End Stage Liver Disease with GERD and Bleeding Esophageal Varices

FSHN 450
Fall 2015
Due Date: November 6, 2015
Admission Data: 57 year old male admitted from ES c/o N&V, and abdominal pain radiating to
Rt side. Patient presented with scleral icterus (yellowing of the eye), increased abdominal girth
secondary to ascites, black stools.(due to bleeding from ulcer or from esophageal)
Current Dx: Upper GI Bleed, Cirrhosis
MedHx: Htn, cholecystectomy, alcoholism
Social: Divorced for past 15 years. Mother living. Father died at age 65 from CHF. 4 living
siblings: brother 53 has atherosclerotic heart disease, brother 40 and sister 46 in apparent good
health, sister age 48 is obese.
Medications at home: TUMS, Zantac, Lisinopril
Medications: Lactulose, Octreotide, Vitamin K, Compazine, Morphine, albumin iv, furosamide
iv
Physical: Ht. 5'7 Current BW 190 # BP 128/80 Pulse 90 RR 16 Temp 98.9
Hospital Course:
6/17 Admission Laboratory:
Na
120 mEq/L
K
4.7 mEq/L
Cl
87 mEq/L
CO2 19.3 mmol/L
Glu
91 mg/dl
BUN 13 mg/dl
Creat 1.6 mg/dl
PTT 43.1 seconds (reference: 23.7 - 32.7 seconds)
RBC 2.88 x106/mm3
Hgb 9.1g/dl
Hct 26.9 %
Albumin 2.3 g/dl
Triglycerides 325 mg/dl
Total Cholesterol 250 mg/dl
HDL-Cholesterol 40 mg/dl
Physical and Neurological Exam: 0 Asterixis 0 edema of extremities

Gastroscopic Examination showed bleeding esophageal varices

Diet History reveals the following usual intake:
8am
1 cup black coffee with 1 shot bourbon
10 am
1cup cornflakes with c 2% milk
12 noon
1 hot dog on bun with relish and mustard
2 cans beer
30 potato chips
2 pm
1 snickers bar
Afternoon
3 shots bourbon
6 pm
1 cup pasta or baked macaroni and cheese
2 cans beer
Evening
2 cans beer
3 shots bourbon
6/28 Patientss condition continues to deteriorate. Current BW : 194 pounds. Diet: NPO.
Surgical jejeunostomy tube placed and nutrition support consult ordered.
6/17 Lab values
Na

Patients values
120 mEq/L

Normal ranges
136-144

K
Cl

4.7 mEq/L
87 mEq/L

3.5-5
98-107

CO2
Glu
BUN
Creat

19.3 mmol/L
91 mg/dl
13 mg/dl
1.6 mg/dl

22-29 mmol/L
70-99 mg/dl
8-23 mg/dl
0.4-1.2

PTT

43.1 sec

23-36 sec

RBC
Hgb

2.88 x 106 /mm3

9.1 g/dl

4.7-6.1 million/mm3
14.6-17.5 g/dl

Hct

26.9%

41-51%

Albumin

2.3 g/dl

3.5-5.0 g/dl

Triglycerides

325 mg/dl

<150 mg/dl

Total cholesterol

250 mg/dl

120-199 mg/dl

HDL-cholesterol

40 mg/dl

40-60 mg/dl

Reasoning
Low due to
malabsorption
normal
Low due to acute
infection, edema
Metabolic acidosis
normal
normal
Increased due to renal
disease
High due to hepatic
disease
low
Low due to cirrhosis,
anemia
Low due to cirrhosis,
anemia
Low due to hepatic
disease, anemia
Alcoholism, hepatic
disease
High due to alcohol
intake
normal

What was the cause of the weight gain????

Pt is experience weight gain due to fluid retention that is caused by the ascites. Also theres a
high caloric intake from alcohol, which could cause a weight gain.

What is the purpose of each of the patients medications? List any important
drug:nutrient interactions.
TUMS- Used to help with patients GERD because antacids help with acid reflex. Patient should
be taking this antacid with adequate vitamin D essential to normalize Ca/ bone metabolism
Zantac- An antigerd, a balanced diet is recommended. Take drug at least 2 hr before or after Fe
suppl. Take Mg suppl or Al/Mg antacids separately by at least 2 hrs. limit caffeine.
Lisinopril- is used as antihypertensive drug which may decrease weight.
Lactulose- to treat increased ammonia levels. No not take concurrently with antacid. Increase
fiber and drink lots of fluids
Octreotide- used for treating bleeding esophageal varices. Monitor fat-soluble vitamin absorption
Vitamin K- given because intestinal disease may decrease absorption of vit K, which is why you
give a Vit K supplement. There is no known toxicity
Compazine- has anticholinergic effects and hypotension but less ESP. This drug can increase
appetite, weight and could decrease absorption of B12
Morphine- is used to help with patients pain. Take with food to decrease GI distress. This drug
can cause of decrease in weight and increase thirst.
albumin iv- pt albumin levels are low so he needs to be supplemented with an albumin iv which
can also help the pt diuretic be more responsive. Do not mix with protein hydrolysates or
solutions containing alcohol.
furosamide iv- is used to with hepatic cirrhosis and edema associated with that. It inhibits Na and
Cl from being reabsorbed in the loop of the renal, monitor pt electrolyte levels

Why was a surgical jejeunostomy tube placed?

