Cirrhosis And Hepatic Failure/ pancreatitis Flashcards
What is cirrhosis
Severe scarring of the liver which in turn alters the function of the liver
How does the function of the liver deteriorate
Altered bile duct flow and stasis
Impaired hepatic venous outflow
Decreased blood flow to and through the liver
What are complications of portal hypertension
Ascites
Hemmorhage of varices
Hepatic encephalopathy (HE)
Hepato renal syndrome
What is the only feasible treatment for end stage liver cirrhosis
Liver transplant
What is albumin
A blood protein with a long 1/2 life of 20 days is a late indicator
Of malnutrition
If albumin is decreased what will result
Poor wound healing due to decreased zinc levels
Prealbumin
1/2 life of 2-3 days
Sensitive indicator of nutritional status with treatments
What deficiency is common in liver disease
Thiamine related to poor diet, impaired GI absorption
What is this one needed for
This one is needed to maintain cerebral and nerve impulse function
What does alcohol do to the liver
Alcohol depletes the liver from gluconeogenesis
What are causes of acute liver failure
Toxins, drugs especially acetaminophen
Viral hepatitis
Hypoperfusion / shock due to ischemia
What are ALF signs and symptoms
N/V Malaise Evidence of coagulopathy ( bruising, bleeding, lab abnormalities, DIC,) Decreased LOC HEPATIC ENCEPHALOPATHY
What is collaborative management of ALF
Obtain detailed history focused on viral infections, drugs, toxins, direct injury, acetaminophen intake
Prevent cerebral edema and MODS
What are complications of ALF
Respiratory insufficiency/ failure Hemodynamic instability Infection/ sepsis Hypoglycemia Electrolyte imbalances Renal failure Malnutrition
Acetaminophen
Readily absorbed from G.I tract Primarily metabolized by the liver Half life 2-4 hours Peaks levels 4 hours after overdose 90% excreted by the kidneys Unintentional poisoning may result from repeated high doses
What exacerbates acetaminophen toxicity
Fasting
What is treatment of acetaminophen toxicity
If less than 4 hours perform gastric lavage
Draw serum acetaminophen levels between 4 hrs and 24 hrs post ingestion
Promptly administer actetylcysteine I.V in 3 separate infusions over 20-24 hours
Can be given PO
GIVE REGARDLESS OF TIME OF INGESTION based on weight
Can give activated charcoal is ingested within 2 hours
What is considered toxic for acetaminophen
INGESTION of 7-10 grams is toxic over 8 hrs or less
What are additional complications of acetaminophen toxicity
Seizures that are usually well controlled with benzodiazepines
What are signs and symptoms of hepatic encephalopathy
Can start with forgetfulness, mild confusion, poor judgement, wandering, inappropriate behavior or language, poor sleep patterns, worsening handwriting, tremors, slow movement
Can hepatic encephalopathy recur
It can recur after treatment due to various triggers
What drug can be used to reduce the risk of recurrence of hepatic encephalopathy
Xifaxan-rifaximin
These are drugs that alter the bacterial content of the G.I tract
What is portal hypertension
Abnormally high blood pressure in the portal venous system due to resistance to portal blood flow
What are consequences of portal hypertension
Varices in the lower esophagus, stomach, rectum,
Splenomegaly
Ascites
Hepatic encephalopathy
What is hepatic encephalopathy
The accumulation of toxins related to liver failure causes disruption of neurotransmission
What are symptoms of hepatic encephalopathy
Personality changes
Confusion
Memory loss
Stupor, coma, death
What is hepatorenal syndrome
Renal failure demonstrating oliguria, sodium and water retention, hypotension, and peripheral vasodilation due to advanced liver disease
What is a way cirrhosis is caused
Biliary channels become obstructed and cause portal hypertension, blood is shunted away from the liver and a hypoxic necrosis develops
What is secondary biliary cirrhosis
Obstruction
What is primary biliary cirrhosis
Autoimmune
What is pancreatitis
Inflammation of the pancreas
Associated with several clinical disorders ( alcohol intake and cholelithiasis, caused by injury or damage to pancreatic cells and ducts causing a leakage of pancreatic enzymes into the pancreatic tissue)
What are manifestations of pancreatitis
