Sonja SilvaEnd Stage Liver Disease with GERD and Bleeding Esophageal Varices

FSHN 450Fall 2014

Admission Data: 57 year old male admitted from ES c/o N&V, and abdominal pain radiating to Rt side. Patient presented with scleral icterus, increased abdominal girth secondary to ascites, black stools. Also c/o heartburn of several months duration.

Dx: GERD, GI Bleed, Cirrhosis

Hx: Htn, removal of gall bladder, GERD

What was the cause of the weight gain????Weight gain was probably caused by excessive intake of alchohol.

Why was a surgical jejeunostomy tube placed?With liver disease, there is always malabsorption and impaired GI function present. The jejunostomy was to help the patient absorb the proper nutrients.

Evaluate the patient’s nutrient needs and prescribe a tube feeding including type (brand name), total volume and rate. Include a start rate and progression.

I would prescribe Nutrihep at a total volume of 1500 ml since fluid should be restricted to this volume. The patient should start with 0.5 g/kg BW protein/day for the first 2-3 days and then progress at a rate of .25g/kg/day.

You do not have to calculate a TPN, BUT you should reevaluate protein and Kcal needs and suggest a protein sources for the TPN and explain why you selected this product. Kcal- 35 kcal/kg/dayProtein- 0.5 g/kg/day increase by .25 g/kg after 2-3 daysProtein Source-BCAA, low AAAFreamineHBC is a good source of BCAAs and is an appropriate amino acid solution to use. I chose Nutrihep as a the TPN product of choice because it was designed for liver disease and most of the protein is from BCAAs from whey concentrate. It is relatively low in protein which is important for this stage of liver disease. It is low in fat, with a high ration of MCTs to LCTs for better absorption and high in calories to reduce malnutrition.

What is the drawback to using this product???The main drawback to this product is that it has a high ration of omega-6 to omega-3 fatty acids which can cause immunosuppression.

What is paracentesis and why was it preformed?

Paracentesis is the drawing of fluid from the abdominal cavity to reduce ascites. It was probably performed because the patient has stage 3 liver disease and edema and is probably accumulating fluid in the abdominal cavity.

7/11 Patient stabilized. TPN tapered and patient diet order changed to clear liquid progressing to oral diet as tolerated. Fluid restricted to 2000 ml/day, 2400 mg Na+, soft diet. Prepare to discharge to home. Dx: chronic cirrhosis with stable encephalopathy, GERD and esophageal varices.

Answer the questions in bold above.

Conduct a nutrition assessment in ADIME for transition to oral diet (on 7/11)

Develop three PES statements, one to nutrition problem to deal with each of three medical diagnoses (esophageal varices, GERD, chronic cirrhosis)

Suggest an intervention and follow-up for each nutrition diagnosis.

Assesment:

Age: 57 y/oGender: MaleHt: 5'7” Current BW: 194 # BMI: 30 obeseBP 128/80 Pulse 90 RR 16 Temp 98.9Sx: chronic cirrhosis with stable encephalopathy, GERD and esophageal varices Diet Hx: High alcohol consumption and intake of processed carbohydrates.Medications: TUMS, Zantac, Lisinopril, Lactulose, Octretide, Vitamin K, Famitodine, Compazine, Morphine, MgSO4 iv, albumin ivMedication interactions: Patient should not take antacids with Lactulose. Avoid natural licorice.Kcal needs- 30 g/kg/day= 2640 kcalProtein needs- 1.0 g/kg/day= 88g proteinFluids- 1500ml/ dayLabs: low RBC, Hgb, Hct, Albumin. High Triglycerides.

Diagnosis:

Altered GI function AEB esophageal varices R/T acid reflux.Excessive energy intake AEB GERD R/T elevated triglycerides.Excessive alcohol intake AEB chronic cirrhosis R/T alchoholism.

Intervention:

Patient should not consume alcohol or significantly reduce intake to 1-2 drinks per day. He should consume adequate protein around 88 grams per day. Lean meats may be best since they are high in branch chain amino acids. A whey protein supplement may be used and incorporated

into meals. The diet should be low in saturated fats since the gallbladder is absent and the liver is not functioning well. A diet low in fructose is important to lower triglycerides. The diet should contain whole grains and complex carbohydrates along with whole fruits and vegetables. Weight loss is encouraged since patient is obese. This can be accomplished by decreasing kcals by 500 per day making total kcal needs around 2100 per day. Medications should be taken with caution as Compazine may cause weight gain, lactulose interacts with antacids, and the patient is taking two H2 blockers simultaneously which may cause decreased appetite along with other medications. Adequate fluids around 1500 ml per day are recommended.

Monitoring/Evaluation:

Triglycerides should be monitored as well as blood glucose and hepatic function. Weight loss should also be monitored.

Honor Pledge:

“I have not given, received or used any unauthorized assistance on this assignment.”

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