Patrick Burrows

Angelina Caradonna
KNH 411
9/22/15
Case Study # 12 Cirrhosis of the Liver
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
i.
glycogenesis
ii.
glucogenesis
iii.
glycolysis
b. protein metabolism
i.
synthesis of serum proteins
ii.
prothrombin
iii.
globin of hemoglobin
c. lipid metabolism
i.
lipogenesis
ii.
lipolysis
iii.
fatty acid oxidation
d. vitamin and mineral metabolism
i.
methylation of niacinamide
ii.
phosphorylation of pyridoxine
iii.
formation of coenzyme B12
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?
Cirrhosis is a condition where the liver slowly deteriorates and cannot function normally due to
chronic or injury. Healthy tissue is replaced by scar tissue which blocks the flow of blood
through the organ resulting in loss of liver function. The liver normally can regenerate its own
cells, however if the damage is too severe, the liver cannot adequately regenerate and the liver
creates the scar tissue. This buildup of scar tissue is what specifically diagnosis cirrhosis, and
over time this scar tissue will lead to liver failure (Cirrhosis, 2014). MELD, Model for End-Stage
Liver Disease, was created in 2002 by the Mayo Clinic to determine the severity of an
individuals liver disease and to prioritize the patients waiting for a liver transplant. It is based on
three blood tests, the international normalized ratio (INR), bilirubin, and creatinine. INR
measures the livers ability to make blood clotting factors, bilirubin measures how effectively the
liver produces bile, and creatinine measures kidney function. MELD is a numerical scale ranging
from 9 to 40, nine being mild and forty being severe. The score shows how severe an individual
has liver disease and how urgently the patient needs a liver transplant. By these values it can be
assessed the mortality of the patient within three months, determining the likeliness of the patient
to live with a liver in the diseased state. There are five levels to the disease severity scale, greater

than 40 with 72% mortality, 30-39 with 52% mortality, 20-29 with 20% mortality, 10-19 with 6%
mortality and less than 9 with 2% mortality (MELD and the Waiting List for Liver Transplant,
2014). With the diagnosis of cirrhosis, Mis. Wilcoxs MELD score of 23 shows that she is around
the middle severity of the disease with a little over a 20% mortality risk (Nelms, 2011).
3. The most common cause of cirrhosis is alcohol ingestion. What are other
potential causes of cirrhosis? What is the cause of this patients cirrhosis?
Other potential causes of cirrhosis are hepatitis C, cryptogenic causes, hepatitis B, autoimmune
hepatitis, primary biliary cirrhosis, secondary biliary cirrhosis, primary sclerosing cholangitis,
hemochromatosis, Wilsons disease, alpha-1 antitrypsin deficiency, granulomatous disease, type
IV glycogen storage disease, drug induced liver disease, venous outflow obstruction, chronic
right sided heart failure, and tricuspid regurgitation (456). The cause of this patients cirrhosis is
hepatitis C.
4. Explain the systemic physiological changes that occur as a result of cirrhosis.
As the liver becomes increasingly damaged, it loses its ability to carry out its function which
then goes on to cause other damage throughout the body. Some complications of cirrhosis
include portal hypertension, in which the scar tissue partially blocks the flow of blood causing an
increase in pressure in the portal vein. The portal vein carries blood from the stomach, intestines,
spleen, gallbladder, and pancreas to the liver. Disruption of blood flow in the portal vein can
cause edema and ascites, varices in the esophagus and/or stomach, splenomegaly, and mental
confusion due to a buildup of toxins in the blood which accumulate in the brain, also known as
hepatic encephalopathy. Cirrhosis can also result in metabolic bone disease caused by
abnormalities in vitamin D, calcium, and phosphorous which can lead to osteoporosis. The
prevention of free flowing bile causes it to harden and creates gallstones and bile duct stones,
which can cause jaundice. A person with cirrhosis may bruise and bleed more easily because the
liver slows or stops the production of the proteins needed for blood clotting. Insulin resistance
and type 2 diabetes can also occur because cirrhosis causes a resistance to insulin, leading to
glucose build up in the bloodstream. Other complications in cirrhosis include liver cancer,
increased rate of infection, kidney and lung failure (Cirrhosis, 2014).
