Week 3 - Cirrhosis of the Liver PDF

CIRRHOSIS OF THE LIVER Objectives Define cirrhosis Etiology of cirrhosis Nursing management of cirrhosis Interprofessional care Diagnostic studies QUESTION What is cirrhosis? What are some signs and symptoms of cirrhosis? CIRRHOSIS a chronic disease of the liver marked by degeneration of cells, infl...

CIRRHOSIS OF THE LIVER Objectives Define cirrhosis Etiology of cirrhosis Nursing management of cirrhosis Interprofessional care Diagnostic studies QUESTION What is cirrhosis? What are some signs and symptoms of cirrhosis? CIRRHOSIS a chronic disease of the liver marked by degeneration of cells, inflammation, and fibrous thickening of tissue. It is typically a result of alcoholism or hepatitis DESCRIPTION OF CIRRHOSIS Copyright © 2017, Elsevier Inc. All Rights Reserved. Usually happens after decades of chronic liver disease Eighth leading cause of death in United States Twice as common in men as compared to women Copyright © 2017, Elsevier Inc. All Rights Reserved. ETIOLOGY AND PATHOPHYSIOLOGY Most common causes in United States are chronic hepatitis C and alcohol-induced liver disease Other causes Extreme dieting, malabsorption, obesity Environmental factors Genetic predisposition Copyright © 2017, Elsevier Inc. All Rights Reserved. CIRRHOSIS Copyright © 2017, Elsevier Inc. All Rights Reserved. CLINICAL MANIFESTATIONS Relatively few symptoms in early stage disease Fatigue and enlarged liver may be early symptoms Blood tests may be normal- compensated cirrhosis QUESTION What is compensated cirrhosis? ANSWER Compensated cirrhosis means the liver is scarred but still able to perform most its basic functions at some level Copyright © 2017, Elsevier Inc. All Rights Reserved. CLINICAL MANIFESTATIONS Late manifestations Result from liver failure and portal hypertension Jaundice, peripheral edema, ascites Other late manifestations Skin lesions, hematologic disorders , endocrine disturbances , and peripheral neuropathies QUESTION What is portal hypertension? ANSWER Portal hypertension is an increase in the blood pressure within a system of veins called the portal venous system Copyright © 2017, Elsevier Inc. All Rights Reserved. CLINICAL MANIFESTATIONS Jaundice WHY!!!! Decreased ability to conjugate and excrete bilirubin Overgrowth of connective tissue in liver compresses bile ducts Leads to obstruction Increase in bilirubin in vascular system May be minimal or severe Copyright © 2017, Elsevier Inc. All Rights Reserved. CLINICAL MANIFESTATIONS Skin lesions Due to increase in circulating estrogen caused by inability of liver to metabolize steroid hormones Spider angiomas (teleangiectasia or spider nevi) (swollen blood vessels) found slightly beneath the skin surface, often containing a central red spot and reddish extensions which radiate outwards like a spider's web) Palmar erythema (is a rare skin condition where the palms of both hands become reddish. This change in color usually affects the base of the palm and the area around the bottom of your thumb and little finger. In some cases, your fingers may also turn red) PALMAR ERYTHEMA Copyright © 2017, Elsevier Inc. All Rights Reserved. CLINICAL MANIFESTATIONS Hematologic disorders Thrombocytopenia (deficiency of platelets in the blood. This causes bleeding into the tissues, bruising, and slow blood clotting after injury). Leukopenia (a reduction in the number of white cells in the blood, typical of various diseases). Anemia Coagulation disorders (Coagulopathy (also called a bleeding disorder) is a condition in which the blood's ability to coagulate (form clots) is impaired. This condition can cause a tendency toward prolonged or excessive bleeding, which may occur spontaneously or following an injury or medical and dental procedures) QUESTION What is gynecomastia? What is Amenorrhea ? Copyright © 2017, Elsevier Inc. All Rights Reserved. CLINICAL MANIFESTATIONS Endocrine disorders Secondary to decreased metabolism of hormones Gynecomastia, loss of axillary and pubic hair, testicular atrophy, impotence and loss of libido (men) Amenorrhea or vaginal bleeding (an abnormal absence of menstruation). Hyperaldosteronism in both sexes ( a disorder in which the adrenal gland releases too much of the hormone aldosterone into the blood.) Copyright © 2017, Elsevier Inc. All Rights Reserved. CLINICAL MANIFESTATIONS Peripheral neuropathy Dietary deficiencies of thiamine, folic acid, and cobalamin (vitamin B12) Sensory and motor symptoms Sensory symptoms may predominate Copyright © 2017, Elsevier Inc. All Rights Reserved. COMPLICATIONS Compensated cirrhosis Decompensated cirrhosis (Decompensated cirrhosis is a term that doctors use to describe the complications of advanced liver disease). Portal hypertension Esophageal and gastric varices Peripheral edema Abdominal ascites Hepatic encephalopathy Hepatorenal syndrome Copyright © 2017, Elsevier Inc. All Rights Reserved. COMPLICATIONS Portal hypertension Increased venous pressure in portal circulation Splenomegaly Large collateral veins Ascites Gastric and esophageal varices Copyright © 2017, Elsevier Inc. All Rights Reserved. COMPLICATIONS Esophageal varices Complex of tortuous, enlarged veins at lower end of esophagus Gastric varices Upper portion of stomach Both are very fragile, bleed easily Most life-threatening complication DEFINITION OF ESOPHAGEAL VARICES Esophageal varices (sometimes spelled esophageal varix, or esophageal varices) are extremely