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Vancomycin 1g twice daily if in hospital patient or from another hospital Anticoagulation – aspirin 150mg given in evening of Day 0 for off bypass patients medicine 93 5298 best order prometrium. Chest Drains Usually removed on day 1 symptoms torn meniscus order discount prometrium online, provided the drainage is less than 100mls over a four hour period and the patient is sitting upright to promote chest drainage medicine of the people discount prometrium online master card. If patient in bed for prolonged periods use calf compressors Pacing wires wrapped in gauze if not in use treatment vs cure cheap prometrium generic. The most important haemodynamic indicator in the early postoperative period is cardiac output. Rather, all are evaluated in combination to determine appropriate therapeutic interventions. The goal is to maintain adequate systemic perfusion to protect cerebral, myocardial, and visceral function. It is the end-diastolic volume in the ventricle and serves as an estimation of average diastolic fibre length. In other words, if the end diastolic volume increases, there is a corresponding increase in stroke volume. As the heart fills with more blood than usual, there is an increase in the load experienced by each muscle fibre. This stretches the muscle fibres, increasing the affinity of troponin C to Ca2+ ions causing a greater number of cross bridges to form within the muscle fibres. This increases the contractile force of the cardiac muscle, resulting in increased stroke volume. Frank Starling curves can be used as an indicator of muscle contractility (inotropy. However, there is no single Frank-Starling curve on which the ventricle operates, but rather a family of curves, each of which is defined by the afterload and inotropic state of the heart. The preload that provides optimal cardiac output varies from each patient and is dependant on ventricular size. Precordial Leads Six Precordial Electrode Placement: are directly on the chest Records potential in the horizontal plane. Five large squares = 1sec ~ Amplitude is measured on the vertical axis: standard is 1mv = 10mm which is two large squares: compares waveform voltage P wave ~ represents atria excitation or contraction ~ Small, rounded & no taller than 2. If there is an infarcted area of the heart the electrical flow will go opposite to where it is expected to flow. Occasionally, all evidence of infarction may be lost with the passing of time; this is due to shrinkage of scar tissue. Bleeding: ~ Definition Characterised by chest drain output of > 100mls /hour ~ Causes Post bypass coagulopathies ~ Contact of the blood between the non physiological surfaces of the bypass machine causes a decrease in the number of platelets, platelet survival and function. The purpose of this is to find the bleeding site, release the pressure in the chest from tamponade, and to improve cardiac function. Brady arrhythmias: Include Sinus Brady, heart blocks, idioventricular, and junctional. This risk accelerates with increasing time on bypass and pre-existing renal dysfunction. The left lower lobes are the most common site for atelectasis due to reduced lung volume during surgery. Moderate hypothermia (28deg to 32 deg) decreases normal oxygen requirements by approx 50% therefore providing major organs some protection against ischaemia. This may involve plastic surgery using the Pectoralis major muscle Sternal dehiscence. Blue arrows: point to one group of sternal wires that are displaced to the right of the midline Red arrow points to a lower wire that has travelled with the left half of the dehisced sternum Black arrow points to a prosthetic aortic valve. These complex reactions activate the complement, clotting, and fibrinolytic cascades and cause a bleeding tendency, micro emboli and fluid retention (Salenger et al 2003) A. Volume and Pressure There are factors that lead to extra vascularisation of fluid into the interstitial compartment during both bypass and the early post-operative phase. Renal Function Can either be polyuric or oliguric during the early post-operative phase. While vasopressin induces renal vasoconstriction thus decreasing blood supply to the renal bed leading to a reduction in urine output. Direct Cardiac Effects Hypothermia leads to cardiac depression which can reduce the cardiac output and may lead to bradycardias. Haemolysis Mechanical contact with the bypass circuit causes damage to red blood cells releasing Hb into the serum. This is secondary to the initiation of the clotting cascade and platelet dysfunction or clumping Treatment Should be corrected by infusion of packed cells and platelets. Hyperglycaemia Increased glyconeogenesis and decreased insulin secretion secondary to sympathetic response. It involves opening the chest wall to repair or remove part of or all of the lung tissue. Some of the types of thoracic surgeries are ~ Lobectomy ~ Wedge resection ~ Segmentectomy ~ Pneumonectomy ~ Decortication ~ Pleurodesis Below is a diagram explaining some of the various types