week 4 content exam 2 Flashcards
- Various strains of ___________ – HAV, HBV, HCV, Epstein-barr, cytomegalovirus
Systemic virus that mainly affects the liver = cause viral hepatitis
causes of cirrhosis
SATA
- Hep B
- Hep C
- Excessive alcohol intake
- Idiopathic
- Non-alcoholic fatty liver disease
- genetics
which is most common
- Hep B
- Hep C
- Excessive alcohol intake - most common
- Idiopathic
- Non-alcoholic fatty liver disease
X- genetics
cirrhosis commonly causes portal HTN which causes varices and ascites
what is portal HTN?
what is varices?
what is ascites?
portal HTN = high blood pressure in the portal vein, which is the large blood vessel that carries blood to the liver.
Varices are abnormally enlarged blood vessels. ex: Varicose veins, Rectal varices/hemorrhoids, Esophageal varices
ascites is accumulation of excess fluid in the abdominal cavity.
viral hep
s/s
- jaundice
- dark urine
- clay colored stool
- liver enlargement
- liver painful to palpation RUQ
- fatigue
- abdominal pain persists or increases
prodromal, icteric, recovery?
icteric (active/actual phase of illness)
2 classes of drugs for chronic Hep____
- Interferons
- Nucleoside analogs
hep B
grey turners sign = (Ecchymoses) bruises or discolorations caused by bleeding pancreas, leaky vessels and blood pooling under the skin in what location?
cullens sign (Ecchymoses) bruises or discolorations caused by bleeding pancreas, leaky vessels and blood pooling under the skin in what location?
flank/sides of stomach = grey turners sign
periumbilical/belly button = cullens sign
T/F
cirrhosis is…
-Irreversible, inflammatory, fibrotic liver disease
-Structural changes from injury like alcohol, hep virus
-Structural changes from fibrosis
- structural changes leads to obstructive biliary channels and blood flow = jaundice and portal hypertension
-Regeneration is disrupted by hypoxia, necrosis, atrophy, and liver failure
-Fibrosis can reversed if treated soon enough
all true except
- Fibrosis can be halted, but not reversed
Cirrhosis patho
1. _______ cells destroyed
2. Cells try to regenerate
3. Disorganized process
4. __________ growth
5. Poor blood flow and ______ tissue
6. Hypoxia
7. Cell death and liver failure
Cirrhosis patho
1. Liver cells destroyed
2. Cells try to regenerate
3. Disorganized process
4. Abnormal growth
5. Poor blood flow and scar tissue
6. Hypoxia
7. Cell death and liver failure
Fulminant liver failure = chronic or acute liver failure?
Acute live failure
3 classifications of jaundice
___________ = increased RBC breakdown
____________ = liver is unable to take up bilirubin from blood, or unable to conjugate it
___________= decreased or obstructed flow of bile, bilirubin can’t get out of liver (r/t gallstones)
Hepatocellular, Obstructive, Hemolytic
3 classifications
- Hemolytic = increased RBC breakdown
- Hepatocellular = liver is unable to take up bilirubin from blood, or unable to conjugate it
- Obstructive = decreased or obstructed flow of bile, bilirubin can’t get out of liver (r/t gallstones)
which issue with the liver Manifests in this way?
- Dark urine
- High liver enzymes
- Normal or clay colored stool
- Pruritis
jaundice
-Ecchymoses - bruises or discolorations caused by bleeding _________, leaky vessels and blood pooling under the skin
o Location – flank/sides of stomach = grey turners sign
o Location – periumbilical/belly button = cullens sign
associated with what issue?
