Coloquio (2) 112-164

A 70-year-old lady with known arterial hypertension and stage 3 chronic kidney disease was admitted to the ward due to severe pneumonia. You have successfully cured the infection with an adjusted dose of antibiotic and supportive measures. On discharge he wants lady to talk to you about the diet that is most suitable for her. The lady is well-nourished, her body mass index is 24 kg/m2 . You advise her: It should increase protein intake, as this prevents malnutrition, which is often present in kidney patients. We advise her restriction of fiber, which adversely affects the blood sugar level in kidney diseases. Limit protein intake, as a hypoprotein diet is one of the therapeutic measures that is equivalent to other forms of treatment for kidney diseases. He should also limit the intake of foods that are rich in phosphorus. Body mass index should be maintained between 22 and 25 kg/m2 and ensures regular physical activity. The patient should eat according to the principles of the Mediterranean diet, which is the most suitable diet for all patient populations. She does not need to adjust her protein intake. Increase protein intake, as this prevents malnutrition, which is often present in kidney patients. The energy intake should be from 20-25 kcal/kgTT/day as is the recommendation for the general population. He should limit protein intake, as a hypoprotein diet is one of the therapeutic measures that is equivalent to other forms of treatment for kidney diseases. Increase the intake of foods rich in phosphorus and potassium. The body mass index should be maintained between 20 and 22 kg/ m2 and ensure regular physical activity.

A 52-year-old lady with current compensated cirrhosis of the liver due to primary biliary cholangitis with Sjögreon's syndrome and Hashimoto thyroiditis is admitted to your department for preparation before liver transplantation. On clinical examination, you notice jaundice of the sclera and skin and mild atrophy of the lower extremities. He is in a normal state of consciousness and does not have a fluttering tremor of the hands. The serum ammonia level is within normal limits, the body mass index is 22 kg/m2 . The lady is extremely motivated to perform the transplant in the best possible state of performance and is aware that proper nutrition and regular physical activity will help her in this. You can help her with the following tips: To prevent the development of hepatic encephalopathy, the lady should limit her protein intake below 1 g/kg WT/day. Part of the protein should replaced by branched chain amino acids. Despite the fact that her basic disease is compensated, it is necessary to increase the energy intake to 35ÿ40 kcal/kgTT/day and protein intake to 1.2 to 1.5 g/kg WT/day. The patient should try to eat a normal diet and does not currently need dietary restrictions. We recommend several smaller ones meals per day, the last meal should be late in the evening and rich in carbohydrates. The patient does not currently require special dietary restrictions. We advise her to have several small meals a day, and one meal in the evening let it go. The patient should try to eat a normal diet and not need dietary restrictions. But it is necessary to increase energy intake to 35ÿ40 kcal/kgTW/day.

You are examining a 47-year-old man with known chronic pancreatitis in the clinic. He has lost 7 kg since his last check-up three months ago. He notices that his stool is bright, smells strong, foams and sticks to the shell. You conclude that Mr. Pancreatic enzyme replacement will be necessary. Which test will you use to confirm your working diagnosis?. US or EUZ of the abdomen. Measurement of fecal elastase. Calprotectin measurement in stool. No investigations required. The gentleman must strictly avoid alcohol. Serum trypsin value.

You admit a 65-year-old gentleman to the intensive care unit due to septic shock. Upon admission, the patient receives antibiotic and supportive therapy and is hemodynamically, acid-base- and electrolyte-regulated. With a clinical examination, you assess that this is a malnourished patient who will not be able to consume food per os in the following days. The patient is not peritonitis, he is not vomiting or bleeding from the gastrointestinal tract, you have ruled out ileus with imaging and clinical examination. What will be the further nutritional measures?. We will wait at least 48 hours with nutritional support for the patient, because it is not of particular importance for patients in intensive care units therapy. Preference for the patient is parenteral nutrition, enteral nutrition will be introduced after a couple of days of parenteral nutrition feeding. In principle, there is no need for increased protein intake in the gentleman. When protein intake exceeds 1 g/kg of body weight, complications such as hyperthermia and a higher likelihood of aspiration pneumonia may occur from overload. A higher protein intake is recommended for men: from 1.2-1.5 g per kg of body weight. Nutritional support will begin within the first 24 hours, we will begin enteral feeding via a nasogastric tube. We will switch to parenteral nutrition only if enteral feeding will not be successful. There are no contraindications for enteral feeding in intensive care units. Even if the patient develops paralytic ileus, we will continue with enteral nutrition, as enteral nutrition has a significant effect on the intestinal mucosa and has a trophic effect.

