Pathogenesis of Liver Cirrhosis Paper

Assignment 3

The purpose of this paper is to address the following clinical scenario with the use of your textbook, external credible literature, and/or reliable electronic sources. Use the guide below to draft your paper and review the rubric to ensure you have met the assignment criteria. The expected length of the paper is approximately 4-5 pages, which does not include the cover page and reference page(s).Pathogenesis of Liver Cirrhosis Paper

James Alvarez is a 52 y.o., recently divorced, Latino male; new patient who arrives at the community health clinic for an appointment with a primary care Nurse Practitioner. His chief complaint of abdominal pain and vomiting, fatigue, and weight loss. He notes that although he has experienced overall weight loss, his stomach “looks huge.” As his history is taken, he notes no alcohol use.  In speaking with him, the Nurse Practitioner notices a yellow tinge to the whites of his eyes. During examination, the Nurse Practitioner notes organomegaly in the right upper quadrant.

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Please use the following headings/subheadings as a guide to draft your paper:

Introduction (including purpose statement)

What would be your priority diagnosis for Mr. Alvarez?

Identify the organ and describe the pathophysiological processes, which may have caused the organomegaly.

Develop a comprehensive and holistic plan of care for this patient based on James\’ diagnosis.

Conclusion

Within your description, place in bold font the key pathophysiological concepts (terms).

Include recommendations for follow-up with the Nurse Practitioner.

Incorporate a population-based component to Mr. Alvarez\’ plan of care.

In regards to APA format, please use the following as a guide:

Include a cover page and running head (this is not part of the 4-5 page limit)

Include transitions in your paper (i.e. headings or subheadings)

Use in-text references throughout the paper

Use double space, 12 point Times New Roman font

Spelling, grammar, and organization are appropriate

Include a reference list (this is not part of the 4-5 page limit)

Attempt to use primary sources only. That said, you may cite reliable electronic sources (i.e. ANA)

Advanced Pathophysiology-Liver Cirrhosis
Introduction

Nurse practitioners should have a deep understanding of pathophysiological processes, which lead to the manifestation of a patient’s conditions. Conditions involving the abdomen that result to organomegaly require nurses to utilize expert assessment and clinical management skills to undergo complex diagnostic and treatment interventions for the patients. Nurses should also understand advances in managing all disorders under their specialization to help restore patients’ health and normal body functions (Sharma & John, 2019). This paper describes pathological processes of that resulted in abdominal pain and vomiting, fatigue, weight loss, and jaundice in Mr. James, a Latino male aged 52 years old. It also describes the comprehensive plan of care following the latest clinical guidelines and essential follow-up care. Pathogenesis of Liver Cirrhosis Paper

Case Overview

James Alvarez is a 52 years old, recently divorced, Latino male; new patient who arrives at the community health clinic for an appointment with a primary care Nurse Practitioner with  chief complaints of abdominal pain and vomiting, fatigue, and weight loss. He notes that although he has experienced overall weight loss, his stomach “looks huge.” As his history is taken, he notes no alcohol use. In speaking with him, the Nurse Practitioner notices a yellow tinge to the whites of his eyes. During examination, the Nurse Practitioner notes organomegaly in the right upper quadrant.

Priority diagnosis for Mr. Alvarez

Based on Alvarez’ presenting signs and symptoms, he is likely suffers from liver cirrhosis in a non-alcoholic. Liver cirrhosis is a histologic condition that involves diffuse fibrosis, which disrupts hepatic function and formation of abnormal nodules in the liver. Liver cirrhosis is common among alcoholics. However, the study by Nilsson et al. (2016) shows that cirrhosis can also occur in non-alcoholics. Among non-alcoholics obesity and a history of hepatitis C are key risk factors for cirrhosis. However, in the case of James Alvarez, it is not possible to tell whether he has similar predisposing factors. Liver-cirrhosis affects twice as many men as women, and most patients are between 40-60 years of age.

Organ and the Pathophysiological Processes

The organomegaly noticed in the right upper quadrant in Mr. Alvarez is enlargement of the liver. Liver cirrhosis has an insidious onset and a protracted course. Causative factors include exposure to chemicals (arsenic, phosphorus), infectious schistosomiasis and hepatotoxic substances (medications, general anesthesia agents, inhalants, illicit injectable drugs). Diffuse fibrosis triggered by the hepatotoxic substances or alcohol involves the excess deposition of collagens, and glycoproteins in response to liver injury by triggers and occurs between the hepatocytes and sinusoids (Böttcher & Pinzani, 2017). The liver becomes inflamed with a sharp nodular edge that can be elicited during physical examination through abdominal palpation.