5. List the most common signs and symptoms of cirrhosis, and relate each of
these to the physiological changes discussed in question 4.
The most common signs and symptoms of cirrhosis are fatigue, weakness, nausea, poor appetite,
malaise, jaundice, dark urine, light stools, steatorrhea, itching, abdominal pain, and bloating.
Malnutrition is a common side effect of cirrhosis as well as bruising and bleeding not related to
injury. Patients may exhibit abnormal hematocrit and hemoglobin levels due to poor vitamin and
mineral intake as well as the livers reduced ability to synthesize protein clotting factors (457).
Fatigue and weakness can be attributed to poor nutrition as related to poor appetite. Poor appetite
could be related to abdominal edema caused by portal hypertension not allowing the stomach to
expand without onset of pain. Bruising and bleeding is related to poor intake of vitamins and
minerals due to lack of appetite as well as the liver's inability to synthesize protein clotting
factors. Patients may also exhibit light stool

6. After reading the patients history and physical, identify her signs and
symptoms consistent with her diagnosis.
Mis. Wilcox was diagnosed with Hepatitis C 3 years ago, which is shown to be a major cause of
cirrhosis. She is showing signs of fatigue, anorexia, N/V, weakness, and a loss of 10 lbs within 6
months which all point to malnutrition. The bruising on her skin also indicates the lack of
proteins available for adequate blood clotting, and she is showing signs of jaundice which could
be due to inadequate bile flow. Telangiectasis is also seen on her chest. Her family medical
history is pretty prominent, specifically with her paternal grandfather having been diagnosed
with cirrhosis, however her mother, father, maternal grandmother, maternal grandfather, and
paternal grandmother all reported a wide range of health disparities. Her stools are light brown
and she has cloudy, amber colored urine. The enlarged esophageal veins in her throat could be
caused by portal hypertension. She also reports some mild distension, which could attribute to
hepatomegaly, however she shows no ascites.
7. Hypoglycemia is a symptom cirrhotic patients may experience. What is the
physiological basis for this? How might this affect Ms. Wilcoxs nutritional status?
When cirrhosis progresses to a point where 80% of hepatocytes are dysfunctional, serum glucose
levels become erratic causing hypoglycemia. Cirrhosis also causes increased energy expenditure
due to vasodilation and increased blood volume. This can affect Ms. Wilcoxs nutritional status
because when the body will not have an adequate amount of glycogen reserves so after an
overnight fast the body will begin mobilization of skeletal muscle amino acids for
gluconeogenesis (458). With repetitive breakdown of skeletal muscle Ms. Wilcox may lose
weight as well as decrease her energy expenditure due to the loss of muscle mass.
8. What are the current medical treatments for cirrhosis?
In treating cirrhosis, the goal is to slow the progression of tissue scarring in the liver. However a
person may need additional treatments and to be hospitalized if the cirrhosis worsens. Treatments
include avoiding alcohol and illegal substances as this will cause more liver damage. Specifically
in Ms. Wilcoxs case her cirrhosis can be aided in treatment by first prescribing antiviral
medications to treat hepatitis C (Cirrhosis, 2014). Since there is no cure in cirrhosis, lifestyle
changes play a huge role in treatment of the disease. Some recommended changes include losing
weight if overweight or obese, regular exercise to reduce muscle wasting, and to practice good
hygiene to lessen the chance of infection (Cirrhosis - Treatment, 2015). In nutrition therapy for
cirrhosis, patients should first be tested for nutritional deficiencies, specifically protein-calorie
malnutrition. Calorie and protein recommendations are 35-40 kcal/kg per day with a protein
intake of 1.6 g/kg per day. It is important not to decrease protein intake, even for encephalopathy,
which can be addressed through enteral feedings if needed. Fat restriction to less than 30% of
calories is recommended with patients showing high lipid levels in the blood. Carbohydrate
intake is often spread out between multiple meals in order to minimize hyo/hyperglycemia and
type 2 diabetes. In ascite management, a restriction of 2 g of sodium a day is required. This is
often paired with fluid restriction as this will lessen ascite and edema as well. Supplementation is
also recommended as it pertains to certain vitamins and minerals that are not being adequately
absorbed, which can be determined by the patients blood work Nelms, 2011). There are also
some options in terms of treating the consequences associated with cirrhosis. This includes

lowering blood pressure by use of medication to reduce pressure on the portal vein. Beta blocker
medication may also be prescribed to reduce the risk of bleeding/ reduce the severity of bleeding
that could occur, which are often used to treat varices. Vitamin K supplements and plasma may
be given to the patient to help with blood clotting as well. If the liver severely damaged by
scarring and and has stopped functioning, a liver transplant then becomes the only option
(Cirrhosis - Treatment, 2015).
