Liver Disease CLASS PPT Flashcards
1
Q
How many lobes does the liver have?
A
2
2
Q
Cholecystectomy =
A
removal of gall bladder
3
Q
What can occlude the common bile duct?
Danger of gall bladder disease?
A
Biliary sludge–> tiny stones + thick bile, can occlude common bile duct
gall bladder disease + some erosion –> bile can leak out into sterile cavity + begin process of autodigestion. Can lead to sepsis
4
Q
Functions of liver:
A
- Takes glucose from portal vein and converts it to glycogen which is stored for later use. Can synthesize additional glucose through glycogenesis
- STORES vit A, B, D and B complex, iron, copper
- Provides bile for the breakdown of fat - collected in bile ducts and stored in gallbladder.
- Breaks down fatty acids into ketones if availability of glucose is decreased.
- Excretes bilirubin from breakdown of hemoglobin – eliminated in bile
- Protein metabolism
- Uses Vit K to synthesis prothrombin and other clotting factors
- Metabolizes alcohol and some drugs
- Ammonia conversion – created when protein goes through gluconeogenesis – converted into urea for excretion by kidneys
5
Q
What occurs when lipids accum in hepatocytes?
A
Normally, Breaks down fatty acids into ketones if availability of glucose is decreased.
Lipids may accumulate in the hepatocytes resulting in Non Alcoholic fatty liver Disease (NAFLD)
6
Q
What gives stool its colour?
A
bile
7
Q
How does the liver contain the ability to self protect?
A
Regenerates itself by repairing or replacing injured tissue.
The liver has many cell units responsible for the same task. Therefore, if one area is injured, other cells will perform the functions of the injured section indefinitely or until the damage has been repaired.
Left lobe can take over for right lobe and vice versa
Will do this indefinitely or until damage has been repaired
8
Q
Key components of health hx for pt with liver issues?
A
- Will focus on exposure of the patient to hepatotoxic substances or infectious agents
- Occupational, recreational, and travel history
- History of drug and substance use (prescribed, over-the-counter, herbal remedies, dietary supplements, recreational) and alcohol use
- Lifestyle behaviours tattooing, high risk sexual practices, blood transfusions prior to early 1990’s
- Past medical history family history,
- Symptoms
9
Q
T/F the enlargement of the liver is always abnormal?
A
T
10
Q
Physical assessment of liver components
A
Full abd assessment Abd circumference Fluid wave Bowel sounds Tenderness Enlarged liver – regular or irregular margin, smooth or modular, in cirrhosis margin in hard, in hepatitis the margin is soft. Color Percuss Tender if enlargement recent, may not be tender if chronic.
11
Q
Is liver disease more common in men or women?
Can children have it?
What is the leading cause of liver disease in Canada?
A
Twice the rate in men than in women.
Affects children
Non-Alcoholic Fatty Liver Disease leading cause of liver disease in Canada.
Hepatitis C next leading cause but decreasing (better tx now).
12
Q
What causes cirrhosis?
What is it?
A
Cirrhosis is a consequence of chronic liver disease characterized by replacement of liver tissue by fibrosis, scar tissue and regenerative nodules that leads to loss of liver function.
Cirrhosis is common end result of many chronic liver disorders.
Diffuse scarring of liver – follows hepatocellular necrosis of hepatitis.
Inflammation – healing with fibrosis - Regeneration of remaining hepatocytes from regenerating nodules.
Loss of normal architecture & function.
13
Q
Causes of hepatitis?
A
virus, inherited disorders, and sometimes by certain medications or toxins such as alcohol and drugs
14
Q
Causes of non-viral hep?
A
Hepatotoxic chemicals such as carbon tetrachloride, trichloroethylene, vinyl chloride
Hepatotoxic drugs such as acetaminophen
Poisonous mushrooms
15
Q
Do pt’s typically recover from non-viral hep?
A
Most patients recover from non-viral hepatitis; although some develop cirrhosis
16
Q
Tx of non-viral hep?
A
Effective treatment aims to remove the causative agent by lavage, catharsis, or hyperventilation
Go lightly: laxative use to clean people out for bowel surgery. Will use this here too
17
Q
What is a pill bezoar? (r/t drug overdose)
A
Can get “pill bezoar” in gut – think pt is recovering from drug overdose, but then start to see drop in LOC. This is due to chunk breaking off from the bezoar
18
Q
Viral hep - do ppl typically recover?
