Liver

Question 1

Liver, gallbladder, pancreas, and bile passage

Answer 1

Question 2

Liver functions:

Answer 2

• Removes potentially toxic by products of certain medications
• Metabolizes, or breaks down, nutrients from food to produce energy, when needed
• Helps your body fight infection by removing bacteria from the blood
• Produces most of the substances that regulate blood clotting
• *Prevent shortages of nutrients by storing vitamins, minerals, and sugar
• Produces most proteins needed by the body
• produces erythropoietin
• Produces bile, a compound needed to digest fat and to absorb vitamins A, D, E, and K

Question 3

AGE RELATED CHANGES OF THE HEPATOBILIARY SYSTEM

Answer 3

• Atypical clinical presentation of biliary disease
• More severe complications of biliary tract disease
• More rapid progression of hepatitis C infection & lower response rate to therapy
• Increased prevalence of gallstones due to the increase in cholesterol secretion in bile
• Decrease in the following:
  — Clearance of hepatitis B surface antigen
  — Drug metabolism and clearance capabilities
  — Intestinal and portal vein blood flow
  — Gallbladder contraction after a meal
  — Rate of replacement and or repair of liver cells after injury
  — Size and weight of liver (especially in women)

Question 4

Liver Cirrhosis

Answer 4

• Chronic progressive liver disease
• Irreversible scarring of the liver tissue

Question 5

Liver Cirrhosis (Scar)

Answer 5

• Widespread/extensive fibrotic (scarred) tissue develops
• Liver tissue becomes nodular. These nodules can block bile ducts and normal blood flow throughout liver

Question 6

Types of cirrhosis

Answer 6

• Alcoholic cirrhosis
  — most common type of cirrhosis
  — Scar tissue surrounds portal areas
  — Caused by chronic alcoholism (Laennec’s Cirrhosis)
• Postnecrotic cirrhosis
  — Broad bands of scar tissue
  — Late result of previous acute viral hepatitis {Caused by *viral hepatitis (esp Hep C) and certain drugs/toxins}
• Biliary cirrhosis
  — *Liver scarring around bile ducts
  — Usually results from chronic biliary obstruction, infection or *autoimmune disease
  — Much less common type

Question 7

Cirrhosis s/s

Answer 7

• Usually no symptoms for decades (until late stage)
• In early disease, if symptoms occur- they are usually vague/nonspecific:
  — Loss of appetite, indigestion, dull ab pain esp.in right upper quad, nausea, vomiting
• Late stage: Jaundice, GI bleeding, spontaneous bleeding
• Jaundice of skin/yellowing of eyes
• Dry itchy skin- don’t forget the lotion!
• Ascites
• Peripheral dependent edema
• Palmar erythema (red hands)
• Spider angiomas (spider veins)
• Thrombocytopenia- early indication of liver dysfunction
• Ecchymoses/petechiae
• Compensated vs decompensated (Chart 43-9)

Question 8

Cirrhosis s/s

Answer 8

• Usually no symptoms for decades (until late stage)
• In early disease, if symptoms occur- they are usually vague/nonspecific:
  — Loss of appetite, indigestion, dull ab pain esp.in right upper quad, nausea, vomiting
• Late stage: Jaundice, GI bleeding, spontaneous bleeding
• Jaundice of skin/yellowing of eyes
• Dry itchy skin- don’t forget the lotion!
• Ascites
• Peripheral dependent edema
• Palmar erythema
• Spider angiomas
• Thrombocytopenia- early indication of liver dysfunction
• Ecchymoses/petechiae

Question 9

Cirrhosis- complications

Answer 9

• Portal Hypertension: persistent increase in pressure in liver; decrease of blood into liver; back flow of blood into spleen
  — Splenomegaly
  — Esophageal varies (distended veins)
  — Ascites: increased vascular permeability; can get peritonitis
• Hepatic Encephalopathy; toxins ammonia build up in brain
• Hepatorenal Syndrome: back up causes kidneys to fail

Question 10

Portal Hypertension

Answer 10

• elevated pressure in the portal vein because blood flow is obstructed through the liver
• Major complication of cirrhosis
• Blood flows back into the spleen= splenomegaly

Question 11

splenomegaly

Answer 11

• Bleeding, risk of infection
• spleen stores plts and WBCs)
  — Thrombocytopenia, bleeding
  — Increased risk of infection

Question 12

Esophageal varies (distended veins)

Answer 12

• Veins becoming dilated in the stomach, intestines, abd, rectum & esophagus
• The fragile thin- walled esophageal veins become dilated and tortuous from increased pressure
• Potential to bleed severely
• Severe blood loss potentially leading to hypovolemic shock

