Liver Diseases Flashcards
Describe the structures and functions of the GI system, specifically, the liver, pancreas and gallbladder.
Largest internal organ in the body
Functions:
-Bile Synthesis functions include: bile production, excretion and storage
-for fat, carbohydrate, and protein metabolism
-Helps create blood clotting factors (coagulants) because bile helps vit K get absorbed
-stores glycogen. Released when needed
-stores Vit and minerals. ADEK, B1, B12, folic acid, copper, ferritin
-Filters blood. To remove hormones like estrogen and aldosterone and alcohol and drugs.
-Immuno - Mononuclear phagocyte system Komfer cells breakdown old RBC’s, WBC’s, bacteria, etc. -Breakdown of Hgb to bilirubin and biliverdin
Komfer cells destroy pathogens that enter the liver via the gut
-Absorbs and metabolizes bilirubin. Stores the iron byproduct and is used to make the next generation of RBCs
- Albumin production. For oncotic pressure
-Synthesis of angiotensinogen hormone. To raise BP via vasoconstriction by stimulating the RAAS
Describe the purpose of key diagnostic and lab tests involved in evaluating the liver, gallbladder and pancreas.
Explain the etiology, pathophysiology, clinical manifestations, complications, collaborative care and nursing management of patients with:
Cirhhosis
Hepatitis
Cirrhosis - the final stage of chronic liver disease
men>women
ages 40-60
-2ndary to alcoholism
-nodular surface dt liver cell Regenerative process is disorganized
- Abnormal blood vessel and bile duct formation
-Overgrowth of new fibrous connective tissue (scar) distorts liver’s normal structure, impedes blood flow.
-Irregular and disorganized regeneration, poor cellular nutrition and hypoxia d/t inadequate blood flow and scar tissue result in decreased liver functioning.
tx:
-goal: stopping or delaying progression
-symptom management
- ex diuretics - to remove excess fluid to prevent edema and ascites
-laxatives like lactulose to help absorb toxins and speed up the removal of toxins from intestines
-beta blockers - to lower portal HTN to stop bleeding. (from stomach/esophagus varicies). Varicies can be wrapped with a band or injected with a hardening agent
-alcohol cessation
-low salt diet
-if caused by hepatitis = antiviral medication
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Cirrhosis causes
1. alcohol. is hepatotoxic and causes necrosis of liver cells and fat infiltration into the liver
2. Nonalcohol fatty liver disease (NAFLD)
3. nutrition- malabsorption, malnutrition, extreme dieting
4. Hep B, C
5. genetic, environmental
Hepatitis
Inflammation of the liver. Usually viral
Hepatitis A -consuming food or water contaminated by feces.
-Diagnosed by detection of anti-HAV IgM in the serum.
-Supportive care as no tx available
-Self-limiting (usually 4-6 wks duration)
-Confers lifelong immunity
-Hep A Vaccine good for 10 years
-Rare that hep A infection turns into acute liver failure, Hep B can tho
S/S
a, n/v
malaise, fatigue, headache
low-grade fever
RUQ pain
skin rashes
arthralgia
+/- jaundice
Hepatitis B
-As an RN you must be immunized for it
-Screening tests: HBsAg, Anti-HBs and Anti-HBc
-Transmission perinatally, percutaneously, sexually or horizontally (by permucosal exposure to infectious blood, blood products or other body fluids).
-acute and chronic
-Self limiting with intact immune system. Immunocompromised people are at risk of developing chronic
-Most patients with HBV chronic infection require long-term treatment.
-All infants born to HB+ mothers must receive 1st dose of vaccine and immunoglobulins within 12h of birth. Breastfeeding is safe if this is done.
-Hepatitis B: What if you are exposed? -they will titre you for immunity level
Hepatitis C
-direct contact with contaminated ____blood_________ and ___body________ fluids, percutaneously.
-common - needle stick
-Diagnostic testing:
Antibody testing (anti-HCV)
Acute infection confirmed (if above +) with HCV RNA.
-Chronic Hep C is curable with medication therapy (direct-acting antiviral agents or DAAs). ALL patients with chronic Hep C should be treated unless they have severely decompensated cirrhosis.
