1. End Stage Liver Disease with GERD and Bleeding Esophageal Varices
FSHN 450
Fall 2015
Due Date: November 6, 2015
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.
Current Dx: Upper GI Bleed, Cirrhosis liver damage
MedHx: Htn, cholecystectomy (removal of gallbladder), alcoholism
Social: Divorced for past 15 years. Mother living. Father died at age 65 from CHF. 4 living
siblings: brother 53 has atherosclerotic heart disease, brother 40 and sister 46 in apparent good
health, sister age 48 is obese.
Medications at home: TUMS, Zantac, Lisinopril
Medications: Lactulose, Octreotide, Vitamin K, Compazine, Morphine, albumin iv, furosamide 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
K 4.7 mEq/L
Cl 87 mEq/L
CO2 19.3 mmol/L
Glu 91 mg/dl
BUN 13 mg/dl
Creat 1.6 mg/dl
PTT 43.1 seconds (reference: 23.7 - 32.7 seconds)
RBC 2.88 x106
/mm3
Hgb 9.1g/dl
Hct 26.9 %
Albumin 2.3 g/dl
Triglycerides 325 mg/dl
Total Cholesterol 250 mg/dl
HDL-Cholesterol 40 mg/dl
Physical and Neurological Exam: 0 Asterixis 0 edema of extremities
Gastroscopic Examination showed bleeding esophageal varices
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. 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 weight gain is most likely due to the overconsumption of alcohol in the diet.
Currently alcohol makes up about 54% of the overall diet. Diet is also low in nutrient dense
foods, but still overall high in energy intake. (total alcohol consumption = 1528 kcal; Total energy
intake = 2793 kcal; 1528kcal/ 2793 kcal = 54%)
What is the purpose of each of the patient’s medications? List any important
drug:nutrient interactions.
1.Lactulose is a laxative (hyperosmotic), to treat increased ammonia level; take with high fiber
and1.5-2.0 l of fluid/day to prevent constipation; no with lactose or galactose restricted diet; don’t
take with antacids/ Ca or Mg supplement; caution with glutamine because in theory may decrease
the antiammonia effect.
2. Octreotide is an anti-diarrheal and is used for acute bleeding esophageal varices treatment;
decreasing fat in diet may decrease GI effects.
3. Vitamin K is taken to treat hypoprothrombinemia and increase blood clotting; need to watch
sources of vitamin K in diet and maintain consistent vitamin K intake if taking anticoagulaent
drugs.
4. Compazine is an antipsychotic, antiemetic, and antianxiety; take magnesium supplement
separately by 2 hours before or after taking Compazine and limit caffeine intake.
5. Morphine is an analgesic, narcotic, and opioid; it is important to avoid alcohol when taking
morphine.
6. Albumin iv is taken to increase the amount of albumin in blood.
7. Furosamide iv is a diuretic and antihypertensive; it is beneficial to increase Na and Mg, and to
decrease Ca and Na when taking furosemide iv.
8.Tums is an antacid, and mineral supplement; it is important for adequate fluid intake/hydration
and to take separately from large amounts of high fiber, high oxalate or high phytate foods.
9. Zantac is a histamine H2 receptor antagonists, antiulcer, antigerd, and antisecretory; a bland
diet may be recommended, take drug at least 2 hours before or after Fe or antiacid supplement,
and limit caffeine.
10. Lisinopril is an angiotensin converting enzyme inhibitor, antihypertensive, and used for CHF
treatment; when taking lisinopril it is important to insure adequate fluid intake, decrease Na and
Ca, avoid salt substitutes, and be cautious with K supply.
Why was a surgical jejeunostomy tube placed?
A surgical jejunostomy tube has been placed because signs of esophageal bleeding were present.

