Liver Disorders John Nation, RN, MSN Fall 2011 From the notes of Charlene Morris, RN, MSN Austin...

Liver DisordersLiver Disorders

John Nation, RN, MSNJohn Nation, RN, MSNFall 2011Fall 2011

From the notes ofFrom the notes ofCharlene Morris, RN, MSNCharlene Morris, RN, MSNAustin Community CollegeAustin Community College

Overview of Today’s Overview of Today’s LectureLecture A & P ReviewA & P Review Hepatitis AHepatitis A Hepatitis BHepatitis B Hepatitis CHepatitis C Cirrhosis Cirrhosis Portal HypertensionPortal Hypertension Esophageal VaricesEsophageal Varices Hepatic EncephalopathyHepatic Encephalopathy Hepatorenal SyndromeHepatorenal Syndrome Liver Transplant Liver Transplant

A and P ReviewA and P Review

Largest Largest internalinternal organ- organ-weighs around 3 lbs!weighs around 3 lbs!

A and P ReviewA and P Review

A LiverA Liver B Hepatic veinB Hepatic vein C Hepatic C Hepatic

arteryartery D Portal veinD Portal vein E Common bile E Common bile

ductduct F StomachF Stomach G Cystic ductG Cystic duct H GallbladderH Gallbladder

Blood Supply – 2 sourcesBlood Supply – 2 sources

Hepatic arteryHepatic artery::– 500ml/min of oxygenated blood. 500ml/min of oxygenated blood. – 30% of Cardiac output goes to the liver30% of Cardiac output goes to the liver

Portal veinPortal vein – 1000ml/min – 1000ml/min – partly oxygenated blood supplies 50 - 60% partly oxygenated blood supplies 50 - 60%

O2 O2 plus rich supply of nutrients, toxins, drugsplus rich supply of nutrients, toxins, drugs

– from stomach, small and large from stomach, small and large intestines, pancreas and spleenintestines, pancreas and spleen

Hepatic Blood Supply Hepatic Blood Supply (Cont’d)(Cont’d) Both empty into Both empty into

capillaries/sinusoidscapillaries/sinusoids

Liver filters the bloodLiver filters the blood

Hepatic vein to inferior vena Hepatic vein to inferior vena cavacava

Lobule –

Functional unit of the liver

Capillaries

Metabolic Functions of Metabolic Functions of the liverthe liver

““Body’s Refinery” Over 400 functionsBody’s Refinery” Over 400 functions

Primary role in anabolism and Primary role in anabolism and catabolismcatabolism

Metabolic Functions of the LiverMetabolic Functions of the Liver

1. 1. Metabolism of GlucoseMetabolism of Glucose

2. Protein2. Protein StorageStorage

3. Fatty acids3. Fatty acids

4. Cholesterol4. Cholesterol

Other functionsOther functions

ImmunologicImmunologic

Blood storageBlood storage

Plasma protein synthesisPlasma protein synthesis

ClottingClotting

Waste products of hemoglobin Waste products of hemoglobin

Formation and secretion of bileFormation and secretion of bile

Steroids and hormonesSteroids and hormones

AmmoniaAmmonia

Drugs, alcohol and toxins metabolismDrugs, alcohol and toxins metabolism

To Summarize….To Summarize….

The liver:The liver:– changes food into energy changes food into energy – removes alcohol and poisons from removes alcohol and poisons from

the bloodthe blood– makes bile, a yellowish-green liquid makes bile, a yellowish-green liquid

that helps with digestionthat helps with digestion

HepatitisHepatitis

Simply means inflammation of Simply means inflammation of the liverthe liver– ““itis” means inflammation, “hepa” itis” means inflammation, “hepa”

means liver. means liver. Viral hepatitis Viral hepatitis

– Most common causeMost common cause– Viral types include A, B, C, D, E, and Viral types include A, B, C, D, E, and

GG

HepatitisHepatitis

Other possible causesOther possible causes– Drugs (alcohol)Drugs (alcohol)– ChemicalsChemicals– Autoimmune liver diseaseAutoimmune liver disease– Bacteria (rarely)Bacteria (rarely)

Hepatitis Hepatitis EtiologyEtiology CausesCauses

– A, B, C, D, E, and G virusA, B, C, D, E, and G virus– CytomegalovirusCytomegalovirus– Epstein-Barr virusEpstein-Barr virus– Herpes virus Herpes virus – Coxsackie virusCoxsackie virus– Rubella virusRubella virus

Hepatitis AHepatitis A

Hepatitis A virus (HAV)Hepatitis A virus (HAV)– RNA virusRNA virus– Transmitted fecal–oral route, Transmitted fecal–oral route,

parenteral (rarely)parenteral (rarely)– Frequently occurs in small outbreaksFrequently occurs in small outbreaks


3000 new cases of hepatitis A 3000 new cases of hepatitis A occur annually in the United occur annually in the United StatesStates

1.4 million cases of hepatitis A 1.4 million cases of hepatitis A occur annually worldwideoccur annually worldwide– Nearly universal during childhood in Nearly universal during childhood in

developing countriesdeveloping countries

Hepatitis A Hepatitis A

Hepatitis A virus (HAV)Hepatitis A virus (HAV)– Found in feces 2 or more weeks Found in feces 2 or more weeks

before the onset of symptoms and before the onset of symptoms and up to 1-2 weeks after the onset of up to 1-2 weeks after the onset of jaundice jaundice

– Present in blood brieflyPresent in blood briefly– No chronic carrier state No chronic carrier state

Hepatitis A:Hepatitis A:Incubation PeriodIncubation Period 2-6 weeks2-6 weeks Acute onsetAcute onset Mild flu-like manifestationsMild flu-like manifestations Symptoms last up to 2 monthsSymptoms last up to 2 months Liver usually repairs itself, so no Liver usually repairs itself, so no

permanent effectspermanent effects


Hepatitis A virus (HAV)Hepatitis A virus (HAV)– Anti-HAV immunoglobulin M (IgM)Anti-HAV immunoglobulin M (IgM)

Appears in the serum as the stool becomes Appears in the serum as the stool becomes negative for the virusnegative for the virus

Detection of IgM anti-HAV indicates acute Detection of IgM anti-HAV indicates acute hepatitis hepatitis

– Anti-HAV immunoglobulin G (IgG)Anti-HAV immunoglobulin G (IgG) IgG anti-HAV: Indicator of past infection or IgG anti-HAV: Indicator of past infection or

immunizationimmunization Presence of IgG antibody provides lifelong Presence of IgG antibody provides lifelong

immunity immunity

Hepatitis A:Hepatitis A:Mode of TransmissionMode of Transmission Mainly by ingestion of food or Mainly by ingestion of food or

liquid infected with the virusliquid infected with the virus– Poor hygiene, improper handling of Poor hygiene, improper handling of

food, crowding housing, poor food, crowding housing, poor sanitation conditions are all factors sanitation conditions are all factors related to Hepatitis Arelated to Hepatitis A

