Chapter 48 Liver, Biliary Tract, and Pancreas Problems Part 1 Flashcards
What organs are closely positioned together and associated with digestive functions?
Liver, pancreas, and gallbladder
These organs work together in the digestive system.
What are some potential consequences of liver and pancreas problems?
Altered nutrient absorption and use, malnutrition, impaired elimination
These consequences can significantly affect overall health.
What symptoms may be present in patients with liver or pancreatic issues?
Pain, nausea, vomiting
These symptoms can indicate inflammation or other complications.
What is the focus of nursing care for patients with liver and pancreatic problems?
Helping the patient and caregiver manage symptoms and cope with diagnosis and prognosis
Supportive care is essential for quality of life.
What does health promotion for liver problems focus on?
Reducing risk through immunizations and avoiding substance use
Preventative measures can help maintain liver health.
What is hepatitis?
Inflammation of the liver
It can be caused by various factors including viral infections.
What is the most common cause of hepatitis?
Viral infections
Hepatitis viruses include A, B, C, D, and E.
What are some other causes of hepatitis besides viral infections?
- Alcohol
- Medications
- Chemicals
- Autoimmune diseases
- Metabolic problems
Hepatitis can arise from various non-viral factors.
What is the incubation period for Hepatitis A Virus (HAV)?
15-50 days (average 28 days)
HAV is primarily transmitted through the fecal-oral route.
How is Hepatitis A Virus (HAV) primarily transmitted?
Fecal-oral route
Transmission can occur through contaminated food, water, and shellfish.
What are common sources of infection for Hepatitis A?
- Contaminated food
- Milk
- Water
- Shellfish
- Crowded conditions (e.g., daycare, nursing homes)
- Infected food handlers
- Poor personal hygiene
- Poor sanitation
When is Hepatitis A most infectious?
Most infectious during 2 weeks before onset of symptoms
Infectious for 1-2 weeks after symptoms start.
What is the incubation period for Hepatitis B Virus (HBV)?
115-180 days (average 56-96 days)
HBV is transmitted through percutaneous or mucosal exposure.
What are the modes of transmission for Hepatitis B Virus (HBV)?
- Percutaneous (parenteral) exposure to blood
- Mucosal exposure to blood
- Sexual contact
- Perinatal transmission
What is the incubation period for Hepatitis C Virus (HCV)?
14-180 days (average 56 days)
HCV is transmitted through percutaneous or mucosal exposure.
What are the modes of transmission for Hepatitis C Virus (HCV)?
- Percutaneous exposure to blood
- Mucosal exposure to blood
- High-risk sexual contact
- Perinatal contact
What is the incubation period for Hepatitis D Virus (HDV)?
2-26 weeks
HBV must precede HDV infection.
What is the relationship between Hepatitis B Virus (HBV) and Hepatitis D Virus (HDV)?
HBV must precede HDV infection
Chronic carriers of HBV are always at risk for HDV.
What is the incubation period for Hepatitis E Virus (HEV)?
15-64 days (average 26-42 days)
HEV is transmitted through the fecal-oral route.
What are common sources of infection for Hepatitis E Virus (HEV)?
- Contaminated water
- Poor sanitation
- Blood and blood products
- Needles and syringes
Which viruses can also cause liver disease besides the main hepatitis viruses?
- Cytomegalovirus (CMV)
- Epstein-Barr virus (EBV)
- Herpesvirus
- Coxsackievirus
- Rubella virus
What type of virus is Hepatitis A Virus (HAV)?
Ribonucleic acid (RNA) virus
HAV is a self-limiting infection.
What are the risk factors for Hepatitis A transmission?
- Poor hygiene
- Improper food handling
- Homelessness
- Crowded situations
- Poor sanitary conditions
What is the primary symptom of Hepatitis A?
Mild flu-like illness and jaundice
In severe cases, it can cause acute liver failure.
Who is at increased risk for Hepatitis A infection?
- Drug users (IV and non-injection)
- Men who have sex with men (MSM)
- Persons traveling to developing countries
When is Hepatitis A virus present in feces relative to symptom onset?
1-2 weeks before onset of symptoms and at least 1 week after onset of illness
This means it can be carried by persons with undetectable infection.
How long can fecal excretion of Hepatitis A virus occur in infants?
For months
This can lead to transmission even after the initial infection.
What is the incubation period for hepatitis A virus (HAV)?
Typically 2 to 6 weeks
The period between exposure to the virus and the onset of symptoms.
What does jaundice indicate in hepatitis?
A symptom often associated with liver dysfunction.
What is the significance of T ALT in hepatitis diagnosis?
Alanine aminotransferase (ALT) levels indicate liver inflammation.
What does the presence of Anti-HAV IgM indicate?
Acute hepatitis A infection.
What does the presence of Anti-HAV IgG indicate?
Past infection or immunity to hepatitis A.
Which population has a higher incidence of hepatitis B?
Asian Americans and Pacific Islanders.
Which population has a higher incidence of hepatitis C?
Blacks.
What is the primary cancer associated with hepatitis B?
Liver cancer.
Which group has the highest incidence of gallbladder disease?
Whites and Native Americans.
What does the presence of HAV IgM indicate during the acute phase?
Active hepatitis A infection.
What is the best way to prevent hepatitis A outbreaks?
HAV vaccination and thorough hand washing.
What does HBsAg indicate in hepatitis B infection?
Active hepatitis B infection.
What is the global prevalence of hepatitis B virus (HBV)?
3.5% to 3.9%.
What are common modes of transmission for HBV?
- Perinatal transmission
- Percutaneous transmission
- Sexual transmission.
Who is at increased risk for HBV infection among men?
MSM (men who have sex with men) practicing unprotected anal intercourse.
What are common risk factors for hepatitis C virus (HCV) infection?
- IV drug use
- High-risk sexual behavior among MSM.
What type of virus is hepatitis C virus (HCV)?
A blood-borne RNA virus.
How is HCV primarily transmitted?
Percutaneously, often through sharing contaminated needles.
What is a key complication of chronic HBV infection?
Liver cancer and severe liver inflammation.
What does the presence of anti-HBs in the blood indicate?
Immunity from the HBV vaccine or past infection.
What is a common source of HBV infection in healthcare settings?
Accidental needle-stick injuries.
Fill in the blank: The presence of HBsAg in the serum for _______ indicates chronic HBV.
6 months or longer.
True or False: Hepatitis B virus can be transmitted through casual contact like hugging.
False.
What is the main mode of transmission for hepatitis E virus (HEV)?
Fecal-oral route
What are the acute symptoms of hepatitis?
Anorexia, lethargy, nausea, vomiting, skin rashes, diarrhea or constipation, malaise, fatigue, muscle pain, joint pain, RUQ tenderness
What is the incubation period for hepatitis E virus infection?
It varies, but HEV infection epidemics occur primarily in the tropics
What is the role of the immune response in viral hepatitis pathophysiology?
Hepatocytes become targets of the virus through direct action or cell-mediated immune response
What is a significant risk factor for chronic hepatitis C virus (HCV) infection?
Immunosuppressed individuals, such as liver transplant recipients and HIV positive persons
What percentage of people in the United States infected with HCV are estimated to be undiagnosed?
Greater than 50%
What complications can arise from chronic viral hepatitis?
Fibrosis, cirrhosis, liver failure, primary liver cancer
What is the significance of a positive anti-HCV test?
It indicates a past infection, followed by a viral load test to confirm active infection
True or False: There is a vaccine available for hepatitis C virus (HCV).
False
What is the relationship between hepatitis B virus (HBV) and hepatitis D virus (HDV)?
HDV requires HBV to infect hepatocytes and cannot survive on its own
What is the primary method of transmission for hepatitis D virus?
Similar to HBV transmission
What can happen to the liver after acute hepatitis resolves without complications?
