Hepatic System Flashcards
1
Q
Liver
A
- largest gland in the human body
- 4 lobes
- produces bile
- aides in digestion and removes waste from blood
2
Q
What quadrant is the liver located in?
A
right upper quadrant (RUQ)
- found under the diaphragm
3
Q
If the liver was injured, where would the patient feel pain? (referred pain)
A
R shoulder and/or R mid back
4
Q
Blood supply of the liver
A
- hepatic artery
- portal vein
- hepatic veins return to the inferior vena cava
5
Q
Nerve supply of the liver
A
hepatic plexus runs with the hepatic artery/vein
6
Q
What is liver disease caused by?
A
a buildup of waste and fats that progresses to abnormal function, scarring, and blockage
7
Q
Bile
A
bitter tasting dark green/yellowish fluid produced by the liver that is stored in the gall bladder
- helps increase absorption of fats
- helps with absorption of fat soluble vitamins
- helps excrete bilirubin
8
Q
Biliary system
A
- drain bile into small intestine to aid in digestion to break down fat
- drain waste products into small intestine from the liver
9
Q
When does the gall bladder release bile?
A
when fats need to be broken down in the small intestine
10
Q
Where does the common bile duct send bile?
A
to the small intestine
11
Q
Gallbladder
A
pear shaped organ found under the liver that produces bile and stores/releases bile for fat digestion
12
Q
What are gallstones?
A
hard cholesterol plaque buildups that may block the bile duct
13
Q
What can gallstone lead to?
A
cholecystitis
pancreatitis
14
Q
Referred pain for cholecystitis?
A
RUQ pain radiating to the R shoulder and mid back
- you will really know it’s not musculoskeletal when typical PT is not working
15
Q
S/S of a blocked bile duct?
A
abdominal pain, nausea, vomiting, jaundice, pain in R shoulder and mid back
16
Q
Treatment for gallstones
A
- observe
- lifestyle modifications
- meds
- surgery (for a block)
17
Q
When is a cholecystectomy indicated?
A
with acute or chronic cholecystitis
18
Q
Pancreatitis
A
inflammation or infection of the pancreas
- most common causes are cholecystitis and alcohol abuse
19
Q
What can chronic pancreatitis lead to?
A
reduction in the production and release of insulin leading to diabetes
20
Q
Referred pain for pancreatitis?
A
severe LUQ pain that radiates to mid back and L shoulder
21
Q
S/S of pancreatitis?
A
nausea, vomiting, greasy stools, tachycardia, pain in L shoulder and mid back
- feels WORSE in supine
- feels BETTER with sitting/leaning forward
22
Q
Treatment for pancreatitis
A
- diet modification
- meds
- avoid alcohol
- surgery
23
Q
What is the most common major injury to the liver?
A
hepatitis
24
Q
What is a red flag when the liver is involved?
A
when the liver is easily palpated under the ribcage = enlarged liver
25
What systems are affected by the liver damage?
integumentary system
- nails, skin tone, itching, spider veins, edema
musculoskeletal system
- spine, shoulder, bone pain, ankle, wrist, LE, UE, Fx risk
neurologic system
- confusion, tremors, hyperreflexia
GI system
- nausea, vomiting, anorexia, abdomen will feel full
26
Why are multiple body systems affected by liver damage?
if the liver is damaged it cannot filter toxins so the excess of toxins in the body lead to changes in other body systems
27
Liver disease presentation: neurologic
- confusion
- sleep disturbances
- muscle tremors
- hyperactive reflexes
- asterixis
28
Liver disease presentation: musculoskeletal
- pain in R shoulder
- thoracic pain
- carpal/tarsal
- tunnel syndrome
- osteoporosis
- bone pain
- vertebral wedging
- kyphosis
29
Liver disease presentation: integumentary
- jaundice
- itching
- brusing
- spider angioma
- palmar erythema
- digital clubbing
- pallor
- orange/green tinged skin (change in skin tone)
30
Liver disease presentation: hepatic
- dark urine
- stool color changes (light chalky or clay color)
- edema
- oliguria
- RUQ abdominal pain
- ascites
31
Non alcoholic fatty liver disease (NAFLD)
cause is unknown, a build up of fat in the liver cells
- when >5-10% of liver weight of from fat
- chronic disease associated with obesity and diabetes
- silent condition (asymptomatic until late stages)
32
S/S of non alcoholic fatty liver disease
- fatigue
- weakness
- weight loss
- loss of appetite
- abdominal pain
- jaundice
- itching
- LE edema
- ascites
- confusion
33
Management of non alcoholic fatty liver disease
- life style management
- weight loss through diet and exercise (decrease saturated fats)
- meds
- reduce or stop alcohol intake
34
PT role in non alcoholic fatty liver disease
encourage healthy lifestyle, prevention, education
35
Hepatitis A
fecal oral transmission of contaminated food/water, person to person (infected food handlers), presents as acute illness
36
S/S hepatitis A
- extreme fatigue
- anorexia
- fever
- arthralgia
- clay colored stool
- RUQ pain
- dark urine
- jaundice
- headache
- altered sense of taste/smell
37
Prevention of hepatitis A
hand hygiene and immunization
38
Hepatitis B
transmission via blood, body fluids, needle sticks, oral, sexual contact
39
S/S of hepatitis B
mild to severe presentation
- jaundice
- arthralgia
- rash
- dark urine
- anorexia
- nausea
- vomiting
- fever
- painful abdominal bleeding
40
Prevention of hepatitis B
education, universal precautions, immunizations
41
Hepatitis C
transmission via blood, body fluids, needle sticks, oral, sexual contact (same as hepatitis B) as well as blood transfusion
* needle sharing is the most common
42
S/S of hepatitis C
similar to hepatitis B (I think??)