3. In order to relieve some stress and give time for the esophagus to heal, a feeding tube has been
inserted into the jejunum to ensure that appropriate nutrition is administered in order to reverse
the malnutrition.
Evaluate the patient’s nutrient needs and prescribe a tube feeding including
type and brand name, total volume and rate. Include a start rate and
progression. Include ONLY the Assessment section of the ADIME at this
point.
Assessment:
57 y/o overweight (BMI: 29.8kg/m2
) male presents with upper GI bleed and cirrhosis. Has a
medical history of alcoholism and cholecystectomy, and a family history of CHF, coronary heart
disease, and obesity. Patient complains of nausea and vomiting, abdominal pain, and black stools.
Patient presents today with scleral icterus, increased abdominal girth, hypertension, esophageal
bleeding, and altered lab values. Lab results included low levels of Na (120mEq/L), low levels of
Cl (87 mEq/L), low levels of CO2 (19.3 mmol/L), high levels of creatine (1.6 mg/dL), high levels
of prothrombin time (43.1 seconds), low levels of RBC (2.88 x 108
/mm3
), low levels of
hemoglobin (9.1g/dL), low levels of hematocrit ( 26.9%), low levels of albumin ( 2.6 mg/dL),
high levels of triglycerides (325 mg/dL), and high cholesterol (250 mg/dL). Patient’s current
medications include: TUMS, Zantac, Lisinopril, Lactulose, Octreotide, Vitamin K, Compazine,
Morphine, albumin iv, and furosemide iv. Patient was ordered NPO and surgical jejeunostomy.
Nutritional needs based on MNT for end stage liver disease
• Will use Nestle’s NutriHep at 1.5kcal/ml because it is a low fat, high-branched chain
amino acid formula.
• Patients total energy needs at the start of enteral feeding: 2646kcal/day (30 kcal/kg)
o 1764ml of NutriHep per day
o NutriHep has a max hang time of 8 hours so the rate would be 1.23mL/ min for 24
hours with changing the bag 3 times a day; could also administer 2 times a day at a
rate of 1.84mL/min for 16 hours.
• If patient was tolerating these energy levels, would progress to 3087 kcal/day (35 kcal/
kg)
o 2058 mL of NutriHep per day
o Changing bag three times a day would give a rate of 1.43 mL/ min for 24 hours;
changing the bag two times a day would give a rate of 2.14 mL/ min for 16 hours.
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 %

4. Albumin 2.6 g/dl
Tube feeding is not well tolerated. Patient disoriented to time and place (grade 2-3). Mild
asterixis and 2+ edema present (all symptoms of cirrhosis). Patient transferred to ICU. Tri-
luminal catheter placed and nutrition support consult ordered for TPN with Hepatamine®, limit
1500 ml.
List the probably reasons for the tube feeding intolerance in this patient?
The mild asterixis and 2+ edema shows there is a large accumulation of fluid in the extremities
and abdomen. This inflammation is a large reason why there would be a development of tube
feeding intolerance. This inflammation could be related to the continuous low amount of albumin
(2.6g/dL).
Another reason could be due to electrolyte imbalances including the low levels of sodium (122
mEq/L) and chloride (98 mEq/L).
Lastly, the continuation of the degradation of gut bacteria related to the low blood pH which can
be seen by noting the low CO2 levels (10mmol/L). This will lead to malabsorption and tube
feeding intolerance as well.
You do not need to calculate a TPN but you should reevaluate protein and Kcal needs.
Kcal needs: 2646kcal/day (30 kcal/kg); Protein needs: 44g/ day (0.5g/kg)
Why was Hepatamine® ordered and what at is the drawback to using this product?
Hepatamine was ordered in order for the treatment of hepatic encephalopathy in patients with
cirrhosis. With an 8% concentration of amino acids it may be hard to reach the protein goal, along
with the energy goal, and stay under the fluid requirement of 1.5 L.
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, 2300 mg sodium, soft diet. Prepare to
discharge to home. Dx: chronic alcoholic cirrhosis with stable encephalopathy and esophageal
varices.
Why was a soft diet ordered?
A soft diet was ordered in order to prevent the reoccurrence of bleeding of varices. The soft diet
will also be soft in texture and low in fiber making the food easier to digest for the patient.
Conduct a follow-up nutrition assessment and report in ADIME format for
transition to oral diet (on 7/11)
Assessment:
57 y/o overweight (BMI: 29.8kg/m2
) male recently came off of TPN and is preparing to be
discharged. Patient was on TPN for last 10 days after intolerance to EN occurred. Patient is
diagnosed with chronic alcoholic cirrhosis with stable encephalopathy and esophageal varices.
Patient has a medical history of alcoholism and cholecystectomy, and a family history of CHF,
coronary heart disease, and obesity. Patient complains of nausea and vomiting, abdominal pain,
and black stools. Recent lab results included low levels of Na (122 mEq/L), low levels of CO2 (10
mmol/L), high levels of creatine (1.6 mg/dL), high levels of prothrombin time (43.1 seconds), low
levels of RBC (2.88 x 108
/mm3
), low levels of hemoglobin (9.1g/dL), low levels of hematocrit
( 26.9%), and low levels of albumin ( 2.6 mg/dL).
Nutritional needs:
• Less than 2000 mL/day of fluid
• Less than 2300 mg/ day of sodium