Liver cells can regenerate and resume normal appearance and function
Fill in the blank: Chronic viral hepatitis can be _______ and silent, causing persistent destruction of infected hepatocytes.
insidious
What systemic effects may occur during the early phases of hepatitis infection?
Rash, angioedema, arthritis, fever, malaise, cryoglobulinemia, glomerulonephritis, vasculitis
What is the typical duration of the acute phase of viral hepatitis?
1 to 6 months
What is the common reason for liver transplantation in the United States?
HCV hepatitis
What is the impact of co-infection with HIV and HCV?
Increased risk for progression to cirrhosis if HCV is untreated
What are the antibodies tested in the context of hepatitis B infection?
Anti-HBs IgG, Anti-HBc IgM, Anti-HBc IgG, HBeAg, Anti-HBe
What is a potential outcome of severe acute hepatitis?
Liver failure or death
What is the primary focus of current efforts regarding chronic HCV?
Prevent transmission, screening, and provide necessary healthcare
What is hepatomegaly?
Hepatomegaly is the enlargement of the liver.
What are common physical assessment findings in hepatitis?
Common findings include hepatomegaly, lymphadenopathy, abdominal tenderness, and sometimes splenomegaly.
What is the acute phase of hepatitis?
The acute phase is the period of maximal infectivity.
What does jaundice indicate?
Jaundice indicates a change in normal bilirubin metabolism or disruption of the flow of bile.
What can cause darker urine in hepatitis?
Darker urine can occur due to the kidneys excreting excess bilirubin.
What color are stools if conjugated bilirubin cannot pass into the intestines?
Stools will be clay-colored.
List some manifestations of acute hepatitis.
- Anorexia
- Clay-colored stools
- Dark urine
- Diarrhea, constipation
- Fatigue, lethargy, malaise
- Flu-like symptoms
- Jaundice
- Hepatomegaly
- Nausea, vomiting
- RUQ tenderness
What is asterixis?
Asterixis, also known as ‘liver flap’, is a tremor of the hand when the wrist is extended.
What is pruritus?
Pruritus is intense generalized itching that can accompany jaundice.
What characterizes the convalescent phase of hepatitis?
The convalescent phase can last weeks to months, with malaise and fatigue.
What is the mortality rate for acute hepatitis?
The overall mortality rate for acute hepatitis is less than 1%.
What complications can arise from acute hepatitis?
- Chronic hepatitis
- Cirrhosis
- Portal hypertension
- Liver cancer
- Acute liver failure
What is chronic hepatitis?
Chronic hepatitis is a long-lasting inflammation of the liver.
What percentage of people with chronic HBV may develop cirrhosis or liver cancer?
15% to 40% of people with chronic HBV may develop cirrhosis or liver cancer.
Which type of hepatitis is more likely to become chronic, HBV or HCV?
HCV infection is more likely than HBV to become chronic.
Define hemolytic jaundice.
Hemolytic jaundice is caused by increased breakdown of RBCs, producing increased unconjugated bilirubin in blood.
What causes hepatocellular jaundice?
Hepatocellular jaundice results from the liver’s altered ability to take up or excrete bilirubin.
What is obstructive jaundice?
Obstructive jaundice results from decreased or obstructed flow of bile through the liver or biliary duct system.
What are the common causes of obstructive jaundice?
- Common bile duct obstruction from stones
- Biliary strictures
- Pancreatic cancer
- Sclerosing cholangitis
What does elevated serum bilirubin indicate?
Elevated serum bilirubin indicates severe disease.
True or False: Most patients with acute viral hepatitis recover completely.
True
What is the test for Hepatitis A (HAV) acute infection?
HAV immunoglobulin M (IgM)
Indicates recent infection with HAV
What does HAV immunoglobulin G (IgG) indicate?
Previous infection or immunization
Indicates immunity to HAV
What is the significance of HBsAg in Hepatitis B (HBV)?
Marker of infectivity
Present in acute or chronic infection
What does Anti-HBs signify in HBV infection?
Indicates previous infection with HBV or immunization
Indicates immunity to HBV
What does HBeAg indicate in chronic HBV?
Indicates high infectivity
Used to determine clinical management
What is the purpose of HBV genotyping?
Indicates the genotype of HBV
Helps in determining treatment approach
What does Anti-HCV test for?
Marker for acute or chronic infection with HCV
Indicates exposure to HCV
What does HCV RNA quantitation indicate?
Active ongoing viral replication
Best indicator of treatment effectiveness
True or False: Anti-HEV IgM indicates active infection with Hepatitis E.
True
Indicates recent or acute infection
What is ascites?
Accumulation of excess fluid in the peritoneal cavity
Common manifestation of cirrhosis
What causes ascites in hepatitis patients?
Reduced protein levels in the blood
Leads to decreased plasma oncotic pressure
What is the screening test for HCV infection?
HCV antibody testing
Antibodies can be detected within 4 weeks of infection
What does a prolonged prothrombin time indicate in acute hepatitis?
Liver cell injury
Indicates impaired liver function
What abnormal finding is associated with alkaline phosphatase in acute hepatitis?
Moderately elevated
Indicates impaired excretory function of liver
What is the significance of total bilirubin levels in acute hepatitis?
Increased to about 8-15 mg/dL
Indicates liver cell injury and conjugated hyperbilirubinemia
Fill in the blank: HCV RNA testing assesses for chronic _______.
HCV infection
Follows positive antibody test
What skin manifestations may occur in advanced liver disease?
Spider angiomas, palmar erythema, gynecomastia
Common in patients with liver dysfunction
What are potential complications of hepatic encephalopathy?
Neurologic, psychiatric, and motor disturbances
Results from the liver’s inability to remove toxins
What is the purpose of HCV RNA testing?
To confirm chronic infection and assess recent HCV infection.
HCV RNA testing is particularly important for immunocompromised patients who may not develop detectable antibody levels.
How many genotypes does HBV have?
At least 8 different genotypes (A to H).
HBV genotype may predict disease course and treatment outcomes.
What is the most common HCV genotype in the United States?
HCV genotype 1 causes 70% of HCV infections.
What is the role of a liver biopsy in hepatitis diagnosis?
Allows for histologic examination of liver cells and determination of inflammation, fibrosis, or cirrhosis.
A liver biopsy may not be performed on patients with bleeding disorders due to the risk of bleeding.
What is one noninvasive method to assess liver fibrosis?
Ultrasound elastography (e.g., FibroScan).
Magnetic resonance elastography (MRE) is another technique for measuring liver fibrosis.
What is emphasized in the management of acute viral hepatitis?
Adequate nutrition and rest to help the liver regenerate and repair.
What type of specialists may be involved in the care of patients with chronic viral hepatitis?
Liver specialists, infectious disease specialists, pharmacists, dietitians, and mental health or substance use specialists.
What are the key components of the diagnostic assessment for viral hepatitis?
- History and physical assessment
- Liver function tests
- PT time and INR
- Hepatitis testing (HAV, HBV, HCV, HDV, HEV)
- FibroScan
- FibroSure (FibroTest)
What is the main goal of drug therapy for chronic HBV?
To decrease viral load and liver enzymes, slowing disease progression.
What do nucleoside and nucleotide analogs do?
Inhibit viral DNA replication by mimicking normal DNA building blocks.
Name two nucleoside analogs used to treat chronic HBV.
- Lamivudine (Epivir)
- Adefovir (Hepsera)
True or False: There is a specific treatment for acute viral hepatitis.
False.
Most patients with acute viral hepatitis are managed at home.
Fill in the blank: One supportive drug therapy for chronic hepatitis may include _______.
Antihistamines for generalized itching.
What is the purpose of HBV core Ab (HBVcAb) IgG testing?
To determine if the patient has a history of recovered HBV infection.
What does HCV genotyping determine?
The choice and duration of therapy for HCV treatment.
What is FibroSure (FibroTest)?
