Running head: HEPATOBILIARY CASE STUDY

Hepatobiliary Case Study

Sarah Fennewald
Fontbonne University

HEPATOBILIARY CASE STUDY

Hepatobiliary Case Study

Case Study A
A.) A diet order of fat-restricted, high protein with no alcohol was prescribed to Mr. L for
several reasons. First of all, no alcohol is included in the order because Mr. Ls alcohol
consumption has caused a fatty liver and hepatitis. Mr. L will continue to damage his
liver if he drinks alcohol, possibly leading to cirrhosis. At this point Mr. Ls condition is
reversible if he stops drinking, but if develops cirrhosis it will be irreversible. High
protein is prescribed to Mr. L because alcoholic hepatitis causes injury to the liver and
stress, which increases protein needs, along with calorie needs. Protein use is also
increased with liver disease, so a higher protein intake is required to keep nitrogen
balanced. The goal of MNT is to prevent any more liver injury and enhance regeneration
of the liver cells, which requires extra protein, unless encephalopathy is present, which it
is not in this case. The patient is put on a fat-restricted diet because fat cannot be
absorbed as well when the liver is injured. The liver normally produces bile to break
down fat, but with a fatty liver not enough bile is produced to absorb fat properly,
therefore fat is restricted to 30 to 45 grams daily. Overall, this diet order was prescribed
to help Mr. L maintain his nutritional status while trying to regenerate liver cells and
resolve the hepatitis.
B.) I would use the Subjective Global Assessment and diet intake to assess Mr. Ls
nutritional status. I would use those methods instead of looking at traditional measures
since many markers are affected by liver disease, such as protein labs. More specifically,
I would look at anthropometric measurements and evaluate Mr. Ls dietary intake from a
24 hour food recall or usual day intake. The SGA examines history of the patients

HEPATOBILIARY CASE STUDY

weight and food preferences, physical findings, and existing conditions that may
influence nutrition. In Mr. Ls case more information is needed to determine nutritional
status using the SGA.
As far as history goes, we have Mr. Ls weight for the past 6 months and know
that he has lost 20 lbs. We also know that his ascites has gotten worst over the past 6
months and that can be taken in to consideration when assessing his weight change.
When he first came to the hospital, he felt slightly bloated, but now he is on a sodium
restricted diet due to the ascites. We also know Mr. L is having some gastrointestinal
problems; both times at the hospital he has complained of epigastric pain and bloating.
Other than that he is not dealing with any nausea, vomiting, or diarrhea. As far as
physical findings, we know that ascites is present with Mr. Ls hepatitis. We also know
about Mr. Ls existing conditions. We do know some about Mr. Ls intake for the last
two days, since he has been in the hospital, but it is not his usual intake due to a NPO
status for tests and a dislike of the hospital food.
Even though we know some of Mr. Ls intake for the past two days, we still do
not know his usual intake. I would want to do a typical day intake with Mr. L to get a
better sense of what he normally eats to really see what his calorie, protein, and sodium
intake is and if he is meeting his needs. I would also want to assess his appetite and find
out if his tastes have changed or he has early satiety. He has not eaten much the past
couple days because he does not like the low sodium diet and he hasnt been allowed to
eat, but that doesnt really tell me if he has an appetite or if satiety is an issue. I would
also want to asses more of Mr. Ls physical findings because we do not know if he has fat
stores or muscle wasting. A visual assessment might help to determine this, but a physical

HEPATOBILIARY CASE STUDY

assessment would also be necessary to check for muscle loss and edema. I would also
collect more information about any existing conditions Mr. L might have that would
affect his nutritional intake. At this point it does not seem like there are any conditions
besides the ascites, but Mr. L could provide more information himself or his test results
might help to determine if there any conditions such as an infection, renal insufficiency
or GI bleeding. Lastly, I would ask Mr. L how he handles normal daily activities to assess
his functional status.
C.) See Attachment
D.) Mr. Ls diagnosis of portal hypertension and esophageal varices are related to his liver
disease and ascites. Portal hypertension is high blood pressure in the portal vein and it
increases collateral blood flow and can result in swollen veins, or varices, in the GI tract
(Hasse & Matarese, 2012, p. 660). It is often occurs when the liver is damaged and blood
flow through the liver is obstructed and slowed down. In Mr. Ls case, his hematemesis
was most likely the result of esophageal varices bleeding. Ascites is also another
complication from portal HTN and Mr. L already had ascites present. When bleeding
occurs, like in Mr. Ls case, food cannot be consumed enterally and treatment may
include banding of the varices to prevent bleeding in the future.
E.) The elevated NH3 is significant because it is believed to lead to hepatic encephalopathy,
which Mr. L is experiencing. When ammonia levels are elevated in the bloodstream and
brain, neural functions become impaired (Hasse & Matarese, 2012, p.661). This occurs
with liver disease because the liver is usually responsible for detoxifying ammonia to
urea. The main source of ammonia is produce by the GI tract from the metabolism of
protein and from the degradation of bacteria and blood from GI bleeding (Hasse &

HEPATOBILIARY CASE STUDY

Matarese, 2012, p. 661). The lactulose enema will help because it is will draw ammonia
from the blood to the colon and cause it to leave the body instead of stay in the
bloodstream. The goal is for a patient to have 4 stools a day so that the ammonia is
excreted from the body and cannot reach the brain.
F.) I would recommend a soft, high protein, sodium restricted diet for the patient at home. I
would recommend the patient consume around 2000 kcals, 100 g of protein, and 4 g of
sodium. I would also recommend that the patient consume a multivitamin daily and
additional thiamin and folate daily. I would recommend a soft diet since Mr. L was
diagnosed with esophageal varices. I would recommend high protein because protein
needs will still be increased with ESLD and Mr. L is still very weak. Sodium is restricted
to keep the ascites down, but it is not as strict as before because Mr. L did not eat very
well on a 1 g sodium diet. It will be important for Mr. L to consume 2000 kcals daily, so
he must like the food he can eat. 2000 kcals were prescribed because Mr. Ls energy
needs will be increased with ESLD and he lost a lot of weight in the past 6 months.
Lastly, alcohol would be restricted to prevent Mr. Ls condition from getting any worse.
G.) Four other health care providers that would be needed for Mr. Ls care include a
hepatologist, nurse, gastroenterologist, and a social worker. The hepatologist would be
MR. Ls main physician who specializes in liver disease and can help to treat Mr. Ls
hepatitis and ESLD. The nurse would be important to Mr. L during his hospital stays by
providing fluids, medications, and providing overall support. The nurse would also be
able to monitor the patients oral intake, which was a concern. The gastroenterologist is a
physician who specializes in the GI tract and he would be necessary to help Mr. L with
his varices and complications of the portal hypertension. He would probably be the one to

HEPATOBILIARY CASE STUDY

place bands on the varices if needed. Lastly, a social worker would be important to Mr. L,
since he has trouble with drinking alcohol. The social worker could help Mr. L find a
support group and help him to take steps to quit drinking.

HEPATOBILIARY CASE STUDY

7
References

Hasse, J. M. & Matarese, L. E. (2012). Medical nutrition therapy for hepatobiliary and pancreatic
disorders. In L. K. Mahan, S. Escott-Stump, & J. L. Raymond (Eds.), Krauses food and
the nutrition care process (13th ed., pp.645-674). St. Louis, MO: Elsevier.