Liver Disease Part 2 Flashcards
ascites is the accumulation of fluid, serum _______, and electrolytes in the ______ cavity
proteins
peritoneal
ascites is caused by ________ or ________
portal hypertension
decreased production of albumin
treatment for ascites
paracentesis
diuretics
MNT for ascites
2 g Na rescriction
possible fluid restriction of 1-1.5 L/day
adequate protein to replace losses from frequent paracentesis
when would someone be given a fluid restriction
if hypervolemia and significant hyponatremia (<125 mEq/L)
syndrome characterized by impaired mentation, neuromuscular disturbances, and altered consciousness
hepatic encephalopathy (HE)
theories for why hepatic encephalopathy occurs
elevated ammonia levels*
increased aromatic amino acids (AAA) &
decreased branched chan amino acids (BCAA)
Stage 1 of Hepatic Encephalopathy
mild confusion
irritability
decreased attention
Stage 2 of Hepatic Encephalopathy
lethargy
disorientation
inappropriate behavior
drowsiness
asterixis
Stage 3 of Hepatic Encephalopathy
Somnolent but arousable
confused
incomprehensible speech
Stage 4 of Hepatic Encephalopathy
coma
precipitating cause of HE
GI bleeding
Uremia
Constipation
Muscle catabolism*
Fluid & electrolyte abnormalities
Infection
Sedatives
Portacaval shunts
Excessive dietary protein (rare)
Medications used for HE treatment
Lactulose
Rifaximin
what does lactulose do
osmotic laxative to remove ammonia
what does Rifaximin do?
decreases colonic ammonia production
food drug interactions for lactulose
diarrhea
flatulence
N/V
food drug interactions for Rifaximin
no food drug interactions
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
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)
acute kidney failure in the absence of prior kidney disease due to decreased renal blood flow
hepatorenal syndrome
hepatorenal syndrome may require _________
dialysis
MNT for hepatorenal syndrom
possible restriction of…
Fluid, Na, K+, Phos
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
Carbohydrate metabolism in ESLD
EARLY in disease, individual will get ________ from __________
hyperglycemia
peripheral insulin resistance decreasing glucose uptake
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
D
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
