Chronic Cirrhosis With Ascites
CHRONIC CIRRHOSIS WITHASCITESSHWETA D. KAMBLIR.D. INTERN
PATIENT PROFILE Name: Mrs. XYZ Occupation: Farmer Age: 47 No. of family members: 7 Gender: Female Addictions: None Community: Maharashtrian Dietary pattern: Non-Vegetarian State: Maharashtra; Taluka: Yawal; District: SGA Score: CJalgaon Date of Admission: 25/10/2016 Residential area: Rural Date of Discharge: 26/11/2016 Economic Status: Lower socio-economic status Length of hospital stay: 32 days
CLINICAL ASSESSMENT Present Complaints: k/c/o Pulmonary hypertension, liver cirrhosis now admitted with c/o severe ascites;distension of stomach since 4 months; pedal edema, poor appetite, loss of weight, weakness, shortness ofbreath and dyspnea on exertion and heaviness of chest present. Past Medical History: 17 years back patient had a case of fluid accumulation in abdomen during postpregnancy duration. Patient took ayurvedic medications and it settled down. Family Medical history: None.Final Medical Diagnosis: LIVER CIRRHOSIS WITH ASCITES AND DILATED CARDIOMYOPATHY.
LIVER CIRRHOSIS Cirrhosis is a condition in which the liver slowly deteriorates and is unable to function normally due tochronic, or long lasting injury. In the early stages of cirrhosis, the liver continues to function. However, as cirrhosis gets worse and scar tissue replaces healthier tissue, this blocks the flow of bloodthrough the liver. Chronic liver failure, which is also called end-stage liver disease, progresses over months, years, oreven decades. With end-stage liver disease, the liver can no longer perform important functions oreffectively replace damaged cells.
Pulmonary hypertension: Liver disease can cause “portal hypertension,” meaning there is an increasedblood pressure in the veins that enter the liver. This increased pressure causesblood to bypass the liver. As a result, the blood vessels of the lungs are exposed to possible toxicsubstances and this can damage the small arteries of the lungs, causingpulmonary arterial hypertension (PAH). The pulmonary arteries, which are responsible for transporting the blood fromthe right ventricle heart to the lungs, become narrowed and blocked due to thedisease. To properly pump the blood, the heart needs to work harder, becomingenlarged and weakened, increasing the risk of suffering right heart failure.
Dilated cardiomyopathy: Cardiomyopathy refers to diseases of the heart muscle. In dilated cardiomyopathy, the heart's ability to pump blood is decreased because the heart's main pumpingchamber, the left ventricle, is enlarged, dilated and weak. At first, the chambers of the heart respond by stretching to hold more blood to pump through the body. With time, the heart muscle walls weaken and are not able to pump as strongly.Ascites: The mechanism by which ascites develops in cirrhosis is multifactorial. Severe sinusoidal portal hypertension and hepatic insufficiency are the initial factors. They lead to acirculatory dysfunction characterized by arterial vasodilation, arterial hypotension, high cardiac output,hypervolemia and to renal sodium and water retention.
Malnutrition: Patients with cirrhosis frequently have either global malnutrition or alterations in specific aspects ofnutritional status, such as micronutrient deficiencies, due to multiple mechanisms, including poornutritional intake, poor absorption, and increased losses. In addition, one of the most significant nutritional problems in cirrhotic patients is muscle wasting andsarcopenia.(McClain, C. J. (2016). Nutrition in Patients with Cirrhosis. Gastroenterology & Hepatology, 12(8), 507–510.)
ANTHROPOMETRIC ASSESSMENTMEASUREMENTSVALUESHeight147cmWeight37 Kgs during admissionDry weight post tapping is 34 Kg)Dry Body mass index (BMI)15.73Kg/m2Ideal Body Weight (IBW)42Kg
635353536363535.535.53636363534.534.5FLUID INPUT(ml)FLUID 08659009309957401050125014001250USG GUIDEDASCITIC FLUIDTAPPING(ml)2500ml1100ml500ml-
BIOCHEMICAL ASSESSMENT
RESULTTESTREFERENCE mChlorideAmmoniaAST/ SGOTALT/ SGPTBilirubin totalBilirubin Unconjugated (BU)Bilirubin Conjugated (BC)Bilirubin deltaAlkaline phosphataseTotal proteinsAlbuminGlobulinAlbumin/Globulin 9.114428210.800.360.000.44817.083.713.381.1BNP Peptide958-----Blood sugar RandomBlood urea NitrogenUric AcidSerum Creatinine93115.30.7-0.8-0.7-Prothrombin timeWBCAdenosine deaminase activity (ADA)Sample type- Ascitic fluidBlood group15.80A Positive19/11/1622/11/1613.011-14 Seconds4-1010 3/uL11.5-16g/dl140-440 10 3/uL137-145mmol/L3.5-5.1mmol/L98-107 mmol/L9-33 umol/L15-46 U/L13-69 U/L0.2 – 1.3 mg/dL0-1 mg/dL0-0.3 mg/dL0-0.2 mg/dl38-126 IU/L6.3-8.2mg/dl3.5 – 5 g/dL2.4 – 3.5 g/dL1.1 -2.2 400 pg/ml- heart failureprobable65-165mg/dl7-17mg/dL2.5-6.2 mg/dL0.7-1.2mg/dL 30U/L
b. Other espiration(b/min)Blood 90/6022/11/201610:00am98702090/60CT Scan of abdomen: Indicate severe Ascites and Splenomegaly.Liver biopsy: Sections reveal variably sized nodules separated by fibrotic bands. Granulomas were notseen.Microbiological testing of the Ascitic fluid: No pus cells, no organisms seen.
