Liver Failure R/T cirrhosis

core0 · Jun 16, 2007

several questions:
1. can portal pressure be measured by a b/p cuff?
no. you need u/s with doppler.
2. how do you know that the distended abd is ascites?
you can do a fluid wave or shifting dullness. however, i still get fooled after five years especially in an obese patient.
http://www.fpnotebook.com/gi40.htm
http://www.fpnotebook.com/gi42.htm
3. are hyperactive bs an indication of ascites?
not usually. if anything ascites can cause decreased bowel sounds due to bowel edema. usually the bowel sounds are normal.
4. can coughing cause occult blood?
not usually. if you get a nosebleed from it maybe. any blood you swallow can cause occult blood. in cirrhotics its usually varices.
thanks!

david carpenter, pa-c

studentIVlife · Jun 16, 2007

wow I can't wait to learn all that stuff. Sorry just getting excited

Daytonite, BSN, RN · Jun 16, 2007

You can read about the assessment of the abdomen on this webpage from UC San Diego medical school. There is a lot about assessing for ascites there. I was trying to pull up some assessment information from Loyola Medical School but I'm having trouble getting into their website.

http://medicine.ucsd.edu/clinicalmed/abdomen.htm

oldiebutgoodie, RN · Jun 17, 2007

You can read about the assessment of the abdomen on this webpage from UC San Diego medical school. There is a lot about assessing for ascites there. I was trying to pull up some assessment information from Loyola Medical School but I'm having trouble getting into their website.
http://medicine.ucsd.edu/clinicalmed/abdomen.htm

A great site, Daytonite! If only the model wasn't so hairy... :lol2:

Oldiebutgoodie

kwagner_51 · Jun 17, 2007

4. I should have clarified. She has varacies in her throat. Thus the question about coughing. I can't get her full history, just what her sister tells me. I do know that stool samples x 6 came back + for blood. Her sister said that the coughing was causing the occult blood.

Needless to say, I need all the help I an get!!

Thanks!!

nursepearl · Jun 17, 2007

When my boyfriend was in Liver failure he had ascities but the MD did not believe it was as bad as we said it was. He was a short gut pt. so he had NO intestine...his normal belly was caved in. When we went to the MD and showed him his abd, he said there was no ascities at all and he looked normal. So, my point being that sometimes they wont have a HUGE belly, but it depends on the pts baseline. He started to believe us once he had pitting 3+ edema.

Daytonite, BSN, RN · Jun 17, 2007

kathy. . .for blood to be classified as "occult" it has to be "concealed" or "in such minute quantity that it can be recognized only by microscopic examination or by chemical means." (page 1334, taber's cyclopedic medical dictionary, 18th edition, published in 1997 by f.a. davis company). guiac testing would be how it would be detected.

with cirrhosis and esophageal varices the veins and arteries of the organs that are connected to the portal circulation are engorged with blood and under pressure. think about the worst case of varicose veins you've ever seen in a person's leg. well, that's what's going on inside this person's liver and esophagus. some of the blood is leaking out into the esophagus (see the definition from taber's that i listed above). it doesn't help that the liver is damaged either because the normal clotting mechanism is screwed up secondary to liver damage. so, it's easier for these patients to bleed. on top of that, coughing is a very traumatic thing. pressure builds up in the entire upper torso when there is a lot of coughing which would create increased pressure in these varicose vessels. that combined with the compromised clotting mechanism results in some microscopic bleeding. traumatic coughing itself can result in some minor bleeding from the arteries in the alveoli of the lungs in a normal person. this happens quite frequently in pneumonia to give patients a rust colored sputum. but sometimes you can cough so hard that you bring up some stomach contents too. in the case of your patient, some of their stomach contents would contain blood. what is happening is some of that minute blood that is oozing out of their esophageal varices and just making its way up into the pharynx when they cough and ends up in the sputum. most of it, however, is continuing on down through the gi tract where the stool samples are showing + for occult blood. keep in mind that the gi tract is one continuously long tube that runs from the mouth to the orifice with a few side streets here and there where it picks up secretions and other things.

here are some articles on this disease:

http://www.emedicine.com/med/topic3183.htm - cirrhosis
http://www.emedicine.com/med/topic745.htm - esophageal varices

you can also find information on medline plus (http://www.medlineplus.gov/) by doing a search for the disease or symptoms. it will link you to more resources.

i worked on several units that had both alcohol detox patients as well as gi patients and we had a fair share of patients with cirrhosis and liver disease. hemorrhage is one of the major complications. you need to watch for this. keep an eye on this person's coagulation studies. when these patients get a boo-boo, they bleed they stuck pigs. they will have frequent nosebleeds, bruising and bleeding gums. another complication they may or may not get is elevated ammonia levels which leads to encephalopathy, confusion and coma. it always seemed to me that some patients tended to go more in one direction of complications while others went in another. we had cirrhosis patients with urine darker than the strongest tea you can make. by far, the worst are the patients who get the portal hypertension and bleeding. we had people who would spontaneously start hemorrhaging from a wound. or, they would continue to drain peritoneal fluid for days and days from a paracentesis puncture that was done to remove ascites fluid that would just never clot off and close.

core0 · Jun 17, 2007

4. I should have clarified. She has varacies in her throat. Thus the question about coughing. I can't get her full history, just what her sister tells me. I do know that stool samples x 6 came back + for blood. Her sister said that the coughing was causing the occult blood.
Needless to say, I need all the help I an get!!
Thanks!!

The blood could be from varices. The issue is that patients with liver disease have coagulation disorders and poor platelet function so nose bleeds are very common also. They need an EGD to look for stigmata of bleeding and then consider ligation. Also pretty much anyone with heme positive stool needs a colonoscopy.

David Carpenter, PA-C

mshultz · Jun 18, 2007

A great site, Daytonite! If only the model wasn't so hairy...
Oldiebutgoodie

The male model in my Paramedic Emergency Care book is also quite hairy. On the other hand, one of the male models in my Health Assessment & Physical Examination book has no chest or facial hair. Unfortunately, his genitals are covered, but there is no hair below his navel, either. Something about his fat distribution does not seem right. Perhaps he has a male hormone deficiency?

On the other hand, in the same book, one of the female breast exam models has thick black axillary hair (thicker than the male model in the next chapter). I chuckle at the picture of the doctor palpating her axillary nodes with his bare fingers stuck in her armpit hair.

I know this is off topic, but still interesting.