Liver Disease Part 2 Flashcards by Sydney Perry

ascites is the accumulation of fluid, serum _______, and electrolytes in the ______ cavity

proteins
peritoneal

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ascites is caused by ________ or ________

portal hypertension
decreased production of albumin

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treatment for ascites

paracentesis
diuretics

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MNT for ascites

2 g Na rescriction

possible fluid restriction of 1-1.5 L/day

adequate protein to replace losses from frequent paracentesis

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when would someone be given a fluid restriction

if hypervolemia and significant hyponatremia (<125 mEq/L)

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syndrome characterized by impaired mentation, neuromuscular disturbances, and altered consciousness

hepatic encephalopathy (HE)

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theories for why hepatic encephalopathy occurs

elevated ammonia levels*

increased aromatic amino acids (AAA) &
decreased branched chan amino acids (BCAA)

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Stage 1 of Hepatic Encephalopathy

mild confusion
irritability
decreased attention

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Stage 2 of Hepatic Encephalopathy

lethargy
disorientation
inappropriate behavior
drowsiness
asterixis

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Stage 3 of Hepatic Encephalopathy

Somnolent but arousable
confused
incomprehensible speech

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Stage 4 of Hepatic Encephalopathy

coma

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precipitating cause of HE

GI bleeding
Uremia
Constipation
Muscle catabolism*
Fluid & electrolyte abnormalities
Infection
Sedatives
Portacaval shunts
Excessive dietary protein (rare)

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Medications used for HE treatment

Lactulose
Rifaximin

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what does lactulose do

osmotic laxative to remove ammonia

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what does Rifaximin do?

decreases colonic ammonia production

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food drug interactions for lactulose

diarrhea
flatulence
N/V

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food drug interactions for Rifaximin

no food drug interactions

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MNT for Hepatic Encephalopathy ACUTE

provide 1.0-1.5 g/kg of protein

for patients requiring TF - use a formula with appropriate protein content

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MNT for Hepatic Encephalopathy CHRONIC

High fiber

High dairy (casein is lower in AAA and higher in BCAA)

Vegetarian diet is questionable (veg pro is high in BCAA)

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acute kidney failure in the absence of prior kidney disease due to decreased renal blood flow

hepatorenal syndrome

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hepatorenal syndrome may require _________

dialysis

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MNT for hepatorenal syndrom

possible restriction of…
Fluid, Na, K+, Phos

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Protein metabolism in ESLD

increased levels of _______, ______, and ______ due to the _______ state

decreased synthesis of serum ______, ______, and _______

increased ______ levels

glucagon, epinephrine, & cortisol
catabolic state

albumin, transport proteins, & clotting factors

ammonia

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Carbohydrate metabolism in ESLD

EARLY in disease, individual will get ________ from __________

hyperglycemia

peripheral insulin resistance decreasing glucose uptake

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Carbohydrate metabolism in ESLD LATE in the disease, individual gets __________ from ________ and _______

fasting hypoglycemia loss of hepatic glycogen stores depressed gluconeogenesis

Lipid Metabolism in ESLD _________ due to _______ ______ may occur due to ______

Increases lipolysis depletion of fat reserves fat malabsorption decreases production of bile and blocked bile ducts (cholestatic liver disease)

Effects of ESLD on vitamin and minerals

decreased intake, absorption, transport, and storage of micronutrients altered metabolism of micronutrients

Factors that cause malnutrition in ESLD

Inadequate oral intake Disturbances in macronutrient metabolism leading to catabolism Decreased capacity of the liver to store nutrients Protein losses from large-volume paracentesis Malabsorption of fat

Malnutrition is present in ______ of those with cirrhosis. more common in those with _________ ________ is a defining feature of malnutrition in decompensated ESLD associated with compromised immune function & respiratory function, delayed wound healing, longer hospital stays, and increased risk for mortality

50-90% alcoholic liver disease sarcopenia

inadequate oral intake in ESLD due to ?

Anorexia N/V Dysgeusia Early satiety Restrictive diets Alcohol abuse Financial issues Food-drug interactions

Malabsorption of Fat due to ?

