Erica Burdon
March 3, 2014
PANCREATITIS/LIVER DISEASE 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:
TEST
RESULT
NORM
TEST
RESULT
NORM
PT
12.2 sec
12.0-14.4
sec
Cl
103 mEq/l
99-112
mEq/l
Lipase
463 u/l
7-58 u/l
ALT
125 u/l
5-40 u/l
Glucose
145 mg/dl
70-110
mg/dl
Ser.
Amylase
685 u/l
5-115 u/l
Mg.
1.2 mEq/l
1.4-2.5
mg./dl
K
3.1 mEq/l
3.5-5.3
mEq/l
Total Bili.
3.2 mg./dl
0.2-1.3
mg/dl
Ser. Alb.
2.9 g/dl
3.5-5.0
g/dl
Na
144 mEq/l
135-145
mEq/l
AST
183 u/l
10-35 u/l
The 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:
1. Pancreatin (Pancreatin tablets)--enough for 3 days
2. 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.
QUESTIONS
1. Explain the reasoning behind the diet order Mr. G received: "Low fat, high
protein, with absolutely no alcohol.
From my reading someone with acute pancreatitis should have been
admitted to the ICU and treated and observed with an NPO diet for rest. Since
Mr. G refused the doctor recommended a low fat diet in order to help decrease
the amount of enzymes needed to digest meals. A low fat diet may also be a
good idea for patients with high triglyceride and cholesterol levels from
pancreatitis. High protein is important in both liver disease and pancreatitis
because deficiency of certain amino acids can enhance inflammation of the
pancreas. Alcohol is prohibited since this will continue to irritate and damage the
pancreas and liver.
2. Outline the instruction you would give Mr. G concerning his diet and liver
disease.
-
Avoid all alcohol, at this time the acute pancreatitis and enlarged liver can be
reversed.
Eat small frequent meals (6) high calorie and high protein
Avoid high fat and salty foods ex: Fast food, potato chips and pastries etc.
3. List the lab values in the chart above that are indicative of liver disease.
Glucose can be increased or decreased, Mg & K decreased, Total Bilirubin
increased, Elevated ALT (Alanine Aminotransferase) , & AST (Aspartate
aminotransferase) measures enzymes in the blood and amount of tissue
damage. ALT is more specific to the liver. Albumin can be low but not a good
indicator*.
4. What abnormal lab values are indicative of pancreatitis?
Lipase and Serum Amylase elevated – Enzymes that are secreted by the
pancreas for nutrient digestion.
5. What was the purpose of the physician giving Mr. G the potassium chloride?
The physician gave Mr. G potassium Chloride since it is a mineral supplement.
Since Mr. G potassium level was slightly low.
6. Give the pathophysiology of fatty liver 2o alcoholism (page 474)
Stage 1 Fatty liver: *Steatosis can be cause by alcohol and/or excess dietary
lipids. Acetaldehyde promotes hepatic fat accumulation. At this stage it can be
reversible
Stage 2 Hepatitis: Enlargement of liver is mild but fever and tachycardia occur as
well as scarring and thickening.
Stage 3 Cirrhosis: Not Reversible Death of tissue will occur and scar tissue
regenerates causing loss of normal liver function.
Stage 4 Encephalopathy or Coma: This can lead impaired mental status, altered
neuromuscular function and consciousness or even death.
Mr. 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 (malabsoprtion of fat), and alcoholic cirrhosis.
Lab values included:
Hemoglobin 9.7 g/dl Hematocrit 27%
BUN 35 mg/dl Increased prothrombin time
Serum glucose 68 mg/dl Serum albumin 2.4 g/dl
Serum potassium 3.0 mEq/L Serum sodium 132 mEq/L
Increased AST, ALT, ALP Triglycerides 310 mg/dl
Cholesterol 289 mg/dl
Ammonia 60 mmol/dL
Mr. TG's weight was now 192 lbs. The physician noted 2+ pitting edema of
the lower extremities. Mr. G was alert and oriented.
QUESTIONS (cont)
7.
Describe the functions of the liver, including from where the blood is
supplied and what is produced by the liver.
The Liver gets its blood supple from two sources the hepatic artery and the
hepatic portal vein. Most of the blood entering the liver is from the hepatic portal
vein and is deoxygenated and nutrient-rich. The Liver supports every organ to
some extent. It main function is to produce bile which is needed to digest fats.
The liver also:
 Detoxifies the blood to rid it of harmful substances such as alcohol and
drugs
 Stores some vitamins and iron
 Stores the simple sugar glucose
 Converts stored sugar to usable sugar when the body’s sugar (glucose)
levels fall below normal.
 Breaks down hemoglobin as well as insulin and other hormones
 Converts ammonia to urea, which is vital in metabolism
 Destroys old red blood cells – this gives feces it usual brown color
8.
Calculate Mr. G's IBW and percent IBW – I used his @ ht. 5’ 11’’ wt. 192lb
IBW = 106 + (6x11) = 172 lbs
% IBW = 192/172 = 112% IBW
9.
Calculate Mr. G’s total energy needs. (Show your calculations and weight
basis).