MEDICATION DURING HOSPITAL STAY
MEDICATIONDOSAGEMECHANISM OF ACTIONTAB. ENDOBLOC 10MG1-0-0Medicine used for the treatment of pulmonary hypertension. It works by widening the arteries andreducing the blood pressure.TAB. CAVERTA 25MG1-0-1 (5Days aweek)TAB. LANOXIN 0.25MG1-0-0TAB. LASILACTONE100MG1-0-0SIDE- EFFECTSPeripheral edema, Nasal congestion, Sinusinflammation, FlushingUsed for the treatment of high blood pressure. It works by relaxing the blood vessels and widening headache, flushing of the face, and upset stomach.the blood vessels in the lung.nausea, vomiting, loss of appetite; fast, slow, oruneven heart rateUsed to treat various heart conditions such as atrial fibrillation, atrial flutter and heart failure.Used in the treatment of fluid retention. Works by preventing the body to absorb too much salt,eliminating unneeded water and sodium from the body into the urine.Increased production of urine, dehydration,decreased blood pressure, weakness, drowsinessUsed for Maintaining the proper balance of body fluids and body's acid base balance, Neutralizingthe free radicals and participates in vital redox reactions of the body, Raising the level ofTAB.MULTIVIT GOLD1-0-0glutathione thus prevents cells against peroxidative damage, Works for the healing purpose,Vomiting, dehydration, gastrointestinaldisturbances, fatigue, itching of skin.Improving the body's metabolism, Widening the blood vessels, Increasing the effects of insulin,Promoting the formation of active prothrombin in liver, Helping in bone and collagen synthesis.TAB. PAN 40MGLASIX 10MG1-0-1Used in the treatment of acidity, heartburn, intestinal ulcers and stomach ulcers. It lowers the acidproduction in the stomach.1-0-1It is a potent diuretic that is used to eliminate water and salt from the body. It works by blockingthe absorption of sodium, chloride and water from the filtered fluid in the renal tubules, causing aprofound increase in the output of urine.TAB. ZEVIT1-0-0It is a multi-vitamin supplement mainly utilized therapeutically as nutritional support in variouscases of deficiency of vitamin B complex , folic acid and vitamin C.CALCITROLGRANULES SACHETEvery 4Th DayIt is used for the treatment of vitamin D3 deficiency, rickets and osteomalacia1-0-0It reduces the accumulation of ammonia in patients with poor liver function thereby relievingsymptoms associated with abnormal ammonia metabolism.HEPA MERZ SACHETNausea, Headache, Abdominal pain, Constipation,Diarrhea, FlatulenceDizziness, light headedness, headache,blurred visionBitterness of mouth, Gastrointestinal problems,Flatulence, Loss of appetite, Bloating, stomachpain, Nausea, Anxiety, Persistent itchy rashes onskin.weakness, fatigue, headache, nausea, vomiting,constipation, dry mouth, metallic taste, muscle pain,or bone pain.Vomiting, Nausea, Diarrhea, Abdominal pain,Flatulence
DIETARY ASSESSMENT : 24Hr. Home diet recall
MenuTeaIngredients AmountsHouseholdEnergy (Kcal)measuresCHO (g)Protein (g)Fat (g)Vit C (mg)Fe (mg)Na (mg)K (mg)0.10.0736.570063.2746.27:00am - EARLY MORNING21.652150014.2314.110:00am - BREAKFASTIF (g)SF (g)Calcium(mg)MilkSugar50ml5g15g1/2 cup1 tsp.2no.332090Rice Flakes30g1/2 cup100212.5OnionOil50g5ml1 small1 tsp.2045500.50052:00pm - LUNCH10.6263.5Jowarichi Bhakri Jowar flour30g2 tbsp.100212.501.232.1939.32.40.517.5Shengachi Bhaji DrumstickOnionTomatoOil50g50g25g5ml1 stick1 small1/2 no.1 3129.563.536.515201250ml5g15g1/2 cup1 tsp.2 ato50gOil5mlTOTALCALORIE (Kcal)PERCENT (%)2 tbsp.3no.1/2 no.1 5.5851093KhariKande PoheTeaKhariVangi bhaatMilkSugar6425KCal/Kg BW0.50.50.500.500.250055:00pm - SNACK1.6520014.19:00pm - DINNER2.50.50.500.50051629622587310.4g/Kg 742103218
