Topic 13: Cirrhosis, liver failure, liver CA

chronic hep C and alcohol induced liver disease

what is the MCC of cirrhosis in the US

cirrhosis

extensive degeneration and destruction of liver cells

• jaundice, peripheral edema, and ascites from liver failure/portal HTN

• skin lesions: spider angiomas, palmary erythema

• low RBCs, WBCs, platelets

• endocrine disturbances due to slow metabolism/break down

• peripheral neuropathies

what are the S/S of cirrhosis

• portal HTN

• esophageal and gastric varices

• peripheral edema

• abdominal ascites

• hepatic encephalopathy

• hepatorenal syndrome (renal failure)

what are complications of cirrhosis

splenomegaly, ascites, gastric and esophageal varices

what can portal HTN cause

gastric varices

life threatening complication of cirrhosis, due to fragility and easy bleeding

acid reducers (octreotide), vasoconstrictors, shunt to bypass liver

what is the treatment for gastric varices

exogenous albumin (they don’t have enough colloids in their system)

what is treatment for peripheral edema which may occur as a complication of cirrhosis

• paracentesis (give albumin after)

• diuretics (spironolactone, furosemide, triamterene)

• albumin IV and increased PO intake

• sodium restriction

• TIPS (transjugular intrahepatic portosystemic shunt) procedure

what is treatment for ascites which may occur as a complication of cirrhosis

hepatic encephalopathy

occurs when the liver is unable to convert ammonia so it builds up and crosses the BBB leading to neurotoxic effects

• confusion

• lethargy

• inappropriate behavior

• asterixis (flapping tremors in arms and hands)

• sleep disturbances

• trouble concentrating

• impaired writing (apraxia)

• fector hepaticus (musty, sweet odor of ammonia in breath)

what are the S/S of hepatic encephalopathy

• lactulose (traps ammonia in the gut)

• antibiotics

• prevent constipation

• treat cause

  • decrease dietary protein (when broken down it becomes urea → ammonia)

  • control GI bleeding

  • remove blood from GI tract (when blood is broken down it becomes urea → ammonia)

• maintain a safe environment and patient will need a sitter

what is the treatment for hepatic encephalopathy

hepatorenal failure

renal failure with azotemia, oliguria, and intractable ascites; no structural abnormality of the kidneys but portal HTN leads to vasodilation and renal vasoconstriction

liver transplant

what is the only treatment for hepatorenal syndrome

• adequate rest

• avoid alcohol

• minimize/avoid acetaminophen, aspirin, NSAIDs

what does general management of cirrhosis include

• increased: AST, ALT, bilirubin, coagulation times (PT), ammonia

• decreased albumin

what are diagnostics for cirrhosis

transjugular intrahepatic portosystemic shunt (TIPS)

procedures that creates a shunt between hepatic and portal vein to bypass the liver which reduces strain on portal vein which decreases ascites, peripheral edema, risk for portal HTN, and risk for esophageal varices

• prevent bleeding/hemorrhage

  • avoid alcohol, aspirin, Tylenol (acetaminophen), NSAIDs

  • Non-selective BB to decrease HR to not rupture varices

• long term: TIPS procedure, repeated band ligation, portosystemic shunts

• balloon tamponade

  • ALWAYS KEEP SCISSORS AT BEDSIDE

what is management for esophageal and gastric varices

• stabilize patient (CAB!)

  • FFP, PRBCs, vitamin K, PPIs

  • lactulose for high ammonia

  • antibiotics for possible peritonitis

• octreotide (somatostatin) to decreased blood flow to GI

• vasopressin

• band ligation

what is interventions for an active esophageal/gastric varices

balloon tamponade (Blake more)

mechanical compression of varices that prevents and occludes further bleeding of varices

ALWAYS KEEP SCISSORS AT BEDSIDE**

• label each lumen

• secure the tube to prevent movement which could result in occlusion

• deflate the balloons for 5 mins Q8-12H

• keep scissors at bedside

  • if patient is nauseated/vomiting cut it and pull it out

what are the nursing interventions for a balloon tamponade done to repair varices

• high cal (3000/day)

• increased carbs

• mod/low fat

• protein restriction only for severe encephalopathy

• low Na for ascites and edema

• small, frequent meals

what does nutrition for a patient with cirrhosis include

• have them void immediately before

• high fowlers or sitting on site of bed during

• monitor BP, HR and for hypovolemia, bleeding, and electrolyte imbalances

what is nursing management for a patient undergoing a paracentesis

hypokalemia and hyponatremia

what electrolyte imbalances may occur with cirrhosis

acetaminophen

what is the MCC of drug induced liver injury which can cause acute liver failure

• drug induced liver injury: acetaminophen, isonazid

• alcohol

• viral hep A, B, C

what are common causes of acute liver failure

fulminant hepatic failure

life threatening, rapid onset of encephalopathy and coagulation disorders (bleeding) due to hep, drugs, or alcohol that causes cerebral edema, changes in mentation (first sign), and risk for herniation (leading COD)

• hep C

• cirrhosis

• metastasis from other sites of body

what are causes of liver CA

poor, because there is no cure for hep C (main cause) so no cure for their cancer and it progresses rapidly with usually a late diagnosis

what is prognosis for a patient with liver CA

• prevention of hep b/c (blood and bodily fluid trasmitted)

• treat alcohol addiction

• surgical resection, ablation, embolization

• TACE and TARE

• comfort measures

• 6-12 month life expectancy

• may get a transplant (if so will be on corticosteroids for rest of their life)

what is treatment of liver CA