liver disease | NURS240

true or false: the liver is very vascular

true

review the functions of the functions of the liver…

1. play a role in CHO, lipid, and protein metabolism

2. stores glycogen, vitamins and mineral

3. produce and excrete bile

4. synthesize albumin, prothrombin, and fibrinogen

5. detoxifies and purifies blood

what is the main difference in ALT and AST for liver function test

an elevated AST tell you that their is damage happening to the liver but not by how much but ALT will show you how much damage is happening to the liver

what does alkaline phosphate tell us about liver function?

indicate liver functions and possible metastasis disease to the bone

what is the expected range of bilirubin (total) in both female and male?

0.3-1.0 mg/dL

what is the expcted range of albumin in both female and male?

3.5-5.0 g/dL

where does bilirubin come from?

bilirubin is produced form the breakdown of old red blood cells

1. old RBCs are broken down in the spleen, liver, and macrophages

2. hemoglobin → heme → bilirubin

how is unconjugated bilirbun transported to the liver?

1. unconjugated bilirubin travels through the blood bound to albumin

2. it is transported to the liver, where it will be processed

what happens to bilirubin in the liver?

1. bilirubin is conjugated with glucuronic acid

2. it becomes conjugated (direct) bilirubin

3. this form is water-soluble

4. conjugated bilirubin is then secreted into bile

what happens to bilirubin after it enters the intestine?

bile carrying conjugated bilirubin enters the Intestine.

intestinal bacteria convert bilHow does bilirubin metabolism affect urine color?

irubin into urobilinogen.

urobilinogen has two main pathways:

• some returns to the liver

• some continues through the intestine.

how does bilirubin metabolism affect urine color?

some urobilinogen enters the bloodstream and travels to the Kidney.

it is converted into urobilin, which gives urine its yellow color.

how does bilirubin metabolism affect stool color?

most urobilinogen remains in the intestine and is converted by bacteria into stercobilin.

stercobilin gives stool its brown color.

what is the difference between MASH and non-MASH cirrhosis?

1. MASH = nonalcoholic

2. non-MASH = alcoholic

what is cirrhosis?

a condition where normal liver structure is replaced by fibrotic scar tissues → which can occur due to:

1. chronic inflammation

2. hepatocyte (liver cell) damage

3. necrosis of liver tissue

the scar tissue forms fibrotic bands that distort the liver’s normal structure and impair its function

how does cirrhosis develop?

cirrhosis develops slowly over time due to repeated liver injury

1. chronic liver inflammation

2. liver cell death (necrosis)

3. replacement with scar tissue (fibrosis)

4. distortion of normal liver architecture

this gradually reduces the liver’s ability to perform its metabolic and detoxification functions

what are the most common causes of cirrhosis?

1. chronic alcohol abuse

2. hepatitis C

both causes long-term liver inflammation, which eventually leads to fibrosis and cirrhosis

what is cirrhosis considered a progressive disease?

cirrhosis progresses gradually because repeated liver injury continues to produce scar tissues → as fibrosis increases:

1. liver blood flow becomes disrupted

2. liver function declines

3. complications such as portal hypertension and liver failure may develop

what is nonalcoholic fatty liver disease (NAFLD)

a condition where fat accumulates in the liver in people who drink little or no alcohol → the condition is strongly associated with:

1. obesity

2. insulin resistance

3. type 2 diabetes

4. metabolic syndrome

MASH is now one of the most common liver disease

what are the two types of nonalcoholic fatty liver disease (NAFLD)

• Nonalcoholic Fatty Liver (NAFL)

  • fat in the liver

  • little or no inflammation

  • usually does not cause liver damage

• Nonalcoholic Steatohepatitis (NASH/MASH)

  • fat + inflammation + liver cell damage

  • can progress to cirrhosis or liver failure

what are common symptoms of nonalcholic fatty liver disease?

NAFLD is often asymptomatic.

if symptoms occur, they may include:

• fatigue

• mild right upper quadrant discomfort

• enlarged liver

many cases are discovered incidentally during routine blood tests or imaging.

how is nonalcoholic fatty liver disease diagnosed?

diagnosis may involve:

• elevated liver enzymes on blood tests

• ultrasound, CT, or MRI showing fatty liver

• liver biopsy (sometimes used to confirm NASH)

diagnosis often occurs when abnormal liver tests are found during routine exams.

how is nonalcoholic fatty liver disease treated?

there is no specific medication, so treatment focuses on lifestyle changes:

• weight loss

• healthy diet

• regular exercise

• control of diabetes and cholesterol

these interventions can reduce fat in the liver and prevent progression to cirrhosis.

what are the main types of cirrhosis?

