1. Cirrhosis of the Liver with Resulting Hepatic Encephalopathy
By:
Michelle Hoffman

2. Patient Dx: Probable cirrhosis secondary to chronic hepatitis
Teresa Wilcox
Physician: P. Horowitz, MD
Education: doctoral graduate student
Age: 26-years-old
Height: 5’9” (1.7 m)
Current Weight: 125 lbs (56.8 kg)
Usual Body Weight: 145 lbs
BMI:18.5 kg/m^2
Underweight
Dx: Probable cirrhosis secondary to chronic hepatitis

3. Patient History Hepatitis C Dx 3 years ago
Complaints of fatigue, anorexia, N/V, weakness
Lost 10 lbs since last visit 6 months ago
Bruising and yellowish skin
Family hx cirrhosis (grandfather)

4. Physical Exam Tired in appearance Enlarged esophageal veins
Warm and dry skin with bruising on lower arms and legs
Normal muscular tone and ROM
No edema or ascites

5. Nutrition History Has not an an appetite for last few weeks
Has not eaten in the last 2 days
Nutrition therapy of small, frequent meals with plenty of liquids 3 years ago
Breakfast: calcium-fortified orange juice
Lunch: soup and crackers with diet coke
Dinner: Chinese or Italian carry-out
Fluids: small sips of water, diet coke, or juice
Does not consume alcohol
Current diet order: Soft, 4-g Na, high-kcal

6. Abnormal Chemistry Albumin Total protein Bilirubin Normal: 3.5-5 g/dL
Ms. Wilcox: 2.1 g/dL
Total protein
Normal: 6-8 g/dL
Ms. Wilcox: 5.4 g/dL
Bilirubin
Normal: ≤ 0.3 mg/dL
Ms. Wilcox 3.7 mg/dL

7. Abnormal Hematology RBC HGB HCT (hematocrit) Normal: 4.3-5.4
Ms. Wilcox: 4.1x10^6/mm^3
HGB
Normal: g/dL
Ms. Wilcox: 10.9 g/dL
HCT (hematocrit)
Normal: 37-47%
Ms. Wilcox: 35.9%

8. Abnormal Hematology MCV (mean cell volume)
Normal: μm^3
Ms. Wilcox: 102 μm^3
Ferritin(protein that stores iron)
Normal: mg/mL
Ms. Wilcox: 18 mg/mL
PT (prothrombin time)
Normal: sec
Ms. Wilcox: 18.5 sec

9. Diagnosis Cirrhosis 12th leading cause of death in the U.S.
Ending stage of liver disease
Secondary to chronic hepatitis C
Replacement of healthy liver tissue with scar tissue
Blocks the flow of blood through the liver, causing kidney failure, enlarged liver, thickening of various tissues, portal hypertension, ascites, etc.

10. Diagnosis

12. Etiology Common causes of cirrhosis: Alcohol-related liver disease
Chronic hepatitis C
Chronic hepatitis B
Autoimmune hepatitis
Nonalcoholic fatty liver disease (NAFLD)
Bile duct disorders
Hereditary disorders

13. Symptoms Weakness Fatigue Loss of appetite N/V Weight loss
Abdominal pain and bloating
Itching

14. Complications & Warning Signs
Edema &Ascites
Bruising and bleeding
Portal hypertension
Esophageal varices
Jaundice
Hepatic encephalopathy
Insulin resistance and type II diabetes

15. Ascites

16. Diagnosing Cirrhosis Look at the clinical signs & symptoms
Biopsy, CT Scan, and MRI may reveal an enlarged liver, reduced blood flow, and /or ascites
Biopsy’s are less common because it it expensive, and usually only confirms a diagnosis

17. Diagnosing Cirrhosis Blood tests to measure: Liver enzymes:
Measures function of the liver
Albumin
Bilirubin
PT (Prothrombin Time)
Liver enzymes:
Measures injury to the liver
ALT
AST

18. Severity MELD Model for end-stage liver disease
score range—6 is a likelihood that patient will survive 90 days
Score comes from:
Bilirubin count—measures bile pigment in the blood
Creatine levels—tests kidney function
INR (international normalizes ratio)—tests blood clotting tendency

