MNT for Liver Disease Part 2

Question 1

_____ _____ is a syndrome characterized by impaired mentation, neuromuscular disturbances, and altered consciousness

Answer 1

Hepatic encephalopathy

Question 2

The pathogenesis of hepatic encephalopathy is unknown, but two theories include…

Answer 2

-Elevated ammonia levels
-Increased aromatic amino acids (AAA) and decreased branched-chain amino acids (BCAA)

Question 3

Symptoms of stage I of hepatic encephalopathy:

Answer 3

-Mild confusion
-Irritability
-Decreased attention

Question 4

Symptoms of stage II of hepatic encephalopathy:

Answer 4

-Lethargy
-Disorientation
-Inappropriate behavior
-Drowsiness
-Asterixis (uncontrolled flapping of hands)

Question 5

Symptoms of stage III of hepatic encephalopathy:

Answer 5

-Somnolent but arousable
-Confused
-Incomprehensible speech

Question 6

Symptoms of stage IV of hepatic encephalopathy:

Answer 6

Coma

Question 7

Precipitating causes of hepatic encephalopathy:

Answer 7

-GI bleeding (source of ammonia)
-Uremia
-Constipation (more time for bacteria to produce ammonia)
-Muscle catabolism (ammonia)
-Fluid and electrolyte abnormalities
-Infection
-Sedatives
-Portacaval shunts
-Excessive dietary protein (rare)

Question 8

What two drugs can be used to treat hepatic encephalopathy?

Answer 8

-Lactulose
-Rifaximin

Question 9

Lactulose is an ____ ____ that removed excess ammonia

Answer 9

Osmotic diuretic

Question 10

What are food medications with Lactulose?

Answer 10

-Diarrhea
-Flatulence
-N/V

Question 11

Rifaximin decreases colonic ____ production

Answer 11

Ammonia

Question 12

Are there any food-drug interactions with Rifaximin?

Answer 12

No

Question 13

With hepatic encephalopathy, a ____ restriction is no longer recommended

Answer 13

Protein

Question 14

A low-protein diet increases catabolism of ___ ___ ___, which worsens hepatic encephalopathy

Answer 14

Lean body mass

Question 15

Protein recommendation for someone with hepatic encephalopathy:

Answer 15

1.0-1.5 g/kg

Question 16

For patients with hepatic encephalopathy requiring tube feeding, use a formula with appropriate ____ content

Answer 16

Protein

Question 17

MNT for chronic hepatic encephalopathy includes…

Answer 17

-High fiber
-High dairy (casein is lower in AAA and higher in BCAA)
-Vegetarian diet can be used since vegetable protein is high in BCAA

Question 18

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

Answer 18

Hepatorenal

Question 19

Those with hepatorenal syndrome may require _____

Answer 19

Dialysis

Question 20

MNT for hepatorenal syndrome:

Answer 20

-Possible restriction of fluid, Na, K+, and phosphorus (depending on treatment modality)

Question 21

In end-stage liver disease, someone would have increased levels of ____, ____, and ____ due to the catabolic state

Answer 21

Glucagon, epinephrine, and cortisol

Question 22

Someone with end-stage liver disease would have decreased synthesis of…

Answer 22

-Serum albumin
-Transport proteins
-Clotting factors

Question 23

Someone with end-stage liver disease would have increased ____ levels

Answer 23

Ammonia

Question 24

Early in end-stage liver disease, someone might experience ____ due to peripheral insulin resistance and decreased glucose uptake

Answer 24

Hyperglycemia

Question 25

Late in end-stage liver disease, someone might experience fasting hypoglycemia due to...

Answer 25

-Loss of hepatic glycogen stores -Decreased gluconeogenesis

Question 26

Someone with end-stage liver disease has increased _____, leading to a depletion of fat reserved

Answer 26

Lipolysis

Question 27

Fat malabsorption with end-stage liver disease may occur due to...

Answer 27

-Decreased production of bile -Blocked bile ducts (cholestatic liver disease)

Question 28

Someone with end-stage liver disease may have decreased ____, ____, ____, and ____ of micronutrients (also altered metabolism of micronutrients)

Answer 28

Intake, absorption, transport, and storage

Question 29

Malnutrition is present in ____-___% of patients with cirrhosis

Answer 29

50-90

Question 30

Malnutrition is more common in those with ____ liver disease

Answer 30

Alcoholic

Question 31

____ is a defining feature of malnutrition in decompensated end-stage liver disease

Answer 31

Sarcopenia

Question 32

Malnutrition is associated with...

