Liver Disease Flashcards
1
Q
Liver: major metabolic organ (3)
A
- receives nutrient-rich blood from GI; mix of venous and arterial blood
- gets nutrients ready for metabolism
- regulates glucose and protein metabolism
2
Q
liver metabolism
A
- protein metabolism: ammonia –> urea, excreted in urine
- synthesis albumin (transporter), clotting factors
- break down of fatty acids for energy
3
Q
liver metabolism (bile, bilirubin)
A
- bile: removal of waste from blood stream into bile (bilirubin, urea)
- bile: digestive function (emulsification of fats)
- bilirubin: from breakdown of Hg, excreted mostly through bile
4
Q
liver metabolism (drug metabolism)
A
- drug metabolism: barbiturates, opioids, sedatives, anesthetics
- mostly drug inactivation by binding of medication with other compound
- excretion in feces or urine (before reaching blood stream)
5
Q
liver metabolism (PO meds)
A
- PO meds: decreased availability in serum if major metabolism by liver before reaching systemic circulation (first pass effect) - IV route
- morphine, insulin (first pass effect) –. that is why they are given IV/subq
6
Q
age related changes of the hepatobiliary system (11)
A
- steady decrease in size and weight of liver, particularly in women
- decrease in blood flow
- decrease in replacement/ repair of liver cells after injury
- reduced drug metabolism
- slow clearance of hep B surface antigen
- more rapid progression of hep C infection and lower response rate to therapy
- decline in drug clearance capability
- Increased prevalence of gallstones due to the increase in cholesterol secretion in bile
- decreased gallbladder contraction after a meal
- atypical clinical presentation of biliary disease
- more severe complications of biliary tract disease
7
Q
Liver assessment: health hx (9)
A
- alcohol***/drug use, hepatotoxic meds
- exposure to toxins, infection
- occupation, travel
- lifestyle, recreational habits
- PMH, family hx
- nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH)
- strongly associated with obesity
- Increased r/o liver cancer
- obesity raises ALT, marker of liver damage in children, adolescents
8
Q
Liver assessment: clinical manifestations
A
- symptoms: fever, anorexia, edema, personality changes
- jaundice, pruritus
- fatigue, weakness, malaise
- abd pain, increased abdominal girth, hematemesis
- sleep disturbances
9
Q
Liver physical assessment (7)
A
- pallor, jaundice (skin, mucosa, sclera)
- muscle atrophy, edema, palmar erythema
- ecchymosis, petechiae. spider angiomas
- mental status/neurologic changes (recall, memory) (late, severe disease). **Report to provider sudden late changes: possible hepatic encephalopathy **
- tremor, weakness, asterisks (late, severe disease, report)
- slurred speech (late, severe disease)
- palpable liver, abdominal fluid wave (late, severe disease)
10
Q
Palpating the liver (4)
A
-place left hand under right lower rib cage –> lightly press the abdomen down on the same side –> try to feel for the inferior border of the liver –> healthy liver will not be palpable
11
Q
Liver Diagnostic evaluation (4)
A
- liver panel or liver function tests –> * ALT, AST, alkaline phosphatase (more common), bilirubin*, albumin (edema), total protein, serum globulin, lactate dehydrogenase, PT, INR, aPTT (coagulation)
- lipid panel: LDL, HDL, total cholesterol
- biopsy
- US, CT, MRI
12
Q
May take more than __% tissue damage before abnormal __.
A
70%, LFTs
13
Q
ALT
A
liver-specific, monitor cirrhosis, hepatitis
14
Q
AST
A
tissues with high metabolic activity – liver, heart, skeletal muscle, kidney cell damage/death
15
Q
What is jaundice?
A
bilirubin accumulation in the blood
16
Q
normal total bilirubin range
A
0.3-1.9 mg/dl
17
Q
portal hypertension
A
from obstruction of blood flow –> ascites, esophageal varices
18
Q
portal hon assessment
A
daily weight and abdominal girth measurement
19
Q
ascites (how it happens)
A
increase in capillary pressure, obstruction of venous blood flow through the damaged liver
20
Q
ascites management (3)
A
- low sodium diet, diuretics (spironolactone), bed rest, paracentesis
- daily weight loss 1-2 kg
- monitor for FE imbalances
21
Q
Paracentesis
A
- larger volume (5-6L) ascites causes respiratory distress
- concurrent infusion of albumin
- monitor postparacentesis VS, renal, respiratory
22
Q
Transjugular Intrahepatic Portosystemic Shunt (TIPSS)
A
facilities drainage of engorged liver into vena cava
23
Q
Why does hepatic encephalopathy happen?
A
from increased serum ammonia, dehydration, meds, electrolyte unbalance
24
Q
hepatic encephalopathy clinical manifestations
A
ALOC, motor changes (asterixis)
25
What to manage during hepatic encephalopathy?
