Hepatology Review: Cirrhosis Pathophysiology

After going through the functions of the liver in our previous lecture, we’ll be discussing the different types of liver diseases like hepatitis, ascites, cirrhosis, and encephalopathy. We’ll also tackle the different ways on how clients with these diseases should be cared for.

We highly recommend that you go through the first liver lecture before continuing with this one because that talks about the liver’s general pathophysiology.

With this liver disease lecture, we’ll focus on liver cirrhosis. Let’s begin.

What Is Cirrhosis?

To easily remember what cirrhosis is, you can call it, “scarrhosis,” since the condition is basically the scarring of the liver.

Just a quick review and as mentioned in the first lecture, the liver acts like a recycling company that entails a first pass phenomenon; this company is called as the PDSM Recycling Company. PDSM stands for People Drink So Much Recycling Company. The liver’s primary functions are production, detoxification, storage, and metabolism.

The First Pass Phenomenon

When a person drinks alcohol, it passes through the mouth, stomach, and into the duodenum of the small intestine. The small intestine is divided into three parts – duodenum, jejunum, and the acetabulum (DJA). And once the alcohol has passed the intestines, blood will scoop it up.

However, before the alcohol is sent to different parts of the body, it first has to pass “customs” for detoxification. Because the last thing that you want is to have the alcohol or anything you’ve ingested to be circulated around the body without going through the liver to undergo filtering and detoxification.

Alcohol and Cirrhosis

Liver cirrhosis is a condition that is mainly caused by alcohol. When a person drinks so much alcohol, aside from increased toxins going into the blood, the liver also ends up being scarred. Increased scarring due to long-term alcohol consumption creates a barrier that prevents blood to pass through from the duodenum and into the portal circulation of the liver.

Critical Thinking Question

What happens if blood can no longer pass into the liver? Where does it go?

Answer:

If blood can no longer pass through the liver due to increased scarring, it backflows into the intestines, the spleen, and even into the esophageal tract.

Once backflow happens, there are a series of unfortunate medical conditions that occur, and the most apparent is that whatever organ that is affected by the backflow, gets enlarged. What are some instances?

  1. Splenomegaly – spleen enlargement
  2. Esophageal varices due to a swollen esophagus followed by vomiting of blood
  3. Pancreatitis – inflammation of the pancreas
  4. Portal hypertension due to the increased pressure of the blood being pushed on the portal vein

TIPS: A Medical Intervention

As medical professionals, you have to ensure that the liver is functioning optimally to resume the normal detoxification process. How is this done?

Schedule the client for a transjugular intrahepatic portosystemic shunt (TIPS) to put a stent into the liver and cause a bridge between the liver and the vein to decrease portal hypertension.

The stent now serves as a bridge to decrease portal hypertension which takes the pressure off of the spleen, pancreas, and the esophageal tract.

Liver Transplant

If the liver cells responsible for detoxification have been destroyed completely, a liver transplant is advised. However, getting a liver transplant requires a lot of effort from the medical team in terms of finding a healthy liver donor that would be a match for the client.

If your client is an alcoholic and has undergone liver transplant, you have to make the client understand that if he or she will continue, the transplanted liver will also get killed eventually. And it is the medical team’s responsibility to look for psychological issues when dealing with an alcoholic.

On our next liver lecture, we’ll talk about PDSM in terms of what the liver produces.

 

Hepatology Review: What is Hepatic Encephalopathy?

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Continuing from a series of lectures on the liver, we have indicated the importance of remembering the PDSM Recycling Company. This recycling company is the liver and PDSM suggests the liver’s primary functions – Produce, Detox, Storage, and Metabolize.

When it comes to hepatic encephalopathy, the liver’s metabolic properties are compromised.

Focusing on Metabolism

What does metabolism have to do with hepatic encephalopathy? The liver metabolizes ammonia into urea. Ammonium, on the other hand, is the waste product of protein. In our previous lectures, we have discussed that ammonium can be considered as the wrapper of a protein bar.

The Wrapper

Normally, if there’s waste inside the body, it will be filtered by the liver and is metabolized into something that can be excreted. This is what happens with ammonia.

Ammonia goes into the liver to be metabolized as urea and is then excreted through the kidneys and into the potty. So, what happens if the liver is broken due to scarring or other injuries? Aside from the other functions being compromised, metabolism cannot happen. Therefore, converting ammonia into urea will be difficult for the liver.

The ammonia (wrapper) will now stay inside the bloodstream and will travel around the body and affect the vital organs like the brain. The wrapper is now wreaking havoc inside the body, and one of the primary manifestations that ammonia has reached the brain is altered level of consciousness (LOC).