A 50-year-old patient with HCV cirrhosis who was successfully treated with antiviral therapy had two episodes of mild hepatic encephalopathy in the last 12 months. He complains of taste disturbances. He had no gastrointestinal bleeding. He regularly takes 40 mg Furesimide and 100 mg Spironolactone. On examination, mild ascites and mild jaundice are present. MELD is 8 points. What is the correct answer regarding his nutritional treatment?. A. A 25% reduction in protein intake reduces the chances of hepatic encephalopathy. B. Thiamine replacement is not necessary in such patients. C. Short-chain amino acids must be the sole source of protein. D. Hypermagnesemia can cause changes in his taste. E. Vitamin A deficiency may increase the risk of hepatocellular carcinoma.

In a 55-year-old man with a body mass index of 29, with diabetes on a diet, who drinks 2 glasses of wine a day, the laboratory results revealed: ALT 3.4 ucat/L, AST 1.99 ucat/L, AF 2.55 ucat /L, whole. bilirubin 25.6 µmol/L, blood sugar 9.8 mmol/L, platelets 200x109 /L. What is the most likely reason for abnormal liver tests?. A. Alcoholic hepatitis. B. Nonalcoholic fatty liver disease and steatohepatitis. C. Autoimmune hepatitis. D. Wilson's disease. E. Ischemic hepatitis.

A 32-year-old woman comes for a check-up for pathological liver tests. She feels more tired, her joints hurt. He drinks alcohol occasionally, does not take medicines or nutritional supplements. She is eating normally, the US of the abdomen, including the liver vessels, is within normal limits. Laboratory findings: bilirubin 16/6 µmol/L (normal), AST 9 ukat/L (normal up to 0.52); ALT 14 ukat/L (normal up to 0.57); gammaGT 0.4 ucat/L (normal up to 0.63); alkaline phosphatase 1.3 ucat/L (normal up to 1.64); IgG 28 (normal up to 14). Which diagnosis is most likely?. A medication failure. B alcoholic hepatitis. C non-alcoholic fatty liver disease. D autoimmune hepatitis. E Budd-Chiari syndrome.

A 42-year-old patient bought a preparation for weight reduction via the Internet, which is the product of "green coffee". She has been using it for 4 months and it is very effective, as she lost weight from 98 to 88 kg. In addition, she used 2 tbl of Edemide (furosemide) to lose weight on her once-a-week "weigh-in day", which she received from her 72- year-old mother, who is receiving the drug for cirrhosis of the liver caused by the hepatitis B virus. (the mother was infected by transfusion during the delivery of the patient's younger sister). All family members are vaccinated against the hepatitis B virus. Lately, she notices that she has become jaundiced. In the blood they found 10- a multiple increase in the value of bilirubin, and especially elevated enzymes alkaline phosphatase and gamma-GT. Both transaminases are only moderately elevated. Abdominal ultrasound shows no abnormalities, no signs of chronic liver damage (no ascites, liver is homogeneous). The most likely diagnosis for this patient: a) Liver cirrhosis due to vertically transmitted hepatitis B virus. b) Acute hepatitis due to dehydration while receiving furosemide. c) Cholestatic hepatitis with the slimming preparation "green coffee". d) Cirrhosis of the liver due to a weight loss preparation. e) Hemolytic anemia due to furosemide dehydration.

In a 64-year-old man with no known diseases and no known liver diseases, who does not take medicines, herbal preparations or nutritional supplements, does not drink psychoactive substances, but drinks a glass of wine every day, in the laboratory results you found only an elevated ALT of 1.3 mkat/L (2x above the normal value ) What will you do in the first step of diagnostics? A. we will order him for control laboratory investigations of liver tests in 6 months B. We refer him for an abdominal ultrasound C. Let's do tests to determine hepatitis B and C infection D. Blood is taken to determine iron, transferrin and ferritin E. FibroSCAN is performed and blood is taken for ANA, ASMA, AMA, ceruloplasmin alpha 1-antitrypsin. A. abc. B. bcd. C. acd. D. cde. E. abe.

The following applies to ALT and AST aminotransferases: a. ALT is a more specific indicator of liver damage than AST. b. ALT and AST are equally specific indicators of liver damage. c. ALT is elevated only in hepatitis. d. the magnitude of the increase in AST and ALT is proportional to the severity of the liver disease. e. in circulatory shock, aminotransferase values are reduced.