9. What is hepatic encephalopathy? Identify the stages of encephalopathy, and
outline the major theories regarding the etiology of this condition.
Hepatic encephalopathy is a syndrome characterized by CNS dysfunction in association with
liver failure (437, 444). The CNS dysfunction causes impaired mental status and neuromuscular
function. The stages of encephalopathy are outlined by the West Haven Staging Scale for Hepatic
Encephalopathy. The stages are rated on a 0-4 scale with 0 being no abnormality detected. Stage
1 presents with trivial lack of awareness, euphoria or anxiety, shortened attention span,
impairment in performance of addition. Stage 2 presents with lethargy or apathy, minimal
disorientation for time or place, subtle personality change, inappropriate behavior, and impaired
performance of subtraction. Stage 3 presents with somnolence to semi-stupor but responsive to
verbal stimuli, confusion, and gross disorientation. Lastly stage 4 presents with a coma (445). A
major theory regarding the etiology of hepatic encephalopathy is that it involves
neurotransmission failure rather than the previous theory that related it to energy failure. Another
theory is that prolonged exposure of ammonia to the brain causes edema and then in turn causing
neurotransmitter defects and altered mental status (Mousseau, D., & Butterworth, R.).
10. Protein-energy malnutrition is commonly associated with cirrhosis. What are
potential causes of malnutrition in cirrhosis? Explain each cause.
Overall, cirrhosis leads to malnutrition because it can cause loss of appetite, changes in
metabolism, and reduced absorption of vitamins and minerals (Cirrhosis, 2014). Loss of appetite
can be due to nausea, diarrhea, constipation, indigestion, pain, ascites and early satiety due to the
stomachs reduced ability to stretch and to accommodate an increased amount of food as often
seen in cirrhosis. Liver damage causes severe changes in metabolism as the liver functions to
form blood proteins, amino acid interconversion, and amino acid deamination by which ATP can
be produced in times of starvation since protein is not used foremost for energy needs. Fatty acid
malabsorption is also common as the liver fails to produce an adequate amount of bile and
decreased micelle formation. Glycogen also becomes inadequately synthesized and stored, thus
causing the unavailability of glucose from carbohydrates sources in the body. This causes a
constant breakdown of muscle and fat, leading to tissue depletion and muscle wasting (Eghtesad
et al, 2013). Because of the changes in nutrient metabolism, this causes a reduced absorption of
vitamins and minerals. Specifically in irregular fat metabolism, fat soluble vitamins A, D, E, and
K are often compromised.However water soluble B vitamins can also compromised, specifically
thiamine and folate. Deficiency in minerals can include magnesium, calcium, sodium, and zinc
(Krenitsky, 2003).
II. Understanding the Nutrition Therapy
11. Outline the nutrition therapy for stable cirrhosis and the rationale for each
modification.

Calorie recommendations for patients with cirrhosis are 35-50g/day. This increase is to combat
the loss of lean body mass due to the patient being malnourished. Protein intake is increased to
21.6g/kg per day for the same rational. Enteral feedings are often required based on the level of
malnutrition that the patient is experiencing. Fat is restricted to less than 30% of calories in
patients that are experiencing steatorrhea. Sodium should be restricted to less than 2g/day to
prevent fluid retention since the body retains fluid because of ascites. Lastly carbohydrate intake
should be spread out between meals to prevent hypo and hyperglycemia (458).
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.
