I. Understanding the Disease and Pathophysiology
1. The liver is an extremely complex organ that has a particularly important role in nutrient metabolism. Identify three functions of the liver for each of the following:
• Carbohydrate Metabolism
Glucogensis, gluconeogensis, oxidation via TCA cycle, glycogenolysis, glycolysis
• Protein Metabolism
Synthesis of serum proteins, synthesis of prothrombin, globin of hemoglobin, apoferritin, nucleoproteins and serum mucoprotein, degradation of some proteins to peptides and amino acids, synthesis of urea
• Lipid Metabolism
Lipogensis, lipolysis, saturation/desaturation, ketogenesis, esterification of fatty acids, fatty acid oxidation, uptake/formation/breakdown/esterification/excretion of cholesterol. Formation of lipoproteins
• Vitamin and Mineral Metabolism
Formation of acetyl CoA from pantothenic acid, hydroxylation of vitamin D to 25‐OH D3, formation of 5‐methyl tetrahydrofolic acid, methylation of niacinamide, phosphorylation of pyridoxine, dephospsorylation of thiamin, formation of coenzyme B12
2. The CT scan and liver biopsy confirm the diagnosis of cirrhosis. What is cirrhosis?
• Cirrhosis is any pathological condition where fibrous connective tissue replaces healthy tissue in an organ, usually as a consequence of inflammation or other injury.
3. The most common cause of cirrhosis is alcohol ingestion. What are additional causes of cirrhosis? What is the cause of this patient’s cirrhosis?
• Other causes of cirrhosis are Hepatitis B, Hepatitis C, cryptogenic causes, autoimmune hepatitis, primary bilary cirrhosis, primary sclerosing cholangitis, Wilson’s disease, cystic fibrosis, type IV glycogen storage disease, chronic rightsided heart failure and hemochromatosis.
• Ms. Wilcox’s cirrhosis is most likely caused from her Hepatitis C diagnosis.
4. Explain the physiological changes that occur as a result of cirrhosis.
• In cirrhosis, blood flow to the liver is hampered because scarred tissue replaces normal, healthy tissue and prevents or obstructs the normal flow of blood to the liver. As scar tissue begins to replace more and more of the healthy liver tissue, liver function begins to decrease and liver cells die. Life threatening complications can occur if cirrhosis goes untreated until later stages of the disease and the patient is at a risk for early mortality.
5. List the signs and symptoms of cirrhosis, and relate each of these to the physiological changes discussed in question 4.
• Symptoms of cirrhosis often include fatigue, weakness, nausea, poor appetite, malaise, jaundice, dark urine, light stool, steatorrhea, itching, abdominal pain, and bloating. The major clinical complications with cirrhosis are portal hypertension, hepatic encephalopathy, ascites, and esophageal varices.
6. After reading this patient’s history and physical, identify her signs and symptoms that are consistent with the diagnosis.
• Mrs. Wilcox’s signs and symptoms include a diagnosis of hepatitis C, constant fatigue, poor appetite, nausea and vomiting, rapid weight loss and weakness.
7. Hypoglycemia is a symptom that cirrhotic patients may experience. What is the physiological basis for this? Is this a potential problem? Explain.
• Hypoglycemia is a common problem associated with cirrhosis. To avoid this it is advised to follow a diet of small frequent meals that include complex carbohydrates such as breads and rice. This problem occurs in those with cirrhosis because the liver is not able to store enough energy in the form of glycogen. Since the body is able to break down carbohydrates quick and use them for energy, this diet is recommended in order to avoid problems caused by hypoglycemia. Hypoglycemia in someone who has cirrhosis can present a problem is not addressed by altering the diet.
8. What are the current medical treatments for cirrhosis?
• There are four main treatments for cirrhosis. These treatments include preventing damage to the liver, treating the complications of cirrhosis, preventing liver cancer or detecting it early, and lastly liver transplant.
9. What is hepatic encephalopathy? Identify the stages of encephalopathy and outline the major theories regarding the etiology of this condition.
• Hepatic encephalopathy is a syndrome of impaired mental status and abnormal neuromuscular function that results from major liver failure. • When cirrhosis is present, liver cells cannot function normally because they are damaged or because they have lost their normal relationship with blood. In addition, some of the blood in the portal vein bypasses the live through other veins. The results of these abnormalities are that the liver cells cannot remove toxic substances, and instead the toxic substances accumulate in the blood. When these toxic substances accumulate sufficiently in the blood and the function s of the brain are impaired, which is called hepatic encephalopathy.
10. Protein‐energy malnutrition is commonly associated with cirrhosis. What are the potential causes of malnutrition in cirrhosis? Explain each cause.
• The majority of cirrhotic patients unintentionally follow a low caloric diet. Loss of appetite is attributed to the presence of tumor necrosis or alcohol‐induced anorexia. Also early satiety due to impaired gastric accommodation and impaired expansion capacity of the stomach due to the presence of clinically evident ascites, which often leads to an inadequate nutrient intake. Another factor in malnutrition is the presence of impaired digestion and nutrient absorption due to portal hypertension. Cholestatic liver disease is another reason for impaired absorption, especially of fat‐soluble vitamins such as A, D, E, and K, due to the reduced intraluminal bile salt concentrations.