A
. In most patients hepatic cells eventually regenerate with little or no damage
Complicated by age and underlying disorders which increase the likelihood of complications
19
Q
WHen is prognosis poor for viral hep pts?
A
Prognosis is poor in the presence of edema and hepatic encephopathy
20
Q
Spread of hep A?
Acute or chronic?
A
This is caused by eating infected food or water. The food or water is infected with a virus called HAV (hepatitis A virus). Anal-oral contact during sex can also be a cause.
Nearly everyone who develops Hepatitis A makes a full recovery - it does not lead to chronic disease.
21
Q
Spread of hep b?
A
STD
infected blood, semen, and some other body fluids. Spread through the obvious ways plus:
Sharing personal items, such as a toothbrush or razor, with an infected person.
Being bitten by someone who is infected.
22
Q
How does Hep B r/t cancer risk?
A
The liver of a person infected with hepatitis B swells. The patient can suffer serious liver damage due to infection, resulting in cancer.
23
Q
Hep B - acute or chronic?
A
For some patients the hepatitis becomes chronic (very long-term or lifelong).
24
Q
How does CA risk differ those infected w hep B + C?
A
In hepatitis C, unlike hepatitis B, liver cancer risk is only increased in people with cirrhosis and only 20% of hepatitis C patients get cirrhosis. Feces is never a route of transmission in hepatitis C. Donated blood is also tested for hepatitis C.
25
Spread of hep C?
Hepatitis C is usually spread through direct contact with the blood of a person who has the disease. It is caused by the virus HCV (hepatitis C Virus). The liver can swell and become damaged.
26
How is Hep C transmitted?
BLOOD primarily
According to the internet: you can contract hepatitis C by coming into direct contact with an infected person’s blood. It can also be transmitted by contact with bodily fluids including saliva or semen of an infected person, but this is rare.
27
What are the respiratory symptoms seen in hepatitis?
pleural effusion, limited thoracic expansion, dyspnea, hypoxia
28
Will you hear crackled w pleural effusion?
Pleural effusion – not going to hear coarse lung sounds. Air isn’t travelling through fluid. May hear reduced or distant breath sounds. Big liver (inflamed) pushing up onto diaphragm toward lungs. Further compromise of expansion.
29
GI symptoms of hepatitis?
anorexia, malnourished, indigestion, nausea and vomiting, constipation or diarrhoea, dull abdominal ache, GI bleed, clay coloured stools
30
Hematological symptoms of hep?
bleeding tendencies, anemia, DIC, Thrombocytopenia, WBCs, Hypokalemia , Hypocalcemia, Hypo/Hypernatremia, Hypomagnesia
31
Endocrine symptoms of hep?
testicular atrophy, menstrual irregularities, gynecomastia, loss of chest and axillary hair
32
Hepatic & "other" symtoms caused by hep?
HEPATIC: jaundice, hepatomegaly, ascites, edema of the legs
MISCELLANEOUS: musty breath, enlarged superficial abd veins, muscle atrophy, pain right upper abd quad worsening when pt sits up or leans forward, palpable liver or spleen, elevated temp (38.3 to 39.4C), bleeding from esophageal varices
33
Tx of hep B?
TIME TO REST!
Rest in the early stages of the illness
Small meals high in calories and protein
Chronic Hep B with liver inflammation is tx with interferon alfa-2b for 16 weeks
Lamivudine therapy to decrease viral load of Hep B (antiretroviral medication used to prevent and treat HIV/AIDS and used to treat chronic hepatitis B )
34
What is essential to monitor during tx with interferon alfa-2b?
blood counts
35
What meds are used to tx hep c?
Hep C can be treated with interferon and ribavirn therapy.
Decisions regarding treatment made after labs and biopsy results confirm inflammation early cirrhosis. Tx lasts 6 -18 months
36
What sort of diet is appropriate for pt with cirrhosis?
Cirrhosis is the final stage of liver disease. The fibrous tissue caused by cirrhosis prevents the liver from functioning properly, including metabolizing and storing nutrients. One of the nutrients affected by cirrhosis is protein. The cirrhotic liver causes the body to breakdown proteins at a fast rate, quickly depleting stores and increasing body needs. However, some people with cirrhosis have high levels of ammonia, a by-product of protein metabolism, in their blood and may need to restrict protein intake to prevent adverse effects.