Answer 32

-Compromised immune and respiratory function -Delayed wound healing -Longer hospital stays -Increased risk for mortality

Question 33

What are factors that lead to malnutrition in someone with end-stage liver disease?

Answer 33

-Inadequate oral intake -Disturbances in macronutrient metabolism, leading to catabolism -Decreased capacity of the liver to store nutrients -Malabsorption of fat

Question 34

What factors lead to inadequate intake in someone with end-stage liver disease?

Answer 34

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

Question 35

What leads to malabsorption of fat?

Answer 35

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

Question 36

What traditional assessment parameters are affected by liver disease?

Answer 36

-Weight, BMI, and %wt change are affected by fluid status -Decreased synthesis of transport proteins (e.g., albumin, prealbumin) -Hyperammonemia and hepatorenal syndrome affect validity of nitrogen balance studies

Question 37

What should we ask in the diet history portion of the nutrition assessment for someone with end-stage liver disease?

Answer 37

-Appetite -Weight change -Taste changes -Persistent GI problems -Assessment of dietary intake -Previous diet -Supplement use

Question 38

What should be looked in the NFPE for someone with end-stage liver disease?

Answer 38

-Muscle wasting -Fat stores -Ascites or edema -Micronutrient deficiencies

Question 39

In the nutrition assessment, we should also evaluate the current diagnosis, along with ____ and ____

Answer 39

Complications and PMHx

Question 40

What lab assessments are included in the Liver Function Tests?

Answer 40

-Albumin -NH3 (Ammonia) -Total bilirubin (indirect/unconjugated and direct/conjugated) -Prothrombin time -Alanine aminotransferase -Aspartate aminotransferase -Alkaline phosphatase -Gamma-glutamyl transpeptidase

Question 41

All nutrition calculations for someone with end-stage liver disease should be based on ___ weight

Answer 41

Dry

Question 42

What are some options to use if dry weight is unavailable?

Answer 42

-Use IBW -Adjust body weight based on the amount of ascites and peripheral edema

Question 43

If someone has mild ascites and dry weight is unknown, subtract ____% from body weight

Answer 43

5

Question 44

If someone has moderate ascites and dry weight is unknown, subtract ____% from body weight

Answer 44

10

Question 45

If someone has severe ascites and dry weight is unknown, subtract ____% from body weight

Answer 45

15

Question 46

We can subtract an additional ___% from body weight if pedal edema is present

Answer 46

5

Question 47

To calculate energy requirements for someone with end-stage liver disease, use ___ ____ if possible

Answer 47

Indirect calorimetry

Question 48

Calories requirements for those with end-stage liver disease:

Answer 48

25-35 kcal/kg

Question 49

Malnourished patients may need up to ____ kcal/kg to promote anabolism

Answer 49

40

Question 50

Protein recommendations for someone with end-stage liver disease:

Answer 50

1.2-1.5 g/kg

Question 51

For someone with end-stage liver disease, we should monitor for _____, and they may need insulin and a consistent carbohydrate diet

Answer 51

Hyperglycemia

Question 52

Someone with end-stage liver disease may experience ____ hypoglycemia

Answer 52

Fasting

Question 53

MNT for someone who is experiencing hyperglycemia or fasting hypoglycemia:

Answer 53

-Small, frequent meals and an evening snack -Avoid alcohol

Question 54

For someone with end-stage liver disease, ___% of their total kcal should come from fat

Answer 54

30

Question 55

However, if someone is having steatorrhea, they should be on a ___ gram low-fat diet

Answer 55

40

Question 56

If someone has hypervolemia and severe hyponatremia (serum Na <125 mEq/L), a fluid restriction of ___-___ L/d may be indicated

Answer 56

1-1.5

Question 57

How should we monitor fluid intake?