Indirect hyperbilirubinemia is a. may be a congenital metabolic disorder b. indicates hemolysis c. it is dangerous in adulthood d. the cause may be increased physical activity e. histological examination of the liver shows hepatitis. A. a, c, d. B. a, b, d. C. b, c, d. D. a, b, e. E. c, d, e.

Alkaline phosphatase in the blood is: a. is formed exclusively in the liver b. formed in the bones, intestines and liver c. excreted mainly through the kidneys d. excreted in bile e. an elevated value is an indicator of impaired conjugation of bilirubin f. an elevated value is an indicator of biliary obstruction. A. b, d, f. B. a, d, f. C. b, c, f. D. b, d, e. E. b, c, e.

What is true about chronic hepatitis B: a. develops in 80% of those infected with hepatitis B virus b. patients have characteristic clinical symptoms c. it is proven by determining anti-HBs antibodies in serum d. the presence of HBs antigen in the serum indicates infectivity e.a late complication may be hepatocellular carcinoma. A. a, c. B. b, d. C. b, e. D. d, e. E. a, d.

The Child-Turcott-Pugh classification for assessing the degree of liver disease includes. a. assessment of encephalopathy, assessment of ascites, albumin, bilirubin and PC/INR. b. level of direct bilirubin, portal hypertension PC/INR, assessment of hepatic encephalopathy. c. assessment of ascites, albumin, PC/INR, gamma globulin concentration, edema on the lower limbs. d. gamma globulin concentration, assessment of hepatic encephalopathy, assessment of ascites, bilirubin. e. prothrombin time, hepatic encephalopathy, edema, ascites, portal hypertension.

AMA antibodies are characteristic of which disease. A. autoimmune hepatitis. B. primary biliary cholangitis. C. primary sclerosing cholangitis. D. alcoholic hepatitis. E. chronic C hepatitis.

A 34-year-old patient is brought to the clinic in a somnolent condition. He was not previously treated for decompensated liver cirrhosis. Laboratory findings reveal elevated aminotransferase values 100 times above normal values and a 3-fold prolonged INR. Ammonia is highly elevated. What are the most likely diagnoses? A) Alcoholic hepatitis B) Acute viral hepatitis A, B, C, E C) acute liver failure D) autoimmune hepatitis E) toxic or drug-induced acute liver failure. A. abc. B. cde. C. bcd. D. abe.

A 50-year-old Caucasian woman with chronic hepatitis C returned from Mexico with jaundice and altered mental status. Additional tests showed a cirrhotic liver, total bilirubin 171 µmol/L, creatinine 132 µmol/L and INR 2.5. The lady has acute liver failure due to infection with hepatitis Which of the following is a known risk factor for the fulminant course of the disease?. A. Gender. B. Mode of transmission of infection. C. Chronic hepatitis C infection. D. Race. E. Age.

Alcoholic liver cirrhosis develops a. in 10% of alcoholics b. the type of alcoholic beverage is important c. occasional abstinence worsens liver disease d. in men, the activity of aldehyde dehydrogenase in the gastric mucosa is lower than in women e. the cause lies in genetic factors. A. a, c. B. b, d. C. a, e. D. d, e. E. a, d.

A 55-year-old gentleman with developed liver cirrhosis due to hepatitis C has started to notice that his abdomen is getting bigger and he has gained weight in the last three months. In the status find ascites. Laboratory findings: Sodium 130 mEq/L, urea 4.3 mmol/L, creatinine 35.4 µmol/L, total bilirubin 22.2 µmol/L, albumin 29 g/L, INR 1.5. Which therapy will most effectively prevent ascites build-up?. A. Fluid restriction. B. Restriction of salt intake and use of diuretics. C. Limitation of fluid and salt intake. D. Limiting salt intake. E. Paracentesis of ascites.

A 42-year-old man, who eats healthily and does not drink alcoholic beverages, comes for examination due to increased fatigue and decreased libido. During the examination, you find that it is slightly hyperpigmented, otherwise the clinical status is unremarkable. All and liver tests are within normal range. A routine blood test at the selected doctor showed 55% iron saturation. The patient's brother died at the age of 52 from hepatocellular carcinoma in a cirrhotic liver. What is the most appropriate test to demonstrate hemochromatosis in our patient?. a. Genetic testing for the C282Y mutation. b. Measurement of serum ferritin. c. Carry out HLA typing in the remaining siblings. d. Measure the amount of iron in the liver by MRI. e. Assess response to phlebotomy.

