Liver Flashcards
Hepatitis A transmission
oral-fecal; contaminated food or water
Hepatitis A symptoms
fever, fatigue, nausea, diarrhea, anorexia, jaundice, RUQ pain
Hepatitis B transmission
blood; transfusion, IV drug, sexual contact, hemodialysis
Hepatitis C transmission
blood; transfusion, IV drug, sexual contact
Fulminant hepatitis
rare and frequently fatal form of acute Hep B in which the pts condition rapidly deteriorates, with hepatic encephalopathy, necrosis of the hepatic parenchyma, coagulopathy, renal failure, and coma
Peginterferon
used to treat chronic hepatitis B and C; reduces the amount of hepatitis virus in the body and helps immune system fight the infection
Lamivudine - HBV
used to treat hepatitis B; not a cure and does not prevent passing to others; slows the growth of the virus , decreasing the liver damage caused by the virus
Adefovir
used to treat chronic viral infection of hepatitis B; slows the growth of the virus; not a cure and does not prevent passing to others
Entecavir
used to treat hepatitis B; helps to decrease the amount of hep B in the body; antiviral
Telbivudine
used to treat hepatitis B; helps to decrease the amount of hep B in the body; antiviral; not a cure and does not prevent spread of virus to others
Ribavirin
used in combination with other antivirals; used to treat hep C; reduces the amount of hep C virus in the body
Alcoholic or nutritional cirrhosis (Laennec’s)
assoc with chronic ETOH abuse; “when was your last drink”; withdrawal symptoms from 2-12 hrs after last drink (mild anxiety and shakiness to seizures and delirium tremens; thiamine should be administered before glucose as energy source; at risk for Wernicke syndrome; ETOH causes metabolic changes in liver; fat accumulates in liver; potentially reversible if ETOH consumption ceases
Post necrotic cirrhosis
results from complication viral hep (esp hep C), and certain other drugs or toxins; liver shrinks because lobules have been destroyed; broad bands of scar tissue form within the liver
Biliary cirrhosis (cholestatic)
assoc with chronic biliary obstruction, autoimmune disease, or infection; retained bile damages and destroys liver cells causing fibrosis of liver; ERCP is done
Endoscopic Retrograde Cholangiopancreatogram (ERCP)
checks the ducts that drain the liver, gallbladder, and pancreas; can treat certain problems found during the test (biopsy an abnormal growth, remove gallstone in the common bile duct, dilate a narrowed bile duct by inserting a stent, measure the pressure inside the bile ducts)
Cardiac cirrhosis
results from long-standing severe right sided heart failure; elevated central venous pressure can cause stasis of blood in veins of liver which leads to fibrosis
Causes of cirrhosis - Hep C
leading cause; infectious blood borne illness that causes chronic disease; inflammation caused by infection leads to progressive scarring; usually takes decades to develop; ETOH use in combination with Hep C may speed process
Causes of cirrhosis - Hep B
causes inflammation and low grade damage over decades; can ultimately lead to cirrhosis
Causes of cirrhosis - Hep D
infects the liver in people who have Hep B
Causes of cirrhosis - ETOH
has a direct toxic effect on the hepatocytes; causes liver inflammation; liver becomes enlarged with cellular degeneration and infiltration by fat, leukocytes, and lymphocytes; inflammatory process decreases and destructive phase increases; scar formation is caused by fibroblast infiltration and collagen formation; damage to liver progresses as malnutrition and repeated exposure to ETOH continue; if ETOH is withheld, the fatty infiltration and inflammation is reversible; if ETOH continues, widespread scar tissue formation and fibrosis infiltrate the liver as a result of cellular necrosis
Causes of cirrhosis - biliary
occurs as a result of obstruction of the bile duct; pts with PBC typically have a predisposition to the disease
Cirrhosis Pathophysiology
end-stage of chronic liver disease; progressive - leads to liver failure; insidious onset with prolonged course; twice as common in men; hepatocytes are destroyed and portal htn develops; liver cells attempt to regenerate; regenerative process is disorganized; functional liver tissue is destroyed; scarring of liver occurs; new fibrous connective tissue distorts liver’s normal structure with impeded blood flow