Painful abdomen is evident because of the rapid liver enlargement. The liver cells are loaded with fatty deposits. The liver enlargement produces tension on Glisson’s capsule (its fibrous covering). Scar tissue gradually replaces destroyed liver cells. The disease’s hallmark is decompensated cirrhosis is the incapacity of liver to synthesize substances such as proteins and clotting factors. The inflamed liver increases the resistance of blood flow in the portal circulation, leading to portal hypertension. According to Böttcher & Pinzani (2017), increased splanchnic arterial flow and a subsequent increase in the venous flow into the liver increases portal hypertension further. Other complications, which may arise are ascites, coagulopathy, GI bleeding from varices in the portal circulation, and decreased detoxification function of the liver, which leads to hepatic encephalopathy. Pathogenesis of Liver Cirrhosis Paper

The failure of liver function due to cirrhosis partly obstructs portal circulation, causing portal hypertension. The result is back up of blood into the GI tract and spleen, making them stagnant with blood and unable to function correctly. Altered bowel functions and ingestion result. Fluid rich in proteins may accumulate in the peritoneal cavity, resulting in ascites. Although it is not mentioned whether Mr. Alvarez had ascites, the ascites fluid can be demonstrated through precision for fluid wave or shifting dullness.

Reduction of protein synthesis and loss of proteins into ascites contributes to typical malnutrition and weight loss. Studies by Jung & Yim, (2017) show that many patients experience muscle wasting, fatigue and anorexia. Without prompt treatment, the scar tissue is extensive than the healthy and well-functioning one. The residual healthy hepatic tissue provides a chance of regeneration, giving the cirrhotic liver a typical hobnail appearance.

Diagnostic Tests

To confirm the diagnosis, laboratory and other diagnostic tests are vital. The patient needs to understand why and how the tests are performed to build a good therapeutic relationship. Therefore, the diagnostic tests to order include blood tests for hemoglobin, hematocrit, liver enzymes, total serum albumin/protein, total serum bilirubin/indirect bilirubin prothrombin time, and electrolytes. Liver enzyme tests to determine liver damage (high serum alkaline phosphatase, ALT, AST, and AGT levels). Serum cholinesterase level may increase. Bilirubin levels measure bile excretion or retention, and elevated levels may be present in cirrhosis. Prothrombin time is prolonged because of reduced synthesis of clotting factors (Fukui et al., 2016). Arterial blood gas analysis may reveal hypoxia and ventilation-perfusion imbalance.

Abdominal X-ray is useful in showing the extent of hepatomegaly. Doppler ultrasonography scanning measures the difference in density of scar tissue and parenchyma cells. Doppler US can also check hepatic blood vessels. Computed tomography (CT) with intravenous contrast, abdomen radioisotope scan and abdominal MRI give detailed information about hepatic blood flow, obstruction and liver size. The diagnosis is confirmed through a liver biopsy.Pathogenesis of Liver Cirrhosis Paper

Care Plan

Alvarez’s management depends on his presenting symptoms. Therefore, the management is both supportive and preventative (Giulio Romanelli & Stasi, 2016). For instance, he will need nutritional supplements and vitamins to promote healing of damaged liver tissue and improve the nutritional status. Correction of electrolytes is also essential to promote nervous system function, restore fluid balance among body compartments among other body functions. Antacids may be prescribed to minimize the possibility of GI bleeding and decrease gastric distress. Potassium sparing agent such as spironolactone (Aldactone) may be prescribed to reduce ascites. The findings of the study by Adebayo et al. (2019) demonstrate that aldactone minimizes fluid and electrolyte changes that occur in comparison with other diuretics. Beta-blockers are vital to control blood pressure. Oral antibiotics such as metronidazole, vancomycin and quinolones serve to decrease the colonic concentration of bacteria.

Surgical interventions may be required to relieve the ascites by paracentesis with caution to prevent intracellular fluid volume depletion in a patient on diuretics. A peritoneovenous shunt should be the last resort if other methods fail to treat ascites. The shunt permits return of ascites fluid into intravascular prevents further fluid accumulation and protein loss. If the treatment does not resolve ascites and other complications within more than a year, liver transplantation is appropriate. The surgery is considered for salvaging the patient before the onset of liver failure. The replacement of diseased liver a healthy one occurs at the same anatomical location (Neuberger, 2016). Immunosuppression is essential to prevent rejection.

