Assessment & Management of Hepatic Disorders Flashcards
How many lobes make up the liver?
Which one is larger?
What separates them?
Two lobes
Right is larger
Falciform ligament
How many different functions does the liver have?
Around 8 or so
What does the liver metabolize?
Carbs
Proteins
Fats
What does the liver store and filter?
The liver stores and filters blood.
What do the hepatocytes or liver cells make?
Bile
What form of glucose is stored in the liver?
What does the liver do when the glycogen is depleted?
Glycogen
Liver can convert protein and fat to glucose. This is called gluconeogenesis.
Which proteins are formed in the liver?
Plasma proteins.
Albumin is a big one for oncotic pressure.
But there are others:
globulin, prothrombin, fibrinogen, etc.
Which vitamins are stored in the liver?
B2, B6, B12
A, D, E, K, folic acid
What does bile contain that causes jaundice?
What does bile do to fat before it goes to intestines?
Bilirubin
Bile emulsifies the fat
What hormones does the liver have to do with?
Sex hormones
Aldosterone
Which enzyme stimulates gallbladder contraction, Oddi sphincter to open, and releases pancreatic juices all in order to secrete bile?
CCK-PZ
cholecystokin-pancroenzymin
What is ammonia converted to by the liver?
Urea
What are the liver serum enzyme labs we should pay attention to?
AST ALT GGT GGTP LDH
What other serum values should we look out for with the liver?
Ammonia Alkaline Phosphate Protein Bilirubin (urine as well tho) Creatinine & BUN
Other lab values?
Cholesterol Prothrombin time CBC WBC platelets
Why would they do a biopsy of the liver?
Cancer
What diagnostics could be done for the liver?
CT
MRI
EGD
TIPS or Transjugular intrahepatic portosystemic shunt (it helps relieve portal hypertension)
What side should we place the patient on if they are having hepatic pressure?
Their right side for hepatic issues.
What is Jaundice?
What substance is the cause of Jaundice?
Yellow/green colored body tissue & possible discoloration of the sclera or eyes. (could also be deep orange)
Bilirubin accumulation
Four types of Jaundice?
Hemolytic
Heptocellular
Intrahepatic obstruction
Hereditary hyperbilirubinemia
T/F
Immature kidneys cause jaundice in newborns.
False.
It is the immature LIVER that will cause this to occur in newborns.
Main cause of Hepatocellular Jaundice?
Damaged Liver cells cause Hepatocellular jaundice.
Hepatocellular Jaundice symptoms
How ill will they present?
What will their weight look like?
What will energy levels be like?
What will an infectious origin appear as?
Hepatocellular Jaundice:
They will present mild or severely ill.
Due to loss of appetite, they will appear thin.
They will be very tired and fatigued.
If infectious: headache, chills, and fever.
(Intrahepatic) Obstructive Jaundice Symptoms
UO appearance? Stool appearance?
GI symptoms?
Skin?
How to treat the jaundice?
Obstructive Jaundice:
UO orange-brown in color. Stool is clay colored.
GI will have impaired digestion; especially of fat.
Pruritus of the skin
Remove the stone
How can you help pruritus?
Warm bath or fan
Benadryl.. but pay attention to liver enzymes.
Topical meds are much better.
What is portal hypertension?
What does it contribute to?
High BP in veins that carry blood from intestines to liver
Ascites
Varices: rectal or esophageal. Up or down really.
Management of portal hypertension?
Not anti-hypertensives bc this is not a systemic problem.
Do re-routing with stents or correct underlying cause.
Ascites results from?
- The increased portal hypertension causing increased capillary pressure and and obstruction of venous blood.
- Aldosterone changes also increase retention of fluid.
- Albumin gets pulled into peritoneal cavity
How to monitor ascites?
Measure girth
Takes weight daily
Percuss and fluid shift checks
Monitor F&E
How to specifically treat ascites?
Diet
Meds
Activity
Procedure
Ascites Treatment:
Put them on a low sodium diet
Meds like Diuretics & salt poor albumin (they need to give them protein to improve oncotic pressure but not anymore salt)
Bedrest
Paracentesis, TIPS
What is a TIPS?