Typical methods for anthropometric and biochemical assessment of nutritional status are not
reliable for patients with cirrhosis, because of edema and ascites. Dry weight may not be
obtainable and electrical impedance analysis will not be accurate. The liver protein values in the
lab used to determine visceral protein status will be abnormal because of hepatic dysfunction. To
replace the information that would have been obtained from these labs, other methods to test the
patient can be used. This includes the Subjective Global Assessment (SGA) and measurement of
mid-arm muscle circumference (MAC) or mid-arm circumference, and triceps skinfold thickness
(TST), which can all be used to nutritionally test the patient. The 2013 ASPEN guidelines for
critical care suggest that the energy requirements of the patient are assessed using indirect
calorimetry or by predictive equations (Nelms, 2011).
13. Dr. Horowitz notes that Ms. Wilcox has lost 10 lbs since her last exam. Assess
and interpret Ms. Wilcoxs weight.
Using Ms. Wilcoxs weight in kilograms and her height in meters it can be calculated that her
BMI is 19. A BMI of 19 is within a normal range but it is on the lower end of the normal
spectrum. Ms. Wilcoxs current weight is 92% of her UBW which indicates that she has
experienced some weight loss. Ms. Wilcox does not seem to be in danger due to this weight loss
but it could indicate a bigger problem in her nutritional status.
14. Calculate the patients energy and protein needs. Provide the rationale for
the standards you used for these calculations.
According to Nelms, the calorie recommendation for patients with cirrhosis are 35-40 kcal/kg
per day, and the protein recommendation is 1.6 g/kg per day. Compared to the recommendation
for a normal healthy individual, which constitutes a caloric need of 23-24 g/kg per day and a
protein need of 0.8 g/kg per day, the values for cirrhosis are much higher. This is because
patients with cirrhosis are frequently malnourished because of protein degradation and
malabsorption as well as an increase in energy expenditure due to vasodilation and a growth in
blood volume (Nelms, 2011).
By using the above calculation determine Ms. Wilcoxs caloric and protein needs was obtained
as shown below.
125 lb x 2.2 = 57 kg, 68 in x 2.54 = 173 cm

35 x 57 = 1,995 kcal per day

40 x 57 = 2280 kcal per day
1,995-2280 range kcal per day
1.6 x 57 = 91.2 g of protein per day
Using Mifflin-St. Jeor equation:
Women REE: (10 x 57 kg) + (6.25 x 173 cm) - (5 x 26 yrs) -161 = 1360 kcal
1360 x 1.5 PAL = 2040 kcal per day
Ms. Wilcoxs energy needs if she were healthy are 2040 kcal per day, which puts her on the
lower side of the energy requirements calculated for cirrhosis. However since she has lost a
significant amount of weight due to malnutrition and increased energy expenditure as caused by
cirrhosis, I would recommend a higher caloric intake in reference to the higher value of 2280
kcal per day in the cirrhosis range. Since the goal of this energy intake is to make sure that her
body is well nourished and to prevent further weight loss, the higher caloric value is needed. Her
protein needs are calculated to be around 91 g of protein per day.
15. Evaluate the patients usual nutritional intake using nutrient analysis.
Based on the patients usual nutritional intake she is not taking in enough calories. The patient
also consumes an unbalanced diet that needs to be fortified with fruits, whole grains, protein, and
vegetables to combat the impending nutritional problems (456).
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.
Loss of appetite in cirrhosis is caused by an accumulation of many factors. These include
abdominal pain, fatigue, nausea, bloating, constipation, indigestion, and diarrhea. Early satiety is
also a cause due to dysfunctional gastric accommodation, and the inability of the stomach to
expand due to ascites (Eghtesad et al, 2013).
17. Why was a soft, 4-g Na, high k-calorie diet ordered? Should there be any
other modifications?
She was ordered a soft, 4-g Na, high k-calorie diet for various reasons. The soft food is to keep
from harming the patients possible esophageal varices. The sodium limitation is an effort to
lessen the amount of fluid that is retained because patients with cirrhosis. The high calorie diet is
an effort to combat malnutrition linked to the lack of appetite displayed by Ms. Wilcox. The Na
restriction should be dropped to 2g/day to assist with the control of ascites and fluid overload
(458)
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.