Hepatitis A:Hepatitis A:Mode of Transmission Mode of Transmission (Cont’d)(Cont’d) Occurs more frequently in Occurs more frequently in

underdeveloped countriesunderdeveloped countries Contaminated watersContaminated waters

– Drinking water, contaminated Drinking water, contaminated seafoodseafood

Food-borne Hepatitis A outbreaks Food-borne Hepatitis A outbreaks usually due to infected food handlerusually due to infected food handler– Contamination of food during Contamination of food during

preparationpreparation

Hepatitis A:Hepatitis A: Vaccine Vaccine

2 doses IM2 doses IM– Initial doseInitial dose– Booster in 6 to 12 monthsBooster in 6 to 12 months

Post-exposure Post-exposure ProphylaxisProphylaxis Standard IG-immune globulinStandard IG-immune globulin

– Given IM within 2 weeks of exposureGiven IM within 2 weeks of exposure Hepatitis A VaccineHepatitis A Vaccine

IG is recommended for persons who do not IG is recommended for persons who do not have anti-HAV antibodies and have had food have anti-HAV antibodies and have had food borne exposure or close contact with HAV-borne exposure or close contact with HAV-infected person infected person

Remember 2/2/2/2 Remember 2/2/2/2 RuleRule 2 doses IM for vaccination2 doses IM for vaccination Signs & symptoms last 2 monthsSigns & symptoms last 2 months Contagious 2 weeks before signs & Contagious 2 weeks before signs &

symptomssymptoms Post-exposure dose given IM within 2 Post-exposure dose given IM within 2

weeks of exposureweeks of exposure Must report within one dayMust report within one day

Hepatitis BHepatitis B

Worldwide, nearly 2 billion people Worldwide, nearly 2 billion people infected with Hepatitis B. 350 million infected with Hepatitis B. 350 million have chronic infectionhave chronic infection

43,000 new cases of Hepatitis B 43,000 new cases of Hepatitis B annually in United Statesannually in United States– Incidence Incidence decreased due to HBV vaccinedecreased due to HBV vaccine

1.25 million people chronically 1.25 million people chronically infected in the United Statesinfected in the United States

Hepatitis B Hepatitis B

Hepatitis B virus (HBV)Hepatitis B virus (HBV)– DNA virusDNA virus– Transmission of HBVTransmission of HBV

Perinatally by mothers infectedPerinatally by mothers infected Percutaneously (IV drug use)Percutaneously (IV drug use) Sexually transmittedSexually transmitted Mucosal exposure to infectious blood, blood Mucosal exposure to infectious blood, blood

products, or other body fluidsproducts, or other body fluids

Hepatitis BHepatitis B

Hepatitis B virus (HBV)Hepatitis B virus (HBV)– Sexually transmitted diseaseSexually transmitted disease– Can live on a dry surface for 7 daysCan live on a dry surface for 7 days– More infectious than HIVMore infectious than HIV

Hepatitis B- Hepatitis B- PrecautionsPrecautionsSource: UptodateSource: Uptodate PREVENT INFECTION OF FAMILYPREVENT INFECTION OF FAMILY — Acute and — Acute and

chronic hepatitis B are contagious. Thus, people with chronic hepatitis B are contagious. Thus, people with hepatitis B should discuss measures to reduce the risk hepatitis B should discuss measures to reduce the risk of infecting close contacts. This includes the following:of infecting close contacts. This includes the following:

Discuss the infection with any sexual partners and use Discuss the infection with any sexual partners and use a latex condom with every sexual encounter. a latex condom with every sexual encounter.

Do not share razors, toothbrushes, or anything that Do not share razors, toothbrushes, or anything that has blood on it. has blood on it.

Cover open sores and cuts with a bandage. Cover open sores and cuts with a bandage.

Do not donate blood, body organs, other tissues, or Do not donate blood, body organs, other tissues, or sperm. sperm.

Hepatitis B- Hepatitis B- PrecautionsPrecautionsSource: UptodateSource: Uptodate Immediate family and household members Immediate family and household members

should have testing for hepatitis B. Anyone should have testing for hepatitis B. Anyone who is at risk of hepatitis B infection should who is at risk of hepatitis B infection should be vaccinated, if not done previously. (See be vaccinated, if not done previously. (See "Patient information: Adult immunizations".) .)

Do not share any injection drug equipment Do not share any injection drug equipment (needles, syringes, etc). (needles, syringes, etc).

Clean blood spills with a mixture of 1 part Clean blood spills with a mixture of 1 part household bleach to 9 parts water.household bleach to 9 parts water.

Hepatitis B- Hepatitis B- PreventionPrevention

No Evidence Hepatitis B Spread by:No Evidence Hepatitis B Spread by: Sweating Sweating Urine (in free of blood)Urine (in free of blood) TearsTears BreastfeedingBreastfeeding

Hep B Incubation Hep B Incubation PeriodPeriod

6-24 weeks6-24 weeks PreventionPrevention

–Vaccine-3 dosesVaccine-3 dosesInitial doseInitial doseDose at 4 weeksDose at 4 weeksDose 5 months laterDose 5 months later

Post-exposure Hep BPost-exposure Hep B

Hepatitis B Immune globulinHepatitis B Immune globulin IM in 2 dosesIM in 2 doses

– First dose within 24 hours to 7 days of First dose within 24 hours to 7 days of exposureexposure

– Second dose 20 to 30 days post-Second dose 20 to 30 days post-exposureexposure

Provides short-term immunityProvides short-term immunity Give HBV vaccine concurrently- vaccine Give HBV vaccine concurrently- vaccine

can be beneficial post- exposurecan be beneficial post- exposure

Hepatitis B Hepatitis B

Hepatitis B virus (HBV)Hepatitis B virus (HBV)– Complex structure with three Complex structure with three

antigensantigens Surface antigen (HBsAg)Surface antigen (HBsAg) Core antigen (HBcAg)Core antigen (HBcAg) E antigen (HBeAg)E antigen (HBeAg)

– Each antigen—a corresponding Each antigen—a corresponding antibody may develop in response to antibody may develop in response to acute viral Hepatitis Bacute viral Hepatitis B

Hepatitis B VirusHepatitis B Virus

Presence of Hepatitis B Surface Presence of Hepatitis B Surface AntibodiesAntibodies– Indicates immunity from HBV Indicates immunity from HBV

vaccinevaccine– Past HBV infectionPast HBV infection– With chronic infection, liver enzyme With chronic infection, liver enzyme

values may be normal or ↑values may be normal or ↑– 15% to 25% of chronically infected 15% to 25% of chronically infected

persons die from chronic liver persons die from chronic liver diseasedisease

Hepatitis CHepatitis C

170 million people chronically infected 170 million people chronically infected worldwide worldwide

Approximately 4 million people in the USApproximately 4 million people in the US 8000 to 10,000 people in the 8000 to 10,000 people in the

United States die each year from United States die each year from complications of end-stage liver disease complications of end-stage liver disease secondary to HCVsecondary to HCV

