N363 Liver

portal vein

venous source of blood to liver

hepatic artery

arterial source of blood to liver

nutrient rich

oxygen poor

75% of blood to liver

characteristics of portal vein

nutrient poor

oxygen rich

25% of blood to liver

characteristics of hepatic artery

liver lobules

where does the blood from the portal vein and hepatic artery mix

200-400 mL

how much blood does the liver store

70%

how much of liver is damaged before levels may become abnormal

enzyme activity

how is liver function usually measured

liver enzymes are released (ALT/AST)

what happens when there is liver cell damage

serum aminotransferases

indicators of injury to liver cells

useful in detecting hepatitis

Alanine aminotransferases (ALT)

levels increase primarily in liver disorders

monitors course of hepatitis, cirrhosis, effects of treatments toxic to liver

Aspartate aminotransferase (AST)

not specific to liver

may be increased in cirrhosis, hepatitis, liver cancer

Gamma-glutamyl transferase (GGT)

associated with cholestasis, alcoholic liver disease

liver biopsy

needle inserted through abdominal wall and tissue is aspirated for analysis

Bile peritonitis

gallbladder inadvertently damage and bile spills into peritoneum with liver biopsy

bleeding (look at coag studies prior)

complication of liver biopsy

severe ascites

abnormal coag studies

when is a blind needle biopsy not preferred

Trans-venous biopsy

use of fluoroscopy or real-time X-ray to guide catheter through internal jugular vein, through right hepatic vein, and to liver

have pt lay on right side

pillow under right costal margin

check dressing for bleeding

avoid heavy lifting

avoid coughing/straining

post-op interventions liver biopsy

Q 10-15 min (1 hr)

Q 30 min (1-2 hours)

VS protocol post-biopsy

antibiotics

NSAIDs

anticonvulsants

prescription meds that cause liver dysfunction

liver unable to excrete bilirubin

why do you see jaundice with liver dysfunction

decreased ability to make proteins

why do you see muscle atrophy with liver dysfunction

broken capillaries d/t low platelet count

why do you see petechiae with liver dysfunction

increased clotting time

why do you see ecchymotic areas with liver dysfunction

spider angiomas

abnormal collection of blood vessels near skin surface

increased estrogen levels

what is palmar erythema due to

asterixis

liver flap

hepatic encehalopathy

when do we see liver flap (asterixis)

child-pugh classification

scale used to predict outcome of pt with liver disease

higher score —> poorer prognosis

ascites

bilirubin

albumin

PT

encephalopathy

parameters on child-pugh classification

jaundice

bilirubin concentration in blood is elevated

Levels > 2.0 mg/dL

hepatocellular

obstructive

what types of jaundice are most associated with liver disease

Hemolytic jaundice

increased destruction of RBCs

cannot excrete bilirubin as quickly as it is formed

Hepatocellular jaundice

liver cells damaged, liver can’t clear bilirubin

Obstructive jaundice

occlusion of bile duct d/t gallstones, tumor, inflammatory process

bile cannot flow normally into intestine and backs up

moderate/severely ill

lack of appetite

N/V

malaise

H/A

fever/chills

S/Sx of hepatocellular jaundice

orange-brown urine

clay-colored stool

dyspepsia

intolerance of fats

pruritus

impaired digestion

S/Sx of obstructive jaundice

ascites

varices

major consequences of portal HTN

splenomegaly

thrombocytopenia

what can portal HTN cause

ascites

shift of fluid into peritoneal cavity

distended and enlarged abdomen

stretch marks

SOB (pressure pushing upward)