A biomarker that assesses the extent of hepatic fibrosis using serum test results.
What are the drug classes used for treating Viral HBV?
- Immune modulator
- Nucleoside and nucleotide analogs
Name two examples of nucleoside and nucleotide analogs used for HBV.
- adefovir
- entecavir (Baraclude)
What is the mechanism of action of pegylated interferon?
Has antiviral, antiproliferative, immune-regulating actions
What chronic condition is treated with adefovir?
Chronic HBV
What is the role of NS3/4A protease inhibitors in HCV treatment?
Blocks viral protease enzyme. Prevents viral replication in genotype 1 HCV
List two examples of NS5A inhibitors.
- elbasvir
- ledipasvir
What are combination therapies in HCV treatment?
- elbasvir + grazoprevir (Zepatier)
- ledipasvir + sofosbuvir (Harvoni)
- pibrentasvir + glecaprevir (Mavyret)
- velpatasvir + sofosbuvir (Epclusa)
- velpatasvir + sofosbuvir + voxilaprevir (Vosevi)
True or False: Interferon therapy can have flu-like side effects.
True
What is the treatment duration for most patients receiving DAA therapy for HCV?
12 weeks
What is the goal of drug therapy for chronic HCV?
Eradicating the virus and preventing HCV-related complications
Fill in the blank: Patients with advanced fibrosis or cirrhosis can receive drug therapy if liver _______ is not present.
[decompensation]
What nutritional considerations are important during acute viral hepatitis?
Adequate calories are important because the patient usually loses weight
What vitamin supplements may be given to patients with viral hepatitis?
- B-complex
- Vitamin K
How often should patients receiving interferon have blood counts and liver function tests?
Every 4 to 6 weeks
What is a common side effect of interferon therapy that needs monitoring?
Depression
What is the significance of monitoring liver enzymes after stopping HBV treatment?
Severe exacerbations can develop after ending treatment
What is the preferred treatment for patients with stable HIV and intact immune systems who also have HCV?
HCV treatment with the goal of eradicating HCV and reducing the risk for progression to cirrhosis
True or False: There is a special diet for the treatment of viral hepatitis.
False
What are important health history factors to consider in hepatitis assessment?
Hermophilia, cancer, exposure to infected persons, ingestion of contaminated food or water, exposure to hepatotoxic agents, crowded living conditions, exposure to contaminated needles, recent travel, organ transplant, new drug regimens, hemodialysis, blood transfusions before 1992, HIV status.
Include specific exposures and health conditions that increase risk for hepatitis.
What medications should be assessed in patients with hepatitis?
Use and misuse of acetaminophen, new medications or supplements.
Important due to potential liver toxicity.
What subjective data should be gathered regarding health perception and management in hepatitis patients?
IV drug use, chronic alcohol use, malaise, distaste for cigarettes, high-risk sexual behaviors.
Behavioral factors that may contribute to hepatitis.
What are some nutritional-metabolic symptoms associated with hepatitis?
Weight loss, anorexia, nausea, vomiting, feeling of RUQ fullness.
Symptoms indicating liver dysfunction.
What elimination symptoms might indicate hepatitis?
Dark urine, light-colored stools, constipation or diarrhea, skin rashes, hives.
These symptoms reflect biliary obstruction or liver dysfunction.
What cognitive-perceptual symptoms are common in hepatitis?
RUQ pain, liver tenderness, headache, itching.
Indicative of inflammation or liver dysfunction.
What general objective findings may be present in a hepatitis patient?
Low-grade fever, lethargy, lymphadenopathy.
Non-specific signs of infection or systemic illness.
What are some possible diagnostic findings in hepatitis?
Liver enzyme levels, serum total bilirubin, hypoalbuminemia, anemia, bilirubin in urine, prolonged PT time, positive hepatitis tests, abnormal liver scan, abnormal liver biopsy results.
Diagnostic tests to confirm hepatitis and assess liver function.
What clinical problems may arise for patients with viral hepatitis?
Nutritionally compromised, activity intolerance, risk for bleeding.
Potential complications that require nursing interventions.
What are the overall goals for a patient with viral hepatitis?
Relief of discomfort, resuming normal activities, return to normal liver function without complications.
Goals to guide nursing care and intervention.
What are some preventive measures for hepatitis A?
Personal and environmental hygiene, health education, hand washing, use of PPE when contamination is likely.
Essential practices to prevent transmission.
Who should receive the hepatitis A vaccine?
Children at 1 year, adults at risk including travelers, MSM, IV drug users, persons with clotting factor disorders, chronic liver disease.
Target populations for vaccination to prevent hepatitis A.
What is the composition of the HAV vaccine?
Inactivated HAV protein, available as Havrix and Vaqta.
Types of vaccines used for hepatitis A prevention.
What is the recommended schedule for HAV vaccination?
Primary immunization consists of 1 dose IM, with a booster recommended 6 to 12 months later.
Schedule to ensure long-term immunity.
What are the side effects of the HAV vaccine?
Mild soreness and redness at the injection site.
Common reactions to vaccination.
What is Twinrix?
A combined HAV and HBV vaccine for people over 18, consisting of 3 doses on a 0-, 1-, and 6-month schedule.
Vaccine option for high-risk populations.
What is the purpose of immune globulin (IG) in hepatitis A prevention?
Provides temporary passive immunity after exposure, effective for 1 to 2 months.
Used in postexposure prophylaxis.
What are general measures for the prevention of Hepatitis A?
- Hand washing
- Proper personal hygiene
- Environmental sanitation
- Control and screening of food handlers
- Serologic screening for carriers
- Active immunization: HAV vaccine
These measures help reduce the risk of Hepatitis A transmission.
What is the recommended timing for administering immune globulin after exposure to Hepatitis A?
1-2 weeks after exposure
Early administration is crucial for effective prophylaxis.
What special considerations should health care personnel take regarding Hepatitis A?
Health care personnel should follow standard precautions and be aware of infection risks related to Hepatitis A.
What are the two main transmission routes for Hepatitis B and C?
- Percutaneous transmission
- Sexual transmission
Understanding these routes is vital for implementing prevention strategies.
What screening tests are used for Hepatitis B and C?
- HBV: HBsAg
- HCV: Anti-HCV
These tests help identify infected individuals.
What are general preventive measures for Hepatitis B?
- Hand washing
- Avoid sharing toothbrushes and razors
- HBIG administration for exposure
- Active immunization: HBV vaccine
These measures are essential to prevent the spread of Hepatitis B.
What is the HBV vaccine schedule?
0-, 1-, and 6-month schedule
The vaccine is highly effective in preventing Hepatitis B infection.
What is the effectiveness of the HBV vaccine?
95% effective
This high efficacy underscores the importance of vaccination.
What is the newer formulation of the HBV vaccine called?
Heplisav-B
It is approved for individuals 18 years or older and is given in 2 doses.
What is recommended for infants born to mothers positive for HBsAg?
HBIG administration and HBV vaccination
This approach helps protect newborns from potential infection.
What precautions should be taken for postexposure prophylaxis for Hepatitis B?
HBV vaccine series and HBIG
This combination provides both active and passive immunity.
What is the primary prevention strategy for Hepatitis C?
Identify high-risk individuals and teach risk reduction
No vaccine is currently available for Hepatitis C.
What are key measures to prevent Hepatitis C transmission?
- Screening of blood, organ, and tissue donors
- Using infection control precautions
- Modifying high-risk behavior
These measures aim to reduce the incidence of Hepatitis C.
What are general measures for the prevention of Hepatitis A?
- Hand washing
- Proper personal hygiene
- Environmental sanitation
- Control and screening of food handlers
- Serologic screening for carriers
- Active immunization: HAV vaccine
These measures help reduce the risk of Hepatitis A transmission.
What is the recommended timing for administering immune globulin after exposure to Hepatitis A?