-Chronic Hep B and C infection can lead to severe scarring of the liver and cirrhosis, HCC, and liver failure if left untreated.
Acute Liver Failure
def: Rapid deterioration of liver function resulting in encephalopathy and coagulopathy in a person with no known hx of liver disease.
-Fulminant Hepatic Failure: development of encephalopathy within 8 wks of onset of illness
-most common cause of liver failure- acetaminophen (actually lethal)
Tx: Acetylcysteine dose based on level of acetaminophen.
-limit 4g /day
S/S
Earliest sign- cognitive changes
Jaundice
Coagulation abnormalities
Encephalopathy
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Common Complications:
Cerebral edema
Renal Failure
Hypoglycemia - lack of glucose to brain= neuro changes
Metabolic acidosis
Sepsis
Multiorgan failure
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Diagnostics:
LFTs (esp ALT and AST): increased (ALT spec to liver)
Serum bilirubin: increased
PT: prolonged/increased seconds
Glucose: low
CBC: RBC low dt loss, platelets low dt production
Acetaminophen levels: Screening
Drugs and other toxins: Screening (depending on hx)
Viral hepatitis serology: Especially HAV, HBV and HEV
Plasma Ammonia: increased
Liver biopsy may be performed via transjugular route b/c of coagulopathies or when other liver diseases are suspected.
Nursing management:
-transfer to ICU after dx
-tx of choice for acute liver: transplant
-transfer to transplant center for Grade 1 or 2 encephalopathy
-Neurological monitoring very important! AVOID things that could increase ICP or chemically alter mental status.
-Protect renal function by:
-maintaining hydration status
-avoid nephrotoxic meds- NSAIDs, aminoglycosides
-promptly identify and tx infection
-Minimize agitation
-Ensure seizure pads on bedrails and pt environment is safe
-Provide good skin and oral care (often dependent)
-Consider nutritional impact!
BE CAUTIOUS with NG tube insertion and use!!
because risk of rupturing esophageal varices
Liver Transplant
Indications:
-Localized and/ or recurrent hepatocellular carcinoma (HCC)
-Some with end-stage liver disease (depending on cause)
Contraindications:
-Widespread malignant disease
-Severe extrahepatic disease
-Recent hx of other malignancy
-Ongoing drug/ alcohol use
-Inability to adhere/comprehend rigorous post-transplant course
(long-term and strict Immunsuppresatns to avoid rejection)
liver sources:
-Deceased (cadaveric) donor
-Living donor (a portion), but significant risk of complications exists
Post-transplant complications:
-bleeding infection, rejection
Monitoring for infection is KEY b/c it is the leading cause of morbidity and mortality post-transplant.
-Cant mount an immune response – so SIRS criteria doesn’t look normal
(when on immunosuppressants)
-Fever may be the only sign of infection!!!
Flapping tremors – hepatic encephalopathy
Decompensated Cirrhosis
Laboratory values
Total bilirubin (Normal: 3-17 umol/L)
188 umol/L
AST (Normal: 10-40u/L)
150 U/L
ALT (Normal: (Normal: 7-56u/L)
226 U/L
Serum ammonia ( Normal: <35 umol/ L)
55 umol/L
PT (Normal: 10-13s)
18 secs
Platelets (Normal: 150-400uL)
45uL
WBC (Normal: 4-11.0)
21.45 × 109/L
Hematocrit (Normal female: 36-48%)
24%
Priority of care:
A – good
B- RR 24 O2 97.5
C!!!
do not give iV fluids because will dilute the already low platelets and hemoglobin
take VS-> 98/60
HR 120
RR24
Looks like bleeding, hypotension
cause= ruptured esophageal varicies
tx
-vasoconstriction to hepatic portal ex. octreotide medication (octaplex) $$++
-varicies can burst and bleed out in front of you
-PPI for decreased ulcer
Egfr- 61ml/min kidenys are fine
Call doc and get order for blood admin, Group and screen for blood admin, crossmatch, consent
Prolpngued pt-
-tx with octiplex to reverse prolonged PT. Works faster than vit.K. Buys time before getting to OR
