I.

GENERAL INFORMATION

Name: Mr. D. B.

Age: 51 years old

Gender: Male

Nationality: Caucasian

Civil Status: Divorced

Height: 5’7 ft. ~ 170.18 cm

Weight: 175 lbs. ~ 80 kg

Date and Time of Admission: August 17, 2014

Means of Admission: tense ascites for the second time

Attending Physician: Dr. Ira Azneer

II. MEDICAL HISTORY

A. Present Illness/Diagnosis and Chief Complaint

 Cirrhosis

 Tense Ascites

Mr. B. presented at the Bay Pines VA Emergency Room on August 17, 2014 with

tense ascites for the second time. According to his attending physician, Dr. Ira Azneer, Mr.

B. complained of nausea, vomiting, shortness of breath, and abdominal pain persisting for

the past four days. Along with the ascites, he also had 2++ edema in his extremities. Mr.

B.’s MRSA screening test came back positive, so he was placed in an infection control

setting.
 B. Past Surgery and History of Hospitalization

He was diagnosed with cirrhosis in July 2014. His medical history also includes

GERD, a cholecystectomy, hepatitis C, alcohol dependence, tobacco use disorder (smokes

a pack a day), mood disorder, anxiety disorder, depression, and a subdural hematoma. In

July 2014, Mr. B. was also first diagnosed with ascites, and underwent his first

paracentesis.

C. Appetite, elimination and sleeping patterns

 Poor appetite

 Alcohol Dependent

D. Socio-economic History

 Type of Residence: Living alone in a motel

 Alcohol drinker

 He served in the army from 1981-1984, and subsequently worked as a carpenter.

He has been unemployed for eight years and receives $997 monthly from Social

Security Disability Insurance.

 Lifestyle: Sedentary

III. BACKGROUND OF MEDICAL DIAGNOSIS

Cirrhosis is the most serious and irreversible type of liver injury. It is a chronic liver disease

where increased fibrous connective tissue replaces the functioning liver cells following fatty

degeneration of long standing. In contrast to the enlarged fatty liver, the cirrhotic liver is

continuously losing most of its function. The large volume of blood supply cannot pulse easily
through the mass. As the disease progresses, the scarring becomes more extensive, leaving fewer

areas of healthy tissue. A cirrhotic liver is often shrunken and has an irregular, nodular appearance.

Ascites is the most common complication of cirrhosis, caused by extreme vasodilation of the

arteries in the abdomen. Scarring of the liver leads to shutting off of some hepatic blood vessels,

resulting in portal hypertension and formation of collateral veins to compensate for the loss of

others. Blood that builds up in the decompensated liver begins to be shunted to the systemic

circulation and nitric oxide is produced by nearby cells to help dilate blood vessels in the area,

both mechanisms intended to help relieve portal hypertension.

IV. ETIOLOGY

The main etiologies of cirrhosis are chronic viral hepatitis (HBV and HBC), alcoholism, and

nonalcoholic fatty liver disease.

Chronic Alcoholism

Chronic alcoholism is the leading cause of cirrhosis in the United States. Drinking too

much alcohol can cause the liver to swell, which over time can lead to cirrhosis. The amount

of alcohol that causes cirrhosis is different for each person.

Chronic Viral Hepatitis

Viral hepatitis causes the liver to swell, which over time can lead to cirrhosis. Chronic

hepatitis C is the second leading cause of cirrhosis in the United States. About one in four

people with chronic hepatitis C develop cirrhosis. Chronic hepatitis B and hepatitis D also

can cause cirrhosis.

 Nonalcoholic Steatohepatitis (NASH)

Fat build up in the liver that is not caused by alcohol use, is nonalcoholic steatohepatitis

(NASH). NASH can cause the liver to swell and can lead to cirrhosis. People with NASH

often have other health issues including diabetes, obesity, high cholesterol and heart disease.