Nutritional calculation of home diet recall Energy: 842Kcal (25KCal/Kg BW) Interpretation of home diet recall: Proteins:16g (0.4g/Kg BW) HBV: 3.3gThe recall indicates that there are large gapsbetween the meals. Carbohydrate: 135g (64.09% of TC) The protein content in the diet is very low. Fats: 29g (30.67% of TC) No cereal pulse combination recipes areincluded. Calories to Nitrogen ratio: 338:1 180Kcals/842Kcal is achieved from Khari. Sodium: 92.69mg No fruit consumption in the diet.
NUTRITION ASSESSMENT SUMMARY BMI 15.73Kg/m2 which indicates that the patient is severely ere thinnessModeratethinnessMild thinnessNormal rangePrincipal cut-offpoints 18.50 16.00Additional cut-off points 18.50 16.0016.00 - 16.9916.00 - 16.9917.00 - 18.4917.00 - 18.4918.50 - 22.9923.00 - 24.9918.50 - 24.99Lancet, Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies; 2004 Mar13;363(9412):902.
SGA Score - C; Presence of mild to moderate edema, severe ascites, poor foodintake, severe loss of functional status, strength and stamina; indicates that thepatient is undernourished. Low hemoglobin levels indicating the presence of anemia. Hence, provide optimaliron through diet and nutrition supplement. Include source of Vitamin C in the diet toenhance the absorption of Iron.
MEDICAL NUTRITION THERAPYENERGY: Presence of Ascites has found to increase energy expenditure. Daily caloric recommendations for patients withliver cirrhosis range from 25 to 40 kcal/kg/day. ESPEN: 35-40 kcal/kg/day (M. Plauth et al; ESPEN Guidelines on Enteral Nutrition: Liver disease, January 2006; 25, 285–294.) ASPEN: With acute encephalopathy: 35 kcal/kg/day Without encephalopathy: 25-35 kcal/kg/day Stable and malnourished: 30-40 kcal/kg/day(Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical CareMedicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.; Journal of Parenteral and Enteral Nutrition,Vol 33, Issue 3, pp. 277 – 316)
PROTEIN: Cirrhosis is a catabolic disease with increased protein breakdown, inadequate resynthesis, depleted status,and muscle wasting. Negative nitrogen balance due to protein restriction leads to protein-energy malnutrition and decrease thesurvival rate in patients with liver cirrhosis.(O'Brien A, Williams R (2008) Nutrition in end-stage liver disease: principles and practice. Gastroenterology 134: 1729-1740.) ESPEN: 1.0-1.5 g/kg dry weight/day ASPEN:With acute encephalopathy: 0.6-0.8 g/kg dry weight /dayWithout encephalopathy: 1.0-1.5 g/kg dry weight /day Altered amino acid metabolism is a hallmark of liver disease, characterized by low levels of circulatingBCAAs and elevated levels of circulating aromatic amino acids, and methionine. BCAA supplementation appears to be associated with decreased frequency of complications of cirrhosis andimproved nutritional status when prescribed as maintenance therapy.
CARBOHYDRATES: Carbohydrates should be the major source of calories in the diet. Fasting low blood sugar can occur because of the decreased availability of glucose from glycogen.Therefore, carbohydrate should provide most of the non-protein calories.LIPID: Several investigations have concluded that excess dietary fat may encourage cirrhosis progression. High intakes of total fat, saturated fat, and polyunsaturated fat have been implicated. Medium chain triglycerides should be included in the diet for liver cirrhosis as it is better tolerated bythe patients and is absorbed in the absence of bile.(Corrao G, Ferrari PA, Galatola G (1995) Exploring the role of diet in modifying the effect of known disease determinants:application to risk factors of liver cirrhosis. Am J Epidemiol 142: 1136-1146.)