From class:
When considering diet for pt with cirrhosis, got to figure out where they’re at (in acute phase, or chronic? And how do we treat that protein?) Want high in protein with Hepatitis w/o cirrhosis. Ammonia levels high = no protein.
When in an acute phase, will go low in protein levels b/c don’t want to inc ammonia. When recovering want to titrate up. Don’t ever stop the lactulose! Lactulose binds with ammonia and therefore helps it be excreted w frequent BMs.
37
Is malnutrition common in cirrhosis pts?
| How is nutrient absoption, synthesis etc affected?
Malnutrition is common in patients with cirrhosis. This is due to a poor appetite and intake, malabsorption of nutrients and impaired nutrient metabolism. Malnutrition increases the risk of disease and death.
While protein breakdown is elevated with cirrhosis, synthesis is decreased, which causes muscle wasting and a decrease in blood protein. Getting enough protein in a diet to meet physical needs is essential to maintain adequate levels of protein and prevent further illness.
38
What pattern is seen in alcohol liver injury? What stages can be reversed/not?
```
Alcoholic Liver disease - Patterns:
Fatty change,
Acute hepatitis
Chronic hepatitis with Portal fibrosis
Cirrhosis, Chronic Liver failure
```
All reversible except cirrhosis stage.
39
Signs + symptoms of end stage liver disease? (seems to fit under alcoholic section mostly...)
```
Neurological:
Asterixis Paraesthesias
Dec LOC
Sensory disturbances
Behavorial changes Cognitive changes
```
```
Spider angiomas Palmar erythma
Jaundice
Pruitis
Dec hair production Caput medusa
inc pigmentation Bruising
White Nails
```
40
Why is ativan used in alcohol withdrawal?
Less hepatotoxic
41
What meds are given for alcohol liver failure?
Lactulose is administered because it breaks down ammonia (NH3) which is elevated d/t GI bacterial action. The Lactulose breaks down NH3 into components absorbed and excreted in stool.
Metronidazole may also be administered to ↓ bacteria and subsequently
a ↓ in NH3.
42
Important consideration for giving lactulose?
Watch fluids balance - If fluid and electrolyte balance worsens, there is an ↑ risk of hepatorenal failure.
43
What level of serum bilirubin would cause jaundice?
>40umol/l, (3mg/dl)
44
Types of jaundice?
Conjugated & Unconjugated types
Obstructive & Non Obstructive (clinical)
Pre-Hepatic, Hepatic & Post Hepatic types
45
Skin care for pt with jaundice?
Why do you see pruritis?
keep clean + moisturized
Pruritus caused by cutaneous lipid deposits d/t malabsorption
Antihistamines not routinely administered d/t compromised liver
46
Beyond yellow skin, how might jaundice present?
urine dark rusty yellow. Tears can be yellow. If wound, serous fliud is yellow.
47
What cause of jaudice r/t uncojugated/free bilirubin + which has conjugated?
UnConjugated: Hemolytic + hepatocellular (if d/t liver damage)
Conjugated: Post hepatic + hepatocellular (if swelling, canalicular obstruction)
48
Will you see bilirubin in the urine if hemolysis is the cause?
No (d/t fact that it's unconjugated I think so not water soluble)
49
What causes obstructive jaundice?
| What symptoms would show in addition to jaundice itself?
Obstructive jaundice is a particular type of jaundice and occurs when the essential flow of bile to the intestine is blocked and remains in the bloodstream. This might be due to blocked bile ducts caused by gallstones, or tumours of the bile duct which can block the area where the bile duct meets the duodenum.
biliary atresia; biliary disease or blockage due to inflammation; gall stones; cholestatic medications can cause internal blockage of ducts;
Bile cannot flow into the intestines but backs up into liver, blood, staining skin, sclera, urine bright orange and frothy. Stool clay colored, skin itchy
Intolerance of fatty foods, fatty stools
If not reversed can damage liver.
50
What is seen w portal HTN? (complications)
Ascites
Porta systemic shunts
Varices,
Splenomegaly
51
Why else, beyond liver disease, would you see ascites?
Ascities usually due to liver disease or damage but may also be due to heart failure, ca, kidney disease.
52
Cause of portal htn in liver disease?
Obstructed bld flow through the damaged liver results in increased bp throughout the portal venous system.
53
Why ascites in liver failure?