dilated sub-mucosal veins in the lower third of the esophagus. They are most often a consequence of portal hypertension, commonly due to cirrhosis; people with esophageal varices have a strong tendency to develop bleeding QUESTION What is ascites? Copyright © 2017, Elsevier Inc. All Rights Reserved. COMPLICATIONS Ascites Accumulation of serous fluid in peritoneal or abdominal cavity Several mechanisms Portal hypertension Hypoalbuminemia Hyperaldosteronism DEFINITIONS Hypoalbuminemia (or hypoalbuminaemia) is a medical sign in which the level of albumin in the blood is abnormally low. Hyperaldosteronism, also aldosteronism, is a medical condition wherein too much aldosterone is produced by the adrenal glands, which can lead to lowered levels of potassium in the blood (hypokalemia) and increased hydrogen ion excretion (alkalosis) Copyright © 2017, Elsevier Inc. All Rights Reserved. COMPLICATIONS Hepatic encephalopathy Neurotoxic effects of ammonia Abnormal neurotransmission Astrocyte swelling Inflammatory cytokines Liver unable to convert increased ammonia Ammonia crosses blood-brain barrier Copyright © 2017, Elsevier Inc. All Rights Reserved. COMPLICATIONS Hepatic encephalopathy Changes in neurologic and mental responsiveness Impaired consciousness and/or inappropriate behavior Sleep disturbances, trouble concentrating, coma Copyright © 2017, Elsevier Inc. All Rights Reserved. COMPLICATIONS Hepatic encephalopathy Asterixis Flapping tremors Most common in arms and hands Impairment in writing Difficulty in moving pen left to right Apraxia (inability to perform particular purposive actions, as a result of brain damage). Fetor hepaticus Musty, sweet odor of patient’s breath DEFINITION OF FETOR HEPATICUS Fetor hepaticus or foetor hepaticus (see spelling differences), also known as breath of the dead or hepatic foetor, is a condition seen in portal hypertension where portosystemic shunting allows thiols to pass directly into the lungs Copyright © 2017, Elsevier Inc. All Rights Reserved. COMPLICATIONS Hepatorenal syndrome Renal failure with azotemia, oliguria, and intractable ascites No structural abnormality of kidneys Portal hypertension → vasodilation → renal vasoconstriction Treat with liver transplantation Copyright © 2017, Elsevier Inc. All Rights Reserved. DIAGNOSTIC STUDIES Liver enzyme tests Total protein, albumin levels Serum bilirubin, globulin levels Cholesterol levels Prothrombin time Ultrasound elastography (Fibroscan) Liver biopsy Copyright © 2017, Elsevier Inc. All Rights Reserved. INTERPROFESSIONAL CARE Ascites Sodium restriction Albumin Diuretics Copyright © 2017, Elsevier Inc. All Rights Reserved. INTERPROFESSIONAL CARE Esophageal and gastric varices Prevent bleeding/hemorrhage Avoid alcohol, aspirin, and nonsteroidal anti-inflammatory drugs (NSAIDs) Screen for presence with endoscopy Copyright © 2017, Elsevier Inc. All Rights Reserved. INTERPROFESSIONAL CARE If bleeding occurs, stabilize patient, manage airway, provide IV therapy and blood products Drug therapy Octreotide Vasopressin Endoscopic therapy Band ligation Sclerotherapy Copyright © 2017, Elsevier Inc. All Rights Reserved. INTERPROFESSIONAL CARE Supportive measures for acute bleed Fresh frozen plasma Packed RBCs Vitamin K Proton pump inhibitors Lactulose (Cephulac) and rifaximin (Xifaxan) Antibiotics QUESTION The nurse is reviewing the lab results for a pt with cirrhosis and notes that the ammonia level is elevated. Which diet does the nurse anticipate to be presribed for this pt? Low-protein High-protein Moderate-fat High-carb ANSWER Low-protein diet Protein provided by the diet is transported to the liver via the portal vein. The liver breaks down protein, which results in the formation of ammonia. QUESTION During assessment of a pt with obstructive jaundice, the nurse would expect to find: 1. clay colored stools 2. dark urine and stool 3. pyrexia and pruritis 4. elevated urinary urobilinogen ANSWER clay colored stool QUESTION The pt with advanced cirrhosis asks why his abdomen is so swollen. The nurse's best response is based on the knowledge that a. a lack of clotting factors promotes the collection of blood in the abdominal cavity b. portal hypertension and hypoalbuminemia cause fluid shift into the peritoneal space. c. decreased peristalsis in the GI tract contributes to gas formation and distention of the bowel d. bile salts in the blood irritate the peritoneal membranes, causing edema and pocketing of fluid. ANSWER B Ascites is accumulation of serious fluid in peritoneal cavity. With portal hypertension, protein shifts from the blood into the lymph. When the lymph system is unable to carry excess, it leaks thru the liver into the peritoneal cavity. osmotic pressure of the proteins pulls additional fluid into cavity. Second mechanism of ascites if hypoalbuminemia from the liver unable to synthesize albumin, resulting in decreased colloidal oncotic pressure. QUESTION The health care provider orders lactulose for a patient with hepatic encephalopathy. The nurse will monitor for effectiveness of this medication for this pt by assessing what? a. relief of constipation b. relief of ab pain c. decreased liver enzymes d. decreased ammonia levels ANSWER D hepatic encephalopathy is associated with elevated ammonia levels. Lactulose traps ammonia in the intestinal tract. It's laxative effect then expels ammonia from the colon, resulting in decreased ammonia levels, correcting hepatic encephalopathy.