Bob is a 45 year old Accountant who has been admitted to the local medical ward with a history of increasing breathlessness and jaundice. He had been diagnosed with end stage liver disease three months previously.
Susan, Bob’s wife is 35 years old and is 7 months pregnant with her first child. This is Bob’s second marriage and his two sons (aged 18 and 10 years) from his first marriage live with their mother.
Due to his history of alcohol abuse in the past Bob has limited contact with his sons. Also his employers in the past years have been unhappy with his work performance which has resulted in several meetings with him. One hour following admission, Bob has a large haematemesis.
The liver is the largest gland and solid organ in the body. Approximately weighing 1.8Kgs in men and 1.3Kgs in woman.
Located on the right side under the diaphragm
2 Main lobes - (right being larger than left) which are subdivided into approximately 100,000 small lobes.
Hepatocytes absorb nutrients and detoxify and remove harmful substances from the blood.
Double blood supply via hepatic artery and hepatic portal vein.
Processing digested food from the intestine
Controlling levels of fats, amino acids and glucose in the blood
Combating infections in the body
Clearing the blood of particles and infections including bacteria
Neutralising and destroying drugs and toxins
Storing iron, vitamins and other essential chemicals
Breaking down food and turning it into energy
Manufacturing, breaking down and regulating numerous hormones including sex hormones
Making enzymes and proteins which are responsible for most chemical reactions in the body, for example those involved in blood clotting and repair of damaged tissues .
End stage liver disease is an irreversible condition when liver disease has progressed to the point where the liver can no longer carry out its functions properly.
End stage liver disease may be the final stage of many liver diseases.
Hypertension within the portal system
Accumulation of serous fluid within the peritoneal cavity
Hypotension within the hepatic vein
Causes low cardiac output
Fibrosis evident in biopsy cause by cell necrosis.
Increased ALT/AST in Liver Function Tests, especially ALT:AST = 2:1 caused by destruction of liver cells.
Pain caused by chronic inflammation and liver enlargement.
Effect on other systems.
Nausea and anorexia due to taste distortion and slow gastric emptying.
Heartburn due to gastric reflux.
Pale, loose, foul-smelling stools due to high levels of fat & lack of bile.
Vitamin deficiency due to malabsorption of nutrients
Spontaneous Peritonitis caused by bacterial overgrowth infecting ascites.
Hypotension & tachycardia due to increased sympathetic stimulation
Sweating due to affected hypothalamus
Reduced level of consciousness due to encephalopathy.
Loss of coordination and poor short term memory due to WK syndrome.
Opthalmoplegia caused by nerve damage and mitochondrial damage.
Tremor, bradykinesia, coordination problems due to Parkinsonism.
Gastric & Bowel dysfunction due to defect of vagus nerve.
Muscle wastage due to protein depletion for gluconeogensis.
Cholesterol deposits under skin (Xanthoma) due to inability to process in liver
Hypernatraemia due to Sodium/Potassium imbalance
Cachexia may be masked by oedema.
The process of undertaking an holistic needs assessment:
Identifies people who need help. Patients who have had liver disease for a long period of time may have already discussed this with their families. End-of-life discussions can be very difficult, particularly depending upon the underlying cause of the liver disease. There may be unresolved anger or fear in the family of a patient who developed cirrhosis because of alcohol ingestion, drug use, or viral hepatitis, for example. In this case Bob has a history of alcohol abuse and due to this Bob has limited contact with his sons from his previous marriage. Bob may feel isolated as he might not want to tell his sons that he has the disease as this may cause more stress and anger within the family and Bob himself.
Provides an opportunity for the person to think through their needs and, together with their healthcare professional, to make a plan about how to best meet these.
End-stage liver disease is irreversible without a liver transplant. If a patient is not a candidate for transplantation, end-of-life issues must be addressed with the patient and family, especially if a life-threatening complication or a sudden decomposition of liver function develops. Bob is due to be a father and if he is not a candidate for a transplant then end of life issues should be addressed. Health professionals should reassure Bob and provide additional support from the appropriate team for example mental health professionals to assess Bob’s mental state.
