Liver Flashcards
Hepitis A
Non chronic inflammation of the liver
Hep B is spread
By blood, therefore high risk places need vaccination
Hep C
Similar
Physcial manifestiatiojn of hepitis
Many patients have no symptoms and are unaware of their infection
anorexia, n/v, malaise, fatigue, headache, low-grade fever, arthralgias, skin rashes, jaundice (icteric) and RUQ discomfort. Food., ETOH, or cigarettes may be distasteful.
Physical exam would reveal
Physical exam: hepatomegaly, splenomegaly, lymphadenopathy.
Hep A tx
PREVENTION IS KEY! No specific treatment. Immunization if going to places where hygiene is poor
Hep B tx
Immunization in high-risk areas.
The goal of therapy is to reduce viral road, normalize liver enzymes and slow rate of disease progress through medication therapy.
Hep C
Sometimes spontaneously resolves (50% of infections)
In others, progresses to chronic Hep C infection. Can be cured with medication.
Liver Cancer
80-90% of HCC patients have cirrhosis
Similar to cirrhosis; minimal in early stages
Treatment: surgical removal or palliation
Focus of care: symptom management
Liver transplant
Living donors can donate segment of liver and will regrow the lost part
Living-donor liver transplant is possible because the human liver regenerates and returns to its normal size shortly after surgical removal of part of the organ
KNOW Clinical manifestations: Hem problems, how Cirhosisis impact the hem system
Esophogeal varicies
Enlarged veins in esophagus that can rupture and cause severe bleedings
- Usually caused by cirrhosis. Unmanaged portal hypertension
Intoxicated vs Alcohol W/d
SS:
Intox - CNS Depression, slurred speech, altered gait, decreased LOC
Lab: BAC
Tx. Not drinking (no aclohol)
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SS of W/d: N/V, tremors, agitations, hallucinations, sweats
Lab: No test.
- Hx is important (WHEN THEY STOPPED drinking last)
Tx. Thiamine, lorazepam (Benzos)
Wernickes
SS:
Ataxia, abnormal eye movement (Nystagmus), blurred vision, altered LOC
- Thymine deficiency (cant be tested)
tx basd on history and SS
No Labs
Tx. Thiamine admin
Liver is
Largest interal organ in the body organ
Functual units of the liver
Lobules
What does a lobule consist of
a plate of specialized hepatocytes around a central vein
Cuppher cells
Break down RBCs, and phagocytize as well
The liver recieves which blood
1/3 of from hepatic artery - oxygenated
2/3 from portal vein (Blood flow from the spleen, intestines, stomach, and pancreas) - partially oxygenated
- Carries substances absrobed from spleen and intestines, stomach and pancreas
Blood leaves the liver via
Hepatic vein, emtpyting into inferior vena cava
Metabolic functions of the liver
carbohydrate, protein and fat metabolism; detoxification of the blood; steroid metabolism
Bile synthesis function include
bile production, excretion
Storage funciton of liver
: glucose (in the form of glycogen); fat-soluble vitamins (ADEK), and water-soluble vitamins (B1, B12, folic acid); fatty acids; minerals (ie iron); amino acids in the form of ALBUMIN and beta-globulins
Monuclear phagocyte sytem functions of liver
breakdown of old RBC’s, WBC’s, bacteria, etc. Breakdown of Hgb to bilirubin and biliverdin
Functions of liver (Don’t need to know)
Bile production
- For breakdown of fats, cholestor and some vits
Absorbs and metabs bilirrubin (Used to make next generation of RBCs
Assists in creating blood clotting factors (Coagulants) - i.e. Vit K
Fat metabolism (Breaks them down to make easier to digest
Carb metabolism - stored and then broken into glucose, stored as glycogen, released whenever requried
VItamin storage - iron for hemoglobin
Protein metabolism - to make them more digestable
Filters the blood - hormones, drugs, alcohol
- Drug metabolism
Immunological - destroys pathoegens
Production of albumin - helps maintain oncotic pressure
Synthesis of angiotension
How often is alcoholism related to cirhossis
90%
Cirhossis
Liver cells attempt to regenerate.
Regenerative process is disorganized.
Abnormal blood vessel and bile duct formation
Overgrowth of new fibrous connective tissue distorts liver’s normal structure, impeding blood flow.
Irregular regeneration and disorganized regeneration, poor cellular nutrition and hypoxia d/t inadequate blood flow and scar tissue result in decreased liver functioning.
Cirrhosis is the final stage of chronic liver disease.