of surgeries Midwestern Cardiac Surgery 2009 Pleurodesis ~ Is a procedure that is performed that causes the membrane (pleural) around the lung to stick together ~ It prevents build up of fluid in the spaces between the membranes ~ Irritants such as Blemycin, Tetracycline or talc powder are instilled in pleural space. Action Calcium channel blockers bind to L-type calcium channels located on the vascular smooth muscle, cardiac myocytes, and cardiac nodal tissue (sinoatrial and atrioventricular nodes. E Textbook of Medical Physiology(11thEd) Coronary Circulation Wesley Norman PhD 1999 – homecast. Cardiac Surgery in the Adult Third Edition Chapter 15, Post op care of the Cardiac Surgical Patient. There may be primarily low-quality evidence, or high “We suggest quality evidence suggesting benefits and risks are closely balanced Level of Evidence Additional research is considered very unlikely to change confidence A – High in the estimate of effect Further research is likely to have an important impact on the estimate B – Moderate of effect C – Low Further research is very likely to change the estimate of the effect [Good Practice Statement] Ungraded recommendations advising about performing certain actions considered by surgeons to be essential for patient care and supported only by indirect evidence. We suggest coronary revascularization before aneurysm repair in patients with stable angina and two-vessel disease that includes the proximal left descending artery and either ischemia on noninvasive 2 B stress testing or reduced left ventricular function (ejection fraction < 50%. In patients who may need aneurysm repair in the subsequent 12 months and in whom percutaneous coronary intervention is 2 B indicated, we suggest a strategy of balloon angioplasty or bare-metal stent placement, followed by 4 to 6 weeks of dual antiplatelet therapy. We suggest deferring elective aneurysm repair for 30 days after bare metal stent placement or coronary artery bypass surgery if clinical 2 B circumstances permit. Assessment of medical comorbidities Level of Quality of Recommendation recommendation evidence In patients with a drug-eluting coronary stent requiring open aneurysm repair, we recommend discontinuation of P2Y12 platelet receptor inhibitor therapy 10 days preoperatively with continuation of aspirin. The relative risks and benefits of perioperative bleeding and stent thrombosis should be discussed with the patient. We suggest continuation of beta blocker therapy during the perioperative 2 B period if it is part of an established medical regimen. If a decision was made to start beta blocker therapy (because of the presence of multiple risk factors, such as coronary artery disease, renal 2 B insufficiency, and diabetes), we suggest initiation well in advance of surgery to allow sufficient time to assess safety and tolerability. We recommend preoperative hydration in non dialysis dependent 1 A patients with renal insufficiency before aneurysm repair. We recommend restarting metformin no sooner than 48 hours after administration of contrast material as long as renal function has remained 1 C stable (<25% increase in creatinine concentration above baseline. We recommend perioperative transfusion of packed red blood cells if the 1 B hemoglobin level is <7 g/dL We suggest hematologic assessment if the preoperative platelet count is 2 C <150,000/ L. Aneurysm imaging Level of Quality of Recommendation recommendation evidence We recommend using ultrasound, when feasible, as the preferred 1 A imaging modality for aneurysm screening and surveillance. Screening should be performed 2 C in first-degree relatives who are between 65 and 75 years of age or in those older than 75 years and in good health. Aneurysm imaging Level of Quality of Recommendation recommendation evidence If initial ultrasound screening identified an aortic diameter >2. We suggest elective repair for the patient who presents with a 2 C saccular aneurysm. We recommend a thrombin inhibitor, such as bivalirudin or argatroban, as an alternative to heparin for patients with a history of heparin-induced 1 B thrombocytopenia. We recommend that all portions of an aortic graft be excluded from direct 1 A contact with the intestinal contents of the peritoneal cavity. The patient with a ruptured aneurysm Level of Quality of Recommendation recommendation evidence We suggest a door-to-intervention time of <90 minutes, based on Ungraded a framework of 30-30-30 minutes, for the management of the Good Practice Statement patient with a ruptured aneurysm. Good Practice Statement We recommend implementing hypotensive hemostasis with restriction of fluid resuscitation in the conscious 1 B patient. We recommend that any potential sources of dental sepsis Ungraded be eliminated at least 2 weeks before implantation of an Good Practice Statement aortic prosthesis. Intraoperative fluid resuscitation and blood conservation Level of Quality of Recommendation recommendation evidence We recommend using cell salvage or an ultrafiltration 1 B device if large blood loss is anticipated.

