liver disease

The liver is a

vital organ that is multifaceted and

maintaining overall health. When the liver

becomes diseased, the patient will exhibit various signs

and symptoms. The liver's

intricate functions are vital for maintaining metabolic balance,

maintaining homeostasis, detoxifying harmful

substances out of the blood system

supporting various physiological

processes. And all of that

combined makes the liver cornerstone of overall health

and well being. This image shows

the anatomy of the liver and the

surrounding organs. Notice how intertwined

the liver, gallbladder, pancreas,

and intestines are. You can also see here

the spleen comes over, is connected to the liver, and sends blood to

the liver as well. We'll look at the

liver's blood supply. It's important

to understand that the liver is a highly vascular organ. It actually receives 25% of our resting

cardiac output. It has a dual

blood supply, where it receives blood from the hepatic artery, which is oxygenated,

and it receives deoxygenated blood from the GI and

accessory organs. The blood that it

receives through the vein is rich

in nutrients, but it is also

rich in toxins. It has dead

blood cells and breakdown of

cellular debris that comes to it

from the spleen. Insulin and

glucagon come from the pancreas Now that blood is incompletely

oxygenated, but it still

actually supplies 75% of the oxygen to the hepatocytes

that the liver needs to do all

of its functions. Now one thing

that's interesting to me is that it

keeps a reserve of up to 1,000 mills of blood at all times when our patients

begin to become dehydrated or hypovolemic for

some other reason. Going into a

shock syndrome that reserved blood

will actually shift into circulation to help improve our

patient's profusion. When the blood has gone through the

different lobules, it will leave the

liver through the inferior vena cava and travel up

to the heart. Now, if a patient has

right heart failure, that blood will

back down into that inferior vena cava and into the liver itself. The liver is located in the right upper quadrant, right under the diaphragm, behind the rib cage, except for there

is a portion of it that is in the

epigastric area. Healthy livers

cannot be palpated. However, if a pigeon has advanced liver disease, you'll feel a hard, tight mass right under

the rib cage. Livers have two

large lobes and two small lobes. The functional unit of the liver is

called a lobule. Each lobule, there's

up to 100,000 of them are located

around a central vein, and then they have a

portal triad here, which has some

arterial blood, a bio duct, and then a portal vein

blood supply. Now our liver has

over 400 functions. It has functions that

work with synthesis and production

and storage, protection, metabolism,

detoxification. The liver stores essential vitamins and minerals. Vitamins A, D, E, K, B, 12 Mag, and iron. All that will be released when it

senses through that blood supply

that there's a short supply of it

throughout the body. It also stores and

produces bile, which aids in

fat absorption and digestion through

the small intestine. The liver plays

a large role in our body's protection in several different ways. Cover cells are

phagocytic cells that help to remove

waste toxins, harmful substances,

old cells, debris, from the

blood supply. The liver works

to detoxify the blood by filtering and neutralizing

those toxins, converting them into

water soluble compounds, where they then go out of the liver for excretion either through

bile or urine. The liver has a large role in the immune system, where it will produce

immune factor proteins. It eliminates bacteria

from the blood and produces clotting

factors that help us prevent bleeding. It also forms albumin, which contributes

to the fluid balance by preventing the leakage of fluid

from blood vessels into surrounding tissues. Over here we talk

about the metabolism of the liver is responsible for the

deamination of protein, where it converts

ammonia into urea. If you remember, ammonia is created

by the breakdown of proteins and it's

very toxic to the brain. Once the liver

converts it to urea, the kidneys then can dispose of it

through the urine. Old red blood cells are broken down and

in doing so they create a brownish yellow substance

called bilirubin. The liver can take

that bilirubin and place it

into the bile. Send it to the kidneys. I'm send it to

the intestines where it's then excreted

through the stool. The liver can process nutrients from the

digestive system. It can regulate glucose

levels by converting excess glucose into

glycogen for storage. It can create glucose through gluconeogenesis. It plays a crucial role

in lipid metabolism. It produces and regulates cholesterol and

triclycerides. As you can see, there are hundreds of

functions for the liver. One thing just to note, especially as you go into the hospital

