Alcoholic Liver Disease:

A Nutrition Focused

Approach to Treatment

By Laura JohnsonMontana State Dietetic Intern

OBJECTIVES

1. UNDERSTAND HOW MALNUTRITION IS RELATED TO CIRRHOSIS

2. LEARN AT LEAST ONE NUTRITION INTERVENTION THAT COULD BE USED

TO TREAT CIRRHOSIS

PATIENT

• MALE

• ALCOHOL INTAKE

• SUBJECTIVE DATA

• 2-12 BEERS 1-2 TIMES/WEEK

• LAST DRINK NOT DOCUMENTED

• NO PREVIOUS MEDICAL HISTORY PRIOR TO THIS YEAR

MEDICAL HISTORY

• JANUARY: FIRST ADMITTED FOR ABDOMINAL PAIN, BLOODY URINE

• DIAGNOSED WITH COLON CANCER

• COLON RESECTION

• ASCITES: 2 LITERS OF FLUID REMOVED

“EXTREMELY CIRRHOTIC AND NODULAR LIVER”

CAUSE: ALCOHOL

CIRRHOSIS OF THE LIVER SECONDARY TO ALCOHOL

LIVER’S ROLE IN ALCOHOL METABOLISM 1

ADH - liver

1. Ethanol + NAD Acetaldehyde +

NADH (cytosol)

MEOS – other organs

1. Ethanol + NADPH Acetaldehyde

+NADP

ADH

ALDH

CP450

2. Acetaldehyde + NAD Acetate +

NADH (mitochondria)

*cell and liver damage

3. Acetate Skeletal muscle Kreb Cycle

4. Excess Acetate Excess Acetyl coA Fatty Acid Synthesis

• altered NAD/NADH ratio

• inhibited nutrient pathways

LIVER’S ROLE IN PROTEIN METABOLISM 2

1. SYNTHESIZE BLOOD PROTEINS

• CLOTTING FACTORS, CARRIER AND TRANSPORT PROTEINS

2. MAKES NON-ESSENTIAL AMINO ACIDS

3. BREAKDOWN PROTEINS FOR GLUCOSE

• GLUCONEOGENESIS

4. UREA SYNTHESIS

• EXCRETE TOXIC AMMONIA

AN IMPAIRED LIVER ALTERS PROTEIN METABOLISM MALNUTRITION

FACTORS FOR MALNUTRITION IN CIRRHOSIS 2

1. DECREASED INTAKE

• EARLY SATIETY AND ASCITES

2. UNABLE TO STORE AND MAKE ADEQUATE AMOUNTS OF GLYCOGEN

• GLUCOSE NOT READILY AVAILABLE

• EARLY FASTING STATE = PROTEIN AND FAT BREAKDOWN

3. INCREASED ACTIVITY OF SYMPATHETIC NERVOUS SYSTEM

• INCREASE IN HORMONES = HYPERMETABOLIC

NUTRITION ASSESSMENT3

• STATED HIS LAST FULL MEAL WAS IN DECEMBER 2016

• TYPICAL DAILY INTAKE AFTER DECEMBER:

• 2 SMALL MEALS

• 2 NUTRITION SUPPLEMENTS

• ESTIMATED NUTRIENT NEEDS:

• 1600-2300 CALORIES 4

• 65-80 GRAMS OF PROTEIN 5, 6

Nutrition Care Manual – Cirrhosis 5, Oncology 6

Nutrition Focused Physical Exam Pocket Guide, 2015 4

SYMPTOMS

• ADMITTED FOR RECTAL BLEEDING AND ASCITES 5

• OTHER SYMPTOMS 5, 7

• MUSCLE WASTING

• ABDOMINAL PAIN

• WEIGHT LOSS

• LOW APPETITE

• LOW ENERGY

• JAUNDICE

ANTHROPOMETRICS

• ADMIT WEIGHT: 65.2 KG

• USUAL WEIGHT: 70 KG

• HEIGHT: 175.26 CM

• ADMIT BMI: 20.37

WEIGHT TRENDS

Date Weight (kg)

Usual body weight 70.0

January 3rd 72.3

January 22nd 75.9

January 27th 71.8

February 6th 65.2

February 8th 64.4

Percent weight loss in 1 month 4:

8.7%

PHYSICAL EXAM 4

SEVERE MUSCLE LOSS IN THE CLAVICLES, PATELLAR REGION, CALVES AND THIGHS

SEVERE FAT LOSS IN TRICEPS

NUTRITION DIAGNOSIS 3

SEVERE PROTEIN CALORIE MALNUTRITION (CHRONIC) RELATED TO POOR

APPETITE SECONDARY TO ALCOHOLIC LIVER CIRRHOSIS AS EVIDENCED

BY SEVERE MUSCLE AND FAT LOSS PER PHYSICAL EXAM AND SEVERE

WEIGHT LOSS GREATER THAN 5% IN ONE MONTH

NUTRITION INTERVENTION 3

1. MEDICAL FOOD SUPPLEMENTS

• 2 PROTEIN SUPPLEMENTS PER DAY

NUTRITION GOAL: DIET TO ADVANCE BY NEXT RD VISIT

1. MEDICAL FOOD SUPPLEMENTS 3

• DIFFERENT PROTEIN SHAKE

2. MEALS AND SNACKS

• SMALL, FREQUENT MEALS

• EARLY SATIETY

• GLUCOSE READILY AVAILABLE

3. NUTRITION EDUCATION

• REVIEWED CIRRHOSIS DIET GUIDELINES

WITH PATIENT AND FAMILY

NEW GOAL: EAT AT LEAST 50% OF AT LEAST 2

MEALS PER DAY

Snacks

MONITOR AND EVALUATE 3

• FOOD AND NUTRIENT INTAKE: AMOUNT, FREQUENCY, TYPE, ADEQUACY

• NUTRITION FOCUSED PHYSICAL FINDINGS: APPETITE, PAIN

• BODY COMPOSITION: WEIGHT TRENDS

2013 Review 2 Middle East Journal of Digestive Diseases

• Ammonia can be present regardless of intake

• Vegetables – low in AAA

• Dairy protein – high in BCAA

Grams of protein/kg

• 0.5 = muscle breakdown 8

• <1 = increased risk of muscle wasting and negative

nitrogen balance 9

• 1.2 = muscle mass was maintained 10

Hepatic Encephalopathy (HE)Too much ammonia

can worsen HE

Question: Treat malnutrition or HE?

