Liver Case Study
1. The liver is an extremely complex organ that has a particularly
important role in nutrient metabolism. Identify three functions of the
liver for each of the following:
Carbohydrate Metabolism
---- Glucogensis, gluconeogensis, oxidation via TCA cycle,
Glycogenolysis
Protein Metabolism
---- urea synthesizing, prothrombin synthesizing, apoferritin
Lipid Metabolism
---- Formation of lipoproteins, lipogensis, lipolysis, ketogenesis, Cholesterol synthesis,
esterification of fatty acids
Vitamin and Mineral Metabolism
---- Thiamin converts sugar into energy, phosphorylation of pyridoxine which assists in
metabolizing protein, the liver stores fat soluble vitamins A, B12, D, E, and K until the body
needs it
2. The CT scan and liver biopsy confirm the diagnosis of cirrhosis. What
is cirrhosis?
--fibrous connective tissue replaces healthy tissue, normal cells are damaged and replaced with
scar tissue
3. The most common cause of cirrhosis is alcohol ingestion. What are
additional causes of cirrhosis? What is the cause of this patient’s
cirrhosis?
--Our patient was diagnosed with Hep C
--Some other causes = bilary cirrhosis, cystic fibrosis, Hepatitis B, and C, Wilson’s disease,
hemochromatosis.
4. Explain the physiological changes that occur as a result of cirrhosis.
-- Scar tissue replaces healthy tissue which obstructs the normal flow of blood to the liver, liver
function starts failing building toxins in the body, Toxins building up in the blood can cause
Wernicke’s Syndrome, other complications occur due to the toxins building up and this can
cause death.
5. List the signs and symptoms of cirrhosis, and relate each of these to
the physiological changes discussed in question 4.
-- fatigue, weakness, nausea, vomiting, jaundice, ascites, esophageal varices, steatorrhea
6. After reading this patient’s history and physical, identify her signs and
symptoms that are consistent with the diagnosis.
--She has hepatitis C accompanied by, weakness, fatigue, nausea, poor appetite, vomiting, and
has lost a significant amount of weight
7. Hypoglycemia is a symptom that cirrhotic patients may experience.
What is the physiological basis for this? Is this a potential problem?
Explain.
--eating small frequent meals that include complex carbohydrates and whole grains.
--liver cannot store glycogen, the brain is dependent on this to receive regular glucose so it can
function, if hypoglycemia is not addressed, there could be problems with the central nervous
system, if glucose cannot be released a patient can go into a coma
8. What are the current medical treatments for cirrhosis?
--treating and preventing the complications of cirrhosis,
Preventing further liver damage (usually through diet, i.e. No alcohol) and a liver transplant if
damage is too severe.
9. What is hepatic encephalopathy? Identify the stages of
encephalopathy and outline the major theories regarding the etiology
of this condition.
--impaired mental status which can lead to dementia, seizures, and coma
-- The liver cannot remove toxins in the blood which build up in the system, the toxins can pass
through the blood-brain barrier causing altered brain function.
10. Protein‐energy malnutrition is commonly associated with cirrhosis.
What are the potential causes of malnutrition in cirrhosis? Explain
each cause?
--Cholestasis causes malabsorption of fat‐soluble vitamins because of reduced bile production.
-- Cirrhosis causes nausea and poor appetite creating a low intake of nutrients,
-- alcoholics with cirrhosis also have malabsorption due to their high alcohol intake, impaired
gastric function due to ascites along with it causing early satiety due to the fluid buildup in the
abdominal cavity
-- Poor food intake can also be attributed to esophageal varices.
11. Outline the nutrition therapy for the following stages of cirrhosis with
the rationale for each:
Diagnosis Sodium Potassium Protein Fluid
---- Stable cirrhosis
-Sodium: 2000mg *low sodium diet due to water retention/ edema
-Potassium: 3g * normal requirements are 2.2 to 2.4, cirrhosis requires more potassium for fluid
regulation
-Protein: 1.5g/ 56.8kg = 85g of prot. *Cirrhosis requires 1-1.5g/kg of protein, but begin at 0.8-1
to study nitrogen balance, but incr to 1.5 if no encephalopathy.
-Micronutrients: Need more vit D and B because of tissue repair needs
-Fluid: 1568ml * requires fluid restriction lower than 30ml/kg, chose 28ml/kg
---- Cirrhosis w/ acute encephalopathy
-Sodium: 2000mg *reduced sodium intake
-Potassium: 2.5g *slightly higher than normal requirement, still retention of fluids, use of
diuretics requires slightly more potassium.