TIPS is an ascites procedure that can be done. Stands for transjugular intrahepatic portosystemic + shunt
Putting a stent in liver where the hepatic and portal veins connect in order to reroute the blood flow.
Placing the shunt decreases congestion.
What will ascites look like?
Striae (sort of like stretch marks)
Distended veins
Umbilical hernia from extra pressure
What are esophageal varices?
Essentially collateral circulation developing due to portal hypertension. Rupture and bleed easily.
Esophageal varices symptoms?
Esophageal varices symptoms:
Hematemesis (bleeding)
Melana (dark tarry stool)
Decrease BP – shock or vascular collapse can occur.
How to manage esophageal varices: give the explanation
Lavage?
Tamponade?
Shock complications?
Managing esophageal varices explanation:
Saline Lavage (taking fluids out or washing out something) or ice saline due to vasoconstriction
Balloon Tamponade to provide internal pressure
BUT the tissue is fragile so be aware of possible damage. Don’t leave in too long bc it can cause necrosis.
Shock can happen due to bleeding. Need to administer oxygen, IVF, and blood transfusions to return back to normal.
How to manage esophageal varices: give the explanation
Check VS
H&H
Cognitive status
Why might you check UO?
Maintain airway
Managing esophageal varices explanation:
Check Vitals for a good baseline especially since this involves someone possibly losing blood.
Check the H&H bc this lab is associated with blood loss
Alterations in cognition can indicate lack of perfusion to the cerebral areas.
UO is an indicator that the kidneys are at least being perfused.
Maintain the airway because with the tamponade, this is a balloon going down the esophagus. It can make breathing difficult for this with breathing patterns or anxiety. Can also make breathing hard if placed incorrectly.
You can reposition the patient, check the tubing, and GI suctioning if they need it.
How to manage esophageal varices: give explanation
Why might they give vasoconstricting medications?
Managing esophageal varices explanations:
Vasoconstriction meds help the varices constrict so that BP goes back up and control bleeding
Surgical methods for esophageal varices?
TIPS
Endoscopic sclerotherapy
Esophageal Band
Shunt
TIPS to reduce the portal hypertension that caused the varices in the first place
Endoscopic sclerotherapy will help stop bleeding by using a sclerosing agent.
Esophageal Banding cuts off blood flow.
Shunt is for drainage and decongesting
What is portal encephalopathy?
What dietary food group can make this worse?
Other problems that can occur?
Loss of neurological from liver not being able to remove ammonia and other toxins from the blood
Protein can make it worse.
all sorts of issues. Could have GI bleed or ascites
Neurological symptoms to look for with portal encephalopathy?
Confusion
Lethargic
LOC alterations
Management of Encephalopathy and Coma?
Assess?
Precautions?
Labs to monitor?
Assess neuro status
Seizure precautions
Monitor Ammonia and Potassium
F&E in general
Constructional Apraxia
A symptom of encephalopathy
Cannot copy or recreate something based off a model .
Unable to build a lego version of something
Asterexis meaning?
What is it a symptom of?
Cannot hold hand in dorsal flexion. It moves down.
A neuro symptom of Encephalopathy
Patient teaching of encephalopathy?
Don’t let them sign important papers
May need DPOA for legal issues.
Most common medication to get ammonia down?
Lactulose is used to get ammonia down. It is a laxative and can be used as one too. But overall, we want a bowel movement to excrete the ammonia.
Why would they use IV glucose to help with ammonia?
Dietary restrictions they can do? Supplements?
IV glucose can metabolize protein and therefore cut down on the increase of ammonia
Cut down on protein for diet. Talk to dietician. They will need some protein but not a lot usually. May need amino acid supplement
What ways can they remove more ammonia from the gut?
Suction
enemas
oral antibiotics
Considering that the body cannot clear the ammonia, can it clear medications?
No. Discontinue .. Sedatives Analgesics Tranquilizers. And do not give Tylenol or Acetaminophen
If we have to give pain meds - we need to really balance it.
Monitoring for stages of coma and encephalopathy
stage 1
stage 4
This is really a staging of 1 to 4.
1 being normal LOC
4 is being not responding to painful stimuli
Strickert said you don’t need to know individual stages all that much.
T/F
Cirrhosis is a typical reason why patients have liver issues
True.