FE imbalance, serum ammonia level
26
hepatic encephalopathy: lactulose *****
promotes ammonia excretion through feces; monitor for soft bowel movements
27
hepatic encephalopathy: Rifaximin
better tolerated and works faster than lactulose; also used for travelers diarrhea and IBS. Few and mild side effects
28
hepatic encephalopathy: management (3)
- watery diarrhea: medication overdose
- monitor VS, FE imbalance, IO, neuro, handwriting, arithmetic, serum ammonia
- protein intake moderately restricted, avoid foods high in protein
29
Nutritional management of hepatic encephalopathy (5)
- minimize the formation and absorption of toxins, principally ammonia, from the intestine
- keep daily protein intake between 1.2-1.5 g/kg body weight per day
- avoid protein restriction if possible, even in those with encephalopathy
- for patients who are truly protein intolerant, provide additional nitrogen in the form of an amino acid supplement.
- provide small, frequent meals and 3 small snacks per day in addition to a late-night snack before bed
30
Stage 1 hepatic encephalopathy: clinical symptoms, clinical signs and EEG changes
Clinical symptoms --> normal LOC with periods of euphoria and lethargy; reversal of day-night sleep patterns
Clinical signs and EEG changes --> impaired writing and ability to draw line figures. Normal EEG
31
Stage 2 hepatic encephalopathy: clinical symptoms, clinical signs and EEG changes
Clinical symptoms --> increased drowsiness; disorientation, inappropriate behavior; mood swings, agitation
Clinical signs and EEG changes --> asterixis; fetter hepatitis. Abnormal EEG with generalized slowing.
32
Stage 3 hepatic encephalopathy: clinical symptoms, clinical signs and EEG changes
Clinical symptoms --> stuporous; difficult to arouse; sleeps most of the time; marked confusion; incoherent speech
Clinical signs and EEG changes --> asterixis; increased DTR; rigidity of extremities. EEG markedly abnormal
33
Stage 4 hepatic encephalopathy: clinical symptoms, clinical signs and EEG changes
Clinical symptoms --> comatose; may not respond to painful stimuli absence of asterixis; absence of DTR; flaccidity of extremitie. EEG markedly abnormal
Clinical signs and EEG changes --> absence of
asterixis; absence of DTR; flaccidity of extremitie. EEG markedly abnormal
34
Other manifestations of hepatic dysfunction (4)
- edema (low serum albumin- lack of production by liver)
- Bleeding: Implement fall precautions ***** due to increased risk for bleeding, report any falls to MD
- vitamin deficiency
- pruritus
35
esophageal varices (what it is, clinical manifestations, monitor, how to treat) (5)
- profuse bleeding may lead to airway loss and hemorrhagic shock
- hematemesis, melena, acute clinical deterioration
- VS, endoscopy, CBC, LFT
- vasoactive drugs for acute blood loss (IV octerotide)
- Sclerotherapy (thrombosis), vaticeal banding
36
What is cirrhosis?
normal tissue replaced with diffuse fibrosis; decreased liver function
37
most common cause of cirrhosis
- alcoholic --> scar tissue takes place of normal liver
38
What is biliary cirrhosis?
scarring around bile duct
39
s/s compensated cirrhosis (10)
- intermittent mild fever
- vascular spiders
- palmar erythema
- unexplained epistaxis
- ankle edema
- vague morning indigestion
- flatulent dyspepsia
- abd pain
- firm, enlarged liver
- splenomegaly
40
s/s decompensated cirrhosis (14)
- muscle wasting
- ascites
- jaundice
- weakness
- weight loss
- continuous mild fever
- clubbing of fingers
- purpura
- spontaneous bruising
- epistaxis
- hypotension
- sparse body hair
- white nails
- gonadal atrophy
41
Hepatic cirrhosis clinical manifestations (5)
- hepatomegaly, anemia, vitamin deficiency, mental deterioration
- portal obstruction and ascites
- Infection and peritonitis (translocation of intestinal flora; *** elevated temp is an ominous sign****
- GI varices (esophageal, rectal, abdominal)
- edema: reduced plasma albumin
42
Hepatic cirrhosis dx (4)
- liver function tests
- serum albumin, globulin, AST, ALT, bilirubin, PT, US, CT, MRI
- liver biopsy
- ABGs
43
Hepatic cirrhosis medical management (3)
- antacids, H2 antagonists (minimize GI bleeding)
- vitamins, nutritional supplements, improvement of nutritional status
- K-sparing diuretics: spironolactone (pts with hypokalemia), triamterene
44
Hepatic cirrhosis medical management --> 2020 study
-increased r/o hepatic encephalopathy in patients with cirrhosis prescribed short-term and chronic opioids prescription
