AMS Liver

1. Heart sends OXYGENATED blood to AORTA

2. Aortic arteries (celiac, sup. mesen., inf. mesen.) send blood to GI system

3. Supplies liver, spleen, stomach, pancreas, small intestine, colon

4. HEPATIC ARTERY branches off celiac and supplies liver specifically

5. All GI system is connected to PORTAL VEIN

6. Portal vein brings DEOXYGENATED blood to LIVER to be filtered

7. HEPATIC veins brings filtered blood from liver to IVC to heart

What is the pathway for splanchnic circulation?

Hepatic artery

What aortic artery specifically supplies the liver?

LOW pressure and HIGH volume system

What type of system is the portal vein?

1. Filter of the body

2. Nutrient metabolism

3. Bile production

4. Protection

5. Metabolizes bilirubin

6. Synthesizes plasma proteins

7. Ammonia converted to urea

8. Regulates blood glucose levels

9. Metabolism and transport of cholesterol

10. Stores iron and vitamins

11. Process drugs and harmful substances

12. Regulates clotting

13. Production of immune factors

What are ALL the functions of the liver?

Kupffer cells and hepatocytes

What cells does the liver use to filter and store blood?

Kupffer cells

Produced in the bone marrow which are phagocytic (engulf bacteria) and secrete antimicrobial proteins which gets rid of harmful substances

Converts fat-soluble waste → water-soluble waste + urea where it can be excreted in urine and stool

Generally, how does the liver act as a filter in the body?

Drugs, toxins, hormones, viruses, bacteria

What are the specific things that the liver can detoxify?

1. Proteins

2. Fats

3. Carbs

Ingested

The liver is responsible for the uptake, processing, and distribution for what 3 things?

Uses it for ENERGY or stores certain VITAMINS, MINERALS, and SUGAR to prevent shortages

What does the liver do to nutrients that are metabolized?

Glycerol and fatty acids

What does the liver regulate in our adipose (fatty) tissue?

1. Glycogenesis (breakdown stored glucose)

2. Gluconeogenesis (make glucose from amino acids and fatty acid)

How does the liver regulate glucose levels?

1. Proteins are broken down into amino acids in the GI tract

2. Amino acids are then used to build other proteins, enzymes, and regulate hormones

3. Excess proteins go to liver

4. Metablized to AMMONIA

5. Ammonia is converted to UREA (water-soluble)

6. Urea is excreted in URINE

How does the liver metabolize proteins that we consume?

Ammonia is toxic and must be converted to a less toxic substance like urea which goes out in urine

Why does ammonia have to be converted to urea to be excreted?

1. Coagulation proteins (fibrinogen, prothrombin, clotting factors)

2. Transport proteins (albumin, globulin)

3. Copper and iron binding

4. Protease inhibitor proteins (inhibits other proteins)

What plasma proteins does the liver synthesize?

Makes triglycerides, ATP, ketones from fatty acids and glycerol, which it stores in adipose tissue

How does the liver synthesize fats?

When carbs are broken down in GI tract, the liver can store it as glycogen

• The excess glucose is turned into FAT and stored in adipose tissue

What does the liver to do glucose?

1. RBC are made of hemoglobin (heme (iron) + globulin (protein))

2. Heme is converted to biliverdin then to UNCONJUGATED bilirubin

3. Unconjugated bilirubin is sent to the LIVER

4. Liver converts unconjugated bilirubin to CONJUGATED bilirubin (binding to something)

5. Conjugated bilirubin converted to urobilirubin

6. Urobilirubin goes to intestines or urine to be EXCRETED

How does the liver metabolize RBCs?

Unconjugated bilirubin is fat-soluble which can’t be excreted, but conjugated is water-soluble which can be excreted

Why must bilirubin be conjugated to be excreted?

Bilirubin

Orange-yellow chemical, COMPONENT of bile

• Byproduct of breakdown of RBC

• Gives stool and urine their color (only small amount in urine)

Bile

Yellow-green liquid secreted from the liver

• Stored in GALLBLADDER

700-1200 mL/day

How much bile is created from liver?