1-2 weeks after exposure
Early administration is crucial for effective prophylaxis.
What special considerations should health care personnel take regarding Hepatitis A?
Health care personnel should follow standard precautions and be aware of infection risks related to Hepatitis A.
What are the two main transmission routes for Hepatitis B and C?
- Percutaneous transmission
- Sexual transmission
Understanding these routes is vital for implementing prevention strategies.
What screening tests are used for Hepatitis B and C?
- HBV: HBsAg
- HCV: Anti-HCV
These tests help identify infected individuals.
What are general preventive measures for Hepatitis B?
- Hand washing
- Avoid sharing toothbrushes and razors
- HBIG administration for exposure
- Active immunization: HBV vaccine
These measures are essential to prevent the spread of Hepatitis B.
What is the HBV vaccine schedule?
0-, 1-, and 6-month schedule
The vaccine is highly effective in preventing Hepatitis B infection.
What is the effectiveness of the HBV vaccine?
95% effective
This high efficacy underscores the importance of vaccination.
What is the newer formulation of the HBV vaccine called?
Heplisav-B
It is approved for individuals 18 years or older and is given in 2 doses.
What is recommended for infants born to mothers positive for HBsAg?
HBIG administration and HBV vaccination
This approach helps protect newborns from potential infection.
What precautions should be taken for postexposure prophylaxis for Hepatitis B?
HBV vaccine series and HBIG
This combination provides both active and passive immunity.
What is the primary prevention strategy for Hepatitis C?
Identify high-risk individuals and teach risk reduction
No vaccine is currently available for Hepatitis C.
What are key measures to prevent Hepatitis C transmission?
- Screening of blood, organ, and tissue donors
- Using infection control precautions
- Modifying high-risk behavior
These measures aim to reduce the incidence of Hepatitis C.
What is the best way to reduce HBV infection?
Identify those at risk, screen them for HBV, and vaccinate those who are not infected.
List general measures for the prevention of Hepatitis A.
- Hand washing
- Proper personal hygiene
- Environmental sanitation
- Control and screening of food handlers
- Serologic screening for virus carriers
- Active immunization: HAV vaccine
What should patients at high risk for contracting HBV be taught?
To follow good hygienic practices, including hand washing and using gloves when expecting contact with blood.
What personal items should patients not share to prevent HBV transmission?
- Razors
- Toothbrushes
- Other personal items
What is the recommended vaccination schedule for the HBV vaccine?
A series of 3 IM injections in the deltoid muscle on a 0-, 1-, and 6-month schedule.
What is the effectiveness rate of the HBV vaccine?
95% effective.
True or False: The HBV vaccine can be given during pregnancy.
True.
What is the newer formulation of the HBV vaccine called?
Heplisav-B.
What is the dosage schedule for Heplisav-B?
2 doses, spaced 4 weeks apart.
What is recommended for household members of a patient with HBV?
They should be tested and vaccinated if they are HBsAg and antibody negative.
What is the role of HBIG in postexposure prophylaxis?
HBIG has antibodies to HBV and confers temporary passive immunity.
When should HBIG ideally be administered after exposure?
Within 24 hours of exposure.
What are some measures to prevent HCV transmission?
- Screening of blood, organ, and tissue donors
- Using infection control precautions
- Modifying high-risk behavior
What is the recommended action for acute exposure to a sexual partner of an HBsAg-positive person?
Administer HBIG to the sexual partner.
Fill in the blank: The traditional HBV vaccine of 3 doses is normally given in _______.
[childhood]
What should be done for infants born to mothers positive for HBsAg?
They should receive HBIG and vaccination.
What is the purpose of using disposable needles and syringes in healthcare settings?
To reduce the risk of HBV transmission.
What is the main goal of the CDC recommendations for patients with HBV?
Follow standard precautions to prevent HBV transmission.
True or False: There is currently a vaccine available for Hepatitis C.
False.
What is the primary recommendation for HCV testing in patients with known risk factors?
Testing for patients with known risk factors for HCV is recommended.
What does RDT stand for in the context of HCV testing?
Rapid Diagnostic Tests
What is a major risk factor for hepatitis C virus (HCV)?
IV drug use
Why is early diagnosis of HCV important?
For best patient outcomes and preventing transmission to others.
What are the US current screening guidelines for HCV testing for individuals 18 years and older?
One-time opt-out HCV testing is recommended.
What is recommended for IV drug users regarding HCV screening?
Annual HCV screening.
Where is jaundice typically first observed in light-skinned individuals?
In the sclera of the eyes.
In dark-skinned individuals, where is jaundice usually seen first?
In the hard palate of the mouth and inner canthus of the eyes.
What may cause the urine to have a dark-brown or brownish-red color in hepatitis patients?
Bilirubin excretion from the kidneys.
What comfort measures can help relieve symptoms in hepatitis patients?
Relieve itching, headache, and joint pain.
What dietary approach may help a patient with hepatitis who has anorexia?
Small, frequent meals may be preferable.
What is the recommended fluid intake for patients with hepatitis?
2500 to 3000 mL/day.
What is critical for promoting hepatocyte regeneration in hepatitis patients?
Rest.
What should be assessed to ensure a patient is coping with their care plan?
The patient’s response to the rest and activity plan.
What are some complications to assess for in hepatitis patients?
- Bleeding tendencies
- Encephalopathy
- Bloody or tarry stools
- Vomiting of blood
- High liver enzymes
After a diagnosis of hepatitis, how long should patients have regular follow-ups?
At least 1 year.
What should all patients with chronic HBV or HCV avoid?
Alcohol.
What is a potential consequence of excessive alcohol use on the liver?
Injury and necrosis of liver tissue.
What can occur after decades of excessive alcohol use?
Advanced fibrosis and cirrhosis.
Fill in the blank: The presence of jaundice is usually seen first in the ______ for light-skinned persons.
sclera of the eyes
True or False: Anorexia in hepatitis patients is often more manageable in the evening.
False
What is the primary recommendation for HCV testing in patients with known risk factors?
Testing for patients with known risk factors for HCV is recommended.
What does RDT stand for in the context of HCV testing?
Rapid Diagnostic Tests
What is a major risk factor for hepatitis C virus (HCV)?
IV drug use
Why is early diagnosis of HCV important?
For best patient outcomes and preventing transmission to others.
What are the US current screening guidelines for HCV testing for individuals 18 years and older?
One-time opt-out HCV testing is recommended.
What is recommended for IV drug users regarding HCV screening?
Annual HCV screening.
Where is jaundice typically first observed in light-skinned individuals?
In the sclera of the eyes.
In dark-skinned individuals, where is jaundice usually seen first?
In the hard palate of the mouth and inner canthus of the eyes.
What may cause the urine to have a dark-brown or brownish-red color in hepatitis patients?
Bilirubin excretion from the kidneys.
What comfort measures can help relieve symptoms in hepatitis patients?
Relieve itching, headache, and joint pain.
What dietary approach may help a patient with hepatitis who has anorexia?
Small, frequent meals may be preferable.
What is the recommended fluid intake for patients with hepatitis?
2500 to 3000 mL/day.
What is critical for promoting hepatocyte regeneration in hepatitis patients?
Rest.
What should be assessed to ensure a patient is coping with their care plan?
The patient’s response to the rest and activity plan.
What are some complications to assess for in hepatitis patients?
- Bleeding tendencies
- Encephalopathy
- Bloody or tarry stools
- Vomiting of blood
- High liver enzymes
After a diagnosis of hepatitis, how long should patients have regular follow-ups?
At least 1 year.
What should all patients with chronic HBV or HCV avoid?
Alcohol.
What is a potential consequence of excessive alcohol use on the liver?
Injury and necrosis of liver tissue.
What can occur after decades of excessive alcohol use?
Advanced fibrosis and cirrhosis.
