CHRONIC CIRRHOSIS WITH ASCITES

SHWETA D. KAMBLI R.D. INTERN

PATIENT PROFILE

 Name: Mrs. XYZ  Occupation: Farmer

 Age: 47  No. of family members: 7

 Gender: Female  Addictions: None

 Dietary pattern: Non-Vegetarian  Community: Maharashtrian

 SGA Score: C  State: Maharashtra; Taluka: Yawal; District: Jalgaon  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 of breath 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 post pregnancy 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 to 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. With end-stage liver disease, the liver can no longer perform important functions or effectively replace damaged cells.

Pulmonary hypertension: • Liver disease can cause “portal hypertension,” meaning there is an increased blood pressure in the veins that enter the liver. This increased pressure causes blood to bypass the liver.

• As a result, the blood vessels of the lungs are exposed to possible toxic substances and this can damage the small arteries of the lungs, causing pulmonary arterial hypertension (PAH).

• The pulmonary arteries, which are responsible for transporting the blood from the right ventricle heart to the lungs, become narrowed and blocked due to the disease.

• To properly pump the blood, the heart needs to work harder, becoming enlarged 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 pumping chamber, 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 a circulatory 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 of nutritional status, such as micronutrient deficiencies, due to multiple mechanisms, including poor nutritional intake, poor absorption, and increased losses. • In addition, one of the most significant nutritional problems in cirrhotic patients is muscle wasting and sarcopenia.

(McClain, C. J. (2016). Nutrition in Patients with Cirrhosis. Gastroenterology & Hepatology, 12(8), 507–510.) ANTHROPOMETRIC ASSESSMENT

MEASUREMENTS VALUES

Height 147cm

37 Kgs during admission Weight Dry weight post tapping is 34 Kg)

Dry Body mass index (BMI) 15.73Kg/m2

Ideal Body Weight (IBW) 42Kg

ABDOMINAL WEIGHT USG GUIDED FLUID INPUT FLUID OUTPUT DATE GIRTH CHARTING ASCITIC FLUID (ml) (ml) CHARTING (Kg) TAPPING (cms) (ml) 25/10/2016 72 37 1000 550 2500ml 27/10/2016 70 36 1000 1050 - 29/10/2016 70 35 850 500 - 31/10/2016 67 35 950 770 - 2/11/2016 67 35 1000 590 - 4/11/2016 66 36 1150 830 - 6/11/2016 68 36 1000 610 1100ml 8/11/2016 67 35 950 865 - 10/11/2016 66 35.5 1000 900 - 12/11/2016 66 35.5 1000 930 - 14/11/2016 67 36 900 995 - 16/11/2016 66 36 1025 740 - 18/11/2016 65 36 1000 1050 500ml 20/11/2016 63 35 1000 1250 - 22/11/2016 62 34.5 1000 1400 - 24/11/2016 63 34.5 1250 1250 - 26/11/2016 Discharge BIOCHEMICAL ASSESSMENT

RESULT TEST REFERENCE RANGE

25/10/16 27/10/16 5/11/16 8/11/16 19/11/16 22/11/16 Prothrombin time 14.2 13.50 13.30 13.0 11-14 Seconds 4-10 WBC - - 6.04 4.22 4.73 4.75 10^3/uL Hemoglobin 7.5 - 8.10 7.5 8 9.1 11.5-16g/dl Platelets 142 - 107 142 141 144 140-440 10^3/uL Sodium 142 - 138 138 - - 137-145mmol/L Potassium 4.10 - 4.2 3.7 - - 3.5-5.1mmol/L Chloride 103 - 100 100 - - 98-107 mmol/L Ammonia - - - 9.00 - - 9-33 umol/L AST/ SGOT 20 19 24 23 26 28 15-46 U/L ALT/ SGPT 14 12 13 15 18 21 13-69 U/L Bilirubin total 0.84 0.98 0.86 0.80 0.71 0.80 0.2 – 1.3 mg/dL Bilirubin Unconjugated (BU) 0.29 0.46 0.34 0.26 0.26 0.36 0-1 mg/dL Bilirubin Conjugated (BC) 0.00 0.00 0.00 0.00 0.00 0.00 0-0.3 mg/dL Bilirubin delta 0.55 0.52 0.52 0.54 0.45 0.44 0-0.2 mg/dl Alkaline phosphatase 55 44 57 52 57 81 38-126 IU/L Total proteins 7.21 6.48 7.15 6.74 6.54 7.08 6.3-8.2mg/dl Albumin 3.82 3.61 3.78 3.52 3.47 3.71 3.5 – 5 g/dL Globulin 3.39 2.87 3.37 3.22 3.07 3.38 2.4 – 3.5 g/dL Albumin/Globulin ratio 1.12 1.26 1.12 1.09 1.13 1.1 1.1 -2.2 >400 pg/ml- heart failure BNP Peptide 958 - - - - - probable Blood sugar Random 93 - - - - - 65-165mg/dl Blood urea Nitrogen 11 - - - - - 7-17mg/dL Uric Acid 5.3 - - - - - 2.5-6.2 mg/dL Serum Creatinine 0.7 - 0.8 - 0.7 - 0.7-1.2mg/dL

