Cirrhosis of the Liver with Resulting Hepatic Encephalopathyby Dustin Moore, Michelle Anderson, Stacey James and Candace Woodbury

MNT

Good nutrition therapy is essential because malnutrition will have a profound negative impact on prognosis

For assessment, SGA parameters should be considered

History Weight change Appetite Taste changes and early satiety Dietary recall Persistent gastrointestinal problems

Physical Muscle wasting Fat stores Ascites or edema

Existing Conditions Disease state and other problems

that could influence nutrition status such as hepatic encephalopathy, GI bleeds, renal insufficiency, infection

Nutritional Rating Well nourished Moderately malnourished Severely malnourished

Overall Goals of Nutrition Management Increase energy

intake with small frequent meals

Sodium restriction (2g/d)

Fluid restriction to reduce incidence of hyponatremia (1-1.5L/d)

CHO controlled diets for managing hypo and/or hyperglycemia

Vitamin and mineral supplementation

Supplement with enteral tube feeding as needed (esophageal pain, dysguesia, etc.)

Energy Requirements Highly variable in cirrhotic patients General recommendations:

In cirrhotic patients without ascites = 120-140% of REE

In cirrhotic patients with ascites, infection, or overall malnutrition = 150-170% of REE

The above mentioned amounts come out to about 30-40 calories/kg of estimated dry body weight. Diet based off of ascites will result in overfeeding

Carbohydrates Glucose metabolism is highly compromised in

cirrhotic patients A single overnight fast in a cirrhotic patient =

2-3 days of starvation in a healthy individual Both hypo and hyperglycemia can occur B.G. should be monitored closely Current recommendation for CHO intake is 5-

6 g/kg/d spread evenly throughout the day Patients should eat about 50 g of CHO right

before bed to maintain blood glucose levels and combat catabolism

Fats Lipid oxidation increases in cirrhotic

patients, so 25-40% of calories from fat are recommended

Lipid oxidation maxes out at about 1 g/kg/d ≥ 1 g/kg/d will result in triglyceride

deposition For patients suffering from

steatorrhea, provide supplementation with MCT’s

Protein

Most controversial nutrient with regards to cirrhosis

Most patients should be started at .8-1 g/kg

In order to promote positive or stable N2 balance, recommendation is a minimum of 1.2 g/kg-1.5 g/kg

Protein restriction is not recommended and PEM can worsen the patient’s status

Use of BCAA’s Some have proposed BCAAs to be beneficial for

hepatic encephalopathy Altered neurotransmitter theory:

With compromised glucose metabolism, BCAAs are used more for energy, causing serum levels to drop

The decreased levels of BCAAs now have to compete for transport at the blood brain barrier with aromatic amino acids, which are now more plentiful.

The amino acid imbalance worsens the state of H.E., so the theory is that providing BCAA’s to the patient will correct the H.E.

While good in theory, a cochrane review showed no significant benefits in patients suffering with H.E. after supplementation with BCAAs

Protein cont. Diet modifications can be made to try

and improve the state of hepatic encephalopathy

Main sources of aromatic amino acids Red meat, chicken, fish, turkey, eggs,

milk, cheeses, nuts Therefore, the majority of the diet

should consist of vegetables, grains, and smaller amounts of meat or animal products ( 3oz /day)

Compensated and Uncompensated Liver Failure

Uncompensated liver failure Unstable stage of the liver disease▪ High ammonia level, deficits in lab values▪ Signs of jaundice, ascites, GI varices▪ Severely compromised function

More severe dietary restrictions▪ < .8 g/kg protein▪ < 1 gram Na▪ Enteral supplementation may be necessary because of increased calorie needs▪ TPN is only used under emergencies, or when the patient will be NPO for 5 days or more

Compensated liver failure Stabilized stage of the liver disease

▪ Low ammonia levels, close to normal lab values▪ Lack of jaundice and ascites▪ Functional capacity

Goal is to prepare a person for a liver transplant Diet restrictions are less severe:

▪ Modified protein intake beginning at .8-1.0 g/kg▪ Evenly spread carbs capped at 5-6 g/kg▪ Sodium and fluid restriction

Vitamin Needs

Vitamin deficiencies are fairly common and patients should consider supplement use

Fat malabsorption may lead to the need for fat soluble vitamin supplements (ADEK)

Large doses (100mg/d) of thiamin are recommended in cirrhotic patients if a deficiency is suspected

Mineral Needs The following may either be needed as supplements

(in RDA or AI amounts) or are contraindicated:▪ Iron: Necessary with excessive GI bleeding, but

contraindicated in patients with hemochromatosis.▪ Copper/Manganese: Supplements provided should not

include these minerals. Because of reduced bile excretion, toxicity may occur.

▪ Magnesium: Depletion is common in ESLD▪ Zinc: Depletion is common, especially with diuretic

therapy. Supplementation possibly improves glucose tolerance.

▪ Calcium: Supplementation may be needed especially if a vitamin D deficiency exists.

▪ Sodium: Typically restricted to about 2 g/day. Depending on severity of ESLD, as low as 500 mg/d.

Case Study

Another Look at Teresa Wilcox Client name: Teresa Wilcox DOB: 3/5 Age: 26 Sex: Female Education: Doctoral graduate assistant Occupation: Graduate teaching assistant Hours of work: Teaches late morning and

late afternoon; take classes and conducts research during most evenings

Chief Complaint

“It just seems as if I can’t get enough rest. I feel so weak. Sometimes I’m tired I can’t go to campus to teach my classes. Does my skin look yellow to you?”

Subjective Global Assessment Parameters for Nutrition Evaluation of Liver Disease Patients Decrease in weight (10#) Appetite: Anorexia, taste changes,

early satiety Dietary Recall: Calorie-deficient , low

in protein, high sodium Peristent Gastrointestinal Problems:

Nausea, vomiting, difficulty swallowing

Physical Findings

Bruising on the lower arms and legs Mild distension of RUQ, but it isn’t

diagnosed as ascites Splenomegaly w/o heptomegaly Enlarged esophageal veins

Existing Conditions

Hepatitis C about 3 years ago

Nutritional Rating

Moderately or suspected of being malnourished

Nutrition Assessment Patient is 26 year old female who

complains of fatigue, general weakness, anorexia, N/V, and appears jaundiced.

Ht: 5’9” (175.26 cm); Wt: 125 lbs. (56.8 kg); BMI: 18.5; IBW: 145 lbs. (86%)

Current Meds: YAZ, Allegra

Nutrition Diagnosis: PES Inadequate protein-energy intake

related to anorexia secondary to cirrhosis as evidenced by decreased albumin levels and absence of food intake over past two days

Nutrition Intervention: MNT

Nutrition education (E-1.4). Will educate the patient on the importance of maintaining a good nutritional status so as to not worsen her prognosis. Will also teach patient overall goals for her condition

Give patient ideas to improve her oral intake

Nutrition Monitoring

Will follow up with the patient after her first week to see if intake and food choices have improved