acute pancreatitis
Liver failure not caused by cirrhosis or any other type of liver disease =
Fulminant liver failure or acute liver failure
complications of acute pancreatitis -
_____________ complications
o pain = pt isn’t taking deep breaths
o pleural effusion
-
_____________- = shock
-
- tetany from ________calcemia = monitor electrolytes
- pulmonary complications
- hypotension
- hypocalcemia
LFT - liver function tests
1. check liver enzymes
increased =
2. check bilirubin
increased =
3. check ammonia (the liver breaks it down)
increased =
4. check protein and albumin (liver creates)
decreased =
5. check Prothrombin time (liver makes PT)
increased PTT =
decreased PT =
- Liver enzymes increased = liver dysfunction
- Bilirubin increased = liver dysfunction
- Ammonia (liver breaks down) increased = liver dysfunction
- Protein and albumin (liver creates) decreased = liver dysfunction
- Prothrombin time (liver makes PT) increased = liver dysfunction
PT decreased = PTTime increased = slower to clot, more likely to bleed
Types of Cholelithiasis or Nephrolithiasis
- Cholesterol
- Pigmented
- Mixed
Cholelithiasis
manifestations of _________
- severe epigastric pain - region of the abdomen above the navel and below the sternum.
oSudden onset
oPain may radiate to back
oTender
- n/v
- abdominal distention – fluid in peritoneal cavity
- hypoactive bowel sounds
- fever – r/t inflammatory process
- hypotension and tachycardia – r/t fluid loss
- jaundice – r/t blocked common bile duct
- Ecchymoses - bruises or discolorations caused by bleeding __________, leaky vessels and blood pooling under the skin
o Location – flank/sides of stomach = grey turners sign
o Location – periumbilical/belly button = cullens sign
acute pancreatitis
etiology of _______ HTN
o systemic hypotension
o vascular underfilling
o stimulation of vasoactive system (RAAS system)
o plasma volume expansion
o increased CO = ascites
portal
Patho of which liver issue?
- Edematous hepatocytes and patchy areas of necrosis and inflammatory cell infiltrates and disrupts liver tissue
Fulminant liver failure or acute liver failure
Acute pancreatitis =
- Usually mild, resolves spontaneously
- 20% becomes severe and needs hospitalization
pancreas inflammation
Cirrhosis pharm
2nd line
Moa
- Inhibitis bacterial RNA synthesis by binding to bacterial DNA – initially used as an abx for GI infections
- Sometimes used as preventative drug
Route – PO
s/e
- Peripheral edema
- Nausea
- Ascites
- Dizzy
- Fatigue
- Pruritis
- Skin rash
- Abdominal pain
- Anemia
Has been associated with increased risk of C diff – monitor
Rifaximin
does liver make it or break it down:
ammonia?
protein?
albumin?
prothrombin?
billirubin?
ammonia - break it down
protein - makes it
albumin - makes it
prothrombin - makes it
billirubin - makes it
_____________ – liver inflammation can occur from alcohol abuse, drugs, chemicals, bacteria
___________ – inflammation of liver from systemic viral infection
hepatitis
viral hepatitis
tylenol reccomendations?
Tylenol + hepatitis
______ grams/day
Tylenol + advanced liver disease
________ grams/day
Tylenol + hepatitis
< 2grams/day
Tylenol + advanced liver disease
AVOID Tylenol
normally = <4 grams/day
Cholelithiasis
“gallstones” – stones in the gallbladder
viral hep
s/s
- jaundice stops
- symptoms diminish
- liver enlarged and tender
- LFTs return to normal
prodromal, icteric, recovery?
recovery (6-8 weeks after exposure)
Cirrhosis
Liver scarring
acute pancreatitis labs
- glucose – _________ or _________
- amylase, lipase, WBC – __________ r/t damage to organs
labs
- glucose – can be increased or decreased
- amylase, lipase, WBC – increased r/t damage to organs
- manifestations of _________
o asymptomatic until complications occur
o variceal hemorrhage
o ascites
o peritonitis
o hepatorenal syndrome
o cardiomyopathy - treatment
o prevent and treat complications
o only way to treat _________ is liver transplant b/c it is irreversible
portal HTN
Etiology of acute pancreatitis
SATA
- Obstruction of the outflow of pancreatic enzymes, r/t pancreatic and bile duct obstruction (gallstones)
- alcohol
- drugs
- DM
- viral infection
- Obstruction of the outflow of pancreatic enzymes, r/t pancreatic and bile duct obstruction (gallstones)
- alcohol
- drugs
X- DM - viral infection
Manifestations of Cholecystitis
- Fever
- Leukocytosis
- Rebound tenderness
- guarding
- Pain similar to gallstones
- When stones get lodged – _______ and ________ location of pain
o Biliary colic – pain occurs 30 mins to several hours after eating ________ foods
Manifestations
- Fever
- Leukocytosis
- Rebound tenderness and guarding
- Pain similar to gallstones
- When stones get lodged – epigastric pain and RUQ pain
o Biliary colic – pain occurs 30 mins to several hours after eating fatty foods
cirrhosis causes __________ _________ which is a condition that occurs when the liver is unable to filter toxins from the blood. These toxins can build up in the brain and lead to a variety of symptoms, including confusion, disorientation, and altered mental status.
