Cirrhosis of the Liver

Case Study
Kristie (Oi Yee) Chow, Jemima Collins, Jessica Gunther,
Jenna Kristoff, & Belen Rediet

Introduction to Patient

TW, female, 26 yo
Doctoral graduate student in architecture
Single, lives with a roommate
No children

CC: Cant get enough rest, weak, tired, yellow skin

PE: Enlarged esophageal veins, mild distension, no
ascites, hepatomegaly, telangiectasias, tired-looking
Diagnosed with cirrhosis of liver (CT scan and biopsy)

Pathophysiology
Chronic liver disease where healthy tissue gradually dies
and turns into scar tissue
Scar tissue blocks flow of blood through the liver (portal
vein) which causes portal hypertension
ascites, toxin buildup-hepatic encephalopathy,
esophageal varices
malabsorption of fat, jaundice, edema
Usually caused by hepatitis, alcohol abuse, or fatty liver
disease

Treatment and Drugs

Lifestyle modifications
weight loss, abstaining from alcohol

Antibiotics
Anti-inflammatory medications
Anti-hypertensive medications
Diuretics
Laxatives

Nutrition Assessment: Medical History

Hepatitis C Dx 3 years ago
treated with alpha-interferon and ribavirin

Lost 10# in 6 months

Bruising on skin, fatigue, anorexia, N/V &
weakness

Nutrition Assessment:

Lab values

Ref. Range

Pt. Value

Implications

Alanine
aminotransferase
(ALT) (U/L)

4-36

62**

High- Enzyme found in liver cells. When the liver is damaged,

inflammation occurs and these enzymes are released into the blood.
Increased serum levels indicate the possibility of cirrhosis

Aspartate
aminotransferase
(AST) (U/L)

0-35

230**

High- Enzyme found in liver cells. When the liver is damaged,

inflammation occurs and these enzymes are released into the blood.
Increased serum levels indicate the possibility of cirrhosis

Alkaline phosphatase
(ALP) (U/L)

30-120

275**

High- Enzyme found in liver cells. When the liver is damaged,

inflammation occurs and these enzymes are released into the blood.
Increased serum levels indicate the possibility of cirrhosis

Bilirubin (direct)
(mg/dL)

<0.3

3.7**

High- Pigment produced by the breakdown of red blood cells in the

liver and then excreted in the bile. Higher than normal levels of bilirubin
in either test is suggestive of cirrhosis

Chemistry

Nutrition Assessment:

Lab values

Ref. Range

Pt. Value

Implications

Glucose (mg/dL)

70 - 110

115

High- Stress, hepatic dysfunction

Lactate dehydrogenase (U/L)

208 - 378

658

High- Indicates tissue damage and possibly liver disease

Total protein (d/dL)

6-8

5.4

Low- Hepatic disease, malnutrition

Albumin (g/dL)

3.5 - 5

2.1**

Low- Inflammation, acute stress, cirrhosis, malnutrition

Prealbumin (mg/dL)

16 - 35

15

Low- Hepatic disease, malnutrition, low protein intake,

inflammation

Triglycerides (mg/dL)

35 - 135

256

Borderline high- Indication of liver damage or cirrhosis

4 - 36

18.5**

High- Blood clotting proteins made in the liver. Longer time to

clot indicates liver damage.

Coagulation
Prothrombin time (sec)

Nutrition Assessment:

Lab values

Ref. Range

Pt. Value

Implications

RBC (X106/mm3)

4.2 - 5.4 F

4.1

Low- Anemia, malnutrition

Hematocrit (%)

37 - 47 F

35.9

Low- Fluid buildup due to cirrhosis causes dilution of red blood cells;
anemias, prolonged dietary deficiency of protein & iron, liver disease

Hemoglobin (Hgb,
g/dL)

12 - 15 F

10.9

Low- Can indicate anemia, prolonged dietary deficiency of iron,

malnutrition, liver disease

Protein (mg/dL)

Neg

1+

Positive- Can indicate liver damage.

Bilirubin

Neg

1+

Positive- Can indicate liver damage. Bilirubin normally travels to liver

and is excreted in bile.

