University of the East – Manila

Department of Nutrition and Dietetics

2nd Semester, A.Y. 2021 – 2022

GROUP WORK No. 2 on the MNT of LIVER CIRRHOSIS

Prepared by: Vheejay B. Tampol, RND, MD, DPAAB

General Instructions: Follow the specific instructions below. Upload your output in PDF format,
in the Assignment Section of our Nutrition Therapy 2 course site in Canvas. Follow this format for
the filename: GROUP No._MNT_LIVER CIRRHOSIS

Read the case below and answer the guide questions.

T.W. is a 26-year-old architecture doctoral student who was in relatively good health until 3 years
ago when she was diagnosed with hepatitis C.

History of Present Illness:

Onset of disease: Hepatitis C Dx 3 years ago—previously treated with alpha-interferon and

ribavirin; seasonal allergies treated with antihistamines

Medical history: Currently, she complains of fatigue, anorexia, nausea and vomiting, and
weakness. She has lost 10lbs since her last office visit, which was 6 months ago. She also reports
that she has been experiencing bruising of her skin that did not happen previously and does not
appear to be related to injury.

Surgical history: No surgeries

Medications at home: Allegra 60 mg po qd

Tobacco use: No

Alcohol use: Yes

Family history: Mother (living)—HTN, diverticulitis, cholecystitis, carpal tunnel syndrome;

father (deceased)—diabetes mellitus, peptic ulcer disease; maternal grandmother—
cholecystitis, bilateral breast cancer; maternal grandfather—leukemia; paternal grandfather—
cirrhosis; paternal grandmother—amyotrophic lateral sclerosis

Demographics:

Marital status: Single—lives with roommate who is a law student

Number of children: 0

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Level of education: Postgraduate

Language: Filipino & English

Occupation: Doctoral graduate student in architecture

Hours of work: Teaches late morning and late afternoon; takes classes and conducts research
during most evenings

Ethnicity: Filipino American

Religious affiliation: Protestant

Admitting History & Physical Examination:

Chief complaint: “It just seems as if I can’t get enough rest. I feel so weak. Sometimes I’m so
tired, I can’t go to campus to teach my classes. Does my skin look yellow to you?”

General appearance: Tired-looking young female

Vital Signs: Temp: 96.9F Pulse: 72 bpm Resp rate: 19 cpm BP: 102/65 mmHg

Anthropometrics: Height: 5'8" Weight: 125 lbs

Heart: Regular rate and rhythm, no gallops or rubs, point of maximal impulse at the fifth
intercostal space in the midclavicular line
HEENT: Head: Normocephalic
Eyes: Wears contact lenses to correct myopia; PERRLA
Ears: Tympanic membranes w/out lesions
Nose: Dry mucous membranes w/out lesions
Throat: Enlarged esophageal veins
Genitalia: Normal female
Neurologic: Alert and oriented x 3
Extremities: Normal muscular tone, normal range of motion; no edema; no asterixis noted
Skin: Warm and dry; bruising noted on lower arms and legs; telangiectasias noted on chest
Chest/lungs: Respirations normal; no crackles, rhonchi, wheezes, or rubs noted
Peripheral vascular: Pulse 3+ bilaterally
Abdomen: Pierced umbilicus, upper right abdomen; mild distension, hepatomegaly; no ascites

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Admission Orders:

CT scan of liver and biopsy

Test stool for occult blood
Daily I/O
Spironolactone 25 mg qid

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 Propranolol 40 mg bid
Soft, high-kcal, high-protein diet—small, frequent meals
Multivitamin/mineral supplement
Bed rest

Dx: Cirrhosis—MELD score 23

Nutrition:

Current diet order: Soft, 4 grams sodium, high-kcal

General: Has not had an appetite for the past few weeks. She states that she drinks calcium
fortified orange juice for breakfast most mornings. Lunch is usually soup and crackers with a
Diet Coke. Dinner at home but may be carry-out. If carry-out, it’s usually Chinese or Italian food.

Usual dietary intake: Sips of water, juice, and Diet Coke only. Has not eaten for the past 2 days.

