Liver Disease

Question 1

Hepatitis

Answer 1

• inflammation of the liver
• caused by infectious organism that enters body or by a toxin (alcohol or medications)
• non-infectious hepatitis may occur secondary to exposure to a chemical or medication
• viral hepatitis can be acute or chronic

Question 2

5 Major Categories of Viral Hepatitis

Answer 2

1) hepatitis A virus (HAV)
2) hepatitis B virus (HBV)
3) hepatitis C virus (HCV)
4) hepatitis D virus (HDV)
5) hepatitis E virus (HEV)

hepatitis F and G have been identified but are uncommon

Question 3

Routes of Transmission for each Category

Answer 3

Hepatitis A and E: oral-fecal route (ie. ingestion of contaminated water)

Hepatitis B and C: blood (ie IV drug abuse, sexual contact, health care work)

Hepatitis D: co-infection with HBV

Question 4

Prevention of Viral Hepatitis

Answer 4

1) Hep B vaccination prophylaxis for all health care workers
2) proper use of standard precautions
3) use of needleless system when delivering medications and parenteral solutions
4) use of PPE appropriate to type of exposure (gown, gloves, goggles)
5) report hepatitis outbreaks to health authorities
6) frequent hand hygiene (before eating, after using toilet)
7) if traveling to underdeveloped countries, drink bottled water and limit sharing of bed linens and eating utensils

Question 5

Manifestations of Hepatitis

Answer 5

1) headache
2) fatigue
3) arthralgia (joint pain) and myalgia (muscle pain)
4) pruritis
5) low-grade fever
6) RUQ abdominal pain
7) nausea and vomiting
8) jaundice
9) dark urine

Question 6

Laboratory Tests

Answer 6

1) enzyme-linked immunosorbent assay (ELISA) or recombinant immunoblot assay (RIBA)
2) elevated serum liver enzymes:
- alanin aminotransferase (ALT): most definitive for assessment of liver tissue damage
- aspartate aminotransferase (AST)
- alkaline phosphatase (ALP)
- serum bilirubin
3) serologic markers
- identifies presence of virus (HAV, HBsAg and Anti HBc IgM, HCV, HDV, HEV)
- serum presence of HBsAg for longer than 6 mos. indicates chronic hepatitis and/or hepatitis carrier status.
- serum presence of HBsAb indicates immunity to HVB following the recovery from hepatitis B or a successful vaccination

Question 7

Diagnostic Procedures

Answer 7

1) abdominal x-rays
- used to visualize possible hepatomegaly, ascites, and spleen enlargment
2) liver biopsy
- most definitive
- used to identify intensity of infection and degree of tissue damage

**post liver biopsy, client will be required to lie on affected surgical side for short period of time and nurse should monitor BP and HR to detect bleeding

Question 8

Nursing Care

Answer 8

1) enforce standard and contact precautions
2) private room or room with other clients with same infection
3) gloves and gowns worn by nurses AND visitors while in client’s room
4) limit client’s activity (bed rest, rest periods) in order to promote hepatic healing
5) provide dietary education regarding high-carb, high-calorie, low-to moderate-fat, and low-to moderate-protein diet and small, frequent meals to promote nutrition and healing
6) only necessary meds are administered in order to promote hepatic rest and regeneration of tissue.
- cautious, if any, use of acetaminophen due to potential for liver damage
7) educate client and family regarding measures to prevent transmission of disease w/ others at home (avoid sexual intercourse until hepatitis antibody testing is negative)

Question 9

Medications Used to Treat Hepatitis

Answer 9

1) Immunoglobulin:
- may be prescribed for household members and sexual partners of clients with hepatitis A
- prophylactic injections may be given to individuals traveling to high-risk countries
2) biologic response modifiers (BMRs):
- administered to clients with chronic hepatitis B or C for several months to induce remission
3) antivirals:
- lamivudine (Epivir, adefovir (Hepsera), or ribavirini (Rebetol) may be given for clients with chronic hepatitis B to decrease incidence of cirrhosis, or clients waiting for liver transplant

Question 10

Complications

Answer 10

1) chronic hepatitis
- results from hepatitis B, C, or D
- increases client’s risk for liver cancer
2) fulminating hepatitis
- a fatal form of hepatitis due to inability of liver cells to regenerate with progression of necrotic process
- results in hepatic encephalopathy and death
3) cirrhosis of the liver
- continued episodes of chronic hepatitis result in scarring and permanent injury to liver and are a risk factor for liver cancer
4) liver cancer
5) liver failure

Question 11

Cirrhosis

Answer 11

• occurs secondary to inflammation of the liver
• functional liver tissue is replaced with fibrotic, scar tissue
• caused by hepatitis, alcohol abuse, or inflammatory disorders

Question 12

Risk Factors for Cirrhosis

Answer 12

1) alcohol abuse
2) chronic viral hepatitis (B, C, or D)
3) autoimmune hepatitis (destruction of liver cells by immune system)
4) steatohepatitis (fatty liver disease causing chronic inflammation)
5) damage to liver caused by drugs, toxins, and other infections
6) chronic biliary cirrhosis (bile duct obstruction, bile stasis, hepatic fibrosis)
7) cardiac cirrhosis resulting from severe right heart failure, inducing necrosis and fibrosis due to lack of blood flow
8) obesity