Hematology

Urinalysis

Nutrition Assessment: Anthropometric Data

Height: 58

Weight
125 lbs (current)
UBW: 135 lbs (lost 10 lbs in 6 months)
IBW: 140 lbs
%IBW: 89%
%UBW: 93%
% Weight Change: 7% (not significant or severe)
Current BMI: 19 (normal weight, low end)
Usual BMI: 21 (normal)

Nutrition Assessment:

Estimated Calorie and Protein Needs

General Energy & Protein needs for Cirrhosis
35-40kcal/kg
Up to 1.6g protein/kg
TW
Energy needs: 35kcal/kg x 61.4kg= 2149 2200 kcal a day
(Patient is out of bed stable and weight gain is desired)
Protein needs: 1.5g/kg x 61.4kg= 92.1g 95 g protein
(She has lost weight unintentionally and we want to prevent muscle wasting)

Nutrition Assessment:

Diet History Summary

Pt has no appetite- has not eaten in past 2 days.

Presence of N/V (nausea and vomiting).
Food aversions: Liver and lima beans.
Previous NTR therapy: small, frequent meals, plenty of liquids
Vitamin/mineral intake: 400 mg vitamin E, 600mg calcium with 400 IU
vitamin D; multivitamin/mineral daily; 200mg milk thistle 2x/day;
chicory 3g daily; 500 mg ginger at least 2x/day.

Diet history

Breakfast: Orange Juice

Lunch: Soup & Crackers with Diet Coke
Dinner: Italian or Chinese take out

Inadequate calories, complex

carbohydrates, and protein
Excessive sodium
Excessive fat

Nutrition Diagnosis: PES Statements

1. Inadequate oral intake RT liver dysfunction AEB
anorexia for two days and nausea and vomiting.
2. Unintended weight loss RT liver dysfunction
increasing nutrient needs AEB poor appetite and 7%
weight change in 6 months.
3. Altered nutrition-related lab values RT liver
dysfunction AEB elevated serum AST level of 230
U/L, ALP level of 275 U/L, and ALT level of 62 U/L.

Nutrition Intervention
1. Recommend 2,200 kcal with 95g protein, no more than
70g fat, and at least 275g carbohydrates, with 2g of
Na+, 2g of K+, and 1.2L fluid.
2. Recommend weight gain of 0.5lbs per week.
3. Recommend 6 small, frequent meals a day
comprised of soft, non-greasy, mild-flavored foods.
4. Recommend spreading carbohydrate intake evenly
throughout the day.
5. Eliminate alcohol.

Implementation of Goals
1. Assess food preferences to offer her an appealing
menu.
2. Counsel her on low sodium diet; provide handout on
low-sodium diet.
3. Provide meal plan based on diet order.
4. Educate her on portion sizes using food models.

Monitoring and Evaluation

1. Follow diet order as above as evidenced by nurses notes and food
journal.
2. Gain 0.5lb per week until previous weight is restored.
3. Increase frequency of meals.
4. Spread carbohydrates evenly throughout the day as evidenced by
nurses notes and food journal.
5. Avoid alcohol.
6. State understanding of low sodium diet.
7. Understand her food options and be able to apply them when
dining out.

Question Time!
1. Regarding protein and energy intake with patients who have
cirrhosis...
a. energy needs are increased, protein needs are decreased.
b. energy needs are increased, protein needs are increased.
c. energy needs are decreased, protein needs are decreased.
d. energy needs are decreased, protein needs are increased.

Question Time!
1. Regarding protein and energy intake with patients who have
cirrhosis...
a. energy needs are increased, protein needs are decreased.
b. energy needs are increased, protein needs are increased.
c. energy needs are decreased, protein needs are decreased.
d. energy needs are decreased, protein needs are increased.

Question Time!
2. A common symptom of cirrhosis is
a. frequent urination
b. blurry vision
c. esophageal varices
d. muscle cramps

Question Time!
2. A common symptom of cirrhosis is
a. frequent urination
b. blurry vision
c. esophageal varices
d. muscle cramps