ANTIOXIDANTS AND B-VITAMINS: Cirrhotic patients have significant reductions in antioxidant enzymes and antioxidant nutrients, such ascarotenoids, selenium, vitamin E, and zinc. Deficiency of folate is also found in liver cirrhotic patients and an estimated 50% have increased bloodhomocysteine concentrations which cause liver fibrosis and ultimately cirrhosis.(Halifeoglu I, Gur B, Aydin S, Ozturk A (2004) Plasma trace elements, vitamin B12, folate, and homocysteine levels in cirrhoticpatients compared to healthy controls. Biochemistry (Mosc) 69: 693-696.) Hepatic osteodystrophy or osteopenia can develop from vitamin D deficiency. Therefore,supplementation is necessary.(McClain, C. J. (2016). Nutrition in Patients with Cirrhosis. Gastroenterology & Hepatology, 12(8), 507–510.)
SODIUM RESTRICTION: A diet low in sodium can help to treat ascites and edema as it will minimize the amount of saltentering the kidney, leaving less sodium available for re-absorption, therefore, less fluid is retained.(Dolz C, Raurich JM, Ibáñez J, Obrador A, Marsé P, et al. (1991) Ascites increases the resting energy expenditure in livercirrhosis. Gastroenterology 100: 738-744.) A 2000 mg sodium-restricted diet is effective, when combined with diuretic therapy, for controllingfluid overload in 90% of patients with cirrhosis and ascites.(Runyon BA (1998) Management of adult patients with ascites caused by cirrhosis. Hepatology 27: 264-272.)
FLUID: It is important to carefully monitor and maintain the electrolyte and fluid balance. In liver diseases, the blood vessels ability to retain fluid is diminished because ofdecreased protein synthesis in the liver, mainly albumin. This causes fluid leaks in your blood vessels, which in turn, causes fluid buildup in othertissues, or ascites. By limiting the amount of salt and fluid in your diet, fluid retention and swelling can bereduced.
CASE PROGRESSIONDay 1NBMDay 2 - Day 17Soft Hepatic Salt Restricted DietDay 18 – Day 31Full Hepatic Salt Restricted Diet
SHORT TERM GOALS OF MANAGEMENT To treat symptoms and prevent complications. To prevent the progression of the complications and manage them. To administer fluid and sodium restriction to prevent further complications. To slow the progression of the scar tissue. To correct nutritional deficiency if any. To provide adequate nutrition to prevent macronutrient and micronutrient deficiencies. To provide adequate protein with high biological value to ensure anabolism and toprevent protein breakdown for energy synthesis. To provide small frequent soft meals to reduce the patient’s discomfort. To improve and maintain the nutrition status.
HOSPITAL PRESCRIBED DIET
Nutritional calculation of Hospital diet(Soft hepatic salt restricted diet- Day 2-Day 17 Type of diet: Soft hepatic salt restricted diet Carbohydrate: 165g (62.84% of TC) Frequency of meals: Distributed 8 meals perday Fats: 26g (22.62%) MCT: 10g (40% of total fat) Calories to Nitrogen ratio: 168:1 Sodium: 431mg (Sodium restriction of2000mg/day) Salt per day: 4 gm/day Fluid: 1000ml Consistency of diet: Soft Energy: 1052Kcal (31KCal/Kg BW) Proteins: 39g (1.1g/Kg BW) HBV: 20.25g
MenuIngredients Amounts Energy (Kcal) CHO (g)Protein (g)Fat (g)Vit C (mg) Fe (mg)Na (mg)K (mg)36.5706.324.9IF (g)SF (g)Calcium (mg)7:00am - EARLY MORNINGTeaThreptin no.21.92.41.50.710.1600.078:00am - BREAKFASTUpmaBoiled .05261.42.880.8733011:00am - 0.960.2731:00pm - LUNCHSoft riceRice30g100212.50.500.21Boil DalMoong dal30g1001770.501.178.163451.950.5122.5Saute potato with jeerapowderBoiled 0Curd4:00pm - SNACKSTeaThreptin no.21.92.41.50.70.07
