What can be done to improve the situation?

• Try to get him to stop drinking and save what remains of his liver and pancreas.
• Optimize his residual liver and pancreas function.
• Oral pancreatic enzyme replacement.
• Selectively increase protein and amino acid intake so as to increase serum albumin levels and slow his muscle proteolysis. Remember the aromatics.
  • Meat is high in aromatics and vegetable low.
  • Figure protein at 1-1.5 gm/kg body weight.
• Vitamin supplementation and use of water-soluble vitamin formulations. Remember he can't absorb fats.
  • Remember his labs? What did you make of that prolonged PT?
  • Vitamins here include not just the fat soluble ones (especially K) but B-complex, C and minerals such as zinc and magnesium.
  • One must be cautious about too much vitamin A and D.
• Calculate energy needs at 1.5 to 1.75 times the predicted or expected.
• If Mr. Bullroar's problem was just his cirrhosis, we'd be shooting for a fat intake of about 40-50% of his non-protein calories.
  • However, his chronic pancreatitis and diminished lipase output changes the dynamic. He will have malabsorption and develop steatorrhea.
  • One will need to limit long-chain triacylglycerol (LCT) fats.
• Avoid or limit caffeine because of bowel motility and pancreas irritation.
• If he ends up with nasogastric suction, which is pretty likely, we must be careful of his electrolyte and acid-base balance.

So, how did our man do?