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CCN > Liver failure > Flashcards

Liver failure Flashcards

1
Q

Which lobe of the liver is the gallbladder closest to?

A

Right lobe

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2
Q

What does the gallbladder do?

A

Stores bile produced by the liver

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3
Q

What does the gibsons capsule do?

A

Is a layer of connective tissue surrounding the liver and protecting the hepatic artery, portal vein, and bile ducts

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4
Q

What do kupffer cells do?

A

Phagocytic and macrophagic properties, engulf bacteria in the sinusoids

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5
Q

What is the portal triad?

A

1) Hepatic artery (25% blood flow)
2) Portal vein (75% blood flow)
3) Bile duct

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6
Q

What is the dual blood supply of the liver?

A

1) Hepatic artery supplies the liver with oxygenated blood, arises from the celiac artery (25% blood flow)
2) Portal vein supplies liver with deoxygenated blood (75% blood flow) from stomach, spleen, intestines, etc

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7
Q

What is supplied in the portal vein circulation?

A

Deoxygenated blood, rich in nutrients, hormones, toxins, bacteria etc

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8
Q

What are the functions of the liver?

A

Carbohydrate, protein, fat metabolism, bile formation, vitamin and mineral storage, hematological functions, detox

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9
Q

How does the liver metabolize carbohydrates?

A

Stores serum glucose as glycogen (glucogenesis)

Breakdown of glycogen (glycogenolysis)

Creates glucose from proteins, fats (gluconeogenesis)

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10
Q

How does the liver metabolize proteins?

A

Synthesis of proteins such as albumin

Breakdown of proteins into ammonia, urea

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11
Q

How does the liver metabolize fats?

A

Synthesis of phospholipids, cholesterol

Breakdown of fats into glycerol, fatty acids, ketones

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12
Q

What are the hematological function of the liver?

A

Synthesis of albumin, clotting factors (fibrinogen, prothrombin, vitamin K)

Kuffer cells filter blood to remove bacteria

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13
Q

What are the detoxification functions of the liver?

A

Deactivates hormones such as estrogen

Conjugates steroids and hormones

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14
Q

What is cirrhosis?

A

Chronic liver disease where normal liver cells and structures are altered by regenerating nodules / scar tissues that interrupt arterial, portal, and bile circulation.

Liver becomes congested with increased resistance

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15
Q

What 2 things does cirrhosis cause?

A

1) Portal hypertension

2) Ascites

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16
Q

What is portal hypertension?

A 
Backup of blood into portal venous system causing vein distention in:
Esophagus
Intestine, stomach
Spleen
Umbilicus, rectum
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17
Q

What does vein distention due to portal hypertension cause?

A

Varices with risk of hemorrhage

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18
Q

What is ascites?

A

Accumulation of serous fluid in the peritoneal cavity

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19
Q

What causes ascites?

A

Portal hypertension (increased hydrostatic pressure forces fluid out of veins into peritoneum)

Hypoalbuminemia (decreased oncotic pressure causes fluid to leave blood vessels)

Impaired water excretion

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20
Q

What does ascites result in?

A

Third spacing, generalized edema, eventually causes hypovolemia

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21
Q

What compensatory mechanisms are activated when the body gets ascites?

A

Triple A:

ADH
Aldosterone
Angiotensin

Try to compensate by retaining fluid but just makes ascites worse

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22
Q

What is the treatment for ascites?

A

Albumin infusion, diuretics, abdominal paracentesis

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23
Q

How can GI hemorrhages be prevented?

A

GI prophylactics, early enteral feeding

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24
Q

How can GI hemorrhage due to cirrhosis be treated?

A

Meds to constrict splenic arteries such as vaso

Vitamin K to help clotting

Special NG tubes to tamponade the blood (usually esophageal)

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25
Q

What is hepato-renal failure?

A

Acute renal failure as a complication of hepatic failure d/t hypovolemia or impaired renal perfusion from ascites

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26
Q

What does hepato-renal failure cause?

A

Fluid overload and eventual respiratory failure

27
Q

What is acute liver failure?

A

Severe liver damage with rapid onset (e.g. tylenol OD)

May occur with or without pre-existing liver disease, massive necrosis of hepatocytes and onset of encephalopathy

28
Q

What can cause acute liver failure?

A

Viral hepatitis, meds, toxins, overdose e.g. Tylenol

29
Q

What are assessment findings correlated to liver damage?

A

Hepatic insufficiency:
Ankle edema, ascites, anemia, jaundice, hemorrhagic tendency, coma or decreased LOC

Hyperestrogenism:
Testicular atrophy, gynecomastia, red palms, altered hair distribution, spider nevi

30
Q

What are spider nevi and what do they represent?

A

Collection of small dilated arterioles clustered close to surface of the skin (web like), sign of cirrhosis and hyperestrogenism

31
Q

What are assessment findings correlated to portal hypertension?

A

Ankle edema, ascites, splenomegaly, esophageal varices, caput medusa

Hypersplenism:
Anemia (d/t low hgb), leukopenia (increased risk of infection), thrombocytopenia (decreased platelets)

32
Q

What is caput medusa and what does it represent?

A

Distended and engorged superficial epigastric veins radiating from umbilicus across the abdomen.

Indicates portal hypertension

33
Q

Where is the spleen and what does it do?