Cirrhosis is mainly due to alcohol. It just means scarring of the liver.
Why do cirrhosis patients sometimes have nutritional deficiencies?
Alcoholic patients have nutrition deficiencies because alcohol is where they get their calories but there is no nutritional benefit from it
Why are patients with liver problems anemic a lot?
Most likely due to the bleeding and hemorrhaging from their diagnosis
What vitamins might they need?
Fat soluble vitamins
Especially vitamin B for cirrhosis or alcoholics
Should patients with encephalopathy or other liver issues be given carbs?
What size of meals do you give the patient?
Yes. This food group is actually a group they rely on for energy.
But make sure you check BG bc liver issues can affect pancreas.
Give small, frequent meals and snacks.
Why might a patient have to be on low sodium and fluid diet with liver issues?
Due to possible ascites.
Acquired (adaptive) Immunity results because of what?
Most common type?
Another type?
What cells are involved?
How long does it last?
Acquired immunity results due to a prior exposure to an antigen.
Common one is from a vaccination.
Exposure to certain disease like Measles.
T-cells and B-cells are involved.
Hard to say but you may have to get more shots and boosters.
What is Active Immunity?
When the immune system develops a defense on its own & lasts for life
Passive Immunity?
Example?
Temporary
Gamma globulin injection
Antibodies given to the baby from breastfeedig
Innate (natural) immunity
Examples?
Immunity tools present from birth. Surfactant in lungs Skin Mucous Membranes WBCs Cough reflex Stomach acid nasal hairs
These are not things that the immune system picked up and learned from as they got older. They were born with these.
Definition of Hepatitis?
Two MAJOR categories?
Seriousness?
Inflammation of the liver.
Viral: ABCDE
Toxic
Can be acute or chronic
What is toxic hepatitis caused by?
Inflammation is caused by something that has been ingested. Alcohol Chemicals Drugs Meds Supplements ((mushrooms even)
How soon is the onset of toxic hepatitis?
What can this lead to?
What treatment is needed?
It can go either way.
Within hours, days, months
Can lead to cirrhosis or liver failure
Liver transplant
Common symptoms of Toxic Hepatitis?
Labs to check?
Very similar to other liver issues.
Jaundice
Weight loss
Dark urine
Very similar labs.
Bilirubin
Liver enzymes
Meds that can cause toxic hepatitis?
Acetaminophen (tylenol)
Statins
Dilantin
Augmentin
Supplements that can cause toxic hepatitis?
Aloe Vera
Ephedra used for weight loss
Blach Cohosh for menopause
Chemicals that can cause toxic hepatitis?
Carbon Tetrachloride
Vinyl Chloride
Risk factors of toxic hepatitis?
Ingesting or working around something harmful
Already having liver issues like Cirrhosis, chronic hepatitis, or non-alcoholic fatty liver disease rt abdominal obesity
Aging
Viral Hepatitis symptoms?
Similar to the other liver issues
Jaundice Pruritus RQ pain Dark urine/clay stool Flu like symptoms
Labs done for viral hepatitis?
serum liver ALT, AST, ALP
serum bilirubin
Diagnostic Procedures for viral hepatitis?
Xray for hepatomegaly size, ascites, or spleen enlargment
Biopsy for possible infection or cancer
How is Hepatitis A transferred?
At risk people?
Fecal matter
- drinks/water/food
- sex
Travelers Sexual partners Caregivers Drug users Natural Disaster population Foreign/third world countries
How is Hep A treated?
Vaccine?
Any major complications?
Well it usually resolves by itself.
Really need to focus on prevention.
Yes there is a vaccination. Can even give it 2 weeks after exposure.
Gamma Globulin to boost passive immunity/recovery
No major complications
Types of Hepatitis transmission through blood/bodily fluids? 3
Other Hepatitis caused be fecal matter + raw shellfish + animals/zoonotic?
Hep B
Hep C
Hep D
Hep E : fecal matter + raw shellfish + animals/zoonotic
Hep B
Hep C
Hep D
likely causes?
Infants born to infected moms Sex Injection drug use Blood transfusions Healthcare workers bc of exposure Caregivers bc of exposure
Hep B
Hep C
Hep D
Treatment?
Chronic Hep B and Hep C treatment?