- jaundice
- arthralgia
- rash
- dark urine
- anorexia
- nausea
- vomiting
- fever
- painful abdominal bleeding
43
Prevention of hepatitis C
education, universal precautions, there are no immunizations
~ 1/2 of cases progress to chronic
44
Chronic hepatitis
inflammation in the liver lasting > 6 months
* also known as "liver dysfunction"
45
S/S of chronic hepatitis
* may be asymptomatic
- fatigue
- jaundice
- abdominal pain
- anorexia
- arthralgia
- fever
- weakness
- ascites
- malaise
- RUQ pain
46
Cirrhosis
complications of liver disease due to irreversible scaring
- affects multiple systems bc of a poor functioning liver
- can create blockages that restricts flow of blood/nutrients in and out of the liver
47
Risk factors for cirrhosis
- alcohol abuse
- hepatitis B/C
- fatty liver disease
48
Complications/symptoms of cirrhosis
- edema
- ascites
- hepatic encephalopathy
- liver cancer
49
Asymptomatic cirrhosis
also known as compensated cirrhosis
- individual may live for years without any awareness of changes in liver
50
Management of cirrhosis
- supportive care
- fluid balance
- vitamin/electrolyte replacement
- dietary modifications
- behavior modifications
- paracentesis (for ascites)
- liver transplant
51
What is the most common cause of cirrhosis?
hepatitis C followed by alcoholism
52
S/S of cirrhosis
- weight loss/gain
- fatigue
- jaundice
- LE edema
- anorexia
- nausea
- vomiting
- fever
- decreased urine output
- urine color changes (dark yellow/amber)
- bowel changes
- GI bleeding
- altered mental status
- RUQ pain
- weakness
53
PT monitoring for cirrhosis
educate patient on avoiding valsalva and do not push the patient to the point of fatigue
- watch for LE edema, ascites, abnormal blood loss, excess bruising
54
Progression of cirrhosis
backflow contributes to increased pressure which can be life threatening
- esophageal varices
- backflow can lead to spleen enlargement
- backflow can lead to portal vein blockages (portal vein HTN)
- increased risk of liver cancer
55
Portal vein
formed from the superior and inferior mesenteric veins that divides into 2 branches to supply the liver
56
Portal vein HTN
occurs when blood cannot flow through the liver and exit via the hepatic vein which backs up into the system
- can lead to scarring/fibrosis which can cause blockages
- complication of chronic alcoholism
57
S/S of portal vein HTN
- GI bleeding (black, tarry stools)
- blood in stool
- vomiting blood
- ascites
- encephalopathy
- confusion
- reduced blood count (increases risk of infection)
- splenomegaly
58
Wilson's disease
impaired removal of copper from the system which builds up in the body affecting liver and brain function
- usually presents in teen to early 20's
- equally affects men and women
59
Wilson's disease symptoms
- jaundice
- LE edema
- ascites
- fatigue
- excessive brusing
- tremors
- involuntary movements
- dysphagia
- dysarthria
- spasticity
- impaired coordination
- rigidity
- psychological symptoms
- asterixis
- parkinsonism
- premature arthritis
- osteoprosis/osteopenia
60
Hemochromatosis
excess iron builds up in the body that gets stored in a liver
- the most common genetic disorder causing liver failure
- presents in men > 40 yrs old
- presents in women after menopause
61
S/S of hemochromatosis
- fatigue
- abdominal pain
- memory fog
- heart palpitations
- irregular heartbeat
- arthalgia
- hair loss
- vertigo
62
What can happen when hemochromatosis goes untreated?