MenuIngredients Amounts Energy (Kcal) CHO (g)Protein (g)Fat (g)Vit C (mg) Fe (mg)Na (mg)K (mg)IF (g)SF (g)Calcium (mg)6691.31.3170.480.13536:00pm - LATE EVENINGFruitPapaya100g501000570.58:00pm - DINNERKhichdiRice15g5010.51.250.2500.21Moong tfreeButter5g35005Boiled carrotsBoiled .62.50.120.27314012010.136.570601109431179710:00pm - BEDTIMEWarm milkMilk50ml14.52.31.250.05Threptin biscuitBiscuit1no.21.92.41.50.710521653926CALORIE (Kcal)661156238PERCENT (%)63TOTAL31KCal/KgBW151.1g/Kg BW23136632
Nutritional calculation of Hospital diet(Full hepatic salt restricted diet- Day 18-Day 31 Type of diet: Full hepatic salt restricted diet Carbohydrate: 189 g (63.46% of TC) Frequency of meals: Distributed 8 meals perday Fats: 32g (24.05% of TC) MCT: 10g (30% of total fat) Calories to Nitrogen ratio: 180:1 Sodium: 339mg (Sodium restriction of2000mg/day) Salt per day: 4gm Salt packet Fluid: 1000ml Consistency of diet: Full diet Energy: 1188Kcal (34KCal/Kg BW) Proteins: 41.2g (1.2g/Kg BW) HBV: 20.25g
MenuIngredientsAmounts Energy (Kcal) CHO (g) Protein (g)Fat (g)Vit C (mg)Fe (mg)Na (mg)K (mg)0.136.570IF (g)SF (g)Calcium(mg)7:00am - EARLY MORNINGTeaThreptin no.21.92.41.50.71600.078:00am - BREAKFASTPohaBoiled EggRice 81.10.7176203011:00am - MIDMORNINGFruitBanana100g11627.21.20.31:00pm - LUNCHChapatiWheat flour30g100212.50.501.47694.52.880.8714.4Dudhi 6.750.163.2336.512Oil5ml45005Boil DalMoong 120.27314012010.136.570601.950.5122.54:00pm - SNACKSTeaThreptin no.21.92.41.50.70.07
MenuIngredientsAmounts Energy (Kcal) CHO (g) Protein (g)Fat (g)Fe (mg)Na (mg)K (mg)IF (g)SF (g)Calcium(mg)570.56691.31.3170.480.1351.5Vit C (mg)6:00 - LATE EVENINGFruitPapaya100g5010008:00pm - DINNERKhichdiRice15g5010.51.250.2500.105Moong ltfreeButter10g700010Boiled potato with jeerapowderBoiled pm - BEDTIMEWarm milkMilk50ml14.52.31.250.05Threptin biscuitBiscuit1no.21.92.41.50.711881894132CALORIE (Kcal)754165286PERCENT (%)631424TOTAL34KCal/KgBW1.2g/KgBW125617
NUTRITIONAL COMPLIANCE
9303132Type of dietSoft hepatic Salt Restricted dietSoft hepatic Salt Restricted dietSoft hepatic Salt Restricted dietSoft hepatic Salt Restricted dietSoft hepatic Salt Restricted dietSoft hepatic Salt Restricted dietSoft hepatic Salt Restricted dietSoft hepatic Salt Restricted dietSoft hepatic Salt Restricted dietSoft hepatic Salt Restricted dietSoft hepatic Salt Restricted dietSoft hepatic Salt Restricted dietSoft hepatic Salt Restricted dietSoft hepatic Salt Restricted dietSoft hepatic Salt Restricted dietSoft hepatic Salt Restricted dietFull hepatic Salt Restricted dietFull hepatic Salt Restricted dietFull hepatic Salt Restricted dietFull hepatic Salt Restricted dietFull hepatic Salt Restricted dietFull hepatic Salt Restricted dietFull hepatic Salt Restricted dietFull hepatic Salt Restricted dietFull hepatic Salt Restricted dietFull hepatic Salt Restricted dietFull hepatic Salt Restricted dietFull hepatic Salt Restricted dietFull hepatic Salt Restricted dietFull hepatic Salt Restricted dietPlannedEnergy- 1052Kcal ;Protein- 39gEnergy- 1052Kcal ;Protein- 39gEnergy- 1052Kcal ;Protein- 39gEnergy- 1052Kcal ;Protein- 39gEnergy- 1052Kcal ;Protein- 39gEnergy- 1052Kcal ;Protein- 39gEnergy- 1052Kcal ;Protein- 39gEnergy- 1052Kcal ;Protein- 39gEnergy- 1052Kcal ;Protein- 39gEnergy- 1052Kcal ;Protein- 39gEnergy- 1052Kcal ;Protein- 39gEnergy- 1052Kcal ;Protein- 39gEnergy- 1052Kcal ;Protein- 39gEnergy- 1052Kcal ;Protein- 39gEnergy- 1052Kcal ;Protein- 39gEnergy- 1052Kcal ;Protein- 