hepatic encephalopathy
which hep?
- Transmission – parenteral, sexual
- Onset – insidious
- Mild – severe
- Large chance can develop into chronic hep
- Any age group
- Prevention – screen blood, hygiene, NO vaccine
- Leads to liver cancer and liver transplant
Hepatitis C
viral hepatitis Patho
1. Viral infection of liver
2. Immune response – inflammatory mediators show up in and around liver
3. ________ of infected cells
4. Edema and swelling of tissue in and around liver
5. Tissue __________ in and around liver
6. Liver cells (_______cytes) die from hypoxia = long term liver failure or problems
Patho
1. Viral infection of liver
2. Immune response – inflammatory mediators show up in and around liver
3. Lysis of infected cells
4. Edema and swelling of tissue in and around liver
5. Tissue hypoxia in and around liver
6. Liver cells (hepatocytes) die from hypoxia = long term liver failure or problems
portal vein -
first pass effect -
- The blood from below (the stomach, intestines, spleen, pancreas and LE) enters the liver through the portal vein
- after digestion the absorbed products go directly to the liver, and it takes a % of the absorbed product.
Manifestations of Cholelithiasis
- Asymptomatic
- When stones get lodged, 2 locations of pain = ___________
o Biliary colic – pain occurs 30 mins to several hours after eating ________ foods
- Intolerance to _________ foods
- Vague symptoms – heartburn, flatulence, food intolerance (fats, cabbage)
- When stones block bile duct – __________
Manifestations
- Asymptomatic
- When stones get lodged – epigastric pain and RUQ pain
o Biliary colic – pain occurs 30 mins to several hours after eating fatty foods
- Intolerance to fatty foods
- Vague symptoms – heartburn, flatulence, food intolerance (fats, cabbage)
- When stones block bile duct – jaundice
which hep?
- Transmission – fecal-oral, parenteral, sexual
- Onset - Acute onset with fever
- Mild severity
- Doesn’t lead to chronic hep
- Children and adults
- Prevention – hand hygiene, vaccine
Hepatitis A
Treatment chronic Hep B is for these high risk pts only:
- ___creased AST levels
- Hepatic inflammation
- Advanced fibrosis
Treatment is for these high risk pts only:
- Increased AST levels
- Hepatic inflammation
- Advanced fibrosis
which hep vaccine?
- 3 doses, 4 months apart
- Recommendation
o All newborns
hep B
________________
pancreatic enzymes replacement
indications
- chronic or acute pancreatitis only?
- Reduces secretion of pancreatic enzymes
s/e
- Rare
Nursing implications
- Take with every meal/snack, needed for digestion
pancrelipase
chronic pancreatitis only!
Etiology of Fulminant liver failure or acute liver failure
- Acetaminophen OD – most common
o Occurs __ days – __ weeks after OD
o Treated with ___________
- 6-8 weeks after a viral hep or metabolic liver disease
Etiology
- Acetaminophen OD – most common
o Occurs 5 days – 8 weeks after OD
o Treated with acetylcysteine
- 6-8 weeks after a viral hep or metabolic liver disease
etiology of acute or chronic pancreatitis?