Fill in the blank: The presence of jaundice is usually seen first in the ______ for light-skinned persons.
sclera of the eyes
True or False: Anorexia in hepatitis patients is often more manageable in the evening.
False
What is acute alcoholic hepatitis characterized by?
Hepatomegaly, jaundice, increased liver enzymes (AST, ALT, alkaline phosphate), low-grade fever
Ascites and prolonged PT time are possible. These manifestations may improve if alcohol intake ceases.
What can result from abstaining from alcohol in patients with end-stage cirrhosis?
Significant reversal in some patients
If liver function does not recover after abstaining from alcohol for 6 months or longer, liver transplantation may be an option.
What is chemical hepatotoxicity?
Liver injury caused by exposure to certain compounds (e.g., carbon tetrachloride, gold compounds)
Some agents can cause hepatotoxicity, cholestasis, necrosis, or liver cancer.
What is the main cause of drug-induced liver injury (DILI)?
Antimicrobial agents, especially amoxicillin-clavulanate
The most common cause of acute liver failure is acetaminophen.
What is Wilson disease?
An autosomal recessive disorder involving cellular copper transport
A defect in biliary excretion leads to copper accumulation in the liver.
What are the hallmark signs of Wilson disease?
Corneal Kayser-Fleischer rings, low serum ceruloplasmin levels, and elevated copper concentrations from liver biopsy
First-degree relatives of patients with Wilson disease need to be screened.
What are the first-line treatments for symptomatic patients with Wilson disease?
Chelating agents such as D-penicillamine or trientine
Zinc acetate (Galzin) is another therapy that interferes with copper absorption.
What is hemochromatosis?
A condition in which excess iron accumulates in the body
Mainly caused by a genetic defect (hereditary hemochromatosis).
What is autoimmune hepatitis?
A chronic inflammatory liver disorder where the immune system attacks the liver
Characterized by autoantibodies and high levels of serum immunoglobulins.
What laboratory tests are useful in diagnosing autoimmune hepatitis?
Antinuclear antibody (ANA), anti-smooth muscle antibody (ASMA), and antimitochondrial antibody (AMA) testing
A liver biopsy can confirm the diagnosis.
What is primary biliary cholangitis (PBC)?
A chronic disease of the small bile ducts of the liver characterized by T cell-mediated attack
This leads to loss of bile ducts and cholestasis.
What are common laboratory findings in primary biliary cholangitis?
High serum alkaline phosphatase, AMA, ANA, and serum lipid levels
Most patients diagnosed with PBC are middle-aged women.
What are the goals of treatment for primary biliary cholangitis?
Suppressing ongoing liver damage, preventing complications, and symptom management
True or False: Acetaminophen is safe when taken at recommended levels.
True
Fill in the blank: The most common cause of acute liver failure is _______.
acetaminophen
What should be done if drugs are identified as the cause of liver injury?
All drugs identified as the cause of liver injury should be stopped
What drugs are used for Primary Biliary Cholangitis (PBC)?
Ursodiol and obeticholic acid (Ocaliva)
These drugs decrease bile in the liver.
What are the main care focuses for patients with PBC?
- Preventing malabsorption
- Managing hyperlipidemia
- Addressing vitamin deficiencies
- Treating anemia
- Managing fatigue
- Treating skin disorders like itching and xanthomas
- Monitoring for progression to cirrhosis
Cholestyramine is used to treat itching.
What is Primary Sclerosing Cholangitis (PSC)?
A condition characterized by chronic inflammation, fibrosis, and narrowing of the medium and large bile ducts inside and outside the liver
The cause of PSC is unknown.
What are common complications associated with PSC?
- Cholangitis
- Cholestasis with jaundice
- Bile duct cancer
- Cirrhosis
Most patients with PSC also have ulcerative colitis or, less often, Crohn’s disease.
What is the fundamental characteristic of Nonalcoholic Fatty Liver Disease (NAFLD)?
Accumulation of fatty infiltration in the hepatocytes
NAFLD occurs in individuals who do not consume excess alcohol.
What is the progression of Nonalcoholic Steatohepatitis (NASH)?
NASH can progress from fatty liver (steatosis) to cirrhosis, liver cancer, and liver failure
NASH occurs in 3% to 6% of the US population.
What are risk factors for NASH?
- Obesity
- Diabetes
- Hyperlipidemia
- Hypertension (or metabolic syndrome)
About 20% of patients with NASH progress to cirrhosis.
What tests are used to diagnose NAFLD?
- Elevated liver function tests (ALT, AST)
- Ultrasound
- CT scans
- Liver biopsy for definitive diagnosis
Liver function tests are often the first sign of NAFLD.
What is the primary goal of therapy for NAFLD?
Weight loss of at least 10% of body weight, if overweight or obese, and exercise
Bariatric surgery for morbidly obese persons can reduce the risk of NAFLD.
What is cirrhosis?
The end stage of liver disease characterized by extensive degeneration and destruction of liver cells
This results in fibrosis and regenerative nodules.
What are common causes of cirrhosis in the United States?
- Chronic HCV infection
- Nonalcoholic steatohepatitis (NASH)
- Alcohol-induced liver disease
Malnutrition can exacerbate alcohol-induced liver damage.
What is the role of chronic inflammation in cirrhosis development?
Chronic inflammation and cell necrosis from viral hepatitis can lead to progressive fibrosis and cirrhosis
Chronic hepatitis combined with alcohol use accelerates liver damage.
What is cardiac cirrhosis?
A spectrum of liver problems resulting from long-standing, severe right-sided heart failure
It causes hepatic venous congestion and fibrosis over time.
What are early manifestations of cirrhosis?
- Fatigue
- Enlarged liver
- Normal liver function tests (compensated cirrhosis)
Patients may be unaware of their liver condition in early stages.
What happens during the regenerative process of the liver in cirrhosis?
The regenerative process is disorganized, leading to abnormal blood vessel and bile duct architecture
This results in lobules of irregular size and shape and impeded blood flow.
What is liver fibrosis?
Liver fibrosis is the formation of excess fibrous connective tissue in the liver.
What are common symptoms associated with liver dysfunction?
- Pain
- Fever
- Nausea
- Vomiting
- Anorexia
- Fatigue
What hormonal changes can occur due to liver dysfunction?
- Increased androgens and estrogens
- Decreased hormone metabolism
What is gynecomastia?
Gynecomastia is the enlargement of breast tissue in males, often due to increased estrogen levels.
What is portal hypertension?
Portal hypertension is increased blood pressure in the portal venous system.
What is hyperbilirubinemia?
Hyperbilirubinemia is an excess of bilirubin in the blood, leading to jaundice.
What are the skin lesions associated with liver dysfunction?
- Spider angiomas
- Palmar erythema
What is ascites?
Ascites is the accumulation of fluid in the abdominal cavity, often due to liver failure.
What are some hematologic problems associated with liver dysfunction?
- Thrombocytopenia
- Leukopenia
- Anemia
True or False: Jaundice results from an increased ability to conjugate and excrete bilirubin.
False
What causes the increase in bilirubin in the vascular system?
Decreased ability to conjugate and excrete bilirubin due to liver damage.
Fill in the blank: The liver’s inability to metabolize steroid hormones can lead to _______.
[skin lesions]
What is the relationship between splenomegaly and hematologic problems?
Splenomegaly causes increased removal of blood cells from circulation, leading to hematologic issues.
What are the late manifestations of liver failure?
- Jaundice
- Peripheral edema
- Ascites
- Skin lesions
- Hematologic problems
- Endocrine problems
- Peripheral neuropathies
What are esophageal and gastric varices?
Varices are swollen veins in the esophagus and stomach that can result from portal hypertension.
What is hepatic encephalopathy?
Hepatic encephalopathy is a decline in brain function due to severe liver disease.
What is the outcome of advanced liver dysfunction?
The liver becomes small and nodular, with dramatically impaired function.