The most important feature of ascites in spontaneous bacterial peritonitis is (circle the correct answer): a. It is thick, green and has a characteristic smell. b. LDH concentration is higher than serum concentration. c. Increased number of neutrophil granulocytes. d. Increased concentration of proteins in ascites. e. In ascites, the glucose concentration is at least two times lower than the serum level.

The family doctor is called to the clinic in the morning by the relatives of a man with known liver cirrhosis. He was recently hospitalized in the gastroenterology department due to worsening of the disease with ascites and swelling of the legs, at which time the degree of liver function impairment was assessed as Child Pugh class C. He drank yesterday, he felt bad in the morning. He vomited fresh twice in the morning blood, shortly afterwards his relatives found him lying on the toilet floor. They noticed completely black, smelly, liquid feces in the toilet bowl. He soon regained consciousness, but he is still "bad" during the phone call. Which working diagnosis is most likely?. A. Bleeding from a duodenal ulcer. B. Bleeding from a Mallory Weiss puncture. C. Bleeding from esophageal varices. D. Bleeding from the papilla of Vateri. E. Bleeding from angiodysplasias of the small intestine.

The family doctor is called to the clinic in the morning by the relatives of a man with known liver cirrhosis. He was recently hospitalized in the gastroenterology department due to worsening of the disease with ascites and swelling of the legs, at which time the degree of liver function impairment was assessed as Child Pugh class C. He drank yesterday, he felt bad in the morning. He vomited fresh blood twice in the morning, and shortly afterwards his relatives found him lying on the toilet floor. In the toilet bowl they noticed completely black, smelly, liquid mud. He soon regained consciousness, but he is still "bad" during the phone call. The doctor at the internal medicine first aid found anemia with a hemoglobin of 67g/L, ordered blood for transfusion and the patient referred to an appropriate emergency examination, where bleeding from the gastrointestinal tract was detected and treated. What can we expect in a patient with profuse gastrointestinal bleeding and known Child Pugh C liver cirrhosis in the following hours?. A. Onset or worsening of hepatic encephalopathy. B. formation of ileus. C. Perforation of the hollow digestive organ. D. Development of iatrogenic pancreatitis. E. Myocardial infarction.

Hepatic encephalopathy is triggered by: T1. Gastrointestinal bleeding. T2. Dehydration. T3. Beta blockers . T4. Paracentesis of a very large volume of ascites. T5. Excessive dietary protein intake. a. T1, T2, T3. b. T1, T3, T4, T5. c. T1, T2, T4, T5. d. T1, T4, T5. e. T2, T3, T4, T5.

What is true about primary biliary cholangitis (PBC) and liver transplantation?. A. Compared to other etiologies, patients with PBC after liver transplantation have a lower 1-annual and 5-year survival. B. PBC recurs in most liver transplant patients. C. The presence of AMA antibodies after liver transplantation indicates disease recurrence. D. Patients with PBC have a poor quality of life due to fatigue and constant pruritus indication for liver transplantation. E. The number of liver transplants due to PBC is increasing every year.

Which of the following statements about hepatitis E virus infection is correct?. A. A common way of transmitting the infection is through infected needles. B. Acute liver failure does not occur in pregnant women with HEV infection. C. Among patients infected with HEV, pregnant women are more susceptible to developing acute liver failure. D. Although HEV infection is common in India, it is a very rare cause of acute liver cancellation in this country. E. HEV infection is the second most common cause of acute liver failure in Slovenia.

A 50-year-old businessman recently returned from a 3-day trip to Asia. A few weeks later he fell ill with a fever body temperature, malaise, decreased appetite and yellow sclera. His two children who visit daily care, they recently fell ill with diarrhea. What is the most likely risk factor for hepatitis A infection in this patient?. A. Contact with an infected person. B. Travel to endemic areas. C. Children in day care. D. Exposure to contaminated food or leads. E. Use of illicit drugs.

What is the most common way to get hepatitis A?. A. Direct contact with blood or body fluids. B. Unprotected sexual intercourse with an infected person. C. Use of illicit drugs. D. Fecal-oral route of transmission. E. Parenteral route of transmission.

The most common liver diseases in early pregnancy are: a) Nausea and vomiting b) Acute viral hepatitis c) Intrahepatic cholestasis in pregnancy d) Preeclampsia e) HELLP syndrome. A. a,b. B. a, c. C. b, d. D. d, e. E. c, d.

