A 65-year-old man is admitted to the hospital with the diagnosis of cirrhosis of

Question

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 90160, 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 How does the cirrhosis of the liver cause the jaundice seen in this patient? Explain physiologically relating to normal bile production and bilirubin metabolism. 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? 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.

Explanation / Answer

1. ANS: Cirrhosis is a late stage of scarring (fibrosis) of the liver caused by many forms of liver diseases. Cirrhosis occurs in response to damage to your liver. The most common symptom and sign of cirrhosis is yellowing of the skin (jaundice) due to the accumulation of bilirubin in the blood. the disease jaundice generally occurs when the diseased liver doesn't remove enough bilirubin, a blood waste product, from your blood.

The liver is the only organ where complete biosynthesis of bile can occur. Synthesis of bile acids is one of the mechanisms for the excretion of excess cholesterol. Bile is important for fat digestion and absorption and waste removal from blood. The major pathway for the synthesis of the bile acids is initiated via hydroxylation of cholesterol at the 7 position via the action of cholesterol 7-hydroxylase which is an ER localized enzyme. The most abundant bile acids in human bile are chenodeoxycholic acid (45%) and cholic acid (31%). These are referred to as the primary bile acids.

2. ANS: Ascites is the most common major complication of cirrhosis. Accumulation of fluid in the abdominal cavity is called ascites. Cirrhotic ascites forms as the result of a particular sequence of events. As portal hypertension develops, vasodilators are locally released. These vasodilators affect the splanchnic arteries and thereby decrease the effective arterial blood flow and arterial blood volume. Then the neurohumoral excitation increases, more renal sodium is retained, and plasma volume expands. This leads to overflow of fluid into the peritoneal cavity.

3. ANS: Proteins are complex polymers of amino acids. Liver play a key role in protein digestion. By the help of liver enzymes at first breakdown in to aminoacids and later it degraded and later in the liver deamination and transamination of amino acids taken placed. It converts the non-nitrogenous part of those molecules to glucose or lipids.

Hyperammonemia is a metabolic condition characterized by elevated levels of ammonia in the blood. When the liver is damaged then the urea cycle does not taken placed. The urea cycle is a set of biochemical reactions that produces urea from ammonium ions in order to prevent a toxic level of ammonium in the body. It occurs primarily in the liver. So the level of ammonium ions was highly accumulated due to this the serum ammonia ion concentration also increased.

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