- alcohol abuse – toxic metabolites release inflammatory cytokines and cause destruction of acinar cells and islet of Langerhans
chronic pancreatitis
which liver issue
Manifestations – similar to cirrhosis
Early
- GI issues
- n/v
- anorexia
- flatulence
- change in bowel habits
- fever
- weight loss
- palpable liver RUQ
late (often when it gets diagnosed)
- jaundice
- peripheral edema
- decreased albumin and PT
- ascites
- skin lesions – spider veins
- hematologic problems – anemia, bleeding
- endocrine problems – reproductive/sex issues
- esophageal and anorectal varices
- portal HTN
- encephalopathy – toxins aren’t cleared and build up in blood
Fulminant liver failure or acute liver failure
Cholecystitis
inflammation of the gallbladder
- Acute or chronic
viral hep
s/s
- Fatigue
- Anorexia
- Malaise
- n/v
- h/a
- hyperalgesia – pain
- cough
- low grade fever
- highly contagious
prodromal, icteric, recovery?
Prodromal manifestations (2 weeks after exposure)
which hep vaccine?
- 2 doses, 6 months apart
- Recommendations
o All kids 12 months +
o Special high risk populations
hep A
cirrhosis Manifestations
Early or late signs?
- GI issues
- n/v
- anorexia
- flatulence
- change in bowel habits
- fever
- weight loss
- palpable liver RUQ
-
Early or late signs?
- jaundice
- peripheral edema
- decreased albumin and PT
- ascites
- skin lesions – spider veins
- hematologic problems – anemia, bleeding
- endocrine problems – reproductive/sex issues
- esophageal and anorectal varices
- portal HTN
- encephalopathy – toxins aren’t cleared and build up in blood
when does it often get diagnosed?
Early
Late (often when it gets diagnosed)
Risk factors for _______
- Obesity
- Female
- Middle aged
- Use of oral contraceptives
- Rapid weight loss
- Native American
- Genetics
- Pancreatic or ileal disease
Cholelithiasis
Cirrhosis pharm
Class - Hyperosmotic laxative
1st line
Indication
- Reduction of ammonia absorption in hepatic encephalopathy
- Not just given for high ammonia levels – must have s/s of hepatic encephalopathy
MOA
- Reduces blood ammonia levels by converting ammonia to ammonium (gets excreted via stool)
Route
- Po
- Enema/rectal
Considerations
- Can be given to titrate by number of stool or by ammonia levels
- Make sure pt is not hypokalemic – monitor K+
Lactulose
Treatment for Fulminant liver failure or acute liver failure?
- drugs
or
- Liver transplant
liver transplant
Increased level of __________ in the blood stream causes jaundice
> ___ - _____
good places to check for jaundice?
1.
2.
3.
4.
Increased level of bilirubin in the blood stream causes jaundice
- > 2- 2.5
- Yellow skin and deep tissue
o Mucus membranes
o Palms
o Sclera
o Soles of feet
Concern with Cholecystitis
- Pressure against distended wall of gallbladder = ___creased blood flow =
ischemia?
necrosis?
perforation?
asymptomatic?
Concern
- Pressure against distended wall of gallbladder = decreased blood flow = ischemia, necrosis, perforation
Alcoholic liver disease stages
___________
o Mild
o Asymptomatic
o Reversible
_____________
o Precursor to cirrhosis
o Inflammation
o Degeneration of hepatocytes
o Irreversible
______________
o Fibrosis and scarring alter liver structure
o Irreversible
– Alcoholic steatohepatitis, Alcoholic cirrhosis , Alcoholic fatty liver
-Alcoholic fatty liver
o Mild
o Asymptomatic
o Reversible
-Alcoholic steatohepatitis
o Precursor to cirrhosis
o Inflammation
o Degeneration of hepatocytes
o Irreversible
-Alcoholic cirrhosis
o Fibrosis and scarring alter liver structure
o Irreversible
Etiology of Cholelithiasis
Impaired metabolism of
- Cholesterol
- Bilirubin
- oxalate (protein)
- Bile acids
- calcium
- Cholesterol
- Bilirubin
X- oxalate (protein) - kidney stones - Bile acids
X- calcium - kidney stones
treatment for Hep ___
- Direct acting antiviral therapy
- Interferon based regiments
- Some require treatment along with a nucleoside analogue med as well
Hep C
- No vaccine
- Treatable now with New drugs
2 types of billirubin
The type of bilirubin that is elevated can help to determine the underlying cause of jaundice.