Approximately 30% to 40% of Approximately 30% to 40% of HIV-infected patients also have HIV-infected patients also have HCVHCV

Hepatitis C Hepatitis C

Hepatitis C virus (HCV)Hepatitis C virus (HCV)– Transmitted primarily Transmitted primarily

percutaneouslypercutaneously– Risk factorsRisk factors

IV drug useIV drug use–Most common mode of Most common mode of transmission in United States transmission in United States and Canadaand Canada

Blood transfusionsBlood transfusions

Hepatitis CHepatitis C

Hepatitis C virus (HCV)Hepatitis C virus (HCV)– Risk factors (cont’d)Risk factors (cont’d)– High-risk sexual behaviorHigh-risk sexual behavior

HemodialysisHemodialysis Occupational exposureOccupational exposure Perinatal transmissionPerinatal transmission

Hepatitis C:Hepatitis C:TransmissionTransmission

Hepatitis C virus (HCV)Hepatitis C virus (HCV)– Up to 10% of patients with HCV Up to 10% of patients with HCV

cannot identify a sourcecannot identify a source– Risk of body piercings, tattooing, Risk of body piercings, tattooing,

and intranasal drug use in and intranasal drug use in transmission of HCVtransmission of HCV

Hepatitis CHepatitis CDiagnostic StudiesDiagnostic Studies

Anti-HCV antibody- Anti-HCV antibody- marker marker for acute or chronic infection with HCVfor acute or chronic infection with HCV

HCV RNA- HCV RNA- indicates ongoing viral indicates ongoing viral replicationreplication

Enzyme Immunoassay (EIA)- Enzyme Immunoassay (EIA)- initial screening for HCVinitial screening for HCV

Hepatitis DHepatitis D

Hepatitis D virus (HDV)Hepatitis D virus (HDV)– Also called Also called delta virusdelta virus– Defective single-stranded RNA Defective single-stranded RNA

virusvirus– Cannot survive on its ownCannot survive on its own– Requires the helper function of Requires the helper function of

HBV to replicateHBV to replicate

Hepatitis DHepatitis D

Hepatitis D virus (HDV) Hepatitis D virus (HDV) (cont’d)(cont’d)– HBV-HDV co-infectionHBV-HDV co-infection

↑ ↑ Risk of fulminant Risk of fulminant hepatitishepatitis

More severe acute diseaseMore severe acute disease

Hepatitis EHepatitis E

Hepatitis E virus (HEV)Hepatitis E virus (HEV)– RNA virusRNA virus– Transmitted fecal–oral routeTransmitted fecal–oral route– Most common mode of Most common mode of

transmission is drinking transmission is drinking contaminated watercontaminated water

– Occurs primarily in developing Occurs primarily in developing countriescountries

Hepatitis GHepatitis G

Hepatitis G virus (HGV)Hepatitis G virus (HGV)– RNA virusRNA virus– Poorly characterized parenterally Poorly characterized parenterally

and sexually transmitted virusand sexually transmitted virus– Found in some blood donorsFound in some blood donors– Can be transmitted by blood Can be transmitted by blood

transfusiontransfusion

Hepatitis GHepatitis G

Hepatitis G virus (HGV) Hepatitis G virus (HGV) (cont’d)(cont’d)– Coexists with other hepatitis Coexists with other hepatitis

viruses and HIVviruses and HIV– Does not appear to cause Does not appear to cause

liver damage by itselfliver damage by itself

Pathophysiology of Pathophysiology of HepatitisHepatitis Acute infection- widespread Acute infection- widespread

inflammation of liver tissueinflammation of liver tissue– Liver damage mediated byLiver damage mediated by

Cytotoxic cytokines Cytotoxic cytokines Natural killer cells Natural killer cells

– Liver cell damage results in Liver cell damage results in hepatic cell necrosishepatic cell necrosis

Acute HepatitisAcute Hepatitis

Hepatitis A: acute onset, flu-like Hepatitis A: acute onset, flu-like symptomssymptoms

Hepatitis B: Hepatitis B: – symptoms usually more severesymptoms usually more severe– 30% of patients asymptomatic30% of patients asymptomatic

Hepatitis C: Hepatitis C: – 80% asymptomatic80% asymptomatic– Often mildOften mild


Incubation Phase: after exposure to virus, no Incubation Phase: after exposure to virus, no symptomssymptoms

Preicteric Phase: Preicteric Phase: – General malaiseGeneral malaise– FatigueFatigue– Body aches, headacheBody aches, headache– GI symptoms- nausea/vomiting, diarrhea, GI symptoms- nausea/vomiting, diarrhea,

abdominal discomfortabdominal discomfort– Chills, low grade feverChills, low grade fever


Icteric or Jaundice Phase:Icteric or Jaundice Phase:– Usually 5-10 days after pre-icteric symptomsUsually 5-10 days after pre-icteric symptoms– Jaundice results when bilirubin diffuses into Jaundice results when bilirubin diffuses into

tissuestissues– Sclera jaundicedSclera jaundiced– Urine darkens due to excess bilirubin being Urine darkens due to excess bilirubin being

excretedexcreted– If bilirubin cannot flow out of liver, stool will be If bilirubin cannot flow out of liver, stool will be

light or clay-coloredlight or clay-colored– Pruritus can accompany jaundicePruritus can accompany jaundice

Accumulation of bile salts beneath the skinAccumulation of bile salts beneath the skin– When jaundice occurs, fever subsidesWhen jaundice occurs, fever subsides– Liver usually enlarged and tenderLiver usually enlarged and tender

Severe JaundiceSevere Jaundice

Acute HepatitisAcute Hepatitis Concalescent Phase:Concalescent Phase:

– Healing generally within 3-16 weeksHealing generally within 3-16 weeks– Begins as jaundice is disappearingBegins as jaundice is disappearing– GI symptoms minimalGI symptoms minimal

HepatitisHepatitis

Liver cells can regenerate Liver cells can regenerate with time and if no with time and if no complications occur, complications occur, resume their normal resume their normal appearance and functionappearance and function

Hepatitis Hepatitis ComplicationsComplications

Fulminant Hepatic FailureFulminant Hepatic FailureChronic HepatitisChronic HepatitisCirrhosisCirrhosisHepatocellular CarcinomaHepatocellular Carcinoma

Fulminant HepatitisFulminant Hepatitis

Results in severe impairment or Results in severe impairment or necrosis of liver cells and potential necrosis of liver cells and potential liver failure liver failure

Develops in small percentage of Develops in small percentage of patientspatients

Occurs because of Occurs because of Complications of Hepatitis BComplications of Hepatitis B Toxic reactions to drugs and Toxic reactions to drugs and

congenital metabolic disorderscongenital metabolic disorders

Diagnostic testsDiagnostic tests

Liver function studiesLiver function studies– ALTALT (Alanine aminotransferase) – elevates: (Alanine aminotransferase) – elevates:

enzyme in liver cellsenzyme in liver cells released into bloodstream released into bloodstream with injury or disease (0 – 50) normalwith injury or disease (0 – 50) normal

– ASTAST (Aspartate aminotransferase) – elevates: (Aspartate aminotransferase) – elevates: enzyme in liver & heart cellsenzyme in liver & heart cells released into released into bloodstream (0 -41)bloodstream (0 -41)

– GGTGGT – gamma glutamyltransferase: – gamma glutamyltransferase: present in all present in all cell membranescell membranes, inj or disease = elevates in cell , inj or disease = elevates in cell lysis, (8 – 55). increases when bile ducts are lysis, (8 – 55). increases when bile ducts are blocked & hepatitis. Elevated until function returns.blocked & hepatitis. Elevated until function returns.


