Cirrhosis of the Liver with Resulting Hepatic Encephalopathy

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

2. 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

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 • 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 • Normal: 4.3-5.4 • Ms. Wilcox: 4.1x10^6/mm^3 • HGB • Normal: 12-15 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: 80-96 μm^3 • Ms. Wilcox: 102 μm^3 • Ferritin(protein that stores iron) • Normal: 20-120 mg/mL • Ms. Wilcox: 18 mg/mL • PT (prothrombin time) • Normal: 11-16 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: • 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 • 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

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

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 • 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

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 2012. Web. 11 Nov. 2012. <http://bestpractice.bmj.com/best-practice/monograph/278/follow-up/prognosis.html>. • Longstreth, George F. "Cirrhosis: MedlinePlus 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 MedicineNet." MedicineNet. N.p., 2012. Web. 11 Nov. 2012.<http://www.medicinenet.com/cirrhosis/page5.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. <http://digestive.niddk.nih.gov/ddiseases/pubs/cirrhosis/>. • "Learning About Your Health." Cirrhosis of the Liver. CPMC Sutter Health, 2012. Web. 11 Nov. 2012. <http://www.cpmc.org/learning/documents/cirrhosis-ws.html>.