With cirrhosis it is important to be careful when prescribing supplements since the liver is
compromised, the supplement my build up in the body to unhealthy levels and cause more
damage than need be. Since the vitamins and minerals in her multivitamin are not listed, it is

important to note that supplements of iron and copper should not be given to patients with
cirrhosis as these can easily accumulate in the liver and cause toxicity. Fat soluble vitamins E
and D however, are beneficial supplements because patients with cirrhosis are often lacking in
these vitamins as caused by fat malabsorption. Vitamin E is an antioxidant and has anti
inflammatory properties, and vitamin D will help with calcium absorption and prevention of
bone loss that can lead to osteoporosis as frequently seen in cirrhosis patients. This paired with a
calcium is good since her current diet does not show many foods that would contain an adequate
amount of calcium. Research on the effectiveness of milk thistle on cirrhosis patients caused by
hepatitis C are mixed. It is suggested that silymarin (a substance in milk thistle) can protect liver
from damage including viruses, toxins, alcohol, and certain drugs (Cirrhosis, 2013). Ginger can
help with nausea, diarrhea, and abdominal pain, which are all prevalent symptoms of cirrhosis,
however it should be noted that ginger can increase the risk of bleeding problems. This may
make the bruising and bleeding tendency of those with cirrhosis worse (Cirrhosis liver, 2012).
Chicory has a history of being known to produce hepatoprotective and antioxidant effects,
effectively lowering heightened serum levels of AST, ALT, and ALP enzymes, which note the
function of the liver. The high amount of soluble fiber in chicory can reduce strain on the liver by
removing extra water and toxins. It also stimulates the flow of bile, which can treat gallstones
and aid in the treatment of jaundice (Adb El-Mageed, 2011).
19. Examine the patients chemistry values. Which labs support the diagnosis of
cirrhosis? Explain their connection to the diagnosis.
Ms. Wilcoxs cirrhosis diagnosis is supported by several irregular lab values. The lab values
supporting this diagnosis are AST, ALT, bilirubin, and albumin. Lab value that are indicative of
liver damage when high are AST and ALT. These increased levels are due to bile duct blockage.
Her albumin levels are low which a decreased value is associated with hepatic disease and
inflammatory state. The bilirubin level being increased is a reflection of the liver's ability to
conjugate and excrete bilirubin (442, 443).
20. Examine the patients hematology values. Which are abnormal, and why?
Does she have any practical symptoms consistent with your findings?
Abnormalities in hematology values in cirrhosis patients are frequent and are a sign of poor
prognosis of the disease. Ms. Wilcox shows a low WBC of 4.8 and a low RBC of 4.1. This can
be caused by the destruction of platelets in the enlarged spleen due to portal hypertension, and
low RBC count can be attributed to anemia and liver damage (Qamar & Grace, 2009). Ms.
Wilcox also has a low hemoglobin of 10.9 and hematocrit of 35.9. These are signs of internal
bleeding which could be attributed to varices. Her ferritin levels are high as well at 120, which is
a sign that her liver is not correctly processing iron. Her vitamin B12 levels were high at 100 as
well as her folate levels at 25. Since the liver is the main storage site of vitamin B12 and folate
and plays a critical role in metabolizing these vitamins. Damage to the liver causes an increase of
vitamin B12 and folate in the blood. Higher levels of folate are more common in individuals with
cirrhosis caused by hepatitis than alcohol (Viral Hepatitis).
21. What signs and/or symptoms would you monitor to determine further liver
decompensation?

I would monitor Ms. Wilcoxs lab values to monitor for further irregularities as well as watch for
peripheral edema. If she develops peripheral edema it would be indicative of hepatorenal
syndrome. Hepatorenal syndrome is the development of renal failure in patients with advanced
cirrhosis (457).
22. Dr. Horowitz prescribes two medications to assist with the patients
symptoms. What is the rationale for these medications, and what pertinent
nutritional implications of each?
The first medication, spironolactone, is in a class of medications called aldosterone receptor
antagonists. It causes the kidneys to get rid of excess water and sodium from the body through
the urine, but reduces the loss of potassium from the body. This helps with excess fluid retention
in the body such as edema and ascites. Alcohol should not be consumed with this medication,
other dietary instructions include avoiding potassium containing salt substitutes and natural
licorice and limiting the amount of potassium-rich foods consumed, such as bananas, prunes,
raisins, and orange juice (Spironolactone, 2015) (Nelms, 2011). The second medication,
propanolol, is in a class of medications called beta-blockers. It is known to reduce blood pressure
by relaxing the blood vessels and slowing heart rate. In cirrhosis patients, it can help with portal
hypertension. It is important to take this medication with food in order to increase bioavailability.
