2.5 0.25 0 0.5 0.3 1 31.75 10
Coconut oil 5ml 1 tsp. 45 0 0 5
Boiled egg Egg 50g 1 no. 90 0 7 7 0 1.05 30
12:00pm - MIDMORNING
Fruit Chickoo 100g 1 no. 50 10 0 0 6 1.25 5.9 269 9.1 1.8 28
1pm – LUNCH
Masala Bhaat Rice 30g 2 tbsp. 100 21 2.5 0.5 0 0.21 0.96 0.27 3
Masoor 15g 1 tbsp. 50 8.5 3.5 0.25 0 1.137 6.015 94.35 2.02 0.34 10.35
Tomato 25g 1/4 small 6.25 1.5 0.25 0 6.75 0.16 3.23 36.5 12
Potato 50g 1/2 small 50 12 0.5 0 8.5 0.24 5.5 123.5 0.55 0.3 5
Groundnut
oil 5ml 1 tsp. 45 0 0 5
Curd Curd 100ml 1/2 cup 30 4 3.33 0 2 0.2 73 140 120
Fresh Amba haldi Fresh
Amba haldi 5g 1"pc.
4pm - SNACK
Tea Milk 50ml 1/2 cup 15 2 1.66 0 1 0.1 36.5 70 60
Sugar 5g 1 tsp. 20 5 0 0 0.07
Roasted chana Roasted
chana 15g 2 tbsp. 50 8.5 3.5 0.25 0 1.425 5.595 121.2 3.78 0.465 8.7
Menu Ingredient Amounts Household
measures Energy (Kcal) CHO (g) Protein (g) Fat (g) Vit C (mg) Fe (mg) Na (mg) K (mg) IF (g) SF (g)
Calcium
(mg)
6pm - LATE EVENING
Ghavacha satva Whole
wheat 30g 2 tbsp. 100 21 2.5 0.5 0 1.47 6 94.5 2.88 0.87 14.4
Jaggery 5g 1 tsp. 20 5 0 0 0.132 4
8:00pm - DINNER
Naachnichi Bhakri Naachni
flour 30g 2 tbsp. 100 21 2.5 0.5 0 1.17 3.3 122.4 2.97 0.48 103.2
Kulithcha Pitla Kulith
Flour 30g 2 tbsp. 100 17 7 0.5 0 2.031 3.45 228.6 86.1
Onion 25g 1/2 small 10 2.5 0.25 0 0.5 0.3 1 31.75 10
Groundnut
oil 5ml 1 tsp. 45 0 0 5
Dudhi bhaji Dudhi 75g 1 bowl 18.75 4.5 0.75 0 0 0.345 1.35 65.25 1.275 0.225 15
Ghee 5ml 1 tsp. 45 0 0 5
10:00pm - BEDTIME
Glucon D Glucon D 20g 4 tsp. 72 18 0 0 34
Water 50ml 1/2 cup
Garden
cress seeds 5g 2 tsp. 22.7 1.65 1.26 1.22 0 5 18.85
TOTAL 1350 220 43 32 26 24 195 1667 27 5 746
CALORIE (Kcal) 879 174 285
PERCENT (%) 65 13 21
39KCal/Kg
BW
1.2g/Kg
BW
DIETARY ALTERNATIVES
Menu Alternatives Functional Food
8:00am - EARLY MORNING
Naachni satva Ghavacha satva/ Rawa kheer Cardomom
10:00am - BREAKFAST
Tea Plain Milk/Masala Milk Ginger
Poha Upma/Daliya upma Turmeric, lemon juice
Boiled egg Plain Omlette/Masala Omlette
12:00pm - MIDMORNING
Fruit Orange/Banana//Papaya/Guava/Apple/Pear
1pm - LUNCH
Masala Bhaat Dal Rice/Vaangi Bhaat/Dal Khichdi Ginger, Garlic, Pepper, Cinnamon,
Turmeric
Curd Buttermilk Curd
Mango ginger (Amba Haldi) White Turmeric/Fresh Ginger Mango ginger
4pm - SNACK
Tea Plain Milk/Masala Milk Ginger
Roasted chana Boiled Moong/Boiled chana
5pm - LATE EVENING
Ghavacha satva Naachni satva/Rawa kheer Cardomom
8:00pm - DINNER
Naachnichi Bhakri Jowarichi Bhakri/ Bajrichi bhakri
Kulithcha Pitla Zhunka/ Moong dal Turmeric, Garlic
Dudhi bhaji Shepu chi bhaji/ Palak chi bhaji Garlic, Kokum
10:00pm - BEDTIME
Glucon D with garden cress
seed
Lime water with Glucon D & garden cress seed/Whey with Glucon D &
garden cress seed Garden cress seed
FAT CALCULATIONS
Fat allowance: 31.72g
Visible fat: 20g (Groundnut oil, ghee and coconut oil)
Invisible fat: 11.72g
MCT: 10g (30%)
Food Item SFA MUFA PUFA Ω3 Ω6
Wheat 0.15 0.09 0.38 0.051 0.33
Rice 0.27 0.24 0.306 0.006 0.3
Naachni 0.192 0.42 0.21 0.03 0.18
Masoor 0.04 0.06 0.144 0.024 0.12
Roasted chana 0.085 0.18 0.555 0.03 0.525
Ghee 3.47 1.4 0.125 - 0.125
Groundnut oil 2.09 4.93 2.99 - 2.99
Coconut oil 4.475 0.39 0.1 - 0.1
Achieved fat ratio 10.772 7.71 4.81 0.14 4.67
SUPPLEMENTS RECOMMENDED ON DISCHARGE
Supplement name Dosage Form Composition Cost/Day
Multivit gold 1-0-0 Tablet
Carbohydrate 0.08 g, protein 0.24 g, fat 0.43 g, ginseng extract 21.25 mg, ginkgo biloba extract 20
mg, citrus bioflavonoids 12.5 mg, green tea extract 10 mg, carotenoids 5 mg, garlic powder 2 mg,
lycopene 2 mg, niacinamide 15 mg, vitamin C 12.5 mg, vitamin E acetate 12.5 IU, inositol 10 mg,
pantothenic acid 5 mg, vitamin A 1600 IU, vitamin B1 1 mg, vitamin B2 1 mg, vitamin B6 0.5 mg,
vitamin K 80 mcg, folic acid 50 mcg, biotin 30 mcg, vitamin D3 200 IU, vitamin B12 0.5 mcg, iron
18 mg, zinc 15 mg, choline bitartrate 10 mg, potassium 10 mg, chloride 9.07 mg, manganese 5 mg,
calcium 5 mg, phosphorus 3.86 mg, copper 2.2 mg, silicon 2 mg, boron 1 mg, molybdenum 0.5 mg,