• laennec’s (alcoholic) cirrhosis → fatty accumulation causes scarring which stopping drinking can help reverse damage

• post-necrotic cirrhosis → seen in patient with chronic Hepatitis B or C and patient who overdosed on tylenol

• biliary cirrhosis → biliary obstruction from inflammation lead to necrosis which lead to scarring

• cardiac cirrhosis → left first then right → blood back into the liver which causes congestion which lead to the liver being enlarged → causes inflammation → necrosis → scarring

These types are classified based on the underlying cause of liver damage.

what history questions are important when assessing for cirrhosis?

Important history topics include:

• alcohol (ETOH) use

• medication use (including OTC drugs)

• illicit drug use

• dietary habits

• exposure to chemicals or toxins

• past medical history such as:

  • Viral Hepatitis

  • heart failure

  • biliary tract disorders

  • obesity

These help identify risk factors for chronic liver damage.

what are the common early physical exam signs of cirrhosis?

1. weight loss

2. loss of appetite (anorexia)

3. fatigue

4. gastrointestinal symptoms

5. abdominal pain or liver tenderness

these occur because the liver is losing its metabolic and digestive functions

why do patients with cirrhosis develop Gi symptoms and abdominal pain?

as the liver damage progresses

1. digestion and metabolism become impaired

2. liver enlargement or inflammation may occur

these can cause abdominal discomfort, liver tenderness, and GI symptoms

why might patients with cirrhosis develop personality changes or altered sleep patterns?

liver dysfunction allows toxins (especially ammonia) to accumulate in the bloodstream which can affect brain functions and lead to personality changes, confusion, and sleep disturbances (these are characteristics of Hepatic Encephalopathy)

what are the common late physical exam signs of cirrhosis?

• jaundice

• skin changes (dry skin, rashes)

• petechiae or ecchymosis - due to decreased clotting factor production

• caput medusae (visible vein in the abdomen)

• palmar erythema

• ascites

• dependent edema

• fetor hepaticus - musty or sweet odor on the breath

• asterixis (AKA liver flap) - flapping tremor of the hands when the patient extend their wrists

• sign of vitamin C deficiency

• messed up protein metabolism

these occur due to severe liver dysfunction and portal hypertension

why do patients with cirrhosis develop ascites and edema?

ascites occurs because of portal hypertension and low albumin production of which the increased pressure and not enough albumin causes fluid to leak from the blood vessels into the third space of the peritoneum and causes fluid build up

what physical exam assessments are important for cirrhosis?

1. skin inspection (look for jaundice, spider angiomas, bruising)

2. palpation of the liver and spleen (hepatomegaly/spleenomegaly)

3. measurement of the abdominal (ABD) girth to monitor fluid accumulation

4. assessment for ascites - fluid wave test (a wave of fluid is felt across the abdomen when one side is tapped) and shifting dullness (dullness shift when the patient changes position due to free fluid in the abdomen)

what serum enzyme levels are commonly elevated in cirrhosis?

• ↑ AST (aspartate aminotransferase)

• ↑ ALT (alanine aminotransferase)

• ↑ LDH (lactate dehydrogenase)

• ↑ alkaline phosphatase

these elevation indicate liver cell injury and impaired bile flow

why are ammonia levels elevated in cirrhosis

The liver normally converts ammonia to urea for excretion.

In cirrhosis:

• damaged liver cells cannot detoxify ammonia

• ammonia accumulates in the bloodstream

High ammonia can lead to Hepatic Encephalopathy.

why are PT and INR elevated in cirrhosis?

The liver produces many clotting factors.

When liver function declines:

• clotting factor production decreases

• prothrombin time (PT) increases

• INR increases

This results in increased bleeding risk.

what lab values may be decreased in cirrhosis?

• ↓ albumin and total protein

• ↓ RBC, hemoglobin, and hematocrit

• ↓ WBC

• ↓ sodium (Na⁺)

These changes reflect poor liver synthesis, portal hypertension, and fluid imbalances.

what diagnostic tests are commonly used to evaluate cirrhosis?

• liver Ultrasound - to help detect liver enlargement, nodular liver surfacer, ascites, and changes in blood flow

• computed Tomography or Magnetic Resonance Imaging - to evaluate liver structure, identity tumors or complications, and assess portal hypertension and ascites

• esophagogastroduodenoscopy - used to check for esophageal or gastric varices

• liver Biopsy - to confirm diagnosis of cirrhosis and assess degree of fibrosis

these tests help evaluate liver structure, complications, and extent of damage.

what is portal hypertension and how does it relates to cirrhosis?

portal hypertension occurs when scarring in the liver (cirrhosis) blocks normal blood flow through the liver of which causes an increased in pressure in the portal vein with blood backing up into surrounding organs especially the spleen and GI tract

what complications result from portal hypertension caused by cirrhosis?