Adenosine deaminase activity (ADA) 15.80 <30U/L Sample type- Ascitic fluid

Blood group A Positive b. Other Investigations:

Temperature Pulse Respiration Blood Pressure Date Time (F) (b/min) (b/min) (mmHg) 25/10/2016 10:00am 98 76 20 100/70 27/10/2016 10:00am 98 72 20 100/80 5/11/2016 10:00am 98 71 22 100/60 8/11/1016 10:00am 98 82 18 90/60 19/11/2016 10:00am 97 70 20 90/60 22/11/2016 10:00am 98 70 20 90/60

CT Scan of abdomen: Indicate severe Ascites and Splenomegaly. Liver biopsy: Sections reveal variably sized nodules separated by fibrotic bands. Granulomas were not seen. Microbiological testing of the Ascitic fluid: No pus cells, no organisms seen. MEDICATION DURING HOSPITAL STAY

MEDICATION DOSAGE MECHANISM OF ACTION SIDE- EFFECTS

Peripheral edema, Nasal congestion, Sinus Medicine used for the treatment of pulmonary hypertension. It works by widening the arteries and TAB. ENDOBLOC 10MG 1-0-0 inflammation, Flushing reducing the blood pressure.

1-0-1 (5Days a Used for the treatment of high blood pressure. It works by relaxing the blood vessels and widening headache, flushing of the face, and upset stomach. TAB. CAVERTA 25MG week) the blood vessels in the lung. nausea, vomiting, loss of appetite; fast, slow, or TAB. LANOXIN 0.25MG 1-0-0 Used to treat various heart conditions such as atrial fibrillation, atrial flutter and heart failure. uneven heart rate

TAB. LASILACTONE Used in the treatment of fluid retention. Works by preventing the body to absorb too much salt, Increased production of urine, dehydration, 1-0-0 100MG eliminating unneeded water and sodium from the body into the urine. decreased blood pressure, weakness, drowsiness Used for Maintaining the proper balance of body fluids and body's acid base balance, Neutralizing the free radicals and participates in vital redox reactions of the body, Raising the level of Vomiting, dehydration, gastrointestinal 1-0-0 glutathione thus prevents cells against peroxidative damage, Works for the healing purpose, TAB.MULTIVIT GOLD disturbances, 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. Nausea, Headache, Abdominal pain, Constipation, Used in the treatment of acidity, heartburn, intestinal ulcers and stomach ulcers. It lowers the acid TAB. PAN 40MG 1-0-1 Diarrhea, Flatulence production in the stomach.

It is a potent diuretic that is used to eliminate water and salt from the body. It works by blocking Dizziness, light headedness, headache, LASIX 10MG 1-0-1 the absorption of sodium, chloride and water from the filtered fluid in the renal tubules, causing a blurred vision profound increase in the output of urine. Bitterness of mouth, Gastrointestinal problems, It is a multi-vitamin supplement mainly utilized therapeutically as nutritional support in various Flatulence, Loss of appetite, Bloating, stomach TAB. ZEVIT 1-0-0 cases of deficiency of vitamin B complex , folic acid and vitamin C. pain, Nausea, Anxiety, Persistent itchy rashes on skin. weakness, fatigue, headache, nausea, vomiting, CALCITROL Every 4Th Day It is used for the treatment of vitamin D3 deficiency, rickets and osteomalacia constipation, dry mouth, metallic taste, muscle pain, GRANULES SACHET or bone pain. It reduces the accumulation of ammonia in patients with poor liver function thereby relieving Vomiting, Nausea, Diarrhea, Abdominal pain, HEPA MERZ SACHET 1-0-0 symptoms associated with abnormal ammonia metabolism. Flatulence

DIETARY ASSESSMENT : 24Hr. Home diet recall Household Calcium Menu Ingredients Amounts Energy (Kcal) CHO (g) Protein (g) Fat (g) Vit C (mg) Fe (mg) Na (mg) K (mg) IF (g) SF (g) measures (mg)

