N271 - Liver Patients

lecture 12

Why is the liver important?

has > 500 different functions; largest organ; digestion, metabolism, and nutrition are affected by a diseased liver

Describe cirrhosis of the liver.

irreversible scarring of the liver; destruction of the liver cells → replaced by fibrous cells; can be asymptomatic; chronic reaction to inflammation adn necrosis

What is the major cause of cirrhosis in the US?

chronic alcoholism and hepatitis C

What is the major cause of cirrhosis in other countries?

hepatitis B, hepatitis D

What is the pathophysiology of cirrhosis?

fibrotic bands of connective tissue, hepatic inflammation, destruction of liver cells, nodular tissue; elevated liver function tests

How does fibrotic bands of connective tissue cause cirrhosis?

changes normal composition of liver; wide strand scar tissue

How does hepatic inflammation cause cirrhosis?

caused by toxins/diseases resulting in hepatocyte destruction

How does destruction of liver cells cause cirrhosis?

diseases caused by hematocyte death

How does nodular tissue cause cirrhosis?

can block bile ducts and normal blood flow to liver

Which liver function tests are elevated in patients with cirrhosis?

AST, ALT, alkaline phosphotase, total billirubin

Which liver function tests is decreased in patients with cirrhosis?

albumin; oncotic pressure maintained by albumin → decreased albumin causes fluid leaks from intravascular to peritoneal cavity → ascites;

What does elevated bilirubin in cirrhosis indicate?

can indicate liver not breaking down water products effectively or RBCs are breaking down too rapidly

What are the different types of liver cirrhosis?

Laennec’s/alcoholic cirrhosis, post necrotic cirrhosis, biliary cirrhosis, cardiac cirrhosis

Describe Laennec’s/alcoholic cirrhosis.

most common; caused by chronic alcoholism

Describe post necrotic cirrhosis.

caused by viral hepatitis; could also be caused by meds - before administering hepatotoxic meds, monitor pt liver enzymes

Describe biliary cirrhosis.

caused by chronic billiary obstruction → usually from gallbladder disease

Describe cardiac cirrhosis.

very rare; caused by heart failure

What are some complications of cirrhosis?

portal hypertension, bleeding esophageal varices, jaundice

Describe portal hypertension.

d/t impaired blood flow through the liver as a result of increased resistance d/t fibroses and degeneration of liver tissue; blood flow becomes sluggish and results in increased pressure in portal circulation

Describe bleeding esophageal varices.

veins dilate and varices are formed d/t increased venous pressure; happens spontaneously and can lead to extreme blood loss; production of bile in the liver is decreased and prevents fat soluble vitamins from being absorbed

Describe jaundice.

a complication of cirrhosis and described as a yellow discoloration of the skin/eyes; caused by two mechanisms - hepatocellular disease and intrahepatic obstruction

Describe hepatocellular disease.

liver unable to excrete bilirubin effectively; decreased bilirubin excretion leads to large amounts being retained and lots of bilirubin circulating in bloodstream

Describe intrahepatic obstruction.

edema, fibroses and scarring of hepatic bowel channels; interfere w/normal bile and bilirubin excretion

Describe ascites.

collection of fluid in the peritoneal cavity decreased circulating plasma protein d/t excessive fluid; decreased albumin production d/t liver’s inability to produce albumin; decreased colloid osmotic pressure; fluid shift from the vascular system to the abdomen; results in a form of 3rd spacing

What is ascites caused by?

increased hydrostatic pressure from portal hypertension

What are some side effects of esophageal varices?

hematemesis and melena

What are the fat-soluble vitamins?

vitamin A, vitamin D, vitamin E, vitamin K,

What happens if there is a deficiency in vitamin A?

problems w/vision, night blindness

What happens if there is a deficiency in vitamin D?

soft bones, more prone to fractures

What happens if there is a deficiency in vitamin E?

affects immune system function

What happens if there is a deficiency in vitamin K?

bleeding; needed for coagulation and produces clotting factors 2,7,9,10

What is the treatment for bleeding esophageal varices?

fluid resuscitation, blood transfusions, platelets, fresh frozen plasma, vasopressin (Pitressin), beta blockers, Sengstaken-Blakemore tube, mechanical ventilation

Describe vasopressin (Pitressin).

controls esophageal bleeding; mimics ADH → increases water reabsorption in distal and collecting ducts; affects posterior pituitary; causes vasoconstriction and stops bleeding

Describe Sengstaken-Blakemore tube.

has a balloon at the end that is inflated → puts pressure on varices to help stop bleeding; rarely used only if absolutely necessary to stop bleeding

What is an adverse effect of Sengstaken-Blakemore tube?

esophageal and gastric perforation

Descirbe endoscopic variceal ligation.

application of small band to the base of the varices → decreases blood flow to it; doesn’t cause any discomfort to patient

Describe endoscopy sclerotherapy.

injects sclorsing agent into varices → shrinks wall of the vessel → stops bleeding; can cause mucosal ulcerations → can lead to further bleeding

Describe portal systemic encephalopathy.

complication of cirrhosis; ammonia levels are high; diseased liver is unable to convert ammonia to a less toxic form; ammonia is in the blood and goes into the brain; low protein diet for pt w/this condition

What are signs and symptoms of portal systemic encephalopathy?

high levels of ammonia leads to confusion, changes in LOC, personality changes, slurred speech

What are the nutritional therapy for patients with cirrhosis?