It is most likely like Mr. G is malnourished I would not want to feed him to quickly
since he can be at risk for refeeding syndrome. Mr. G has Ascites and edema
which is contributing to his weight gain although he will still need higher energy
needs and protein. I would use his current wt. 192 lbs to determine kcals and
protein needs.
Mifflin St Joer
6.25 (180cm) + 9.99 (87kg) – 4.92 (56) + 5=
1125 + 869 – 276 + 5 = 1,723 kcals
10.
11.
Why is the BUN at 35 mg/dl?
Slightly high 2o recent GI Bleed esophageal varices
Why is blood sugar decreased?
This one I was not sure of. I was thinking because his acute pancreatitis became
worse. I know that chronic pancreatitis can cause blood sugar abnormalities.
12.
Explain the prolonged prothrombin time.
Prothrombin time is a blood test that measures the time it takes for your blood to
clot. The most common time to have this test done is when you are taking a
medication called Warfarin (Coumadin). The results are given in INR
(internationalized normalized ratio). If you are on blood thinning medication your
INR should be between 0.8-1.1 or 11- 13.5 seconds.
13.
Why is the cholesterol level elevated?
Cholesterol levels are elevated due to pancreatitis not producing enough lipase.
As well as liver disease which inhibits the liver from making bile, which is needed
to digest fats. Bile’s salts break up fat into smaller pieces so it can be absorbed
more easily in the small intestine.
14.
Why is the serum albumin decreased?
Low serum albumin is decreased because of ascites, malabsorption, liver
disease and malnutrition.
15.
List the stages or levels of Hepatic Encephalopathy. (page 488)
Grade 0: Minimal hepatic encephalopathy minimal changes in memory,
concentration and intellectual function.
Grade 1: Some lack of awareness. Mild confusion, insomnia, inversion of sleep
pattern and depression.
Grade 2: Lethargy and apathy. Disorientation and inappropaite behavior, slurred
speech, drowsiness and personality changes.
Grade 3: Unable to perform mental taks, disorientation about time and place,
confusion, fits of rage sleepiness but can be aroused.
Grade 4: Coma with or without response to painful stimuli.
16.
What factors may be involved in precipitating Hepatic Encephalopathy?
Factors that may be involved in precipitating Hepatic Encephalopathy are GI
bleeding, abnormal electrolytes, renal failure, infection, diuretic therapy, use of
sedatives or medications that affect the central nervous system and constipation.
17.
What can you expect the ammonia level to be (elevated or low)? How does
this affect your medical nutrition therapy?
Elevated. MNT would change especially for protein started at 0.8g/kg increase to
no higher than 1.5 g/kg. Use 30 kcal/kg for energy. Replete glucose
intravenously. Vitamin-mineral supplements may be needed and monitor the fat
soluble vitamin intake. Small meals and snacks throughout the day is still
recommended. Strict restriction is not recommended in protein, sodium, fluids
and fiber.
18.
What are the nutrition-related effects of the following medications, which
are often used to treat these patients?
Neomycin-Treats a condition called hepatic coma, in which the liver does not
filter toxins properly and they build up in the blood. This medication is given to
prevent hepatic encephalopathy it keeps the ammonia levels low. Side Effects:
rash, little or no urine, dizziness, N/V and diarrhea.
Lactulose- Laxative used to treat increased ammonia levels which can be seen
in level disease and to prevent or treat portal systemic encephalopathy. High
fiber diet and plenty of fluids is recommended. Do not take antacids, Ca or Mg
supplements. Side Effects: Bloating, gas, stomach pain, diarrhea, and N/V.
19.
How much protein should Mr. G receive per day?
I would give Mr. G between 1-1.5 g/kg. With encephalopathy could be as low as
0.5g/kg. Also with Encephalopathy consider Branched Chain Amino Acids and
glutamine.
20.
Explain the relationship between alcohol and esophageal varices?
Excessive alcohol causes fatty liver which can turn into cirrhosis. This causes
portal hypertension which increase pressure and blood flow. Some people can
experience variceal hemorrhage
21.
When Mr. G's diet is advanced, what diet modifications would you
suggest?
When Mr. G’s diet advanced I would recommend high calories and protein with
low fat diet. Possibly the use of MCT oil would be a good idea it is the preferred fuel in
liver cirrhosis. MCT oil is absorbed directly into the blood without the need for pancreatic
enzymes. Not ideal for all pretty expensive. Recommend eating 4-6 small meals a day.
Limiting sodium to 2g a day. * Note maybe challenging for a person to handle all this on
their own. May need to start with just low fat restriction. Also people who are really sick
are hardly eating. At this time high protein and calorie foods, small frequent meals with
plenty of fluid would be my first recommendation.
References:
Escott-Stump, Sylvia. Nutrition and Diagnosis-Related Care. 7.
Pronsky, Z. M., and J. P. Crowe. Food-medication interactions. 17. Birchrunville, PA:
Food-Medication Interactions, 2012.
Hark, L., and G. Morrison. Medical nutrition and disease: A case-based approach . 4th.
London: Blackwell Publishing , 2009.
http://espen.info/documents/Acutepancreatitis.pdf
http://stanfordhospital.org/digestivehealth/nutrition/DH-Nutrition-Therapy-for-ChronicPancreatitis.pdf