Also, orange juice and natural licorice should be avoided as well as decreasing dietary calcium
and sodium, as these may interfere with adequate absorption of the medication (Propranolol,
2015) (Bellows & Moore, 2014).
IV. Nutritional Diagnosis
23. Select two nutrition problems and complete the PES statements for each
Inadequate protein intake (NI-5.7.1) related to 24 hour diet recall as evidenced by low protein lab
value.
Inadequate Energy Intake (NI-1.2) related to 24 diet recall as evidenced by 10# weight loss in a 6
month period
V. Nutrition Intervention
24. Ms. Wilcox 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?
I agree with parts of this diet. It is important for cirrhosis patients to consume soft foods because
this lessens the chance of causing internal inflammation and bleeding. In Nelms, it is
recommended that cirrhosis patients be put on a 2 g sodium diet instead of 4 g, but I agree with
the 2 L fluid restriction. Restricting sodium and fluid will help with excess fluid retention, as
seen in ascites and edema (Nelms, 2011). I would discuss with Ms. Wilcox the importance of
following this diet restriction, as well as describing the benefits that would occur if she does. I
would also make sure she understands the foods she should be avoiding while taking
spironolactone and propanolol, as mentioned above.

25. Ms. Wilcox asks if she can use a salt substitute at home. What would you tell
her?
I would tell Ms. Wilcox that she is not able to use a salt substitute that contains potassium. Ms.
Wilcox should avoid a salt substitute that contains potassium because of the interaction with her
prescribed drug spironolactone (Spironolactone, 2015) (Nelms, 2011). Ms. Wilcox should
instead take a salt free approach to her diet by trying to season foods with other herbs and
spices. (Salt Substitutes)
26. Using the information from her usual dietary intake, what suggestions might
you make to assist with compliance with the fluid and sodium restrictions?
In Ms. Wilcoxs usual dietary intake I notice that she drinks calcium-fortified orange juice in the
morning, Which should be avoided according to the nutrient drug interaction in spironolactone
and propranolol. Soup and crackers contain a lot of salt as well as fluid, and restaurant food
typically contains a lot of salt as well, especially Chinese or Italian. Diet sodas, such as diet coke,
can increase insulin resistance and inflammation. Specifically in cirrhosis, additional damage to
the liver can occur and it is not recommended to be consumed (Nseir et al, 2010). Based off her
usual dietary intake, she is consuming above the sodium and fluid restriction. I would work with
her to determine what types of foods she would be willing to eat instead, making sure that they
are within the prescribed sodium and fluid restrictions.
Evaluation and Monitoring
27. When you see Ms. Wilcox 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?
Ms. Wilcox is most likely experiencing ascites. Poor liver function is a consequence of cirrhosis
and is a leading cause of hepatorenal syndrome. Ascites is the retention of fluid within the
peritoneal cavity. When a patient suffers from hepatorenal syndrome they will begin to retain
fluid in their legs due to poor liver function (437, 443). This could be confirmed if the patient has
abnormal lab values as well as edema in the extremities (456,457).
28. Her diet history is as follows:
Breakfast: 1 slice of 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 whole wheat 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.
Since Ms. Wilcox is prescribed a soft food, restricted sodium and fluid diet, it is important for
her to follow this regimen in order for her to reduce further damage in her liver. Since the soft
food diet also includes foods with lower fiber content, it is important for her to avoid high-fiber
foods as well. For breakfast I would remove the toast since it is not a soft food, and reduce the
amount of skim milk. Instead I would replace these with a smoothie. The smoothie can contain

the peanut butter for protein, cup of skim milk, and seedless, skinless fruit which will provide
the nutrients she needs without the damaging aspects of the fiber. For lunch I would keep the 1
cup of skim milk but remove the potato chips, since they are high in sodium and a hard food, and
replace it with a soft vegetable such as cooked carrots or even mashed potatoes if she wanted to
stick with potatoes. Since grilled cheese sandwiches are hard because of the grilled bread and
bread is high in fiber, I would switch out the bread for a.well cooked pasta. She could switch out
the American cheese, since it is high in sodium, for a lower sodium cheese such as mozzarella,
with her pasta. For supper I would switch the bbq chicken wings for a fish, since they have a
softer texture than meat. I would remove the french fries since they are high in sodium and a
harder food, and replace it with a cooked vegetable. I would also remove the lemonade since it is
typically higher in sugar, and replace it with an unsweetened fruit juice.
