GI + Nutrition - Cirrhosis

what is chirrosis?

what is chirrosis?

o   Irreversible, permanent scarring and fibrosis of the liver d/t chronic inflammation (hepatitis B/C)

what are the causes of cirrhosis?

hep.C

alcohol

fatty liver

what is portal HTN?

o   Back up of blood causes portal hypertension

what are the S/S specific to portal htn?

Ascites

splenomegaly

bleeding varices - can be gastric and esophageal

why does ascites occur in portal HTN?

high pressure and low albumin

§  Big swollen fluid belly (think of a beer belly)

• Fluid is sitting in the stomach

what is the purpose of albumin?

§  Albumin exerts an oncotic pressure which sucks fluid inwards

what happens if albumin is low?

fluid will leak out of the veins and into belly leading to ascites

why does splenomegaly occur in portal HTN?

d/t back up of blood from portal vein

what will you see in a pt with splenomegaly in portal HTN?

·      Thrombocytopenia

·      Leukopenia

·      Anemia

why is the spleen important?

§  Responsible for making, storing, recycling platelets, white blood cell, and red blood cell

§  The high pressure causes the spleen to malfunction leading to low platelet, low WBC, and low RBC

if the liver is compromised and the liver cannot make clotting factors what can occur?

the pt will be at risk for bleeding

why do gastric varices occur in portal htn?

·      Vessels puff out inside the GI tract. If there is a weaken vein and there is too much pressure from the portal vein, the weaken vein can burst causing internal bleeding in the GI tract

o   This causes dark colored stool (blood in stool)

what are esophageal varices?

Bleeding in the esophagus causing a cough

what is the priority for a pt with esophageal varices?

AIRWAY

·      Too much blood in the esophagus can cause aspiration

what are the EARLY s/s of cirrhosis?

§  There are NO s/s

§  Liver enzymes are often normal

§  Liver enlargement goes unnoticed

§  Patient may be fatigued

what are the late S/S of cirrhosis?

§  Late s/s result from liver failure and portal HTN

-jaundice

-pruritus

-dark urine

-skin lesions (spider angiomas, palmar erythema)

-bleeding issues

-endocrine issues

-encephalopathy

why does encephalopathy occur in cirrhosis?

·      d/t ammonia buildup – comes from protein

o   when you eat protein and it is digested, one of the byproducts is ammonia. Liver takes ammonia (toxic to body) and converts it and excretes as urea

what symptom will tell you ur pt has encephalopathy?

confusion

what type of diet will pts with encephalopathy be on?

normal protein diet until pt exhibits confusion and ammonia levels are high

switch diet to lowest amount of protein

what diagnostics procedures will you do for pts with cirrhosis?

ultrasound

abdominal xray

ct scan

MRI

ERCP – Endoscopic Retrograde Cholangiography

EGD - Esophagogastroduodenoscopy

What is Endoscopic Retrograde Cholangiography (ERCP) for?

§  Used to view biliary tract to assist in removing stones, collect specimens for biopsy, and stent replacement

what is Esophagogastroduodenoscopy (EGD) for?

§  Detects the presence of esophageal varices, ulcerations in the stomach, or duodenal ulcers and bleeding

§  Goes through small intestine into bile duct

what procedure will de done for a pt with cirrhosis?

liver biopsy

TIPS

Paracentesis

Liver transplant

why does a pt with cirrhosis need a liver biopsy?

to Identify the progression and extent of the cirrhosis and Identifies cancer cells

what are the complications of a liver biopsy?

bleeding - Priority ABC - Circulation

tachycardia

what will your nursing intervention be for a pt who is bleeding after a liver biopsy?

·      Position pt on the right side to put pressure on the liver

·      Place gauze

• If there is blood – apply pressure, call for help

• Do not leave pt alone to get help

why does a pt with cirrhosis need a Transjugular Intrahepatic Portosystemic Shunt (TIPS) procedure?

to Shunt blood away from the varices and relieves pressure in the portal vein.

what is TIPS?

·      Creates a “bridge” from the portal vein to the hepatic vein which takes blood back to the heart relieving pressure. This “bridge” makes blood bypass the liver and this does not allow for the blood to be detoxified and nutrient absorption

·      This is not a fix – it buys time!!

·      Suitable for pts who are waiting for a liver transplant

what does a pt who undergoes a TIPS procedure at risk for?

·      Post procedure bleeding

what is a paracentesis procedure?

procedure for the Removal of ascites fluid from the abdomen

when would a paracentesis procedure be performed?

if the pt is having SOB d/t the increased pressure

what are the interventions for a paracentesis procedure?