V. INCIDENCE

Cirrhosis is an increasing cause of morbidity and mortality in more developed countries.

It is the 14th most common cause of death in adults worldwide.

According to the latest WHO data published in May 2014 Liver Disease Deaths in

Philippines reached 10,388 or 1.99% of total deaths. The age adjusted Death Rate is 15.58 per

100,000 of population ranks Philippines #87 in the world.

VI. PATHOPHYSIOLOGY

Alcohol Abuse Laennec’s

Malnutrition Cirrhosis

Infection Postnecrotic
Drugs Cirrhosis

Billary Billary
Obstruction Cirrhosis

Destruction of HEPATOCYTES

FIBROSIS/SCARRING

Obstruction of blood flow

Pressure in the venous and sinusoidal channels
Fatty infiltration FIBROSIS/SCARRING

PORTAL HYPERTENSION

ASCITES
VII. PROGNOSIS

Any patient with cirrhosis carries a risk of specific life-threatening complications such as

variceal bleeding, sepsis, or hepatorenal syndrome. There is also a significant risk of nonspecific

life-threatening complications due to the frequent association of comorbidities. The general course

of the disease is characterized by a longstanding phase of compensated cirrhosis, followed by the

occurrence of specific complications. It has been shown that 10 years after diagnosis, the

probability of developing decompensated cirrhosis is 60%, ascites being the most frequent

complication (50%). Once patients have developed the first episode of decompensation,

complications tend to accumulate and life expectancy is markedly reduced.

VIII. ASSESSMENT OF THE NUTRITIONAL STATUS

A. Anthropometric Assessment

Parameter Measurement Remarks References

Height 170 cm Patient

Weight 81.5 kg Patient

BMI 28 Overweight WHO Formula

% Ideal Body Weight 67 kg 67 Hamwi’s Method

(DBW)

Weight is not an accurate reflection of nutritional status for patients with fluid alteration

like Mr. B., but a chart is included below with available recent weight history.
 MR. B.'S WEIGHT
Weight

185
181.9
180

175 175.4
172
170

165

160
157.2
155

150

145

140
1/13/2014 2/13/2014 3/13/2014 4/13/2014 5/13/2014 6/13/2014 7/13/2014 8/13/2014

B. Biochemical

After paracentesis, Mr. B.’s peritoneal fluid was assessed in the laboratory for bacteria

and white blood cells. Bacteria were not found, indicating that no infection of the peritoneal

cavity was present. White blood cells were found in normal amounts. The most important lab

values in monitoring cirrhosis and ascites are reported in the table below.

Normal Aug 17 Aug 19 Aug 20 Aug 21 Remarks

values
Glucose 74-118 91 105 92 94
mg/dL
Sodium 136-144 133 136 136 137
mEq/L (low)
Potassium 3.6-5.1 3.8 3.7 (low) 3.9 4.0
mEq/L
Magnesium 1.8-2.4 1.7 (low) 1.8 1.8
mEq/L
Calcium 8.9-10.3 8.2 7.7 (low) 7.8 (low) 7.8 (low) Low calcium
(low) related to
impaired
absorption of
vit. D.
Prothrombin 9.6-12.5 17 19.6 18.6 18.9 (high) Prothrombin
time sec (high) (high) (high) time is
elevated
because the
liver is not
making the
right amount
of blood
clotting
proteins.
BUN 8-20 mg/dL 6 (low) 7 (low) 4 (low) 7 (low)
Albumin 3.5-4.8 2 (low) 1.5 (low)
g/dL
Ammonia 9-33 16
umol/L
Bilirubin 0.2-1.3 3.6 2.3 (high)
mg/dL (high)
AST/ALT 0.5-1.1 2.84 2.63 An AST to
ratio (high) (high) ALT ratio of
2:1 or greater
is suggestive
of alcoholic
liver disease
RBC 4.23-5.75 3.67 3.09 (low) 3.23 3.24 (low) Decrease of
M/uL (low) (low) RBC, WBC,
Hemoglobin 12.8-17 12.7 10.6 (low) 11.2 11.1 (low) Hemoglobin
g/dL (low) (low) and Platelet
WBC 4.0-10.6 5.3 3.3 (low) 3.3 (low) 3.9 (low) count related
Platelet 160-410 98 (low) 57 (low) 65 (low) 72 low) to portal
K/uL hypertension

C. Clinical

Mr. B. is somewhat wasted physical appearance, including evidence of moderate

lipoatrophy in his triceps and evidence of severe temporal muscle wasting.