How much fluid can accum?
Liver unable to metabolize Aldosterone increasing Na and water retention, that increases intravascular fld volume and decreases synthesis of albumin. Fluid then moved from the vascular system to the peritoneal space. – it then draws more Na causing a self perpetuating problem.
Up to 15 + liters of albumin rich fluid may accumulate in the abd.
54
S+S of ascites?
increased girth, increased wt, sob, distended veins, umbilical hernias
Fluid and electrolyte imbalances are common
55
Tx of ascites?
dietary modification - low sodium diet
Diuretics (spiralnolactone + lasix) and sodium restriction
Bedrest
Paracentesis (for comfort)
Trans jugular intrahepatic portosystemic shunt
Albumin administration to shift fluid from interstitial to vascular space
56
What vitamins will all pts with alcholism be given? WHy?
Nutrition: all patients with alcoholism should be given Thiamine and multivitamins to prevent Korsakoff’s Dementia on every admission and be on multivitamins daily
Korsakoff syndrome is a chronic memory disorder caused by severe deficiency of thiamine (vitamin B-1). Korsakoff syndrome is most commonly caused by alcohol misuse, but certain other conditions also can cause the syndrome
Korsakoff's syndrome is caused by lack of thiamine (vitamin B1), which affects the brain and nervous system. People who drink excessive amounts of alcohol are often thiamine deficient. This is because:
many heavy drinkers have poor eating habits and their diet does not contain essential vitamins
alcohol can interfere with the conversion of thiamine into the active form of the vitamin (thiamine pyrophosphate)
alcohol can inflame the stomach lining, cause frequent vomiting and make it difficult for the body to absorb the key vitamins it receives. Alcohol also makes it harder for the liver to store vitamins.
57
What is the result of nutritional deficiencies in liver damage?
Inability of the damaged liver cells to metabolize certain vitamins leading to:
Impaired functioning of the central and peripheral nervous systems.
Abnormal bleeding tendencies.
58
What causes hepatic encephalopathy?
Due to accumulation of ammonia in the serum due to impaired protein metabolism.
59
What causes esophageal varices?
Increased opbstruction of the portal vein so venous bld seek alt route back to right atrium resulting in increased pressure in the vessels in the submucosal layer of
Vessels not elastic so very fragile
60
Causes of bleeding from esophageal varices?
Bleed caused by coughing, lifting, sneezing, emesis, reflux
| Endoscopy for dx
61
What are the risks of liver biopsy?
| What needs to be established as normal before doing this?
mainly to evaluate lesions
risk for bleeding and bile peritonitis
done if coagulation studies normal or issues dealt with.
62
Differentiate the types of liver function tests:q
ALT increases primarily in liver disorders – used to monitor the course of hepatitis or cirrhosis or the effects of treatments that may be toxic to the liver.
AST not specific to liver, may indicated high metabolic activity or damage to an organ
GGT elevation linked to cholestasis or alcoholic liver disease
63
What sort of scans may be done for diagnosis in liver idsease?
CT – 3 dimensional image
MRI – done without contrast media
PET – sees cell uptake so mainly for cancers (faster uptake)
Ultrasound doppler – good for assessing bld flow
Scope – can visualize liver and other pelvic structures. Diagnose and stage cancers.
64
What kind of treatments are done for liver disesase?
Medications to decrease portal hypertension (beta blockers)
Medications that cause selective GI vasoconstriction and slow motility.
Balloon Tamponade
Endoscopic Sclerotherapy
Esophageal Banding Therapy
Transjugular Intrahepatic Portosystemic Shunting
Paracentesis
Surgical managment
65
What is Sclerotherapy
What is more effective here?
injection of an agent to promote thrombis and sclerosis
Sclerotherapy for esophageal varices, also called endoscopic sclerotherapy, is a treatment for esophageal bleeding that involves the use of an endoscope and the injection of a sclerosing solution into veins.
Banding more effective at preventing recurrent bleeding.
66
TIPS
Transjugular Intrahepatic Portosystemic Shunting
cannula is threaded into the portal vein by the transjugular route, stent is inserted and serves as an intrahepatic shunt to decrease portal hypertension
67
Is surgery a common tx for liver disease?
| What kind of procedures may be done?
Surgery last ditch effort – high mortality rate – bypass procedures –
Partial transplants from cadavers and living donors
68
What medications are used to tx of liver disease?
