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what is the etiology of cirrhosis
- 1. Alcohol
- 2. viral hepatitis
- 3. Autoimmune hepatitis
- 4. steatohepatitis (Fatty hepatitis)
- 5. Drugs and toxins
- 6. Biliary disease
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what are some more etiologies of Cirrhosis with Metabolic/Genetic
- -hemachromatosis- (excessive iron storage)
- -Wilson's disease (disorder of copper metabolism)
- -Alpha antitrypsin deficiency
- -cystic fibrosis
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what is the etiology of Cirrhosis with Cardiovascular disease
Right sided heart failure
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how is Cirrhosis diagnosed (Lab studies)
- AST, ALT, LDH, ALK PHOS, Bilirubin, Protein, Albumin, PT/INR, PLT, CBC, Ammonia
- Liver biopsy
- Ct scan, ultrasound
- Endoscopy (EGD) esophageal variecs
- Barium studies
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what are some early signs and symptoms of Cirrhosis
- HX of failing health
- nausea and vomiting
- anorexia
- indigestion
- flatulence
- constipation
- weight loss with water retention
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what are some more early signs of Cirrhosis
- malnutrition
- RUQ pain
- Pruitus (from Jaundice)
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what are some later signs and symptoms of cirrhosis
- Ascites
- Jaundice/Icterus
- Edema
- Rashes/dry skin/ palmer erythema
- petechiae/ ecchymosis
- spider angiomas on nose, cheeks, upper thorax and shoulders
- bleeding/Anemia/Melena
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more signs and symptoms of Cirrhosis
- Fetor hepaticus (liver Breath)
- Gynecomastia
- Asterixis
- Hepatomegaly
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what is liver flap
when someone with cirrhosis hand cannot stay straight it moves back and forth
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what is the treatment of Cirrhosis with drugs
- depends on signs and symptoms
- -vitamin K
- -Diuretics
- -Folic acid and Thiamine especially in alcoholics
- -vitamins and minerals
- -Albumin IV (if having a paracentesis, fluid in the ab.)
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how would you treat the symptoms of someone with Cirrhosis
manage the symptoms
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what should be monitored in someone with Cirrhosis
monitor bleeding
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what should be supported in someone with Cirrhosis
support respirations
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what should be done with the CNS
neurologic monitoring
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what else should be monitored with Cirrhosis
- fluid and electrolyte balance
- prevent infection
- prevent bleeding and falls
- promote nutrition
- control itching
- skin care
- promote positive self esteem
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how should someone with Cirrhosis treatment be (diet)
- restrict sodium
- fluids may be restriced
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someone with cirrhosis may need a paracentesis what is it
fluid taken out of the abdomin
-
more treatments of Cirrhosis
- GI intubation/Blakemore tube
- Endoscopic O Bands/Sclerotherapy
- Blood Transfusions
- Surgeries
-
what type of surgeries for Cirrhosis
- Peritoneovenous Shunt
- Portcaval Shunt
- Tips (Transjugular intrahepatic portal systemic shunt) shunt blood to another part of the body
- Alcohol control
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Esophageal Varices issues
- most dangerous
- primary prophylaxis
- if bleeding establish source
- lavage with NG tube
- Meds, Vasopressin, Inderal, Sandostatin
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more esophageal varices issues
- Surgery
- Shunts (TIPS, Surtgical Shunts)
- balloon tamponade (blakmore tube, Intensive care)
- Sclerotherapy (can inject Saline)
- NG tube placed by physician not nurse
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caused by a disturbance in bilirubin metabolism (hepatocellular as the liver cells cannot effectively excrete bilirubin)
Jaundice
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may also result from hemolysis and/or obstruction of biliary ducts (intrahepatic obstruction)
jaundice
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the higer the bilirubin
the more yellow
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can be seen in skin, mucous membranes, sclera, tissues, and other body fluids
Jaundice
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what is a major side effect of jaundice
Itching (treat the itching) little bit of benadryl
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how should someone with Jaundice clothes be
loose, cool clean and also their bedding
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should someone with jaundice use creams and lotions
yes
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what else can be given for itching
antihistamines
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what type of environment should someone with jaundice be in
cool
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how should someone with jaundic baths be
Tepid, not hot baths
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what should someone with Jaundice avoid
activities causing sweating and increased temperature
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what type of activities should they be involved in
divertional activities?