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Decreased venous return/metabolic acidosis Venous return to the heart decreases in response to peritoneal gas insuf a tion 7 medications that can cause incontinence purchase 200 mg prometrium otc. This effect is most prominent in hypovolemic patients 5 medications for hypertension buy 100 mg prometrium otc, as the pneumoperi toneum will easily compress the poorly distended vena cava symptoms xanax buy prometrium in united states online. Cardiac output is decreased by impairment of venous return treatment brown recluse spider bite order prometrium australia, and metabolic (lactic) acidosis results from decreased visceral perfusion. This may be exacerbated by the decreased capac ity for respiratory compensation [35]. Laparoscopy in the elderly was once thought to be contraindicated because of the effect of pneumoperitoneum on cardiac and pulmonary physiology. Several studies have con rmed the bene ts of laparoscopy in the elderly, including decreased hospital stay and fewer wound and pulmonary complications when compared to traditional operative approaches [36]. Hemorrhage/shock Patients with severe cardiac disease or with profound hypovolemia may not compensate well and may manifest a dramatic fall in cardiac output with peri toneal gas insuf ation. Although laparoscopy has been recommended as a diag nostic tool in some intensive care unit patients [37], laparoscopy should not be performed in patients who manifest shock, particularly from acute hemorrhage. Trendelenburg position/intraabdominal pressure Peritoneal gas insuf ation can cause increased intracranial pressure during lower abdominal or gynecologic procedures that require the use of the Trende lenburg position. When accompanied by an associated acidosis, laparoscopy can cause hazardous intracranial pressure elevations in susceptible patients, espe cially those with acute brain injury. Also, a theoretical risk of intracranial insuf a tion exists in the case of a defective shunt valve [38,39]. No long-term data are available concerning the devel opment of the child after maternal laparoscopy, but recent clinical data suggest that adverse outcomes are rare when laparoscopy is performed in the second trimester of pregnancy [41–44]. Advantages of the second trimester Because of the possible teratogenicity of anesthetic agents, elective surgical procedures in general are contraindicated in the rst trimester. In the third trimester, the risk of pre-term labor also contraindicates elective surgical proce dures. The second trimester (13–26 weeks gestation) is a relatively safe period for indicated abdominal operations. Diagnostic or operative laparoscopy for appendectomy and gynecologic emergencies have been reported in all trimesters with fetal loss rates that are equivalent to open surgery [41–44]. Thus, no absolute contraindications exist, except in the late third trimester, when the gravid uterus obliterates the peritoneal space, and most indicated procedures are preceded by induction of labor or cesarean section. Coagulopathy the presence of known coagulation disorders was once considered to be a contraindication for laparoscopic surgery. This is rarely the case now, with im proved surgical techniques and the development of recombinant coagulation factors. Laparoscopic splenectomy is becoming the standard approach for med ically refractory immune thrombocytopenia purpura. The coagulopathy associ ated with congenital coagulation disorders should be corrected before operation. Uncorrected coagulopathy is a relative contraindication to both laparoscopic and open operations because of the dif culty in controlling bleeding. Surgical Judgment the laparoscopic skill set and experience of the surgeon are also important variables which must be taken into account when considering the feasibility of a particular minimally invasive operation. Also, when attempting a dif cult case it is imperative that the surgical assistants be experienced. Therefore, inexperi ence on the part of the surgeon or assistants is a relative contraindication for advanced procedures. Given an experienced surgeon and staff, it is also important for the surgeon to make an overall assessment early in the case as to whether it is likely or unlikely that a given case will be successfully completed using laparoscopic means. Advanced minimally invasive cases are unforgiving in that the inability to carry out just one of the many laparoscopic tasks required for the successful completion of a procedure may necessitate conversion. As an example, if, during a segmental colectomy in a patient with considerable adhesions, it becomes necessary to run the small bowel extracorpeally, to nd and repair a partial thickness enterotomy (incurred during adhesiolysis), the small bowel loops must 30 S P Bowers and J G Hunter be mobile enough to be externalized. If the small bowel is densely matted together, then, despite the fact that the anterior abdominal wall adhesions have been successfully taken down (making the laparoscopic colectomy feasible), conversion, in the end, will most likely be unavoidable. Rather than busying themselves with the parts of the operation that are feasible laparoscopically, the surgeon must be disci plined enough to make an early judgment about the steps of the operation that will be the most dif cult. Conclusion Contraindications to laparoscopic surgery may be anatomic or physiologic. Familiarity with and attention to the responsible factors will assure the lowest risk of adverse outcomes. The skill set and experience of the surgeons must also be taken into account when considering a minimally invasive approach. The deci sion to convert to an open operation must be based on the experience of the surgeon and the anatomic and physiologic constraints of the patient. Risks of the minimal access approach for laparoscopic surgery: multivariate analysis of morbidity related to umbilical trocar insertion. Access techniques: Veress needle–initial blind trocar insertion versus open laparoscopy with the Hasson trocar. Role of microlaparoscopy in the diagnosis of peritoneal and visceral adhesions and in the prevention of bowel injury associated with blind trocar insertion. Laparoscopic cholecys tectomy for patients who have had previous abdominal surgery. Alternative site entry for laparoscopy in patients with previous abdominal surgery. Access problems in laparoscopic cholecystectomy: postoperative adhe sions, obesity, and liver disorders. Laparoscopy extends the indications for