7:00am - EARLY MORNING Tea Milk 50ml 1/2 cup 33 2 1.65 2 1 0.1 36.5 70 60 Sugar 5g 1 tsp. 20 5 0 0 0.07 Khari 15g 2no. 90 14.23 1 4.1 10:00am - BREAKFAST Kande Pohe Rice Flakes 30g 1/2 cup 100 21 2.5 0.5 0 6 3.27 46.2 0.96 0.27 6 Onion 50g 1 small 20 5 0.5 0 1 0.6 2 63.5 20 Oil 5ml 1 tsp. 45 0 0 5 2:00pm - LUNCH Jowarichi Bhakri Jowar flour 30g 2 tbsp. 100 21 2.5 0.5 0 1.23 2.19 39.3 2.4 0.51 7.5 Shengachi Bhaji Drumstick 50g 1 stick 12.5 3 0.5 0 60 0.09 129.5 2.4 0.5 15 Onion 50g 1 small 20 5 0.5 0 1 0.6 2 63.5 20 Tomato 25g 1/2 no. 6.25 1.5 0.25 0 6.75 0.16 3.23 36.5 12 Oil 5ml 1 tsp. 45 0 0 5 5:00pm - SNACK Tea Milk 50ml 1/2 cup 33 2 1.65 2 1 0.1 36.5 70 60 Sugar 5g 1 tsp. 20 5 0 0 0.07 Khari 15g 2 no. 90 14.23 1 4.1 9:00pm - DINNER Vangi bhaat Rice 30g 2 tbsp. 100 21 2.5 0.5 0 0.21 0.96 0.27 3 Brinjal 50g 3no. 12.5 3 0.5 0 6 0.19 1.5 100 2.3 0.85 9 Potato 50g 1/2 no. 50 12 0.5 0 8.5 0.24 5.5 123.5 0.55 0.3 5 Oil 5ml 1 tsp. 45 0 0 5 TOTAL 842 135 16 29 85 10 93 742 10 3 218 CALORIE (Kcal) 540 62 258 PERCENT (%) 64 7 31 25KCal/Kg BW 0.4g/Kg BW

Nutritional calculation of home diet recall

 Energy: 842Kcal (25KCal/Kg BW)  Interpretation of home diet recall:

 Proteins:16g (0.4g/Kg BW)  The recall indicates that there are large gaps between the meals.  HBV: 3.3g  The protein content in the diet is very low.  Carbohydrate: 135g (64.09% of TC)  No cereal pulse combination recipes are  Fats: 29g (30.67% of TC) included.  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 underweight. Classification BMI(kg/m2) Principal cut-off Additional cut-off points points Underweight <18.50 <18.50 Severe thinness <16.00 <16.00 Moderate 16.00 - 16.99 16.00 - 16.99 thinness Mild thinness 17.00 - 18.49 17.00 - 18.49 18.50 - 22.99 Normal range 18.50 - 24.99 23.00 - 24.99

Lancet, Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies; 2004 Mar 13;363(9412):902.

• SGA Score - C; Presence of mild to moderate edema, severe ascites, poor food intake, severe loss of functional status, strength and stamina; indicates that the patient is undernourished.

• Low hemoglobin levels indicating the presence of anemia. Hence, provide optimal iron through diet and nutrition supplement. Include source of Vitamin C in the diet to enhance the absorption of Iron. MEDICAL NUTRITION THERAPY

ENERGY:

• Presence of Ascites has found to increase energy expenditure. Daily caloric recommendations for patients with liver 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 Care Medicine (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 the survival 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 /day Without 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 circulating BCAAs and elevated levels of circulating aromatic amino acids, and methionine. • BCAA supplementation appears to be associated with decreased frequency of complications of cirrhosis and improved 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 by the 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 as carotenoids, selenium, vitamin E, and zinc.

• Deficiency of folate is also found in liver cirrhotic patients and an estimated 50% have increased blood homocysteine 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 cirrhotic patients 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 salt entering 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 liver cirrhosis. Gastroenterology 100: 738-744.)

• A 2000 mg sodium-restricted diet is effective, when combined with diuretic therapy, for controlling fluid 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 of decreased protein synthesis in the liver, mainly albumin. • This causes fluid leaks in your blood vessels, which in turn, causes fluid buildup in other tissues, or ascites. • By limiting the amount of salt and fluid in your diet, fluid retention and swelling can be reduced. CASE PROGRESSION

Day 1 NBM

Day 2 - Day 17 Soft Hepatic Salt Restricted Diet

Day 18 – Day 31 Full 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 to prevent 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 per  Fats: 26g (22.62%) day  MCT: 10g (40% of total fat)  Consistency of diet: Soft  Calories to Nitrogen ratio: 168:1  Energy: 1052Kcal (31KCal/Kg BW)  Sodium: 431mg (Sodium restriction of  Proteins: 39g (1.1g/Kg BW) 2000mg/day)

