LIVER DISORDERSEnd Stage Liver

Disease

1

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

Manufacturing bile

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.

The Liver

Hypertension within the portal system

Accumulation of serous fluid within the peritoneal

cavity

Hypotension within the hepatic vein

Causes low cardiac output

Hypovolaemia

TachypnoeaDyspnoeaHypoxiaCyanosisPulmonary Oedema

OliguriaAnuriaRenal failureEndotoxaemiaFluid retentionShockGynaecomastiaAmenorrhoeaErectile dysfunction

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.

AIRWAY:

Check airway is not obstructed.

Speak to patient and listen for vocal response.

Secure and maintain airway

BREATHING:

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.

CIRCULATION:

Assess colour of patient. Are there signs of blue tinge?

Check carotid pulse

Assess rate, rhythm, volume, tension, bradycardic/

tachycardia

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

DISABILITY:

Is patient conscious?

AVPU

Is patient to place, person, date, time?

To stop bleeding endoscopic therapies may be used.

EXPOSURE:

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-year1

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 20082, 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. 3rd

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

www.britishlivertrust.org.uk

www.patient.co.uk

Waugh A, Grant A. (2010) Ross & Wilson: Anatomy & Physiology In Health & Illness.

11th Ed. Edinburgh: Churchill Livingstone.