Liver dysfunction - Neurologic findings
asterixis; paresthesias of feet; peripheral nerve degeneration; portal-systemic encephalopathy; reversal of sleep-wake pattern; sensory disturbances
Liver dysfunction - GI findings
abdominal pain; anorexia; ascites; clay-colored stools; diarrhea; esophageal varices; fetor hepaticus; gallstones; gastritis; GI bleeding; hemorrhoidal varices; hepatomegaly, hiatal hernia; hypersplenism; malnutrition; nausea; small nodular liver; vomiting
Liver dysfunction - Renal findings
hepatorenal syndrome; increased urine bilirubin
Liver dysfunction - Endocrine findings
increased aldosterone; increased antidiuretic hormone; increased circulating estrogens; increased glucocorticoids; gynecomastia
Liver dysfunction - immune system disturbances
increased susceptibility to infection; leukopenia
Liver dysfunction - cardiovascular findings
cardiac dysrhythmias; development of collateral circulation; fatigue; hyperkinetic circulation; peripheral edema; portal hypertension; spider angiomas
Liver dysfunction - pulmonary findings
dyspnea; hydrothorax; hyperventilation; hypoxemia
Liver dysfunction - hematologic findings
anemia; DIC; impaired coagulation; splenomegaly; thrombocytopenia
Liver dysfunction - dermatologic findings
axillary and pubic hair changes; caput medusa; ecchymosis; increased skin pigmentation; jaundice; palmar erythema; pruritus; spider angiomas
Liver dysfunction - fluid and electrolyte disturbances
ascites; decreased effective blood volume; dilutional hyponatremia or hypernatremia; hypocalcemia; hypokalemia; peripheral edema; water retention
Three phases of hepatitis
preicteric, icteric, and posticteric
Preicteric phase
1st phase of hepatitis; includes n/v, decreased appetite, weight loss, fever, fatigue, HA, joint pain, RUQ abdominal pain, enlarged spleen/liver/lymph nodes, and rash and itching of the skin (urticaria)
Icteric phase
2nd phase of hepatitis; include preicteric symptoms and jaundice, pruritus, and clay or light colored stools and dark urine
Posticteric phase
3rd phase of hepatitis; involves cessation of the first two phase symptoms, liver enlargement, and fatigue; complications include need for liver transplant, liver cirrhosis, hepatitis coma, and death; manage hepatitis by following the plan f care; notify provider of signs of bleeding, confusion edema, lethargy, and weight gain
Liver function study - ALT
elevated (0-50 norm); enzyme in liver cells; released into bloodstream with injury or disease
Liver function study - AST
elevated (0-41 norm); enzyme in liver and heart cells; released into bloodstream with injury or disease
Liver function study - GGT
elevated with cell lysis (8-55 norm); present in all cell membranes; increases when bile ducts are blocked and hepatitis; elevated until function returns
Liver function study - Alkaline phosphatase
elevated (44-147 norm); present in liver and bone cells
Liver function study - CBC
low RBC, Hct, Hgb r/t anemia, RBC destruction bleeding, folic acid, and vitamin deficiencies
Liver function study - WBC
decreased WBC and platelets; increased blood flow to spleen; cells destroyed faster than needed
Liver function study - AFP
liver cancer marker
Liver function study - lactic dehydrogenase
LDH5 specific for liver damage
Liver function study - Coagulation
prolonged PT (12-13 norm) d/t poor production of prothrombin by liver and decreased Vit K absorption
Liver function study - INR
1.2-2.5 norm; 0.8-1.2 without anticoagulation therapy
Liver function study - sodium
hyponatremia (136-145 norm) d/t hemodilution
Liver function study - potassium
hypokalemia (3.5-5 norm) d/t malnutrition and renal loss
Liver function study - phosphate
hypophosphatemia (2.7-4.5 norm) d/t malnutrition and renal loss
Liver function study - magnesium
hypomagnesemia (1.5-2.5 norm) d/t malnutrition and renal loss
Liver function study - bilirubin
total (2-14 norm); direct (0-4); elevated in liver disease
Liver function study - serum albumin
low (3.3-5 norm) d/t impaired liver production
Liver function study - ammonia
high (0-150 norm)
Liver function study - glucose and cholesterol