Food allergies/intolerances/aversions: Does not like liver or lima beans

Previous nutrition therapy: 3 yrs ago: small, frequent meals, plenty of liquids

Food purchase/preparation: Self and/or significant other

Vit/min intake: 400 mg vitamin E, 600 mg calcium with 400 IU vitamin D; multivitamin/mineral
daily; 200 mg milk thistle twice daily; chicory 3 grams daily; 500 mg ginger at least twice daily

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Guide Questions:

I. Understanding the Disease and Pathophysiology

1. The liver is an extremely complex organ that has a particularly important role in nutrient
metabolism. Identify three functions of the liver related to each of the following:
a. carbohydrate metabolism
b. protein metabolism
c. lipid metabolism
d. vitamin and mineral metabolism

2. The CT scan and liver biopsy confirm the diagnosis of cirrhosis. Explain this diagnosis. The
diagnosis also includes a MELD score. What is this, and how does her score relate to the
severity of liver failure?

3. The most common cause of cirrhosis is alcohol ingestion. What are other potential causes
of cirrhosis? What is the cause of this patient’s cirrhosis?

4. Explain the systemic physiological changes that occur because of cirrhosis.

5. List the most common signs and symptoms of cirrhosis, and relate each of these to the
physiological changes discussed in question #4.

6. After reading this patient’s history and physical, identify her signs and symptoms consistent
with her diagnosis.

7. Hypoglycemia is a symptom that cirrhotic patients may experience. What is the physiological
basis for this? How might this affect TW’s nutritional status?

8. What are the current medical treatments for cirrhosis?

9. What is hepatic encephalopathy? Identify the stages of encephalopathy, and outline the
major theories regarding the etiology of this condition.

10. Protein-energy malnutrition is commonly associated with cirrhosis. What are potential
causes of malnutrition in cirrhosis? Explain each cause.

II. Understanding the Nutrition Therapy

11. Outline the nutrition therapy for stable cirrhosis and the rationale for each modification.

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III. Nutrition Assessment

12. Measurements used to assess nutritional status may be affected by the disease process and
not necessarily be reflective of nutritional status. Are there any components of nutrition
assessment that would be affected by cirrhosis? Explain.

13. The MD’s notes that TW has lost 10 lbs since her last exam. Assess and interpret
her weight.

14. Calculate the patient’s energy and protein needs. Provide the rationale for the standards
you used for these calculations.

15. Evaluate the patient’s usual nutritional intake using nutrient analysis.

16. Her appetite and intake have been significantly reduced for the past several days. Describe
factors that may have contributed to this change in her ability to eat.

17. Why was a soft, 4-g Na, high-calorie diet ordered? Should there be any other modifications?

18. This patient takes multiple dietary supplements. Identify the possible rationale for each,
and identify any that may pose a risk for someone with cirrhosis.

19. Examine the patient’s chemistry values. Which labs support the diagnosis of cirrhosis?
Explain their connection to the diagnosis.

20. Examine the patient’s hematology values. Which are abnormal, and why? Does she have
any physical symptoms consistent with your findings?

21. What signs and/or symptoms would you monitor to determine further liver
decompensation?

22. The doctor prescribes two medications to assist with the patient’s symptoms. What is the
rationale for these medications, and what are pertinent nutritional implications of each?

IV. Nutrition Diagnosis

23. Select three nutrition problems and complete the PES statements for each.

V. Nutrition Intervention

24. TW is discharged on a soft, 4-g Na diet with a 2-L fluid restriction. Do you agree with
this decision? Are there additional nutrition concerns that you would want to discuss with her?

25. TW asks if she can use a salt substitute at home. What would you tell her?

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26. Using the information from her usual dietary intake, what suggestions might you make to
assist with compliance with the fluid and sodium restrictions?

VI. Nutrition Evaluation & Monitoring

27. When you see TW one month later, her weight is now 140 lbs. She is wearing sandals
because she says her shoes do not fit. What condition is she most probably experiencing? How
could you confirm this?

28. Her diet history is as follows:

Breakfast: 1 slice toast with 2 tbsp peanut butter, 1 c skim milk
Lunch: 2 oz potato chips, grilled cheese sandwich (1 oz American cheese with 2
slices of wholewheat bread; grilled with 1 tbsp margarine), 1 c skim milk
Supper: 8 barbeque chicken wings, 1 c French fries, 2 c lemonade

What changes might you make to her nutrition therapy? Identify foods that should be
eliminated and make suggestions for substitutions.

List of References (Use APA Format):