Epigastric pain radiating to the back
Fever and leukocytosis
Hypotension and hypovolemia
Characterized by a increase in amylase
What is chronic pancreatitis related to
Chronic alcohol abuse
What is albumin administered for
To expand blood volume
Helps maintain vascular fluid volume
Tells if liver is damaged and if so how much
What are causes of hypoalbuminemia
Severe burns
Trauma
What are cause of hyperalbuminemia
They are not associated with hepatic disease it is associated with dehydration
What is ammonia
Waste product of protein metabolism
The liver converts ammonia to urea. In liver disease the conversion doesn’t take place thus increasing ammonia levels
Hepatic encephalopathy is the result of what
High ammonia levels in the brain
The brain is very sensitive to ammonia levels
What is treatment for high ammonia levels
Medications ( lactulose, enemas)
Diet (protein intake)
What does lactulose do
It eliminates ammonia through the feces, it also causes hypokalemia as k+ is excreted through the stool
Signs and symptoms of hepatic encephalopathy
Confusion
Affects fine motor control such as writing
If a patient has liver disease, what happens to bilirubin levels
They increase
In liver disease, how does coagulation studies relate
PT, INR aPTT will be increased because the liver synthesizes clotting factors 2,7,9,10. The blood will be unable to clot quickly leading to increased risk of bleeding
What are hepatic enzymes
ALP, GGT, AST, are enzymes produced mainly in the ,over. These enzymes help identify is the liver is diseased and how badly. The higher the levels the worse the liver prognosis
Manifestations of liver disease
Portal HTN
ascites
Hepatic encephalopathy hepatorenal syndrome
What is portal HTN
Elevated pressure within the portal system due to resistance to portal blood flow
Varices
Develops on stomach, lower part of esophagus, and rectum, due to built up pressure in the portal system. They can be so distended that they rupture. A person can hemmorhage and die before they reach medical treatment
What does rectum varices manifest as
Hemmorhoids
Consequences of portal HTN
Splenomegaly
Ascites
Hepatic encephalopathy
Symptoms of hepatic encephalopathy
Usually happens over hours to days Personality changes Confusion Hallucinations Loose fine motor skills Memory loss, stupor, coma, death
What are signs and symptoms of hepatorenal syndrome
Oliguria Na and H2O retention Hypotension Peripheral vasodilation Ascites Peripheral edema Electrolyte fluid shifts Hypovolemia Decreased renal blood flow Decreased GFR and urine output
Cirrhosis
Irreversible
Can only manage and prevent further damage
Can the liver regenerate itself
Yes it can
How does jaundice occur
Biliary channels are blocked
Who is more prone to cirrhosis
Woman
What is biliary cirrhosis
Auto immune
Obstruction in bile duct
What is post necrotic cirrhosis
Results from chronic disease
What is treatment for end stage cirrhosis
Liver transplant
What lab tells if HRS is developing
Creatinine
Thiamine deficiency
Common in liver disease due to impaired GI absorption
What does alcohol do in regards to the liver
Alcohol depletes the liver from the ability to provide gluconeogenesis
What electrolytes are decreased in cirrhosis and hepatic failure
k+, Na, Mg, phosphorus
What are causes of ALF
Acetaminophen
Viral Hep B
What are signs and symptoms of ALF
N/V
Malaise
Decreased LOC
What’s the toxic range of acetaminophen
7-10 gms
What’s the antedote to acetaminophen
Acetylcysteine
For acetaminophen poisoning what should you do
Give acetylcysteine regardless of when poisoning occurred
Activated charcoal if ingested within 2 hrs
Gastric lavage if ingested with 4 hrs
What are complications of ALF
Respiratory failure Cardiac arrest Infection/ sepsis Hypoglycemia Renal failure Hemodynamic instability electrolytes Seizures
MAT
Medication assisted treatment
MAT 4 opioids
Methadone
Buprenorphine
Naltrexone
MAT 4 alcohol use disorder
Disulfiram ( Antabuse, makes person violently ill if they try to sneak alcohol)
Acomprosate
Naltrexone
When do mild symptoms of alcohol withdrawal occur
Within 6-12 hrs of last drink
When do peak symptoms of alcohol withdrawals occur
They appear in 24-48 hrs
What are nutritional needs for alcohol withdrawal
Thiamine
Folic SCIs