abnormal d/t impaired liver function
Liver function study - abdominal ultrasound
liver size, ascites, or nodules
Liver function study - esophagascopy
look for varicies
Needle biopsy
most common in past
Laparoscopic biopsy
used to remove tissue from specific parts of the liver
Transvenous biopsy
catheter into a vein in the neck and guiding it to the liver; biopsy needle is placed into the catheter and advanced into the liver; used for pts with blood-clotting problems or excess fluid
Pre-liver biopsy procedure
watch for adequacy of clotting (PT/INR, platelets); type and cross match for blood; hold aspirin, ibuprofen, and anticoagulants; chest x-ray; consent form; NPO 4-8 hrs prior; VS; empty bladder
During biopsy procedure
supine position; R arm above head; hold breath after expiration when needle inserted; be still during procedure (approx. 20 min); complications - puncture of lung or gallbladder, infection, bleeding, pain
Nursing care post liver biopsy
pressure to site; pt on right side to maintain pressure for 1-2 hrs; flat for minimum of 3 hrs; VS; check for bleeding; NPO 2 hrs after biopsy; assess for peritonitis, shock, and pneumothorax; R shoulder pain common, usually radiates to shoulder for a few hrs or days; soreness at incision site; avoid aspirin or ibuprofen for pain control for the first week; avoid coughing, straining, lifting for 1-2 wks; rest is priority; diet high cal and protein, low fat; Vit sup B complex and K; avoid ETOH and drugs
Portal hypertension
results from increased resistance to or obstruction of the flow of blood through the portal vein and its branches; blood seeks alternative venous channels around the high pressure area; blood backs into the spleen; veins in the esophagus, stomach, intestines, abdomen, and rectum become dilated; splenomegaly results from backup of blood into the spleen; enlarged spleen destroys platelets causing thrombocytopenia and increased risk for bleeding (usually the first clinical sign of liver dysfunction); can result in ascites, esophageal varicies, prominent abdominal veins, and hemorrhoids
Ascites
fluid shift from the vascular system into the abdomen; form of “third spacing”; pt may have hypovolemia and edema at the same time; fluid is plasma filtrate with high concentration of albumin; calcium is attached to albumin decreases so phosphorus increases; potassium is low d/t aldosterone
Esophageal varices
distention of fragile, thin-walled esophageal veins d/t increased pressure; result of portal hypertension; blood backs up from the liver and enters the esophageal and gastric vessels that carry it into the systemic circulation; bleeding may be either hematemesis or melena
Biliary obstruction (coagulation defects)
production of bile in the liver is decreased; prevents the absorption of fat soluble vitamins (Vit K); clotting factors are not produced in sufficient quantities and pt is susceptible to bleeding and easy bruising
Jaundice
caused by: hepatocellular disease - liver cells cannot effectively excrete bilirubin; decreased excretion results in excessive circulating bilirubin levels; or by intrahepatic obstruction - edema, fibrosis, or scarring of the hepatic bile channels and bile ducts; interferes with normal bile and bilirubin excretion; pts with jaundice often report pruritus
Portal-systemic encephalopathy (stage 1)
Prodomal - subtle manifestations; personality changes; behavior changes; emotional lability; impaired thinking; inability to concentrate; fatigue; drowsiness; slurred or slowed speech; sleep pattern disturbances
Portal-systemic encephalopathy (stage 2)
Impending - continuing mental changes; mental confusion; disorientation to time, place, or person; asterixis (liver flap)
Portal-systemic encephalopathy (stage 3)
Stuporous - progressive deterioration; marked mental confusion; stuporous; drowsy but arousable; abnormal electroencephalogram tracing; muscle twitching; hyperreflexia; asterixis
Portal-systemic encephalopathy (stage 4)
Comatose - unresponsiveness, leading to death in most pts; unarousable, obtunded; usually no response to painful stimulus; no asterixis; positive Babinski’s; muscle rigidity; fetor hepaticus (liver breath: sweet musty odor); seizures
Hepatorenal syndrome (HRS)