PROS TO VEGETABLE PROTEIN 11

1. FIBER

• SLOW CARB ABSORPTION = SHORT TIME IN FASTING STATE

• INCREASES RATE OF NITROGEN EXCRETION POSITIVE

NITROGEN BALANCE

2. LOW IN AROMATIC AMINO ACIDS (AAA)

• EX: TRYPTOPHAN OXYPHENOL

3. LOW IN SULPHATED AMINO ACIDS

• EX: METHIONINE MERCAPTANS

4. HIGH IN AMINO ACIDS: ORNITHIONE AND ARGININE

• INCREASE RATE OF UREA SYNTHESIS

CONS TO VEGETABLE PROTEIN 11 1. BULK

• EARLY SATIETY

2. PALATABILITY

• NO SALT

3. BIOAVAILABILITY OF PROTEIN AND MINERALS

• IRON, CALCIUM

• PROTOCOL

• 1.2 GRAMS OF PROTEIN/KG/DAY FOR 2 WEEKS

• 4 MEALS/DAY + EVENING SNACK OF COMPLEX CARBS

• MEASURED

• BLOOD AMMONIA AND NUMBER CONNECTION TEST (NCT)

• RESULTS

• PATIENTS IMPROVED: 79.7% - SS

• MOST IMPROVEMENT SEEN IN PATIENTS WITH SEVERE HE

• NOT IMPROVED: 20.3%

• 0.5 GRAMS OF PROTEIN/KG/DAY + NITROGEN SUPPLEMENTS

JOURNAL OF GASTROENTEROLOGY 10

• PROTOCOL

• 3 DIETS: ALL SUBJECTS TRIED EACH FOR 2 WEEKS

• RESULTS

• BOTH VEGETABLE GROUPS IMPROVED NCT TIME - SS

• 80 GRAM GROUP: EEG TEST IMPROVEMENT –SS

• MEASURES BRAIN ACTIVITY

JOURNAL OF DIGESTIVE DISEASES AND SCIENCES 12

Summary

• Malnutrition is a common complication of cirrhosis

• Symptoms and treatments to consider:

• Decreased intake small frequent meals for

regular glucose

• Hypermetabolic state protein and energy needs

• Protein Intake

• 1.0-1.2 grams/kg

• Consider hepatic encephalopathy

• Treatment with vegetable and dairy protein may be

beneficial

Our role is important! ☺

Resources

1. King, Michael W., PH.D. "Ethanol Metabolism." Ethanol (Alcohol) Metabolism: Acute and Chronic Toxicities. N.p., Jan. 2017.

Web. 23 Jan. 2017. http://www.themedicalbiochemistrypage.org/ethanol-metabolism.php#acetate

2. Eghtead, S. Hossein, P. Malekzadeh, R. “Malnutrition in Liver Cirrhosis: The Influence of Protein and Sodium.” Middle East

Journal of Digestive Diseases. 2013 Apr; 5(2): 65–75. Web. 20 Mar. 2017

3. International Dietetics & Nutrition Terminology (IDNT) Reference Manual: Standardized Language for the Nutrition Care

Process. Academy of Nutrition and Dietetics, nd. 2013.

4. Mordarski, B. Wolff, J. “Nutrition Focused Physical Exam Pocket Guide.” Academy of Nutrition and Dietetics, n.d. 2015.

5. "Cirrhosis." Nutrition Care Manual. Academy of Nutrition and Dietetics, n.d. Web. 10 Feb. 2017.

http://www.nutritioncaremanual.org/topic.cfm?ncm_catagory_id

6. “Oncology.” Nutrition Care Manual. Academy of Nutrition and Dietetics, n.d. Web. 15 May. 2017.

https://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&ncm_toc_id=255467

7. "Cirrhosis." MedlinePlus Medical Encyclopedia. U.S National Library of Medicine, 14 Aug. 2015. Web. 5 Feb. 2017.

https://medlineplus.gov/ency/article/000255.htm

8. Cordoba J, Lopez-Hellin J, Planas M, Sabin P, Sanpedro F, Castro F. et al. Normal protein diet for episodic hepatic

encephalopathy: results of a randomized study. J Hepatol. 2004;41:38–43

9. Charlton MR. Protein metabolism and liver disease. Baillieres Clin Endocrinol Metab. 1996;10:617–35

10. Gheorghe L, Iacob R, Vădan R, Iacob S, Gheorghe C Rom J Gastroenterol. 2005 Sep; 14(3):231-8

11. Amodio, P., Caregaro, L., Pettenó, E., Marcon, M., Delpiccolo, F., & Gatta, A. (2001). Vegetarian diets in hepatic

encephalopathy: facts or fantasies? Digestive and Liver Disease, 33(6), 492-500. doi:10.1016/s1590-8658(01)80028-1

12. Uribe M, Marquez MA, Garcia Ramos G, Ramos-Uribe MH, Vargas F, Villalobos A. et al. Treatment of chronic portal--

systemic encephalopathy with vegetable and animal protein diets: A controlled crossover study. Dig Dis Sci. 1982;27:1109–16.

2017