Alcoholic Liver Disease with

Encephalopathy
Emily Tieu
Patient Profile
Age: 61 yrs
Sex: Male
Lives with wife, at least one son
Height: 172 cm
Weight: 81.9 kg
BMI: 27.7
IBW: 69.2 kg (118%)
ABW: 72 kg
Chief Complaint
Family notes that for the past 2 days the
patient was having progressive confusion
and waxing and waning mentation along
with progressive jaundice and abdominal
pain.
Admitted 4/10
Medical History
Alcoholic liver disease
Alcohol abuse
Hypertension
Acute kidney injury
Metabolic Acidosis
Physical Exam
Vitals: 96.8 F Temp., HR 95, BP 101/63
General: Patient is confused. Oriented to self
and place, but not time.
HEENT: Pupils round. No oral lesions.
Abdomen: Positive for distension and
tenderness
Skin: Jaundiced
Edema, ascites
Lab Values
Normal Mr. B
BUN 8-18 mg/dL 112 mg/dL (H)
Creatinine 0.6-1.2 mg/dL 3.87 mg/dL (H)
AST 0-35 U/L 133 U/L (H)
ALT 4-36 U/L 85 U/L (H)
Albumin 3.5-5 g/dL 1.8 g/dL (L)
Ammonia 15-45 ug/dL 46.3 ug/dL (H)
Total bilirubin <0.3 mg/dL 2.3 mg/dL (H)
Medications
Lactulose
GI upset, hypernatremia, diarrhea
Omeprazole
Phytonadione
Prednisone
Supplements:
MVI
Folic acid
Thiamine
Diagnosis and Treatment
Admit diagnosis: encephalopathy
NPO
Dobhoff tube
Jevity 15 ml/hr
382 kcal
16 g pro
Encephalopathy
Impaired mental status and abnormal
neuromuscular function
S/S: Loss of memory and cognitive ability
Pathogenesis unknown
3 Hypotheses:
Ammonia
Synergistic neurotoxin
False neurotransmitter
Tx: Decrease ammonia levels
Nutrition History
No food allergies
Last drink reported to be 1 month ago
No diet recall due to encephalopathy
Nutrition Diagnosis
PES Statement
Inadequate protein-energy intake related to
inability to eat oral diet as evidenced by
receiving only 382 kcal and 16g pro/d
through tube feeding
Nutrition Therapy
Energy needs
Ireton-Jones REE: 1717 kcal
1.0-1.3*REE= 1720-2230 kcal
Protein needs
43-72g PRO/d (0.6-1.0g/kg ABW)
Nutrition Intervention
Higher calories
Protein restriction
Low potassium and sodium
Suplena @ 50ml/hr
2160 kcal
54g PRO (0.66g/kg PRO)
Suplena
Chronic kidney disease
Calorie dense (1.8 kcal/ml)
Low in protein, potassium, sodium, and
phosphorus
Oral or tube feeding
Reflection
Protein restriction unnecessary
No clinical benefit
Greater protein breakdown
BCAA supplementation may be beneficial
Decrease in BCAA to AAA ratio
BCAA enteral formulas:
NutriHep, Hepatic-Aid II
Monitoring and Evaluation
Weight
Lab values
Hydration
Changes in GI function
Outcome
4/14 AM:
Respiratory Failure
Liver failure, aspiration, or
encephalopathy
DNR
Deceased 4/14
References
http://abbottnutrition.com/brands/suplena
http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682338.html
http://www.ninds.nih.gov/disorders/encephalopathy/encephalopathy.htm
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1115757/
Nelms, M. Sucher, K. Lacey, K. & Roth, S. (2009) Nutrition Therapy &
Pathophysiology. Belmont, CA: Wadsworth
https://www.nutritioncare.
org/Professional_Resources/Guidelines_and_Standards/Standards_of_P
ractice/Standards_for_Nutrition_Support__Adult_Hospitalized_Patient/
http://www.badgut.org/information-centre/health-and-
nutrition/prednisone-and-diet-1.html