Case Study 5: Cirrhosis

DG is a 48 year old female, who presents to her physician complaining of general malaise. She lives with her significant other for 20 years. In addition to c/o fatigue, aches, pains, she complains of right upper quadrant pain, some nausea and GI upset. She has been in relatively good health for the past 30 years. Gravida 0/para 0. On admission to the hospital, all laboratory tests proved negative except for liver enzymes. Physician diagnosis is HCV cirrhosis s/p anti-HCV and HCV RNA tests and liver biopsy; nutrition consult called to determine appropriate MNT. PMHx: depression; seasonal allergies; no previous surgeries (-) tobacco use; (+) use of alcohol: socially, 1-2 glasses of wine/week; last drink 2 days ago. Current Meds: Prempro, Allegra, Wellbutrin Physical Exam: 56, 145 lbs General Appearance: tired-looking middle-aged female Vitals: Temp 99.6 F, BP 100/60 mm Hg, HR 75 bpm, RR 20 bpm Heart: Regular rate and rhythm, no gallops or rubs HEENT: o Head: normocephalic o Eyes: wears contact lenses to correct myopia, PERRLA o Ears: tympanic membranes without lesions o Nose: Dry mucous membranes without lesions o Throat: Normal mucosa without exudates or lesions Genitalia: Normal female Neurologic: Alert and oriented x3 Extremities: Normal muscular tone, normal ROM Skin: Warm and dry Chest/Lungs: Respirations normal; no crackles, rhonchi, wheezes or rubs noted Peripheral vascular: Pulse 3+ bilaterally Abdomen: Tattoo on lower abdomen close to pubis; right abdominal guarding

Nutritional Hx: General: Appetite is usually good, has not had an appetite for the past few weeks. She eats cereal and orange juice for breakfast most morning (orange juice every AM). Lunch is usually in the office (carryout) or at a restaurant. Dinner at home, but may be carry-out. If carry-out, its usually Chinese food. No food allergies.

Usual dietary intake: Breakfast: 1.5 c Sugar Frosted Flakes or Frosted Mini-Wheats, about 1/2c 2% milk; occasionally a banana sliced on top of cereal; strawberries or raspberries when in season; 8 oz calcium-fortified orange juice AM: Unsweetened, flavored hot or iced tea during morning in office Lunch: Cheeseburger, 12 oz Diet Coke; half-order of waffle-cut French fries with ketchup Dinner: Cashew shrimp: 3 oz shrimp, 1.5 c veggies, c cashews, 1 c steamed rice; 5 fl oz wine, usually white HS Snack: 3-4 Famous Amos cookies (choc chip with pecans); ice water 24 hr recall: Sips of orange juice; hot tea; 4 saltine crackers; 5 c jello; 12 oz Sprite; c cream of chicken soup; hot tea. Lab results: (+) HCV Bilirubin: 1.5mg/dL (0.2-1.3) SGPT (ALT): 340U/L (10-60) SGOT (AST): 500 U/L (5-40) Alk Phos: 302 U/L (98-251) Alb: 4.2 g/dL (3.5-5.0)

Answer the following Case Questions (type please) and complete NCP form

1.) The liver is an extremely complex organ that has a particular important role in nutrient metabolism. Identify 3 functions of the liver related to each of the following: a. Carbohydrate metabolism Glycogenesis: converts galactose and fructose to glucose and stores the newly converted glucose as glycogen Glycogenolysis: breaks down glycogen to glucose to return it to the bloodstream when levels are low Gluconeogenesis: produces new glucose from precursors b. Protein metabolism Transamination and oxidative deamination o Convert AAs to substrates used in energy and glucose production o Synthesis of non-essential AAs Produce clotting factors, lipoproteins, and serum proteins

c. Lipid metabolism Converts FAs from diet and adipose tissue to Acetyl-CoA through oxidation to produce energy Produces ketones Synthesizes/hydrolyzes triglycerides, phospholipids, cholesterol, and lipoproteins d. Vitamin & mineral metabolism Stores fat-soluble vitamins, vitamin B12, iron, zinc, copper, and magnesium Synthesizes proteins that transport vitamin A, iron, zinc, and copper in the bloodstream Converts o Carotene Vitamin A o Folate 5-methyl tetrahydrofolic acid o Vitamin D 25-hydroxycholecalciferol 2.) Explain the systemic physiological changes that occur as a result of cirrhosis. In cirrhosis, the liver undergoes deterioration and malfunction because scar tissue formation replacing healthy tissue partially blocks blood flow through the liver, which causes liver function to decrease. 3.) List the common signs & symptoms of cirrhosis, and relate each of these to the physiological changes discussed in question 2. Weakness, fatigue, loss of appetite/early satiety, nausea/vomiting, weight loss, maldigestion/malabsorption, abdominal pain/bloating Portal hypertension and varices increases collateral blood flow and can result in swollen veins in the GIT Ascites or edema Accumulation of fluid in the abdominal cavity, due to Portal hypertension. Early satiety is a frequent complaint and may lead to malnutrition. Hepatic encephalopathy when the liver fails, it is unable to detoxify ammonia, a cerebral toxin, to urea for excretion. Ammonia is a product of the GIT from the metabolism of protein and the degradation of bacteria and blood from GI bleeding. Accumulation of ammonia, leads to impaired neural function, cell swelling, and depletion of glutamate. Vitamin/mineral deficits due to impaired storage, synthesis of transport proteins, and conversion of vitamins/minerals to their active forms Hyponatremia - ability to excrete H2O resulting from the persistent release of ADH, sodium losses via paracentesis, excessive diuretic use, or overly aggressive sodium restriction Glucose intolerance decreased availability of glucose from glycogen and the failing gluconeogenic capacity of the liver Jaundice

4.) What are the current medical treatments for cirrhosis? Current medical treatments available for cirrhosis include diuretic therapy, medications for encephalopathy, management of portal hypertensive bleeding, and monitoring of blood glucose levels. 5.) Protein-energy malnutrition is commonly associated with cirrhosis. What are potential causes of malnutrition in cirrhosis? Explain each cause. Potential causes of malnutrition in cirrhosis include; Inadequate oral intake cause by feeding problems such as early satiety, taste acuity, nausea/vomiting (due to certain medications used to treat liver disease) or other GI symptoms, and an impalatable diet due to sodium restriction Altered metabolism decreased micronutrient transport due to decreased synthesis of proteins responsible for transport Paracentesis removal of fluid accumulated in the abdominal cavity which may increase protein and sodium losses Medications