state of progressive oliguric renal failure associated with hepatic failure; results in functional impairment of kidneys with normal anatomic and morphologic features; indicates poor prognosis for pt with hepatic failure; often the cause of death in pts with cirrhosis
Spontaneous bacterial peritonitis
susceptible pts with very advanced liver disease; bacteria responsible for SBP are from the bowel and reach the ascetic fluid after migrating through the bowel wall and transversing the lymphatics; manifestations may include fever, chills, and abdominal pain and tenderness
Treatment of ascites
should be focused on dietary restriction of sodium less than 2000 mg daily; use of diuretics (spironolactone and furosemide); fluid restriction for those with serum sodium concentration of less than 120 or symptomatic hyponatremia
Treatment of refractory ascites
optimization of medical therapy, serial large volume therapeutic paracentesis with the use of IV albumin, TIPS, and liver transplantation; peritoneovenous shunt is palliative measure reserved for pts who are not candidates for other therapies
Spontaneous bacterial peritonitis treatment
ascritic fluid polymorphonuclear count greater than or equal to 250 cells/mm3 prompts empiric antibiotic treatment with IV cefotaxime for 5 days
Treatment for hepatorenal syndrome
pts with untreated type 1 have very poor short term survival; should be referred for urgent liver transplantation evaluation; placement of a chest tube is contraindicated in pts with hepatic hydrothorax d/t risk of massive fluid loss and high morbidity and mortality
Caput medusae
the dilated cutaneous veins around the umbilicus
Spider angioma
swollen blood vessels found slightly beneath the skin surface; often contains central red spot and reddish extensions which radiate outwards like a spiders web
Ascites nursing management
assess for resp distress; measure abd girth; high fowler’s; low protein, low sodium diet; k-sparing diuretics; mouth care; monitor for dehydration; perform paracentesis; monitor albumin, daily weight, input/output, fluid and electrolytes; perform fluid wave test
Paresentesis for ascites
treats resp distress; pt with lose 10-30 g protein; pt in sitting position; empty bladder first
Post paresentesis for ascites
apply pressure to site; bedrest for 4 hrs; monitor VS hourly x 4 hrs; monitor puncture site for leakage, abd wall hematoma, bowel perf; measure abd girth; monitor Na, Hgb, Hct, input/output, weight post-procedure and daily; admin salt poor albumin as ordered (25 cc for every 2 L ascritic fluid removed; avoids intravascular fluid shift and renal failure after large volume paracentesis)
Spironolactone/furosemide
diuretic; decreases aldosterone levels, K+ sparing
Salt-poor albumin
decreases complications of paracentesis such as electrolyte imbalance and increases in serum creatinine levels secondary to large shifts of intravascular volume
Neomycin
decreases ammonia forming organisms; only recommended when unable to tolerate lactulose
Lactulose
decreases ammonia forming organisms and inreases acidity of bowel; goal is 2-3 loose stools/day
Ferrous sulfate/folic acid
treats anemia/vitamin deficiency
Propranolol/nadolol
beta blocker; prevents bleeding of esophageal varices in conjunction with isosorbide mononitrate; lowers hepatic venous pressure
Pantoprazole
proton pump inhibitor; decreases irritation of varices
Lorazepam/diazepam
benzodiazepine; for ETOH withdrawal, sedation, sleep; metabolized in liver; use cautiously
Metolazone
helps treat edema in CHF; increases excretion of sodium, water, potassium, and hydrogen ions by inhibiting reabsorption of sodium in distal tubules; my be more effective in those with impaired renal function
Mannitol
inhibits tubular reabsorption of electrolytes by increasing the osmotic pressure of glomerular filtrate; increases urinary output
Esophageal varices treatment
active bleeding: central line and pulmonary artery pressures; blood transfusions and fresh frozen plasma for clotting factors; somatostatin or vasopressin to constrict gut vessels; nitroglycerine to counter negative affects of vasopressin; airway/trach; prevention of re-bleeding: beta blockers; long-acting nitrates (isosorbide dinatrate, isosorbide mononitrate); soft food, chew well, avoid intra-abdominal pressure; protonix
