Liver Problems Flashcards
Major Functions of Liver
Metabolism &/or storage of:
* Fat, CHO, PRO, vitamins and minerals
Blood volume reservoir
* Distends/compresses to alter circulating blood volume
Blood filter
* Helps purify blood
Blood clotting factors
* Including prothrombin & fibrinogen
Drug metabolism and detoxification
Portal Circulation
- The portal circulatory system brings blood to the liver from the stomach, intestines, spleen, and pancreas
- The blood enters the liver through the
portal vein - The absorbed products of digestion come directly to the liver, and are sent to the lobules
- This is the “first pass effect”
Components of the Liver funtion tests (LFT)
Liver enzymes
-ALT, AST, Alk Phos
Bilirubin
-conjugated (direct), unconjugated (indirect)
Serum Ammonia
Serum Protein
Serum Albumin
Prothrombin time (PT)
Jaundice (Icterus) caused by:
- Caused by increased level of bilirubin in the bloodstream
- Usually causes problems and is noticeable with total bilirubin is greater than 2-2.5mg/dl
- Look at conjugated versus unconjugated to determine possible cause
- Yellowish discoloration of skin and deep tissues
3 classifications of Jaundice
- Hemolytic: increased breakdown of RBCs
- Hepatocellular: liver unable to take up bilirubin from blood or unable to conjugate it
- Obstructive: decreased or obstructed flow of bile
What is Bilirubin?
By product of heme breakdown (mainly hemoglobin)
DIRECT: Conjugated INDIRECT:unconjugated
Elevations of INDIRECT bilirubin:
Bilirubin overproduction OR impaired liver functioning
Elevations of DIRECT bilirubin:
Liver working, but can’t get the bilirubin out
* Bile duct obstruction, gall stones
Jaundice: Clinical Manifestations
- Urine is darker
- Liver enzymes = elevated
- Stools = Normal or clay colored
- Pruritis
What is Viral Hepatitis?
Systemic virus that mainly affects the livers
* Inflammation of the liver
Various strains cause the different types of hepatitis
* HAV, HBV, HCV
* Other viruses that can cause hepatitis (Epstein-Barr, cytomegalovirus)
T/F: Hepatitis is always from a viral infection
FALSE: can occur from other causes
* Alcohol abuse, drugs, chemicals, and bacteria
Viral Hepatitis: Pathogenesis
- Viral infection
- Immune response: imflammatory mediators
- Lysis of infected cells
- Edema and swelling of tissue
- Tissue hypoxia
- Hepatocyte death
Clinical Manifestations of Viral Hepatitis
- Similar between all types
- Many cases of ALL types of hepatitis are asymptomatic
- But can range from none, mild, to liver failure
- Causes abnormal elevated LFTs– but NOT consistent with cellular damage within the liver
Hepatitis: Prodromal
- 2 weeks after exposure
- Fatigue, anorexia, malaise, nausea, vomiting, HA hyperalgesia, cough, low- grade fever
- HIGHLY transmissible
Hepatitis: Icteric
- Begins with jaundice
- Jaundice, dark urine, clay-colored stools
- Liver enlarged and may be painful to palpation
- Fatigue abdominal pain persists or increases in severity
Hepatitis: Recovery
- Resolution of jaundice
- 6-8 weeks after exposure, symptoms diminish
- Liver remains enlarged/tender
Viral Hepatitis: Complications
- Chronic hepatitis
- Liver cirrhosis
- Liver cancer
- Fulminant viral hepatitis – acute liver failure
Most patients with acute viral hepatitis recover completely with no complications
Overall mortality rate is less than 1%
* Higher mortality in elderly and comorbidities
Hepatitis A
-transmission, progression, population, prevention
- Transmission: fecal-oral, parental, sexual
- Acute onset with fever
- Usually mild severity
- Does NOT lead to chronic hepatitis
- Usually affects children and adult
- Hand hygiene, Hep A vaccine
Hepatitis B
-transmission, progression, population, prevention
- Transmission: parental, sexual
- Insidious onset
- Severe disease, may be prolonged course or develop into chronic
- Any age group affected
- HBV vaccine and safe sex and hygiene
Hepatitis C
-transmission, progression, population, prevention
- Transmission: parental, sexual
- Insidious onset
- Mild to severe symptoms
- Can develop into chronic hepatitis (80%)
- Any age is affected
- Screening blood, hygiene; NO vaccine
- Leads to hepatocellular carcinoma, liver transplant
- New treatment is developing and becoming more widely available
Prevention of Hepatitis: Vaccines
Hep A Series
- 2 doses 6 months apart
Recommendations - All children beginning at age 12 months
- Special “high risk” populations
Prevention of Hepatitis: Vaccines
Hep B Series
- 3 doses at least 4 months apart
- Recommendation: All infants beginning as newborns
Prevention of Hepatitis: Vaccines
Hep C
NO vaccine
Two classes of drugs are used for chronic HBV:
- Interferons
- Nucleoside analogs
HBV treatment is only for high-risk patients who have:
- ↑ AST levels
- Hepatic inflammation
- Advanced fibrosis
Disadvantages of HBV treatment:
- Prolonged therapy
- Costs and adverse effects
- High relapse
How is HCV treated
- Treated with direct-acting antiviral therapy and interferon-based regiments
- Some require treatment along with a nucleoside
analogue medication as well - Now easily treatable and eliminated in most all patients
Can take tylenol although must be <2,000 mg
What is Cirrhosis?