What causes dark urine in liver dysfunction?
Increased urobilinogen due to decreased bilirubin metabolism.
What is the effect of decreased vitamin K absorption?
Bleeding tendency due to impaired coagulation.
What is the significance of albumin levels in liver dysfunction?
Decreased albumin levels indicate impaired liver function and can lead to edema and ascites.
What is hepatic encephalopathy?
A neurologic condition resulting from liver dysfunction
What is asterixis?
A flapping tremor seen in hepatic encephalopathy
Name three integumentary manifestations of liver problems.
- Jaundice
- Spider angioma
- Palmar erythema
What is fetor hepaticus?
A musty or sweet odor of the breath in liver disease
List two gastrointestinal symptoms associated with liver issues.
- Anorexia
- Nausea
What are esophageal and gastric varices?
Enlarged veins in the esophagus and stomach due to portal hypertension
What hematologic condition is common in liver disease?
Anemia
What metabolic imbalances can occur in liver dysfunction?
- Hypokalemia
- Hyponatremia
- Hypoalbuminemia
What reproductive issue can arise due to liver problems in men?
Gynecomastia
True or False: Peripheral edema occurs only after ascites develops.
False
What is portal hypertension?
Increased pressure in the portal venous system due to liver obstruction
What are collateral circulation pathways?
Alternate blood flow routes developed to reduce pressure in portal hypertension
What is caput medusae?
A ring of varices around the umbilicus due to portal hypertension
What can happen if esophageal varices rupture?
Variceal hemorrhages, considered a medical emergency
What are the signs of peripheral edema?
Swelling in lower extremities and presacral area
What causes peripheral edema in liver disease?
Decreased colloidal oncotic pressure and increased portacaval pressure
What is the significance of splenomegaly in liver disease?
It is a sign of portal hypertension
What is the relationship between liver dysfunction and coagulation?
The liver’s inability to make prothrombin leads to coagulation disorders
What are the two types of cirrhosis?
- Compensated cirrhosis
- Decompensated cirrhosis
What is the risk associated with large esophageal varices?
Higher likelihood of bleeding
Fill in the blank: Peripheral neuropathy in alcoholic cirrhosis is likely due to a deficiency of _______.
thiamine, folic acid, and cobalamin
What is hematemesis?
Vomiting blood
What can happen to younger women with cirrhosis?
They may develop amenorrhea
What is the potential consequence of improper aldosterone metabolism in cirrhosis?
Hyperaldosteronism with sodium and water retention
What is ascites?
Accumulation of serous fluid in the peritoneal or abdominal cavity.
Ascites is a common manifestation of cirrhosis.
What is the first mechanism that leads to ascites formation?
Portal hypertension causing proteins to shift from blood vessels into lymph space.
This leads to leakage into the peritoneal cavity.
What happens when the lymphatic system cannot carry off excess proteins and water?
They leak into the peritoneal cavity.
The osmotic pressure of proteins pulls more fluid into the peritoneal cavity.
What is the second mechanism of ascites formation?
Hypoalbuminemia resulting from the liver’s decreased ability to synthesize albumin.
This results in decreased colloidal oncotic pressure.
What is the third mechanism of ascites formation?
Hyperaldosteronism due to the damaged hepatocytes metabolizing aldosterone.
Increased aldosterone leads to sodium reabsorption and water retention.
How does hyperaldosteronism contribute to edema?
Increased sodium reabsorption by renal tubules leads to water retention.
This, combined with increased antidiuretic hormone, further contributes to edema.
What are the clinical manifestations of ascites?
Abdominal distention, weight gain, eversion of the umbilicus, abdominal striae, distended abdominal wall veins.
Patients may also show signs of dehydration and decreased urine output.
What is a common electrolyte imbalance associated with ascites?
Hypokalemia.
This is due to excessive loss of potassium caused by hyperaldosteronism.
Fill in the blank: Ascites is a common manifestation of _______.
[cirrhosis]
What factors contribute to ascites formation?
- Hepatic lymph flow
- Hyperaldosteronism
- Impaired water excretion
- Portal hypertension
- Serum colloidal oncotic pressure
These factors interact to cause ascites.
True or False: The increase in abdominal pressure from fluid accumulation can lead to umbilical eversion.
True
What can low potassium levels result from in patients with ascites?
Diuretic therapy
Diuretics are often used to manage fluid retention in ascites.
What risk do patients with severe ascites face related to pleural effusion?
Increased risk for hepatic encephalopathy
Hepatic encephalopathy can be precipitated by factors that increase ammonia.
What is spontaneous bacterial peritonitis (SBP)?
A bacterial infection of the ascitic fluid
SBP is common in patients with cirrhosis and ascites.
Which bacteria are most often responsible for SBP?
Gram-negative enteric pathogens, such as Escherichia coli
These pathogens migrate from the intestines into the peritoneal space.
What are some neurologic manifestations of hepatic encephalopathy?
Impaired consciousness, inappropriate behavior, sleep problems, trouble concentrating, deep coma
Changes in mental status can occur suddenly or gradually.
What grading system is used for hepatic encephalopathy?
A classification system based on levels of consciousness and neurologic findings
This system helps assess the severity of hepatic encephalopathy.
What is asterixis?
Flapping tremors commonly seen in hepatic encephalopathy
Asterixis may be observed when a patient is asked to hold their arms and hands outstretched.
What is the pathogenesis of hepatic encephalopathy?
Multifactorial including neurotoxic effects of ammonia, abnormal neurotransmission, astrocyte swelling, inflammatory cytokines
A major source of ammonia is from the deamination of amino acids in the intestines.
What happens to ammonia levels when blood is shunted past the liver?
Ammonia levels in systemic circulation increase
This occurs because the liver cannot convert ammonia to urea.
What are some risk factors for hepatic encephalopathy?
- Cerebral depressants
- Constipation
- Dehydration
- GI bleeding
- Hypokalemia
- Hypovolemia
- Infection
- Metabolic alkalosis
- Paracentesis
- Uremia
Each factor influences ammonia production or metabolism.
What is the grading scale for hepatic encephalopathy based on?
Level of consciousness and intellectual function
The scale ranges from normal to comatose states.
What are signs of Grade 1 hepatic encephalopathy?
Normal to minimal change in consciousness and intellectual function
Patients may experience subtle personality changes.
What characterizes Grade 2 hepatic encephalopathy?
Lethargy, short attention span, impaired memory, mild confusion
Patients may show personality changes and mild depression.
What are the signs of Grade 3 hepatic encephalopathy?
Somnolent, disoriented, marked confusion, incomprehensible speech
Patients may exhibit asterixis and abnormal reflexes.
What is the state of consciousness in Grade 4 hepatic encephalopathy?
Not arousable, comatose
Patients are unresponsive and may show decerebrate posturing.
What are writing impairments?
Difficulty moving the pen or pencil from left to right and apraxia
Apraxia refers to the inability to construct simple figures.
What are some signs associated with writing impairments?
Hyperventilation, hypothermia, twitching of the tongue, grimacing, and grasping reflexes
Fetor hepaticus may also occur, characterized by a musty, sweet odor of the patient’s breath.
What is fetor hepaticus?
A musty, sweet odor of the patient’s breath due to the accumulation of digestive by-products that the liver cannot degrade
Define hepatorenal syndrome.
A type of renal failure with azotemia, oliguria, and intractable ascites, without structural kidney problems
What is the primary cause of hepatorenal syndrome?
Portal hypertension and liver decompensation leading to renal vasoconstriction
What can reverse renal failure in hepatorenal syndrome?
Liver transplantation
What can trigger hepatorenal syndrome in patients with cirrhosis?
Diuretic therapy, GI bleeding, or paracentesis
What liver function tests are typically abnormal in patients with cirrhosis?
