NURM-103 Liver Pancreas Exam Review

What does bile do?

Breaks down fat in the small intestine

Liver functions

• Metabolism (carbs/fats/proteins)

• Digestion via bile production

• Detoxification of the blood + Filtering of old blood cells

• Storage (Vit ACK, minerals and iron)

• Produces proteins and clotting factors

Cirrhosis

Final, irreversible stage of liver damage

• Widespread scar tissue that causes loss of function + constricts blood flow

Icterus

Jaundice of the eyes

What is this?

Caput medusae!

• Symptom of cirrhosis

Common causes of cirrhosis

• Alcoholic liver disease

• Chronic viral Hepatitis

• Non-alcoholic fatty liver disease (NAFLD)

• Autoimmune + biliary diseases

Liver Hx assessment

• Occupation + travel

• Substance abuse

• Medications + OTC + Herbs and supplements

• Family + Health Hx

In early stages of cirrhosis, palpation of the liver will feel…

Tenderness in RUQ

In later stages of cirrhosis, palpation of the liver will feel…

Hardened and small in the RUQ

Asterixis

“Liver flap”

• Involuntary flapping of the hand when trying to hold it up as if to stop something

Cirrhosis pt general appearance

• Jaundice

• Pallor + Muscle wasting

• Ascites/edema

Why would a cirrhosis pt be itchy?

Due to bile salt accumulation

Cirrhosis pt skin assessment findings

• Reported itching due to bile salt

• Spider angiomas

• Palmar erythema

Cirrhosis pt neuro assessment findings

• Confusion

• Lethargy

• Dysarthria

• Asterixis

What causes the confusion in a cirrhosis pt?

Ammonia accumulation → Hepatic encephalopathy

What hormonal changes can cirrhosis produce?

Gyno + Testicular atrophy

Acute liver failure

Sudden and severe impairment with no prior liver disease

• Jaundice

• Coagulation issues

• Neuro dysfunction

INR of liver failure pt

> 1.5

What is the most common cause of acute liver failure?

Viral hepatitis!

Why do acute liver failure pts require rapid intervention?

Risk of cerebral edema, KF and infection

Types of jaundice

1. Hemolytic (Pre-Hepatic)

2. Hepatocellular (Intrahepatic)

3. Obstructive (post-hepatic)

Hemolytic (Pre-hepatic) jaundice

Occurring before the liver

Hepatocellular (Intrahepatic) s/s

Occurring within the liver, it cannot process normal amount of bilirubin

• Lack of appetite + Nausea,

• Fatigue + Weakness

Obstructive (post-hepatic) jaundice s/s

Occurring after the classic signs

• Deep orange foamy urine

• Light/clay-colored stool

• Severe itching of skin

• Intolerance to fat

Cirrhosis pts are at risk of (bleeding/clotting).

bleeding

What is high ammonia treated with?

Lactulose!

What is the primary therapeutic effect/sign of improvement from high ammonia?

Improved LOC

LFTs

Elevated when liver is damaged

• ALT + AST + GGT

What is the golden standard for confirming cirrhosis? What’s a risk of it?

Liver Bx

• Bleed risk due to invasive nature

Major complications of liver disease

• Portal HTN

• Hepatic encephalopathy

• Esophageal varices

Portal HTN

Scar tissue obstructs blood flow → Blood backs up and causes more symptoms

What can portal HTN cause?

• Ascites + Distended/Taut abd

• SoB

• Stretched skin

• Bulging flanks when supine

• Esophageal varices

• Splenomegaly

How is ascites caused by cirrhosis?

• Blood is backed up in vessels → Leaks out

• Lack of albumins → Fluid not remaining in vessels

How does portal HTN cause splenomegaly?

Spleen enlarges as it attempts to manage backed up blood

Why does portal HTN cause SoB?

Fluid pushes up on diaphragm → Cannot take deep breath

What is the primary procedure to treat portal HTN?

Transjugular Intrahepatic Portosystemic Shunt (TIPS)

What is a shunt?

Redirects flow of some sort of fluid in the body

TIPS procedure

Invasive procedure in interventional radiology

• Catheter inserted into jugular → Guided to the hepatic vein → Connected to the portal vein

• Stent placed to create permanent bypass/shunt

What is the greatest risk associated with the TIPS procedure?

Hepatic encephalopathy

• Bypass → Intestinal blood (with ammonia) doesn’t get filtered by liver

Other risks associated with the TIPS procedure

• HF

• Shunt stenosis/failure (over time)

• Bleeding + infection during procedure

Hepatic encephalopathy cause

Damaged liver cannot convert ammonia into urea for excretion

How does hepatic encephalopathy cause neurological symptoms?

Ammonia builds up in blood → Becomes toxic to brain

• Confusion + Personality changes + Coma

Stages of encephalopathy

1. Mild (something off)

2. Moderate (clear confusion)

3. Severe (barely awake)

4. Coma

Mild encephalopathy

First stage encephalopathy

• Personality changes

• Day/night reversal

• Forgetfulness

How can you assess stage 1 encephalopathy if it’s so subtle?

• Talk to the family

• Ask pt to write name → Sloppy

Moderate encephalopathy

Second stage of encephalopathy

• Lethargic + Disoriented

• Inappropriate behavior

• ASTERIXIS occurs here

How do you assess for asterixis?

