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.