5. • Soft diet of soft textured foods and low fiber
• 3086 kcal/ day (35 kcal/kg/day)
• 88-106g/day of protein (1.0-1.2 g/ kg/day)
Develop three PES statements, one in each domain and plan an intervention
and follow-up for each nutrition diagnosis.
Clinical
Diagnosis: Altered GI function related to a diagnosis of chronic alcohol cirrhosis as evidence by
encephalopathy and esophagus varices.
Intervention/Monitoring:
1. Restrict any alcohol consumption beginning with discharge
2. Follow a soft diet as tolerated beginning with discharge
a. Restrict any caffeine intake, crunchy and coarse foods like nuts, breads, cereals,
crackers, and seeds, high fat foods like meats, olives, and coconuts, and avoid raw fruits and
vegetables.
b. Look for protein in sources like lean ground meats, fish, eggs, milk, cheese, tofu,
creamy peanut butter, and tapioca.
c. It is acceptable to eat carbohydrate rich foods like refined, white flour products, cream
of wheat, grits, cream of rice, white pasta, white rice, sweet and white potatoes are okay without
the skin, and finally, fruits and vegetables from a can are also acceptable.
3. Limit fluid intake to no more than 2 L per day.
4. Limit sodium intake to no more than 2300 mg/ day.
5. Consume no more than 3080 kcal per day.
6. Consume between 88-106 g of protein per day.
Evaluation/ Follow up:
Check weight to see if the amount of intake is accurate, ask for a food recall and look to see that
eating behaviors have improved according to intervention, and recheck the stability of
encephalopathy and esophagus varices.
Behavioral
Diagnosis: Undesirable food choices related to the overconsumption of alcohol as evidence by a
diagnosis of chronic alcohol cirrhosis and BMI of 29.8 kg/m2
.
Intervention/ Monitoring:
1. Restrict any alcohol consumption starting from discharge.
2. Follow a soft diet as tolerated to help with the chronic alcohol cirrhosis starting from
discharge.
3. When alcohol is around in social settings, make sure to stick with the restriction of alcohol
and opt for another non-alcoholic alternative.
4. Limit fluid intake to no more than 2 L per day
5. Limit sodium intake to no more than 2300 mg/ day.
6. Consume no more than 3080 kcal per day.
7. Consume between 88-106 g of protein per day.
Evaluation/Follow up:
Weigh the patient, ask for a food recall and look to see that eating behaviors have improved
according to intervention, and recheck the stability of encephalopathy and esophagus varices.

6. Intake
Diagnosis: Limited food acceptance related to a diagnosis of chronic alcohol cirrhosis as
evidence by patient being tapered off of TPN and an order of a soft diet.
Intervention/ Monitoring:
1. Restrict any alcohol consumption starting from the date of discharge.
2. Follow soft diet as tolerated starting from date of discharge.
3. Limit fluid intake to no more than 2 L per day
4. Limit sodium intake to no more than 2300 mg/ day.
5. Consume no more than 3080 kcal per day.
6. Consume between 88-106 g of protein per day.
Evaluation/ Follow up:
Weigh the patient, ask for a food recall and look to see that eating behaviors have improved
according to intervention, and recheck the stability of encephalopathy and esophagus varices.
*** DO NOT forget to answer all the questions in bold.

7. Intake
Diagnosis: Limited food acceptance related to a diagnosis of chronic alcohol cirrhosis as
evidence by patient being tapered off of TPN and an order of a soft diet.
Intervention/ Monitoring:
1. Restrict any alcohol consumption starting from the date of discharge.
2. Follow soft diet as tolerated starting from date of discharge.
3. Limit fluid intake to no more than 2 L per day
4. Limit sodium intake to no more than 2300 mg/ day.
5. Consume no more than 3080 kcal per day.
6. Consume between 88-106 g of protein per day.
Evaluation/ Follow up:
Weigh the patient, ask for a food recall and look to see that eating behaviors have improved
according to intervention, and recheck the stability of encephalopathy and esophagus varices.
*** DO NOT forget to answer all the questions in bold.