39gEnergy- 1188Kcal ;Protein- 41gEnergy- 1188Kcal ;Protein- 41gEnergy- 1188Kcal ;Protein- 41gEnergy- 1188Kcal ;Protein- 41gEnergy- 1188Kcal ;Protein- 41gEnergy- 1188Kcal ;Protein- 41gEnergy- 1188Kcal ;Protein- 41gEnergy- 1188Kcal ;Protein- 41gEnergy- 1188Kcal ;Protein- 41gEnergy- 1188Kcal ;Protein- 41gEnergy- 1188Kcal ;Protein- 41gEnergy- 1188Kcal ;Protein- 41gEnergy- 1188Kcal ;Protein- 41gEnergy- 1188Kcal ;Protein- 41g% ComplianceEnergy- 71% ;Protein- 76%Energy- 70% ;Protein- 75%Energy- 71% ;Protein- 76%Energy- 72% ;Protein- 76%Energy- 81% ;Protein- 79%Energy- 80% ;Protein- 78%Energy- 81% ;Protein- 79%Energy- 82% ;Protein- 80%Energy- 80% ;Protein- 79%Energy- 79% ;Protein- 80%Energy- 81% ;Protein- 79%Energy- 80% ;Protein- 78%Energy- 81% ;Protein- 79%Energy- 82% ;Protein- 80%Energy- 81% ;Protein- 79%Energy- 81% ;Protein- 79%Energy- 86%; Protein- 96%Energy- 87%; Protein- 96%Energy- 86%; Protein- 96%Energy- 88%; Protein- 97%Energy-90%; Protein- 98%Energy-90%; Protein- 98%Energy-90%; Protein- 98%Energy-90%; Protein- 98%Energy- 100%; Protein- 100%Energy- 100%; Protein- 100%Energy- 100%; Protein- 100%Energy- 100%; Protein- 100%Energy- 100%; Protein- 100%Energy- 100%; Protein- 100%DischargeReasons Patient during admission hadsevere loss of appetite and wasnot willing to eat food. Later, through variousstrategies like counselling thepatient, a marked increase inthe food consumption wasseen.
DISCHARGE DIET
LONG TERM GOALS OF MANAGEMENT To provide adequate nutrition to prevent macronutrient and micronutrient deficiencies. To prevent the progression of the complications and manage them. To slow the progression of the scar tissue. To administer fluid and Sodium restriction to prevent further complications. To prevent nutritional deficiency. To provide nutrition education to the patient and the care giver. To improve quality of life.
Nutritional calculation of Discharge diet(Full hepatic salt restricted diet) Type of diet: Full hepatic salt restricted diet Carbohydrate: 219.65g (65.10% of TC) Frequency of meals: Distributed 8 meals perday Fats: 31.72g (21.15% of TC) MCT: 10g (32% of total fat) Calories to Nitrogen ratio: 194:1 Sodium: 194.91mg (Sodium restriction of2000mg/day) Salt per day: 4gm Salt packet Fluid: 1200ml Consistency of diet: Full diet Energy: 1349.7Kcal (39KCal/Kg BW) Proteins: 43.41g (1.2g/Kg BW) HBV: 14g
EXCHANGE LIST OF THE PRESCRIBED MNT
Food groupExchangeAmountsEnergy (Kcal)CHO (g)Protein (g)Fat (g)Cereal5150g50010512.52.5Pulse260g20034141Milk & Milk products2200ml6086.650Egg150g90077Veg A1100g25610Veg B1/250g2050.50Veg 019.200Glucon D1/220g721800Oil220ml1800020Garden cress seeds1/45g22.71.651.261.22TOTAL13502174332CALORIE (Kcal)869174285PERCENT (%)64132139KCal/Kg BW1.2g/Kg BW
MEAL DISTRIBUTION
Food GroupEarlymorningCereal1Breakfast Midmorning Lunch11PulseMilk & 21/4Veg C3/411/41/21/2Fruits1/211/411/41/41/41Glucon D1/2Oil1/21/21Garden cress seedsTotal Calories(Kcal)120280TotalExchanges21/4Veg BBedtime1Veg ASugar/JaggerySnack50281851203191/221/41/4951350
DETAILED PRESCRIBED MENU
MenuIngredientHouseholdAmountsEnergy (Kcal) CHO (g) Protein (g)smeasuresFat (g)Vit C (mg) Fe (mg)NaachniJaggery30g5g2 tbsp.1 tsp.100208:00am - EARLY MORNING212.50.5500TeaMilkSugar50ml5g1/2 cup1 tsp.1520251.660PohaRice flakes30g2 tbsp.10021Onion25g1/2 small10Coconut oil5ml1 tsp.Boiled eggEgg50gFruitChickooMasala ba haldiNaachni satvaNa (mg)K (mg)IF (g)SF 36.5702.50.5063.2746.22.50.2500.50.3131.75450051 no.90001.05100g1 no.5061.2530g15g25g50g2 tbsp.1 tbsp.1/4 small1/2 35.594.3536.5123.55ml1 tsp.45005100ml1/2 cup3043.33020.2731401205g1"pc.4pm - 10:00am - BREAKFASTCurdFresh Amba haldiTeaRoasted chanaMilkSugarRoastedchana7712:00pm - MIDMORNING10001pm – LUNCH212.50.58.53.50.251.50.250120.5050ml5g1/2 cup1 tsp.15202515g2 62.020.270.340.550.3310.351253.780.4658.7
