Term
| What are clinical manifestations of portal hypertension? |
|
Definition
| Ascites, hyponatremia, and esophageal varices |
|
|
Term
| Describe the starvation state seen in liver patients |
|
Definition
| The loss of glycogen stores that occurs in patients with advanced liver disease causes them to enter a starvation state within a few hours of fasting. This leads to peripheral muscle proteolysis to provide amino acids for gluconeogenesis, thus contributing to protein malnutrition. |
|
|
Term
| What percentage of alcoholic hepatitis patients have malnutrition? |
|
Definition
| Almost all alcoholic hepatitis patients have some degree of malnutrition |
|
|
Term
| What are the current dietary recommendations for treatment of NAFLD? |
|
Definition
| Diet and physical activity for weight reduction, weight loss surgery for extreme obesity |
|
|
Term
| Is ketogenic diet recommended for NASH patients? |
|
Definition
| Yes, it has been shown to lead to significant weight loss and histologic improvement of fatty liver disease |
|
|
Term
| Is St. John's wort appropriate for patients taking HCV protease inhibitors? Why? |
|
Definition
| No because it can lead to loss of efficacy |
|
|
Term
| What is management for hereditary hemachromatosis? |
|
Definition
- Monthly blood donations (phlebotomy)
- Limited dietary iron intake
- Avoidance of excess vitamin C supplementation (enhances iron absorption)
- Avoidance of excess alcohol (increases risk of cirrhosis)
|
|
|
Term
| What is Wilson's disease? |
|
Definition
| Heterogenous inborn error of copper metabolism |
|
|
Term
| What is the medical management of Wilson's disease? |
|
Definition
- Chelating agents
- Zinc acetate
- Avoidance of high-copper foods (liver, chocolate, shellfish, and nuts)
|
|
|
Term
| What are the nutritional consequences and management of chronic cholestasis? |
|
Definition
| Calcium and fat-soluble vitamin malabsorption, both of which should be supplemented |
|
|
Term
| How does the presence of ascites increase resting energy expenditure? |
|
Definition
| Presence of ascites increases REE by 10% |
|
|
Term
| How does long-term energy expenditure differ in starving patients vs fasting cirrhotic patients? |
|
Definition
| In starving patients, REE decreases over time. Fasting cirrhotic patients continue to have normal or increased energy expenditures. |
|
|
Term
| How does cirrhosis affect macronutrient metabolism? |
|
Definition
| Cirrhotic patients often have decreased carbohydrate use and storage capacity plus an increase in fat and protein catabolism, resulting in a chronic catabolic state |
|
|
Term
| What schedule should meals be provided to advanced liver disease patients? Why? |
|
Definition
Three meals (the first of which should be early in the morning), three snacks, and one bedtime supplement.
This minimizes fasting AND the early breakfast improves cognitive function in patients with minimal HE. |
|
|
Term
| What is the benefit to an early breakfast in patients with hepatic encephaloathy? What is the advantage of the bedtime supplement? |
|
Definition
| The early breakfast improves cognitive function. The bedtime supplement improves body protein stores. |
|
|
Term
| Should protein be restricted in liver disease? |
|
Definition
| Only in HE refractory to medication |
|
|
Term
| What defines decompensated cirrhosis? |
|
Definition
| Cirrhosis with ascites and/or encephalopathy |
|
|
Term
| What are the protein and energy recommendations for decompensatic cirrhosis? |
|
Definition
35-40 kcal/kg
1-1.5 g protein/kg |
|
|
Term
| What are the AA recommendations for PN support in HE? |
|
Definition
| If the patient is unable to tolerate standard amino acids, a BCAA-enriched solution specifically designed for liver disease can be used |
|
|
Term
| What is the preferred route of nutrition support in liver disease? |
|
Definition
| Enteral nutrition (typically via NG or OG) |
|
|
Term
| What are the recommendations for vitamin E relative to liver disease? |
|
Definition
| 800 IU vitamin E may benefit patients with NASH |
|
|
Term
| What is GSH? Is it recommended for liver disease? |
|
Definition
| GSH is a tripeptide synthesized from glutamate, cysteine, and glycine. It is sometimes used in liver disease but no recommendations exist |
|
|
Term
| Are SAM/Betaine recommended for liver disease? |
|
Definition
| No. Trials have not shown benefit. |
|
|
Term
| Is zinc supplementation recommended for liver disease? |
|
Definition
| Yes, although there is no standard dosing |
|
|
Term
| What is silymarin? How frequently is it used in liver disease? Is it recommended for liver disease? |
|
Definition
| Silymarin is an extract of milk thistle. It is the most common CAM supplement used in liver disease. It is safe, but studies have shown questionable benefit in liver disease. |
|
|
Term
| Are BCAAs recommended for patients with cirrhosis? |
|
Definition
| Yes, they have shown benefit and should be considered in patients with cirrhosis |
|
|
Term
| What vitamin deficiencies are patients with liver disease particularly prone to? |
|
Definition
|
|
Term
| How can ascites be prevented? |
|
Definition
|
|
Term
| At which level of hyponatremia should fluid restriction be considered in liver dz patients? |
|
Definition
| Fluid restriction is reasonable for serum sodium <125 |
|
|
Term
| Is nasoenteric tube placement recommended for cases of esophageal varices? |
|
Definition
| Patients with esophageal varices can receive tubes EXCEPT during or immediately after treatment of bleeding esophageal varices |
|
|
Term
| Is PEG placement indicated in ascites? |
|
Definition
| No, it is contraindicated |
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