Question 13

Ascites

Answer 13

• excessive peritoneal fluid
• Dehydration
• Hypokalemia
• Acute spontaneous peritonitis (SBP) as result of low proteins

Question 14

Hepatic Encephalopathy (aka portal-systemic encephalopathy PSE)

Answer 14

• accumulation of ammonia due to liver failure -can lead to neurologic issues (sleep & mood disturbance, mental status changes & speech problems)
• ALOC
• Life threatening complication
• Reversible
• Asterixis in hepatic encephalopathy
• give lactulose: allows pt to poop out ammonia

Question 15

Hepatorenal Syndrome

Answer 15

• Life threatening complication of advanced liver disease
• Kidneys lose ability to function due to compromised blood supply (Renal failure associated with hepatic failure)
  — indicates poor prognosis (liver transplant needed in most cases)
  — often cause of death for cirrhosis pts.
• *Sudden decrease in urine flow “oliguria” (<400mL/24hrs)
• Elevated BUN and Creatinine levels with abnormally decreased urine sodium excretion
• Increased urine osmolarity (more concentrated)

Question 16

Cirrhosis Assessment

Answer 16

• Decreased mental function
• Poor cognition & movement disorders
• SOB
• Peripheral dependent edema
• Ascites
• Jaundice, pruritus, dry skin
• Red palms (palmer erythema)
• Spider angiomas
• Bleeding, Ecchymosis
• Petechiae
• Hematemesis or melena (esophageal varices)

Question 17

Cirrhosis Nursing Care

Answer 17

• Promote rest
• Nutrition
• Skin care
• Enhance pt positioning (semi- fowlers)
  — to optimize pulmonary function
• Prevent injury
• Monitor for changes in neuro status
• Monitor & maintain F&E balance
• Monitor for infection (ab pain and fever may signal onset of infection
• Prepare for possible Paracentesis
• Drug therapy
  — Vitamins
  — - Fat soluable
  — - Vit K
  — Diuretics
  — Lactulose
  — Antibiotics
  — H2 receptor blockers/PPIs
  — Meds to stop bleeding

Question 18

Care of the Patient with Paracentesis:

Answer 18

• Explain the procedure, and answer patient questions.
• Obtain vital signs, including weight.
• **Ask the patient to void before the procedure to prevent injury to the bladder! ***
• Position the patient in bed with the head of the bed elevated.
• Monitor vital signs per protocol or physician’s request.
• Describe the collected fluid.
• Measure the drainage, and record accurately.
• Label and send the fluid for laboratory analysis; document in the patient record that specimens were sent.
• After the physician removes the catheter, apply a dressing to the site; assess for leakage.
• Maintain bedrest per protocol.
• Weigh the patient after the paracentesis; document in the patient record weight both before and after paracentesis.

Question 19

Cirrhosis Possible Procedures:

Answer 19

• Endoscopic variceal ligation (EVL)
• Endoscopic sclerotherapy (EST)
• TIPS
• Balloon tamponade

Question 20

Endoscopic variceal ligation (EVL)

Answer 20

“banding” ◦ Small bands placed around base of varices to decrease blood supply to varices

Question 21

Endoscopic sclerotherapy (EST)

Answer 21

Varices injected with sclerosing agent to thrombose and destroy distended veins

Question 22

TIPS

Answer 22

• In pts with severe liver problems
• This is a procedure to create new connections between two blood vessels in your liver.
  used to control long-term ascites and reduce variceal bleeding
• Stent inserted via catheter to portal vein
  — will redirect blood from liver to systemic circulation
  — Stent will divert blood flow and reduce portal hypertension
• Effective in decreasing sodium retention and improving kidney response to diuretics and preventing recurrence of fluid accumulation
• High cost compared to paracentesis & albumin
• Stent is inserted to connect the portal veins to adjacent blood vessels that have lower pressure.
  — This relieves the pressure of blood through the diseased liver and can help stop bleeding and fluid back up.

Question 23

Balloon tamponade

Answer 23

• to treat bleeding varices if unable to have endoscopic procedures or TIPS procedure
• Balloon is inflated to put pressure on the bleeding esophageal varices to decrease bleed
• Potentially life-threatening complications
  — Ex. Sengstaken-Blakemore Tube

Question 24

Parecentisis

Answer 24

• Removal of fluid from peritoneal cavity
• incision through ABD. Wall
• sterile: U.S. guided
• diagnostic
• 5-6 liters removed