Exam 4 - Liver Flashcards
what vitamins and minerals are stored in the liver
A
B12
several B complex
D
Fe
copper
functions of the liver
bile formation, excretion
drug metabolism (first pass effect)
vitamin, iron storage
how long to auscultate before determining absent bowel sounds
5 minutes
is damage done before you see a rise in liver enzymes
Yes
what are the liver enzymes
AST (10-30)
ALT (10-40)
ALP (38-126)
what should be done before liver biopsy
check coag studies
informed consent
NPO 4-6 hours prior
void prior
what to instruct pt to do during liver biopsy
hold breath after a full expiration during needle insert
post liver bx instruction
lay on R side x2 hours
strict bedrest x24 hours
pillow under costal margin
monitor VS at 10-20 minute intervals
monitor bx site hourly
where to assess for internal bleeding re: liver bx
costovertebral angle
danger signs post liver bx
abdominal distention
rigidity
pain
rebound tenderness
absent bowel sounds
when to caution liver bx
plt < 100000
PT > 3
liver tumor with large # of veins
ascites
infection
angiomas of liver
biliary obstruction
destruction of liver parenchyma and replacement by scar tissue
Cirrhosis
4 types of cirrhosis
laennec’s (alcoholic; portal)
biliary
cardiac
postnecrotic
describe alcoholic cirrhosis-laennec’s
fatty infiltration of liver d/t increase fatty acid and triglyceride synthesis, decrease of lipoproteins
T or F. if etoh intake ceases, the liver can heal itself
true
alcohol WD s/sx
tremors
N/V
psychosis
elevated HR, BP
posthepatic/necrotic cirrhosis occurs from advanced progression from which liver diseases
hepatitis B, C
or unknown cause
what occurs with biliary cirrhosis
retained bile damages and destroys liver cels
cirrhosis is twice as common in ___
men
nonalcoholic fatty liver disease (NAFLD) is ___
genetic
cardiac cirrhosis occurs from what
R sided heart failure
blood isn’t pumping so it backs up into the liver
complications of cirrhosis
portal HTN
impaired metabolism
impaired bile formation and flow
jaundice will form when bilirubin is > ___
> 3
early s/sx of cirrhosis: GI
anorexia
dyspepsia
flatulence
N/V
change in bowel habits
abdominal pain
fever
lassitude
weight loss
enlarged liver, spleen
dull percussion
parathesia occurs d/t a lack of which vitamin
b12
what is asterixis
can’t hold hands out without flapping them
what is fector hepaticus
malodorous breath
alcohol intake increases which hormone
estrogen, decreases progesterone
why is there pruritus with cirrhosis
bile salts are excreted through the skin
will K, Na, and ammonia levels be high or low?
low
what is palmer erythema
red are on the palms of hands that blanches with pressure
where are spider angiomas found
nose
cheeks
upper trunk
neck
shoulders
why does splenomegaly occur
blood backs up from the portal vein
why does bleeding occur
decrease production of hepatic clotting factors
is jaundice a late or early sign of cirrhosis
late
complications of cirrhosis
portal HTN
esophageal, gastric varices
peripheral edema
ascites
hepatic encephalopathy
hepatorenal syndrome
portal HTN is characterized by…
increase venous pressure in portal circulation
splenomegaly
ascites
large collateral veins
esophageal varices
systemic HTN
what are esophageal varices
complex veins at lower end of esophagus
very fragile
most life threatening complication of cirrhosis
where are gastric varices occur
upper portion of the stomach
why does edema occur with cirrhosis
bc albumin cannot be synthesized
is hypo or hyperglycemia common with liver failure
hypoglycemia
which hormone is increased with ascites
aldosterone
Na, water retention
where is girth measured for ascites
level of umbilicus
pt lies flat
done while exhaling
after administering albumin, what indicates it is working
increased UOP
what is common after variceal hemorrhage
bacterial peritonitis
what is given for elevated ammonia
lactulose
PO, NGT, enema
ammonia lab tube color and instruction
green tube, place on ice
hepatic encephalopathy mental responsiveness can range from ___ ___ to ___ to ___ ___
sleep disturbance; lethargy; deep coma
stages of hepatic encephalopathy range from __ - __
0-4
4 is most advanced
hepatic encephalopathy stage 1
slight confusion
reversal of day-night sleep pattern
asterixis
impaired writing
normal EEG
hepatic encephalopathy stage 2
disoriented
sleep most of time
easily aroused
agitation
mood swings
asterixis
fector hepaticus
abnormal EEG
hepatic encephalopathy stage 3
deep sleep
difficult to arouse
incoherent speech
increase deep tendon reflex
rigidity of extremities
markedly abnormal EEG
hepatic encephalopathy stage 4
comatose
cerebral edem IICP
cerebral hypoxia - death
goal of hepatic encephalopathy
decrease ammonia formation
what to monitor after administering lactulose
F/E balance
how does lactulose work
draws water into the gut to excrete ammonia
other drugs for hepatic encephalopathy
aldactone
corgard (BB)
nitrates
Fe
folic acid
vit K
serax (benzo not metabolized in liver)
what is azothemia
BUN, Crt build up
what is hepatorenal syndrome
function renal failure with azotemia, oliguria, intractable ascites
what should be avoided with any liver issues
alcohol
ASA
acetaminophen
NSAIDs
long term management of ascites
peritonevenous shunt (LaVeen, Denver)
ascites fluid and Na restriction
1500cc
2G
pt positioning for paracentesis
MD preference