___________ - Elevation from bilirubin overproduction OR impaired liver function
___________ - Elevation from bile duct obstruction (gallstones), bilirubin cant get out
Direct/conjugated
Indirect/unconjugated
Direct/conjugated
- Elevation from bilirubin overproduction OR impaired liver function
Indirect/unconjugated
- Elevation from bile duct obstruction (gallstones), bilirubin cant get out
complications of acute pancreatitis -
- Abscess - A collection of pus inside or outside of the pancreas?
- Necrosis in the pancreas
- Pancreas may become infected or perforate
- manifestations – abdominal mass, high fever, leukocytosis
- Abscess - A collection of pus inside the pancreas
first pass effect and portal circulation is associated with which organ?
liver
- Bring blood to the liver from the stomach, intestines, spleen, pancreas and LE
- The blood from below enters the liver through the portal vein
- The absorbed products of digestion go directly to the liver and lobules
- This is the “first pass effect”
Neurotoxins crosses BBB and builds up in brain causing LOC changes which often lead to diagnosis of what liver issue?
cirrhosis or hepatic encephalopathy
Pharm for galbladder stones and inflammation
-for pain =
-for n/v =
-to decrease gallbladder secretion and stop smooth muscle spasms, decreases risk of stones getting lodged =
-dissolve stones =
- Analgesic: ketorolac (NSAID) – pain control, can add opioid
- Antiemetics: ondesteron – n/v
- Anticholinergics – decrease gallbladder secretion and stop smooth muscle spasms, decreases risk of stones getting lodged
- Bile acids – dissolve stones
Disadvantage of chronic Hep B treatment
- Prolonged
- unavailable
- Costs
- s/e
- high relapse
- Prolonged
X- unavailable - Costs
- s/e
- high relapse
pancreatic or liver enzymes?
- trypsin
- elastase
- phospholipase A
- kallikrein
- lipase
pancreatic
which hep?
- Transmission – parenteral, sexual
- Onset - Insidious onset
- Severe, prolonged
- Small chance can develop into chronic hep
- Any age group
- Prevention – vaccine, safe sex, hygiene
hep B
Direct/conjugated vs Indirect/unconjugated
if Elevation of bilirubin levels are from bilirubin overproduction
if Elevation of bilirubin levels are from impaired liver function
if Elevation of bilirubin levels are from bile duct obstruction (like gallstones), and the bilirubin cant get out
Direct/conjugated - liver issue
Direct/conjugated - liver issue
Indirect/unconjugated - the liver is working fine, theres an issue somewhere else
Drug therapy for __________
1. Opioids - control pain
- Dicyclomine – antispasmodic (anticholinergic agent)
- decreases secretions
- relaxes smooth muscles (decreases spasms) - antacids
- decrease HCl secretion in the stomach = decreases secretions of pancreatic enzymes (these are what are digesting the pancreas) - h2 receptors antagonists
- same MOA as antacids
- decrease HCl secretion in the stomach = decreases secretions of pancreatic enzymes (these are what are digesting the pancreas) - pancrelipase
- replacement therapy for pancreatic enzymes
- ________ pancreatitis only! - Insulin
- treatment for DM if it occurs
chronic pancreatitis
complications of acute pancreatitis -
- pseudocyst - fluid-filled sac inside or outside of the pancreas?
- Necrotic products and secretions
- Inflammation and scarring
- Manifestations – palpable epigastric mass
- If it perforates (opens) = __________ (release its contents into the abdominal cavity, causing irritation and inflammation)
- pseudocyst - fluid-filled sac surrounds outside the pancreas.
If it perforates (opens) = peritonitis (release its contents into the abdominal cavity, causing irritation and inflammation)
walled off areas of pancreatic juice, necrotic debris, or blood
pancreatic cysts
etiology of Fulminant liver failure or acute liver failure
- 3.