-Protein: 1g/56.8 kg = 56.8 g of prot. * .8-1 g/kg to promote positive nitrogen balance in patient
incr to 1.5 if no encephalopathy, begin with 0.5-0.6 g/kg
-Micronutrients: need all water soluble vitamins B-6, niacin, thiamin, folate, an IV of K for 3
days to avoid deficiency, Ca, and Mg malabsorbed by steatorrhea, no Cu or Mn, Zinc should be
avoided during encephalopathy
-Fluid: 1568ml * requires fluid restriction lower than 30ml/kg, chose 28ml/kg
---- Cirrhosis w/ ascites and esophageal varices
-sodium: 1500mg *1000 -2000mg for mild, 500-1000 for severe
-potassium: 2g * need supplements unless renal failure then must be reduced
-protein: 1.5g/ 56.8kg = 85g * severe ascites requires higher protein needs
-micronutrients: need all water soluble vitamins B-6, niacin, thiamin, folate, an IV of K for 3
days to avoid deficiency, Ca, Zn, and Mg malabsorbed by steatorrhea, no Cu or Mn
-fluid: 1100ml *restriction to 1000 – 1500ml due to severe fluid build up in abdominal cavity
12. Measurements used to assess nutritional status may be affected by the
disease process and not necessarily be reflected of nutritional status.
Are there any components of nutrition assessment that would be
affected by cirrhosis? Explain.
--Edema and excess fluid during Ascites can require different micronutrients, diuretics and
potassium. Esophageal Varices require NDD diet because it can be painful and dangerous to eat
hard foods. These can be measured by a simple urine test and an endoscopy of the throat.
Ammonia tests in urine, increased with ureagenesis can be due to GI bleeds from the disease.
13. Dr. Horowitz notes Ms. Wilcox has lost 10 pounds since her last exam.
Assess and interpret Ms. Wilcox’s weight.
--Ms. Wilcox had not eaten for 2 days prior to her visit which can contribute to some fluid
weight loss. She does not eat much due to a poor appetite (anorexia) and nausea, she mentioned
feeling fatigued as well which could make her skip meals. Varices are also discovered during
screening and that could also be painful to eat with.
14. Identify any nutrition problems using the correct diagnostic term.
--Inadequate energy intake
--Inadequate protein intake
--Inadequate intake of nutrient dense foods
Excessive fat intake
--- Increased nutrient needs due to Hepatitis C diagnosis
B. Calculation of Nutrient Requirement
15. Calculate the patient’s energy and protein needs.
Calories: B.E.E. = 655.1 + (9.563 x 56.8) + (1.850 x 175) -
x
1.5 = 2270
Or 40 x 56.8 = 2272 cal
Protein: up to 1.5 g/kg x 56 kg = 84g protein
16. What guidelines did you use and why?
I used protein recommendations for patients with liver cirrhosis of 1-1.5, I used the higher
amount because she has varices and just came in malnourished. I used both the kcal/kg
recommendations of 35-45 and tested it against Harris Benedict equation while adding a stress
factor of 1.5 and got close to the same answer.
17. Evaluate the patient’s usual nutritional intake.
The patient’s intake was low because she has complained of no appetite and has
varices.
She has only eaten juice, water, and Diet Coke recently. She simply is not taking in enough
healthy nutrients. When she does eat, her normal meals are take out or unhealthy foods.
18. Her appetite and intake have been significantly reduced for the past
several days. Describe the factors that may have contributed to this
change in her ability to eat.
19. Why was a soft, 4‐g Na, high‐kcalories diet ordered? Should there be
any other modifications?
Those diagnosed with cirrhosis should only be consuming 2000mg (2g) Na/day. I
would suggest that the high calorie intake order remains because she is currently malnourished
and needs to maintain a healthy weight so she can heal and take in enough vitamins/nutrients to
do so.
20. This patient takes multiple dietary supplements. Identify the possible
rationale for each and identify any that may pose risk for someone
with cirrhosis.
An A,D,E,K vitamin supplement is good for those with Cirrhosis because they generally
have impaired fat absorption, which also means the fat soluble vitamins are not being absorbed.