The pt is suffering from bleeding of the esophagus and ulcers as evidence seen from his black
stool. A PEG should not be placed down the pt esophagus into the stomach because it cause
further bleeding and worsen the problem. Placing a tube into the jejunum will avoid all areas of
bleeding but still allow the pt to receive nutrients.

Evaluate the patients nutrient needs and prescribe a tube feeding including
type and brand name, total volume and rate. Include a start rate and
progression. Include ONLY the Assessment section of the ADIME at this
point.
I would prescribe a disease specific enteral feeding called Nutrihep. This product is caloric dense
for fluid management and nutrient absorption.
Patient kcal needs
25 kcal/kg BW/day so 25 kcals*87.9kg = 2,197.5 kcals/kg/day.

Based on a grade 1 patient protein needs

.8g Pro/ kg BW/day, so 0.8*87.9kg = 70.3g Pro/kg/day
Total volume based on 77% CHO, 11% PRO, 12% Lipids, pt being 87.9 kg BW, 30 kcal/day, 1g
PRO/day. Total volume for tube feed is 1302 ml/day, so 54.25ml/hr over 24 hrs for total volume
of 1302 ml.
Start rate and progression
I would start the pt at 25ml/hr and increase the rate after pt has received a total of 75ml. I would
then increase the rate by 15ml every 4hr until total ml required has been met.
Assessment:
Pt is 57 y/o male ht 57 190# with and 4# increase over 11 days to 194# BMI is 29.8. Pt
BP is 128/80.
Pt is experiencing N/V, abdominal pain to Rt side. Pt has scleral icterus, black stool,
abdominal girth and ascites.
Pt has a family history of obesity, CHF, and therosclerotic heart disease. Pt has a history
of alcoholism and his diet history is nothing shy of that.
MedHx of Htn, cholecystectomy, alcoholism
Pt diet history shows 11 drink in one day, high CHO and sugar, with no evidence of fruit
and vegetable consumption.
Dx w/ cirrhosis and alcoholism. Pt also has bleeding of the esophageal varices but
physical examination shows 0 edema to the extremities and 0 asterixis.
Pt has low absorption of Cl and Na, creat levels are high. Hct, Hbg, albumin lab values
are all low due to hepatic disease and anemia. Pt total cholesterol is also high due to
alcohol intake.
Pt is taking the following drugs; Lactulose, Octreotide, Vitamin K, Compazine,
Morphine, albumin iv, furosamide iv, TUMS, Zantac, Lisinopril.
7/1 Laboratory
Na
122 mEq/L
K
4.1 mEq/L
Cl
98 mEq/L
CO2 10 mmol/L
Glu
93 mg/dl
BUN 18 mg/dl
Creat 1.6 mg/dl
PTT 43.1 seconds (reference: 23.7 - 32.7 seconds)
RBC 2.88 x106/mm3
Hgb 9.1 g/dl
Hct 26.9 %
Albumin 2.6 g/dl
Tube feeding is not well tolerated. Patient disoriented to time and place. Mild asterixis and 2+
edema present. Patient transferred to ICU. Tri-luminal catheter placed and nutrition support
consult ordered for TPN with Hepatamine, limit 1500 ml.
7/1 lab values

Na

Patients values
122 mEq/L

Normal ranges
136-144

K
Cl

4.1 mEq/L
98 mEq/L

3.5-5
98-107

CO2

10 mmol/L

22-29 mmol/L

Glu
BUN
Creat

93 mg/dl
18 mg/dl
1.6 mg/dl

70-99 mg/dl
8-23 mg/dl
0.4-1.2

PTT

43.1 sec

23-36 sec

RBC
Hgb

2.88 x 106 /mm3

9.1 g/dl

4.7-6.1 million/mm3
14.6-17.5 g/dl

Hct

26.9%

41-51%

Albumin

2.6 g/dl

3.5-5.0 g/dl

Reasoning
Low due to
malabsorption
normal
Low due to acute
infection
Decreased due to
acidosis
normal
normal
Increased due to renal
disease
High due to hepatic
disease
low
Low due to cirrhosis,
anemia
Low due to cirrhosis,
anemia
Low due to hepatic
disease, anemia

