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Name: Dawn OrtizLiver Disease / Pancreatitis Case Study(Adapted from Clinical Nutrition Case Studies, by Wayne Billon)Mr. G is a 56 yo construction worker. He is recently divorced with three children in college. He started drinking heavily when he was in high school and is currently consuming approximately 8 beers and 1-2 shots of whiskey per day. For the last several days, Mr. G has been experiencing severe epigastric pain with radiation to his back. He has also felt nauseous and has had several episodes of vomiting. His abdomen is sore to the touch and slightly distended. His temperature has been elevated. When his symptoms continued for 3 days, Mr. G went to a neighborhood treatment center to see a physician.The physician took a medical history and did an examination that included lab values. His labs were as follows:TestResultNormalTestResultNormalNa144 mEq/l12.0-14.4 secALT125 u/l5-40 u/lK3.1 mEq/l3.5-5.3 mEq/lAST183 u/l10-35 u/lMg1.2 mEq/l1.4-2.5 mg/dlTotal Bili3.2 mg./dl0.2-1.3 mg/dlCl103 mEq/l99-112 mEq/lSer. Amylase685 u/l5-115 u/lGlucose145 mg/dl70-110 mg/dlLipase463 u/l7-58 u/lSerum Albumin2.9 g/dl3.5-5.0 g/dlPT12.2 sec135-145 mEq/lThe physician told Mr. G that he had acute pancreatitis with an enlarged liver. Mr. G was told that his liver enzymes were elevated and that if he continued drinking, he could develop severe liver disease. The physician wanted to admit Mr. G to the hospital for bowel rest, hydration and observation, however, Mr. G refused.The physician told Mr. G that if he stopped drinking, his liver could clear up in a matter of weeks. Mr. G was encouraged to follow a low fat, high protein diet with absolutely no alcohol, and call if the pain and discomfort did not clear up within 2-3 days.Mr. G's height was 5'11" and he weighed 170 lbs. The physician sent Mr. G home with the following prescription:Pancreatin (Pancreatin tablets)--enough for 3 days Potassium chloride (Slow-K)--enough for 3 days The physician advised Mr. G not to take Pancreatin with antacids. He also advised him to take a multivitamin and mineral supplement daily.QuestionsExplain the reasoning behind the diet order Mr. G received: "Low fat, high protein, with absolutely no alcohol. A low fat diet is necessary because the liver is responsible for fat conversion and synthesis. It is also responsible for absorption and storing of fat soluble vitamins, causing fat toxicity in a damaged liver. The liver is also responsible for detoxifying the effects of alcohol. A high protein diet is necessary to repair the damaged liver.Outline the instruction you would give Mr. G concerning his diet and liver disease. Abstain from alcoholConsume a high carbohydrate and protein diet with small, frequent mealsRestrict fluid (1000-1500 mL/day) and sodium (< 2 g/day)25-35 kcal/kg (at least 50% kcal from carbohydrates)1-1.5 gm/kg proteinSupplement thiamin, folate, Vitamin B12, zinc and vitamin DList the lab values in the chart above that are indicative of liver disease. Elevated liver enzymes, such as ALT, AST, Bilirubin and Alkaline Phosphatase indicates build up associated with liver disease. A low PT also indicated slow blood clotting which is also indicative of liver disease.What abnormal lab values are indicative of pancreatitis? Elevated amylase and lipase are indicative of pancreatitis, which are digestive enzymes secreted by the pancreas.What was the purpose of the physician giving Mr. G the potassium chloride? Potassium chloride is used to restore potassium levels after prolonged diarrhea and vomiting. Potassium is important to help sustain blood flow in the body.Give the pathophysiology of fatty liver 2o alcoholism Hepatotoxicity, generally reversible in the early stagesAltered NAD/NADH ratio promotes fatty liver through the inhibition of gluconeogenesis and fatty acid oxidationResults in the accumulation of triglycerides and fats in the liver cellsFat cannot be stored and is used preferentially over other energy fuelsCauses disturbances in protein, carbohydrate and lipid metabolismMr. G followed his diet and took his medication and began to feel better. He stayed off the alcohol for 3 or 4 days but then began to have delirium tremens and started to drink again. He began to have stomach pains different from the epigastric pain he had earlier. He noticed his abdomen seemed to be becoming distended and he felt like he had no energy.Mr. G continued to drink heavily. One morning he woke up with severe epigastric pan and began vomiting blood. Mr. G was brought to the hospital and admitted with GI bleed 2o esophageal varices, weight gain, ascites, steatorrhea, and alcoholic cirrhosis.Lab values includedH/H 9.7/27BUN 35PT increasedBG 68ALB 2.4K 3.0Na 132AST, ALT, Alkaline Phosphatase – all increasedChol 289TG 310Ammonia 60Mr. TG's weight was now 192 