High enzyme levels, low serum total protein and albumin, increased serum bilirubin and globulin levels, prolonged PT time
What might indicate end-stage liver disease regarding enzyme levels?
AST and ALT levels may be normal due to death and loss of hepatocytes
What is the gold standard for a definitive diagnosis of cirrhosis?
Liver biopsy
Is a liver ultrasound reliable for diagnosing cirrhosis?
No, it is not a reliable diagnostic test for cirrhosis
What is ultrasound elastography (Fibroscan)?
A noninvasive test used to quantify the degree of liver fibrosis
List some components of the diagnostic assessment for cirrhosis.
- History and physical assessment
- Liver function tests
- Serum albumin
- Serum electrolytes
- PT time
- Complete blood count
- Liver biopsy (percutaneous needle)
- Liver ultrasound (e.g., Fibroscan)
- Upper endoscopy (esophagogastroduodenoscopy)
- CT scan, MRI
What are components of conservative therapy for cirrhosis management?
- Rest
- B-complex vitamins
- Avoiding alcohol
- Minimizing or avoiding aspirin, acetaminophen, and NSAIDs
What dietary modification is recommended for managing ascites?
Low-sodium diet
What is the purpose of diuretics in ascites management?
To remove excess fluid from the body
What is a paracentesis?
A sterile procedure to withdraw fluid from the abdominal cavity
When is paracentesis indicated for patients with cirrhosis?
For impaired respiration or abdominal discomfort caused by severe ascites not responding to diuretics
What is TIPS?
A procedure used to treat ascites that does not respond to diuretics
What is the role of spironolactone in cirrhosis management?
An effective diuretic that is an aldosterone antagonist and potassium-sparing
True or False: Hyponatremia is a common problem in patients with cirrhosis on diuretics.
True
What is the typical sodium intake limit for patients with ascites?
2 g/day
What can very low-sodium intake result in for patients?
Reduced nutrient intake and malnutrition
What is the main therapeutic goal for esophageal and gastric varices?
To prevent bleeding and variceal rupture by reducing portal pressure.
This goal is critical in managing patients with cirrhosis.
Which medications should patients with esophageal and/or gastric varices avoid?
Alcohol, aspirin, and nonsteroidal anti-inflammatory drugs (NSAIDs).
These substances can increase the risk of bleeding.
What procedure should all patients with cirrhosis undergo to screen for varices?
Upper endoscopy (esophagogastroduodenoscopy [EGD]).
This procedure helps in early detection of varices.
What role do nonselective beta-blockers play in the management of varices?
They decrease high portal pressure, reducing the risk of variceal bleeding.
Common examples include nadolol and propranolol.
What is the first step when variceal bleeding occurs?
Stabilize the patient and manage the airway.
This is critical for patient safety before further treatment.
What type of therapy is often combined for more successful management of bleeding varices?
Drug therapy and endoscopic therapy.
This combination is more effective than either approach alone.
What are the two main drug therapies used for bleeding varices?
- Octreotide (Sandostatin)
- Vasopressin.
Both drugs cause vasoconstriction and decrease portal blood flow.
Why is octreotide preferred over vasopressin for treating bleeding varices?
Octreotide has fewer side effects than vasopressin.
This makes it a safer option for patients.
What is endoscopic variceal band ligation (EVL)?
A procedure that places a small rubber band around the base of the varix to prevent rebleeding.
This technique is commonly used during endoscopy.
What is sclerotherapy?
Injecting a sclerosing solution into swollen veins through a needle placed through the endoscope.
This method helps to manage varices by promoting scarring.
What is balloon tamponade used for?
To control acute esophageal or gastric variceal hemorrhage through mechanical compression of the varices.
It is an alternative when endoscopic methods are ineffective.
What are the key supportive measures during an acute variceal bleed?
- Fresh frozen plasma
- Packed RBCs
- Vitamin K
- Proton pump inhibitors (PPIs).
These measures help stabilize the patient and prevent complications.
What is the risk associated with recurrent bleeding episodes in varices?
High incidence of recurrent bleeding after each episode.
This necessitates ongoing management and monitoring.
What are the long-term management strategies for patients who have had a bleeding episode?
- Nonselective beta-blockers
- Repeated band ligation
- Portosystemic shunts.
These strategies help manage portal hypertension and prevent further bleeding.
What is the TIPS procedure?
A nonsurgical procedure that creates a shunt between the systemic and portal venous systems to redirect portal blood flow.
TIPS is performed to reduce portal venous pressure.
What are the limitations of the TIPS procedure?
- Increased risk for hepatic encephalopathy
- Stenosis of the stent.
It is contraindicated in certain conditions like severe hepatic encephalopathy.
What is a portacaval shunt?
A surgical shunt that anastomoses the portal vein to the inferior vena cava to reduce portal hypertension.
This method preserves liver perfusion while diverting blood flow.
What is the distal splenorenal shunt?
A surgical procedure that anastomoses the splenic vein to the renal vein.
It selectively decompresses esophageal varices while maintaining portal venous flow.
What is the mechanism of action of furosemide (Lasix)?
Acts on distal tubule and loop of Henle to reabsorb sodium and water
What is the mechanism of action of spironolactone (Aldactone)?
Blocks actions of aldosterone, potassium sparing
What does lactulose do in the treatment of cirrhosis?
Acidifies feces in bowel and traps ammonia, causing its elimination in feces
What is the purpose of magnesium sulfate in cirrhosis management?
Corrects hypomagnesemia that may occur with liver dysfunction
What are the effects of nadolol and propranolol in cirrhosis?
Reduce portal venous pressure and esophageal variceal bleeding
How does neomycin sulfate help in cirrhosis treatment?
Reduces bacterial flora, thus reducing ammonia formation
What is the role of rifaximin (Xifaxan) in cirrhosis?
Reduces bacterial flora, thus reducing ammonia formation
What is the function of octreotide (Sandostatin) in cirrhosis?
Hemostasis and control of bleeding in esophageal and gastric varices, constricts splanchnic arterial bed
What does vitamin K correct in patients with cirrhosis?
Corrects clotting problems from decreased vitamin K levels
What are some subjective health history data important for cirrhosis assessment?
- Viral, toxic, or idiopathic hepatitis
- Alcohol use
- Metabolic syndrome
- Chronic biliary obstruction and infection
- Severe right-sided heart failure
What are some functional health patterns to assess in cirrhosis?
- Chronic alcohol use
- Weakness
- Anorexia
- Weight loss
- Dyspepsia
- Nausea and vomiting
- Gingival bleeding
- Dry, yellow skin
- Bruising
What are some objective data findings in cirrhosis?
- Fever
- Cachexia
- Wasting of extremities
- Abdominal distention
- Ascites
- Distended abdominal wall veins
- Palpable liver and spleen
- Foul breath
- Hematemesis
- Black, tarry stools
- Hemorrhoids
What is the goal of managing hepatic encephalopathy?
To reduce ammonia formation
How can lactulose be administered?
- Orally
- As an enema
- Through a nasogastric (NG) tube
What is the importance of regular bowel movements in hepatic encephalopathy management?
Minimize ammonia buildup
What is a common nutritional therapy for a patient with cirrhosis?
High in calories (3000 cal/day), high in carbohydrate content with moderate to low levels of fat
What dietary considerations should be made for a patient with alcoholic cirrhosis?
Oral supplements containing protein from branched-chain amino acids
What is a dietary recommendation for a patient with ascites and edema?
Low-sodium diet
What are some signs of hepatic encephalopathy?
- Altered mentation
- Asterixis
What are potential diagnostic findings in cirrhosis?
- Anemia
- Thrombocytopenia
- Leukopenia
- Abnormal liver function studies
- Increased INR
- Increased ammonia
- Increased bilirubin levels
Fill in the blank: The diet for a patient with cirrhosis should be high in _______.
calories
What are common clinical problems for patients with cirrhosis?
