Blood Flow – Complications of Liver Cirrhosis (Nursing)

00:00 So the first category the first F word is flow.

00:04 Now, the normal flow is impaired because of the scarring or the fibrosis that occurs in cirrhosis.

00:11 So you have an increased pressure in the liver because the tissue is now scarred.

00:16 So blood is not flowing through the liver at the same rate as a healthy liver that isn't cirrhotic.

00:23 So instead of that two and a half minutes for one gallon.

00:26 It's going to be much slower depending on how severe the damages.

00:30 Now we've gone over in detail the portal vein system in other videos, but I just want to put the picture up there again for you to see it.

00:38 You see you've got the liver, the portal vein and how it's connected to the spleen and to the stomach, to the esophagus and into the intestines.

00:46 Remember after that you eat food, it goes into your stomach and it all dumps into the small intestine where the liver drops the bile in to help it be broken down in your intestine, this buds supply that see on your screen brings all those nutrients back up to the liver for the to be stored, processed, altered, all the amazing things that your liver can do.

01:12 When the liver is cirrhotic, now, there is intense pressure that those vessels are not meant to hold.

01:20 So when these vessels start to become all plugged up and backed up we have those things that we've talked about like portal hypertension and esophageal varices.

01:29 Look at that blood flow, trace it around, if it's going to be big and hypertensive, It's going to back up into the spleen is going to back up into the vessels around the esophagus.

01:40 That's how we end up with those problems.

01:42 They become very very fragile vessels.

01:46 So it's just a quick review of what the portal vein system is.

01:50 You see that on your screen.

01:52 We've got the vessels there and the organs that are involved and so you can just a reminder of how when the liver causes elevated pressure in that portal vein system we can have problems in several other organs.

02:06 Okay so when that liver cirrhotic it's going to cause an intense pressure increase and we're going to have back up into the spleen and back up into the esophagus veins and have a lot of complications.

02:18 Let's look at those a little closely.

02:21 So these veins that are causing a backup because our all that pressure is in the liver, you're gonna have these enlarged and swollen veins that are overloading the system because they're not meant to take pressure that that's high and it's all because of the livers problem.

02:39 So we're still in our first of three categories, flow.

02:42 We talked about how that liver that's damaged in a cirrhotic causes intense pressure in these veins that are not meant to be high pressure vessels.

02:52 So then these veins become enlarged and swollen and overloaded because they've got this higher volume of blood backing up from the liver.

03:00 Now it starts to affect the veins that are along the esophagus.

03:04 That's where we get the esophageal varices.

03:07 Now, these guys are not meant to take this kind of volume so they're very fragile and they tend to burst and puts the patient at an increased risk for bleeding.

03:18 Now this is particularly problematic because patients with liver disease have some issues with clotting.

03:23 They don't clot well, they tend to bleed.

03:26 So we've taken these overloaded vessels that are bulging and and really at risk to burst and it's in a patient who doesn't clot well.

03:34 So this can actually become life threatening for your patient.

03:38 Now, we looked at the esophagus.

03:40 We're still talking about flow and how everything is backing up.

03:43 Now, we're talking about it backing up into the spleen.

03:46 Again, I always say this is the most underrated organ in our body.

03:50 So I want to just give you a quick rundown of what a healthy spleen does.

03:53 Normally its job is to filter the blood and remove abnormal cells like old and effective red blood cells.

04:00 Also produces disease-fighting things that we need like in the immune system including antibodies and lymphocytes contacts is a storage center to so this is a super cool organ that just doesn't get enough PR.

04:14 But we're talking about the liver causing increased pressure in that portal vein system.

04:19 We talked about how it goes after those esophageal varices around the esophagus.

04:24 Now, we're going to look at what happens when it backs up and overloads the veins of the spleen.

04:31 It's called splenomegaly meaning a spleen that is too big.

04:36 Now there are some other causes or risk factors of splenomegaly can be hemolytic anemia, that means we've just got way too many red cells that are tying up the spleen, might be an infection because remember it's involved in the immune system and some cancers, but we're focusing on splenomegaly that's caused by an increase in portal hypertension because the patient has cirrhosis.

04:59 And if this portal hypertension is chronic it hangs around long enough and it's high enough the spleen can become enlarged.

05:08 So it's normally a fairly small organ.

05:11 They can end up becoming very large.

05:14 So we wanted to give you a context for splenomegaly.

05:18 So you see on the left, that represents the healthy adult spleen it weighs around 200 grams or seven ounces.

05:26 Look to the right, if you're experiencing portal hypertension for long enough, the spleen can increase to two kilograms or more than 4.4 pounds.

05:38 So when we say splenomegaly that's pretty impressive.

05:42 And remember the reason we're talking about a spleen getting this big is because of the backup of blood and overload caused by portal hypertension.

05:52 Now portal hypertension has this increased pressure in the portal vein.

05:57 We've already talked about that, but this can cause fluid to accumulate in the legs, we call that peripheral edema and in the abdomen that ascites.

06:07 Now we're going to start with some pictures looking at the peripheral edema in the leg.

06:12 So on your screen, you'll see a normal leg and a normal foot.

06:17 That's what we're looking for. That isn't swollen isn't puffy.

06:21 You can see the bones of the feet.

06:23 Everything looks like a go.

06:24 That's what it should look like.

06:26 But a patient with liver failure often has pitting edema.

06:30 Now we're going to show you a leg that is swollen with edema and a foot that is swollen with edema.

06:36 Compare those to the to normal pictures, see the difference? If you haven't been in clinicals yet.

06:42 You will see this in practice.

06:45 Now in order for it to be pitting edema, if I took my thumb and I pressed on their shin bone, not extremely hard, but just enough to make an indentation in their tissue when you release your thumb if you still have an indentation, that is pitting edema.

07:00 Okay so now we've talked about peripheral edema.

07:03 Next we're going to look at what ascites is.

07:07 So we have a great picture for you there, and I'm going to bring in the labels as we're talking about it but peripheral edema is fluid in my tissues in my legs and my feet.

07:16 Ascites is extra fluid in my abdomen.

07:20 Now the cause of both whether it's peripheral edema or ascites is that excess pressure that portal vein hypertension.

07:29 So take a look at our picture. See the blue at the bottom? That's to represent the actual fluid the ascites that's in the patient's peritoneal cavity.

07:38 So now we're going to bring in the label for peritoneal cavity.

07:41 So you can see these kind of half way up there if you standing up, if the patient lays down that fluid will shift.

07:48 Now the third label is the peritoneum that kind of gives you the boundary.

07:53 Now patients with ascites, look at where that's located.

07:56 See how that doesn't leave them much room to breathe.

07:59 So this often Forces them to be very short of breath.

08:03 They're also not able to lay completely flat because all that pushes on their lungs.

08:08 So often times they have to have the head of their bed elevated.

08:12 Now if the ascites is pretty severe you can even tap on the abdomen in your assessment and you may see a Whipple or rave go across the patient's abdomen.

08:21 So let's look at these together.

08:24 Now, you see the peripheral edema on one side.

08:26 You see the ascites on the other.

08:29 Know that both of these are caused by the portal hypertension.

08:33 Now one side note.

08:34 I want to remind you that liver damage patients also to have lower protein levels, which also leads to inappropriate fluid shifting.

08:42 So I just wanted to bring that point in but here we're talking about the effect of portal hypertension is going to force fluid into inappropriate places in patients that already have low protein levels.