Esophageal varices balloon tube tamponade
may be life saving in pts with active variceal bleeding if emergency sclerotherapy or banding is unavailable; main complications are gastric and esophageal ulceration, aspiration pneumonia, and esophageal perforation
Sclerotherapy for esophageal varices
sclerosant solution is injected into the bleeding varix or the overlying submucosa; complications include fever, dysphagia, chest pain, ulceration, stricture, and perforation
Esophageal band ligation for esophageal varices
endoscopy loaded with an elastic rubber band is passed through and overtube directly into the varix or varices to be banded; after suctioning the bleeding varix into the tip of the endoscope, the rubber band is slipped over the tissue causing necrosis, ulceration, and sloughing of the varix; complications include superficial ulceration and dysphagia, transient chest discomfort, perforation, aspiration, infection, fever, reduced breathing rate or depth, adverse reaction to sedatives
Preop and op esophageal band ligation
local anesthetic to numb throat; relaxant medication; pt will lay on left side; VS will be monitored; “bite block” in place; scope into pts mouth down into the esophagus; sucks the enlarged varix into the device chamber and place band(s)
Postop esophageal band ligation
recovery room; tissue that was banded with slough off; teach to inform provider of persistent pain, bleeding, bloody bowel movement, difficulty swallowing, and n/v
Repeated endoscopic treatment for esophageal varices
eradicates esophageal varices in most pts; recurrent variceal bleeding is uncommon; because portal htn persists, pt at risk for recurrent varices
Long term drug treatment for esophageal varices
beta blockers after variceal bleeding; shown to reduce portal blood pressures; lowers risk for further variceal bleeding
Prophylactic management for esophageal varices
beta blockers have been shown to reduce risk of bleeding
Transjugular intrahepatic portosystemic shunt (TIPS)
interventional radiologic technique; reduces portal pressure; may be the most effective treatment for pts with diuretic-resistant ascites; under conscious sedation; IVR places a stent percutaneously from the right jugular vein into the hepatic vein, creating connection between the portal and systemic circulations; becoming the standard of care in pts with diuretic-refractory ascites
Hepatic encephalopathy
alteration in neuro status d/t accumulation of ammonia; precipitating factors: bleeding esophageal varices, narcotics, barbiturates, anesthetics, excessive protein, electrolyte imbalance, hemodynamic alterations, diuretics, severe infection, blood transfusions
Hepatic encephalopathy - Onset phase
personality changes, disturbances of awareness, forgetfulness, irritability, and confusion
Hepatic encephalopathy - Second phase
hyperreflexia, asterixis, altered hand writing, violent, abusive behavior
Hepatic encephalopathy - Coma
positive Babinski’s, hyperactive reflexes obtained with reflex hammer
Neomycin - encephalopathy
used to kill the bacteria in the gut that produce ammonia; helps prevent impaired brain function
Lactulose - encephalopathy
acts as a laxative; speeds up the passage of food; decreases the amount of ammonia that is absorbed by the body
Protein reduction - encephalopathy
ammonia is by-product of protein metabolism
S/S liver trauma
RUQ pain with abd tenderness; abd distention and rigidity; guarding of abd; increased abd pain exaggerated by deep breathing and referred to the right shoulder
S/S hemorrhage and hypovolemic shock
hypotension, tachycardia, tachypnea, pallor diaphoresis, cool clammy skin, and confusion or other change in mental state
Liver cancer
cirrhosis is primary risk factor; Hep C and B are other risk factors; metastatic is more common than primary; may lead to hemorrhage and necrosis; early s/s include hepato/splenomegaly, jaundice, weight loss, ascites, edema, dull abd pain, n/v, anorexia, increased abd girth, pulmonary emboli
Liver cancer diagnostics
liver scan, CT, MRI, MRA, hepatic angiography, ERCP, laparoscopic liver biopsy, serum alpha fetoprotein
Liver cancer treatment