Ineffective tissue perfusion, activity intolerance, fluid imbalance
Additional details on clinical problems and interventions can be found in eNursing Care plan 48.2.
What are the overall goals for a patient with cirrhosis?
- Relief of discomfort
- Minimal to no complications
- Return to as normal a lifestyle as possible
What are common risk factors for cirrhosis?
Alcohol use, malnutrition, viral hepatitis, biliary obstruction, obesity, right-sided heart failure
What is essential for promoting normal liver regeneration in patients at risk for cirrhosis?
Adequate nutrition
What should be encouraged for patients with chronic alcohol use to prevent cirrhosis?
Enrollment in support programs that help maintain sobriety
What is the focus of care for patients with cirrhosis?
Conserving strength while maintaining muscle strength and tone
What measures should be taken to prevent complications in patients requiring complete bed rest?
Prevent pneumonia, thromboembolic problems, pressure injuries
What dietary strategies can help improve nutrient intake in cirrhosis patients?
Oral hygiene before meals, offering between-meal snacks, offering preferred foods
What medications may help relieve itching associated with jaundice?
Cholestyramine or hydroxyzine (Atarax)
What is cholestyramine used for in cirrhosis patients?
It binds bile salts in the intestine, increasing their excretion in the feces
What are potential side effects of cholestyramine?
Nausea, vomiting, diarrhea or constipation, skin reactions
What is the preprocedure assessment for a patient undergoing paracentesis?
Baseline vital signs, pulse oximetry, weight, abdominal assessment, bladder distention
What is important to monitor postprocedure for a paracentesis?
Vital signs, abdominal girth, abdominal pain, signs of hypovolemia
What position should the patient be in during a paracentesis?
High-Fowler’s position with feet on the floor
What should be assessed regarding urine and stool color in jaundice?
Urine is often dark brown, and stool is gray or tan
How should edema and ascites be monitored in cirrhosis patients?
Accurate calculation of intake and output, daily weights, measurements of extremities and abdominal girth
What position helps maximize respiratory efficiency in patients with severe ascites?
Semi-Fowler’s or Fowler’s position
What is a critical aspect of skin care for patients with cirrhosis?
Meticulous skin care to prevent breakdown of edematous tissues
Fill in the blank: The procedure that involves the removal of fluid from the abdominal cavity is called _______.
paracentesis
What is the focus of nursing care for a patient with hepatic encephalopathy?
Maintaining a safe environment, sustaining life, and assisting with measures to reduce ammonia formation.
This includes interventions like range-of-motion exercises, deep breathing, and monitoring vital signs.
What should be monitored in patients taking diuretics for hepatic encephalopathy?
Serum sodium, potassium, chloride, and bicarbonate levels.
Additionally, renal function (BUN, serum creatinine) should be monitored routinely.
How often should neurologic status be assessed in a patient with hepatic encephalopathy?
At least every 2 hours.
This includes noting reflexes, pupillary reactions, and orientation.
What are common signs of hypokalemia?
Dysrhythmias, hypotension, tachycardia, and generalized muscle weakness.
Muscle cramping, weakness, lethargy, and confusion may also occur.
True or False: Patients with hepatic encephalopathy should be placed in a safe environment to prevent falls.
True.
This is crucial due to the risk of confusion and altered levels of consciousness.
What nursing care should be provided for fluid and electrolyte imbalances?
Assess for signs of imbalances, especially hypokalemia, and monitor for muscle cramping and weakness.
Evaluate the patient’s response to treatment measures.
Fill in the blank: Measures to minimize _______ are important to reduce ammonia production in hepatic encephalopathy.
constipation
What should caregivers understand about cirrhosis and the importance of continual health care?
The importance of proper diet, rest, avoiding hepatotoxic drugs, and abstaining from alcohol.
Abstinence from alcohol leads to improvement in most patients.
What is balloon tamponade used for in patients with cirrhosis?
To control bleeding that is unresponsive to band ligation or sclerotherapy.
The gastric balloon is inflated to maintain pressure and control bleeding.
What complications should be monitored for during balloon tamponade?
Rupture or erosion of the esophagus, regurgitation and aspiration of gastric contents, and airway obstruction.
If the gastric balloon breaks, it can lead to asphyxiation.
What are expected outcomes for a patient with cirrhosis?
Maintain food and fluid intake adequate to meet nutrient needs.
This is vital for managing the symptoms and complications of cirrhosis.
What should be included in the education for patients and caregivers regarding cirrhosis?
Complications, when to seek medical attention, and the importance of adequate rest periods.
Instructions about skin care, drug therapy side effects, and observation for bleeding should also be included.
What lifestyle changes may be necessary for patients with cirrhosis due to chronic alcohol use?
Major lifestyle changes to maintain health and manage symptoms.
This may include participation in community support programs.
What is rationing in the context of healthcare?
Rationing is the controlled distribution of scarce resources in healthcare.
What ethical problem does rationing present?
It weighs the needs of individual patients against the needs of many patients with a greater chance of recovery.
What can supersede individual rights in healthcare?
Health interests can supersede the interests or rights of a person.
What are the two individual rights that must be considered in healthcare decisions?
- Constitutional right to privacy
- Right to consent to or refuse medical procedures and therapy
Who may consent to or refuse treatment for healthcare problems?
The competent adult is the only person who may consent to or refuse treatment.
Under what circumstances can an intervening party refuse treatment consented to by a patient?
Only given substantial intervening circumstances and not as a threat to compel future behavior.
What may be necessary if involved parties cannot reach an agreement on treatment?
Legal intervention by way of a court order may become necessary.
What is cirrhosis?
Cirrhosis is a chronic illness that requires continual health care.
What should patients with cirrhosis be taught regarding symptoms?
They should be taught the symptoms of complications and when to seek medical attention.
What should patients with cirrhosis avoid to protect their liver?
They should avoid potentially hepatotoxic over-the-counter drugs.
What lifestyle change is encouraged for patients with cirrhosis?
Abstinence from alcohol is encouraged.
What medications should patients with esophageal or gastric varices avoid?
They should avoid aspirin and NSAIDs to prevent bleeding.
What activities may increase the risk of variceal hemorrhage in patients with portal hypertension?
- Straining at stool
- Coughing
- Sneezing
- Retching and vomiting
What is acute liver failure also known as?
Fulminant hepatic failure.
What characterizes acute liver failure?
Rapid onset of severe liver dysfunction in someone with no history of liver disease.
What is the most common cause of acute liver failure?
Drugs, usually acetaminophen.
What are some other drugs that can cause acute liver failure?
- Isoniazid
- Sulfa-containing drugs
- Anticonvulsants
What are some complications of acute liver failure?
- Cerebral edema
- Renal failure
- Hypoglycemia
- Metabolic acidosis
- Sepsis
- Multiorgan failure
What are common clinical manifestations of acute liver failure?
- Jaundice
- Coagulation problems
- Encephalopathy
What laboratory tests are important in diagnosing acute liver failure?
- Serum bilirubin
- PT time
- Liver enzyme levels (AST, ALT)
- Blood chemistries
- Complete blood count (CBC)
- Acetaminophen level
- Viral hepatitis serology
What imaging studies can provide information about acute liver failure?
CT or MRI can provide information about liver size and contour, presence of ascites or tumors, and blood vessel patency.
What is a critical step in managing patients with acute liver failure?
Planning for transfer to a transplant center should begin early.
What is a frequent complication associated with acute liver failure?
Renal failure.
What can protect renal function in patients with acute liver failure?
- Maintaining adequate fluid balance
- Avoiding nephrotoxic agents
- Promptly identifying and treating infection
What critical aspects must be monitored in patients with acute liver failure?
- Hemodynamic function
- Renal function
- Glucose
- Electrolytes
- Acid-base status
What should be conducted frequently in patients with acute liver failure?
Frequent neurologic evaluations for signs of changes in consciousness.
