Case Study Chapter 30, Disorders of Hepatobiliary and Exocrine Pancreas Function A 65-year-old man is admitted to the hospital

with the diagnosis of cirrhosis of the liver. During the admission assessment, the nurse collects the following data: The patient has been unable to eat secondary to nausea and vomiting for the past 3 days; he has seen moderate amounts of blood twice in the past 24 hours when he vomited; he has noted a slight yellow color to his skin and has had increased itching of the skin for the past 3 weeks; PMH of increased alcohol intake for 20 years. On exam, the following were noted: BP 90/60, p. 110. r. 20 Skin: moderate jaundice with drying and decrease tugor HEENT: sclera is yellow Lungs: clear to auscultation ABD: distended with increased venous markings. BS present. Liver palpable 1 cm below the costal margin EXT: thin, pulses 1+ present and bilateral, capillary refill decreased 1. How does the cirrhosis of the liver cause the jaundice seen in this patient? Explain physiologically relating to normal bile production and bilirubin metabolism. First of all, cirrhosis is a condition in which the liver slowly deteriorates and fails. Scar tissue replaces healthy liver tissue, thus blocking the flow of blood through the liver. Jaundice occurs when the liver does not remove enough bilirubin from the blood. This causes yellowing of the skin. The liver produces bile which collects and drains in the hepatic duct. The bile may enter the small intestine or the gallbladder. The liver produces 600mL to 1 liter if bile in a day. The cirrhosis of liver causes jaundice in this patient because the malfunctioning liver is not eliminating enough bilirubin from the blood. A healthy liver produces bile to help absorb fats. With cirrhosis, the liver can no longer replace damaged cells. Jaundice is a complication of cirrhosis. Jaundice may also cause darkening of the urine and bilirubin is the pigment that gives bile the red-yellow color. The 20 years that this patient has been consuming alcohol is why the cirrhosis is present. The typical symptoms of cirrhosis are: nausea, vomiting, itching, abdominal pain and spiderlike blood vessels on the skin, fatigue, and weakness. These symptoms are occurring to this patient.

2. On physical examination, the nurse noted abdominal distention. If on exam the distension was found to be fluid in the peritoneal cavity, how could you physiologically explain the relationship between the ascites (fluid in the peritoneal cavity) and his cirrhosis? When the liver damage progresses to a life-threatening stage, fluid starts collecting in the legs. This is called edema. When cirrhosis occurs, the portal vein system cannot filter efficiently through the cirrhotic liver which results in increased pressure of the blood flowing from the digestive system. This increased pressure forces fluid out of the blood vessels which collects in the abdominal cavity. This is called ascites. This patient must be treated immediately because ascites can lead to bacterial peritonitis. This is a serious infection and can be life-threatening. On abdominal assessment the liver may feel hard and enlarged. 3. On the third day of hospitalization, the laboratory calls to tell the nurse the patient has a very high serum ammonia. Knowing how proteins are normally metabolized by the liver, explain why the elevated serum ammonia is concerning. Ammonia levels in the blood can increase when the liver is not working properly, and thus not able to convert ammonia to urea. High blood ammonia levels can occur in chronic liver disease, acute liver failure, and gastrointestinal bleeding. Elevated blood ammonia levels may affect brain function. Early diagnosis and treatment of an elevated blood ammonia level can help reduce the risk of potentially life-threatening complications. The normal levels of ammonia should be 10-80 ug/dl.