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the accumulation of free fluid in the peritoneal cavity
Ascites/Paracentesis
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Increased pressure in the portal circulation (Ascites)
portal hypertention
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Increased capillary plasma hydrostatic pressure
Ascites
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Impaired production of albumin decreased capillary plasma oncotic pressure
Ascites
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fluid moves out of the vessel and into the peritoneum
Ascites
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what is the treatment for Ascites
- Paracentesis with IV albumin
- PV shunt
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Decrease in the synthesis of Bile
Coagulation Defects
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prevents the absortption of vitamin K
Coagulation Defects
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clotting factors II, VII, IX and X are not produced
coagulation defects
-
susceptible for bleeding and bruising
abnormal prothrombin times (PT) high
Coagulation Defects
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when PT is high what does it cause
bleeding
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when PT is low what does it cause
Clotting
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splenomegaly (coagulation defects)causes what
casuses thrombocytopenia
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a persistent increase in pressure within the portal vein
portal hypertension
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Development of collateral circulation in high pressure areas
portal hypertention
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what can result from portal hypertention
- esophageal varices
- hemorroids
- splenomegaly
- ascites
-
acute or chronic
liver is unable to metabolize and cleanse the blood of ammonia and mercaption what is this
portal systemic encephalopathy (hepatic coma) (PSE)
-
what is the end product of protein metabolism
ammonia (PSE)
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toxins produced from the metabolism of sulfur containing compounds
Mercaptions (PSE)
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4 stages of PSE
- prodroma
- impending
- stuporous
- comatose
- may progress through the stages or fluctuate among the 4 stages, symptoms vary and may occur quickly or gradually over a few days
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what are the symptoms of PSE portal systemic encephalopathy (hepatic coma)
- Alerations in the level of consciousness
- Decrease in interlectual function
- Changes in behavior and personality
- Changes in neuromuscular function
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what are some meds to decrease ammonia levels in portal systemic encephalopathy (PSE)
- Lactulose (chronulac) decrease ammonia levels and also a laxitive
- Neomycin Sulfate
- Metronidazole (Flagyl)
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what is the most common med to decrease ammonia levels
Lactulose
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what are some precipitation factors we need to identify and treat in PSE
- High protein levels, Infections
- HYPOvolemia HYPOkalemia
- GI hemorrhage (causes large protein load in the intestines)
- drugs
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Sudden kidney failure for no Known cause in a patient with worsening liver failure (MOM)
hepatorenal syndrome
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sudden decrease in urinary flow
hepatorenal syndrome
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elevated Bun and Creatinine levels, with decreased urine sodium excretion
Hepatorenal syndrome
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Increased urine Osmolarity and poor prognosis
Hepatorenal Syndrome
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fever, chills, abdominal pain and tenderness what is this disease
Spontaneous Bacterial Peritonitis
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with Spontaneous bacterial peritonitis what what should be done for treatment and testing
- send a sample of fluid for culture
- treat with antibiotics
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Hepatitis B infection
tylenol overdose
combination of tylenol with alcohol or other drugs what can happen
acute liver failure
-
poison mushrooms (to get High)
Pregnancy
Unknown
what disease
acute liver failure
-
a sudden massive necrosis of hepatocytes in a previously healthy person. all liver function is lost
Acute liver failure
-
75% die within days of onset (Patty)
Acute liver failure
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what are some signs and symptoms of Acute Liver Failure (think of Patty)
- Rapid onset,
- Cerebral Edema
- Jaundice
- mental status changes
- multi organ failure
-
what are some more signs and symptoms of Acute Liver Failure
- Multiple organ dysfunction syndrome
- -kidneys
- -Lungs
- -circulatory system
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how would the blood be in someone with ALF acute liver failure
rapid decrease in coagulation ability (bleeding)
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what kind of encephalopathy will the pt. with ALF have
clinical encephalopathy
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what is the treatment for Acute liver failure (Patty)
- treatment is liver transplant, but it is not always available
- not alot of time to get the liver transplant
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the progressive, irreversible destruction of liver function over time (MOM)
Chronic liver Failure
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End stage liver disease (MOM)
Chronic liver failure
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Cirrhosis of the liver is the typical presentation (MOM)
Chronic Liver failure
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they are doing more live liver transplants but what is a disadvantage
dangerous for the donor
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localized to one portion of the liver
Focal Hepaocellular Disorders
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Abscess
Trauma (stabbing)
Tumor (cancerous)
one portion of the liver
- Focal Hepatocellular disorder
- key is focal is like local (one area)
-
very dangerous can get septic
liver abscess
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comes from gut to liver
Amebic (liver abscess)
-
reaches liver through biliary, vascular, or lymphatic systems
- Pyogenic (liver Abscess)
- High mortality rate
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penetrating injuries (GSW, Stabbing)
Pyogenic (Liver Abscess)
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