Cirrhosis Presentation

Report
Cirrhosis of the Liver
with Resulting
Hepatic
Encephalopathy
By:
Michelle Hoffman
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, 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 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 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/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
6
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%
7
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
8
Diagnosis
• Cirrhosis
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–
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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.
9
Diagnosis
10
11
Etiology
• Common causes of cirrhosis:
–
–
–
–
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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 bloating
• Itching
13
Complications & Warning Signs
• Edema & Ascites
• Bruising and bleeding
• Portal hypertension
• Esophageal varices
• Jaundice
• Hepatic encephalopathy
• Insulin resistance and type II diabetes
14
Ascites
15
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:
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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 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
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Treating Cirrhosis
• Primary medical treatments for cirrhosis:
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Preventing further damage
Treatment of the complications
Liver transplant
Nutrition therapy
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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
•Beta-blockers
•Propanolol
– Hepatic Encephalopathy
•Laxatives (lactulose)
21
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 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 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
– 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 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 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 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
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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
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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: 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.
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