surgical intervention, lobectomy, radiofrequency ablation, cryoablation, percutaneous ethanol injection, percutaneous acetic acid injection, chemotherapy, chemoembolization
Cryoablation
used for unresectable tumors with no s/s of metastasis; liquid nitrogen/argon flows thru cryoprobes into the liver and freezes it
Percutaneous ethanol injection (PEI)/percutaneous acetic acid injection (PAI)
treat non-metastasized but unresectable liver cancers; ethanol or acetic acid injected into site via ultrasound guided catheter
Chemotherapy
used when other procedures fail; leucovorin, sorafenib
Chemoembolization
embolic agent is administered via catheter
Liver transplantation
option in end-stage liver disease; requires rigorous pre-screening; performed using either deceased or live donor; split liver transplant (one liver for two pts); indications - liver disease r/t chronic viral hepatitis
Post op liver transplant complications
infection (most can be treated successfully), cancer, and rejection
Cyclosporine
given to overcome rejection
Liver transplant contraindications
MELD score 50 or CPP
Liver transplant donor evaluated for
liver disease, alcohol/drug abuse, cancer, infection, hepatitis, AIDS, blood type, body size
Liver transplant rejection
about 70% of all liver transplant pts have some degree of organ rejection prior to discharge; anti-rejection medications are given to ward off the immune attack
Hyperacute rejection
occurs in minutes to hours; caused by anti-donor Ab and complement
Accelerated rejection
occurs in days; caused by reactivation of T cells
Acute rejection
occurs in days to weeks; caused by primary activation of T cells
Chronic rejection
occurs in months to years; unclear as to cause
Cyclosporine
immunosuppressant; SE - fever, sweating, chills, body aches, flu symptoms, sores in mouth and throat, weight loss, change in mental state, problems with speech or walking, decreased vision, easy bruising or bleeding, pale skin, confusion or weakness, feeling light headed
Fluconazole
antifungal; SE - allergic reactions, nausea, upper stomach pain, itching, loss of appetite, dark urine, clay colored stools, jaundice, fever, chills, body aches, flu symptoms, severe blistering, peeling, and red skin rash, easy bruising or bleeding, unusual weakness, seizure
Mycophenolate
immunosuppressant; SE - allergic reactions, signs of infection (notify provider), stomach pain, vomiting, diarrhea, weight loss, ear pain, headache, white patches or sores in mouth or throat, pale skin
Nystatin
antibiotic; SE - not likely to occur, nausea, stomach upset vomiting, diarhhea
Prednisone
glucocorticoid; SE - muscle pain/cramps, irregular heartbeat, weakness, swelling hands/ankles/feet, unusual weight gain, signs of infection, vision problems, coffee ground vomit, black/bloody stools, severe stomach/abd pain, mental/mood changes, slow wound healing, thinning skin, bone pain, menstrual period changes, puffy face, seizures, easy bruising/bleeding
Prednisolone
adrenocortical steroid; SE - cataracts, infections, glaucoma, cushing’s syndrome, muscle wasting, bone loss, HTN, increased appetite, indigestion/heartburn, edema, hyperglycemia, labile moods, sleep disturbances
Sirolimus
immunosuppressant; SE - increased risk for infections and lymphoma, impaired wound healing, hypercholesterolemia, hypertriglyceridemia, HTN, thrombocytopenia, anemia, arthralgia, acne, rash, increased risk of interstitial pneumonitis and upper resp tract infections, insomnia, tremor
Tacrolimus
immunosuppressant; SE - nephrotoxicity, hyperkalemia, hypokalemia, hypomagnesemia, HTN, HA, insomnia, weakness, fever, pruritus, n/v, anorexia, abd pain, diarrhea, hyperglycemia, anemia, leukocytosis, abnormal LFT, ascites, peripheral edema, pleural effusion, atelectasis, dyspnea, tremors, paresthesia, back pain
Valganciclovir
antiviral; serious SE - pale skin, feeling light-headed or SOB, rapid heart rate, trouble concentrating, fever, chills, body aches, flu symptoms, mouth/throat sores, easy bruising, unusual bleeding, petechia, urinating less than usual, drowsiness, confusion, mood changes, increased thirst, loss of appetite, n/v, swelling, weight gain, SOB, seizure; SE - dizziness, loss of balance or coordination, diarrhea, constipation, tremor, cold symptoms
