↑↓ Hepatitis

Virus(infection); Hepatotoxins (industrial toxins, ETOH, drugs); secondary to infections ( Epstein-Barr, herpes, varicella, CMV) [even though they target other parts of the body it can still lead to hep] → widespread inflammation & infection of liver cells

• report to local health department/CDC

What hepatitis causes?

1. hepatomegaly → ↓ blood flow to liver

2. ↑ edema of bile channels → pressure & obstruction (jaundice is a late sign) as well as Pruritus and dark-colored urine and clay colored stool

3. necrosis if widespread - fulminant (fatal form)

•     severe acute mainly seen w/ B and D before jaundice can even occur

  • trx. EMERGENCY TRANSPLANT

overall s/s:

• Dark colored urine

• clay colored stool (obstruction of bile ducts)

• Pruritus, Fatigue (chronic form), anorexia

• Gallstones

• abd pain/liver tenderness, fever

• Jaundice (LATE SIGN) also icterus —excessive accumulation of bile pigments (bilirubin) deposited in skin, excreted in urine → Hyperbilirubinemia (acute obstruction)

labs: liver enzymes ( ↑ AST/ALT)

dx.

C: Anti-HCV antibodies → indicates exposure (detectable ~ 4 weeks after infection) using the HCA RNA test (measures viral load (OraQuick – Rapid Antibody Test))

D; delta antigen or rise in HDV-Ab titer

E: no detection: dentified by finding HEV-Ab/IgM in clients blood

Liver Biopsy to confirm; stage/grade of damage or cancer; distinguish cause

• RISK FOR BLEEDING

• Viral hepatitis (acute or chronic) most common

  • HIV positive is more likely to get A,B,D

Nursing considerations:

• acute: Supportive care, individualized

  • Goals - Promote liver regeneration, prevent complications

• Promote nutrition & manage fatigue

  • Educate: Rest ↓ liver’s metabolic demands; activity as tolerated

    • vaccinated

  • ↑ cals/carb diet, mod fat/protein, small frequent meals

  • NO ALCOHOL or acetaminophen

  • Vitamins, anti-emetic PRN N&V; limit most meds

  • Antiviral drugs (HBV & HCV)

• evaluation of outcomes:

  • maintain adequate nutrition

  • report inc energy levels

  • achieve appropriate management of infection and inflammation

Nonalcoholic Fatty Liver Disease (NAFLD) - liver stores excessive amounts of fat from the body not r/t EtOH → Hepatomegaly, firmness & ↓ function

• R/T obesity, ↑ cholesterol, T2DM, metabolic syndrome

TX – lifestyle, diet, weight loss, glucose control

NAFLD → NASH (Nonalcoholic steatohepatitis) is the more

severe form - inflammation→ cirrhosis/failure, liver cancer, death

Cirrhosis

acute hepatic inflammation → fibrosis/irreversible scarring (nodular) → retrograde ↑ pressure/circulation, ↑ metabolic wastes → impairs cellular regulation (structural changes & loss of fx at 75% damage) → necrosis

Types of Cirrhosis:

Post-necrotic

• Viral hepatitis (esp. Hep C)

• Certain drugs or toxins — Alcohol; tylenol; acetaminophen

Biliary

• Chronic biliary obstruction (gallstones)

• Autoimmune disease - primary biliary cirrhosis (PBI)

Alcoholic (Laennec’s) cirrhosis*

• has genetic predisposition (hypersensitivity)

• > 2 drinks/day or 7/wk in women

• > 3 drinks/day or 14/wk in men

Complications:

• Compensated cirrhosis: Liver scarred, still performs essential fx

• Decompensated cirrhosis ~ impaired fx, S/S (at 75%)

• Portal hypertension → Portal vein is blocked by fibrosis → ↑ BP → Ascites & esophageal varices (thin walls = BLEEDING RISK)

  • ascites → blood flows back to spleen (splenomegaly) → Platelet destruction (thrombocytopenia)/BLEEDING RISK

    • Hypoalbuminemia (third spacing-fluid leave the cells into interstitial space)