chromium 200 mcg, nickel 130 mcg, selenium 70 mcg, iodine 50 mcg, vanadium 10 mcg, tin 2 mcg,
methionine 22 mg, glutamic acid 20 mg, lysine 10 mg, L-carnitine 2.5 mg, cysteine 2.5 mg.
Rs. 7/tab
Zevit 0-1-0 Tablet
Calcium Pantothenate 50mg, Vitamin B6 3mg, Vitamin B2 10mg, Vitamin B1 10mg, Vitamin B12
15mcg, Vitamin E 15mg, Vitamin C 150mg, Nicotinamide 50mg, Zinc 41.4mg, Biotin 100mcg, Folic
Acid (Vitamin B9) 1500mcg.
1.1 Re/-
TOTAL COST PER DAY 8.1Rs/Day
RECOMMENDATION
• Frequency of meals:
o Consume small frequent meals.
o Instead of consuming 3 large meals, have 5-8 small meals.
• Method of cooking:
o Roasting, steaming, boiling, pressure cooking is preferred over frying.
• Milk and milk products:
o Prepare Skimmed milk at home by heating the milk and cooling it by storing it in the refrigerator immediately. After some
time separate the fat (malai) from the surface of the milk and use it for other preparations.
• Salt intake:
o Salt intake should be 4gm (1600mg sodium) per day.
o Cook your meals without salt and add it into your food just before consuming it.
o Instead make use of lemon, tamarind, kokum to make the food palatable.
o Make sure that the tamarind and kokum is not stored with salt.
o Avoid using aamchur powder, chaat masala as it has a higher sodium content.
o Add flavor to the food by using a variety of spices such as cinnamon, asafoetida, fennel seeds,
carom seeds, cumin seeds, ginger, garlic, mint leaves, curry leaves.
o Avoid papad, pickles. (since salt content is high).
• Fluids and Beverages:
o Monitor your daily fluid intake so that you don’t exceed your fluid intake.
o Liquids include water, milk, juice, and other beverages. It also includes any food that contains liquid,
such as soup.
o 1 cup of water is 250ml.
Exercise guidelines:
o Restrict lifting things to less than 10 kgs, since these activities increase the pressure in your arteries
and lungs.
o Walking is important to keep your muscles strong and improve circulation.
o However, more strenuous forms of aerobic exercise should not be done regularly since your lungs
may not be able to keep up with the oxygen demands placed on your body during these activities. Any
activities that cause shortness of breath, dizziness, or chest pain should be stopped immediately.
Medication guidelines:
o Know the names of your medications and how they work. Keep a list with you.
o Take your medications at the same time every day. If you forget a dose, do not take two doses to make
up for the dose you missed.
o Do not stop taking or change your medications unless you first talk with your doctor.
Miscellaneous:
o Monitor your weight: weigh yourself at the same time each day and record your weight in a diary or on
a calendar.
o If you notice a rapid weight gain over one week, inform your doctor.
ARF RECIPE:
o Buy the cereal.
o Rinse it in water and drain.
o Soak it in water overnight.
o Drain the water from the vessel.
o In a wet cloth, add the cereal and tie the cloth tightly.
o Keep or hang the cloth in a cool and dry place for 1 day (24 hours) and allow to sprout.
o Roast the sprouted cereal until all the water/moisture present in it is lost.
o Blend it into a fine powder.
o In a kadhai, melt jaggery, add powdered cereal. Mix well. Remove Lumps if any.
o Add water, and cook the powdered Naachni in it.
o Elaichi powder can be added for taste.
OPD FOLLOW-UP
Patient was called for a follow up on 21/12/2016.
She was symptomatically better and hemodynamically stable.
Her appetite had improved and was eating well.
There was an increase in the patient’s body weight by 1.5Kg.
There was no abdominal distention, the organs were palpable and the abdominal girth was
63cms i.e. same as when the patient was discharged, which indicates the absence of
ascites.
Dietary recommendations were reinforced to the patient.
Certain strategies of making meals nutritionally dense were discussed.
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