liver resection in patients with cirrhosis. Laparoscopic versus open cholecystectomy in cirrhotic patients: a prospective study. Two-stage laparoscopic manage ment of generalized peritonitis due to perforated sigmoid diverticula: eighteen cases. Laparoscopic resection does not adversely affect early survival curves in patients undergoing surgery for colorectal adenocarcinoma. A prospective, randomized trial comparing laparoscopic versus conventional techniques in colorec tal cancer surgery: a preliminary report. A prospective comparison of laparoscopy and imaging in the staging of esophagogastric cancer before surgery. Lymphovascular clearance in laparoscopically assisted right hemicolectomy is similar to open surgery. Peritoneal mucinous carcinomatosis after laparoscopic-assisted anterior resection for early rectal cancer: report of a case. Value of peritoneal lavage cytology during laparoscopic staging of patients with gastric carcinoma. Preoperative morbidity and anaesthesia-related negative events in patients undergoing conventional or laparo scopic cholecystectomy. Impairment of cardiac performance by laparoscopy in patients receiving positive end-expiratory pressure. Advanced age: indication or contraindica tion for laparoscopic colorectal surgery Laparoscopic surgery in a patient with a ventriculoperitoneal shunt: a new technique. Laparoscopic cholecystectomy in pregnancy: a review of published ex periences and clinical considerations. The microspheres can Summary be directed to the entire liver or to subregions, where they lodge in the hepatic arterioles (branches of the artery) and 9 Microspheres containing radioactive yttrium-90 embolize (occlude) the blood vessels feeding the tumour. These the microspheres also exert a radiotherapeutic effect by deliver high doses of ionizing radiation to emitting beta radiation that destroys local tumour tissue with inoperable hepatocellular carcinoma, the most 90 little damage to surrounding normal tissue. After they decay to stable zirconium 90, the inert, non 9 Limited evidence from several case series 3 90 biodegradable microspheres remain in the liver. Improved patient selection criteria and technical changes to microsphere delivery have reduced the risks of complications and death. It usually develops in individuals with chronic 1 liver disease, particularly those with viral hepatitis. The median survival time from diagnosis is the use of Y microspheres in the treatment of liver metastases 2 approximately six to 20 months.

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In other words 4 medications walgreens purchase prometrium 200mg with amex, care plans are not set in stone treatment 001 - b buy 100 mg prometrium mastercard, but need to be adapted based on the persons reaction to diferent approaches and modifed as the persons needs change or the disease progresses medications not to take when pregnant discount prometrium 200 mg fast delivery. Examples include Playing music during bathing may reduce agitated actively singing or playing a musical instrument treatment quality assurance unit buy prometrium american express, behaviours (Konno et al. Effective communication strategies and person Approaches are effective in reducing agitated centred approaches to care behaviours in people with dementia (Konno et al. See Appendix A, the Glossary of Terms, for a defnition of person centred approaches. Sensory Interventions Sensory interventions may reduce agitation (Livingston et al. Group Activities in Care Homes Reduces agitation, but not necessarily for those who are severely agitated (Livingston et al. Art Therapies One review, rated weak for methodological quality, reports potential benefts for behavioural or emotional Note: Examples include visual arts, drama/ symptoms (Cowl & Gaugler, 2014. Level of Evidence = V Discussion of Evidence: Afer developing a plan of care for people with dementia (see Recommendation 7. Refer to Appendix J, Resources, for a list of programs and resources to support people with dementia. Some of these programs suggest interventions, actions, and approaches to support that are specifc to behavioural and psychological symptoms of dementia. Pain-reducing interventions may include pharmacological and non-pharmacological measures. The expert panel recommends that health-care providers monitor for both verbal and non-verbal signs of pain. This includes observing for and documenting changes in any symptoms related to pain, in order to determine whether pain reduction measures are efective. Level of Evidence = Ia Discussion of Evidence: Efective communication with people who have dementia has many benefts. A systematic review of quantitative studies rated moderate for methodological quality found that efective communication enhanced positive behaviour, promoted more satisfying interactions, and improved overall quality of life for the person with dementia (Eggenberger, Heimerl, & Bennett, 2013. Efective communication has also been shown to reduce agitation and responsive behavioursG in persons with dementia (Livingston et al. Examples of communication strategies (from a systematic review on mostly qualitative studies, rated moderate for methodological quality) include apologizing, using appropriate humour, distraction, allowing the person to take time to respond to the care provider, and providing reminders of what will happen next (Konno et al. Appendix K outlines communication strategies that are benefcial for dementia care, and the skills, attitudes, and knowledge required to apply these skills. The expert panel adds that positive communication requires certain knowledge, skills, and competencies. Health care providers must understand how dementia afects the brain and, by extension, the persons ability to receive, process, and produce language. In addition, they must also have empathy, compassion, and respect for the person; demonstrate cultural competenceG; and be able to establish a trusting and therapeutic relationship with the person. Furthermore, health care providers must validate the persons emotions, and recognize and accept their thoughts, feelings, sensations, and behaviours as understandable; this does not necessarily mean agreeing with or endorsing the persons behaviour. While the literature highlights the benefts of exercise, suggests potential benefts of advanced care planning for people with dementia in long-term care, and indicates various interventions to support cognition, the expert panel notes that there are many other strategies that may beneft people