This case study describes a 57-year-old male admitted to the hospital with nausea, vomiting, abdominal pain, jaundice, ascites, and black stools. He was diagnosed with GERD, gastrointestinal bleeding, and cirrhosis. During his hospital stay, he received various treatments including tube feeding and TPN. His condition deteriorated and he was transferred to the ICU. He later stabilized and was transitioned to an oral diet to prepare for discharge with diagnoses of chronic cirrhosis, GERD, and esophageal varices.

1. Anya Guy
FSHN 450
Liver Disease and GERD
Case Study
December 5, 2014
“I have not given, received, or used any unauthorized assistance.”

2. End Stage Liver Disease with GERD and Bleeding Esophageal Varices
FSHN 450
Fall 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
Social: Divorced for past 15 years. Mother living. Father died at age 65 from CHF. EtOHism. 4
living siblings: brother 53 had PCI last year, brother 40 and sister 46 in apparent good health, sister
age 48 is obese.
Medications at home: TUMS, Zantac, Lisinopril
Medications: Lactulose, Octretide, Vitamin K, Famitodine, Compazine, Morphine, MgSO4 iv,
albumin iv
Physical: Ht. 5'7” Current BW 190 # BP 128/80 Pulse 90 RR 16 Temp 98.9
Hospital Course:
6/17 Admission Laboratory:
Na 120 mEq/L low
K 4.7 mEq/L normal
Cl 87 mEq/L low
CO2 19.3 mmol/L low
Glu 91 mg/dl normal
BUN 13 mg/dl normal
Creat 1.6 mg/dl high
PTT 43.1 seconds (reference: 23.7 - 32.7 seconds) high
RBC 2.88 x106
/mm3 low
Hgb 9.1g/dl low
Hct 26.9 % low
Albumin 2.8 g/dl low
Triglycerides 325 mg/dl high
Total Cholesterol 250 mg/dl high
HDL-Cholesterol 40 mg/dl low
Physical and Neurological Exam: 0 Asterixis 0 edema of extremities
Gastroscopic Examination showed bleeding esophageal varices

3. Diet History reveals the following usual intake:
8am 1 cup black coffee with 1 shot bourbon
10 am 1cup cornflakes with ½ c 2% milk
12 noon 1 hot dog on bun with relish and mustard
2 cans beer
30 potato chips
2 pm 1 snickers bar
Afternoon 3 shots bourbon
6 pm 1 cup pasta or baked macaroni and cheese
2 cans beer
Evening 2 cans beer
3 shots bourbon
6/28 Patients’s condition continues to deteriorate. Current BW : 194 pounds. Diet: NPO.
Surgical jejeunostomy tube placed and nutrition support consult ordered.
What was the cause of the weight gain????
The cause of the weight gain is fluid accumulation, edema. Ascites also increases fluid accumulation
in the abdomen leading to weight gain.
Why was a surgical jejeunostomy tube placed?
Due to the abnormal lab values, bleeding esophageal varices, and poor diet a surgical jejeunostomy
tube was ordered for this patient.
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.
Calories
• 30 kcal/kg BW/day
• 30 x 88 = 2,640 kcal/day
Fat
• 30% energy
• .3 x 2,640
• 792 kcal from fat
Protein
• 1.2 g/kg BW/day
• 1.2 x 88
• 105.6 g/day
– Nutrihep
o 1.5 kcal/ml
o Pro: .04 g/ml
§ .04 g x 1,760 ml = 70 g protein
§ need extra protein iv (35.6 g)