• Client must empty bladder before

• Position pt in high fowlers position

• Assess site for drainage

if there is drainage after a paracentesis procedure what will the nurse do?

o   You will see a saturated gauze (DO NOT REPORT) and that’s ok b/c the DR will only drain a certain amount (enough to reduce the SOB) to avoid electrolyte imbalance or fluid shift

o   Cover with gauze

o   Replace PRN

what is a liver transplant?

§  Portion of healthy livers from deceased donors

what type of pts do not meet the criteria for a liver transplant?

·      Pt’s with severe cardiac and resp. disease

·      Metastatic malignant liver cancer

·      Alcohol/substance use disorder

what will you educate a pt with a liver transplant?

§  Clients will be on immunosuppression medication (anti-rejection) for life

·      If you are on immunosuppressed meds, you are at risk for infection

what is a complication of a liver transplant?

·      Rejection of the liver

what are the priority complication of cirrhosis?

-ruptured esophageal and gastric varices

-sengstaken blakemore tube

-ascites

-Hepatic Encephalopathy

-Peripheral Neuropathies

If you know the pt has cirrhosis and has portal hypertension and that varices are present, what can be ordered to help bring down the pressure to reduce the risk of bleeding?

betablockers

·      Nadolol (Corgard)

·      Propranolol (Inderal)

If you know the pt has cirrhosis and has portal hypertension and that varices have ruptured, what can be administered?

Octreotide (Sandostatin)

what is the MOA for Octreotide (Sandostatin)?

·      Hemostasis and control of bleeding in esophageal and gastric varices

·      decreases circulation to portal system

·      infuse IV to reduce blood flow to the GI organs

what is the treatment for Ruptured esophageal and gastric varices?

·      Endoscopic band ligation

·      Sclerotherapy – inject the varices to shrivel them up

·      TIPS – relieves pressure in the portal vein

what is Sengstaken Blakemore Tube?

§  Puts pressure on the esophagus to stop variceal bleed

what is the nursing intervention for sengstaken Blakemore Tube?

·      Scissors at bedside to cut it in an emergency – Airway risk

·      Deflate every 6 hours to prevent necrosis of the tissue

what are the S/S of ascites?

·      SOB

·      Weight gain

·      Abdominal distention

·      Dehydration – d/t fluid in the wrong place (tummy)

·      Decreased urine output – d/t dehydration

what is a complication of ascites?

·      Spontaneous bacterial peritonitis (SBP)

o   Bacterial infection of ascitic fluids

o   Peritonitis - Expect rigid board like abdomen, fever

what is the treatment for ascites?

• Albumin infusion: gives oncotic pressure, fluid will go back into the vessels

• Diuretics: You just give pt albumin and fluid from the belly rushes into the body causing the BP to rise and causing fluid overload so give diuretics to get rid of it

• Limit sodium – for dehydration

• Vitamin E & K

• Monitor fluid and electrolytes

• Paracentesis - Treats SOB - Do only if respiratory is affected

what is Hepatic Encephalopathy?

§  Liver is unable to convert ammonia to a less toxic form

§  Can progress to coma and even death from excess ammonia

what must be reported immediately for Hepatic Encephalopathy?

·      Changes in LOC

·      Fetor hepaticus – fruity breath

·      Asterixis – Flappy hands

what are the interventions for Hepatic Encephalopathy?

• Administer lactulose - a Laxative – helps get rid of ammonia through the stool

• You know it worked if the LOC improved, not that they went to the bathroom

what is Peripheral Neuropathies?

§  d/t dietary deficiencies (vitamin absorption issues)

§  Common with alcoholic cirrhosis

§  Feels like pins and needles (paresthesia)

what are the dietary deficiencies for Peripheral Neuropathies?

·      thiamine

·      folic acid

·      cobalamin

MOA for Furosemide (Lasix) – Diuretic?

decrease absorption of sodium and H2O

MOA for Spironolactone (Aldactone) - Diuretic ?

Blocks aldosterone, potassium sparing

MOA for Lactulose – Laxative?

§  promotes excretion of ammonia via stool

Goal for Lactulose – Laxative?

§  3-4 bowel movements per day

MOA for o   Magnesium Sulfate ?

§  corrects low magnesium

MOA for Neomycin Sulfate or Rifaximin (Xifaxan) ?

decreases bacterial flora, reduces ammonia formation

MOA for PPI’s (protonix)?

§  Decreases gastric acidity

MOA for vitamin K?

corrects clotting factors from low potassium levels