- Irreversible, inflammatory, fibrotic liver disease
- Structural changes from injury (alcohol/viruses) and fibrosis
- Regeneration is disrupted by hypoxia, necrosis, atrophy, and liver failure
Chaotic fibrosis leads to:
Obstructive biliary channels and blood flow
which lead to jaundice and portal hypertension
Cirrhosis Common Causes
-Hepatitis B&C
-Excessive alcohol intake
-Idiopathic
-Non-alcoholic fatty liver disease [NASH, NAFLD]
Stages of alcoholic liver disease
- Alcoholic fatty liver
-Mildest, asymptomatic - Alcohol steatohepatitis
-precusor to cirrhosis
-Inflammation, degeneration of hepatocytes - Alcohol cirrhosis
-Fibrosis and scarring alter liver structure
Cirrhosis: Pathogenesis
-Liver cells destroyed
-Cells try to regenerate
-Disorganized process
-Abnormal growth
-Poor blood flow and scar tissue
-Hypoxia
-Liver failure
Cirrhosis: Early Manifestations
GI disturbances
* N/V
* Anorexia
* Flatulence
* Change in bowel habits
Fever, weight loss
Palpable liver
Cirrhosis: Late Manifestations
Jaundice
Peripheral edema
Decreased albumin & PT
Ascites
Skin lesions
Hematologic problems (anemia, bleeding)
Endocrine problems
Esophageal & anorectal varices
Encephalopathy
What is Portal Hypertension?
Resistant portal blood flow leads to varices & ascites
Portal hypertension causes
Causes: systemic hypotension, vascular underfilling, stimulation of vasoactive (RAAS system) systems, plasma volume expansion, increased cardiac output leads to ascites
Portal hypertension symptoms
Asymptomatic until complications
* Variceal hemorrhage, ascites, peritonitis, hepatorenal syndrome, cardiomyopathy
Portal hypertension prevention/treatment
Can’t do anything for the portal hypertension except liver transplant
How is hepatic encephalopathy diagnosed?
LOC is the primary driver of diagnosis
* Graded by severity
- Correlate with liver labs, mainly ammonia which is primary chemical driver of LOC changes
What are the grades of hepatic encephalopathy?
- Minimal: Abnormal results on psychometric or neurophysiological testing without clinical manifestations (see ‘Psychometric tests’ below)
- Grade I: Changes in behavior, mild confusion, slurred speech, disordered sleep
- Grade II: Lethargy, moderate confusion
- Grade III: Marked confusion (stupor), incoherent speech, sleeping but arousable
- Grade IV: Coma, unresponsive to pain
Acute liver failure (fulminant liver failure)
-Common cause
Most common cause: acetaminophen overdose
* Can be treated with acetylcysteine
T/F Acute liver failure caused by cirrhosis
False, acute liver failure is a separate liver failure NOT caused by cirrhosis or other type of liver disease
Acute liver failure: Patho
Patho: edematous hepatocytes and patchy areas of necrosis and inflammatory cell infiltrates and disrupts the liver tissue
Can occur 6-8 weeks after a viral hepatitis or metabolic liver disease
* 5 days to 8 weeks after an acetaminophen overdose
Acute liver failure
-S/S and treatment
- Signs are similar to cirrhosis symptoms
- Treatment: not much, liver transplant