Helps people to self manage their condition. Educating Bob regarding recent diagnose of end stage liver disease to reassure and make him aware of care/treatment/interventions that will be carried out. Good communication skills are vital in this situation so that Bob fully understands the diagnosis.
Helps teams to target support and care efforts and work more efficiently by making appropriate and informed decisions. Health care professionals have the responsibility to ensure that Bob has the correct information and knowledge to enable him to make the most appropriate decisions regarding his day to day life in regards to his work life. Promoting rest is essential so that Bob maintains
As well as considering all the above it is important to assess the patients activities of daily living as Bob may find these difficult to achieve alone.
Haematemesis is the vomiting of blood and is a medical emergency. The probable cause is likely to be oesophageal varacies, as a result of cirrhosis of the liver.
The scarring from cirrhosis prevents blood from flowing through the liver, resulting in portal hypertension.
This dilates the veins at the junction of the oesophagus and causes them to swell. (Varacies)
If these varacies rupture, severe bleeding occurs (haematemesis)
Commence oxygen therapy at 10-15 litres via trauma mask.
Bleeding must be controlled to prevent death.
Essential to establish if blood loss is enough to establish hypovolaemic shock.
Early venous access is essential as there is a potential risk of peripheral shutdown.
Bob will be treated systematically for fluid and blood loss.
Continually assess and record respirations, pulse, blood pressure and peripheral circulation.
Tube inserted into stomach through nose, and inflated with air, applying pressure to the bleeding veins.
Once bleeding is stopped, varices can be treated with medicines and further medical interventions.
Check airway is not obstructed.
Speak to patient and listen for vocal response.
Secure and maintain airway
Check patient is breathing
Look, listen and feel for breath
If no breathing evident seek help and begin chest compressions
Check for signs of Bob using accessory muscles
Listen for breath sounds and noisy breathing – evidence of wheeze/stridor/gurgling?
As medical emergency administer 10-15 litres oxygen via trauma mask.
Assess colour of patient. Are there signs of blue tinge?
Assess pulse, blood pressure, urine output and peripheral perfusion. Capillary refill should be less than 2 seconds.
Assess for signs of hypovolemic shock this being hypotensive and tachycardiac
Gain intravenous access
Is patient conscious?
Is patient to place, person, date, time?
To stop bleeding endoscopic therapies may be used.
Maintain patients dignity and privacy at all times
Check body for obvious abnormalities - Rashes, Bleeding, Swelling, Puritis, Spider naevi which is spider like veins in the face, caput medusa
Liver disease is the only major cause of death still increasing year-on-year 1
Bob like many others have a history of alcohol abuse. In 2010 the average number of daily units drunk by a male Bobs age was between 4-8 daily which estimates if drinking the 8units daily to 56 over the scale of a week compared to the recommended intake of 21units per week for a male.
16,087 people in the UK died from liver disease in 2008 2 , a 4.5% increase since 2007, this includes 1,903 in Scotland .
Liver disease kills more people than diabetes and road deaths combined
In Scotland, in 2007/8 there was a 400% increase in patients discharged from hospital with alcoholic liver disease (6,817) compared to 1996. 7 In 2006-7, 1,094 children aged under 18 were admitted to hospital with an alcohol-related diagnosis. Treatment for alcohol related problems in Scotland costs over £1m a day.
Alexander M, Fawcett J & Runciman P. (2006) Nursing Practice: Hospital & Home. 3 rd Ed. Edinburgh: Churchill Livingstone.
Frith J, Newton J. (2009) ‘Autonomic Dysfunction in Chronic Liver Disease’ in Liver International . Vol 29(4) pp 483-489
Gastroenterology . (2008) Vol 134(6)
Sargent S. (2009) Liver Diseases: An Essential Guide for Nurses & Health Care Professionals . Oxford:Wiley-Blackwell
Waugh A, Grant A. (2010) Ross & Wilson: Anatomy & Physiology In Health & Illness. 11 th Ed. Edinburgh: Churchill Livingstone.