1. Emulsify fats

2. Absorbs fat soluble vitamins

What are the two ways liver uses bile?

By using BILE SALTS, which break them down into smaller, more manageable pieces and turned into glycerol

How does the liver emulsify fats?

Needs fats to be dissolved

• DEKA

What are the fat-soluble vitamins?

Ca and Phos absorption

What is vitamin D responsible for?

Makes clotting factors (II, VII, IX, X) (2, 7, 9, 10)

What is vitamin K responsible for?

• Converts it into bile salts

• Removes LDL and keeps HDL

How does the liver use cholesterol?

Alcohol and cocaine

What drugs and harmful substances does the liver specficially metabolize?

Liver

Which organ in the human body is able to regerate on it’s own?

• Alk phos (not only in liver)

• AST, ALT, LDH (inflammatory marker)

• Bilirubin

• Ammonia

• Coagulation studies (PT/INR, platelets)

• Serum protein (albumin, globulin)

What are the labs for liver?

ALT

Which inflammatory marker is specific to liver?

Pale or clay colored stool

How do you know if a patient has low bilirubin?

• PT/INR: increased

• Platelets: decreased

What would the coagulation studies look like in a patient with liver injury?

• Acute: increased

• Chronic: decreased

• Albumin: low with severe disease (cute or chronic)

What would the serum protein look like in a patient with liver injury?

Inflammatory state

• Albumin significant half-life (16-20 days)

• Globulins released as an immune response

Why might serum proteins be high in acute liver disease?

• Chronic inflammation (long term damage)

• Fluid shifting from ascites/edema

• Breakdown of liver leads to loss of protein production

Why might serum protein be low in chronic liver disease?

• US (primary)

• Ab x-ray (KUB)

• Upper GI series (xray)

• MRI/ab CT

• Angiography

• EGD (+ERCP)

• Liver biopsy

What are the diagnostics for liver?

• Liver and biliary system: ascites, enlarged spleen or liver, stones or obstruction

• US w/ doppler: portal vein thrombosis

• US transient elastography: liver elasticity

What are the types of US for liver?

US transient elastography

Sends sound waves externally into the liver to look at how elastic the liver is (stiffer waves = liver fibrosis)

Esophagous, stomach, duodenum

What does the upper GI series x-raylook at?

Endoscopic retrograde cholangiopancreatography (ERCP)

Combined with EGD (scope) to diagnose or treat bile/pancreatic duct DO

Liver biopsy is usually percutanous (through the skin) where a needle is inserted into RUQ; using IR (image guided US) to remove a sample of liver tissue

What is the cutaneous vs. interventional radiology (IR) for liver biopsy?

• Jaundice

Hepatic dysfunction

• Fatty liver disease (FLD) (alcoholic and non-alcoholic)

• Portal vein HTN

  • Ascites

    • Hepatorenal syndrome

    • Hepatopulmonary syndrome

    • Spontaneous bacterial peritonitis

• Hepatic encephalopathy

• Coagulation deficits

• Cancer

What are the complications of the liver?

Jaundice

Build up of bilirubin causing yellowish discoloration of skin, sclera, and secretions

Hepatocellular disease or intrahepatic obstruction

• Hepatocellular (can’t conjugate bilirubin)

• Obstruction (clog bile duct, no excretion)

• Hemolytic (increased destruction RBC and liver can’t keep up)

• Hereditary hyperbilirubinemia (genetic)

What are the common causes of jaundice?

• Skin: yellow-orange (causes pruritus)

• Sclera: yellow

• Secretions: yellow tinged

• Urine: dark (tea-colored, brown) (bilirubin spills over)

• Stool: clay-colored or white

What are the s/s jaundice?

Buildup of bile salts which irritate peripheral nerves

How does increased bilirubin cause pruritus?