with dementia, especially in the earlier stages of the disese. Exercise One strongly and one moderately rated review show that exercise can potentially improve the ability of people with dementia to carry out activities of daily living (Forbes, Thiessen, Blake, Forbes, & Forbes, 2013) and reduce decline in their ability to do so (Littbrand, Stenvall, & Rosendahl, 2011. Other reviews, which rated weak for methodological quality, have shown general positive efects of exercise (Balsamo et al. Interventions that Support Cognition Cognitive interventions can be described as activities that teach new ways of carrying out cognitive tasks, and strategies to improve functioning or restore abilities in specifc domains (Development Group, 2010. The Development Group of the Clinical Practice Guideline on the Comprehensive Care of People with Alzheimers Disease and Other Dementias (2010) reviewed a wide range of cognitive interventions (e. In addition to these cognitive interventions, the expert panel notes that medications are sometimes prescribed for a limited time to enhance cognition or to treat/manage other symptoms of dementia. Advanced Care Planning Advanced care planning can be described as “a multistage process whereby a patient [person] and their carers achieve a shared understanding of their goals and preferences for future care (Robinson et al. One systematic review, rated moderate for methodological quality, captured fndings from four studies about advanced care planning in long term care. Benefts of advanced care planning in the long-term-care setting include having documentation of a persons preferences for care, reduction in rates of hospitalization, and increased use of hospice services (Robinson et al. The authors point out, however, that the long-term-care setting may be too late for some people to discuss advanced care planning if their capacity to discuss issues is inhibited by the disease process (Robinson et al. The Alzheimer Society of Canada provides guidance on advanced care planning and related topics, including developing a health-care plan, selecting a substitute decision-maker, planning work/volunteer adaptations and living arrangements, planning legal and fnancial matters, and making end-of-life decisions. The Alzheimer Society of Canada provides comprehensive information, support, and resources, including guidance for day-to-day living with dementia, and strategies that address specifc needs and concerns of people with dementia and their families/care partners. Information is provided for diferent stages of dementia (not just Alzheimers), including early, middle, late, and end-of-life. Interventions for caregivers (family caregivers/care partners) must be tailored to the individual needs of those involved (Elvish et al. This is important because dementia progresses at diferent rates, symptoms vary, and the perceived burden of caregiving is interpreted in various ways (Jensen et al. Tese interventions can be ofered directly by health-care providers, over the phone, in group settings, through computer programs, and online. Benefts of Programs Offering Psychological Support and Education Although most of the evidence is methodologically weak, one strong systematic review and meta-analysis of randomized controlled trials found that educational interventions for caregivers in the community decreased caregiver burden and depression (Jensen et al. Other potential benefts may include reduced caregiver depression, reduced caregiver burden, enhanced caregiver well-being (Chien et al. The expert panel suggests that supporting caregivers may be the best way to improve outcomes for people with dementia. The evidence suggests that caregiver programs may be more efective if they are multifaceted (Corbett et al. In a systematic review and meta-analysis by Brodaty & Arasaratnam (2012), it is suggested that programs for caregivers are more successful when they are delivered over a period of time with adequate follow-up. Referring Family Members and Care Partners with Distress or Depression Health-care providers can provide psychological support and education directly to caregivers who are caring for people with dementia (Development Group, 2010; U. For those caregivers experiencing distress or depression, health-care providers should refer them to (or recommend that they see) a primary care provider or mental health specialist (Development Group, 2010. Additional supports or referrals may also be required if caregivers are challenged by other issues associated with the social determinants of health (e. It should be noted that although respite care is generally believed to support caregivers and is frequently recommended by health-care providers, one study, rated weak for methodological quality, concluded that it may be associated with an increased feeling of burden (Schoenmakers et al. Various technology-based programs are available, including educational videos and connecting with peers or professionals online. Studies about these interventions report favourable outcomes overall, but further research is recommended to confrm benefts (Godwin et al. Stronger studies suggest that computer-mediated programs may reduce caregiver burden, stress, depression, and anxiety, and possibly increase caregivers self-efcacy (McKechnie et al. Educational Content Table 3 outlines suggested content for educating caregivers about dementia. Health-care providers may fnd that some of this education is also important for the person with dementia. Table 3: Content for Educating Caregivers About Dementia Dementia the type of dementia, stage, associated losses, evolution of dementia, clinical manifestations, and possible complications of dementia (Development Group, 2010. Medication the purpose, risks and benefts, and side effects of medications used to enhance cognition. Anticipatory guidance For example, regarding the possibility of delirium or depression, and areas of concern that might require urgent attention (e. Level of Evidence = V Discussion of Evidence: the expert panel recommends ongoing monitoring and evaluation of the efectiveness of the plan of care for the person with dementia. Terefore, interventions, including education and support, will need to be adjusted over the course of the disease. Collaboration and communication with the person (as appropriate), family and care partners, and members of the interprofessional team is required. The frequency of monitoring and evaluating the plan of care will vary according to the setting and organizational policy.