 HBV: 20.25g  Salt per day: 4 gm/day

 Fluid: 1000ml

Menu Ingredients Amounts Energy (Kcal) CHO (g) Protein (g) Fat (g) Vit C (mg) Fe (mg) Na (mg) K (mg) IF (g) SF (g) Calcium (mg)

7:00am - EARLY MORNING Tea Milk 50ml 14.5 2.3 1.25 0.05 1 0.1 36.5 70 60 Sugar 5g 20 5 0 0 0.07 Threptin biscuit Biscuit 1no. 21.9 2.4 1.5 0.7 8:00am - BREAKFAST Upma Rawa 30g 100 21 2.5 0.5 0 0.48 6.3 24.9 2.88 0.87 3 Oil 5ml 45 0 0 5 Boiled Egg Egg 50g 90 0 7 7 0 1.05 30 11:00am - MIDMORNING Fruit Muskmelon 100g 50 10 0 0 26 1.4 104.6 341 0.5 0.3 32 1:00pm - LUNCH Soft rice Rice 30g 100 21 2.5 0.5 0 0.21 0.96 0.27 3

Boil Dal Moong dal 30g 100 17 7 0.5 0 1.17 8.16 345 1.95 0.51 22.5 Saute potato with jeera Boiled potato 100g 100 24 1 0 17 0.48 11 247 1.1 0.6 10 powder Saltfree 5g 35 0 0 5 Butter Curd Curd 100ml 29 4.6 2.5 0.1 2 0.2 73 140 120 4:00pm - SNACKS Tea Milk 50ml 14.5 2.3 1.25 0.05 1 0.1 36.5 70 60 Sugar 5g 20 5 0 0 0.07

Threptin biscuit Biscuit 1no. 21.9 2.4 1.5 0.7 Menu Ingredients Amounts Energy (Kcal) CHO (g) Protein (g) Fat (g) Vit C (mg) Fe (mg) Na (mg) K (mg) IF (g) SF (g) Calcium (mg)

6:00pm - LATE EVENING

Fruit Papaya 100g 50 10 0 0 57 0.5 6 69 1.3 1.3 17

8:00pm - DINNER

Khichdi Rice 15g 50 10.5 1.25 0.25 0 0.21 0.48 0.135 3

Moong dal 15g 50 8.5 3.5 0.25 0 1.17 4.08 172.5 0.975 0.255 11.25

Saltfree 5g 35 0 0 5 Butter

Boiled carrots Boiled carrot 100g 40 10 1 0 3 1.03 35.6 108 3 1.4 80

Curd Curd 100ml 29 4.6 2.5 0.1 2 0.2 73 140 120

10:00pm - BEDTIME

Warm milk Milk 50ml 14.5 2.3 1.25 0.05 1 0.1 36.5 70 60

Threptin biscuit Biscuit 1no. 21.9 2.4 1.5 0.7 TOTAL 1052 165 39 26 110 9 431 1797 13 6 632 CALORIE (Kcal) 661 156 238

PERCENT (%) 63 23 15 31KCal/Kg 1.1g/Kg BW BW 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 per  Fats: 32g (24.05% of TC) day  MCT: 10g (30% of total fat)  Consistency of diet: Full diet  Calories to Nitrogen ratio: 180:1  Energy: 1188Kcal (34KCal/Kg BW)  Sodium: 339mg (Sodium restriction of  Proteins: 41.2g (1.2g/Kg BW) 2000mg/day)

 HBV: 20.25g  Salt per day: 4gm Salt packet

 Fluid: 1000ml Calcium Menu Ingredients Amounts Energy (Kcal) CHO (g) Protein (g) Fat (g) Vit C (mg) Fe (mg) Na (mg) K (mg) IF (g) SF (g) (mg)

7:00am - EARLY MORNING Tea Milk 50ml 14.5 2.3 1.25 0.05 1 0.1 36.5 70 60 Sugar 5g 20 5 0 0 0.07