causes veins in the GI system to become dilated and fragile (they are now known as varices) → which can lead to esophageal varices, ascites (due to third spacing), caput medusae, and hemorrhoids

why do esophageal varices develop in cirrhosis?

when portal hypertension occurs, blood is directed into collateral veins around the esophagus of which these veins become distended, fragile, and prone to rupture → making varices a life-threatening complications of cirrhosis

1. these ruptes can be cause by irritation from food or alcohol, mechanical trauma like vomiting or endoscopy, or increased esophageal pressure from coughing or straning

what is hematemesis and why is ti dangerous in cirrhosis?

hematemesis occurs when esophageal varices rupture and bleed → this can cause massive blood loss, hypovolemia, and shock

why do patients with cirrhosis develop coagulation defects?

cirrhosis can interferes with the liver’s ability to produce bile, of which, without bile, the body cannot break down and absorb fat and fat-soluble vitamin (A,D,E,K) → K is an important vitamins for the formation of clotting factors

how does splenomegaly contribute to bleeding problems in cirrhosis?

portal hypertension causes blood to back up into the spleen, leading to splenomegaly → the enlarged spleen traps and destroys platelets, causing thrombocytopenia

what clinical signs indicate coagulation defects in cirrhosis?

patients may develop:

1. easy bruising

2. petechiae

3. prolong bleeding

4. ecchymosis

these symptoms occur due to low clotting factors and low platelet levels from low level of bile, portal hypertension, and splenomegaly

what emergency devices can be used to control bleeding from esophageal varices in cirrhosis?

ballon tamponade tubes can temporarily control bleeding by compressing the varices (e.g., sengtaken-blakemore tube, minnesota tube)

what endoscopic treatment are used to stop bleeding esophageal varices?

during Esophagogastroduodenoscopy, physicians can perform:

• injection sclerotherapy → medication injected into varices to shrink them → dry up the bleeding areas like cautherization

• variceal banding → rubber bands placed around veins to stop bleeding

these are common first-line treatments.

why are blood transfusion given during variceal hemorrhage?

bleeding esophageal varices can cause massive blood loss → transfusion helps with:

1. restore blood volume

2. improve oxygen delivery

3. prevent hypovolemic shocks

what is transjugular intrahepatic portosystemic shunt (TIPS) and why is it used in cirrhosis?

a radiology procedures that creates a channel between the portal vein and hepatic vein → reduce portal hypertension, decrease pressure in esophageal varices, and prevent recurrent bleeding

when is surgery used to treat bleeding esophageal varices?

surgery may be required if other treatment fails

1. a surgical shunt can be place to redirect blood flow, reduce portal vein pressure, and decrease risk of variceal bleeding

why does ascites develop in cirrhosis?

ascites occurs due to to multiple mechanisms:

1. portal hypertension → causes blood to back up and occasionally leak into the peritoneal cavity

2. increased hepatic lymph formation

3. increased hydrostatic pressure in blood vessels

4. fluid leaking from vessels into the peritoneal cavity

these changes causes plasma fluid to accumulate in the abdomen (this process is called third spacing)

what physical findings suggest ascites inc cirrhosis?

1. abdominal distention

2. increased abdominal girth

3. shifting dullness

4. fluid wave

what dietary changes help manage ascites caused by cirrhosis?

dietary management includes:

• low-sodium diet to reduce fluid retention

• fluid restriction if sodium levels are low or fluid overload occurs

• vitamin supplementation to support nutrition

these interventions help reduce fluid buildup in the abdomen.

what medications are commonly used to treat ascites in cirrhosis?

the primary medications are diuretics, which help remove excess fluid from the body.

commonly used diuretics include:

• Spironolactone

• Furosemide

these medications help decrease fluid accumulation and abdominal swelling.

what nursing monitoring is important for patients with ascites?

key monitoring includes:

• daily weight

• calorie count

• intake and output (I/O)

• abdominal girth measurement

• lab monitoring, especially:

  • electrolytes

  • albumin levels

these assessments help track fluid status and treatment effectiveness.

what is paracentesis and when is it used?

paracentesis is a procedure where ascitic fluid is removed using a needle inserted into the abdomen.

it is used to:

• relieve severe abdominal pressure

• improve breathing and comfort

• remove large amounts of fluid.

what surgical procedure may be used for severe ascites in cirrhosis?

one option is Transjugular Intrahepatic Portosystemic Shunt.

