MANAGEMENT OF ASCITES IN MALE ADULT PATIENTS WITH LIVER CIRRHOSIS
(Name of Student)
For the Degree of
(DEGREE)
(NAME OF SCHOOL)
ABSTRACT
Ascites, the most common liver cirrhosis complication, affected approximately 85% of liver cirrhosis patients in the United States in the last 10 years. The development of ascites signifies an important landmark in the disorder that is associated with a 50% mortality rate (Gines, Quintero, Arroyo, Teres et al, 1987). It also indicates a need for liver transplantation as a surgical treatment. In UK, the true incidence and prevalence of ascites may be unknown, but its mortality has rate has increased to 12.7/100000 from 6/100000 (Fisher, Hanson, Phillips et al 1993-2000).
The purpose of this research paper is to conduct trial case management on adult patients diagnosed with liver cirrhosis to help manage their ascites. Trial case management will consist of physical activities, diet, medication, and treatments that are believed to reduce fluid accumulation.
Respondents of this study will be 50 male patients who are between 40 to 60 years old. They will be divided into two groups: 25 of them will belong to the control group while the other 25 will be clustered as the intervention group. Weight, abdominal girth, and intake and output will be closely monitored within the 3-day duration and at significant periods of this study. A qualitative questionnaire will identify barriers, benefits, and suggestions that will be helpful for future studies.
OUTLINE
PREFACE
OBJECTIVES
CHAPTER 1: INTRODUCTION
- What is Liver Cirrhosis?
- What is Ascites?
- How is Case Management defined in the study?
SIGNIFICANCE OF THE STUDY
CHAPTER 3: LITERATURE REVIEW
- Ascites and Liver Cirrhosis incidence, prevalence, and morbidity rate
- Effects of case management components in the study (diet, exercise, medication, treatment) on ascites and liver cirrhosis
CHAPTER 3: METHODOLOGY
- Participants
- Methodology
- Statistical Analysis
CHAPTER 4: RESULTS
CHAPTER 5: DISCUSSION
- Benefits
- Limitations
CHAPTER 6: CONCLUSIONS
REFERENCES
APPENDIX A: QUALITATIVE QUESTIONNAIRE IDENTIFYING BARRIERS, BENEFITS, AND SUGGESTIONS THAT WILL BE HELPFUL FOR FUTURE STUDIES
APPENDIX B: FORM CONTAINING WEIGHT MEASUREMENT (TO BE TAKEN DAILY), ABDOMINAL GIRTH MEASUREMENT (TO BE MONITORED DAILY), INTAKE AND OUTPUT (TO BE MEASURED HOURLY)
OBJECTIVES
The purpose of this study is to identify the effects of short-term physical exercise, diet modification, medication administration and treatments on ascites of adult male patients with liver cirrhosis. The study will examine the significance of the interventions and identify them as either inhibiting or enhancing delivery of nursing care. Objectives guiding this proposal include the following:
INTRODUCTION
Cirrhosis is an irreversible liver condition in which scar tissues replace the original tissus of the liver (Wong, Liu, Blendis et al, 1999). Factors that predispose to liver cirrhosis included hepatitis B and C, excessive consumption of alcohol, and fatty liver disease. It is a progressive disorder that takes years to develop, yet when it becomes full blown it will eventually result to complete liver failure (Allard, Chau, Sandokji et al, 2001).
As liver cirrhosis becomes severe, the kidneys of affected adults will begin retaining water and salt in the body. Because of gravitational effects, the excess water and salt will first accumulate under the skin of legs, ankles, and buttocks. Pressing a fingertip firmly on any area concerned will result to an indentation that will persist for some time despite the release of pressure. The depression on the skin, called pitting edema, will worsen at the end of the day after prolonged standing, sitting, or lying. As more water and salt are retained, fluids will also build up in the abdominal cavity. This accumulation of water and salt that causes increased weight, abdominal discomfort, and abdominal swelling is called ascites.
SIGNIFICANCE OF THE STUDY
Ascites in patients with liver cirrhosis is associated with a 50% mortality rate two years from the time it was diagnosed (Gines, Quintero, Arroyo, Teres et al, 1987). Despite the effectiveness of liver transplantation, half of the patients die while waiting for their scheduled operation. Thus, it is necessary to do whatever means are deemed essential to manage ascites. This study will benefit patients with ascites and liver cirrhosis as it aims to identify more ways to prolong their life and increase their chances avoiding complications. These means hopefully will help them avoid lengthy hospital stays, reduce fluid accumulation in their body, and lessen their discomfort as much as possible. Lack of attention to and disregard for medication, treatment, physical exercise and diet will lead to delayed recovery, suffering, and morbidity.