Threptin biscuit Biscuit 1no. 21.9 2.4 1.5 0.7

8:00am - BREAKFAST

Poha Rice flakes 30g 100 21 2.5 0.5 0 6 3.27 46.2 0.48 0.135 6 Onion 50g 20 5 0.5 0 1 0.6 2 63.5 20 Oil 5ml 45 0 0 5 Boiled Egg Egg 50g 90 0 7 7 0 1.05 30 11:00am - MIDMORNING Fruit Banana 100g 116 27.2 1.2 0.3 7 0.36 36.6 88 1.1 0.7 17 1:00pm - LUNCH Chapati Wheat flour 30g 100 21 2.5 0.5 0 1.47 6 94.5 2.88 0.87 14.4 Dudhi bhaji Dudhi 75g 18.75 4.5 0.75 0 0 0.345 1.35 65.25 1.275 0.225 15 Onion 50g 20 5 0.5 0 1 0.6 2 63.5 20 Tomato 25g 6.25 1.5 0.25 0 6.75 0.16 3.23 36.5 12 Oil 5ml 45 0 0 5 Boil Dal Moong dal 30g 100 17 7 0.5 0 1.17 8.16 345 1.95 0.51 22.5 Curd Curd 100ml 29 4.6 2.5 0.1 2 0.2 73 140 120 4:00pm - SNACKS Tea Milk 50ml 14.5 2.3 1.25 0.05 1 0.1 36.5 70 60 Sugar 5g 20 5 0 0 0.07 Threptin biscuit Biscuit 1no. 21.9 2.4 1.5 0.7 Calcium Menu Ingredients Amounts Energy (Kcal) CHO (g) Protein (g) Fat (g) Vit C (mg) Fe (mg) Na (mg) K (mg) IF (g) SF (g) (mg) 6:00 - LATE EVENING

Fruit Papaya 100g 50 10 0 0 57 0.5 6 69 1.3 1.3 17

8:00pm - DINNER Khichdi Rice 15g 50 10.5 1.25 0.25 0 0.105 0.48 0.135 1.5 Moong dal 15g 50 8.5 3.5 0.25 0 0.585 4.08 172.5 0.975 0.255 11.25 Saltfree 10g 70 0 0 10 Butter Boiled potato with jeera Boiled potato 100g 100 24 1 0 17 0.48 11 247 1.1 0.6 10 powder Curd Curd 100ml 29 4.6 2.5 0.1 2 0.2 73 140 120 10:00pm - BEDTIME