Ask pt to hold out arms in front and extend wrists as if to stop traffic

Severe encephalopathy

Third stage of encephalopathy

• Severe confusion + somnolence

• Asterixis loss + Hyperactive reflexes

Why is asterixis lost in the third stage encephalopathy?

Pt is too lethargic to hold arms up

Coma encephalopathy

Final, life-threatening stage

• Comatose + Areflexia

• Fetor hepaticus

Fetor hepaticus

Sweet, fecal odor in breath due to accumulated toxins excreted via lungs

What is the primary goal in treating encephalopathy?

Reducing ammonia levels

Lactulose

Laxative that traps ammonia in the gut and expels it via stool

• GOAL - 2-3 soft BM per day

Nursing interventions for hepatic encephalopathy pt

• Safe environment

• Frequent neuro assessments

• CONTROL PROTEIN INTAKE

• Avoid sedatives

Why is protein limited in hepatic encephalopathy pt?

Ammonia is produced from protein breakdown

Esophageal varices

Backed up blood from portal HTN causes swollen veins that were never designed for high pressure

• Kinda like an aneurysm, highly prone to rupture

Esophageal varicose bleed s/s

• Hematemesis

• Melena

• Shock s/s

Melena

Black, tarry stool

Shock s/s

• Hypotension + Tachycardia

• Confusion

Bleed stabilization for esophageal varicose

• ICU admission

• Blood transfusion

• IV F&E

Ocreotide

Vasoactive drug given to reduce blood flow to portal system

• During esophageal varix bleeds

Most common treatment for esophageal varices bleed

Endoscopic variceal ligation (banding)

Endoscopic variceal ligation (banding)

Primary procedure for esophageal varices bleeds

• Tiny rubber bands places over varices → Cut off blood supply

Balloon tamponade

Temporary (12-24hr) life-saving measure where balloon inflated inside esophagus to directly pressure bleeding varices

• LAST RESORT. RISKY.

Bleed prevention in esophageal varices pt

• Screening via endoscopy

• Beta-blockers for portal pressure

Primary edema/ascites management

Paracentesis

Paracentesis

Procedure to drain large amounts of fluid from abdomen

• Symptom relief, not underlying cause

Before paracentesis, ensure the pt _____ to prevent ____________.

voids; prevent bladder injury

What is performed after paracentesis?

X-ray to confirm nothing was punctured

What vital sign is checked after paracentesis to ensure therapeutic effect?

Blood pressure

What diet is essential for ascites pt? Why?

Low-sodium to prevent fluid retention

Bleeding and bruising due to cirrhosis

Due to liver’s

1. Inability to produce clotting factors

2. Trapping of platelets in spleen

Cirrhosis risks RT bleeding

• Bleed from minor injuries

• GI bleeds

• Bruising

Cirrhosis vitamin deficiencies and consequences

• Vit K → Impaired clotting

• Thiamine (B1) → Wernicke-Korsakoff syndrome

• Vit A → Night blindness

Vit B1 is also called

Thiamine

Pruritus

Severe itching

Fluid balance monitoring interventions

• Measure abd girth + wt DAILY

• Strict I&Os

• Administer diuretics as ordered

Respiratory intervention for SoB

Position pt upright/high-Fowlers

What is the goal with lactulose?

2-3 soft BM/day

Skincare/pruritus interventions

• Use lotions

• Avoid harsh soaps

• Keep fingernails short

  • Prevents skin breakdown from scratching

Coagulopathy

Fancy ahh word for bleed risk

ERCP is short for

Endoscopic Retrograde CholangioPancreatography

ERCP is (diagnostic/therapeutic).

Both!

What is the goal of ERCP?

Find + relieve blockage in ducts the common bile duct

• Or investigate narrowing

• Or placing stent to open it

Common bile duct

Small duct that drains the gallbladder, liver and pancreas

What can happen due to a gallstone blocking the common bile duct?

Pain, jaundice, infection

Endoscopic Retrograde Cholangiopancreatography Procedure

Endoscopy → Appropriate procedure

• Sphincterectomy

• Stone removal

• Stent placement

What are the risks of ERCP

• Post-ERCP pancreatitis

• Bleeding

• Infection (Cholangitis)

• Perforation

What is the most common complication of an ERCP?

Post-ERCP pancreatitis

Pt education

• Low-sodium + controlled protein diet

• Alcohol abstinence

• AVOID OTC MEDS

What OTC meds should a liver pt especially be wary of?

• NSAIDs

• Certain supplements

• Girl the Tylenol

Phases of Acute Hepatitis

1. Prodromal (Pre-Icteric)

2. Icteric

3. Convalescent

Prodromal (Pre-Icteric) Phase

Initial phase with vague, flulike symptoms

• Malaise, fatigue, low-grade fever

• Muscle aches, nausea

• RUQ tenderness

Icteric phase + s/s

Classic phase where diagnosis is obvious

• Jaundice + Icterus

• Coca-cola urine

• Clay stool

• Pruritus

Convalescent phase

Recovery phase where symptoms subside and energy returns to normal

• Can last for weeks or months

How are Hepatitis A/E transmitted?

Fecal-oral

How is Hepatitis A treated?

Supportive care

Hepatitis B

Chronic hepatitis transmitted via bodily fluids

Hepatitis C

Typically chronic hepatitis transmitted via blood

• Treated via DAAs

• Treatment is COSTLY

Is there a vaccine for Hepatitis A?

Yes