References
Adb El-Mageed, N. (2011). Hepatoprotective effect of feeding celery leaves mixed with chicory
leaves and barley grains to hypercholesterolemic rats. Pharmacognosy Magazine, 151-156.
doi:10.4103/0973-1296.80675
Bellows, L., & Moore, R. (2014, August 8). Nutrient-Drug Interactions and Food. Retrieved
September 21, 2015, from http://www.ext.colostate.edu/pubs/foodnut/09361.html
Cirrhosis. (2013, May 31). Retrieved September 21, 2015, from
https://umm.edu/health/medical/altmed/condition/cirrhosis
Cirrhosis. (2014). Retrieved September 20, 2015, from http://www.niddk.nih.gov/healthinformation/health-topics/liver-disease/cirrhosis/Pages/facts.aspx
Cirrhosis liver. (2012, September 22). Retrieved September 21, 2015, from
http://www.bidmc.org/YourHealth/Conditions-AZ/Cirrhosis-liver.aspx?ChunkID=21738
Cirrhosis - Treatment . (2015, April 15). Retrieved September 20, 2015, from
http://www.nhs.uk/Conditions/Cirrhosis/Pages/Treatment.aspx
Eghtesad, S., Poustchi, H., & Malekzadeh, R. (2013). Malnutrition in Liver Cirrhosis: The
Influence of Protein and Sodium. Middle East Journal of Digestive Diseases, 65-75. Retrieved
September 20, 2015, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3990138/
Krenitsky, J. (2003). Nutrition for Patients with Hepatic Failure. Nutrition Issues in
Gastroenterology. Retrieved September 20, 2015, from
http://www.medicine.virginia.edu/clinical/departments/medicine/divisions/digestivehealth/nutrition-support-team/nutrition-articles/jun03krenitskyarticle.pdf
MELD and the Waiting List for Liver Transplant. (2014). Retrieved September 20, 2015, from
http://www.cpmc.org/advanced/liver/patients/topics/MELD.html#What is MELD? How will it be
used?

Mousseau, D., & Butterworth, R. (1994). Current Theories on the Pathogenesis of Hepatic
Encephalopathy. Experimental Biology and Medicine, 329-344.
Nelms, M., Sucher, K., & Lacey, K. (2011). Nutrition Therapy and Pathophysiology (3rd ed.).
Boston, MA: Cengage Learning.
Nseir, W., Nassar, F., & Assy, N. (2010). Soft Drink Consumption and Nonalcoholic Fatty Liver
Disease. World Journal of Gastroenterology, 2579-2588. doi:10.3748/wjg.v16.i21.2579
Propranolol (Cardiovascular): MedlinePlus Drug Information. (2015, June 15). Retrieved
September 21, 2015, from https://www.nlm.nih.gov/medlineplus/druginfo/meds/a682607.html
Qamar, A., & Grace, N. (2009). Abnormal Hematological Indices in Cirrhosis. Canadian
Journal of Gasterology, 441-445. Retrieved September 21, 2015, from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2721814/
Salt Substitutes. (n.d.). Retrieved September 18, 2015, from
http://my.clevelandclinic.org/services/heart/prevention/nutrition/food-choices/salt-substitutes
Spironolactone: MedlinePlus Drug Information. (2015, May 15). Retrieved September 21, 2015,
from https://www.nlm.nih.gov/medlineplus/druginfo/meds/a682627.html
Viral Hepatitis. (n.d.). Retrieved September 21, 2015, from
http://www.hepatitis.va.gov/patient/complications/cirrhosis/single-page.asp