Warm milk Milk 50ml 14.5 2.3 1.25 0.05 1 0.1 36.5 70 60

Threptin biscuit Biscuit 1no. 21.9 2.4 1.5 0.7

TOTAL 1188 189 41 32 97 14 339 1781 12 5 617

CALORIE (Kcal) 754 165 286

PERCENT (%) 63 14 24

34KCal/Kg 1.2g/Kg

BW BW

NUTRITIONAL COMPLIANCE Day Type of diet Planned % Compliance Reasons 2 Soft hepatic Salt Restricted diet Energy- 1052Kcal ;Protein- 39g Energy- 71% ;Protein- 76% 3 Soft hepatic Salt Restricted diet Energy- 1052Kcal ;Protein- 39g Energy- 70% ;Protein- 75% 4 Soft hepatic Salt Restricted diet Energy- 1052Kcal ;Protein- 39g Energy- 71% ;Protein- 76% 5 Soft hepatic Salt Restricted diet Energy- 1052Kcal ;Protein- 39g Energy- 72% ;Protein- 76% 6 Soft hepatic Salt Restricted diet Energy- 1052Kcal ;Protein- 39g Energy- 81% ;Protein- 79% 7 Soft hepatic Salt Restricted diet Energy- 1052Kcal ;Protein- 39g Energy- 80% ;Protein- 78% 8 Soft hepatic Salt Restricted diet Energy- 1052Kcal ;Protein- 39g Energy- 81% ;Protein- 79% 9 Soft hepatic Salt Restricted diet Energy- 1052Kcal ;Protein- 39g Energy- 82% ;Protein- 80% 10 Soft hepatic Salt Restricted diet Energy- 1052Kcal ;Protein- 39g Energy- 80% ;Protein- 79% • Patient during admission had 11 Soft hepatic Salt Restricted diet Energy- 1052Kcal ;Protein- 39g Energy- 79% ;Protein- 80% 12 Soft hepatic Salt Restricted diet Energy- 1052Kcal ;Protein- 39g Energy- 81% ;Protein- 79% severe loss of appetite and was 13 Soft hepatic Salt Restricted diet Energy- 1052Kcal ;Protein- 39g Energy- 80% ;Protein- 78% 14 Soft hepatic Salt Restricted diet Energy- 1052Kcal ;Protein- 39g Energy- 81% ;Protein- 79% not willing to eat food. 15 Soft hepatic Salt Restricted diet Energy- 1052Kcal ;Protein- 39g Energy- 82% ;Protein- 80% 16 Soft hepatic Salt Restricted diet Energy- 1052Kcal ;Protein- 39g Energy- 81% ;Protein- 79% • Later, through various 17 Soft hepatic Salt Restricted diet Energy- 1052Kcal ;Protein- 39g Energy- 81% ;Protein- 79% 18 Full hepatic Salt Restricted diet Energy- 1188Kcal ;Protein- 41g Energy- 86%; Protein- 96% strategies like counselling the 19 Full hepatic Salt Restricted diet Energy- 1188Kcal ;Protein- 41g Energy- 87%; Protein- 96% 20 Full hepatic Salt Restricted diet Energy- 1188Kcal ;Protein- 41g Energy- 86%; Protein- 96% patient, a marked increase in 21 Full hepatic Salt Restricted diet Energy- 1188Kcal ;Protein- 41g Energy- 88%; Protein- 97% 22 Full hepatic Salt Restricted diet Energy- 1188Kcal ;Protein- 41g Energy-90%; Protein- 98% the food consumption was 23 Full hepatic Salt Restricted diet Energy- 1188Kcal ;Protein- 41g Energy-90%; Protein- 98% seen. 24 Full hepatic Salt Restricted diet Energy- 1188Kcal ;Protein- 41g Energy-90%; Protein- 98% 25 Full hepatic Salt Restricted diet Energy- 1188Kcal ;Protein- 41g Energy-90%; Protein- 98% 26 Full hepatic Salt Restricted diet Energy- 1188Kcal ;Protein- 41g Energy- 100%; Protein- 100% 27 Full hepatic Salt Restricted diet Energy- 1188Kcal ;Protein- 41g Energy- 100%; Protein- 100% 28 Full hepatic Salt Restricted diet Energy- 1188Kcal ;Protein- 41g Energy- 100%; Protein- 100% 29 Full hepatic Salt Restricted diet Energy- 1188Kcal ;Protein- 41g Energy- 100%; Protein- 100% 30 Full hepatic Salt Restricted diet Energy- 1188Kcal ;Protein- 41g Energy- 100%; Protein- 100% 31 Full hepatic Salt Restricted diet Energy- 1188Kcal ;Protein- 41g Energy- 100%; Protein- 100% 32 Discharge 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 per  Fats: 31.72g (21.15% of TC) day  MCT: 10g (32% of total fat)  Consistency of diet: Full diet  Calories to Nitrogen ratio: 194:1  Energy: 1349.7Kcal (39KCal/Kg BW)  Sodium: 194.91mg (Sodium restriction of  Proteins: 43.41g (1.2g/Kg BW) 2000mg/day)

 HBV: 14g  Salt per day: 4gm Salt packet

 Fluid: 1200ml EXCHANGE LIST OF THE PRESCRIBED MNT Food group Exchange Amounts Energy (Kcal) CHO (g) Protein (g) Fat (g) Cereal 5 150g 500 105 12.5 2.5 Pulse 2 60g 200 34 14 1 Milk & Milk products 2 200ml 60 8 6.65 0 Egg 1 50g 90 0 7 7 Veg A 1 100g 25 6 1 0 Veg B 1/2 50g 20 5 0.5 0 Veg C 1/2 50g 50 12 0.5 0 Fruits 1 100g 50 10 0 0 Sugar/Jaggery 1 20g 80 19.2 0 0 Glucon D 1/2 20g 72 18 0 0 Oil 2 20ml 180 0 0 20 Garden cress seeds 1/4 5g 22.7 1.65 1.26 1.22 TOTAL 1350 217 43 32 CALORIE (Kcal) 869 174 285 PERCENT (%) 64 13 21

39KCal/Kg BW 1.2g/Kg BW MEAL DISTRIBUTION Early Late Total Food Group Breakfast Midmorning Lunch Snack Dinner Bedtime morning Evening Exchanges Cereal 1 1 1 1 1 5 Pulse 1/2 1/2 1 2 Milk & Milk 1/2 1 1/2 2 products Egg 1 1 Veg A 1/4 3/4 1 Veg B 1/4 1/4 1/2 Veg C 1/2 1/2 Fruits 1 1 Sugar/Jaggery 1/4 1/4 1/4 1/4 1 Glucon D 1/2 1/2 Oil 1/2 1/2 1 2

Garden cress seeds 1/4 1/4

Total Calories 120 280 50 281 85 120 319 95 1350 (Kcal) DETAILED PRESCRIBED MENU Ingredient Household Calcium Menu Amounts Energy (Kcal) CHO (g) Protein (g) Fat (g) Vit C (mg) Fe (mg) Na (mg) K (mg) IF (g) SF (g) s measures (mg)

8:00am - EARLY MORNING Naachni satva Naachni 30g 2 tbsp. 100 21 2.5 0.5 0 1.17 3.3 122.4 2.97 0.48 103.2 Jaggery 5g 1 tsp. 20 5 0 0 0.132 4