Infections: Spontaneous Bacterial Peritonitis treated with 3rd generation antibiotics e.g. Cefotaxime (a cephalosporin)
H2 receptor blockers administered to prevent stress ulcers and GI bleeding e.g. Ranitidine, Pantaloc, Pariet
Ativan should be administered for withdrawal symptoms since it is less hepato-toxic
- Beta Blockers to decrease portal hypertension
- Lactulose
- Spironolactone (k+ sparing diuretic) and Lasix (loop diuretic)
- Metronidazole
69
WHy lactulose + metronadizole in tx of liver failure?
Lactulose is administered because it breaks down ammonia (NH3) which is elevated d/t GI bacterial action. The Lactulose breaks down NH3 into components absorbed and excreted in stool. The goal is 2 – 4 stools per day; requires close fluid and electrolyte monitoring.
Metronadizole may also be administered to ↓ bacteria and subsequently a ↓ in NH3.
70
What is a blakemore tube?
A Sengstaken–Blakemore tube is a medical device inserted through the nose or mouth and used occasionally in the management of upper gastrointestinal hemorrhage due to esophageal varices (distended and fragile veins in the esophageal wall, usually a result of cirrhosis).
The tube is passed down into the esophagus and the gastric balloon is inflated inside the stomach. A traction of 1 kg is applied to the tube so that the gastric balloon will compress the gastroesophageal junction and reduce the blood flow to esophageal varices. If the use of traction alone cannot stop the bleeding, the esophageal balloon is also inflated to help stop the bleeding. The esophageal balloon should not remain inflated for more than six hours, to avoid necrosis. The gastric lumen is used to aspirate stomach contents.
71
Pt teaching for viral hep?
Regular medical check ups for at least one year
Do not drink EtOh during this time
Signs and symptoms of recurrence
A hepatitis carrier must be advised how to prevent exchange of body fluids during sexual relations
Patient must avoid contact sports for as long as the liver is enlarged
72
Signs + symptoms of hepatic encephalopathy
Confusion, motor disturbances, mood, altered LOC, cannot copy simple figures (constructional apraxia)
Asterixis (flapping tremor of the hands)
ECG show general slowing of brain waves
73
3 means by which lactulose draws serum ammonia out into stool?
1) Ammonia is kept in the ionized state resulting in a fall in colon pH reversing the normal passage of ammonia from the colon to the blood
2) Evacuation of the bowel takes place decreasing and ammonia absorbed from the colon
3) Fecal flora are changed to organisms' that do not produce ammonia from urea
74
Is it likely someone will recover from hepatic encephalopathy?
In class said it's unlikely someone will recover once this occurs - is veyr late stage failure
75
```
What is NAFLD?
Is it common?
What is believed to be assoc w?
Is it easily detected?
Are complications common?
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A condition in which excess fat accumulates in the liver of people who drink little or no alcohol.
One of the most common liver diseases
Is believed to be associated with rising rates of obesity
Goes largely unnoticed as it causes no signs or symptoms.
Tend to be free of complications unless it results in inflammation and scarring - fibrosis
76
Risk/contributing factors of NAFLD?
```
Obesity
High Blood Cholesterol
Type Two Diabetes
Malnutrition
Rapid Weight Gain (or loss?)
Medication: steroids, exposure to toxins and
chemicals
```
77
What is the most common cause of liver disease in children?
NAFLD
NAFLD is a clinic-pathological condition defined by the accumulation of intrahepatic triglyceride fat (IHTF) content in the absence of alcohol consumption .
78
What is NAFLD assoc w in children?
Does it typically progress to cirrhosis?
Outcome for chidlren with this?
Is increasingly diagnosed in obese children and it may progress to cirrhosis even in this age group.
In addition, children with NAFLD have a higher risk of mortality or of requiring a liver transplant .
During the last years there has been a growing interest in the relationship between NAFLD and the development of metabolic and cardiovascular diseases.
79
Tx of NAFLD?
Liver Transplant
No Medication available to treat
Antioxidant vitamins? Studies inconclusive
Ongoing studies with meds designed to increase sensitivity to insulin
Lifestyle changes, encourage to lose weight - LOTS OF HEALTH PROMOTION NEEDED with this disease emerging
80
How serious is alcohol withdrawal?
Alcohol withdrawal results in seizures – is the one kind of withdrawal that you can actually die from