– Alkaline phosphataseAlkaline phosphatase – present in – present in liver & bone liver & bone cellscells. Elevated in hepatitis.(44-147 IU/L). Elevated in hepatitis.(44-147 IU/L)

– CBC CBC – low RBC, Hct, Hgb related to – low RBC, Hct, Hgb related to anemia, RBC anemia, RBC destruction, bleeding, folic acid and vitamin destruction, bleeding, folic acid and vitamin deficiencies.deficiencies.

– Low WBC and PlateletsLow WBC and Platelets Increased blood flow to spleen – cells destroyed Increased blood flow to spleen – cells destroyed

faster than neededfaster than needed

– AFP- alpha fetoprotein– liver cancer markerAFP- alpha fetoprotein– liver cancer marker

– Lactic dehydrogenase LDH5 specific for liver Lactic dehydrogenase LDH5 specific for liver damagedamage


CoagulationCoagulation – prolonged prothrombin time – prolonged prothrombin time due to poor production of prothombin by liver due to poor production of prothombin by liver and decreased Vitamin K absorption (Normal and decreased Vitamin K absorption (Normal PT 12-15 seconds, INR 0.8 to 1.2)PT 12-15 seconds, INR 0.8 to 1.2)

HyponatremiaHyponatremia –hemodilution –hemodilution Hypokalemia, hypophosphatemia, Hypokalemia, hypophosphatemia,

hypomagnesemiahypomagnesemia –malnutrition & renal –malnutrition & renal lossloss

BilirubinBilirubin – Total (2-14 umol/L) – Total (2-14 umol/L)

Bilurubin – direct/conjugated (0-4 Bilurubin – direct/conjugated (0-4 umol/L)umol/L)


Serum albuminSerum albumin – low due to impaired liver production – low due to impaired liver production (3.3 – 5)(3.3 – 5)

Serum ammoniaSerum ammonia – high (0 – 150)(10 to 80 ug/l) – high (0 – 150)(10 to 80 ug/l) Glucose and cholesterolGlucose and cholesterol –abnormal due to impaired –abnormal due to impaired

liver functionliver function Abd. UltrasoundAbd. Ultrasound – liver size, ascites, or – liver size, ascites, or

nodulesnodules EsophagascopyEsophagascopy – look for varices – look for varices Liver biopsyLiver biopsy CT, MRICT, MRI

Rx Impacting LiverRx Impacting Liver

A host of medications can cause abnormal A host of medications can cause abnormal liver enzymes levels. Examples include:liver enzymes levels. Examples include:

Pain relief medications such as aspirin, Pain relief medications such as aspirin, acetaminophen (Tylenol), acetaminophen (Tylenol), ibuprofen (Advil, (Advil, Motrin), naproxen (Narosyn), Motrin), naproxen (Narosyn), diclofenac (Voltaren), and phenylbutazone (Butazolidine) (Voltaren), and phenylbutazone (Butazolidine)

Anti-seizure medications such as Anti-seizure medications such as phenytoin (Dilantin), (Dilantin), valproic acid, , carbamazepine (Tegretol), and phenobarbital (Tegretol), and phenobarbital

Antibiotics such as the tetracyclines, Antibiotics such as the tetracyclines, sulfonamides, isoniazid (INH), sulfonamides, isoniazid (INH), sulfamethoxazole, , trimethoprim, , nitrofurantoin, etc. , etc.

Rx Impacting LiverRx Impacting Liver

Cholesterol lowering drugs such as the Cholesterol lowering drugs such as the "statins" (Mevacor, Pravachol, Lipitor, "statins" (Mevacor, Pravachol, Lipitor, etc.) and niacin etc.) and niacin

Cardiovascular drugs such as Cardiovascular drugs such as amiodarone (Cordarone), hydralazine, (Cordarone), hydralazine, quinidine, etc. , etc.

Anti-depressant drugs of the tricyclic Anti-depressant drugs of the tricyclic type (ie elavil)type (ie elavil)

With drug-induced liver enzyme With drug-induced liver enzyme abnormalities, the enzymes usually abnormalities, the enzymes usually normalize weeks to months after normalize weeks to months after stopping the medications.stopping the medications.

Needle biopsyMost common in past

Laparoscopic biopsy:

Used to remove tissue from specific parts of the liver.

Liver Biopsy

Liver Biopsy (Cont’d)Liver Biopsy (Cont’d)

Transvenous biopsyTransvenous biopsy Catheter into a vein in the neck and Catheter into a vein in the neck and

guiding it to the liver. guiding it to the liver.

A biopsy needle is placed into the A biopsy needle is placed into the catheter and advanced into the catheter and advanced into the liver. liver.

Used for patients with blood-Used for patients with blood-clotting problems or excess fluid clotting problems or excess fluid

Liver BiopsyLiver Biopsy

Adequacy of clotting- PT/ INR, Adequacy of clotting- PT/ INR, Platelets (Vit. K?)Platelets (Vit. K?)

Type and cross match for bloodType and cross match for blood Usually hold aspirin, ibuprofen, and Usually hold aspirin, ibuprofen, and

anticoagulantsanticoagulants Chest x-rayChest x-ray Consent form & NPO 4 to 8 hr. Consent form & NPO 4 to 8 hr.

Liver Biopsy (Cont’d)Liver Biopsy (Cont’d)

Consent form & NPO 4 to 8 hr. Consent form & NPO 4 to 8 hr. Vital signs & Empty bladderVital signs & Empty bladder Supine position, R arm above headSupine position, R arm above head Hold breath after expiration when Hold breath after expiration when

needle insertedneedle inserted Be very still during procedure – 20 Be very still during procedure – 20

minutesminutes

Liver Biopsy Video

Complications are:

Puncture of lung or gallbladder, infection, bleeding, and pain.

After Needle Liver After Needle Liver BiopsyBiopsy

Pressure to site, place pt on Rt side to maintain Pressure to site, place pt on Rt side to maintain site pressure minimum of 2 hrs. & flat 12-14 hrs.site pressure minimum of 2 hrs. & flat 12-14 hrs.

Vital signs & check for bleedingVital signs & check for bleeding

NPO X 2H afterNPO X 2H after

Assess for peritonitis, shock, & pneumothoraxAssess for peritonitis, shock, & pneumothorax

Rt. shoulder pain commonRt. shoulder pain common– caused by irritation of the diaphragm muscle caused by irritation of the diaphragm muscle – usually radiates to the shoulder for a few hours or usually radiates to the shoulder for a few hours or

days.days.