1. Prehepatic (usually in blood; sickle cell anemia, thalassemia, autoimmune)

2. Hepatic (at liver; hepatitis, cancer, cirrhosis, congenital, drugs)

3. Posthepatic (obstruction; gallstones, inflammation, scar tissue, tumors)

What are the 3 types of jaundice?

1. Prehepatic: increased unconjugated

2. Hepatic: both unconjugated and conjugated

3. Posthepatic: increased conjugated

What does the bilirubin levels like like at each type of jaundice?

Results from damage to liver’s parenchymal cells

• Direct: primary liver disease

• Indirect: obstruction of bile flow or derangements or hepatic circulation

How does the liver lose it’s function (hepatic dysfunction)?

Chronic

What type of hepatic dysfunction is most common?

• Infectious agents (bacteria or virus)

• Anoxia

• Metabolic DO

• Toxins and meds

• Nutritional deficiencies (vitamins)

• Hypersensitivity states (autoimmune)

What disease processes cause hepatocelluolar dysfunction?

1. Fatty liver

2. Liver fibrosis

3. Cirrhosis

What are the stages of hepatic dysfunction?

Fatty liver

Deposits of fat around liver that decreases liver function

• Reversible, but can lead to liver fibrosis if not tx

Liver fibrosis

Excess buildup of scar tissue (collagen) in liver from chronic damage or inflammation where the liver becomes inflexible or hardens

• Most part reversible, but leads to cirrhosis of not tx

Cirrhosis

Severe scarring of the liver from chronic disease, loss of normal liver function because normal liver tissue is damaged or destroyed

• Irreversible

1. Alcohol associated

2. Non-alcohol associated (NAFLD)

What are the two types of FLD?

Fatty liver disease

Accumulation of fat (triglycerides) in liver

• Anorexia (from enlarged liver)

• Hepatomegaly (inflammation)

• Abdominal discomfort

What are the s/s FLD?

Liver biopsy

How is FLD diagnosed?

Stop alcohol

What is the tx for alcohol associated FLD?

Metabolic syndrome issues

• Obesity

• T2DM

• Hepatotoxic drugs

What are the causes of NAFLD?

Portal HTN

What is a major complication of cirrhosis?

Portal HTN

Persistent increase in pressure within portal vein

• Cirrhosis: hepatocytes degenerate and are destroyed, causing scarring, which creates structural changes and obstruction

• Obstruction of blood flow causes increased hydrostatic pressure within peritoneal (stomach) capillaries

• Ascites

• Splenic engorgement (backup of blood into spleen)

• Shunting of blood to collateral venous channels causing VARICOSITIES of hemorrhoidal and esophageal veins

What are the complications of portal HTN?

To compensate for increased pressure by trying to decrease pressure

Why are collateral vessels created in portal HTN?

They are weak vessels and cause varicosities (swollen veins), which can lead to hemorrhage

Why are collateral vessels bad long term?

Reducing blood pressure

• Beta blockers (counter acts vasocontriction and decrease pressure)

• Vasocontrictors (reduce blood flow to portal vein)

What is the treatment for portal HTN?

Carvedilol and propanolol

What beta blockers are used for portal HTN?

Increased pressure in portal vein forces fluid into peritoneal cavity

Why does portal HTN cause ascites?

• Portal HTN

• Vasodilation of splanchnic circulation

• Changes in metabolism of aldosterone

• Decreased synthesis of albumin (decreased serum osmotic pressure)

• Movement of albumin into peritoneal cavity

What are the causes of ascites?

• Hypovolemia and edema at the same time

• Decreased albumin (pushed into peritoneal cavity)

• Decreased serum osmotic pressure

• RAAS activation creates more ascites

What are the complications of ascites?

Less volume in blood stream and increased fluid buildup in peritoneal cavity

Why does ascites cause hypovolemia and edema at the same time?

Albumin is responsible for maintaining osmotic pressure in body, and when it is pushed into peritoneal cavity, it begins to draw fluid to it, leading to increased ascites

How does albumin create more ascites?