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Follow-Up with the Nurse Practitioner

The Nurse should follow this Mr. Alvarez and involve the hospital’s hepatologist in care. Counseling on dietary modifications such as low sodium, healthy choices with lean protein will help the patient prevent edema formation. Although James is not alcoholic, avoidance of alcohol, prevention of infections by getting annual influenza and pneumonia vaccinations will be necessary. Follow up will ensure close to monitoring of patient’s state of health. The nurse will assess the patient’s progress at home and helps prevent or mitigate any further complications. Follow-up plan should include meeting Mr. Alvarez and his family for discussions on coping with dietary restrictions. Reinforcing patient teaching answering questions promotes their cooperation in adopting the prescribed lifestyle.

The Nurse Practitioner should assess the prescribed medication to ensure that the drugs do not cause any harm to the already-damaged liver tissues. The Nurse Practitioner will monitor for signs of worsening and coordinate care. Besides, the nurse will teach the patient to be alert to issues that may arise at home. Other nurse’s roles in follow up care are counseling and providing advice to this patient for optimal care. Most importantly, the nurse is a confidant and patient’s advocate, a consistent care team member who ensures smooth navigation of medical interventions throughout the continued care.Pathogenesis of Liver Cirrhosis Paper

Population-Based Component in Relation to Alvarez’ Plan of Care

Despite the treatment modalities and lifestyle modification, Mr. Alvarez requires tertiary prevention measures to preserve life and health promotion services. Additional public health efforts targeting health promotion for the entire population are essential to prevent cirrhosis and disease burden. According to Nilsson et al. (2016, population-based component care shifts focus from acute care of the patient to overall health of the broader population. The nurse practitioner collaborates with public health workers because population health needs such as cirrhosis, managing non-communicable disease, cancer prevention fall with the scope of public health and primary care. Interventions for the population health promotion will include sharing information about limiting alcohol intake, information on immunization against hepatitis, influenza and pneumonia and mobilizing individuals undergo various screening for early detection. Referrals are done to a specialist for patients with conditions requiring social services, diagnostic testing and prescriptions.

Conclusion

Different pathophysiological processes can occur in a patient with liver cirrhosis. A comprehensive assessment of such a patient is essential to guide the management approach. Based on this patient’s history and clinical presentation, it is also suitable to conclude that liver cirrhosis can occur in non-alcoholic patients and that supportive management is essential to improve survival rate. The disease can also advance to stages such as end-stage liver disease, which can warrant transplantation if other treatment modes are ineffective (Sharma & John, 2019). Nurses should possess expert knowledge to be informed care team members who can act as patients’ advocates and ensure safe management.Pathogenesis of Liver Cirrhosis Paper

 References

Adebayo, D., Neong, S. F., & Wong, F. (2019). Refractory ascites in liver cirrhosis. American Journal of Gastroenterology, 114(1), 40-47.

Böttcher, K., & Pinzani, M. (2017). Pathophysiology of liver fibrosis and the methodological barriers to the development of anti-fibrogenic agents. Advanced drug delivery reviews, 121, 3-8.

Fukui, H., Saito, H., Ueno, Y., Uto, H., Obara, K., Sakaida, I., … & Shimosegawa, T. (2016). Evidence-based clinical practice guidelines for liver cirrhosis 2016. Journal of gastroenterology, 51(7), 629-650.

Giulio Romanelli, R., & Stasi, C. (2016). Recent advancements in diagnosis and therapy of liver cirrhosis. Current Drug Targets, 17(15), 1804-1817.

Jung, Y. K., & Yim, H. J. (2017). Reversal of liver cirrhosis: current evidence and expectations. The Korean journal of internal medicine, 32(2), 213.

Neuberger, J. (2016). An update on liver transplantation: A critical review. Journal of autoimmunity, 66, 51-59.

Nilsson, E. M. M. A., Anderson, H., Sargenti, K., Lindgren, S., & Prytz, H. (2016). Incidence, clinical presentation and mortality of liver cirrhosis in Southern Sweden: a 10‐year population‐based study. Alimentary pharmacology & therapeutics, 43(12), 1330-1339.

Sharma, B., & John, S. (2019). Hepatic Cirrhosis. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK482419/

Pathogenesis of Liver Cirrhosis Paper