After Needle Biopsy After Needle Biopsy (Cont’d)(Cont’d) Soreness at the incision siteSoreness at the incision site

Avoid aspirin or ibuprofen for pain control Avoid aspirin or ibuprofen for pain control for the first week because they decrease for the first week because they decrease blood clotting, which is crucial for blood clotting, which is crucial for healing. CONSULT HEALTHCARE healing. CONSULT HEALTHCARE PROVIDER!PROVIDER!

Avoid coughing, straining, lifting x 1-2 Avoid coughing, straining, lifting x 1-2 weeksweeks

Hepatitis CareHepatitis Care

Rest is a priority!Rest is a priority!

Diet –High calorie & protein, Low fatDiet –High calorie & protein, Low fat– Vitamin supplement – B complex & Vitamin supplement – B complex &

KK– Avoid alcohol & drugs detoxed in Avoid alcohol & drugs detoxed in

liverliver

Life style changesLife style changes

Meds for Chronic Meds for Chronic HepatitisHepatitis Chronic HBVChronic HBV

Pegylated a-interferon (Pegasys, PEG-Intron)Pegylated a-interferon (Pegasys, PEG-Intron) Lamivudine (Epivir)Lamivudine (Epivir) Adefovir (Hepsera)Adefovir (Hepsera) Entecavir (Baraclude)Entecavir (Baraclude) Telbivudine (Tyzeka)Telbivudine (Tyzeka) Tenofovir (Viread)Tenofovir (Viread)

Chronic HCVChronic HCV Pegylated a-interferon (Pegasys, PEG-Intron)Pegylated a-interferon (Pegasys, PEG-Intron) Ribavirin (Rebetol, Copegus)Ribavirin (Rebetol, Copegus)

Hepatitis Hepatitis Nursing ManagementNursing Management

Nursing assessmentNursing assessment Past health historyPast health history

– Hemophilia Hemophilia – Exposure to infected persons Exposure to infected persons – Ingestion of contaminated food or Ingestion of contaminated food or

water water – Past blood transfusion (before 1992)Past blood transfusion (before 1992)


Nursing assessmentNursing assessment Medications (use and misuse)Medications (use and misuse)

– Acetaminophen Acetaminophen – Phenytoin Phenytoin – Methyldopa Methyldopa


Nursing assessmentNursing assessment IV drug and alcohol abuseIV drug and alcohol abuse Weight lossWeight loss Dark urineDark urine FatigueFatigue Right upper quadrant painRight upper quadrant pain Pruritus Pruritus


Nursing assessmentNursing assessment Low-grade feverLow-grade fever JaundiceJaundice Abnormal laboratory Abnormal laboratory

valuesvalues


Nursing diagnosesNursing diagnoses Imbalanced nutrition: Less Imbalanced nutrition: Less

than body requirementsthan body requirements Activity intoleranceActivity intolerance Ineffective therapeutic Ineffective therapeutic

regimen managementregimen management


Overall goals: PlanningOverall goals: Planning

– Relief of discomfortRelief of discomfort– Resumption of normal activities Resumption of normal activities – Return to normal liver function Return to normal liver function

without complicationswithout complications


Nursing implementationNursing implementation Health promotionHealth promotion

–Hepatitis A Hepatitis A EducationEducationVaccinationVaccinationGood hygiene practicesGood hygiene practices

Nursing implementationNursing implementation

Health PromotionHealth Promotion– Hepatitis BHepatitis B

VaccinationVaccination EducationEducationWorkplace safetyWorkplace safety



Nursing implementationNursing implementation Health promotionHealth promotion

–Hepatitis CHepatitis C EducationEducation Infection control precautionsInfection control precautions Modification of high-risk behavior Modification of high-risk behavior


Nursing implementationNursing implementation Acute interventionAcute intervention

–RestRest– JaundiceJaundice

Assess degree of jaundiceAssess degree of jaundiceSmall, frequent mealsSmall, frequent meals


Nursing implementationNursing implementation Ambulatory and home careAmbulatory and home care

–Dietary teaching Dietary teaching –Assessment for complicationsAssessment for complications–Regular follow-up for at least Regular follow-up for at least 1 year after diagnosis1 year after diagnosis


Nursing implementationNursing implementation Ambulatory and home careAmbulatory and home care

– Avoid alcoholAvoid alcohol


Evaluation Evaluation Expected outcomesExpected outcomes

– Adequate nutritional intake Adequate nutritional intake – Increased tolerance for activityIncreased tolerance for activity– Verbalization of understanding Verbalization of understanding

of follow-up care of follow-up care


Evaluation Evaluation Expected outcomesExpected outcomes

–Able to explain methods Able to explain methods of transmission and of transmission and methods of preventing methods of preventing transmission to otherstransmission to others

Hepatitis ReportingHepatitis Reporting

Break!

CirrhosisCirrhosis

Cirrhosis Cirrhosis PathophysiologyPathophysiology Cirrhosis is the end stage of Cirrhosis is the end stage of

chronic liver diseasechronic liver disease Progressive, leads to liver failureProgressive, leads to liver failure Insidious, prolonged courseInsidious, prolonged course Ninth leading cause of death in Ninth leading cause of death in

United StatesUnited States Twice as common in menTwice as common in men

Cirrhosis Cirrhosis PathophysiologyPathophysiology Hepatocytes are destroyed and portalHepatocytes are destroyed and portal

hypertension developshypertension develops Liver cells attempt to regenerateLiver cells attempt to regenerate Regenerative process is disorganizedRegenerative process is disorganized Functional liver tissue is destroyed and Functional liver tissue is destroyed and

scarring of liver occursscarring of liver occurs New fibrous connective tissue distorts New fibrous connective tissue distorts

liver’s normal structure, with impeded liver’s normal structure, with impeded blood flowblood flow

Four Types of CirrhosisFour Types of Cirrhosis

Alcoholic Cirrhosis – formerly called Alcoholic Cirrhosis – formerly called Laennec’sLaennec’s

Post necrotic CirrhosisPost necrotic Cirrhosis Biliary/obstructive - bile flow Biliary/obstructive - bile flow

obstructed causing damage to liverobstructed causing damage to liver Cardiac- from right side heart failureCardiac- from right side heart failure

Alcoholic or Nutritional Alcoholic or Nutritional CirrhosisCirrhosis(formerly called Laennec’s)(formerly called Laennec’s)

Usually associated with alcohol Usually associated with alcohol abuseabuse

Most common cause of cirrhosisMost common cause of cirrhosis Causes metabolic changes in Causes metabolic changes in

liver; fat accumulates in liver liver; fat accumulates in liver (fatty liver)(fatty liver)

Fatty liver potentially reversible Fatty liver potentially reversible if alcohol consumption ceasesif alcohol consumption ceases

Post Necrotic Post Necrotic CirrhosisCirrhosis Results from complication of Results from complication of

viral infections, Hepatitis, or viral infections, Hepatitis, or exposure to toxinsexposure to toxins