19. Treating Cirrhosis Primary medical treatments for cirrhosis:
Preventing further damage
Treatment of the complications
Liver transplant
Nutrition therapy

20. Treating Cirrhosis Preventing further damage:
The first thing doctors will recommend is abstaining from alcohol and any drugs that will damage the liver further
Consume a balanced diet and a multivitamin may be recommended (D and K especially)
Avoid nonsteriodalantinflammatory drugs (NSAIDS)
Ibuprofen

21. Treating Cirrhosis Treating complications: Ascites
Antidiuretics
Bleeding from varices
Beta-blockers
Propanolol
Hepatic Encephalopathy
Laxatives (lactulose)

22. Treating Cirrhosis Liver Transplant:
Cirrhosis in irreversible, and many patients will eventually need a liver transplant as the only option left
80% of patient live for 5 years after surgery

23. Nutrition Therapy Recommendation Kcals Protein Fat CHO Sodium Fluid
35-40 kcal/kg
Protein
1.6 g/kg/day
Fat
30% of calories/day
CHO
50-60% of calories/day
Sodium
No more than 2-g/day
Fluid
L/day
Calcium
1,000-1,500 mg
Vitamins
May need multivitamin supplement; see doctor

24. Energy & Protein Ms. Wilcox’s energy needs: Weight: 56.8 kg
35 x 56.8= 1,988 calories
40 x 56.8= 2,272 calories
2,000-2,200 calories/day.
Ms. Wilcox’s protein needs:
1.6 x 56.8=90.8
~ 91 g protein/day

25. Nutrition Problems Inadequate energy intake: NI-1.4
Inadequate oral intake: NI-2.1
Malnutrition: NI-5.2
Inadequate protein-energy intake: NI-5.3
Underweight: NC-3.1

26. PES Statements
Inadequate energy intake related to decreased appetite, fatigue, and nausea by recent cirrhosis of the liver dx as evidenced and diet recall
Underweight related to decreased appetite in past three weeks as evidenced by diet recall, recent 10 lb weight loss, and BMI of 18.5 kg/m^2

27. Nutrition Intervention & Support
Small frequent feedings
Encourage oral liquid supplements
High kcal and protein diet
Restrict sodium intake to ≤ 2-g
Abstain from alcohol consumption
Provide foods that are easy to chew and swallow
Optimize gastric emptying
Avoid excessive fiber
Control blood glucose
Liquids over solids if necessary

28. Prognosis Depends on stage of the disease
Once the liver has scarred over, it cannot be reversed, meaning it cannot return to its normal function
Survival is generally 10 years after dx (90%)
Complications of ascites, portal hypertension, jaundice, hepatorenal syndrome, hepatic encepalopathy, etc.
Liver transplant will most likely be needed as a result of cirrhosis

29. Prognosis: Stages of Cirrhosis
Patients without gastro-esophageal varices or ascites have mortality of ~1% per year
Stage 2
Patients with gastro-esophageal varices but no ascites have mortality of ~4% per year
Stage 3
Patients without gastro-esophageal varices but have ascites have mortality rate of ~20% per year
Stage 4
Patients with GI bleeding from portal hypertension with/without ascites have mortality of ~57% per year

30. References
Nelms, M., Sucher, K. P., Lacey, K., & Roth, S. L. (2011). Nutrition Therapy and Pathophysiology. Belmont, California: Wadsworth, Cengage Learning.
"Prognosis." Best Practice. BMJ Group, 14 June Web. 11 Nov <
Longstreth, George F. "Cirrhosis: MedlinePlus Medical Encyclopedia." Medline Plus. U.S. National Library of Medicine, 16 Oct Web. 11 Nov <
Lee, Dennis. "Cirrhosis (Liver) Symptoms, Causes, Treatment - How Is Cirrhosis Treated? on MedicineNet." MedicineNet. N.p., Web. 11 Nov <
"Cirrhosis." Cirrhosis. University of Maryland Medical Center, Web. 11 Nov <
"National Digestive Diseases Information Clearinghouse (NDDIC)." Cirrhosis. N.p., Dec Web. 11 Nov <
"Learning About Your Health." Cirrhosis of the Liver. CPMC Sutter Health, Web. 11 Nov <