End Stage Liver Failure: Lessons from the ER on Jaundice and Ascites

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Today I want to talk about a patient that I had towards the beginning one of my first weeks working in the emergency room , and we'll call him Bill . Bill was wheeled in in a wheelchair and he was yellow as the sun . He was extremely short of breath and he had an extremely large belly . He looked like he was pregnant with quintuplets .

It was a huge , huge belly on a very small man who was clearly very sick , very malnourished . Can we take a guess of what was going on with Bill ? He had jaundice , that's , the yellow skin , and the big belly . That is called ascites , and these are things that you see in patients with liver failure , and in his case he had end stage liver failure .

So we are going to break down today what causes the yellow skin really , what is jaundice and what's the patho behind it , what causes it and what is ascites ? What caused this man to have this giant pregnant looking belly and how do you treat it ? So first , before we can get into that , let's talk about the liver .

The liver does so much for us , but as it relates to jaundice and ascites , I'm just going to talk about two things . The first is it produces or synthesizes a very important protein called albumin . Albumin does a lot for us . It binds to drugs it binds to certain drugs in our body and it transports them , and it also binds to water .

And why is that important ? Well , because it prevents water from leaking out of our vessels , which is exactly what happens in ascites . Now let's talk about one other thing that the liver does for us in a long list . It breaks down bilirubin , and bilirubin is a pigment that's found in bile .

Bile helps us with digestion , and bilirubin is a pigment that's found in bile and really what it is . It's its broken down dead red blood cells , and one of the liver's functions is to get rid of it , to filter it out , and it goes through our digestive system .

But if our liver isn't functioning , if your liver is damaged or you're an end-stage liver failure , your liver is just scar tissue , it is not functioning . It's hard as a rock , it's going to get clogged and it's not going to perform these functions that it needs to . So if you're not breaking down bilirubin , where's it going to go , this yellow substance ?

It's going to leak out . It's going to leak out into the blood and it's going to get deposited into your skin and that is what causes this jaundice . And in this man's case it was an extreme case because he was an end-stage liver failure and there's really not much you can do to treat this . It's not an acute condition , it's chronic .

So really what he needed was a liver transplant . I don't know if he was at the point where he was going to get one . I don't know his story , but that is what causes the jaundice . All right , let's get into this ascites . What was causing this giant belly ?

Well , this is a condition called ascites and it's really just accumulation of fluid and it can happen anywhere . In this man's case and this liver failure , it happened in his belly . It's not just this lack of albumin . There's some portal hypertension going on with the portal vein . But for now we're just going to talk about albumin .

So if you're not producing albumin and water is not being retained in the liver and in the vessels , then where's it going to go ? It's going to leak out . So you might hear in nursing school something called third spacing and to be honest , in nursing school I understood that the fluid shifted and it went into this third space , but I didn't quite understand .

Well , wait a minute . What's the first space and what's the second space ? And then what's this third space Like ? What's the order ? So the first space is inside your vessels , your intravascular space , so inside your veins , your arteries , any vessel . That's your first space . The second space is your cell .

So the fluid would get pushed out of the vessel into the cell , your intracellular space , and then , when it doesn't have anywhere else to go after that and it's being kicked out , it's going to go into your third space . That's everywhere else . That's your interstitial space . That's between the blood vessels and the cells . So it just leaks .

And if you've got fluid and it's got no albumin to hang on to it , it's just going to leak out into your interstitial space and it's going to cause this giant belly . And what's the risk here ?

Well , let's see , you've got all of this fluid that's accumulating and it's lacking proteins to help you fight infection because you're malnourished , you don't have albumin and so you're at great risk for infection . And the more fluid accumulation you get in your belly it's gonna push up . If you think about it .

If your belly fills up , it's gonna push up into your diaphragm , which is gonna push up into your lungs and you're gonna be extremely uncomfortable and short of breath . That's what happened in this patient's case .

And then , when it gets pushed up even more , you're at great risk for that fluid to go into your lungs and to cause pulmonary edema , basically suffocating in your own body . So you wanna treat this . How do you treat it ? Well , in this man's case he had an extreme case .

He needed what's called a paracentesis , and what happens in a paracentesis is the provider takes a needle and inserts it into the abdomen and drains out all of this fluid . It's literally like sticking a needle inside of a water balloon and not popping it but just sucking it out , draining it out . Now there are other treatments you can do .

You can treat it with drugs , with diuretics . You've got ferrosamide , or Lasix is the brand name or spirulactone , basically a diuretic . It's going to take that fluid and you're just gonna pee it out . It's gonna go out of the body and into the potty , as our friend Nurse Mike says about diuretics . You can also treat it with a low sodium diet .

But in this man's case he was past any of those treatment options . He just needed a paracentesis . So that's where he went . Okay , so that's what was happening there and that's what was happening with the jaundice . You had increased bilirubin that was built up and up and up and gets deposited into the skin . Let's just talk real quick about lab values .

So there's gonna be some different lab values abnormal lab values , in end stage liver failure but let's talk about the ones that we discussed today . The first with albumin , you're going to have low albumin levels in end stage liver failure , cirrhosis , any sort of liver failure , acute or chronic , because your liver is not producing it .

Remember , if we don't have our friend Al albumin , that protein to transport the drugs throughout our body or to retain the water and to bind to water , then you are going to have this .

Third spacing , this ascites . You're also going to have increased bilirubin , as we discussed , because if your liver can't do its function of breaking down and filtering out that bilirubin , those dead red blood cells that have that yellow tint , then you're going to have increased bilirubin .

So if that comes up on an exam for you , I hope that you get it right and I hope that this helped to clarify ascites and jaundice and I hope you have an amazing day . Stay well and I will see you the next time . Bye-bye , thanks for tuning in to the Nursing Student Coach Podcast .