systems and you're taking care of an

aging population, remember that

as people age, their organs decrease

in function. As the liver decreases

in function, we need to be

really careful about the medications

that we give them because they're

at high risk for drug toxicity, because their liver

can't metabolize the drugs out of

their system as well as it does in a

younger population. Hepatitis Hepatitis is

the inflammation of the liver is commonly caused by viral

infections, but it can also

result from alcohol, medications, other toxins,

autoimmune diseases. Viral hepatitis is the

most prevalent form and it's categorized

by type. We have ABCDE and non AE. And you'll see that

there is an activity in your documents for

this class where you can create a chart on the different types of Hepatitis so that you can learn the

differences between these treatment goals Are going to include Rest for the inflamed liver to help reduce the

metabolic demands, we want to increase the blood supply

to promote cellular regeneration and prevent complication. As our patients

have inflammation, we know that if we don't do something to

stop the inflammation, they will get worse until they have something

called cirrhosis. And this is a normal

healthy liver and this is a

cirotic liver. This is just a cross

section of it and you can see how there are fibroids and a lot of damage that's irreversible from inflammation either. Again, virus,

bacteria, hepatotoxin. Hepatotoxin would

include your medicines, alcohol, chemicals for

our pathophysiology. Viral hepatitis

begins with an exposure to a

virus which can be a direct infection

through inhalation, ingestion, or an

intral infection. Or it can result for

a secondary infection such as like with Epstein

bar Herpes Parcell, Zoster infections, inflammation causes

that increase in vasodilation and

capillary permeability. We've talked about

that so many times during this class. Just like in other

diseases that increased inflammatory

process is going to result in swelling

and congestion. The swelling causes those lobular become distorted, resulting in more edema and cellular necrosis. The blood cannot

flow normally through the liver because of all of the distortions. You saw those fibroids in that previous image. The vessels and the

lobules become obstructed because they're

either pinched off or occluded from all

of the swelling. Then the blood flow

is compromised and there's more cellular

and tissue death. The liver begins to

lose its function. The bile ducts often

become obstructed. There will be problems

with the storage and creation of glucose. Toxins won't be

pulled out of blood. Then the blood flow will from the artery and from the Venus supplies

both of them. They're going to be

compromised in back up. You'll have blood backing up from the hepatic

portal vein into the GI system and then

you'll have blood backing up through

the hepatic artery towards the heart. There are stages of

Hepatitis and this is especially with

viral Hepatitis. Hepatitis due to toxins and bacteria sometimes are a little bit different. Acute Hepatitis is that initial phase

characterized by sudden onset of

inflammation and patients will have

symptoms such as fatigue, jaundice, abdominal pain, nausea and dark urine. Hepatitis that

persists for greater than six

months leads to a chronic stage where there is

progressive damage. This goes into

that cirrhosis of the liver or

liver cancer. Sometimes patients

might not have symptoms for years, but eventually

as the liver begins to lose function, they become the same as the acute side

symptoms over here, but often just a little

bit more progressed. Some patients may have

be inactive carriers. This means that

the patient has the virus but their

liver function is relatively normal. This often progresses to a chronic form

of Hepatitis. It's important

to note that patients that

are carriers, even without symptoms or minimal symptomology, can still transmit the

virus to other people. Hepatitis has three phases and it's important

to understand that not all

individuals with Hepatitis will experience

all three phases. The severity and duration

of each phase will be strongly

associated with the type of

Hepatitis they have, whether it is caused by a virus or

alcohol, bacteria. The individual's

overall health and other factors will

also play into their ability to move from the Aric phase into

the postcaric phase. The preteric phase is also called the

prodromal phase. This is the initial

introduction of the virus, the bacteria that will actively replicate

in the liver. Our immune system is going to respond

and this is where inflammation

begins to occur. It lasts up to

two weeks and patients often complain of non specific flu

like symptoms. You can see on your

screen, fatigue, malase, muscle

ache, anorexia, meaning decreased

appetite, nausea, vomiting, diarrhea,

low grade fever, and they do have an

elevated Billy Rubin. During this phase, after about the two week period, your patients will begin