MenuIngredient AmountsHouseholdEnergy (Kcal) CHO (g) Protein (g)measuresFat (g)Vit C (mg) Fe (mg)Na (mg)K (mg)IF (g)SF (g)Calcium(mg)694.52.880.8714.46pm - LATE EVENINGGhavacha satvaWholewheat30g2 tbsp.100212.50.5Jaggery5g1 tsp.2050001.470.13248:00pm - DINNERNaachnichi BhakriNaachniflour30g2 tbsp.100212.50.501.173.3122.4Kulithcha PitlaKulithFlour30g2 tbsp.1001770.502.0313.45228.686.1Onion25g1/2 small102.50.2500.50.3131.7510Groundnutoil5ml1 tsp.45005Dudhi75g1 bowl18.754.50.75000.3451.3565.25Ghee5ml1 tsp.45005Dudhi bhaji2.971.2750.480.225103.21510:00pm - BEDTIMEGlucon DGlucon D20g4 tsp.Water50ml1/2 cupGardencress seeds5g2 1CALORIE (Kcal)87943174PERCENT (%)651339KCal/KgBW1.2g/KgBW3418.851951667275746
DIETARY ALTERNATIVES
MenuAlternativesFunctional FoodGhavacha satva/ Rawa kheerCardomomPlain Milk/Masala MilkUpma/Daliya upmaPlain Omlette/Masala OmletteGingerTurmeric, lemon juice8:00am - EARLY MORNINGNaachni satva10:00am - BREAKFASTTeaPohaBoiled egg12:00pm - MIDMORNINGFruit1pm - LUNCHMasala BhaatCurdMango ginger (Amba Haldi)4pm - SNACKTeaRoasted chana5pm - LATE EVENINGGhavacha satva8:00pm - DINNERNaachnichi BhakriKulithcha PitlaDudhi bhaji10:00pm - BEDTIMEGlucon D with garden cressseedOrange/Banana//Papaya/Guava/Apple/PearDal Rice/Vaangi Bhaat/Dal KhichdiButtermilkWhite Turmeric/Fresh GingerGinger, Garlic, Pepper, Cinnamon,TurmericCurdMango gingerPlain Milk/Masala MilkBoiled Moong/Boiled chanaGingerNaachni satva/Rawa kheerCardomomJowarichi Bhakri/ Bajrichi bhakriZhunka/ Moong dalShepu chi bhaji/ Palak chi bhajiTurmeric, GarlicGarlic, KokumLime water with Glucon D & garden cress seed/Whey with Glucon D &garden cress seedGarden cress seed
FAT CALCULATIONS Fat allowance: 31.72g Visible fat: 20g (Groundnut oil, ghee and coconut oil) Invisible fat: 11.72g MCT: 10g (30%)
Food Masoor0.040.060.1440.0240.12Roasted Groundnut oil2.094.932.99-2.99Coconut oil4.4750.390.1-0.1Achieved fat ratio10.7727.714.810.144.67
SUPPLEMENTS RECOMMENDED ON DISCHARGESupplement name DosageMultivit gold1-0-0FormTabletCompositionCost/DayCarbohydrate 0.08 g, protein 0.24 g, fat 0.43 g, ginseng extract 21.25 mg, ginkgo biloba extract 20Rs. 7/tabmg, citrus bioflavonoids 12.5 mg, green tea extract 10 mg, carotenoids 5 mg, garlic powder 2 mg,lycopene 2 mg, niacinamide 15 mg, vitamin C 12.5 mg, vitamin E acetate 12.5 IU, inositol 10 mg,pantothenic acid 5 mg, vitamin A 1600 IU, vitamin B1 1 mg, vitamin B2 1 mg, vitamin B6 0.5 mg,vitamin K 80 mcg, folic acid 50 mcg, biotin 30 mcg, vitamin D3 200 IU, vitamin B12 0.5 mcg, iron18 mg, zinc 15 mg, choline bitartrate 10 mg, potassium 10 mg, chloride 9.07 mg, manganese 5 mg,calcium 5 mg, phosphorus 3.86 mg, copper 2.2 mg, silicon 2 mg, boron 1 mg, molybdenum 0.5 mg,chromium 200 mcg, nickel 130 mcg, selenium 70 mcg, iodine 50 mcg, vanadium 10 mcg, tin 2 mcg,methionine 22 mg, glutamic acid 20 mg, lysine 10 mg, L-carnitine 2.5 mg, cysteine 2.5 mg.1.1 Re/-Zevit0-1-0TabletCalcium Pantothenate 50mg, Vitamin B6 3mg, Vitamin B2 10mg, Vitamin B1 10mg, Vitamin B1215mcg, Vitamin E 15mg, Vitamin C 150mg, Nicotinamide 50mg, Zinc 41.4mg, Biotin 100mcg, FolicAcid (Vitamin B9) 1500mcg.TOTAL COST PER DAY8.1Rs/Day