nutritional requirements required; high carb, high fat; high protein if patient doesn’t have problems with ammonia

What is the drug therapy for portal systemic encephalophy?

drugs are used sparingly in treating liver disease bc liver is responsible for metabolizing and they are unable to do it; can lead to toxic levels of drug; lactulose (Lactilol), neomycin sulfate (Mycifradin), Metronidazole (Flagyl)

Describe lactulose (Lactilol).

promotes ammonia excretion through stool; increases osmotic pressure in colon; decreases ammonia absorption in colon

What are the adverse effects of lactulose (Lactilol)?

hypokalemia, dehydration d/t diarrhea

Describe Neomycin Sulfate (Mycifradin).

broad spectrum antibiotic; cleans intestinal tract; destroys normal gut flora and is at risk of developing C.diff; nephrotoxic if used long term

Describe metronidazole (Flagyl).

broad spectrum antibiotic; similar to Neomycin but no risk for nephrotoxicity

What is some nursing management for patients with portal systemic encephalopathy?

assess for LOC, check for asterixis (liver flap), fetor hepaticus (liver breath)

What is asterixis?

tremors of fingers and hands

What is fetor hepaticus?

foul smelling breath; “breath of death”

What is viral hepatitis?

caused by infection; widespread inflammation of liver cells; can occurs as a secondary infection

Describe hepatitis A.

survives on hands; killed by chlorine bleach and temps above 195F; fecal oral transmission route; incubation 2-4 weeks; may be asymptomatic; high occurrence in third world countries d/t bad sanitation

How is hepatitis A diagnosed?

serological testing; IgG antibodies and IgM antibodies

Define IgG antibodies.

indicates immunity to virus d/t past infection or vaccination

Define IgM antibodies.

indicates recent exposure or possible infection

What is the treatment of hepatitis A?

clears infection on its own; liver will heal within 6 months; supportive management, nutritional diet, rest

How is hepatitis A prevented?

prevent by vaccination; recommended for people who travel abroad often, people w/chronic hep B and hep C; given in 2 shots

What are the signs and symptoms of hepatitis A?

nausea, anorexia, RUQ pain, jaundice for 2 weeks and dissipates

Describe hepatitis B.

prevalent worldwide; 2-6 months incubation; mostly asymptomatic

How is hepatitis B transmitted?

parenteral contact, infected blood, perinatal transmission - mother to fetus

What are signs and symptoms of hepatitis B infection?

loss of appetite, nausea, vomiting, RUQ pain, dark urine, jaundice

How is hepatitis B treated?

most adults who contract the virus will clear it from their body; those who don’t become carriers of virus → infect others even if you aren’t sick; being a chronic carrier increases you risk of developing liver cancer or cirrhosis

How is hepatitis C transmitted?

transmission is blood to blood; intravenous drug needle sharing; needle stick injury with HCV contaminated blood; intranasal cocaine sharing

Describe hepatitis C infection.

does not clear the body like Hep B; becomes chronic and leads to inflammation, scarring → cirrhosis; major reason for liver transplant

How do we treat hepatitis C infection?

very, very expensive pharmacological treatment; Epclusa - 12 weeks > 95-98% cure rate; Harvoni - 12 weeks > 97-99%

Describe hepatitis D infection.

requires the presence of HBV to replicate; transmitted by blood; 3-7 weeks incubation

What are the signs and symptoms of hepatitis D?

fatigue, clay-colored stool, dark urine, anorexia, nausea, jaundice

Why does clay-colored stool occur in hepatitis D infections?

diminished ability of the liver to excrete bilirubin which gives stool its brown color

What are some prevention techniques for hepatitis D?

safe sex practices, screened blood products, hepatitis B vaccines

Describe hepatitis E.

one of the most common causes of acute hepatitis in developing countries; waterborne (fecal oral route); prevalent in developing countries; 2-9 weeks incubation; no vaccination available

What are some prevention techniques to avoid contracting hepatitis E?

avoiding undercooked foods, drink bottled water, wash your hands with clean water

What are signs and symptoms of late stage liver cancer?

unintentional weight loss, anorexia, weakness, RUQ pain, jaundice, bleeding

Describe liver cancer.

develops as a metastatic process; rarely ever a primary site; cancer spreads to the liver because it is very vascular and there is lymphatic drainage

What is the treatment for liver cancer?

surgical intervention if cancer is confined to one lobe of liver; radiation is not an option because liver cannot handle high levels of radiation; chemotherapy is not effective; transplantation only application if cancer is only present in the liver

Describe liver transplantation.

most commonly d/t hepatitis C; live donor can donate a lobe of liver and within 2 months the liver can regenerate and grow back for both donor and recipient

Who are the best candidates for liver transplants?

end stage liver disease pt, primary liver cancer

Who are not recommended for liver transplants?

active alcoholics or substance users, metastatic tumors

What happens post transplantation?

graft rejection and infection can take place between 4-10 days after transplantation; pt will be on immunosuppressant therapy, steroids; vaccinations and antibiotics

What are examples of immunosupressant drugs?

anti-rejection meds taken for life; Cyclosporine and Tacrolimus

What are some adverse effects of Cyclosporine and Tacrolimus?

hypertension and renal insufficiency

What are the adverse effects of prednisone when treating post transplantation patients?

HTN and hyperglycemia; hyperglycemia caused bc corticosteroids block action of insulin and causes liver to increase glucose release