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Supervising physician will document Advanced Health Practitioners competency prior to performing procedure without direct supervision medicine lodge kansas buy generic prometrium 200 mg online. The Advanced Health Practitioner will ensure the completion of competency sign-off documents and provide a copy for filing in their personnel file and a copy to the medical staff office for their credentialing file medicine emoji order 200mg prometrium fast delivery. The Advanced Health Practitioner will demonstrate competence by successful completion of the initial competency medicine daughter lyrics buy cheap prometrium online. Advanced Health Practitioner must perform this procedure at least three times per year medications information order prometrium 200mg on line. In cases where this minimum is not met, the attending, must again sign off the procedure for the Advanced Health Practitioner. The Advanced Health Practitioner will be signed off after demonstrating 100% accuracy in completing the procedure. A clinical practice outcomes log is to be submitted with each renewal of credentials. Division of Gastroenterology and Hepatology Liver Cirrhosis: A Toolkit for Patients 2 Welcome Welcome to the Cirrhosis Management Program at the University of Michigan. As your healthcare team, we take pride in doing everything possible to maximize your health. You, the patient, can make an enormous difference in your health by eating right, taking your medications properly, and taking control of your disease management. To schedule an appointment, call: 888-229-7408 To speak with a nurse, call: 800-395-6431 What is the liver The liver has many important functions including Preventing infections Removing bacteria and toxins from the blood Digesting food and processing medications and hormones Making proteins that help the blood clot Storing vitamins, minerals, fats, and sugars for use by the body Division of Gastroenterology and Hepatology Liver Cirrhosis: A Toolkit for Patients 3 What is liver cirrhosis When something attacks and damages the liver, liver cells are killed and scar tissue is formed. This scarring process is called fibrosis (pronounced “fi-bro-sis), and it happens slowly over many years. Any illness that affects the liver over a long period of time may lead to fibrosis and, eventually, cirrhosis. Heavy drinking and viruses (like hepatitis C or B) are common causes of cirrhosis. Cirrhosis may be caused by a buildup of fat in the liver of people who are overweight or have diabetes. Other causes include certain prescribed and over-the-counter medicines, environmental poisons, and autoimmune hepatitis, a condition in which a persons own immune system attacks the liver as if it were a foreign body. This prevents blood from flowing through the liver easily and causes the build-up of pressure in the portal vein, the vein that brings blood to the liver. To relieve this pressure, the blood goes around the portal vein, through other veins. Some of these veins, called varices, can be found in the pipe that carries food from your mouth to your stomach (the esophagus) or in your stomach itself. Division of Gastroenterology and Hepatology Liver Cirrhosis: A Toolkit for Patients 4 Portal hypertension also causes blood to back up into another organ called the spleen. With cirrhosis, blood is blocked from entering the liver and toxic substances that the liver normally filters escapes into general blood circulation. Aside from the problems with liver blood flow, when cirrhosis is advanced, there arent enough healthy liver cells to make good substances, such as albumin (a protein) and clotting factors that the liver normally makes. This cancer can occur if some of the sick liver cells start to multiply out of control. There may be no signs of liver cancer until the cancer has grown very large and causes pain. In fact, a person may live many years with cirrhosis without being aware that her liver is scarred. This is because the pressure in the portal vein is not yet too high and there are still enough healthy liver cells to keep up with the bodys needs. But if nothing is done about the cause of cirrhosis (for example, if the person continues to drink alcohol, or if hepatitis or other causes of cirrhosis are not treated), the pressure in the portal vein gets higher and the few remaining healthy liver cells are not able to do all the work for the entire liver. At that point, you may notice symptoms like low energy, poor appetite, weight loss, or loss of muscle mass. As the disease progresses symptoms become more severe and may be life threatening. At this stage you can also develop the following Division of Gastroenterology and Hepatology Liver Cirrhosis: A Toolkit for Patients 5 serious problems: bleeding varices internal bleeding from large blood vessels in the esophagus ascites (pronounced “a-sigh-tees) a buildup of fluid in the belly, encephalopathy (pronounced “en-sef-a-lop-a thee) confusion from the buildup of toxins in the blood Jaundice yellowing of the eyes and skin, Sometimes, if the damaging agent (such as alcohol) is removed, the liver can slowly heal. Other times, the only way to cure cirrhosis is to replace the sick liver with a healthy liver – this is called liver transplantation. Backup of blood from the scarred liver may cause the veins in the wall of the esophagus to enlarge. The pressure inside the enlarged veins, called esophageal