End-Stage Liver Disease PDF

Lissi Hansen & Anna Sasaki 18 End-Stage Liver Disease C H A P T E R KEY POINTS Chronic liver diseas...

Lissi Hansen & Anna Sasaki 18 End-Stage Liver Disease C H A P T E R KEY POINTS Chronic liver disease and cirrhosis is the 12th leading cause of death in the United States. Liver cancer is one of the fastest growing cancers in the world. Patients with end-stage liver disease (ESLD) present with malnutrition, muscle wasting, hyperlipidemia, fatigue, jaundice, and renal disease. Given trends in obesity, fatty liver disease may soon become the leading cause of liver cirrhosis. Nurses need to be aware of the pathophysiology and etiologies of liver disease. Nurses need to explore and acknowledge their assumptions and biases about patients with liver disease and their families. Nurses play a pivotal role in advocating for advance care planning and early palliative care for patients with ESLD and their families. Patients with liver disease benefit from physical, psychosocial, and spiritual interventions offered through palliative care. CASE STUDY J.R. was a 65-year-old man with a history of obesity, hypertension, and insulin-dependent diabetes. He had been seen in the ED with complaints of right upper quadrant pain and nausea. Bloodwork revealed normal liver function tests, normal renal function, and a platelet count of 100,000 µL. A CT revealed cirrhosis and a 4 cm lesion consistent with hepatocel- lular carcinoma (HCC). The HCC was treated with Y-90 and he was referred for liver trans- plantation. However, the HCC recurred. He was determined to no longer be a transplant candidate. Over the next 6 months, he developed decreasing liver function, had the onset of ascites, and had an episode of spontaneous bacterial peritonitis. He was referred to palliative care for treatment of symptoms of pain and itching as well as discussions of goals of care. T he liver is the largest solid organ and weighs 1,200 to 1,500 g (Curry & Bonder, 2017). It lies in the right upper quadrant protected by the ribs and is sup- through the portal vein, which drains the small and large intestine, the spleen, the stomach, and the pancreas. The portal vein, hepatic artery, and bile duct course together plied by the common hepatic artery. The liver is unique in a thin fibrous bundle, and the artery and vein branch in that 60% to 85% of oxygen and nutrients come to it into smaller and smaller diameter vessels while the small Copyright Springer Publishing Company. All Rights Reserved. From: Palliative Care Nursing: Quality Care to the End of Life, Fifth Edition DOI: 10.1891/9780826127198.0018 Matzo_27129_PTR_18_425-438_05-24-18.indd 425  426 III. PHYSICAL HEALTH: LIFE-THREATENING DISEASES bile ductules coalesce into larger ducts and carry bile in DEFINITIONS RELATED TO LIVER DISEASE the opposite direction. The blood in the smallest arteri- oles and venules percolate along cords of liver cells in 1. Cirrhosis is a diffuse pattern of liver injury and repair the sinusoids (leaky capillary-like structures) and drain that leads to fibrosis, changes in liver blood flow, and into the central veins. These join other central veins and loss of liver cells. finally form the hepatic vein, which carries blood to the 2. Compensated cirrhosis is cirrhosis with normal liver inferior vena cava and then to the heart. function (Child’s Class A, see Table 18.1). The liver performs a myriad of functions: 3. Decompensated cirrhosis is cirrhosis with decreases in serum albumin and other proteins, an increase in the Protein synthesis and secretion: almost all plasma international normalized ratio (INR), and the presence proteins (except for gamma globulin), including alpha of one or more complications of portal hypertension. and beta globulins, albumin, and binding proteins for 4. End-stage liver disease (ESLD) is decompensated cir- metals, toxins, hormones, and lipoproteins rhosis with the involvement of other organ systems Excretion: bilirubin, bile salts, heavy metals, lipids, such as kidney, heart, or recurrent encephalopathy. toxins 5. Hepatic encephalopathy is a decrease in the cognitive Storage: iron, vitamin A, glycogen, lipid function often accompanied by a decline in the level Immune: Kupffer cells, which traverse the sinusoids, of consciousness. engulfing bacteria, bacterial products, dead hepato- 6. Hepatocellular carcinoma (HCC), a cancer that arises cytes, and senescent red cells from hepatocytes, increases in patients with compen- Nutrition: governs the fate of amino acids to be used sated and decompensated cirrhosis. as an energy source, to synthesize new proteins, or to be degraded to urea; stores and metabolizes glucose; synthesizes lipids and conjugates them to proteins for INCIDENCE AND PREVALENCE OF CHRONIC secretion and delivery to all cells in the body LIVER DISEASE Metabolism: due to its blood supply, which ­carries blood from the gut, lipid-soluble toxins, both Approximately 5.5 million Americans are affected by ­exogenous and endogenous, contact hepatocytes first chronic liver disease. The treatment for chronic liver and are extracted efficiently from the bloodstream. disease costs more than the treatment for any other Lipid-soluble medications are transformed by the gastrointestinal-related condition (Peery et al., 2015). cytochrome P-450 system and are either excreted in Each year it accounts for more than 290,000 emergency the bile or metabolized to inactive molecules. room visits and 240,000 hospitalizations (Peery et al., 2015). Cirrhosis is the result of chronic liver disease and There are many chronic liver diseases that lead to affects an estimated 633,300 Americans (Scaglione et al., cirrhosis, such as viral hepatitis, autoimmune hepatitis, 2015). Cirrhosis is a progressive destruction of the liver primary biliary cholangitis (PBC), primary sclerosing parenchyma that leads to ESLD, the final stage of this cholangitis (PSC), nonalcoholic steatohepatitis, alcohol, destruction when damage to cells, tissues, and functions some toxins, and inborn errors of metabolism (National of the liver is irreversible, causing complete failure. Institute of Diabetes and Digestive and Kidney Diseases, Chronic liver disease and cirrhosis is the 12th lead- 2014). Whatever the etiology, cirrhosis is the final common ing cause of death in the United States. In 2014, 38,170 pathway, and a new set of concerns and problems develops. Americans died from these conditions (Kochanek, ­Murphy, TABLE 18.1 Child–Pugh–Turcotte Classification of Cirrhosis 1 2 3 Ascites None Slight Intractable Encephalopathy None Mild Severe Albumen >3.3 2.8–3.3