to exhibit jaundice. When that happens, when you can begin

seeing jaundice. Jaundice is the yellowing

of the skin and eyes that's due to the accumulation

of Billy Ruben. They have entered

the Aric phase, also called the

Jaundice phase. This can last for

several more weeks. Again, it's very

dependent on the patient's overall

health and what type of virus or bacteria

they are fighting. Patients that have

toxic exposures like acetaminopin

overdoses, They tend to go into the

space pretty quickly and come out of it pretty quickly if they're

otherwise healthy. The symptoms for

the Aric phase are the same as the prearic phase

plus jaundice. They'll have jaundice

of the skin and eyes. They'll also start

having puritis, that's usually related to the urea and ammonia. They'll have a darker

colored urine, pale colored stools. More pain in the

billy ribbon will remain

elevated during this phase as the patient progresses into the

postteric phase, also called the

convalescent phase, this is a period

of recovery where their jaundice will gradually

diminish and their symptoms

begin improving. It varies in the

length of time it takes a patient to

recover from hepatitis. Some people will think

a full recovery while other patients will

have residual damage. What do we do for

patients with Hepatitis? Well, we really

want them to rest. This helps to reduce the workload of the liver. It helps to

promote blood flow to and through the liver. Depending on

what is wrong, we will prescribe

medications, but during the Aric and the predicteric phase, we recommend using medications

very sparingly. If a patient has

Hepatitis B, they can take a medication called Interferon alpha, which will help to

kill that virus. For Hepatitis C patients, they can take pegylated

interferon alpha with ribavirin. It's less effective and it has more side effects. Unfortunately,

there's also some other direct

acting antiviral drugs that they can take

that will help to kill the virus off. Now patients that have

chronic Hepatitis, this is irreversible

damage. And the damage will slowly get worse and

worse as they go. Those patients who will need a liver transplant, and we'll talk more about those patients in class. Education is key.

Remember, it's all about prevention for most

viral hepatitis. Hand hygiene, clean

water, clean fluid, education about

bodily fluids and sex all have

to take place. We want a patient

with Hepatitis, this is someone

who has Hepatitis. And then of course,

we could vary this education for their family and loved ones, but we want to

teach them to wash their hands

frequently. They need to have

their own towels, sometimes depending

on the type of virus they have, maybe their own drinking

and eating utensils, their own toothbrushes

and razors. Depending again on

the type of virus, they're not recommended to prepare food for

other people. Now it's very important

that they avoid alcohol in any over the

counter medications, especially

medications that are hepatic toxic like

acetaminophenor sedatives. We need to teach

these patients to self protect, meaning

avoid infections. That's especially important for their

family members. We will teach a

liver patient to have a high carbon, low fat, low protein. Diet, they'll

need to increase their fluid

intake and have multiple, small

meals daily. They do not

recommend or accept blood If a patient has Hepatitis because it

is highly contagious, normal contact

is mostly fine with proper

hygiene measures. We need to make

sure that as we teach patients

diagnosed with Hepatitis

that they need to let health

care personnel know when they go to the hospital or to a

new clinic or move. They need to make

sure that all of the health care people taking care of them

understand that they have hepatitis and

what type it is. Here's a quick

comparison of Hepatitis A through E, and I'll let you guys look at that on your own. Hepatitis patients

at risk are people who have crowded

conditions like daycares in nursing

homes or college dorms, or exposure to

poor sanitation. It's transmitted through the fecal ural route, person to person

contaminated food and water, uncooked shellfish or

poorly washed utensils. It has an period of

15 to 20 days and that infectious period

is two to three weeks before one week after

jaundice development. This is really

important to understand that they

might not understand. They have

hepatitis, remember they're very vague. Flu like symptoms. They might not be

as careful with transmission routes until they realize

what's going on. How do we diagnose it? Through blood test,

We'll look at their liver symes

to ALT and AST. We can also look

for IGM and IGG. Igm shows an

active infection which is our Aric face. And IGG will show a past infection and recovered immunity

patient who has GG's might possibly

have only ever had the vaccine and never have the actual virus itself. How do we prevent? Careful hand