D. Dietary

Mr. B.’s usual diet consists of ramen noodles and beef stew from Dollar General,

which he says he likes especially because it has carrots. He reports that one can of soup
 and one package of noodles, mixed and cooked in the microwave, are enough to feed him

two to three days. He typically drank a quarter of a gallon of vodka daily. After his

hospitalization in July, he reports that he decreased his alcohol consumption and now only

drinks two to three four-packs of beer a week, and claims that his drinking is mostly social

while watching football with a friend. He expressed intention to stop drinking, but

consistently turned down counseling from the substance abuse treatment program. He told

the physician that he drinks to dull his abdominal pain.

IX. DRUG-NUTRIENT INTERACTION

Mr. B. was placed in an infection control setting. Dr. Azneer scheduled the paracentesis for

August 18. The procedure removed seven liters (approximately 15 pounds) of fluid. He was

continued on the diuretic regimen of spironolactone and furosemide to flush out excess fluid

accumulation in the rest of his body.

Dr. Azneer also prescribed Mr. B. a potassium chloride supplement, a magnesium sulfate

supplement, a thiamine supplement, and a multivitamin/mineral supplement. Ondansetron was

administered multiple times during his hospital stay for nausea and vomiting. Mr. B. was already

on lactulose, a laxative designed to help him clear ammonia from his system more effectively and

prevent hepatic encephalopathy, omeprazole, a proton-pump inhibitor for his GERD, and

trazodone and paroxetine, antidepressants. The medications and their nutrition-related effects are

shown in more detail in the table below.

Medication Type/Use Nutrition-Related Effects

Spironolactone Potassium-sparing diuretic –
treats fluid retention and
edema
Hyperkalemia (avoid
excessive potassium intake),
possible hyponatremia. Can
cause nausea, vomiting, and
diarrhea.
Furosemide Loop diuretic – treats fluid Hyponatremia, hypokalemia,
retention and edema hypomagnesemia. Can also
cause decreased serum
chloride and calcium, and
increased serum glucose.
Need to increase the
potassium and magnesium in
the diet, and decrease caloric
intake. Avoid natural licorice.
Lactulose Laxative – to treat High fiber diet with 1500-
hyperammonemia 2000 mL liquid. Drug
increases absorption of
calcium and magnesium;
supplementation with these is
generally not recommended.
Omeprazole Proton pump inhibitor – anti- Decreases gastric acid
GERD secretion, increases gastric
pH. Avoid alcohol. Can cause
diarrhea. My decrease
absorption of iron, vitamin
B12, and calcium. Calcium
citrate supplement
recommended. Avoid gingko
and St. John’s Wort.
Ondansetron Anti-emetic, anti-nauseant Can cause abdominal pain,
constipation, and diarrhea.
Potassium Chloride Electrolyte, mineral Do not take with salt
supplement substitutes.
Magnesium Sulfate Mineral supplement, antacid, May cause chalky taste and
laxative. diarrhea. Do not take with
high fiber, oxalate, or phytate
food.
Thiamine B Complex Vitamin – prevent Alcohol inhibits absorption.
Wernicke/Korsakoff
syndrome due to chronic
alcohol abuse
Multivitamin/mineral Supplement – contains Possible vitamin/mineral
vitamin A, D, E, folic acid, toxicities
niacin, pantothenic acid,
riboflavin,
Iron, calcium, magnesium,
manganese,
X. NUTRITION CARE PLAN