F/E imbalance

manifestations of ascites

decrease in osmotic pressure

what does a decrease in albumin synthesis lead to

shifting dullness

fluid moves to dependent locations as pt changes positions

lying supine

when is flank edema most obvious with ascites

spontaneous bacterial peritonitis

major complication of ascites

paracentesis

antibiotics

treatment of spontaneous bacterial peritonitis

Hepatorenal syndrome

form of renal failure without pathological changes to kidney

low sodium diet (500mg-2g/day)

diuretics

bed rest

paracentesis

TIPS

medical management of ascites

aldactone (K+ sparing)

first-line diuretic for ascites

Paracentesis

small surgical incision through abdominal wall to remove fluid from peritoneal cavity

consent

pt void

V/S
wt and abdominal girth

Pre paracentesis

position as upright as possible

V/S

monitor for hypovolemia

during paracentesis

s/s of hypovolemia

wt and abdominal girth

document fluid collected

assess site

neuro status

limit activity

after paracentesis

TIPS procedure

cannula threaded into portal vein and expandable stent is placed (intrahepatic shunt) to decrease portal HTN

considerable risk for encephalopathy

problem with TIPS

decrease sodium retention

improve renal response to diuretics

goals of TIPS

Peritoneovenous shunt

drain peritoneal fluids from peritoneum into veins

redirects ascitic fluid

cirrhosis

most common cause of ascites

portal HTN

main contributor to ascites

varices

veins become dilated and tortuous

esophagus and stomach

where do varices occur

heavy lifting

straining

coughing

vomiting

reflux

aspirin

increased risk of bleeding varices

hematemesis

melena

deterioration of mental and physical status

shock

manifestations of varices

cerebral, renal, hepatic perfusion decrease

increased ammonia levels

s/sx of shock with varices

endoscopy

CT

barium swallow

angiography

diagnostics for varices

10-30% mortality rate

first episode of bleeding varices

balloon tamponade

tube placed to compress bleeding varices

frequent suctioning and cardiac monitoring

what do you need with balloon tamponade tube

constriction

reduce portal pressure

what does vasopressin do for bleeding varices

CAD

when is vasopressin contraindicated

sclerotherapy

provider injects scelrosing agent into varix to shrink it

bleeding

perforation of esophagus

aspiration

stricture

what to monitor for with scelrotherapy

Banding

use of endoscopic tube loaded with rubber band

bleeding varix is suctioned in tip of endoscope and rubber band is slipped over tissue

active bleeding situations

when is TIPS beneficial for varices

profound liver failure

when does hepatic encephalopathy occur

build-up of ammonia

collateral vessels develop, elements of portal blood end up in systemic circulation

patho of hepatic encephalopathy

GI bleeding

high protein diet

bacterial infection

what can precipitate encephalopathy

constructional apraxia

inability to produce simple figure in 2-3 dimensions

ammonia lowering therapy (lactulose)

traps ammonia and expels it in feces

only if lactulose isn’t working

when do you use protein restriction

poor hand hygiene

fecal-oral

how is hepatitis A spread

2-6 weeks

incubation period for hep A

4-8 weeks

how long can hep A last

low-grade fever

anorexia

jaundice

dark urine

epigastric distress

enlagred liver/spleen

manifestations of hep A

Pre-Icteric

before jaundice sets in (hep A)

Icteric phase

jaundice has set in (hep A)

good handwashing

safe water

proper sewage

vaccine

nutritional support

prevention of hep A

blood

saliva

semen

vaginal secretions

how is hep B transmitted

cirrhosis

liver cancer

what is hep B a major worldwide cause of

1-6 months

incubation period of hep B

loss of appetite

dyspepsia

abd pain

aching

malaise

weakness

manifestations of hep B

alpha interferon

antiviral agents

meds for chronic hep B

high risk individuals

routine for infants

vaccine for hep B

blood

sexual contact

needle sticks

how is hep C transmitted

Hepatitis C

most common bloodborne infection and most common reason for liver transplant

15-160 days

incubation period of hep C

antiviral meds

public health programs

screening

safety needles

avoid alcohol

management of hep C

Hep B

What do you need to have first in order to contract Hep D

blood

sexual contact

IV/injection drugs

How to contract Hep D