Decreasing Ammonia

As a medical professional, what are the things that you can do to make sure that protein is no longer broken down to prevent wrappers circulating in the bloodstream?

What are the ways to combat ammonia?

  1. Protein must be withheld.

This is to prevent the small intestine from breaking down protein and causing the release of more ammonia going into the compromised liver. Advising the client to have a low protein diet is also a must.

  1. Give lactulose.

Lactulose acts like a small garbage bin that scoops up ammonia from the blood and into the potty. Therefore, if you give your client lactulose, expect that they will have severe diarrhea. Make sure that the restroom or commode is accessible to your client.

  1. Give neomycin.

Neomycin is a type of antibiotic that kills all of the bacteria in the gut that causes the breaking down of the protein. One thing you have to take note of is that neomycin will kill off not only the bad but also the good bacteria in the stomach. It’s like having a SWAT team go inside a bank, killing off not just the hostage-takers but the bank tellers, managers, and clients as well.

For this reason, neomycin is given on a short-term basis just to decrease the presence of ammonia inside the body.

Nursing Considerations

When taking care of clients with hepatic encephalopathy, there are a couple of nursing considerations that must be made.

  1. Safety.

Since the client has altered level of consciousness, medical professionals must make sure that the client’s safety is the main priority. Therefore, padding the side rails of the bed is necessary. Restraining the client is no longer allowed which is why it is essential to ask the family members to sit with the client or have a CNA to sit at the bedside and watch over the client to promote safety and prevent any liabilities.

  1. Give drugs like lactulose and neomycin.
  2. Promote low protein diet, usually depending on the doctor’s order and the severity of the ammonia level.
  3. Maintain skin integrity.

The liver produces albumin, bile, and coagulation factors. If a client that is at risk for bleeding, due to the absence of coagulation factors, is on bed rest for the entirety of your shift, he or she is also at risk for the following:

  • Bedsores
  • Open wounds
  • Bleeding
  • Bruises
  • Pruritus – happens due to the increased amount of ammonia that causes skin inflammation leading to irritation.

When dealing with skin integrity, you have to do the following:

  • Cool compress
  • Anti-itch lotion

Summary

One of the main considerations with clients who have hepatic encephalopathy is their safety due to altered LOC. Always include drugs like lactulose and neomycin. Low protein diet must be emphasized. Finally, you have to watch out for skin irritation like pruritus and bleeding.

For other nursing topics, drop by SimpleNursing.com.

Liver Cirrhosis Pathophysiology Sing-Along

Memorizing becomes easier with a song. A topic so extensive requires a certain technique that would make it painless for students to remember.

At SimpleNursing.com, Mike has created a song to the tune of “It’s Beginning to Look a Lot Like Christmas”, making it more fun and interesting for students to recall everything there is to know about the pathophysiology of liver cirrhosis. Cool!

The liver cirrhosis song goes:

It’s beginning to look a lot like cirrhosis

Jaundice of the skin

From the hyper-bilirubin

Waste products of hemoglobin

Due to a lack of bile-production

 

It’s beginning to look a lot like ascites

Fluid in the abdomen

From the portal hypertension

The lack of albumin

Increase capillary pressure causing third spacing

 

The liver acts like recycling company

With four major roles and responsibilities

Detoxing ammonia and drug metabolism

Storing glycogen, producing bile

Coagulation factors and albumin

 

It’s beginning to look a lot like encephalopathy

With altered LOC

Too much ammonia in the blood

A by-product of protein metabolism

Give lactulose to aid the excretion

 

It’s beginning to look a lot like cirrhosis

Soon we’ll do a paracentesis

Drain the fluid from the abdomen

Then give albumin

Bring the fluid back into the vascular spaces

 

If you are able to master this by heart, you are guaranteed 82% or higher on your next nursing exam!

Liver Mash-Up Discourse

Wasn’t that song entertaining? Now, to be able to figure out what it all means, let’s to go into the nitty-gritty details revolving around an ailing liver, mainly: cirrhosis, portal hypertension, ascites, encephalopathy, and all the other conditions. Full lectures are available at SimpleNursing.com.

Liver physiology

Before going into the factors that make your liver sick, let’s make a short detour and review what your liver does exactly.

Think of it this way – your liver as a recycling company. It’s called PDSM – People Drink So Much Recycling Company. We named it that because your liver acts as a detoxifier for a lot of different things, mainly alcohol. People who get intoxicated quite so often have a higher risk of developing liver problems.