Nutrition Nutrition Intervention Nutrition Nutrition

Diagnosis Short Term Long Term Monitoring Counseling
Intervention Intervention
Inadequate -Patient must Patient must - Patient must be To optimize the
energy intake have adequate consume foods able to present energy intake,
related to loss of nutritional regarding the food recall every advise the
appetite as support. prescribed diet to week in order for patient to eat 4-6
evidenced by -Consume more long term the dietitian to times a day and
muscle and fat than 75 percent intervention. assess the have a daily
wasting and diet of meals and compliance of physical activity
recall. supplements the diet to help in
provided. recommendation. increasing
Diet consultation hunger and
preventing loss
of lean body
mass.
High Sodium Fluids and Sodium intake Patient’s The patient must
and alcohol sodium restricted should be adequacy of be aware of the
intake related to diet will be restricted to 2000 intake will be food that are rich
his usual diet administered to mg per day. monitored. and low sodium.
consist of ramen the patient. Patient must Advise the
noodles, canned present food patient to replace
goods and vodka diary within a salt shaker with
as evidenced by week for food herb shaker.
fluid retention consumption
and edema.

XI. FOOD PLAN (1 DAY)

A. Food Distribution
Diet Prescription: 2000 kcal; Full, Fluids and Sodium Restricted Diet.
3 Full meals with AM, PM, and MIDNIGHT snacks
TER: Desirable Body Weight x 30 = 67 x 30 = 2010 ~ 2000 kcal
CHO: 2000 kcal x .60 / 4= 300 g
 CHON: 2000 kcal x .15 /4= 75 g
FAT: 2000 kcal x .25 /9 = 55 g

Dx: (300 gm CHO, 75 gm CHON, 55 gm Fat, 2000 kcal TER)

Food Group Amount CHO CHON FAT Sodium ENERGY

(exchange) Na
300 (g) 75 (g) 55 (g) 2000 mg 2000 kcal

Vegetable A 4 6 2 - 14 32

Vegetable B 3 9 3 - 20 48

Fruit 5 50 - - 15 200

Milk (Whole) 1 12 8 10 160 170

Sugar 5 25 - - 100
Rice 8.5 195.5 17 - 244 850

Meat 5.5 ex -
2 (LF) - 16 2 245 82
3.5 (MF) - 28 21 301

Fat 5.5 - - 27.5 7 247.5

TOTAL 297.5 74 60.5 705 2030

B. Sample Menu

MEAL TIME SAMPLE MENU

Breakfast
Fruit (2 Exchange) 1 small apple, ½ banana, 1 tbsp raisins
Protein dish (1 Exchange) 1 boiled chicken egg
Starch Exchange (2 Ex) 2 cups corn flakes
Milk LF (1 ex) 1 glass low-fat milk
Snack AM
Starch Exchange (1/2 ex) ¾ cup lugaw
Vegetable (2 ex) ½ cup malunggay and carrots
Fat exchange (1 ex) 1 tsp cooking oil
Sugar (1 ex) 1 yema

Lunch
Protein Dish (2 ex) 1 slice of fried salmon and 1/3 cup
chickpeas
Vegetable Dish (2 ex) ½ cup spinach and squash
Starch Exchange (2 ex) 1 cup Cooked rice
Fat Exchange (2.5 ex) 2.5 tsp Vegetable oil

Snack PM
Starch Exchange (1 ex) 2 pcs whole wheat bread
Sugar (1 ex) 2 teaspoon jam
Fruit (1 ex) 12 pcs grapes

Dinner
Protein Dish (2 ex) 2 pcs tokwa
Vegetable Dish (3 ex) ¼ cup mungbean sprout and carrots, ½
cup cabbage and chayote
Starch Exchange (2 ex) 1 cup Cooked rice
Fruit (1 ex) 1 ripe mango
Fat Exchange (2 ex) 2 tsp Vegetable oil
Sugar (2 ex) 2 pcs Pastillas