B12
Who is at risk for acute pancreatitis
Alcoholics
What labs diagnose pancreatitis
Increased lipase
Increased calcium
What is trypsin
It protects cells by preventing avtivation of enzymes until they reach the duodenum. During inflammation trypsin activates enzymes early this basically digesting the pancreas in a process called autodigestion
If pancreatitis is left untreated p, what complications can occur
SIRS MODS SEPSIS COAGULOPATHY DIC
What is tx of pancreatitis
Vasopressors AGGRESSIVE fluid rescusitation O2 Keep NPO provide enteral TPN feedings, watch for,fluid overload IV abx, tele,
What are signs and symptoms of acute pancreatitis
Severe abdominal pain
Hypovolemia from dehydration
Hypoperfusion
What is Cullen’s sign
Bluish color Around the umbilicus
Sign of pancreatitis
What is turners sign
Bluish brownish color around the flank area
What is pain mgmt of acute pancreatitis
Morphine sulfate
Meperidine decrease spasms of pancreatic duct
Insulin drip( sliding scale isn’t effective, monitor glucose Q2 hrs
Give zofrna for n/v
PPI or H2 antagonist
What does PPIs and H2 antagonist do
They reduce gastric and pancreatic secretions
What is a appropriate diet for pancreatitis
High carb
Low fat
Low protein
What are complications of pancreatitis
MODS HYPOXEMIA RESPIRATORY COMPROMISE ARDS EDEMA PULMONARY EDEMA SIRS esp 7-14 days after dx
What are meds for pancreatitis
Pancrealipase
What is pancrealipase
It contains lipase, amylase, and protease which are supplemental enzymes needed for life
Pancreatitis leads to an increased risk for what
SEPSIS
What should a person report while in pancrealipase therapy
Report diarrhea, or abdominal cramping
What does pancrealipase tend to increase
Uric acid levels leading to gout
What can pericarditis lead to
SEPSIS
What are signs and symptoms of endocarditis
Murmurs Fever Tachycardia SOB fatigue Dysrthymias
What is tx of endocarditis
IV abx
May need valves replaced
What is dx for endocarditis
Echocardiogram
Increased WBC
What is serum procalcitonin
Early dx of SEPSIS
Serum lactate
Anaerobic metabolism is taking place now, bc the pt is critically ill, the O2 is depleted and cells go into anaerobic mode. Blood cultures will need to be drawn
The higher the lactate the sicker the patient
SIRS is the precursor to what
SEPSIS
Septic shock
The presence of SEPSIS and refractory hypotension
What is refractory
Not responding to tx
D dimer
Test that determines if there is a coagulation defect
What fluid should be given in a fluid challenge
0.9% NS
LR
What is given if BP doesn’t rise in SEPSIS after a fluid challenge
Vasopressors, the goal is to achieve a MAP of 65 or above
Norepinephrine is the drug of choice
Low dose of dopamine Can be given if the pt is not tachycardic
In SEPSIS, how should a fever be treated
Alternate between ibuprofen and acetaminophen
DIC
Can develop clots, bleeding or both, give heparin to dissolve the clots, manage heparin tightly to prevent massive hemmorhaging
How is DIC dx
Decrease platelets Increased D dimer Decreased fibrinogen Increased PT/ PTT increased fibrite degradation products
Cryoprecipitate
Contains clotting factors
How is DIC treated
Mostly crystalloids
Albumin colloids
PRBCs
Pain relief from ischemia
Cardiogenic shock
Hemodynamic problem
A problem within the heart itself
What are signs and symptoms of cardiogenic shock
Decrease CO, leading to decreased BP, LEADING leading to increased SVR
What is hypovolemic shock
A not enough fluid problem a decreased amount of fluid in the intravascular space
What are signs and symptoms of hypovolemic shock
Decreased CO, leading to decreased BP, leading to increased HR
What is distributive shock
Adequate blood flow and fluids, distributed abnormally. Still have decreased CO but not bc of decreased fluids
Fluids won’t help, u must correct the cause
What is obstructive shock
A type of shock related to the heart, the ventricles don’t feel or empty adequately ( a ventricular problem)
What is a disease process that can lead to obstructive shock
Cardiac tamponade
What is spinal shock
Shock resulting form a SCI
there is adequate volume nothing is wrong with the heart
It is a type of distributive shock
What are the stages of shock
Mild- reversible
Moderate- reversible
Severe- body can’t compensate