She also takes Milk Thistle which is usually taken to help those with viral Hepatitis (especially
C), however there is little known about herbal supplements and they may interact with other
medicines. Also if the fat soluble vitamins are taken in excess (especially A), they can be very
harmful to the body’s natural functions and may even cause death.
21. Examine the patient’s chemistry values. Which labs support the
diagnosis of cirrhosis? Explain their connection to the diagnosis.
It was found that Ms. Wilcox had low levels of albumin which indicates that severe
cirrhosis has taken place in the liver. She also had increased levels of ALT and AST in the blood
which may indicate that there is blockage of the bile duct. Ms. Wilcox’s albumin levels were
lower than normal. Testing for high Bilirubin in the urine or blood indicates that the liver has
damage.
22. Examine the patient’s hematology values. Which are abnormal, and
why?
Hemaglobin was
low, usually due to very little iron, this could be due to all the vitamins she is taking including
vitamin A or because she is not taking in or absorbing many nutrients and vitamins. High MCV
can be due again to low nutrient absorption such as vit B12.
23. Does she have any physical symptoms consistent with your findings?
She has complained of fatigue, weakness and is nauseated. These are primarily due to her
malabsorbing a lot of nutrients and vitamins.
24. What signs and/ or symptoms would you monitor to determine
further liver decomposition?
she is getting enough calories. If she doesn’t take in enough calories or vitamins, it will take
much longer for her to recover.
25. Dr. Horowitz prescribes two medications to assist with the patient’s
symptoms. What is the rationale for these medications, and what are
the pertinent nutritional implications of each?
--- Spironolactone: is a diuretic, which reduces fluid in the body and sodium
--- Propranolol: lowers blood pressure to prevent the varices from swelling and rupturing.
** She is also taking a Mineral Supplement: This will help the patient absorb enough fat soluble
vitamins that she is not receiving
28. Select two high priority nutrition problems and complete a PES
statement for each.
Inadequate energy intake related to loss of appetite and nausea from cirrhosis as
evidenced by diet recall.
Inadequate protein intake related to loss of appetite and pain from esophageal varices as
evidenced by 24 hour recall and endoscopy.
29. Ms. Wilcox is discharged on a soft, 4‐g Na diet with a 2‐L fluid
restriction. Do you agree with this decision?
of sodium
Additionally, the fluid recc, is slightly high but still normal, with a high sodium diet and
a lot of fluid, she could develop edema and ascites.
---- A soft diet is good because she should not be eating anything hard or crunchy because the
varices could rupture.
30. Ms. Wilcox asks if she can use a salt substitute at home. What would
you tell her?
would explain that salt substitutes generally contain high levels of potassium. High
potassium levels could be dangerous for her and her condition. Instead I would recommend
adding herbs and spices for added flavor.
31. What suggestions might you make to assist with compliance for the
fluid restriction?
worry about taking in too much water. I would also suggest she avoid sodas, diet or otherwise
because the sugar can cause fatty liver disease, especially diet soda, which usually contains
aspartame which has shown to have adverse effects on the liver.
VI. Evaluation and Monitoring
32. When you see Ms. Wilcox 1 month later, her weight is now 140 lbs.
She is wearing flip‐flops because she says her shoes do not fit. What
condition is she most probably experiencing? How could you confirm
this?
was taking in too much sodium and has began retaining water. She may have to see the doctor to
perform a urinalysis. If it is confirmed that she has Ascites she may have to have the fluid
removed from her abdomen with a tube, if it is Edema it can be resolved with a diuretic and a
low sodium diet
33. Her diet history is as follows:
Breakfast: 1 slice toast with 2 Tbsp peanut butter, 1 c. skim milk
Lunch: 2 oz. potato chips, grilled cheese sandwich (1 oz. American
cheese with 2 slices of whole‐wheat bread, grilled with 1 Tbsp
margarine), 1 c. skim milk
Supper: 8 barbeque chicken wings, french fries‐ 1 c., 2 c. lemonade
What changes might you make to her nutrition therapy? Identify
foods that should be eliminated and make suggestions for
substitutions.
I would recommend that she changes her foods to be softer and lower in sodium. I would
specifically eliminate potato chips and fries because they are crunchy, full of salt and potassium
as well as being poor nutrient dense foods, instead she should eat something more like
applesauce or soft vegetables. She should also eat lower fat items. She can have French fries in
small amounts if they are baked and seasoned with herbs instead of salt.