Liver shrinks because lobules Liver shrinks because lobules destroyed, broad bands of scar destroyed, broad bands of scar tissue form within the livertissue form within the liver

Biliary CirrhosisBiliary Cirrhosis

Associated with chronic biliary Associated with chronic biliary obstruction and infectionobstruction and infection

Retained bile damages and Retained bile damages and destroys liver cells, causing destroys liver cells, causing fibrosis of liverfibrosis of liver

Cardiac Cardiac CirrhosisCirrhosis

Results from long-standing Results from long-standing severe right sided heart failuresevere right sided heart failure

Elevated central venous Elevated central venous pressures cause stasis of blood pressures cause stasis of blood in veins of liver, which leads to in veins of liver, which leads to fibrosisfibrosis

Early Signs of Cirrhosis Early Signs of Cirrhosis ComplicationsComplicationsand Common Manifestationsand Common Manifestations

1.1. Hepatomegaly and RUQ painHepatomegaly and RUQ pain

2.2. Weight lossWeight loss

3.3. WeaknessWeakness

4.4. AnorexiaAnorexia

5.5. Diarrhea and constipationDiarrhea and constipation

CirrhosisCirrhosis Interventions- Interventions- DrugsDrugs

Diuretics-Diuretics-– Aldactone Aldactone (spironolactone): decreases aldosterone (spironolactone): decreases aldosterone

levels, K+ sparinglevels, K+ sparing– Lasix (furosemide) Lasix (furosemide)

Salt-poor albuminSalt-poor albumin

NeomycinNeomycin – decrease ammonia forming organisms. – decrease ammonia forming organisms. Typically only Typically only

recommended when unable to tolerate lactuloserecommended when unable to tolerate lactulose

Lactulose Lactulose – decreases ammonia forming organisms and – decreases ammonia forming organisms and inc. acidity of bowel. Goal is 2-3 loose stools per day.inc. acidity of bowel. Goal is 2-3 loose stools per day.

Ferrous sulfate and folic acidFerrous sulfate and folic acid – to treat anemia/ vitamin – to treat anemia/ vitamin deficiency deficiency

Beta blocker: propranolol (Inderal), nadolol-Beta blocker: propranolol (Inderal), nadolol- to prevent to prevent bleeding of E varices in conjunction with bleeding of E varices in conjunction with isosorbide isosorbide mononitrate (Imdur)mononitrate (Imdur) lowers hepatic venous pressure lowers hepatic venous pressure

Proton Pump Inhibitors, H2 Receptor Blockers– Proton Pump Inhibitors, H2 Receptor Blockers– decrease irritation of varicesdecrease irritation of varices

Serax (oxazepam)Serax (oxazepam) – benzodiazepine for alcohol – benzodiazepine for alcohol withdrawal, sedation, sleep. Is metabolized in the liver withdrawal, sedation, sleep. Is metabolized in the liver – use cautiously.– use cautiously.

Cirrhosis Interventions- Drugs (Cont’d)

Nursing Diagnoses - Nursing Diagnoses - CirrhosisCirrhosis

Fluid Volume deficitFluid Volume deficit Ineffective protection: bleedingIneffective protection: bleeding Disturbed thought processDisturbed thought process Ineffective breathing patternIneffective breathing pattern Impaired skin integrityImpaired skin integrity Imbalanced nutrition: less than Imbalanced nutrition: less than

body requirementsbody requirements

CirrhosisCirrhosis Interventions- Interventions- Diet and fluidsDiet and fluids Low protein (sometimes), high carbohydrate, Low protein (sometimes), high carbohydrate,

high calorie-if signs of acute hepatic high calorie-if signs of acute hepatic encephalopathyencephalopathy

With cirrhosis and no hepatic encephalopathy, With cirrhosis and no hepatic encephalopathy, high carbohydrate, high protein, low salthigh carbohydrate, high protein, low salt

Low sodium-500 mg-2gmsLow sodium-500 mg-2gms At first sign of encephalopathy or ammonia At first sign of encephalopathy or ammonia

level increasing- decrease protein intake level increasing- decrease protein intake (sometimes)(sometimes)

Early stage for liver regeneration- need high Early stage for liver regeneration- need high protein-(75-100gms)protein-(75-100gms)

Later Manifestations of Later Manifestations of Cirrhosis JaundiceCirrhosis Jaundice

Jaundice occurs as a result of Jaundice occurs as a result of the decreased ability to the decreased ability to conjugate and excrete bilirubinconjugate and excrete bilirubin

In the late stages of In the late stages of cirrhosis, patient is usually cirrhosis, patient is usually jaundicedjaundiced

JAUNDICEJAUNDICE

HepatocellularHepatocellular

ObstructiveObstructive

HemolyticHemolytic

Cirrhosis- Cirrhosis- Hepatocellular or Hepatocellular or intrahepatic jaundiceintrahepatic jaundice

Diseased liver cells can’t Diseased liver cells can’t clear normal amounts of clear normal amounts of bilirubin from the blood.bilirubin from the blood.

Obstructive or Obstructive or Extrahepatic JaundiceExtrahepatic Jaundice

Due to the interference with Due to the interference with the flow of bile in the hepatic the flow of bile in the hepatic duct. duct.

Liver is conjugating bilirubin Liver is conjugating bilirubin but it cannot reach small but it cannot reach small intestines so is released into intestines so is released into blood streamblood stream

Hemolytic Hemolytic JaundiceJaundice

Due to excessive destruction of Due to excessive destruction of RBC’s.RBC’s.– transfusion reactiontransfusion reaction

– Faulty hemoglobin – sickle cellFaulty hemoglobin – sickle cell

– Autoimmune destruction of RBC’sAutoimmune destruction of RBC’s

Major Complications of Cirrhosis

Portal hypertension Variceal bleeding Ascites Spontaneous bacterial peritonitis Hepatorenal syndrome Hepatic encephalopathy

• The portal vein carries about 1500 ml/min of blood from the small and large bowel, spleen, and stomach to the liver.

• Any obstruction or increased resistance to flow or, rarely, pathological increases in portal blood flow may lead to portal hypertension with portal pressures over 12 mm Hg.

• alcoholic and viral cirrhosis are the leading causes of portal hypertension in Western countries.

Portal Hypertension

Portal Hypertention Portal Hypertention (Cont’d)(Cont’d)

– Increases in portal pressure cause development of Increases in portal pressure cause development of a portosystemic collateral circulation with resultant a portosystemic collateral circulation with resultant compensatory portosystemic shunting and compensatory portosystemic shunting and disturbed intrahepatic circulation. disturbed intrahepatic circulation.

– These factors are partly responsible for the These factors are partly responsible for the important complications of chronic liver disease, important complications of chronic liver disease, including variceal bleeding, hepatic including variceal bleeding, hepatic encephalopathy, ascites, hepatorenal syndrome, encephalopathy, ascites, hepatorenal syndrome, recurrent infection, and abnormalities in recurrent infection, and abnormalities in coagulation.coagulation.