Question 13

Manifestations of Cirrhosis

Answer 13

1) fatigue, weight loss, abdominal pain, and distention
2) pruritis (severe itching of skin)
3) confusion or difficulty thinking, personality and mentation changes, emotional lability, euphoria, depression
4) GI bleeding
5) ascites
6) jaundice and icterus (yellowing of the eyes)
7) petechiae (round, pinpoint, red-purple lesions), ecchymosis, nose bleeds, hematemesis, melena (black, tarry feces associated with upper GI bleeding)
8) spider angiomas
9) dependent peripheral edema of extremities and sacrum
10) asterixis–coarse tremor characterized by rapid, nonrhythmic extension and flexion of wrists and fingers
11) fetor hepaticus–fruity or musty odor to breath

Question 14

Laboratory Tests

Answer 14

1) serum liver enzymes:
- alanine aminotransferase (ALT) and aspartate aminotransferase (AST) are elevated initially due to hepatic inflammation and return to normal when liver cells are not longer able to create an inflammatory response.
- alkaline phosphatase (ALP) increases in cirrhosis due to intrahepatic biliary obstruction
2) serum bilirubin is elevated
3) serum proteins and serum albumin are lowered due to lack of hepatic synthesis
4) hematological tests:
- CBC, WBC, and platelets are decreased secondary to anemia
5) PT/INR is prolonged due to decreased synthesis of prothrombin
6) ammonia levels rise when hepatocellular injury (cirrhosis) prevents conversion of ammonia to urea for excretion

Question 15

Diagnostic Procedures

Answer 15

1) abdominal films and ultrasonography
- used to visualize possible hepatomegaly, ascites, and splee enlargement
2) liver biopsy (most definitive)
- identifies progression and extent of the cirrhosis
3) esophagogastroduodenoscopy (EGD)
- performed under moderate (conscious) sedation to detect the presence of esophageal varices

Question 16

Care of Client with Cirrhosis

Answer 16

1) monitor respiratory status and oxygen level
2) provide comfort measures by positioning client to ease respiratory effort (may be compromised by plasma volume excess and ascites)
- have client sit in a chair or elevate head of bed to 30 degrees
3) skin integrity:
- monitor client closely for skin breakdown
- implement measures to prevent pressure ulcers
4) pruritis will cause client to scratch. encourage washing with cool water and applying lotion to decrease the itching
5) monitor for signs of fluid volume excess and keep strict I&O.
- restrict fluids and sodium if prescribed and weigh daily
6) neurological status:
- monitor client for deteriorating mental status and dementia consistent with hepatic encephalopathy
7) nutritional status:
- encourage a high-calorie, high-protein (unless has hepatic encephalopathy) diet and supplemental vitamins (B complex), folic acid, and iron
8) GI status:
- in presence of ascites, measure abdominal girth daily
9) pain status:
- assess pain and administer analgesics and GI antispasmodics as needed
10) observe client of potential bleeding complications.
- may need transfusions to replace blood volume and clotting factors as prescribed by provider
11) monitor trends in Hgb and Hct levels and note coagulation studies (aPTT, PT/INR)

Question 17

Medications Used to Treat Cirrhosis

Answer 17

**general medications are administered sparingly (esp. opioids, sedatives, and barbiturates) because metabolism is dependent upon functioning liver
1) diuretics:
administered to decrease ascites
2) PPI and H2 receptor antagonist:
-administered to decrease gastric acid secretion and risk of GI bleeding
3) lactulose:
-administered to promote ammonia excretion via the stool
4) neomycin and metronidazole (Flagyl):
-administered to remove intestinal bacteria (which produces ammonia)

Question 18

Therapeutic Procedures

Answer 18

1) paracentesis
- used to relieve ascites
2) injection sclerotherapy/variceal band ligation
- esophageal varices are either sclerosed or banded endoscopically
- decreased risk of hemorrhage with banding

Question 19

Surgical Interventions

Answer 19

1) transjugular intrahepatic portosystemic shunt (TIPS)
- done to control ascites and variceal bleeding
2) surgical bypass shunting procedures
- used as last resort for clients w/ portal hypertension and esophageal varices
- ascites is shunted form abdominal cavity to the superior vena cava
3) liver transplantation
- portions of healthy livers from trauma victims or living donors may be used for transplant
- transplanted liver portion will regenerate and grow in size based on needs of the body
- clients with severe cardiac and respiratory disease, mestastic malignant liver cancer, and continued hx of alcohol/substance abuse are not candidates

Question 20

Care of Client with Cirrhosis

Answer 20

1) encourage client to abstain from alcohol and engage in alcohol recovery program
- helps prevent further scarring and fibrosis of liver
- allows healing and regeneration of liver tissue
- prevents irritation of stomach and esophagus lining
- helps decrease risk of bleeding
- helps prevent other life-threatening complications

Question 21

Dietary Guidelines for Client with Cirrhosis

Answer 21

1) high-calorie, moderate-fat diet
2) low-sodium diet (if client has excessive fluid in peritoneal cavity)
3) low-protein (if encephalopathy, elevated ammonia)
4) small, frequent, well-balanced nutritional meals
5) supplemental vitamin-enriched liquids (Ensure, Boost)

Question 22

Complications of Cirrhosis

Answer 22

1) portal systemic encephalopathy (PSE)
- clients who have a poorly functioning liver are unable to convert ammonia and other waste products to a less toxic form.
- these products are carried to the brain and cause neurological symptoms
2) esophageal varices
- portal hypertension (elevated BP in veins that carry blood from the intestines to the liver) is caused by impaired circulation of blood through the liver
- collateral circulation is subsequently developed creating varices in upper stomach and esophagus.
- varices are fragile and can bleed easily