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Hypertension Dyslipidemia Polycystic kidney disease (recent diagnosis) Lymph node resection Alcohol abuse with previous evidence of alcoholic hepatitis
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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)03Nov11.00:37 106.329Aug11.15:27 97.8921Aug11.07:39 100.020Aug11.18:50 99.420Aug11.18:34 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
Gluc
BUN
Creat
Ca GFR Pro AlbBili, T
ALP ALT AST
Normal1.6-
2.3
mg/dL
3.7-
5.6
mg/dL
137-146 mmol/L
3.5-5.0 mmol/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 L 138 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/uL
4-5.2 M/uL11.5-15.5 g/Dl
35-45% 77-95 fL 25-33 pg 32-36 g/dL 11.3-15.6%150-400 K/uL
6.6-10.1 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 OrderDate & 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.