what may occur with BP with a shunt and why
HTN; increase fluid in the vascular system
ascites diet
high calorie, high carb, low Na
possible restricted to 60 G protein
want to prevent hypoglycemia and catabolism
hypokalemia s/sx
cardiac dysrhythmias
hypotension
tachycardia
muscle weakness
what are bleeding varices treated with
balloon tamponade
how is balloon tamponade placement verified
XR
balloon tamponade complications
regurgitation
aspiration
balloon, varices rupture
what is a normal CVP range
2-6
varcies will begin to bleed when it reaches 12
procedure of choice for dx and treatment of upper GI bleeds
endoscopy
h. pylori treatment
2 abx & a PPI x 14 days
retest in 30 days; if +, retreat
an gastric lavage is like an
NGT
NGT increases secretion of what in the stomach
HCl
what is sclerotherapy
injection into bleeding ulcer or varices
post sclerotherapy interventions
noncardiac CP 24-72 hours after
monitor, ensure its non-cardiac
administer analgesics
transjugular intrahepatic portosystemic shunt (TIPS) is performed under what
fluoroscopy
vasopressin is what type of hormone
ADH
vasopressin can cause what
midsternal CP, MI
education measure to prevent bleeding variceal
soft tooth brush
avoid high acidic, spicy foods
avoid blowing nose
avoid ASA, NSAIDs
no coughing, straining
how does somatostatin or octreotide work
decrease splanchnic blood flow
reduce portal pressure
must review slide 111 and 112
must review slide 111 and 112
what does a portacaval shunt do
improve survival rate
what to do if abdominal girth becomes larger after a shunt placement
notify HCP
what are 4 causes of liver failure
hepatitis
decreased perfusion
cirrhosis
fatty liver disease
acute vs. chronic liver failure onset
a: rapidly (as little as 48 hours)
c: gradually over many years
what are some causes of acute liver failure
acetaminophen OD
viruses (hep A, B, C)
reaction to Rx and herbals
ingestion of poisonous wild mushrooms
causes of chronic liver failure
cirrhosis - MC cause
hep A, C
long term alcohol consumption
hemochromatosis
malnutrition
early s/sx of acute liver failure
N/D
loss of appetite
fatigue
progressive s/sx of acute liver failure
jaundice
bleeds easily
swollen abdomen
disorientation/confusion
–hepatic encephalopathy
sleepiness
coma
most definitive treatment for liver failure
liver transplant
therapeutic dose of acetaminophen
1-4 G daily
only 2 G daily if consumes alcohol daily
acetaminophen is absorbed from the ___ tract, metabolized in the ___ with a half life of __ to __ hours
GI tract; liver; 2-4 hours
where is acetaminophen excreted
urine
toxic single dose of acetaminophen
7-10 grams
acetaminophen antidote
n-acetylcysteine (mucomyst)
must be within 12 hours to eliminate hepatic injury
what occurs during phase 1 of acetaminophen toxicity
0-24 hours
anorexia
N/V
lethargy
pallor
asymptomatic
what occurs during phase 2 of acetaminophen toxicity
24-72 hours
RUQ pain
AST/ALT elevation
PT, bilirubin, renal - may be elevated
what occurs during phase 3 of acetaminophen toxicity
abdominal pain
N/V
acute liver failure:
–jaundice, encephalopathy, cerebral edema, MODS
death is common in this stage
stage 4 of acetaminophen toxicity
recovery phase
chronic liver impairment does not follow
goal of care re: acetaminophen toxicity
promptly administer antidote
who is a liver transplant for
those with progressive irreversible liver diease
who would NOT be a candidate for a liver transplant
cancer
active etoh or drug use
poor surgical risk
symptoms of a GI bleed
bright red blood coating stool
dark blood mixed with stool
black, tarry stool*
bright red emesis*
coffee ground emesis*
weakness
SOB
faintness
what 2 meds can turn stool black
Fe
bismuth (Pepto Bismol)
1 cause of GI ulcers
H. pylori
cause of upper GIB
PUD
stress ulcer
mallory-weiss tear
esophageal varices
this is a break in mucosal lining where it comes in contact with gastric juices
PUD
PUD risk factors
ASA, ibuprofen, naproxen use
excessive alcohol
smoking, tobacco
what can indicate perforation from PUD
severe abdominal pain with or without evidence of bleeding
s/sx of PUD
abdominal pain
N/V
weight loss
anorexia
fatigue
heartburn/indigestion
belching
chest pain
vomiting blood
bloody, dark tarry stools
what is Zollinger-Ellision syndrome
PUD caused by gastrinoma, a gastrin-secreting tumor of the pancreas, stomach or intestines causing hypersecretion of gastric acid
> 60% are malginant
where does Zollinger-Ellison syndrome occur
stomach
duodenum
esophagus
jejunum
Zollinger-Ellison syndrome can lead to….
diarrhea
steatorrhea
cause by impaired fat and protein metabolism
Zollinger-Ellison Syndrome syndrome
bleeding
perforation
F/E imbalances
PUD dx test
EGD
thin tube inserted through the mouth into the GI tract to look at the stomach and small intestine
4 H. Pylori abxs
amoxicillin (Amoxil)
clarithromycin (Baxin)
metronidazole (Flagyl)
tetracycline HCl (achromycin)
what are the 3 H2 antagonist and PPI of choice for h. pylori
H2:
cimetidine (tagamet)
ranitidine (zantac)
ramotidine (pepcid)
PPI: omeprazole (prilosec)
misc PUD treatment
carafate
bismuth
antacids
Fe preps
DC NSAIDS
how often to do a Gi assessment with PUD
q4h
PUD education
abstinence from all caffeine and alcohol
avoid cigarettes
balance meals are regular intervals
avoid spicy foods
review types of gastric resection, Billroth I and II - slide 157
slide 157