- OA or osteoporosis
- liver caner or cirrhosis
- abnormal skin color (bronze, reddish, gray)
- CHF
- endocrine disorders (diabetes, hypothyroid, hormone imbalance)
63
Hepatic encephalopathy
occurs when liver damage can't filter out toxins (especially ammonia)
- can happen with advanced liver disease, acute liver failure, dehydration, constipation, or infection
- reversible when the underlying cause is addressed
64
What is the main thing that hepatic encephalopathy can lead to?
altered mental status (AMS)
- acute confusion, disorientation, poor judgement, slurred speech, personality changes, shakiness, musty breath
65
West-Haven criteria for altered mental status: score 0
intellect/behavior
- normal
neurologic findings
- normal, impaired psychometric testing
66
West-Haven criteria for altered mental status: score 1 mild
intellect/behavior
- short attention span, slight change in confusion, disorientation, depression
neurologic findings
- mild asterixis or tremor, slurred speech
67
West-Haven criteria for altered mental status: score 2 lethargic
intellect/behavior
- disorientated, inappropriate behavior, lethargy, facial grimace
neurologic findings
- obvious asterixis, increased muscle tone, apraxia
68
West-Haven criteria for altered mental status: score 4 coma
intellect/behavior
- coma, responds to painful stimuli only
neurologic findings
- decerebrate posturing
69
West-Haven criteria for altered mental status: score 3
intellect/behavior
- gross disorientation, bizarre behavior, confusion
neurologic findings
- muscle rigidity and clonus, hyperreflexia, babinski
70
PT implications for hepatic encephalopathy
- altered mental status (patient has difficulty following commands, history is not accurate, poor safety awareness/impulsive)
- asterixis (will be bilateral if there is metabolic encephalopathy, unilateral means brain pathology)
71
Liver cancer
- leading cause of death worldwide
- most common risk factor is hepatitis B/C and cirrhosis
- common with heavy drinkers
- incidence is increasing, especially from metastasis to the liver
72
Liver cancer symptoms
- Pain in RUQ, R scapula, or back
- unexplained weight loss
- hard lump under ribs on R side of body
- overall muscle weakness
- feeling full
- constant ache in mid back
- progressive poor health
** liver function doesn't become impaired until >80% of the liver is cancer
73
Liver transplant
the treatment for end stage liver disease
- ~75% 5 yr survival rate
- immunosuppressive therapy (diabetes, HTN, high cholesterol, osteoporosis, kidney/GI issues)
74
Common infections that occur post liver transplant
infections from bad hygiene or exposure to high risk activities
- viral infection
- fungal infection
- bacterial infection
75
Liver transplant precautions
- infection (contact precautions for immunocompromised patients)
- rejection
- post op respiratory complications
- neurologic complications
76
S/S of liver transplant infection
- headache
- shortness of breath
- cough
- nausea/vomiting
- diarrhea
- fatigue
- burning with urination
- sore throat
77
S/S of liver transplant rejection
- abdominal pain
- fever
- fatigue
- gray stools
- tea/dark yellow/orange colored urine
- decreased exercise tolerance
- yellow eyes
78
Inpatient liver transplant precautions
- lifting restrictions <20 lbs x 6 weeks
- abdominal splinting for effective cough
- diaphragmatic breathing
- log roll for bed mobility
- universal precautions for all equipment
- watch for lines and tubes
- vitals and monitor orthostatic hypotension
- watch for altered mental status
- limit valsalva
- educate on safety awareness and no out of bed without supervision
79
Outpatient liver transplant precautions
- postural correction (kyphosis)
- scar adhesions (liver in abdomen, scar may cause flexed postures)
- functional activities to restore independent with ADLs
- increased fall risk with poor balance, coordination, and endurance
- watch for HTN, immunosuppression, osteoporosis, lifting restriction, depression, altered mental status
80
General PT considerations for liver transplants
- analyze labs inpatient (low platelet count, low iron)
- fluid retention in abdomen or LEs may alter balance and can be painful
- monitor vitals
- posture education/optimal body mechanics
- HEP (regular walking, stretching, strengthening)
81
When do you need immediate MD referral?
- new onset myopathy (especially in older people and people who use statins)
- S/S of hepatic disease
- arthralgia with unknown cause
- bilateral carpal tunnel syndrome or bilateral tarsal tunnel syndrome (especially if you can't reproduce the pain)
- unknown asterixis
- neuropathy of unknown cause
- S/S of liver disease
82
Screening clues for the liver
- unknown R shoulder/scapular/upper midback pain
- shoulder ROM not limited by pain, unable to localize/pinpoint pain
- GI symptoms
- personal history of liver cancer or gallbladder disease
- history of hepatitis especially with joint pain/RA/fibromyalgia
- recent (6 months) drug injection, tattoo, acupuncture, piercing, dialysis, transfusion, multiple sex partners, consuming raw shellfish, hepatitis
- skin tone change, spider angioma, palmar erythema, excessive alcohol consumption
