So, last night was my last lecture of Med/Surg 1. I can't believe how FAST this semester has flown by. I mean I feel like it literally started yesterday. Maybe because we packed all our clinical hours into the first part of the semester, I don't know, but wow, next week I will be DONE with my first year of nursing school. I'm thrilled but terrified at the same time. I have heard that next semester is the hardest out of everything. I go from taking one class to 2. That will be interesting. I've never taken more than 1 class at a time before since I started at FCC 2 1/2 years ago. Its Med/Surg 2 and Psych. We will have clinical pretty much every weekend the entire semester, so I better enjoy having my weekends to myself while I still can! We do half the semester clinical wise in Med/Surg 2, then the other half Psych. I kind of hope to get Med/Surg 2 out of the way first. I feel like that is going to be far more challenging to me. We start taking 2 patients next semester and I'm kind of worried about that. Mostly how I'm going to prioritize their care and such. We shall see. So far I have had REALLY wonderful clinical instructors, hopefully that trend continues. We also get to go to the OR next semester. I'm sort of leery about that. I can watch trauma shows on Discovery Health without a problem, but when its a REAL person, right in your face that's getting cut open, I imagine its quite different LOL!
OK so on to disease factoid of the week. Now remember, I am just writing this to enlighten the general populace, so if you are a health care person reading this, I know this is going to seem way oversimplified, but please bear with me and remember my audience, ok? Yesterday, we covered the liver, gallbladder, and spleen. We spent a LOT of time discussing cirrhosis and liver failure, so I am going to talk about that. I also took care of a liver patient this semester, so it was cool learning how everything fits together. So, what do you need to know about cirrhosis of the liver? Well mainly that the liver does A LOT of things in your body. There's really not a system of the body that the liver doesn't do SOMETHING for. It plays a big role in protien and carbohydrate metabolism, stores carbohydrates, stores iron and copper and many of your fat soluble vitamins, detoxifies your blood (most medications you take are metabolized in your liver, and Tylenol can really do a number on it. The MAX dosage of Tylenol a day is 4 grams. So be careful when you have a cold with aches and a fever. A LOT of cold medicines have Tylenol in them, so if your taking a cold med AND Tylenol for pain or a fever, you are getting a double dose right there.), makes bile which you need to be able to break down the fats that you eat, helps with the breakdown of old red blood cells, makes clotting factors, and makes a protien that is found in your bloodstream called albumin. Albumin helps keep the water contained in your blood in your blood vessels instead of leaking out into your body. So you can see that if your liver is screwed up, well, everything goes wrong.
So cirrhosis. The number one cause of cirrhosis is alcohol abuse. The number 2 cause is chronic hepatitis from infection with Hep B or Hep C, with Hep C really being the worst. As far as alcoholism is concerned, scientists don't know whether it is the actual alcohol or the malnutrition that results from being an alcoholic that causes cirrhosis. They are still looking in to that relationship. Cirrhosis happens when your liver cells (called hepatocytes) and the cells that make up the many vessels in your liver die and try to regenerate. Your liver CAN regenerate. That is why they can take liver transplants from living donors. You could lose part of your liver and it will grow back. Neat huh? Anyway, the different cells in your liver come together in a VERY organized structure. In cirrhosis, when the cells regenerate, they do so in a very unorganized way, essentially making your liver not able to function properly anymore. There are A LOT of complications and signs and symptoms of this disease, but I only really want to tell you about a few of the major ones that I saw with the patient I took care of. Her disease was caused by a combination of alcohol abuse AND Hep C.
1) Jaundice: This is a yellowing of the skin and the sclera (whites) of the eyes because of a build up of bilirubin. Bilirubin is a waste product from the breakdown of red blood cells. There are 3 types of jaundice, but I'm not going to get into that here. That's a little complicated for our purposes :) Your red blood cells have a lifespan of about 120 days. After that, they are broken down. Normally, the liver takes in the bilirubin and breaks it down into less toxic substances that are then excreted from your body in the urine and feces. If your liver isn't working, obviously you can't break the bilirubin down, and it deposits in your skin, giving it that yellow color. So the patient I took care of had end-stage liver disease, so she was pretty jaundiced. I noticed it most in the whites of her eyes. They were quite yellow.