Decreased transport of bile via bile ducts Decreased bile acid production by liver

Many traditional parameters are affected by liver disease: Wt, BMI, & %wt change are affected by fluid status Decreased synthesis of ________ (e.g., albumin, prealbumin) _________ & __________ syndrome affect validity of nitrogen balance studies

transport proteins Hyperammonemia & hepatorenal

Nutrition assesment for ESLD should include...

diet history NFPE current diagnosis, complications, & PMHx Lab assessments

what are some lab assessments we look at ?

albumin ammonia bilirubin prothrombin time aminotransferase alkaline phosphatase gamma-glutamyl transpeptidase

All calculations for ESLD should use ______ for weight

dry weight

if dry weight is not available you can - use _____ and adjust based on amount of ascites and peripheral edema subtract _____ if mild ascites ______ if moderate ______ if severe subtract additional ___ if pedal edema present

IBW 5% 10% 15% 5%

ESLD energy

Use indirect calorimetry if possible 25-35 kcal/kg Malnourished patients may need up to 40 kcal/kg to promote anabolism

ESLD Protein

1.2-1.5 g/kg

ESLD CHO

Monitor for hyperglycemia - may need insulin and a consistent CHO diet Fasting Hypoglycemia MNT: Small frequent meals and an evening snack Avoid alcohol

ESLD Fat

30% of total kcal If steatorrhea=> 40 g low fat diet

ESLD Fluid

If hypervolemia and severe hyponatremia (serum Na <125 mEq/L)=> restriction of 1 - 1.5 L/d may be needed Monitor I & O records, wt, serum Na

ESLD Electrolytes

if ascites or edema = 2g Na restriction monitor electrolytes due to diuretics and paracentesis

ESLD Vitamins

provide MVI additional supplements as needed - fat soluble - thiamin and folic acid - vitamin K

supplementation for fat soluble vitamins - ≥90% of patients with advanced liver disease are vitamin ____ deficient

what vitamins for alcoholic liver disease

thiamin 50-10 mg folic acid 1 mg per day

Minerals for ESLD

provide DRI's except in... 1. cholestatic liver disease 2. hemochromatosis 3. wilson's disease 4. GI Bleeding 5. Alcoholism 6. diuretics 7. steatorrhea

Minerals for ESLD with cholestatic liver disease

No Cu and Mn supplements

Minerals for ESLD with hemachromatosis

no iron supplement

Minerals for ESLD with wilson's disease

no Cu supplementation

Minerals for ESLD with Gi bleeding

may need increases iron

Minerals for ESLD withalcoholism

may need increased Zn and Mg

Minerals for ESLD with Diuretics

may need increased K+, Zn, Mg, Ca

Minerals for ESLD with steatorrhea

may need increased Ca, Mg, Zn

General Recommendations for ESLD eating...

small frequent meals with a bedtime snack dont skip meals nutrient dense snacks nutrition supplements if poor appetite

ENTERAL NUTRITION may be required due to _____, _____, ______, or ______

poor intake malnutrition altered mental status intubation

ENTERAL NUTRITION for ESLD ________ formula A __________ tube is appropriate with non-bleeding esophageal varices PEG placement not recommended for those with _____ or _____

High protein small-bore nasoenteric ascites or gastric varices

indication for parenteral nutrition in ESLD

non-functioning GIT

Parenteral Nutrition can cause ______, ______, and _______

hepatic steatosis cholestasis cirrhosis

Guidelines for Use of PN for Patients with ESLD Avoid overfeeding of _____, ____, or ____ Lipid emulsion should not provide > ____ g/kg/d Use a _______ solution _______ administration recommended For patients with cholestatic liver disease=> _____________

CHO, lipid, or total kcal 1 mixed substrate Cyclic reduce Cu & Mn provided

Chylous Ascites is Leakage of ____ into the peritoneal cavity due to _____ or ______ from ______________

chyle obstruction or leak abdominal lymphatics

what could cause chylous ascites

Malignant obstruction Abdominal surgery: AAA repair, Liver transplant Congenital defects of the lymphatics

what is in this chyle

WBC chylomicrons (TG & fat-soluble vitamins) protein fluid & electrolytes

Consequences of chyle leakage

pain anorexia hypoalbuminemia decreased electrolyte levels fat-soluble vitamin depletion EFAD

Medical Management of chylous ascites

drainage and reducing chyle flow (conservative) surgical repair

Goal of MNT for chylous ascites

reduce chyle flow by decreasing LCT intake to <10 g/d while still providing adequate nutrition

MNT Options for chylous ascites

Very low-fat oral diet with MCT supplementation NPO with TF using a very low-fat elemental formula NPO with TPN

MNT for chylous ascites... diet should be high in _______ ______ can be a concern if ____ are restricted for more than _____

protein EFAD LCT 2 weeks