Indications for liver transplantation are: a) Compensated liver cirrhosis without complications in a patient younger than 65 years b) Advanced chronic liver disease with complications such as variceal bleeding, spontaneous bacterial peritonitis, hepatic encephalopathy, recurrent infections. c) Solitary hepatocellular carcinoma larger than 6 cm. d) Two colorectal cancer tumors smaller than 3 cm e) Acute fulminant liver failure. A. a, b. B. b, e. C. b, c. D. c, d.

A 75-year-old patient with compensated Child A liver cirrhosis, diabetes and heart failure was diagnosed with hepatocellular carcinoma in the 7th liver segment. The tumor was 3 cm in maximum diameter. What treatment would you recommend for him?. A. Radiofrequency or microwave ablation. B. Right-sided hepatectomy. C. Liver transplantation is within the Milan criteria. D. Symptomatic treatment due to comorbidities and age. E. Systemic treatment with sorafenib.

In a 37-year-old healthy woman who receives contraceptives and is under the care of a gynecologist due to CIN 3 of the cervix, an abdominal ultrasound revealed a tumorous change in the liver. Abdominal CT with contrast medium showed an 8 cm tumor with a central scar. What is the most likely diagnosis?. A. Hemangioma. B. Liver adenoma. C. Cancer seed from birth. D. Focal nodular hyperplasia. E. Cystadenoma.

A 45-year-old man with primary sclerosing cholangitis and cirrhosis comes to us because of increased itching and jaundice. He noticed that he had lost 7 kg of unwanted weight in recent months. He denies abdominal pain and is afebrile. V laboratory results: AF 10.7 µkat/L, total bilirubin 99 µmol/L, AST 2.03 µkat/L, ALT 2.04 µkat/L, INR 1.3, hematocrit 0.320, leukocytes 5.0x109 , Ca 19-9 533 U/mL, AFP 23 ng/mL. What is the most appropriate next step in consider?. A. Liver biopsy. B. Initiate treatment with appropriate parenteral antibiotic therapy. C. Preparing the patient for liver transplantation. D. MRI/MRCP. E. ERCP.

In the diagnosis of acute cholangitis, we use three Tokyo criteria; criterion A (a. fever or chills, b. elevated CRP, c. systemic inflammatory response), criterion B (a. jaundice, b. pathological liver tests), criterion C (a. dilated choledochus, b. visible cause of biliary obstruction). An unequivocal diagnosis of acute cholangitis is made if: A. at least one of diagnostic criteria A, at least one of diagnostic criteria B and at least one of diagnostic criteria C present. B. two of the diagnostic criteria A and at least one of the diagnostic criteria B present. C. at least one of the diagnostic criteria A and two of the diagnostic criteria B present. D. at least one of the diagnostic criteria C and two of the diagnostic criteria B present. E. present at least one of the diagnostic criteria A, and two of the diagnostic criteria C.

In a 55-year-old patient with compensated liver cirrhosis due to hepatitis C infection, a newly formed lesion of 9 mm was found during a regular ultrasound examination, which is performed every six months. What is the further procedure. A. We take blood to determine alpha feto protein (AFP). B. We refer him for MRI of the liver with contrast. C. We refer him for a CT scan of the liver with contrast. D. We refer him for an US-guided biopsy. E. We refer him to a follow-up ultrasound of the abdomen in 3 to 4 months.

A 79-year-old patient with liver cirrhosis due to hepatitis C infection came for examination. He denies bleeding from the of the gastrointestinal tract, occurrence of ascites or hepatic encephalopathy in the past. Measured vitals signs: heart rate 64/min, blood pressure 120/70 mmHg. The patient has numerous spider nevi, but the rest is fine clinical status without significant deviations from normal. A gastroscopy was performed to evaluate the varices showed two small varices in the distal esophagus. What would you recommend to the patient?. A. Nadolol (beta blocker). B. Endoscopic variceal ligation. C. Transjugular intrahepatic portosystemic shunt (TIPS). D. Repeat gastroscopy in 1 year. E. Repeat gastroscopy in 3 years.

You have admitted a patient to the ward who needs further internist treatment. An important part of this treatment is the definition of the patient's nutritional status, which you will do as follows. A. We will perform an initial screening according to the NRS 2002 scoring system, if the patient is not nutritionally compromised, the screening will be repeated in a week. B. We will perform an initial screening according to the MUST score, if the patient is not nutritionally compromised, we will repeat the screening in one week. C. We will perform an initial screening according to the NRS 2002 scoring system, if the patient is not nutritionally at risk, the screening does not we repeat. D. We will perform an initial screening according to the MUST scoring system, if the patient is not nutritionally compromised, we will not repeat the screening. E. Routine in-hospital screening for malnutrition is not required.