LITERATURE REVIEW
In 1997, 40% of deaths from cirrhosis resulted from alcoholic liver disease (Kim, Bron, Terrault et al, 2002). A prospective study (Reynolds et al, 1960) found out that a period of alcohol abstinence in patients with high portal pressures help resolve ascites and increase responsiveness to treatment.
A typical American diet consists of 200 to 300 mmol of salt per day while a non salt diet (despite its name) contains 100 to 150 mmol of salt per day (Eisenmenger et al, 1950). Because sodium retention significantly leads to fluid retention, one of the interventions to be included in this study is to encourage a sodium-free diet. On average, ascitic patients can excrete less than 20 mmol of sodidum per day. A high-sodium diet will only further aggravate water and salt accumulation. While salt restriction has been proven adequate to control ascites in some patients, the human body is not designed to tolerate a diet containing sodium that is lower than 88 mmol in a day (Runyon, 1998). Potassium-containing substitutes are also not advisable because of their associated risk with hyperkalemia. As a solution, limiting fluid intake as well as intake of salty foods is advised.
As for medications, aldosterone-blocking diuretics are preferred. While loop diuretics are prescribed as reinforcements, using them alone is ineffective. Compliance with diuretic use and sodium restriction will be evaluated in this study by weighing the patient daily, monitoring hourly intake and output, and collecting urine round-the-clock for sodium measurement. Because rapid fluid loss is not well-tolerated by patients with severe edema, a half kilogram weight loss per day is the target (Runyon, 1997).
Because bed rest is associated with muscle atrophy, extended hospital stays and other complications, this study will also include physical exercise as part of its case management plan (Salo, Gines, Anibarro et al, 1995). As for medical and surgical treatments, one of the safest procedures that can be repeatedly done in short-term hospitalization and even on an outpatient basis is total paracentesis (Tito, Gines & Arroyo et al 1990). However, this should not be done
more than twice in a month. A need for more frequent paracentesis indicates noncompliance to low salt diet. Additionally, indwelling catheters are not advisable since they increase the risk of peritonitis. Colostomy bags for ascitic fluid collection is also discouraged.
As of today, liver transplantation remains as the most definitive treatment for patients with ascites. They also improve prognosis and chances of survival. Patients who developed ascites as a complication of their liver disease should be evaluated for possible liver transplantation.
Effective control of ascites ascites is important to manage cirrhosis. As the effects of diet modification, physical exercise, medication and treatments are focused on in this study, the author hopes to discover more therapeutic options that will greatly enhance survival of liver cirrhotic patients with ascites.
METHODOLOGY
Causal-comparative methodology will be used to establish the effects of medication administration, treatments, diet modification and sodium retention on the weight, abdominal circumference and fluid retention of the experimental group. Close monitoring of both experimental and control groups will be done within the entire duration of the study (3 days). Their weights will be measured daily, their urine will be collected round the clock, their responses to medical treatments will be observed 24/7, and their abdominal girth will be measured once a day. After three days, the measurements of the experimental group who were exposed to the case management will be compared to the control group who did not.
EXPECTED CONCLUSION
References
Allard J.P., Chau J., Sandokji K., et al (2001). Effects of ascites resolution after successful TIPS on nutrition in cirrhotic patients with refractory ascites. Am J Gastroenterol:96:2442-2447.
Bernardi M., Di Marco C., Trevisani F., et al, 1992 . The hemodynamic status of preascitic cirrhosis: an evaluation under steady-state conditions and after postural change. Hepatology 16:341-346.
Eisenmenger W.J., Blondheim S.H., Bongiovanni A.M., et al (1950). Electrolyte studies on patients with cirrhosis of the liver. J Clin Invest. 1950;29:1491-1499.
Kim W.R., Brown R.S., Terrault N.A., et al (2002). Burden of liver disease in the United States: Summary of a workshop. Hepatology;36:227-242.
Reynolds T.B., Geller H.M., Kuzma O.T., et al. Spontaneous decrease in portal pressure with clinical improvement in cirrhosis. N Engl J Med. 1960;263:734-739.
Salo J., Gines A., Anibarro L. et al (1995). Effect of upright posture and physical exercise on endogenous neurohumoral systems in cirrhotic patients with sodium retention and normal supine plasma renin, aldosterone, and norepinephrine levels. Hepatology 22479–487.487 [PubMed]
Tito L., Gines P., Arroyo V., et al (1990). Total paracentesis associated with intravenous albumin management of patients with cirrhosis and ascites. Gastroenterology 98:146-151.
Wong W., Liu P., Blendis L., et al (1999). Long-term renal sodium handling in patients with cirrhosis treated with transjugular intrahepatic portosystemic shunts for refractory ascites. Am J Med: 106:315-322.