Due to low albumin, less blood is able to stay within the blood vessels where albumin usually is

Why is there decreased serum osmotic pressure in ascites?

• Intravascular fluid depletion (dehydration) stimulates the kidneys as it senses low perfusion

• RAAS activated to hold onto sodium and water in blood vessels

• Increases hydrostatic pressure and creates more ascites

• Also ALDOSTERONE is activated which also holds onto more sodium and water

Why is RAAS activated in ascites?

• Monitor I/Os, daily weight and ab girth

• Diet: low sodium

• Monitor dyspnea; HOB >30 degrees

• Diuretic therapy

• Paracentesis

What are the nursing interventions for ascites?

ALBUMIN IV FIRST

• Furosemide (Lasix)

• Spironolactone (Aldactone)

What diuretics are used in ascites management?

Albumin in blood vessels draws fluid out first and then diuretics are used to help excrete the fluid

Why give albumin first before diuretic therapy in ascites?

• US guided

• Relief of acute symptoms

• Drains 1-4 L

• Rapid removal can cause vasodilation and shock

• Document fluid characteristics

What are the nursing considerations for paracentesis in ascites?

Hepatorenal syndrome

Type of kidney failure that is a late sign in liver failure; poor prognosis

• Sudden oliguria (low UOP)

• Elevated osmolality

• Elevated BUN/Cr with decreased sodium excretion (activates RAAS)

What are the s/s hepatorenal syndrome?

Hepatopulmonary syndrome

• Dyspnea from excess intra-abdominal pressure

• Tx: Ascites management

Spontaneous bacterial peritonitis

Infection of ascitic fluid in abdomen

• Sign of advanced liver disease

• Results from low amounts of proteins (from cirrhosis) and ascites

• Bacteria from bowel moves to ascites fluid → lymph system

Signs of SIRS (can become septic)

• Fever, chills, ab pain

What are the s/s of spontaneous bacterial peritonitis?

IV antibiotics

What is the tx for spontaneous bacterial peritonitis?

Shunts

What is a surgical treatment option for portal HTN?

• Transjugular intrahepatic porta-systemic shunt (TIPS) (most common)

• Peritoneovenous shunt

• Portacaval shunt

What are the types of shunts?

Transjugular intrahepatic porta-systemic shunt (TIPS)

Shunt between portal and hepatic vein to decrease pressure = decreased risk for bleeding (hemorrhage)

• Helpful in portal HTN or if pt. can’t have liver transplant

Peritoneovenous shunt

1-way valve drains ascites fluid into SVC

Portacaval shunt

Diverts portal venous blood flow from liver to IVC

• Same as with any abdominal surgery

• Watch for fluid volume overload and bleeding DO

• Measure ab girth every shift

What is the post op care for shunts?

• ABCs

• Monitor VS

• Bleeding (low BP and high HR)

• Early ambulation

• Bowel sounds, illeus, gas

• F/E

• I/O, daily weights, UOP ≥30, ab girth

• Pain

• Infection

What is the post op care for ab surgery?

Hepatic encephalopathy

Disease of the brain resulting from liver

• Seen in pts. with liver failure, cirrhosis, POST TIPS

• Reversible if caught early

TIPS bypass liver and liver typically removes toxins from blood like ammonia

• Increased ammonia in blood crosses BBB and distrupts neurotransmitters

Why does hepatic encephalopathy happen post TIPS?

• Mental status changes (confusion, altered LOC)

• Mood changes

• Sleep disturbances

• Asterixis (arm flap)

• Fetor hepaticus (nasty breath)

• Late: coma and death

What are the s/s hepatic encephalopathy?

• Lactulose (increases intestinal secretion of ammonia)

• Rifaximin (antiobiotic reduces gut bacteria)

What is the tx for hepatic encephalopathy?

• Decreased synthesis of bile in liver

• Splenomegaly

Why do coagulation defects happen in liver disease?