4. – Total volume:
o 2,640 kcal/1.5
o 1,760 ml
– Rate:
o 1,760 ml/24 hr.
o 73.3 ml/hr.
– Start rate:
o ¼ goal rate
o 18.3 ml/hr.
– Progression:
o Advance by 20 ml every 8 to 12 hours to the final volume
7/1 Paracentesis performed, iv albumin and iv Lasix administered.
7/1 Laboratory
Na 122 mEq/L
K 4.1 mEq/L
Cl 98 mEq/L
CO2 10 mmol/L
Glu 93 mg/dl
BUN 18 mg/dl
Creat 1.6 mg/dl
PTT 43.1 seconds (reference: 23.7 - 32.7 seconds)
RBC 2.88 x106
/mm3
Hgb 9.1 g/dl
Hct 26.9 %
Tube feeding is not well tolerated. Patient disoriented to time and place. Mild asterixis and 2+
edema present. Patient transferred to ICU. Tri-luminal catheter placed and nutrition support consult
ordered for PN limit 1500 ml.
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.
Energy: 30 kcal/Kg BW/day
– 30 x 88
– 2,640 kcal/day
Protein: 0.8 g Kg BW/day
– 0.8 x 88
– 70.4 g/day
Hepatamine: this TPN product can reverse encephalopathy and increase branched chain amino acids.
Since the limit is 1500 ml, we will be closer to meeting protein requirements for this patient.
What is the drawback to using this product???
The drawback to this product is that it requires a high volume (2,000 ml) and has the lowest protein.
Since we are allowed 1500 ml, the patient will be close to meeting required protein intake.

5. What is paracentesis and why was it preformed?
Paracentesis is a procedure to remove the fluid buildup from ascites. The fluid is removed by a long
thin needle put through the belly. Paracentesis is performed to diagnose infection in the peritoneal
fluid, check for liver cancer, remove a large amount of fluid that is causing pain, and find the cause
of fluid buildup.
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.
Assessment:
– 57 year old
– Male
– 5’7”
– Admitted at 190#
– Weight gain to 194# on 6/28
– Admission data
o Rt. Side abdominal pain
o Scleral icterus, increased abdominal girth secondary to ascites, black stools
o c/o heartburn of several months duration
– Dx
o GERD, GI bleeding, Cirrhosis
– Hx
o Htn, removal of gall bladder, GERD
– Social
o Divorced, mother alive, father died of CHF, alcoholic, 4 siblings alive
– Medications
o TUMS, Zantac, Lisinopril, Lactulose, Octretide, Vitamin K, Famitodine, Compazine,
Morphine, MgSO4 iv, albumin iv
– Abnormal lab values
– Bleeding esophageal varices
– Diet recall shows high alcohol content, high fat and sugar; processed foods
– 6/28
o NPO
o Surgical jejunostomy tube, nutrition support ordered

6. – 7/1
o Paracentesis performed, iv albumin and Lasix administered
o Tube feed not tolerated well
o Patient disoriented
o Mild asterixis, 2+ edema
o Nutrition support ordered for PN limit 1500 ml.
– 7/22
o Patient stable
o Patient to progress to oral diet as tolerated
o Fluid restriction: 2000 ml, Na restriction: 2400 mg, soft diet
– Dx: chronic cirrhosis with stable encephalopathy, GERD and esophageal varices
– Kcal:
o 30 kcal/Kg BW/day
o 30 x 88
o 2,640 kcal/day
– Protein:
o 1.5 g/Kg BW/day due to cirrhosis and esophageal varices
o 1.5 x 88
o 132 g day
– Fat:
o 30% energy
o .3 x 2,640
o 792 kcal/day
Diagnosis:
– Altered nutrition-related lab values (NC-2.2) related to cirrhosis as evidenced by bleeding
esophageal varices.
– Swallowing difficulty (NC-1.1) related to GERD as evidenced by severe heartburn for past
several months.
– Altered GI function (NC-1.4) related to cirrhosis as evidenced by increased abdominal girth
secondary to ascites.
Intervention:
– Recommend stopping alcohol consumption.
o Monitor diet and fluid intake.
o Recommend support groups.
o Provide information on negative effects of alcohol for people with liver disease.
– Advise maintaining a healthy weight.
– Avoid foods and drinks that trigger heartburn.
– Eat smaller meals.
– Don’t lie down after a meal.

7. o Monitor body weight weekly.
o Evaluate diet recall to assure small meals.
o Monitor signs and symptoms of GERD (heartburn, difficulty swallowing,
regurgitation)
– Recommend a low-sodium, healthy diet.
o Monitor lab values.
o Evaluate that patient is adhering to recommendations of 2,000 ml/day fluid, 2400
mg/day Na, and a soft diet.