washing policies. Make sure that we

take precautions as health care

personnel when handling the stool or

needle precautions, water treatment

recommendations of the Hepatitis A vaccine. For people who are

at risk, such as Us in health care then, they never have had

the HAV vaccine, but they were exposed

to the virus. They can have

immunoglobulin therapy. This infection

is only acute, it does not usually translate into a

chronic infection. Hepatitis B or HBV. People who are IV

drug users and healthcare

personnel are at high risk for this. Virus is

transmitted through blood or bodily fluid contaminated needles,

sexual contact. It is transmitted during the

perinatal period. Hbv is incubation

period is 25 to 180 days and is diagnosed also

through blood tests. Alt and SAT are

liver enzymes. We can detect an

active infection or the antibodies through

the HBSAG test. Prevention washing hands, screening blood donors, screening

pregnant women to make sure that babies are to try to prevent

babies from getting it. Avoiding intimate

contact with somebody who we

know has HPV making sure that we get the Hepatitis

B vaccine. As healthcare

personnel and again, is exposed to a

positive patient and have never

had the vaccine, you can try

immunoglobulin therapy. Usually this

runs undetected and resolves on its own. Hepatitis C is

also called HCV. And is it

increased risk for IV drug users or

health care personnel? Transmission is

blood to blood most frequently and

that's the only way is transmitted. Iv drug users, blood

transfusion patients, patients who've had

organ transplants, both of those before 1992, when they began

to screen for Hep C hemodialysis

patients. We talked about

that a little bit during our renal session. Prisoners are all at

risk for Hepatitis C. It can incubate

anywhere from two weeks to six

months and it can be asymptomatic for years. We'll diagnose

this patient using the ALT and AST standard liver enzymes

as well as looking for the Hepatitis C virus. Rna liver biopsy is used to confirm

the diagnosis. They use the liver biopsy to stage and

grade the damage, check for

potential cancer, and distinguish

the etiology to distinguish that it

is actually HCB. To prevent, we screen blood donors, screen

pregnant women, and use needle precautions and standard

precautions for blood. Even when asymptomatic HCV continues to

damage the liver, it causes continuous

hepatic damage. It creates scar tissue, those fibroids that we saw in that earlier image. And it will lead

to cirrhosis. And it's a huge risk

factor for liver cancer. In fact, Hepatitis C is the leading cause of end stage liver disease

in the world. There's over 170 million positive cases

in the world, about 4 million new

cases every year, and it's the most common chronic blood

borne infection in the United States. And we're going

to talk much more about Hepatitis C in

class, I think we do, but we'll certainly

talk about the results of

Hepatitis C, which are cirrhosis and hepatic damage

and scar tissue. Now, Hepatitis C does not clear up on its own. Once they're infected

without treatment, they will go into

chronic liver disease. It is not

transmitted through casual or intimate

household contact, but if you share

space with a patient who is known

to have Hepatitis C, we do recommend

not sharing items. Hepatitis D. Hdv is common in Mediterranean and Middle Eastern areas. It only occurs in

the presence of HBV. If a patient has HBV, they are susceptible for Hepatitis D has the

same transmission, which is blood

and bodily fluids and it includes

the mucosal route. You can see a

incubation period is 14 to 56 days. Now the blood

test for this one is intrapatic

delta antigen and an increase in the

anti HDB tighter to prevent same

things we do for HBV. That vaccine for HBV will actually help

protect people from getting Hepatitis D. Then HBV immunoglobulence will be used to treat it. Hepatitis E or HEV. This is a water

borne virus that's prevalent in areas

with bad sewage, are contaminated rivers,

communal bathing. So third world countries more frequently people are increased risk include international

travel travelers, especially if

they go to India, Burna, Afghanistan,

Algeria, and Mexico. Eating food or water

contaminated with HEV will help speed up

that virus infection. How do we check? We

look for an increase in the antiGV tighter and to prevent strict

hand washing, water treatment, and

sanitation methods. Again, in your

class documents there is a table

put together that you can organize these

different viruses so that you can see

what is similar and what is different to help you with your study. And then I will provide a key to that table towards the end

of the class.