Answer 57

-Input/output records -Weight -Serum sodium

Question 58

If someone has ascites or edema, they should have a ____ gram sodium restriction

Answer 58

2

Question 59

We should also monitor ____ due to diuretics and paracentesis

Answer 59

Electrolytes

Question 60

For those with end-stage liver disease, we should provide a ____

Answer 60

Multivitamin

Question 61

Many end-stage liver disease patients should be given fat-soluble vitamin supplements, and if someone has malabsorption, they should be given in ___-____ form

Answer 61

Water-soluble

Question 62

>90% of patients with advanced liver disease are deficient in Vitamin ___

Answer 62

D

Question 63

If someone has alcoholic liver disease, they should receive ___-___ mg of Thiamin and ____ mg of folic acid daily

Answer 63

50-100; 1

Question 64

Many people with end-stage liver disease are deficient in vitamin ___

Answer 64

K

Question 65

We should also provide the ____ of minerals, except in specific conditions

Answer 65

DRI

Question 66

Someone with cholestatic liver disease should not receive ____ and ____ supplementation

Answer 66

Copper and manganese

Question 67

Someone with hemochromatosis should not receive any ____ supplementation

Answer 67

Iron

Question 68

Someone with Wilson's Disease should not receive ____ supplementation

Answer 68

Copper

Question 69

If someone is having GI bleeding, they may need increased _____ supplementation

Answer 69

Iron

Question 70

If someone has alcoholism, they may require increased ____ and ____ supplementation

Answer 70

Zinc and Magnesium

Question 71

If someone is on a Diuretic, they may need increased ____, ____, ____ and ____

Answer 71

K+, zinc, magnesium, and calcium

Question 72

If someone is having Steatorrhea, they may need increased ____, ____, and ____

Answer 72

Calcium, Magnesium, and Zinc

Question 73

General recommendations for someone with end-stage liver disease:

Answer 73

-Small, frequent meals with a bedtime snack -Avoid skipping meals -Nutrient-dense snacks -Poor appetite: nutrition supplements

Question 74

Someone with end-stage liver disease may require enteral nutrition due to...

Answer 74

-Poor intake -Malnutrition -Altered mental status -Intubation

Question 75

Someone with end-stage liver disease on enteral nutrition should get a high ___ formula

Answer 75

Protein

Question 76

A small-bore ____ tube is appropriate for someone with non-bleeding esophageal varices

Answer 76

Nasogastric/nasoenteric

Question 77

A ____ placement is not recommended for those with ascites or gastric varices

Answer 77

PEG

Question 78

Parenteral nutrition would be indicated for someone with...

Answer 78

-Non-functioning GIT

Question 79

Parenteral nutrition can lead to...

Answer 79

-Hepatic steatosis -Cholestasis -Possible cirrhosis

Question 80

For someone on parenteral nutrition, we should avoid _____ of carbohydrates, lipids, or total kcal

Answer 80

Overfeeding

Question 81

For someone on parenteral nutrition, a lipid emulsion should not provide more than ____ g/kg/d

Answer 81

1

Question 82

A ____ ____ solution of parenteral nutrition should be given to someone with end-stage liver disease

Answer 82

Mixed substrate

Question 83

____ administration of parenteral nutrition is recommended for those with parenteral nutrition

Answer 83

Continuous

Question 84

For patients with cholestatic liver disease, reduce ____ and ____ provided

Answer 84

Copper and Manganese

Question 85

____ ____ is the leakage of chyle into the peritoneal cavity due to obstruction or leak from abdominal lymphatics

Answer 85

Chylous ascites

Question 86

Possible etiologies of chylous ascites:

Answer 86

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

Question 87

Chyle is made up of...

Answer 87

-White blood cells -Chylomicrons -Fat-soluble vitamins -Protein -Fluid -Electrolytes

Question 88

Consequences of chylous ascites:

Answer 88

-Pain -Anorexia -Hypoalbuminemia -Decreased electrolyte levels -Fat-soluble vitamin depletion -Essential fatty acid deficiency

Question 89

Medical management of chylous ascites includes...

Answer 89

-Conservative management (drainage, reducing chyle flow) -Surgical repair

Question 90

The goal for MNT for chylous ascites is to reduce long-chain triglyceride (LCT) intake to less than ____ g/day while still providing adequate nutrition

Answer 90

10

Question 91

Options for diet for someone with chylous ascites:

Answer 91

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

Question 92

Someone with chylous ascites should receive a high _____ diet

Answer 92

Protein