What is PDSM?

P stands for produce.

The liver produces A, B, and C.

  • A is for Albumin. It has three responsibilities mainly:
    • fluid attraction in the vascular spaces
    • attracts and transports drugs
    • heavily bind with calcium

An easy way to remember the functions of albumin is to think of it as Al Pacino in the movie “Scarface”. It’s not a family-friendly movie but it would ease the burden of you remembering what albumin does. Al Pacino, in Scarface, is a drug lord of a drug cartel and his main goal is to transport drugs, living near Miami which will remind you of the body of water. Cocaine is what he transports which will remind you of calcium because, in its true form, calcium is white.

  • B is for Bile. The bile is the bus of the liver, transporting bilirubin. Bilirubin is a breakdown of old hemoglobin and red blood cells. The red blood cells advance to the spleen where it gets converted into bilirubin. Then, it goes back through the vascular system and into the liver where it gets converted into bile litter. The bile bus basically transports bilirubin and it also transports cholesterol.

As the body breaks down food or drugs, it gets metabolized and is sent directly to the liver to be detoxed in filters and is produced into something that the body can utilize. The liver also detoxifies the body of extra cholesterol to decrease its levels and flushing the excess out of the body in the form of feces. Which is why, if you have a malfunctioning liver, your cholesterol will shoot up and your LDL and HDL will be unbalanced. Bad cholesterol (LDL) will rise and your good cholesterol (HDL) will decrease. In most cases, total cholesterol skyrockets more than 200.

  • C is for Coagulation factors. This makes the blood clot; thus, decreasing the coagulation time. To determine if the clotting factors are in place, we have the PT, PTT, and INR. The absence of coagulation factors makes a person prone to bleeding. Scabs will not be formed. This means that if you have a liver abnormality like hepatitis or cirrhosis, profuse bleeding will occur.

For a person with liver cirrhosis, the laboratory results yield a low albumin and high bilirubin, causing jaundice. The cholesterol levels shoot up of more than 200; LDLs will go more than 100; HDLs will be less than 40.

D stands for detoxifies.

The liver basically detoxes our body from alcohol or what is also referred to medically as ETOH or toxicity. It acts as a detoxifier. Before your alcohol or whatever it is that you have consumed must first go through the liver which is more like your “customs” or your “border patrol”.

Kupffer cells or, as Mike would like to call them – Mr. Kupffer, is that group of cells inside the liver that are responsible for detoxification. So before any of your medications would go into the bloodstream to be distributed to the parts of the body, it would first have to be absorbed in the small intestine first and then that’s the time that it passes the liver – your customs. 

Exam tip: When asked, what is faster: onset of PO medication or intravenous medication? Since the intravenous medication does not have to go through the first pass phenomenon and it is administered directly into the bloodstream, the answer would be intravenous medication.

S stands for storage.

Glycogen storage is another function of the liver. Glycogen is a collection of glucose which is utilized by the body during activities for energy production. Glycogen is a huge wall of glucose and glucose is its building blocks.

How is this knowledge useful for our daily lives? When a person, an athlete, requires sufficient amount of energy before a race or a competition, he or she will undergo carb loading. Here, the athlete will consume tons of carbohydrates the night before so the liver would recognize that there is an abundance of glucose so it would store it collectively as glycogen. When the time comes that the person will need the extra energy, the liver would detect that and would then peel off bits of glucose for the body to use.

M stands for metabolism.

Metabolism is the process of conversion, the breaking down of elements for the purpose of utilization. Ammonia is metabolized into urea.

By principle, ammonium is a by-product of protein metabolism that is used up by the body for muscle building. Ammonium is transported to the liver to be metabolized into ammonia and gets converted into urea. Urea is excreted by your kidneys from your body in the form of urine.

Mechanism of urine production

Once urea gets launched into the bloodstream, it passes to the renal artery and goes in the kidneys. Within the kidneys, urea is processed by glomeruli for filtering and is then passed on to the ureters, down to your bladder becomes urine.

What happens when waste inside the body is not properly excreted?

They go into the bloodstream and your body will go into toxification, resulting in encephalopathy which is basically the brain being intoxicated with so many by-products. Clients who have encephalopathy display a wide array of signs and symptoms like the altered level of consciousness and unstable behavior.

Which is why the doctor will often ask if the ammonia levels of a client who is acting erratically with altered level of consciousness have been checked. The most common denominations would be your ALTs and ASTs.

So there you have it, the major functions of a normal liver. Next discussion will focus on the liver breaking down; thus the basis of the song above.