Management of patients with complications of cirrhosis

Cirrhosis results from repeated hepatocellular injury over time, leading to portal hypertension and the development of ascites, hepatic encephalopathy, and varices. Despite improvements in medical care for patients with cirrhosis, mortality from infection, renal failure, and hepatocellular carcinoma remain high.

Care of the patient with oesophageal varices

Practice profiles are reflective pieces written by nurses in practice and based on continuing professional development articles. This week Suzanne Hudson discusses Oesopahgeal varices. CPD article NS 17. McArdle J (1999) Understanding oesophageal varices.

Understanding oesophageal varices

This article describes the aetiology of oesophageal varices, the variety of treatment options available and the physiological and psychological nursing needs of patients undergoing these treatment regimes. Its purpose is to produce a balanced overview, looking at nursing care in the acute period and the long-term support required to meet the complex needs of these patients and their carers. After reading this article you should be able to: Identify what lifestyle risk factors are associated with patients who have oesophageal varices. Describe the underlying physiology that promotes the development of oesophageal varices. State what treatment options are available and their associated complications. Recognise the needs of carers and staff when attending to this client group. Prepare an action plan for the long-term support of a patient prone to further bleeding episodes.

Esophageal varices: treatment and implications

The purpose of this article is to present an overview of esophageal varices. The causes of esophageal varices and the current treatments are examined. Information is provided regarding surgical and nonsurgical forms of treatment. Various aspects of nursing care are discussed, including the implications involved in the emergency setting, psychological needs, and education for patients and their families.

Evaluation and revision of a vasopressin/nitroglycerin protocol for use in variceal bleeding

BACKGROUND

Continuous infusion of IV vasopressin have been widely used to lower portal pressure and reduce bleeding from esophageal varices. Recently, the combination of vasopressin and nitroglycerin has been noted to be superior to vasopressin alone. This is due to the ability of nitroglycerin to reduce the detrimental effects of vasopressin while preserving its beneficial effects. In September 1989 the authors initiated a protocol in the medical intensive care unit of a large university teaching center that directed caregivers in the simultaneous use of vasopressin and nitroglycerin for use in variceal bleeding.

OBJECTIVE

To determine whether the protocol was being used correctly and whether the addition of nitroglycerin produced the desired cardiovascular effects.

METHOD

Nineteen patients (25 separate episodes) assigned to the vasopressin/nitroglycerin protocol were monitored retrospectively over a 20-month period for a total of 1068 hours of vasopressin/nitroglycerin infusion. Twenty-four patients received nitroglycerin at 10 to 50 micrograms per minute, 13 at 50 to 100 micrograms per minute and 6 at 100 to 400 micrograms per minute.

RESULTS

Nitroglycerin dosage was not advanced appropriately in 78% of episodes despite evidence of bradycardia, hypertension and peripheral vasoconstriction.

CONCLUSIONS

Revision of the protocol, giving additional guidance to clinicians on assessment and nitroglycerin advancement, was necessary and was accomplished.

The adult with bleeding esophageal varices

Bleeding esophageal varices are a life-threatening complication of portal hypertension. During the emergent phase, nurses have an important role in assessing the patient's response to volume replacement and in monitoring interventions to control hemorrhage. Complications contribute to the high mortality associated with variceal hemorrhage. Knowledge of the pharmacologic side effects of vasopressin and of the potential complications associated with endoscopic injection sclerotherapy and esophagogastric balloon tamponade is critical for successful nursing management of the adult with bleeding esophageal varices. The goal of long-term management is to prevent recurrent hemorrhage. This is accomplished by repeated injection sclerotherapy and strategies to reduce portal pressure. Patient education is focused on modification of behaviors that increase the risk for bleeding and on the early recognition of recurrent bleeding.

A new approach to esophageal varices: endoscopic variceal ligation

Bleeding from esophageal varices is a devastating complication of portal hypertension and is associated with a high mortality rate. The management goals for this group of patients are to achieve hemostasis in the acute phase, reduce variceal size, reduce the potential of rebleeding and eliminate varices with a follow-up program. For the past two decades, the gold standard of treatment has been endoscopic sclerotherapy but at the expense of many complications, which often cause serious morbidity. Endoscopic variceal ligation was developed as an alternative to endoscopic sclerotherapy. The experience to date shows that the goals of therapy can be achieved with fewer complications than those associated with sclerotherapy.

Management of esophageal varices: a review of treatment options and the role of the gastroenterology nurse and associate

Esophageal variceal hemorrhage is an important complication of portal hypertension and represents a significant challenge to both the gastroenterologist and gastroenterology nurse and associate (GNA). No single modality has emerged as superior for all patients, and new medications and techniques have continued to be introduced. This article reviews the currently available modalities for treating esophageal variceal hemorrhage and discusses patient management issues and endoscopic techniques that GNAs are likely to be involved with.