Cirrhosis of the Liver with Resulting Hepatic Encephalopathy

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

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

Patient • • Teresa Wilcox Physician: P. Horowitz, MD Education: doctoral graduate student Age:

Patient • • 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 2

Patient History • Hepatitis C Dx 3 years ago • Complaints of fatigue, anorexia,

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) 3

Physical Exam • Tired in appearance • Enlarged esophageal veins • Warm and dry

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 4

Nutrition History • Has not an an appetite for last few weeks – Has

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 5

Abnormal Chemistry • Albumin – Normal: 3. 5 -5 g/d. L – Ms. Wilcox:

Abnormal Chemistry • Albumin – Normal: 3. 5 -5 g/d. L – Ms. Wilcox: 2. 1 g/d. L • Total protein – Normal: 6 -8 g/d. L – Ms. Wilcox: 5. 4 g/d. L • Bilirubin – Normal: ≤ 0. 3 mg/d. L – Ms. Wilcox 3. 7 mg/d. L 6

Abnormal Hematology • RBC – Normal: 4. 3 -5. 4 – Ms. Wilcox: 4.

Abnormal Hematology • RBC – Normal: 4. 3 -5. 4 – Ms. Wilcox: 4. 1 x 10^6/mm^3 • HGB – Normal: 12 -15 g/d. L – Ms. Wilcox: 10. 9 g/d. L • HCT (hematocrit) – Normal: 37 -47% – Ms. Wilcox: 35. 9% 7

Abnormal Hematology • MCV (mean cell volume) – Normal: 80 -96 μm^3 – Ms.

Abnormal Hematology • MCV (mean cell volume) – Normal: 80 -96 μm^3 – Ms. Wilcox: 102 μm^3 • Ferritin (protein that stores iron) – Normal: 20 -120 mg/m. L – Ms. Wilcox: 18 mg/m. L • PT (prothrombin time) – Normal: 11 -16 sec – Ms. Wilcox: 18. 5 sec 8

Diagnosis • Cirrhosis – 12 th leading cause of death in the U. S.

Diagnosis • Cirrhosis – 12 th 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. 9

Diagnosis 10

Diagnosis 10

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Etiology • Common causes of cirrhosis: – Alcohol-related liver disease – Chronic hepatitis C

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 12

Symptoms • • Weakness Fatigue Loss of appetite N/V Weight loss Abdominal pain and

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

Complications & Warning Signs • • Edema & Ascites Bruising and bleeding Portal hypertension

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

Ascites 15

Ascites 15

Diagnosing Cirrhosis • Look at the clinical signs & symptoms • Biopsy, CT Scan,

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 16

Diagnosing Cirrhosis • Blood tests to measure: – Measures function of the liver –

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

Severity • MELD – Model for end-stage liver disease – 6 - 40 score

Severity • MELD – Model for end-stage liver disease – 6 - 40 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 18

Treating Cirrhosis • Primary medical treatments for cirrhosis: – Preventing further damage – Treatment

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

Treating Cirrhosis • Preventing further damage: – The first thing doctors will recommend is

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 nonsteriodal antinflammatory drugs (NSAIDS) • Ibuprofen 20

Treating Cirrhosis • Treating complications: – Ascites • Antidiuretics – Bleeding from varices •

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

Treating Cirrhosis • Liver Transplant: – Cirrhosis in irreversible, and many patients will eventually

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 22

Nutrition Therapy Recommendation Kcals 35 -40 kcal/kg Protein 1. 6 g/kg/day Fat 30% of

Nutrition Therapy Recommendation Kcals 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 1. 2 -1. 5 L/day Calcium 1, 000 -1, 500 mg Vitamins May need multivitamin supplement; see doctor 23

Energy & Protein • • Ms. Wilcox’s energy needs: Weight: 56. 8 kg 35

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 24

Nutrition Problems – Inadequate energy intake: NI-1. 4 – Inadequate oral intake: NI-2. 1

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 25

PES Statements – Inadequate energy intake related to decreased appetite, fatigue, and nausea by

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 26

Nutrition Intervention & Support • • Small frequent feedings Encourage oral liquid supplements High

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 27

Prognosis • Depends on stage of the disease • Once the liver has scarred

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 28

Prognosis: Stages of Cirrhosis • Stage 1 – Patients without gastro-esophageal varices or ascites

Prognosis: Stages of Cirrhosis • Stage 1 – 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 29

References • • • Nelms, M. , Sucher, K. P. , Lacey, K. ,

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 2012. Web. 11 Nov. 2012. <http: //bestpractice. bmj. com/best-practice/monograph/278/followup/prognosis. html>. Longstreth, George F. "Cirrhosis: Medline. Plus Medical Encyclopedia. " Medline Plus. U. S. National Library of Medicine, 16 Oct. 2011. Web. 11 Nov. 2012. <http: //www. nlm. nih. gov/medlineplus/ency/article/000255. htm>. Lee, Dennis. "Cirrhosis (Liver) Symptoms, Causes, Treatment - How Is Cirrhosis Treated? on Medicine. Net. " Medicine. Net. N. p. , 2012. Web. 11 Nov. 2012. <http: //www. medicinenet. com/cirrhosis/page 5. htm>. "Cirrhosis. " Cirrhosis. University of Maryland Medical Center, 2011. Web. 11 Nov. 2012. <http: //www. umm. edu/patiented/articles/what_causes_cirrhosis_000075_ 2. htm>. "National Digestive Diseases Information Clearinghouse (NDDIC). " Cirrhosis. N. p. , Dec. 2008. Web. 11 Nov. 2012. 30