    • s/s Caput medusae—visible, dilated vessels around umbilicus

  • esophageal varices (life-threatening)→ rupture ( can be Spontaneous OR with lifting, exercise, eating dry/hard food)→ shock

    • Upper GI bleeding = hematemesis

    • Lower GI bleeding = melena; frank blood (bright)

    • longer coag times bc liver damage ↓ production of clotting factors (ANEMIA)

    • Spleen involvement: platelet loss/thrombocytopenia

• Biliary obstruction → ↑ serum bilirubin levels→ Jaundice

  • ↓ production of bile → ↓ digestion of fats → Prevents absorption of fat-soluble vitamins (K) (BLEEDING RISK (PT/INR)

  • caused by either Intrahepatic obstruction (acute) by gallstone or Hepatocellular (chronic disease) from edema, scarring/fibrosis

• Hepatic encephalopathy (late stages): Ammonia build up in blood that reaches the brain → CNS depressant/neuro S/S (Asterixis (hand-flapping) or “liver flap”) -stage III; Seizures, unarousable, coma (Stage IV)

other complications:

• Hepatorenal Syndrome (HRS): Poor prognosis; Sudden ↓ in urinary flow

• Spontaneous Bacterial Peritonitis (SBP): Very advanced liver disease → low protein levels → Bacteria from bowel reach ascitic fluid → Fever, chills, abdominal pain

  • DX ~ ascitic fluid analysis via paracentesis

▪ Hepatopulmonary Syndrome: Ascites → breathing/dypsnea

s/s: hepatomegaly (firm & hard) → atrophy

early sys:

• fatigue

• GI ~ anorexia, vomiting (PRIORITY) → catch hepatomegaly early

  • abd girth

• Significant changes in wgt

• Abdominal pain, liver tenderness (often ignored)

Late signs:

• Jaundice (skin), icterus (sclerae)

• bruising; Vascular lesions: spider angiomas

• caput medusae: Dilated abdominal veins

• Vitamin deficiency (ADEK)

  
  

Report: GI bleeding, jaundice, ascites, easy bruising, neuro S/S

dx. ↑ liver enzymes (everthing thing is elevated) except:

• ↓ serum albumin (hypoalbuminemia)

• ↓ total protein

• US 1ST

• Liver biopsy — caution risk for bleeding

Main concerns:

• Fluid overload: 3rd spacing/ascites & peripheral edema

  • monitor abd girth, daily wgts, i/o, lytes

  • monitor for spontaneous, bacterial peritonitis

• Potential for hemorrhage: Portal HTN, bleeding esophageal varices → infection → shock (ME)

  • trx. for rupture: IV vasoactive drugs, BALLOON TAMPONADE

    • complication: aspiration, asphyxia, perforation

      • Shunting procedure ~ TIPS: addresses portal HTN

        • screening: endoscopy

        • prevention med: propranolol

• Acute confusion/cognitive changes: ↑ serum ammonia +/or ETOH withdrawal

  • Neuro checks (q 2-4 hrs) ~ Glasgow Coma Scale (GCS)

  • Assess ~ liver flap (asterixis), breath (fetor hepaticus)

  • Monitor ammonia levels (normal 10-80 mcg/dL)

  • Seizure precautions

  • Prevent GI bleeding

  • mod-protein

trx.

• Nutrition therapy Na+ restriction

  • take vitamins like thymine/folate

• Drug therapy diuretics like spironolactone or furosemide

  • monitor K

  • DON’T GIVE TYLENOL (edu)

• Fluid volume: PARACENTESIS: IF SBP suspected send to lab

  • Nursing Care/Monitoring: bleeding, infection, perforation

  • Semi-Fowlers, vs & weight before/after

  • Resp support: Hepatopulmonary syndrome

    • monitor: Dyspnea: O2, monitor pulse ox, ↑ HOB

drug therapy:

1st. Lactulose ~ ↑ excretion in stool/ ↓ absorption

• laxative effect

  • Observe for cramping, hypokalemia, dehydration

2. Nonabsorbable antibiotics: intestinal antiseptic that Destroy normal flora/ ↓ protein breakdown/production

• Rifaximin: given with lactulose