- Acetaminophen OD – most common
- 6-8 weeks after a viral hep or metabolic liver disease
manifestations of ___________
- acute pancreatitis attacks with progressive signs of dysfunction after attack subsides
- abdominal pain
- Weight loss – can’t absorb nutrition, especially fats
- May lead to DM – r/t loss of islet of Langerhans
what are the 2 big ones to remember
chronic pancreatitis
- abdominal pain
- Weight loss
Etiology Cholecystitis
Gallstone gets lodged in cystic duct = ________ and ___________ gallbladder
distended and inflamed gallbladder
Lab values with Cholecystitis
- ___creased bilirubin
- ___creased alk phos
- Increased bilirubin
- Increased alk phos
- ALT
- AST
- Alk Phos
are these enzymes liver or kidney?
liver
Obstructed bile flow manifestations
T/F
Obstructed bile flow manifestations
- Bile cant flow into duodenum = bile in blood changes skin color = _________
- Soluble bilirubin in urine = _______ colored urine that ______ when shaken
- Bilirubin doesn’t reach small intestine to be converted into urobilinogen = _______ colored stools bc urobilinogen is what turns stool brown
- No bile salts in duodenum, preventing fat digestion = steatorrhea ____________
- Deposits of bile salts into skin tissue = ___________
- No bile in small intestine to help with fat digestion = ___________ to fatty foods
- Decreased absorption of vitamin K = (needed to produce ___________ ) = ________ risk
Obstructed bile flow manifestations
- Bile cant flow into duodenum = jaundice (bile in blood gives skin yellow color)
- Soluble bilirubin in urine = dark amber urine that foams when shaken
- Bilirubin doesn’t reach small intestine to be converted into urobilinogen (this is what turns stool brown) = clay colored stools
- No bile salts in duodenum, preventing fat digestion = steatorrhea (fatty stool)
- Deposits of bile salts into skin tissue = pruritis
- No bile in small intestine to help with fat digestion = intolerance to fatty foods
- Decreased absorption of vitamin K (needed to produce clotting factor) = bleeding risk
- Metabolism and/or storage of: fat, CHO, protein, vitamins and minerals
- Blood volume reservoir – distends and compresses to alter circulating blood volume
- Blood filter – helps purify blood, removes bilirubin
- Blood clotting factors – prothrombin and fibrinogen
- Drug metabolism and detoxification
major functions of which organ?
liver
Complications of viral hep - T/F
- Chronic hepatitis
- cholelithiasis
- Liver cirrhosis
- Liver cancer
- Fulminant viral hepatitis – acute liver failure
- Chronic hepatitis
X- cholelithiasis - Liver cirrhosis
- Liver cancer
- Fulminant viral hepatitis – acute liver failure
risk factors for acute or chronic pancreatitis?
- genetics
- gallstone obstruction
- smoking
chronic pancreatitis
viral hep Manifestations
- Similar between A,B,C
- Asymptomatic
- Ranges from none – liver failure
- Abnormal ___crease in LFTs
Manifestations
- Similar between A,B,C
- Asymptomatic
- Ranges from none – liver failure
- Abnormal increase/elevated LFTs
Pancreas
example of Endocrine dysfunction
example of Exocrine dysfunction
DM
pancreatitis
hepatic encephalopathy
- Graded by severity
o Minimal (lowest) – abnormal neuro test results, no clinical manifestations
o Grade 4 (highest) – coma, unresponsive to pain
- - Correlates with liver labs
o _________ is chemical driver or LOC changes
o High _________ = hepatic encephalopathy
ammonia
- trypsin = edema, necrosis, hemorrhage
- elastase = hemorrhage
- phospholipase A = fat necrosis
- kallikrein = edema, vascular permeability (fluid seeps into pancreas), smooth muscle contraction, shock
- lipase = fat necrosis
which organs enzymes?
pancreas
progressive, fibrotic disease of the pancreas
chronic pancreatitis
T/F
Severity of gallbladder stones depends on
- Movement of stones
- Obstruction
- type of stone
- Movement of stones
- Obstruction
X- type of stone
patho of ______________
- backup of enzymes = autodigestion of pancreatic cells = pancreas inflammation
acute pancreatitis
pancreas is digesting itself