2) Ascites: This is basically a fancy term for build up of fluid in the belly. Patients with ascites are those patients that look 7 months pregnant but aren't. The skin of the abdomen becomes stretched and shiny, and if the fluid buildup is bad enough, the skin can actually start to weep fluid. You can have a build up of fluid anywhere in the body, and that is called edema, but when its massive and in the abdomen, its ascites. There are MANY reasons a person could have edema or ascites, but I am just going to discuss why people with cirrhosis get both edema and ascites here. Normally your body maintains a VERY strict fluid balance and there are many mechanisms within the body that keep your fluid balance where it's supposed to be. So without getting into a lot of complicated concepts, the reason people with cirrhosis have problems with fluid balance are 3. 1) The liver is not making albumin anymore. Remember I said albumin was the protien that keeps the water in your blood inside your blood vessels and not out in your body? Well if you don't have enough of that albumin, the water is going to leave your blood vessels and enter your tissues, causing swelling 2) Malfunctioning of the capillaries in your liver: Remember from bio that the capillaries are the smallest blood vessels in your body? Well the liver has them too and they are called sinusoids. Capillaries are permeable, because they work in the tissues releasing nutrients and oxygen and taking up waste products. Now normally, the openings in the capillaries are NOT big enough to let albumin through, because it is a pretty big molecule. In cirrhosis, the sinusoids are no longer normal, and they allow the albumin to escape. So now we have low albumin because the liver can't make it anymore, and even LOWER albumin in circulation of the liver, because it is being lost. Water is going to follow the albumin out, so we get fluid in the tissues. THIS part is important for the actual ascites because of the location of the liver. If you are losing water from the capillaries of the liver, where is it going to go? Think about the area where your liver is located. There is a good bit of space inside your belly, so the fluid is going to build up there, but you might get swelling elsewhere too, and finally 3) Aldosterone: Aldosterone is a hormone that is made in your adrenal glands, and it tells the kidneys to retain sodium. In the human body, water follows sodium. The liver is the organ that breaks aldosterone down. So now you have high levels of aldosterone telling the kidneys to conserve all this sodium, and you retain water. That is why salty foods make you bloated! Because water follows sodium. I found it kind of strange that my patient didn't really have ascites, since she was end-stage. She did have edema down her legs and feet though. You can imagine why ascites would be bad though? First, having all that fluid in your belly makes it difficult to breathe. Second, you run into a lot of problems because of fluid overload that are too complicated to get into here. Third, all that fluid is nice and warm, and contains nutrients, a perfect breeding ground for bacteria, and you wind up with an infection called peritonitis, which can be fatal.
3) Hepatic Encephalopathy: This is a really end-stage complication, and eventually IS fatal. It's a neurological condition that starts as more of a psychiatric problem (confusion, agitation, mood disturbances) and ends with coma and death. People with this also have a characteristic "hand flapping" tremor called asterixis. My patient definitely had this. She was in the beginning phases of it. She had the confusion, she would often forget where she was, what she was saying, or forget words for things, had flights of ideas, and definitely had mood disturbances. One minute she was in a good mood talking to me, the next she was crying, and the next she was yelling at me because she didn't get any toast on her breakfast tray. She had that tremor too. Its only really noticeable when the person puts their hands out in front of them. So here's its cause. When your body breaks down proteins, one of the waste products is ammonia. A lot of that is done by the bacteria that live in your large intestine. I am sure that you know that ammonia is VERY toxic. Well guess what breaks down ammonia? If you guessed the liver, pat yourself on the back! It converts the ammonia into urea, which is excreted by your kidneys in your urine. So if your liver is not breaking down the ammonia, it starts building up in the blood, and ammonia can cross over your bloodstream into your brain. Most chemicals can't do this because the barrier between your blood and brain is so tight (the blood brain barrier) but ammonia can, and it is also quite toxic to your brain. So that is what causes hepatic encephalopathy. The treatment for it is lactulose, which is essentially a laxative. The special property of lactulose is that it binds up the ammonia in your large intestine, and then you eliminate it. My patient was on this, and I am guess that that was why her condition wasn't worse, although after a while, there isn't anything else that can be done.
So wow. This was long! Thanks for reading, and I hope it was educational :)