List the probably reasons for the tube feeding intolerance in this patient?
Pt conditions are worsening due to his GI bleeding enabling the tube feeding to be affective.
Since the pt is experiencing GI bleeding he is under a lot of distress and also can not absorb
nutrients needed through his intestines.
You do not need to calculate a TPN but you should reevaluate protein and Kcal needs.
I would keep kcal where they are at, so 30kcals/kg Wt/day which would equal 2,637 kcal/day.
But because pt is now on Hepatamine and is high in PRO, I would decrease PRO to .8g PRO/kg
Wt/day, so .8*87.9 = 70.32g PRO/kg/day
Why was Hepatamine ordered and what at is the drawback to using this product?
Hepatamine was order because Hepatamine is used to treat pts with cirrhosis who are not
receiving enough PRO due to intolerant of general purpose of amino acids. Hepatamin contains
both essential and non-essential amino acids which can help decrease blood ammonia levels. The
drawback of using Hepatamine is that it interacts with a lot of drugs; it can also increase BUN
levels, increase fluid retention, decrease blood sodium, and cause fever.
7/11 Patient stabilized. TPN tapered and patient diet order changed to clear liquid progressing to
oral diet as tolerated. Fluid restricted to 2000 ml/day, 2300 mg sodium, soft diet. Prepare to
discharge to home. Dx: chronic alcoholic cirrhosis with stable encephalopathy and esophageal
varices.

Why was a soft diet ordered?

A soft diet is ordered to prevent bleeding of the varices. Foods that are hard may tear the vein in
esophagus and we want to avoid any further bleeding.

Conduct a follow-up nutrition assessment and report in ADIME format for

transition to oral diet (on 7/11)
Assessment:
Pt is 57 y/o male ht 57 190# with and 4# increase over 11 days to 194# BMI is 29.8. Pt
BP is 128/80.
Pt fist admitted to hospital due to N/V, abdominal pain to Rt side. Pt has scleral icterus,
black stool, abdominal girth and ascites.
Pt has a family history of obesity, CHF, and therosclerotic heart disease and pt has a
history of alcoholism.
Pt is taking the following drugs; Lactulose, Octreotide, Vitamin K, Compazine,
Morphine, albumin iv, furosamide iv, TUMS, Zantac, Lisinopril.
Pt has low absorption of Cl and Na, creat levels are high. Hct, Hbg, albumin lab values
are all low due to hepatic disease and anemia.
Pt gained wt in his first 10 days in the hospital due to edema caused by ascites
Pt was ordered a tube feed through jejunostomy tube. Pt didnt react well to the tube feed
and conditions worsened. Pt then showed 2+ edema, mild asterixis, and was disorentet to
time and place. Pt was then transferred to ICU and a tri-lumenal catheter was placed and
a TPN was ordered which included Hepatamine.
Pt began to stabilize and TPN was tapered.
pt dx: chronic alcoholic cirrhosis with stable encephalopathy and esophageal varice.
Pt diet order changed to clear liquid diet progressing to oral soft diet as tolerated with
fluid restriction to 200 ml/day and 2300mg/day Na
Pt is being sent home.
Diagnose
Excessive alcohol intake R/T alcohol consumption in 24 hour diet recall AEB hepatic
cirrhosis
o Intervention:
Encourage pt to limit or completely remove alcohol from diet
Provide information about how he can get help with his alcohol abuse
o Monitor/Evaluate:
At a follow up appointment talk to patient about there current alcohol use
Impaired nutrient utilization R/T alcoholism AEB abnormal lab values of micro and
macro nutrients
o Intervention:
Encourage pt to eat a more balanced meal that is kcal dense.
Encourage pt to keep a journal of diet history and how it progresses from
liquid to soft diet.
o Monitor/Evaluate:
At pt follow up appointment look at pt diet journal give appropriate advice
if any nutrients are seem to be missing significantly from history
Also at appointment do another round of lab test to see if previous

abnormal lab values have gone back to normal

Poor nutrition quality of life R/T alcoholism AEB dx of chronic alcoholic cirrhosis with
stable encephalopathy and esophageal varice.
o Intervention:
encourage a diet high protein to normalize serum AA
educate pt on drug nutrient interaction
educate pt on alcoholism and his diagnosis so he understands the severity
if he continues to drink
o Monitor/Evaluate:
At follow up appointment reevaluate pt conditions and see if they have
gotten worse or better.
At follow up appointment see if pt has stopped using alcohol and if not see
if he needs further guidance for quitting.