Cirrhosis
10th leading cause of death in Canada
- insidious, prolonged course
Serious consequences of cirhossi example
Bleeding from portal hypertension
Factors leading to crihossi
Chronic alcoholism
Nonalcol fatty liver disease (NAFLD)
Nutrtion related (malnutrtion or obesity
Pts with Hep B and C
Environmental and genetic predisp
COmpensated cirhossis ss
Anorexia, NVD, dyspepsia, weakness, constipation
Decompensated Cirrhosis SS
GI issues
- (pale stool)
- anorexia, NVD
- jaundice
- Dark urine
- Perotis
- Energy def (Carb and protein metab probs)
- Anemia from bleeding
- Petichaie, bruising
- Periphe or pulm edema
- Ascites
- Change in LOC
- Fluid overload
- Protrutding abdom
Skin lesions
Spider angioma occuring in nose, cheeks, upper trunk, neck and shoulder
Palmar erythema - a red area that blances
From low estrogen
Hematologica problesm with cirrohis
Thrombocytopenia (regulating produciton of platelts - low)
- Biggest indicator
Leukopenia
Anemia
Coagulopathies
Can be production issues OR destruction issues (of RBC with anemia)
What causes caoagulopathies
Livers inability to produce prothrombin
- essential for clotting
Evidinced by petichaei (non blanch), gum bleed, clotting abnorm, easy bruishing
Prothrombin time will be increased
Endocrine disorders of cirhossis in men
Gynecomastia
Loss of axillary and pubic hair
Testicular atrophy
Impotence +/- loss of libido
Endocrine disorders of cirhossis in women
Loss of menstural bleeding in younger women
Vaginal bleeding in older women
Hyperaldosteronism
Na and water retention secondary to liver cirhosiss
Peripheral neuropathy from cirhossis
Deficiency in thymine, folic acid, and Vit B12
Causing weakness numbness or pain (stabbing buring or tingling)
Complications of liver dx
Portal HTN
Portal HTN
Esophageal varices
Forming bc of increased blood pressure on portal veins, collateral circulation forms to offset pressure, but these veins are not strong, and are a high risk of bleeding
Varices can also be found near umbilicus, groin or stomach
How do we assess for risk of bleeding
Bleeding gums
Bruising
Petichae
Ascities
CBC (Platlet count)
If they have been vomiting - what does it look like (coffee grinds)
Stool (Black)
VS (Drop in BP or rise in HR)
How do we diagnose esophageal varices
Gastronomy
thin tube going all the way to jejunum
Greatest risk with esophageal varices
Bleeding to death
Tx with IV fluids and platelet transfusion
Lagation (elastic band to stop/prevent bleeding on varices)
Edema cause in cirrhosis
Caused by decreased colloial osmotic pressure in vasculature due to decreased production of albumin
And increased hydrostatic pressure from portal HTN
Ascities
Accumulation of serous fluid in peritoneal/abdom cavity
due to elevation of portal pressure
May cause proteins to shift OUT of blood vessels into lymph due to larger pores of sinusides in liver lobules
Ascites looks like
Abdom distension
- Firm hollow sounding
Unbilical eversion
Decreased urin output
Signs of dehydration
Abdom striae
HypoK (diuretics)
Hepatic encephalopathy
Ammonia is normally ocnveted to urea by the liver and then is excreted in urine
When liver is not funcitoning properly, ammonia is not broken down and levels increase. It crosses BBB and can be neurotoxic
- Changes in LOC
- Impaired thinking
- Stupor
- Confusion
- NM change (Asterixixs “flapping), hyperflexia (exagerated reflexes)
Tx. Protein reduction (Ammonia is byproduct)
- Eliminating ammonia quicker from intestines to avoid absorptiond
Wernickes encphalopathy
Primary cause: Malnutriton or starvation associated with chornic drinkning
SS: ALtered mental Status, ataxia, diplopia, nystagmus (horizontal)
Not abrupt, happening over time
Tx is Thymine (reversible)
Liver lab tests
Blood test
Increased liver enzymes: ALT and AST
What is ALT
To the liver what troponin is to the heart
A protein only made by liver when liver cells are damaged
AST
Found in parts of body other the liver (Brain, heart, liver)
Trends can be helpful for liver test diagnosis
Alk phos and liver
Less specific than other test, high conc can indicate blocked ducts or liver damage
GGT
Elevated with liver damage or blocked ducts
The only elevated value in young people post binge drinking episode
Non specific
serum albumin in liver test
Lower levels indicate liver damage or disease
periph edema maube ascities
Prothrombin time in liver disease
Increase pro thrombin time
Decreased synth of prothormbin in liver damage
Unconjugated billlrubin vs conjucated bilirubin
Unconjugated - prehepatic issue causing too much bilirubin in blood
Intrahepatic and posthepatic result in increased levels in both conj and unconj
Conjugated: Hepatic issue resulting in
Collab care of liver dx
Rest
Avoidance of alcohol, aspirin, acetaminaohpen and NSAIDS
Prevention and management of esophageal variceal bleeding
- screening
Management of ascities
Management of encephalpathy
- if non bleeding varices pressnt take non selective beta blockers
What to do if acute esophageal varices begin
Fresh-frozen plasma
Packed RBCs
Vitamin K
Proton pump inhibitors (reduce acid in stomach)
Octreotide
Octaplex (in severe cases)
Endoscopic evaluation of the bleed:
Sclerotherapy (Injecting agent that hardens veins)
Ligation
TIPS
Transjugual intrahepatic portosystemic shunts
Stent forms channel or shunt bypassing liver and reduces BP in portal vein by diverting blood flow away from
ONly done if med and endoscopy tx dont work
Very uncommon
Ascites tx
Na restriction
Diuretics
Paracentisis
- Removes fluids from abdom cavity
Temporary mesure
Not first line therapy
Can cause Massive fluid/electrolyte shifts
Heaptic eneph tx
Reduce ammonia formtion
Tx
Lactulose - prevents hep enceph by decreasing amount of ammonia in the blood
and speeding ups it’s excretion into the stool
Tx of precipating cause (ie controlling GI hemmorhage)
Liver transplant
Wernickes enceph tx
Thiamine administration IV and then PO
Can result in permanent damage if not administered
Nursing implications for cirrohis
Acute Interventions:
Energy conservation
Symptom control
Intake and output monitoring
STRONG ASSESSMENT and advocacy when complications occur
Patent IV access on patients with varices
Drugs and Liver function
Avoid hepatotoxic drugs like Acetaminophen, ASA
First Pass effect
This affects PO meds and they should be given in Smaller doses.
Use caution in administering medications in patients with advanced liver disease.
