Alcohol and the LiverA Case Study

Leslie Anderson

Patient Background

SH was 42 y.o. Caucasian male, married with 2 children

Smoked half a pack a day, drank a fifth of whiskey daily› Admitted to LDSH for alcohol detox – 08/11

Family History significant for Polycystic Kidney Disease

Past Medical History

Hypertension Dyslipidemia Polycystic kidney disease (recent

diagnosis) Lymph node resection Alcohol abuse with previous evidence

of alcoholic hepatitis

Hospital Events/Procedures

11/2: SH admitted to ER

11/3: Transferred to ICU; Intubated d/t respiratory distress

Plan to admit to psychiatric unit to assist in his alcohol detoxification

Alcohol and the Liver

The liver detoxifies 90% of ingested alcohol

Metabolism of alcohol is the main cause of liver damage

Alcoholic Liver Disease (ALD) is the cause of 50% of all liver disease cases› Steatosis Steatohepatitis Cirrhosis

Risk Factors

Binge/Chronic Drinking

Drinking between meals

Type of beverage

Family history of disease

Females > Males

Metabolism of Alcohol Alcohol Dehydrogenase (ALD)

› Metabolizes 80% of ingested alcohol› Ethanol AcetaldehydeAcetateAcetyl-

CoACo2 +H2O› Leads to hepatic steatosis

Cytochrome P450 2E1 (CYP2E1)› Previously called inducible microsomal ethanol-

oxidizing system (MEOS)› Used most in chronic alcoholism

Catalase enzyme› Non-oxidative process › Leads to hepatic steatosis

Toxic Effect of Alcohol Ethanol

› “Leaky gut”› Reactive Oxygen Species (ROS)› Compromised immunity

Acetaldehyde – Key toxin› Cellular damage, inflammation, extracellular

matrix remodeling and fibrinogenesis Acetate/Acetyl Co-A

› Increased IL-6, IL-8, TNF-a

Effects perpetuate and progress

Nutritional Concerns

Malnutrition› Alcohol substitution› Malabsorption

Altered macronutrient metabolism› Reduced glucose production, often

accompanied by insulin resistance› Lipids are malabsorbed and remain in

circulation d/t decreased bile secretion› Increased protein catabolism with

inadequate resynthesis

Vitamin/Mineral Deficiences

Decreased:› Intake of nutritious foods› Absorption› Storage

Increased Use:› Antioxidants› Metabolism of alcohol

Proposed Supplements

Milk Thistle (Silymaryin)› Safe, well-tolerated› No benefit noted

S-Adenyosylmethionine› Precursor to glutathione (antioxidant)› No benefit seen

Metadoxine› Not approved in U.S.› Decreased lipid accumulation

Phosphatidylcholine› Fibrosis-reducing effect› More studies needed

Anthropometrics

Wt: 106.3 kg Ht: 182.9 cm IBW: 80.8 kg % IBW:132 BMI: 31.78 Adj BW: 90.5 kg

Date/Time Weight (kg)

03Nov11.00:37 106.3

29Aug11.15:27 97.89

21Aug11.07:39 100.0

20Aug11.18:50 99.4

20Aug11.18:34 99.4

Estimated Nutrition Needs

2100-2550 kcals (23-28 kcal/kg)

80-95 g protein (1.0-1.2 g/kg)

2800 ml fluid (35 ml/kg)