lbs. The physician noted 2+ pitting edema of the lower extremities. Mr. G was alert and oriented.Questions continued7.Describe the functions of the liver, including from where the blood is supplied and what is produced by the liver.The liver is responsible for carbohydrate conversion and storage, protein conversion and synthesis, fat conversion and synthesis, stores fat soluble vitamins and minerals, detoxifies drugs and removes nitrogenous wastes (mainly ammonia) and produces bile. The portal vein carries blood to and from the liver. The liver is responsible for making glycogen and then converting back to glucose for energy use. The liver synthesizes many visceral proteins such as albumin, fibrinogen and transferrin. It also oxidizes fatty acids, produces high density lipoproteins and the active form of vitamin D. 8.Calculate Mr. G's IBW and percent IBW.IBW: 75 kgMr. G s currently at 116% of his IBW.9. ??? Calculate Mr. G’s total energy needs. (Show your?calculations and weight basis).Based on dry weight (UBW) of 77 kg.Energy: 2310-2695 kcal (30-35 kcal/kg for cirrhosis of the liver patient)10. Why is the BUN at 35 mg/dl? BUN may be elevated due to the esophageal varices and ascites. These conditions cause excessive plasma protein usually stored in the peritoneal cavity.11. Why is blood sugar decreased? Blood sugar is decreased due to impaired glucose metabolism (impaired glycogenesis, glyconeogenesis and glycogenolysis). Diet should be high in carbohydrates (50% kcal) to prevent energy conversion from fat or protein.12. Explain the prolonged prothrombin time.Due to connective tissue overgrowth, esophageal varices and ascites, blood flow is disrupted to and from the liver, resulting in prolonged PT. Blood is slowed entering the liver through the portal vein and leaving the liver through the vena cava.13. Why is the cholesterol level elevated? Altered lipid metabolism and cholesterol synthesis is resulting in elevated LDL cholesterol build up in the blood.14. Why is the serum albumin decreased? Albumin is synthesized in the liver, therefore serum levels are decreased in a damaged liver.15.List the stages or levels of Hepatic Encephalopathy.Stage 0: Clinically normal mental status, but minimal changes in memory, concentration and coordinationStage 1: Mild confusion, euphoria, or depression, decreased attention; irritability, disordered sleep patternStage 2: Drowsiness, lethargy, gross deficits in ability to perform mental tasks, inappropriate behavior, and intermittent disorientationStage 3: Somnolent, but can be aroused, unable to perform mental tasks, marked confusion, present but incomprehensible speechStage 4: Coma with or without response to painful stimuli**Adapted from Haase J. Medical Nutrition Therapy for Liver, Biliary and exocrine pancreatic disorders, 2004.16.What factors may be involved in precipitating Hepatic Encephalopathy?Hepatic Encephalopathy may be precipitated by GI bleeds, infection, diarrhea and vomiting.17.What can you expect the ammonia level to be (elevated or low)? How does this affect your medical nutrition therapy?Hepatic Encephalopathy is caused by the accumulation of ammonia in the liver that goes into the blood steam and crosses the blood stream barrier. Ammonia is the byproduct from the breakdown of protein and is usually converted to urea in a healthy liver. Therefore, in a damaged liver and in cirrhosis there are elevated levels of circulating ammonia present.18.What are the nutrition-related effects of the following medications, which are often used to treat these patients?Neomycin- antibiotic which destroys intestinal bacteria that produce ammonia.Lactulose- strong laxative used to prevent the absorption of ammonia in the intestine.These medications are often most effective if used together. GI distress (especially diarrhea) is a common side effect and therefore result in malabsorption of important nutrients and deficiency is potassium and magnesium.19. How much protein should Mr. G receive per day? Protein: 92-116 g/day (1.2-1.5 g/kg/day and based on dry weight)20. Explain the relationship between alcohol and esophageal varices? Alcohol abuse causes cirrhosis of the liver which leads to esophageal varices. This is a non-reversible condition resulting in altered blood flow into the liver, ascites and edema. 21. When Mr. G's diet is advanced, what diet modifications would you suggest?High calorie (30-35 kcal/kg), high protein diet (1.2 gm/kg) Moderate-high carbohydrate diet (50% of calories)Small, frequent meals to optimize daily intakeFocus on nutrient dense foodsSupplement with B complex vitamins, thiamin, folate, and zincAvoid alcoholAvoid excessive fat and fat soluble vitaminsReferenceNutrition and Liver/Pancreatic Diseases presentation by: Amanda Gordon, RD, LD, CNSC ................
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