Med-Surg - Gastrointestinal System, part 11: Cirrhosis, Paracentesis, Esophageal Varices
by Cathy Parkes November 28, 2021 Updated: December 07, 2022 5 min read 1 Comment
I am Cathy with Level Up RN. In this video, I'm going to talk about cirrhosis, paracentesis, as well as esophageal varices. At the end of the video, I'm going to give you guys a little quiz to test your knowledge of some of the key points I'll be making in this video. So definitely stay tuned for that. If you have our Level Up RN medical surgical nursing flashcards, definitely pull those out so you can follow along. I'm not going to go through all of the details on these cards, but I will hit many of the highlights. With cirrhosis, we have inflammation of the liver that causes the destruction and the replacement of the hepatocytes, which are those liver cells, with scar tissue. The three main causes and types of cirrhosis include postnecrotic cirrhosis, which is caused by viral hepatitis or toxins or drugs. Then we have biliary cirrhosis, which is also called biliary cholangitis. This is where we have damage to the bile ducts, and that causes bile to back up into the liver, which damages those hepatocytes. And then finally, we have Laennec's cirrhosis, which is caused by chronic alcoholism. Early signs of cirrhosis include fatigue, hepatomegaly, which is enlargement of the liver, nausea and vomiting, as well as abdominal pain. As cirrhosis progresses, we end up with many signs and symptoms because the liver is responsible for a lot of different functions in the body. So some of those late signs and symptoms include bleeding and bruising, partially because the liver is responsible for making some clotting factors and those are needed for hemostasis. So if we don't have those clotting factors, we're going to end up with more bleeding.
Patients with cirrhosis will also have jaundice, which is yellow discoloration of the skin, as well as like the whites of the eye. Patients will also have ascites, which is the buildup of fluid in the abdomen, as well as esophageal varices, which are fragile, swollen blood vessels in the esophagus. Patients will also end up with portal hypertension, which is increased pressure in the portal vein, which carries blood from the digestive organs into the liver. In addition, the patient may have peripheral edema, as well as something called Fetor Hepaticus. So this means they have a foul, musty breath odor. Other symptoms include hepatic encephalopathy. So with cirrhosis, we have a buildup of ammonia in the body, and that ammonia could also build up in the brain, which causes confusion. So that is hepatic encephalopathy. In addition, the patient may have pruritus, which is like itching; Petechiae, which are those red dots that show up on the skin, as well as spider angiomas; Palmar Erythema so red palms; dark urine; and clay colored stools. Labs that will be elevated with cirrhosis include increased ALT, AST, bilirubin, as well as ammonia. Labs that will be decreased include decreased serum protein and albumin. So albumin is a really important protein that we find in the bloodstream, and it helps to keep fluid in the intravascular space in those blood vessels. If we don't have enough albumin, which we don't with cirrhosis because the liver isn't functioning properly so it's not making enough albumin, then that fluid will leave the bloodstream and go to the extra vascular space. The gold standard for diagnosing cirrhosis is using a liver biopsy. Other diagnostic tools that can be helpful
include ultrasound, CT, and MRI. There is no cure for cirrhosis. Medications that may be prescribed include vitamin and mineral supplements, as well as diuretics to get rid of that excess fluid, and lactulose, which is a laxative that helps to bring down ammonia levels. And it will also cause the patient to poop a lot because it's a laxative. Procedures include a paracentesis, which helps to remove that excess fluid from the abdomen, and we're going to talk more about that in just a minute. A liver transplant may be an option as well for the patient. In terms of nursing care, we're going to want to monitor our patients' eyes and nose, restrict fluids and sodium as ordered, measure the patient's abdominal girth daily, and then monitor for complications, which can include encephalopathy, portal hypertension, esophageal varices, as well as hemorrhage. In terms of patient teaching, you want to advise your patient to consume a low sodium diet, eat small, frequent meals, and if the patient has an alcohol abuse issue, then you definitely want to encourage an alcohol recovery program.
Next, let's talk about a paracentesis, which is a procedure where we insert a needle through the patient's abdominal wall and remove fluid from that peritoneal cavity. So if the patient has ascites related to their cirrhosis, which is causing respiratory distress, then this procedure can help bring some relief. In terms of nursing care before the procedure, you want to make sure informed consent was received, and you also want the patient to empty their bladder. So if we're poking in their abdomen, we do not want to accidentally perforate their bladder, which is why we have them empty their bladder. In addition, we're going to take the patient's vital signs. We're going to measure their weight and measure their abdominal girth. After the procedure, we're going to measure those same things. So vital signs, weight, and abdominal girth. We're also going to be on the lookout for hypovolemia because that peritoneal fluid that we removed is high in protein, which can cause a fluid shift. In addition, if the provider has prescribed albumin, we will administer that to the patient as well.
The last thing I want to cover in this video are esophageal varices, which I mentioned briefly when I was talking about cirrhosis. So esophageal varices are swollen, fragile blood vessels in the esophagus that can hemorrhage, which is life threatening. So the key risk factor for esophageal varices is portal hypertension. So that portal vein carries blood from the digestive organs into the liver. When the liver is scarred like it is with cirrhosis, then blood flow is impaired into that liver. And that causes increased pressure in that portal vein and causes blood to back up or be shunted into the surrounding blood vessels. So if we have bleeding associated with these esophageal varices, the patient may have symptoms such as hypotension and tachycardia. There are some medications and procedures that can be used to help prevent that bleeding and address those esophageal varices. So medications that can be used include basal constrictors, as well as non-selective beta blockers. And examples of procedures that could be used include endoscopic sclera therapy as well as band ligation. All right, time for quiz. I have three questions for you. First question, what is the key cause of Laennec's cirrhosis? The answer is chronic alcoholism. Question number two, what key medication removes excess ammonia in patients with cirrhosis? The answer is lactulose. Question number three, besides providing informed consent, what does your patient need to do before a paracentesis? The answer is empty their bladder. Okay. That's it for this video. Thank you so much for watching. If you enjoyed this video and learned a little bit, be sure to like it and leave me a comment. Take care and good luck with study. The gold standard for diagnosing cirrhosis is through a liver bopsy [laughter]. A liver bopsy-- okay.
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February 08, 2022
Thank you Cathy, you have simplified the information and made this easier to understand. Taking my test Wedneday for upper and lower GI
I’m feeling more confident that I will pass the test