10:00am - BREAKFAST

Tea Milk 50ml 1/2 cup 15 2 1.66 0 1 0.1 36.5 70 60 Sugar 5g 1 tsp. 20 5 0 0 0.07

Poha Rice flakes 30g 2 tbsp. 100 21 2.5 0.5 0 6 3.27 46.2 0.48 0.135 6

Onion 25g 1/2 small 10 2.5 0.25 0 0.5 0.3 1 31.75 10

Coconut oil 5ml 1 tsp. 45 0 0 5

Boiled egg Egg 50g 1 no. 90 0 7 7 0 1.05 30 12:00pm - MIDMORNING Fruit Chickoo 100g 1 no. 50 10 0 0 6 1.25 5.9 269 9.1 1.8 28 1pm – LUNCH Masala Bhaat Rice 30g 2 tbsp. 100 21 2.5 0.5 0 0.21 0.96 0.27 3 Masoor 15g 1 tbsp. 50 8.5 3.5 0.25 0 1.137 6.015 94.35 2.02 0.34 10.35 Tomato 25g 1/4 small 6.25 1.5 0.25 0 6.75 0.16 3.23 36.5 12 Potato 50g 1/2 small 50 12 0.5 0 8.5 0.24 5.5 123.5 0.55 0.3 5 Groundnut 5ml 1 tsp. 45 0 0 5 oil Curd Curd 100ml 1/2 cup 30 4 3.33 0 2 0.2 73 140 120 Fresh Fresh Amba haldi 5g 1"pc. Amba haldi 4pm - SNACK Tea Milk 50ml 1/2 cup 15 2 1.66 0 1 0.1 36.5 70 60 Sugar 5g 1 tsp. 20 5 0 0 0.07 Roasted Roasted chana 15g 2 tbsp. 50 8.5 3.5 0.25 0 1.425 5.595 121.2 3.78 0.465 8.7 chana Household Calcium Menu Ingredient Amounts Energy (Kcal) CHO (g) Protein (g) Fat (g) Vit C (mg) Fe (mg) Na (mg) K (mg) IF (g) SF (g) measures (mg) 6pm - LATE EVENING Whole Ghavacha satva 30g 2 tbsp. 100 21 2.5 0.5 0 1.47 6 94.5 2.88 0.87 14.4 wheat Jaggery 5g 1 tsp. 20 5 0 0 0.132 4 8:00pm - DINNER Naachni Naachnichi Bhakri 30g 2 tbsp. 100 21 2.5 0.5 0 1.17 3.3 122.4 2.97 0.48 103.2 flour

Kulith Kulithcha Pitla 30g 2 tbsp. 100 17 7 0.5 0 2.031 3.45 228.6 86.1 Flour Onion 25g 1/2 small 10 2.5 0.25 0 0.5 0.3 1 31.75 10 Groundnut 5ml 1 tsp. 45 0 0 5 oil Dudhi bhaji Dudhi 75g 1 bowl 18.75 4.5 0.75 0 0 0.345 1.35 65.25 1.275 0.225 15 Ghee 5ml 1 tsp. 45 0 0 5 10:00pm - BEDTIME Glucon D Glucon D 20g 4 tsp. 72 18 0 0 34 Water 50ml 1/2 cup

Garden 5g 2 tsp. 22.7 1.65 1.26 1.22 0 5 18.85 cress seeds

TOTAL 1350 220 43 32 26 24 195 1667 27 5 746 CALORIE (Kcal) 879 174 285 PERCENT (%) 65 13 21 39KCal/Kg 1.2g/Kg

BW BW DIETARY ALTERNATIVES Menu Alternatives Functional Food 8:00am - EARLY MORNING Naachni satva Ghavacha satva/ Rawa kheer Cardomom 10:00am - BREAKFAST Tea Plain Milk/Masala Milk Ginger Poha Upma/Daliya upma Turmeric, lemon juice Boiled egg Plain Omlette/Masala Omlette 12:00pm - MIDMORNING Fruit Orange/Banana//Papaya/Guava/Apple/Pear 1pm - LUNCH Ginger, Garlic, Pepper, Cinnamon, Masala Bhaat Dal Rice/Vaangi Bhaat/Dal Khichdi Turmeric Curd Buttermilk Curd Mango ginger (Amba Haldi) White Turmeric/Fresh Ginger Mango ginger 4pm - SNACK Tea Plain Milk/Masala Milk Ginger Roasted chana Boiled Moong/Boiled chana 5pm - LATE EVENING Ghavacha satva Naachni satva/Rawa kheer Cardomom 8:00pm - DINNER Naachnichi Bhakri Jowarichi Bhakri/ Bajrichi bhakri Kulithcha Pitla Zhunka/ Moong dal Turmeric, Garlic Dudhi bhaji Shepu chi bhaji/ Palak chi bhaji Garlic, Kokum 10:00pm - BEDTIME Glucon D with garden cress Lime water with Glucon D & garden cress seed/Whey with Glucon D & Garden cress seed seed garden 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 Item SFA MUFA PUFA Ω3 Ω6