– Variceal bleeding is the most serious Variceal bleeding is the most serious complicationcomplication and is an important cause of death and is an important cause of death in patients with cirrhotic liver disease. in patients with cirrhotic liver disease.

PORTAL HYPERTENSIONPORTAL HYPERTENSIONnormal 3 mmHg normal 3 mmHg 12 mmHg = esophageal rupture12 mmHg = esophageal rupture

Resistance to blood flow = Increase in Resistance to blood flow = Increase in pressure in portal venous system.pressure in portal venous system.– Swelling, inflammation, fibrosis, scarring of liverSwelling, inflammation, fibrosis, scarring of liver– Thrombus Thrombus – Resistance in Inferior vena cava: Rt.CHF, Resistance in Inferior vena cava: Rt.CHF,

myopathymyopathy Blood takes collateral channelsBlood takes collateral channels - -

esophagus, stomach, spleen etc, veins, esophagus, stomach, spleen etc, veins, hemorrhoids hemorrhoids

May need shunts or TIPS May need shunts or TIPS Transjugular Transjugular

Intrahepatic Portosystemic ShuntIntrahepatic Portosystemic Shunt to decrease to decrease pressure, beta blockers also helppressure, beta blockers also help

Portal Hypertension

Esophageal

Varices

Caput medusae

(dilated abd. veins)

Hemorrhoids

Arteriovenous shunting

Hypersplenism

Moderate anemia

Neutropenia

Thrombocytopenia

Marked ascites

Ascites &Caput medusae

Spider angiomas

Treatment of esophageal Treatment of esophageal varicesvarices

Active bleedingActive bleeding Central line & pulmonary artery pressuresCentral line & pulmonary artery pressures Blood transfusions & fresh frozen plasma for clotting Blood transfusions & fresh frozen plasma for clotting

factorsfactors Somatostatin or Vasopressin – constrict gut vesselsSomatostatin or Vasopressin – constrict gut vessels Nitroglycerin- to counter negative affects of Nitroglycerin- to counter negative affects of

vasopressinvasopressin Airway/trachAirway/trach

Later prevention of re-bleeding Later prevention of re-bleeding Beta-blockersBeta-blockers Long-acting nitratesLong-acting nitrates Soft food, chew well, avoid intra-abdominal pressure Soft food, chew well, avoid intra-abdominal pressure Protonix (pantoprazole) Protonix (pantoprazole)

Rapid Endoscopy!

Sclerotherapy:

• A sclerosant solution (ethanolamine oleate or sodium tetradecyl sulphate) is injected into the bleeding varix or the overlying submucosa

• Complications can include fever, dysphagia and chest pain, ulceration, stricture, and (rarely) perforation.

Band ligation:

• Band ligation is achieved by a banding device attached to the tip of the endoscope

Band LigationBand Ligation

• The balloon tube tamponade may be life saving in patients with active variceal bleeding if emergency sclerotherapy or banding is unavailable

• The main complications are gastric and esophageal ulceration, aspiration pneumonia, and esophageal perforation.

Balloon Tube Tamponade:

Minnesota Tube-

Four lumens:• one for gastric aspiration

• two to inflate the gastric and esophageal balloons

• one above the esophageal balloon for suction of secretions to prevent

aspiration

Sengstaken-Blakemore Tube

Three Lumens:Three Lumens: Esophageal balloon Esophageal balloon

inflationinflation Gastric balloon Gastric balloon

inflationinflation Gastric aspirationGastric aspiration

Repeated endoscopic treatment Repeated endoscopic treatment eradicates esophageal varices in most

patients, recurrent variceal bleeding is uncommon. Because portal hypertension persists, patients at risk for recurrent

varices

Long term drug treatment The use of beta-blockers after variceal bleeding has been shown to

reduce portal blood pressures and lower the risk of further variceal bleeding.

Prophylactic management Most patients with portal hypertension never bleed, and it is difficult to

predict who will. Beta blockers have been shown to reduce the risk of bleeding.

Long term Management of Esophageal Varices

Transjugular Intrahepatic Transjugular Intrahepatic Portosystemic ShuntPortosystemic Shunt

Special proceduresSpecial procedures – fistula created – fistula created with portal vein and hepatic vein and with portal vein and hepatic vein and then stents placed to keep it open. then stents placed to keep it open.

Bypasses the liver by returning blood Bypasses the liver by returning blood to hepatic vein to inferior vena cavato hepatic vein to inferior vena cava

TIPSTIPS Transjugular intrahepatic Transjugular intrahepatic portosystemic shuntportosystemic shunt

TIPS POSTTIPS POST

• Shunted blood contains high ammonia • Can lead to: hepatic encephalopathy

TIPS:TIPS:

SplenomegalySplenomegaly due to due to Portal hypertensionPortal hypertension The spleen enlarges as blood is The spleen enlarges as blood is

shunted to splenic veinshunted to splenic vein This increases rate of destruction This increases rate of destruction

of RBCs, WBCs, and plateletsof RBCs, WBCs, and platelets Decreases storage capacity of Decreases storage capacity of

spleenspleen Causes anemia, leukopenia and Causes anemia, leukopenia and

thrombocytopeniathrombocytopenia

AscitesAscites – Complication – Complication of Cirrhosisof Cirrhosis Blood flow diverted to mesenteric vesselsBlood flow diverted to mesenteric vessels

– Increased capillary pressure leads to fluid Increased capillary pressure leads to fluid leaving vessels out into peritoneal cavityleaving vessels out into peritoneal cavity

High pressure in liver causes fluid to leave High pressure in liver causes fluid to leave liver into peritoneal cavityliver into peritoneal cavity

This fluid is plasma filtrate with high This fluid is plasma filtrate with high concentration of albuminconcentration of albumin

Minerals- Ca++ is attached to albumin Minerals- Ca++ is attached to albumin decreases so phosphorus increases. decreases so phosphorus increases.

K+ is low due to aldosteroneK+ is low due to aldosterone

Increased capillary

permeability

Increased Na+

&H2O retention

Portal Hypertension

HypoproteinemiaFour Factors Lead to Ascites

Responses to third Responses to third spacingspacing Loss of albuminLoss of albumin to ascites leads to to ascites leads to

hypoproteinemia, depletion of plasma proteinshypoproteinemia, depletion of plasma proteins

Loss of blood volumeLoss of blood volume = lowered BP = lowered BP

ReflexesReflexes aimed at returning blood pressure to aimed at returning blood pressure to normal include release of aldosteronenormal include release of aldosterone– Increases reabsorption of NA+ back into Increases reabsorption of NA+ back into

blood and H2O follows, thus increasing blood and H2O follows, thus increasing blood volumeblood volume

accumulation of high protein fluid in the abdomen - 3rd spacing

ASCITES

Nursing Management ASCITESNursing Management ASCITES

Assess for Assess for Respiratory Respiratory Distress- Fowler’s Distress- Fowler’s position helps position helps ease work of ease work of breathing in breathing in ascitesascites