A 51-year-old woman visits you in the outpatient clinic, who has been noticing light-colored stools and jaundice for the past year. At the same time, she is more tired and reports itching. Laboratory findings reveal elevated alkaline phosphatase, gammaGT and conjugated bilirubin. You conclude that the lady has cholestasis, which may be related to a lack of certain vitamins. Which problems are most likely present in the lady due to hypovitaminosis?. A. Prolonged prothrombin time. B. Hair loss. C. Megaloblastic anemia. D. Dermatitis. E. Koilonychia.

In front of you is a 67-year-old gentleman patient who was brought to the internist's first aid clinic due to severe general weakness. His gait is atactic. He gives a confused history , seems disoriented, complains of poor eyesight. It seems to you that he does not understand you well and has memory disorders. In the clinical examination, you notice nystagmus, ptosis of the eyelids, gynecomastia, tense abdomen and caput medusa. Replacement of which of the following vitamins is most likely to improve the patient's condition?. A. Thiamine replacement. B. Riboflavin replacement. C. Folic acid replacement. D. Cobalamin replacement. E. Niacin replacement.

You are examining a 73-year-old man who has become very weak and lost 5 kilograms in the last month. Eat most of the food you eat. Microcytic anemia is present in laboratory findings. Refer him for gastroscopy, where a growth suspicious for carcinoma is visible, growing from the antrum into the pyloric canal and causing pyloric stenosis, which is passable to the endoscope . The histological findings suggest adenocarcinoma of the stomach. The CT scan shows the spread of the disease to the liver, without other features. Determine that the gentleman needs additional nutritional support. He is currently receiving parenteral nutrition in the ward. Which way of feeding will you choose in further consideration?. A. We continue with parenteral nutrition. B. We will endoscopically insert a percutaneous gastrostomy (PEG) into the gentleman. C. We will endoscopically insert a percutaneous gastrostomy with an extension in the jejunum (J- PEG) because stenosis requires postpyloric feeding. D. The gentleman should try to eat normally as much as possible. E. We will surgically make a percutaneous gastrostomy.

You admitted a 27-year-old patient without other associated diseases to the department for nutritional support before the operative treatment of Crohn's disease. On examination, he is cardiorespiratory compensated, blood pressure 117/72 mmHg, pulse 63/min, saturation without added oxygen 99%, body mass index 16.5 kg/m2 . The patient tells you that he passes liquid stool up to 10 times a day, has a poor appetite and eats very little. He lost 12 kg of body weight in the last six months. You have decided on supplemental parenteral nutrition. What electrolyte abnormalities can you expect a few days after starting parenteral nutrition?. A. Hypophosphatemia, hyperkalemia, hypermagnesemia. B. Hypophosphatemia, hypokalemia, hypomagnesemia. C. Hyperphosphatemia, hypokalemia, hypomagnesemia. D. Hypophosphatemia, hyperkalemia, hypomagnesemia. E. Hyperphosphatemia, hyperkalemia, hypermagnesemia.

You admitted a 27-year-old patient without other associated diseases to the department for nutritional support before the operative treatment of Crohn's disease. On examination, he is cardiorespiratory compensated, blood pressure 117/72mmHg, pulse 63/min, saturation without added oxygen 99%, body mass index 16.5 kg/m2. The patient tells you that he passes liquid stool up to 10 times a day, has a poor appetite and eats very little. You have decided on supplemental parenteral nutrition. In order to avoid potential electrolyte and acid-base disorders when parenteral nutrition is introduced, you will take the following measures into account: A. We will start with an energy intake of 20-25 kcal/kgTT/day for the first three days and then gradually lower it to 10-15 kcal/kg/TT/day. We will replace thiamine and other electrolytes according to laboratory values. B. We will start with an energy intake of 10-15 kcal/kg/day for the first three days and then gradually increase it to 20-25 kcal/kg/day. We will replace thiamine and other electrolytes according to laboratory values. C. Energy intake should be 20-25 kcal/kgWT/day at all times. We will replace thiamine and other electrolytes according to laboratory values. D. We will start with an energy intake of 10-15 kcal/kgTT/day for the first three days and then gradually increase it to 20-25 kcal/kgTT/day. We will replace thiamine, electrolyte monitoring is not necessary. E. We will start with an energy intake of 20-25 kcal/kgTT/day for the first three days and then gradually lower it to 10-15 kcal/kgTT/day. We will replace thiamine, electrolyte monitoring is not necessary.