Wheat 0.15 0.09 0.38 0.051 0.33

Rice 0.27 0.24 0.306 0.006 0.3

Naachni 0.192 0.42 0.21 0.03 0.18

Masoor 0.04 0.06 0.144 0.024 0.12

Roasted chana 0.085 0.18 0.555 0.03 0.525 Ghee 3.47 1.4 0.125 - 0.125 Groundnut oil 2.09 4.93 2.99 - 2.99 Coconut oil 4.475 0.39 0.1 - 0.1

Achieved fat ratio 10.772 7.71 4.81 0.14 4.67 SUPPLEMENTS RECOMMENDED ON DISCHARGE

Supplement name Dosage Form Composition Cost/Day Carbohydrate 0.08 g, protein 0.24 g, fat 0.43 g, ginseng extract 21.25 mg, ginkgo biloba extract 20 Rs. 7/tab mg, 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, iron Multivit gold 1-0-0 Tablet 18 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/- Calcium Pantothenate 50mg, Vitamin B6 3mg, Vitamin B2 10mg, Vitamin B1 10mg, Vitamin B12 Zevit 0-1-0 Tablet 15mcg, Vitamin E 15mg, Vitamin C 150mg, Nicotinamide 50mg, Zinc 41.4mg, Biotin 100mcg, Folic Acid (Vitamin B9) 1500mcg.

8.1Rs/Day TOTAL COST PER DAY RECOMMENDATION

• Frequency of meals:

o Consume small frequent meals.

o Instead 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:

o Prepare Skimmed milk at home by heating the milk and cooling it by storing it in the refrigerator immediately. After some time 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 just before consuming it. o Instead make use of lemon, tamarind, kokum to make the food palatable. o Make sure that the tamarind and kokum is not stored with salt. o Avoid using aamchur powder, chaat masala as it has a higher sodium content. o Add flavor to the food by using a variety of spices such as cinnamon, asafoetida, fennel seeds, carom seeds, cumin seeds, ginger, garlic, mint leaves, curry leaves. o Avoid papad, pickles. (since salt content is high).

• Fluids and Beverages: o Monitor your daily fluid intake so that you don’t exceed your fluid intake. o Liquids include water, milk, juice, and other beverages. It also includes any food that contains liquid, such as soup. o 1 cup of water is 250ml.

 Exercise guidelines: o Restrict lifting things to less than 10 kgs, since these activities increase the pressure in your arteries and lungs. o Walking is important to keep your muscles strong and improve circulation. o However, more strenuous forms of aerobic exercise should not be done regularly since your lungs may not be able to keep up with the oxygen demands placed on your body during these activities. Any activities that cause shortness of breath, dizziness, or chest pain should be stopped immediately.

 Medication guidelines: o Know the names of your medications and how they work. Keep a list with you. o Take your medications at the same time every day. If you forget a dose, do not take two doses to make up for the dose you missed. o Do not stop taking or change your medications unless you first talk with your doctor.

 Miscellaneous: o Monitor your weight: weigh yourself at the same time each day and record your weight in a diary or on a calendar. o If you notice a rapid weight gain over one week, inform your doctor.

ARF RECIPE: o Buy the cereal. o Rinse it in water and drain. o Soak it in water overnight. o Drain the water from the vessel. o In a wet cloth, add the cereal and tie the cloth tightly. o Keep or hang the cloth in a cool and dry place for 1 day (24 hours) and allow to sprout. o Roast the sprouted cereal until all the water/moisture present in it is lost. o Blend it into a fine powder. o In a kadhai, melt jaggery, add powdered cereal. Mix well. Remove Lumps if any. o Add water, and cook the powdered Naachni in it. o Elaichi powder can be added for taste. OPD FOLLOW-UP

 Patient was called for a follow up on 21/12/2016.

 She was symptomatically better and hemodynamically stable.

 Her appetite had improved and was eating well.

 There was an increase in the patient’s body weight by 1.5Kg.

 There was no abdominal distention, the organs were palpable and the abdominal girth was 63cms i.e. same as when the patient was discharged, which indicates the absence of ascites.

 Dietary recommendations were reinforced to the patient.

 Certain strategies of making meals nutritionally dense were discussed.