Measure Measure Abdominal GirthAbdominal Girth

Accurate I&OAccurate I&O

MEDICAL TREATMENTMEDICAL TREATMENT

Na+ restriction-Na+ restriction- 500 mg –2 gms500 mg –2 gms

Fluids-1500 ml/day Fluids-1500 ml/day

Diuretics-AldactoneDiuretics-Aldactone

Albumin - NaCl poorAlbumin - NaCl poor

ParacentesisParacentesis

To treat respiratory To treat respiratory distress distress

Pt will loose 10-30 grams Pt will loose 10-30 grams of proteinof protein

Pt in sitting positionPt in sitting position Empty bladder firstEmpty bladder first Post--watch for Post--watch for

hypotension, bleeding, hypotension, bleeding, shock & infectionshock & infection

Additional Additional ComplicationsComplicationsLiver FailureLiver Failure

Liver FailureLiver Failure

Complex syndrome Complex syndrome characterized by impairment characterized by impairment of many organs and body of many organs and body functionsfunctions

Two conditions:Two conditions: Hepatic EncephalopathyHepatic Encephalopathy Hepatorenal SyndromeHepatorenal Syndrome

Hepatic Hepatic encephalopathy:encephalopathy:

Alteration in neuro Alteration in neuro status status due to accumulation of due to accumulation of ammoniaammonia

Build-up of other Build-up of other substances such as substances such as hormones, hormones, GI toxins, drugs also GI toxins, drugs also contributecontribute

Where does ammonia Where does ammonia come from?come from? A by-product of protein A by-product of protein

metabolismmetabolism Protein and amino acids are Protein and amino acids are

broken down by bacteria in GI broken down by bacteria in GI tract, producing ammonia.tract, producing ammonia.

Liver converts this to urea which Liver converts this to urea which is eliminated in the urineis eliminated in the urine

Precipitating Factors – all Precipitating Factors – all place demands on liverplace demands on liver

Bleeding esophageal varicesBleeding esophageal varices Ingestion of narcotics or Ingestion of narcotics or

barbiturates, anesthetics barbiturates, anesthetics Excessive protein intakeExcessive protein intake Electrolyte imbalanceElectrolyte imbalance Hemodynamic alterationsHemodynamic alterations DiureticsDiuretics Severe infectionSevere infection Blood transfusionsBlood transfusions

Stages of Hepatic Stages of Hepatic EncephalopathyEncephalopathy

Hepatic Encephalopathy - Onset Hepatic Encephalopathy - Onset PhasePhase

Personality Personality changes, changes, disturbances of disturbances of awareness, awareness, forgetfulness, forgetfulness, irritability, & irritability, & confusionconfusion

Hepatic Encephalopathy - Second Hepatic Encephalopathy - Second PhasePhase

HyperreflexiaHyperreflexia Asterixis or Asterixis or

flappingflapping– Altered hand Altered hand

writingwriting Violent, abusive Violent, abusive

behaviorbehavior

Hepatic EncephalopathyHepatic Encephalopathy - Coma - Coma

+ Babinski+ Babinski

hyperactive hyperactive reflexes obtained reflexes obtained with reflex with reflex hammerhammer

Babinski VideoBabinski Video

Medical ManagementMedical Management Hepatic EncephalopathyHepatic Encephalopathy

NeomycinNeomycin

LactuloseLactulose

Protein reductionProtein reduction

- 44thth most common cancer in the most common cancer in the worldworld

- 22,600 new cases annually in US22,600 new cases annually in US- 80% of cases also have cirrhosis 80% of cases also have cirrhosis

of the liverof the liver- 50-60% causes by hepatitis C50-60% causes by hepatitis C- 20% caused by hepatitis B20% caused by hepatitis B- Often metastasizes to lungsOften metastasizes to lungs

Primary Liver Cancer Primary Liver Cancer

Liver Cancer Liver Cancer TreatmentTreatment Surgical resectionSurgical resection Radiofrequency ablationRadiofrequency ablation CryoablationCryoablation Percutaneous ethanol injectionPercutaneous ethanol injection ChemotherapyChemotherapy

Hepatorenal syndromeHepatorenal syndromeComplication of Hepatic Complication of Hepatic FailureFailure

Hepatorenal syndromeHepatorenal syndromeComplication of Hepatic FailureComplication of Hepatic Failure

kidneys may appear normal physically but kidneys may appear normal physically but functioning impaired.functioning impaired.

Usually sudden decrease Urine Usually sudden decrease Urine production, increase BUN & Creatinine, production, increase BUN & Creatinine, jaundice and signs of liver failurejaundice and signs of liver failure

Poor prognosis- Poor prognosis- most die within 3 wks most die within 3 wks without transplantwithout transplant

Think due to decreased perfusion &/or Think due to decreased perfusion &/or toxins from failure of livertoxins from failure of liver

Liver DialysisLiver Dialysis

Bridge to transplantBridge to transplant Dialyze 6 hours at a timeDialyze 6 hours at a time

Donors:Donors:

Live donor liver transplants are an excellent Live donor liver transplants are an excellent option. option.

Liver regenerates to appropriate size for their Liver regenerates to appropriate size for their individual bodies.individual bodies.

Survival rates increase / shorter wait timeSurvival rates increase / shorter wait time

The donor - a blood relative, spouse, or The donor - a blood relative, spouse, or friend, will have extensive medical and friend, will have extensive medical and psychological evaluations to ensure the psychological evaluations to ensure the lowest possible risk.lowest possible risk.

Blood type and body size are critical factors Blood type and body size are critical factors in determining who is an appropriate donor. in determining who is an appropriate donor.

Potential donors evaluated for:Potential donors evaluated for:– liver disease, alcohol or drug abuse, cancer, or liver disease, alcohol or drug abuse, cancer, or

infection. infection. – hepatitis, AIDS, and other infections. hepatitis, AIDS, and other infections. – matched according to blood type and body size. matched according to blood type and body size. – Age, race, and sex are not considered. Age, race, and sex are not considered.

Cadaver donor have to waitCadaver donor have to wait

Liver Transplant VideoLiver Transplant Video

Liver transplant Liver transplant complicationscomplications Rejection. Rejection. About 70% of all liver-transplant About 70% of all liver-transplant

patients have some degree of organ rejection patients have some degree of organ rejection Anti-rejection medications are given to ward Anti-rejection medications are given to ward

off the immune attack.off the immune attack. InfectionInfection Most infections can be treated successfully Most infections can be treated successfully

as they occur. as they occur. CancerCancer

Review

1. Pathophysiology

1. Cirrhosis

2. Portal hypertension

3. Liver failure

1. Encephalopathy

2. Hepato-renal syndrome

2. Signs & Symptoms

3. Treatment

4. Nsg. Care

5. Complications

The EndThe End

Liver Disorders John Nation, RN, MSN Fall 2011 From the notes of Charlene Morris, RN, MSN Austin...

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Transcript of Liver Disorders John Nation, RN, MSN Fall 2011 From the notes of Charlene Morris, RN, MSN Austin...