Adjusted wt used for energy needs IBW used for protein and fluid needs

Biochemical DataDate Mg P Na K Cl

Glu

c

BU

N

Cre

atCa GFR Pro Alb

Bili,

TALP ALT AST

Normal

1.6-

2.3

mg/dL

3.7-

5.6

mg/dL

137-

146

mmol/

L

3.5-

5.0

mmo

l/L

98-109

mmol/

L

65-99

mg/dL

6-21

mg/dL

0.71-

1.18

mg/dL

8.4-

10.4

mg/dL

>60

ml/min/

1.82m²

6.0-

8.4

g/dL

3.3-

4.8

g/dL

0.2-

1.3

mg/dL

40-

120

U/L

12-

61

U/L

16-50

U/L

11/3 1.6 1.8 L138 3.5 104

111 H

6 0.86 7.2 L 7.2 3.1 L 4.4 H 313 H

35 395 H

11/2 143 2.9 L

101 162 H

7 0.84 7.7 L >60 8.2 3.3 4.0 H 352 H

43 465 H

Date WBC RBC Hgb Hct MCV MCH MCHC RDW PLTS MPV

Normal4.5-13.5

K/uL4-5.2 M/uL

11.5-15.5

g/Dl35-45% 77-95 fL 25-33 pg 32-36 g/dL 11.3-15.6%

150-400

K/uL6.6-10.1 fL

11/3 9.3 3.29 L 12.3 L 35.5 L 107.8 H 37.4 H 34.7 22.4 H 66 L 9.3

11/2 11.7 H 3.59 L 13.3 L 38.6 L 107.6 H 37.2 H 34.5 23.8 H 88 L 9.3

Biochemical Data, continued

Date Lipase

Normal 23-300 U/L

11/3 1095 H

11/2 914 H

Date Serum Alcohol

Normal <13 mg/dL

11/3 <10

11/2 358 H

Clinical Data

Febrile – 38.9º C

Tremors – r/t alcohol detoxification

Questionable ascites › Unable to determine d/t body habitus

Medications

Anesthesia/Sedative

› Propofol – (85 kcal/day)

Antianxiety

AntiGERD

Antiemetic

Fluid/Electrolyte/Vitamin replacement

Diet Order

Date & time Diet order PO % Adequate to meet needs?

11/3 NPO d/t elevated lipase

N/A No

Nutrition Assessment

Pt at high nutrition risk r/t inability to take PO, confusion, and intubation. BMI 31.8 indicates obesity. Albumin was wnl upon admit, with lowered labs d/t fluid administration. Altered labs r/t liver disease precipitated by alcohol consumption. Will continue to monitor lipase to determine possibility of PO intake vs. need for NJ past ligament of Trietz upon NPO day 2. Decreased estimated energy requirements d/t intubation. Unable to talk to pt at this time.

Nutrition Problem & Goals

Excessive alcohol intake r/t alcohol or drug addiction AEB elevated alcohol, LFT’s, and lipase lab values.

Advance diet as tolerated and as medically able.

Interventions

MVI, thiamin, folic acid

NPO d/t elevated lipase

Recommendations

If still NPO by tomorrow, recommend initiation of enteral feeds past the ligament of Trietz. Initiate feeds of Peptamen AF @ 20 ml/hr and monitor labs for refeeding syndrome as Phos is already low. End goal rate for pt is Peptamen AF @ 75 ml/hr = 24 kcal/kg Adj wt and 1.7 g prot/kg.

Prognosis

Poor d/t:› PKD› Alcoholic Hepatitis

continued alcohol abuse› Need for continued medical care

Possible dialysis Possible transplants

References

Hasse JM, Matarese LE. Medical nutrition therapy for liver, biliary system, and exocrine pancreas disorders. In: Mahan LK, Escott-Stump S, ed. Krause’s Food & Nutrition Therapy. 12 ed. St. Louise, MO: Saunders Elsevier; 2008:707-727.

The Merck Manual of Diagnosis and Therapy. 18th  ed.  Whitehouse Station, NJ; 2006:1129-1131.

Seth D, Haber PS, Syn WK, Diehl AM, Day CP. Pathogenesis of alcohol-induced liver disease: classical concepts and recent advances. J Gastroenterol Hepatol. 2011:26;1089-1105.

Szabo G, Mandrekar P. Focus on: Alcohol and the liver. Alcohol Res Health. 2010:33;87-96.

Griffith CM, Schenker S. The role of nutritional therapy in alcoholic liver disease. Alcohol Res Health. 2006:29(4):296-306.