Liver Cirrhosis Case Study

1. Portal Hypertension

In cirrhosis, liver cell damage slows down blood flow. This causes a backup of blood through the portal vein, a condition called portal hypertension . The effects of portal hypertension can be widespread and serious, including fluid buildup and bleeding.

2. Ascites and Fluid Buildup. Ascites is fluid buildup in the abdomen. It is uncomfortable and can reduce breathing function and urination. Ascites is usually caused by portal hypertension, but it can result from other conditions. Swelling can also occur in the arms and legs and in the spleen. Although ascites itself is not fatal, it is a marker for severe progression. Once ascites occurs, only half of patients survive after 2 years. In fact, some experts refer to the phases of cirrhosis as preascitic and ascitic . Some doctors even believe that ascites signals the need for liver transplantation, particularly in alcoholic cirrhosis.

3. Variceal Bleeding. One of the most serious repercussions of portal hypertension is the development of varices , which are blood vessels that enlarge to provide an alternative pathway for blood diverted from the liver. In about two-thirds of patients they form in esophagus. Varices pose a high risk for rupture and bleeding because of the following characteristics:

• They are thin-walled.
• They are often twisted.
• They are subject to high pressure.
• Internal bleeding from these varices (variceal bleeding) occurs in 20 – 30% of patients with cirrhosis. The risk of death from a single episode can reach 70%.

Bleeding commonly recurs within 2 weeks of the first episode, but after 6 weeks, the risk for recurrence is the same as for patients who have not had a bleeding event.

Factors that predict variceal bleeding include:

• Ascites.
• Encephalopathy.
• Large veins.

Factors that can increase the danger for a bleeding episode in high-risk individuals include the following:

• Moderate to intense exercise.
• Bacterial infection.
• Certain times of the day. Eating increases portal pressure, and there is a greater risk for bleeding in the evening. A lesser but still significant risk occurs in the early morning.

It is important for patients to be screened for esophageal varices and treated with preventive beta blockers if they show signs of risk. Between 30 – 40% of patients with cirrhosis experience bleeding. this complication has a mortality rate of 20 – 35%. Some experts recommend that all newly diagnosed patients be screened using endoscopy. Screening should also be considered for all previously diagnosed patients who have not been screened but would benefit from preventive treatments.

4. Kidney Failure

Portal hypertension can cause several secondary complications, including kidney failure. Non-steroidal anti-inflammatory drugs (NSAIDs), such as naproxen, may increase the risk for kidney failure.

5. Gastrointestinal Bleeding

Gastrointestinal (GI) bleeding can occur from abnormal blood clotting, which can be result of a combination of complications associated with cirrhosis. They include vitamin K deficiencies and thrombocytopenia — a drop in platelets (the blood cells that normally initiate the clotting process). Some research now suggests that thrombocytopenia itself may be associated with more advanced liver failure.

6. Infections

Bacterial infections are very common in advanced cirrhosis, and may even increase the risk for bleeding. Most bacterial infections, including those in the urinary, respiratory, or gastrointestinal tracts, develop when patients are in the hospital. Abdominal infections are a particular problem in cirrhosis and occur in up to 25% of patients with cirrhosis within a year of diagnosis.

7. Mental Impairment and Encephalopathy

Mental impairment is a common event in advanced cirrhosis. In severe cases, the disease causes encephalopathy (damage to the brain), with mental symptoms that range from confusion to coma and death. A combination of conditions associated with cirrhosis causes this serious complication:

• Buildup in the blood of harmful intestinal toxins, particularly ammonia.
• An imbalance of amino acids that affect the central nervous system.

Encephalopathy is often triggered by certain conditions, including:

• Gastrointestinal bleeding
• Constipation
• Excessive dietary protein
• Infection
• Surgery
• Dehydration

Alcoholics with cirrhosis are believed to be at higher risk for this complication than are nonalcoholic cirrhosis, but one study suggested that alcoholics simply tend to have more severe cirrhosis. Even minimal hepatic encephalopathy (MHE) can have detrimental effects on functional ability. One study suggested that MHE impairs the ability to safely drive a car, and that all patients with cirrhosis be tested for MHE.

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