varices, is higher than normal. The increased pressure can cause the Division of Gastroenterology and Hepatology Liver Cirrhosis: A Toolkit for Patients 6 veins to burst, leading to sudden and severe bleeding. Signs of bleeding varices include vomiting of large amounts of fresh blood or clots. People who have signs of bleeding varices should go to an emergency room immediately. If you vomit blood or your stool turns black and tarry, you must Unless the varices break and go to the emergency room bleed, patients have no symptoms immediately. Larger varices have a higher risk of breaking and bleeding, and if you have them your doctor will start treatment with medications called Beta Blockers. They include Propranolol (Inderal ), taken twice a day Nadolol (Corgard ), taken once a day Carvedilol (Coreg ), taken twice a day Your doctor will generally start you on a very low dose of one of these drugs and check your heart rate (pulse. The goal of treatment is to give you enough of one of these drugs to reduce your heart rate by 25%. Division of Gastroenterology and Hepatology Liver Cirrhosis: A Toolkit for Patients 7 Most people with low blood pressure tolerate beta blockers well. With this procedure the doctor creates an internal tunnel in the liver that reduces blood flow and pressure in varices. Managing ascites Another problem caused by high pressure in the veins of the liver is ascites. The most dangerous problem associated with ascites is infection, which can be life threatening. If you have ascites and you suddenly get a fever or new belly pain, you must go to the emergency room immediately. Abdominal Anatomy the abdominal cavity (the belly) contains the digestive organs such as the stomach, intestines and liver. Ascites is a medical condition in which excess fluid begins to puddle within the abdominal cavity. This fluid is outside of the intestines and collects between the abdominal wall and the organs within. Division of Gastroenterology and Hepatology Liver Cirrhosis: A Toolkit for Patients 8 Causes of Ascites Liver disease is the most common cause of ascites. The word "cirrhosis" means "scar tissue," so this condition is often called “cirrhosis of the liver. This scar tissue changes the normally smooth liver surface to a lumpy surface that blocks the blood from exiting the liver. This condition causes the surface of the liver to "weep" fluid into the abdominal cavity. The liver also sends signals to the kidney to “hold on to salt, resulting in fluid retention in the legs or abdomen. There may be a loss of appetite, frequent heartburn, fullness after eating, or abdominal pain. Eventually, there is swelling of the abdomen that looks similar to the later stages of pregnancy. During the day, gravity may carry some of the fluid down into the scrotum (the sac that hold the testicles) or legs causing swelling, (edema. As the condition worsens, however, the swelling may spread up the leg and be present day and night. As more fluid builds up, it may spread up to the chest and cause difficulty breathing. If infection, cancer, or heart failure is the cause, the treatment is directed appropriately to the underlying problem.

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If fibrosis is found on biopsy medications erectile dysfunction purchase discount prometrium online, it predicts a progression to cirrhosis or end-stage liver disease treatment non hodgkins lymphoma purchase prometrium 100mg without prescription. The normal lobular architecture is obscured and central veins are difficult to locate treatment plans for substance abuse order prometrium 200 mg on line. Continuing necrosis and fibrosis results in the progression from a micro to a macronodular pattern symptoms 8 weeks purchase prometrium visa. This progression is accompanied by a reduction in steatosis in end-stage liver disease. It consists of a myriad of individual microscopic functional units called lobules. The liver performs a variety of functions including the removal of endogenous and exogenous materials from the blood, complex metabolic processes including bile production, carbohydrate homeostasis, lipid metabolism, urea formation, and immune functions. The liver is located in the right upper quadrant, between the fifth intercostal space in the midclavicular line down and the right costal margin. The surfaces of the liver are smooth and convex in the superior, anterior and right lateral regions. Indentations from the colon, right kidney, duodenum and stomach are apparent on the posterior surface. The line between the vena cava and gallbladder divides the liver into right and left lobes. The lobes are divided into eight segments each containing a pedicle of portal vessels, ducts, and hepatic veins. The portal venous system extends from the intestinal capillaries to the hepatic sinusoids (Figure 8. This system carries blood from the abdominal gastrointestinal tract, the pancreas, the gallbladder and the spleen back to the heart (coursing through the liver. The largest vessel in this system is the portal vein, which is formed by the union of the splenic vein and superior mesenteric veins. The left gastric and right gastric veins and the posterior superior pancreaticoduodenal vein drain directly into the portal vein. The portal vein runs posterior to the pancreas and its extrahepatic length is anywhere from 5 to 9 centimeters. At the porta hepatis, it divides into the right and left portal veins within the liver, and