Supportive Treatment like comfort and nutrition fluids
Frequent monitoring for cirrhosis, liver cancer, and further disease
Antiviral drugs
Can antiviral meds cure hepatitis?
Sort of. They can cure certain strands but not each of them.
Which Hepatitis do you have to get before getting Hep D?
What is bad about Hep D?
Transplant?
Hep B and Hep D go together
High risk of progression
Transplant more likely due to progression.
Prevention of
Hep B
Hep C
Hep D?
Vaccines only for Hep B.
But by getting Hep B vaccine you protect yourself from Hep D.
No Hep C vaccine tho.
What type of immunity is Hep B vaccination?
What type is the Hep B immune Globulin?
Active immunity so long
Immune globulin is passive immunity. so short.
Can Hep E progress?
Where is it most common in world?
Is it clinically distinguishable?
Who is at risk?
Any treatment available?
Yes but rare.
Common is East & south asia
No, need to see specific antibodies in blood to know
Travelers are at risk. Avoid tap water
No treatment available that alters the course. But supportive therapy is there.
When will these patients be in the hospital for Hepatitis?
Care precautions?
Diet?
What type of side effects with interferon therapy?
Only be in hospital if they are acutely ill
Yes, contact precautions.
High carbs and calories
Low fat and protein
Small meals
Flu symptoms/side effects
What is Cirrhosis?
Can it be reversed?
Loss of function?
Scarring of the liver; fibrosis that is progressive
Damage is irreversible
Yes, loss of function. Alters blood fluid and impairs hepatocytes.
Cirrhosis risk factors
6
alcohol
Hep B, C, D
Steatohepatitis (fatty liver disease)
Drugs/Toxins
Chronic biliary cirrhosis (this just means the obstruction causes it)
Cardiac cirrhosis from right HF leading to necoris and fibrosis
Cirrhosis symptoms
similar to others
Similar to other liver stuff.
Jaundice
Pruritus
Weight loss
Confusion
GI bleed
Ascites
Edema
Asterexis
Spider angiomas or spider veins
Labs
serum enzymes increased
Bilrubin increased
Proteins increases
CBC decreases due to anemia
PT/INR due to decrease prothrombin
Ammonia increase
Serum creatinine increase due to rt kidney function
Meds that reduce ammonia?
Neomycin
Flagyl
What is nonalcoholic fatty liver disease?
Build up of fat in the liver that is not due to alcohol
What does a non-alcoholic fatty liver disease cause?
Increase in live enzymes
3 types of NAFLD
Nonalcoholic fatty liver
Nonalcoholic steatohepatitis
Nonalcoholic fatty liver associated cirrhosis disease
What happens in nonalcoholic fatty liver NAFLD?
In nonalcoholic fatty liver NAFLD:
liver has trouble breaking down fats so it accumulates
What happens in nonalcoholic steatohepatitis NAFLD?
In nonalcoholic steatohepatitis the fat causes inflammation
What happens in nonalcoholic fatty liver disease associated with cirrhosis?
With NAFLD with cirrhosis the inflammation causes scarring and then leads to liver failure
risk factors of NAFLD
metabolic syndrome
symptoms of NAFLD
What lab is best to check?
Mostly asymptomatic but
jaundice, anorexia, pruritus, and ascites can develop.
Check liver enzymes bc they will be elevated.
protein; albumin
ammonia levels
NAFLD treamtnet
no specific meds prevent progression weight loss and diet control vaccinations for hepaitis avoid toxins
Liver cancer is usually due to?
Hep B
Hep C
Cirrhosis
T/F Cancer generally starts in the liver
False. Cancer usually only travels to liver
risk factors for liver cancer
Cirrhosis
Hep B or C
Alcoholic liver disease
hemochromatosis ; can’t breakdown iron
Liver cancer symptoms
ache in RUQ weight loss jaundice ascites pruritus hepatomegaly
Best labs/diagnostics for liver cancer
Elevated AFP
Elevated CEA
Biopsy
Imaging
What to labs to monitor for liver cancer
blood transfusions
H&H
aPTT
PT/INR
Nonsurgical methods for live cancer treatment
radio-frequency or cryoablation
sclerosing agents
chemo
radiation
