Exemplar 12.3: Liver Disease

You have a patient who is an alcoholic and doesn't quite understand why she should quit drinking. She asks you "what exactly is going to happen if I don't stop?" Select the correct statement you can give to her about cirrhosis.

Select the EARLY clinical manifestations of cirrhosis.

Early in the course of cirrhosis, few manifestations are present. The liver may be palpable and tender. A dull aching pain may be present in the [blank_start]upper right quadrant[blank_end] of the abdomen. Weight loss, weakness, anorexia, and bowel disruption may occur. As cirrhosis progresses, however, manifestations relate to liver cell failure and portal hypertension. [blank_start]Portal hypertension[blank_end] is the shunting of blood to lower-pressure vessels. Some of the collateral veins that are affected are located in the esophagus, causing large, thin-walled, esophageal [blank_start]varices[blank_end]. These vessels can rupture and cause massive hemorrhaging, especially if the liver damage causes [blank_start]thrombocytopenia[blank_end] and impaired production of [blank_start]clotting factors[blank_end]. In addition to being shunted to the esophagus, blood can be shunted to the [blank_start]spleen[blank_end], causing it to enlarge. Enlargement of the [blank_start]spleen[blank_end] can lead to anemia, leukopenia, and thombocytopenia due to increased destruction of blood cells. Because portal hypertension increases hydrostatic pressure, it can also cause [blank_start]ascites[blank_end], which is the accumulation of plasma-rich fluid in the abdominal cavity. In relation to this is the ability to develop [blank_start]spontaneous bacterial peritonitis[blank_end]. Cirrhosis can even cause psychological manifestations. Without functioning liver tissue, [blank_start]ammonia[blank_end] is not converted to uera, causing it to build up in the blood and cause [blank_start]portal systemic encephalopathy[blank_end]. The primary manifestation of this is [blank_start]asterixis[blank_end], which is a muscle tremor that interferes with the ability to maintain a fixed position of the extremities.

Edema and ascites are manifestations of what issues caused by cirrhosis?

Decreased clotting factor synthesis, increased platelet destruction by enlarged spleen, and impaired vitamin K absorption and storage cause what clinical manifestations of liver disease?

What are esophageal varices caused by?

Gastritis, anorexia, and diarrhea are caused by what?

Jaundice is caused by impaired bilirubin metabolism and excretion

Malnutrition and muscle wasting are caused by impaired nutrient metabolism, impaired fat absorption, and impaired hormone metabolism.

Select the clinical manifestations of accumulated metabolic toxins and impaired ammonia metabolism and secretion.

Match each diagnostic test with its description. [blank_start]Esophagoscopy[blank_end]: Used to determine the presence of upper esophageal varices. [blank_start]Bilirubin[blank_end]: Both conjugated and unconjugated versions of this are elevated with severe cirrhosis. [blank_start]Liver function studies[blank_end]: Includes alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, and gamma-glutamyltransferase. These will be elevated in patients with cirrhosis, but will not be as severely in patients with severe hepatitis. [blank_start]Liver biopsy[blank_end]: May be done to distinguish cirrhosis from other forms of liver disease. May be deferred if bleeding is prolonged. [blank_start]Serum electrolytes[blank_end]: Hyponatremia is common, resulting in hemodilution. Hypokalemia, hypophosphatemia, and hypomagnesemia are also frequently seen, r/t malnutrition and altered renal excretion. [blank_start]Serum albumin[blank_end]: This value decreases due to impaired liver production of the protein. [blank_start]Serum ammonia[blank_end]: This value elevates because the liver cannot convert ammonia into urea. [blank_start]CBC w/platelets[blank_end]: Low RBC, hemoglobin, and hematocrit demonstrate anemia r/t bone marrow suppression, increased RBC destruction, bleeding, and deficiencies of folic acid and vitamin B12. Thrombocytopenia and leukopenia occurs because platelets are destroyed by the spleen. [blank_start]Coagulation studies[blank_end]: Prolonged prothrombin time results from impaired production of coagulation proteins and lack of vitamin K. [blank_start]Serum glucose and cholesterol[blank_end]: These 2 values are frequently abnormal in patients with cirrhosis. [blank_start]Abdominal ultrasound:[blank_end] Used to evaluate liver size, detect ascites, and identify liver nodules. It may be used with Doppler studies to evaluate blood flow through the liver and spleen.

Which of the following medications might you give to a patient experiencing edema and ascites from hypoalbuminemia, hyperaldosteronism, and/or portal hypertension?

What two medications are commonly prescribed to treat the accumulation of metabolic toxins due to impaired ammonia metabolism and excretion?

What medication combination would you give to a patient with portal hypertension that is causing esophageal varices?

What medications would you give to a patient suffering from bleeding and bruising due to decreased clotting factor synthesis, thrombocytopenia, and impaired vitamin K absorption and storage?

Diazepam (Valium) is the one benzodiazepine that is not metabolized by the liver, and is therefore safe to treat acute agitation.

You are teaching a cirrhosis patient and his wife about diet and liver failure. Which of the following statements, made by the patient, shows that more teaching is needed?

Select appropriate interventions to enact for a patient with severe liver disease.

What is the FIRST intervention to enact for a patient with active bleeding esophageal varices?

Which of the following is NOT a potential complication for patients receiving a transjugular intrahepatic portosystemic shunt (TIPS)?