the cystic vein typically drains into the right hepatic branch. The portal vein supplies 70% of the blood flow to the normal liver, but only 40% of the liver oxygen supply. The remainder of the blood comes from the hepatic artery, and blood from both vessels mixes in the sinusoids. This dual blood supply—from the portal vein and hepatic artery—allows the liver to be relatively resistant to hypoxemia. Unlike the systemic vasculature, the hepatic vascular system is less influenced by vasodilation and vasoconstriction. This is due to the fact that sinusoidal pressures remain relatively constant in spite of changes in blood flow. A classic example is hepatic vein occlusion resulting in high sinusoidal pressure and extracellular extravasation of fluid. To maintain a constant inflow of blood, hepatic artery blood flow is inversely related to portal vein flow. This appears to be hormonally mediated rather than neurally mediated, since it persists even in the transplanted liver. Amazingly, nearly 50% of individuals who ingest large amounts of ethanol are spared serious injury. In addition to the amount and duration of alcohol use, several other factors have been linked to an increased risk for the development of liver disease. These include genetics, gender, viral liver disease, nutrition, and exposure to other hepatotoxins. Viral Liver Disease Concurrent viral hepatitis increases the incidence of liver injury in alcoholics. These patients also have a much higher chance of developing cirrhosis and hepatocellular cancer compared to alcoholics without hepatitis C (Figure 9. Nutrition Initial hypotheses suggested that alcoholic liver disease was a result of alcohol intake in the face of poor nutrition. Today, however, it is understood that while malnutrition may worsen the severity of disease and obesity may increase the risk of developing disease, alcoholic liver disease does indeed occur in well-nourished individuals. Current research suggests that patients with diets deficient in essential nutrients are more susceptible to the development of liver damage. Alcohol ingestion promotes the absorption of iron from the intestine, increasing hepatic iron stores. Iron acts as an electron donor, accelerating the generation of unstable free oxygen radicals. In addition to contributing to membrane injury, this may also exacerbate inflammatory response. Just as viral hepatitis increases the risk to develop alcohol related liver injury, other hepatotoxins may act synergistically or additively with alcohol. Pathogenesis Several factors have been proposed to explain the pathogenesis of alcoholic liver injury. These include: Variations in alcohol metabolism Centrilobular hypoxia Inflammatory cell infiltration and activation Antigenic adduct formation Variations in alcohol metabolism Alcohol must be metabolized in order for liver injury to occur, and there are several pathways that contribute to its metabolism. There is considerable genetic variability in both of these enzymes, which may account for differences in blood alcohol levels but does not predict susceptibility to liver disease. This allows acetaldehyde to build up causing flushing, tachycardia, hypotension and, usually, an aversion to alcohol. Centrilobular hypoxia Liver injury is most prominent in the zonal region surrounding the central vein. Inflammatory cell infiltration and activation Proinflammatory cytokines and inflammatory cells are often found in the blood and liver of patients with alcoholic hepatitis. These mediators may contribute to injury by promoting leukocyte adherence and activation. Kupffer cells (macrophages in the liver) may also be an important source of injury as they produce inflammatory and fibrogenic cytokines after being activated by alcohol. Chronic alcohol ingestion ultimately increases intestinal permeability, allowing endotoxins into the portal blood (Figure 4. This may exaggerate the release of cytokines and oxygen radicals from alcohol-primed Kupffer cells. Antigenic adduct formation Ethanol is metabolized to acetaldehyde and can also result in the formation of hydroxyethyl radicals. These radicals bind to hepatocellular proteins altering the proteins (forming adducts that are antigenic) and provoking an immune response. Animal studies have shown that guinea pigs immunized with acetaldehyde-protein adducts develop hepatic injury and fibrosis after ethanol ingestion. Other studies suggest that these adducts are not always located in areas that are accessible to the production of an immune response (e. The type of beverage most often consumed, be it beer, wine, or distilled spirits does not influence the likelihood of ethanol-induced hepatotoxicity. Alcohol intake at two or more drinks a day should raise suspicion as patients may underestimate their intake or have concomitant hepatic insults. Biochemical Tests Blood tests are useful in the evaluation of disorders of the liver and biliary system. There are several laboratory abnormalities characteristic of alcoholic liver disease. Aminotransferases Aminotransferase abnormalities are common in alcoholic liver disease. In addition, although symptoms may be nonspecific, increased serum uric acid, hypokalemia, hypomagnesemia and acidosis are indicators that alcohol may play a significant role in liver disease. Leukocytosis is frequent in individuals with alcoholic hepatitis and may correlate with disease severity.

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