TIPS works by:

• creating a pathway between the portal vein and hepatic vein

• reducing portal hypertension

• decreasing formation of ascites.

what is portal systemic encephalopathy (PSE)?

portal systemic encephalopathy occurs when the damaged liver cannot properly detoxify ammonia and other toxins → these toxins enter the bloodstream and reach the brain, causing neurological symptoms → serious complications of cirrhosis

why does ammonia accumulate in patients with cirrhosis?

normally, the liver converts ammonia into urea for excretion.

in cirrhosis:

• liver function is impaired

• ammonia is not detoxified

• ammonia builds up in the blood

high ammonia levels are toxic to the central nervous system (CNS).

what are the common signs and symptoms of portal systemic encephalopathy?

Normally, the liver converts ammonia into urea for excretion.

In cirrhosis:

• liver function is impaired

• ammonia is not detoxified

• ammonia builds up in the blood

High ammonia levels are toxic to the central nervous system (CNS).

what factors can precipitate portal systemic encephalopathy?

• high protein diet

• infection

• hypovolemia

• hypokalemia

• constipation

• GI bleeding

• certain medications

These conditions increase ammonia production or reduce its elimination.

what is hepatitis?

inflammation of liver cells (hepatocytes)

1. acute (short-term inflammation)

2. chronic (long-term liver damage)

inflammation interferes with the liver’s ability to perform metabolic, detoxification, and bile production functions

what are the most common causes of hepatitis?

hepatitis A, B, C, D, E

what other causes can lead to hepatitis besides viral infection?

less common causes include:

• drug-induced liver injury

• toxic exposure (chemicals or toxins)

• alcohol

• certain medications

these substances can damage liver cells and trigger inflammation

what are the common early symptoms of hepatitis?

early symptoms often resemble flu-like illness:

• fatigue

• irritability

• loss of appetite (anorexia)

• nausea and vomiting

• joint and muscle pain

• fever

These symptoms occur as the body responds to liver inflammation.

what Gi symptoms are commonly seen in hepatitis?

Common GI symptoms include:

• abdominal pain

• right upper quadrant (RUQ) tenderness

• nausea and vomiting

• diarrhea or constipation

These symptoms result from inflammation of the liver and digestive disruption.

what laboratory findings are commonly seen in Viral Hepatitis?

liver inflammation causes elevated liver enzymes, including:

• ↑ ALT (alanine aminotransferase)

• ↑ AST (aspartate aminotransferase)

these enzymes increase because damaged liver cells release them into the bloodstream.

What serological markers indicate Hepatitis A infection?

• IgM anti-HAV → indicates current or recent infection

• IgG anti-HAV → indicates past infection or immunity

What serological markers are used to diagnose Hepatitis B?

• HBsAg → indicates active infection

• IgM anti-HBc → indicates acute infection

• anti-HBc → indicates past or current infection

• anti-HBs → indicates immunity or recovery

hat test is used to screen for Hepatitis C?

Diagnosis typically begins with:

• anti-HCV antibody screening test

A positive result indicates exposure to the hepatitis C virus, and further testing confirms active infection.

what are the key features of hepatitis A (HAV)?

Transmission

• fecal-oral route

• contaminated food or water

• person-to-person contact

Risk factors

• poor sanitation or hygiene

• contaminated water supply

• anal intercourse

Symptoms

• flu-like symptoms

• jaundice

• abdominal pain

• clay-colored stools and dark urine

Course

• usually not life-threatening

• symptoms last < 2 months

• does NOT become chronic

Prevention

• HAV vaccine (2 doses 6 months apart)

• infection provides lifelong immunity

Treatment

• supportive care

what are the key features of hepatitis B (HBV)

Transmission

• blood and body fluids

• sexual contact

• contaminated needles (IV drugs, tattoos, piercings)

• blood transfusions

• perinatal transmission

Symptoms

• similar to hepatitis A

Course

• mild to moderate illness

• 5–10% of infected adults develop chronic hepatitis

Prevention

• HBV vaccine (3-dose series over 6 months)

• immunity confirmed by antibody titer

Treatment

• supportive care for acute infection

• antiviral medications for chronic infection

what are the key features of hepatitis C (HCV)?

Transmission

• exposure to infected blood

• IV drug use (shared needles)

• blood transfusions or organ transplants before 1992

• occupational exposure

• tattoos or body piercing

Symptoms

• ~80% have no symptoms

Course

• 75–85% develop chronic infection

• leading cause of liver transplant in the U.S.

Prevention

• no vaccine available

Treatment

• direct-acting antivirals (DAAs)

• may include interferon therapy

What are important nursing interventions and patient teaching for viral hepatitis?

Prevention

• encourage vaccination (HAV & HBV)

• promote safe sexual practices

• maintain proper hygiene

• follow universal precautions

• safe handling of needles and sharps

Patient education

• avoid alcohol

• avoid OTC medications that stress the liver

• get frequent rest

• maintain a balanced diet

• follow precautions if disease is sexually transmitted