Snack Midnight
Starch Exchange (1 ex) ½ cup boiled sweet potato
Fruit (1 ex) 1 ¼ cup strawberry
Sugar (1 ex) 2 tsp condensed milk
XII. ANALYSIS OF THE DIET PRESCRIPTION

Fluids and Sodium Restricted Diet

The patient was prescribed a fluid and sodium restricted diet. A low sodium diet can help

decrease water or fluid retention. Fluids are forced unless edema and ascites are present, in which

case sodium and fluids are restricted according to individual needs. With ascites, 2-4 g sodium-

restricted diet is suggested.

Additional emphasis will also be undertaken to a nutrient that play significant role in

regenerating of the liver cells. The diet should supply 1-1.5 g protein/kg body weight. Be careful

not to give too high of protein to prevent ammonia build-up, which may progress into hepatic

coma. Encourage use of branched chain amino acids (BCAA). Dietary sources of BCAA are red

meat and dairy products. However, meat protein has a high level of aromatic amino acids. better

sources are plant proteins from pasta, vegetable, rice, fruits, and lima beans.

XIII. GOALS OF MEDICAL THERAPY

The Nutritional goals for Mr. B.:

 Reduce sodium intake by replacing canned and package foods with low-sodium

food to help decrease the fluid retention.

 Increase the appetite. Consume more than 75 percent of meals to have an

adequate energy intake.

 Use BCAA from plant-based protein to prevent ammonia build-up.

XIV. CONCLUSION AND RECOMMENDATION

According to Dr. Azneer, the attending physician, Mr. B.’s prognosis is grave. Based on

the Model for End-Stage Liver Disease (MELD), Dr. Azneer estimated he has approximately three

months to live. With optimal nutritional intake, sodium and fluid restriction, vitamin and mineral

supplementation, and alcohol cessation, Mr. B.’s nutritional status could conceivably improve,

which could improve his short-term survival. However, real improvement in his status is unlikely

due to his severe disease state and unwillingness to stop drinking. It is possible that if his pain were

better controlled in general, he would be more likely to stop drinking, but from his past history

with alcohol, complete cessation seems, sadly, unlikely. The only real treatment for cirrhosis that

has advanced to Mr. B.’s state is liver transplant, a treatment they are unlikely to do on someone

with his poor nutritional status, due to increased mortality risk.

XV. GLOSSARY AND TERMS

Ascites - the accumulation of fluid in the peritoneal cavity.

Edema - a condition characterized by an excess of watery fluid collecting in the cavities

or tissues of the body.

Esophageal varices – abnormal, enlarged veins in the lower part of the esophagus.

Lipoatrophy – loss of fat tissue

Morbidity - the quality of being unhealthful

Mortality - is the state of being mortal, or susceptible to death; the opposite of immortality.

Paracentesis – the procedure to take out a fluid that has collected in the belly.

Pathophysiology - the disordered physiological processes associated with disease or

injury.

Portal hypertension – an increase in the blood pressure within the system of veins called

portal venous system.

Prognosis - the likely course of a disease or ailment.

XVI. REFERENCES

Academy of Nutrition and Dietetics (AND). Cirrhosis. Nutrition Care Manual.

http://www.nutritioncaremanual.org. Accessed 9/9/2014.

Cabre E, Gassull M. Nutritional and metabolic issues in cirrhosis and liver transplantation.

Curr Opin Clin Nutr Metab Care. 2000;3:345-354.

MayoClinic. The MELD model. http://www.mayoclinic.org. Accessed October 25, 2016.

Food Exchange List for meal planning 3rd revision. FNRI

Castro, E., Claudio, V. & Jamorabo-Ruiz, A. (2011). Medical nutrition therapy for Filipinos

6th Ed., Merriam & Webster Bookstore. Inc: Manila, Philippines