RECOMMENDATION Frequency of meals:oConsume small frequent meals.oInstead of consuming 3 large meals, have 5-8 small meals.Method of cooking:o Roasting, steaming, boiling, pressure cooking is preferred over frying.Milk and milk products:oPrepare Skimmed milk at home by heating the milk and cooling it by storing it in the refrigerator immediately. After sometime separate the fat (malai) from the surface of the milk and use it for other preparations.
Salt intake:o Salt intake should be 4gm (1600mg sodium) per day.o Cook your meals without salt and add it into your food ju
chronic, or long lasting injury. In the early stages of cirrhosis, the liver continues to function. However, as cirrhosis gets worse and scar tissue replaces healthier tissue, this blocks the flow of blood through the liver. Chronic liver failure, which is also called end-stage liver disease, progresses over months, years, or even decades.
veloped to grade the liver status in cirrhosis. This review will focus on these topics. Keywords Liver cirrhosis.Liver, MR imaging Introduction Hepatic cirrhosis is a chronic inflammatory liver disorder associated with fibrosis. Although fibrosis is considered the hallmark of cirrhosis, regeneration, necrosis and inflamma-
Spider angiomas Cirrhosis Palmarerythema Cirrhosis Splenomegaly Portal hypertension Jaundice Cirrhosis,Biliaryobstruction, hemolysis, Gilbert's Hyperpigmentation Hemochromatosis Kayser‐Fleisher rings Wilsons disease Emphysema/Lung disease Alpha‐1 antitrypsin deficiency Ascites Portal hypertenson, cirrhosis Asterixis Portalhypertension
Complications of CirrhosisComplications of Cirrhosis Lorna M Dove MD MPHLorna M. Dove, MD MPH Associate Professor of Clinical Medicine Columbia University College of Physicians and Surgeonsand Surgeons Outline/Objectives Cirrhosis -Etiology -PiProgression Complications of Cirrhosis -Portal HypertensionPortal Hypertension »Varices »Ascites
Heart failure, Chronic Kidney Disease (CKD) and End-Stage Renal Disease (ESRD) [Advanced Illness] I09.81 ; ICD-10 Rheumatic heart failure . . ICD-10 Alcoholic cirrhosis of liver without ascites . K70.31 : ICD-10 Alcoholic cirrhosis of liver with ascites . K70.40 : ICD-10 Alcoholic hepatic failure without coma .
CIRRHOSIS What is Cirrhosis: Cirrhosis is the end stages of a liver disease. Over time, from years to decades, fibrosis (or scar tissue) progresses through stages while your liver attempts to repair itself. Eventually, if left untreated, fibrosis replaces normal liver tissue and eventually results in cirrhosis.
tients with cirrhosis. The term 'advanced chronic liver disease' (ACLD) has been recently proposed to better mir-ror the late stages of CLD, which should be considered within a continuum spectrum, ranging from severe fibro-sis to fully developed cirrhosis [3]. Compensated versus decompensated cirrhosis: the burden of advanced chronic liver .
effects, chronic inflammation and hormone imbalances Patients with cirrhosis have a 2x higher fracture risk compared to patients without cirrhosis Patients with cirrhosis are susceptible to fractures of different bones: vertebrae, femoral neck, and distal radius Only complication that worsens after transplant (due to immunosuppression)
accounting profession plays in economic and social development of societies. The Imperatives of Accounting Profession. In a long narrative (Burchell, et al., 1980) stated that the roles of accounting which grace the introductions to accounting texts, professional pronouncements and the statements of those concerned with the regulation and development of the profession is a clear manifestation .