A

Upper left part of abdomen.

Filters blood (affects number of RBCs, hgb, platelets), breaks down and removes cells when needed

Stores RBCs, platelets, WBCs

Important immune response function, blood clotting, RBCs

34
Q

What is hyponatremia and why does it occur in liver failure?

A

Na < 135 mmol/L

Common finding due to diuretics or dilutional hyponatremia

Na+ is diluted due to ADH compensating for portal HTN and ascites by retaining more water.

35
Q

Why is hyponatremia dangerous?

A

Shift of H2O intracellularly results in cerebral edema, brain compensates by moving K+ extracellularly causing hyperkalemia

Na replacement should be done slowly to allow gradual ion shift

36
Q

What can occur with rapid hyponatremia correction?

A

Osmotic demyelination

37
Q

What is circulatory failure and why does it occur in liver failure?

A

Caused by intravascular hypovolemia and/or systemic inflammation due to ascites, fluid 3rd spacing

38
Q

How is circulatory failure d/t hepatic failure treated?

A

Fluid replacement and levo infusion is first line

Crystalloid infusion with albumin

Pts often on diuretics and fluid replacement at the same time

39
Q

Why does infection occur with liver failure?

A

Liver is key autoimmune organ and processes toxins / bacteria through venous circulation

40
Q

What are considerations with sedation for liver failure pts?

A

Sedation can worsen liver failure as they are liver-metabolized or renal metabolized.
If sedation required, non-benzos useful (propofol)

41
Q

What position can help ascitic pain?

A

Semi-recumbent position

42
Q

Why does adrenal insufficiency occur with liver failure?

A

Liver is unable to synthesize cholesterols required for adrenal gland to make cholesterol

Pt may need corticosteroid therapy

43
Q

What does ongoing adrenal insufficiency do for pts in liver failure?

A

Ongoing hypotension due to inactivation of SNS

44
Q

What is the normal pressure inside the abdominal cavity?

A

5-7 mmhg

45
Q

What are assessment findings for intra-abdominal hypertension?

A 
Hypotension
Metabolic acidosis 
Oliguria 
Increase in peak airway pressure 
Hypoxemia
Increase lactate
Edema, weeping, 3rd spacing
46
Q

What is abdominal compartment syndrome and how is it diagnosed?

A

Sustained increased abdominal pressure greater than 20mmHg and associated with new organ failure

47
Q

What are the steps to get an intra-abdominal pressure reading?

A

1) Pressure port attached to sampling port of foley
2) System is zerod
3) Foley cath clamped
4) While pt is supine, 25 cc warmed NS is injected into the bladder, allow 30-60 secs to obtain bladder pressure reading at end of expiration

48
Q

What is the grading for abdominal pressure?

A 
Normal 5-7 mmHg
Grade 1 --> 12-15mmHg
Grade 2 --> 16-20 mmHg
Grade 3 --> 21-25 mmHg
Grade 4 --> >25mmHg

If greater than 20mmHg with new organ failure, then abdominal compartment syndrome

49
Q

What is ALT (Alanine aminotransferase) and what happens during liver failure?

A

Enzyme found in liver, increases with injury

50
Q

What is AST (Aspartate aminotransferase) and what happens during liver failure?

A

Enzyme found in liver, bones, cardiac muscle

Increases with injury and ALCOHOL CONSUMPTION

51
Q

What is ALP (Alkaline phosphate) and what happens during liver failure?

A

Enzyme found in liver, biliary tract

Increases with intrahepatic or impaired bile excretion

52
Q

What does total bilirubin include?

A

Total conjugated and unconjugated bilirubin

53
Q

What happens to ALT/AST/ALP in liver injury?

A

Increase

54
Q

What happens to total bilirubin in liver injury?

A

Increase

55
Q

What happens to PT/PTT/INR in liver injury?

A

Increase

56
Q

What happens to albumin in in liver injury?

A

Decrease

57
Q

What happens to ammonia in liver injury?

A

Increase

58
Q

What happens to hemoglobin in liver injury?

A

Decrease or remains normal

59
Q

What is hepatic encephalopathy?

A

Mental confusion progressing to coma resulting from liver failure as toxins accumulate in blood and cross blood brain barrier

60
Q

What is the main chemical responsible for hepatic encephalopathy?

A

Ammonia formed by protein breakdown by intestinal bacteria

61
Q

How is hepatic encephalopathy graded and what are the clinical manifestations?

A

Grade 1 –> Euphoria, depression, mild confusion, slurred speech, slight asterixis

Grade 2 –> Lethargy, moderate confusion, abnormal EEG, marked asterixis

Grade 3 –> Marked confusion, incoherent speech, asterixis, sleeping but arousable

Grade 4 –> Coma, later unresponsive

62
Q

What are 2 medical treatments for hepatic encephalopathy? What are other interventions?

A

1) Neomycin
2) Lactulose

Airway management, avoid sedatives, GI prophylaxis, vitamin K

63
Q

How does neomycin work for hepatic encephalopathy?

A

Inhibits breakdown of proteins into ammonia, decreases ammonia in the blood

64
Q

How does lactulose work for hepatic encephalopathy?

A

Causes ammonium to get excreted by drawing ammonia from the blood into the colon where it gets removed

CCN (27 decks)

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