Liver

Copyright Information

  • Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

  • Copyright © 2021, Elsevier Inc. All Rights Reserved.

Objectives

  • Recall the concept of nutrition.

  • Review pathophysiology of liver disease.

  • Compare and contrast the risk factors for liver disease.

  • Discuss the complications of liver disease.

  • Explain the comprehensive assessment for a client suffering from liver disease.

  • Interpret the expected assessment findings for a client suffering from liver disease to determine actual and potential consequences.

  • Identify client goals and determine expected outcomes for a client suffering from liver disease.

  • Describe nursing and collaborative interventions required to treat and monitor a client suffering from liver disease.

  • Identify pharmacological therapy used to treat liver disease and associated considerations.

  • Discuss client considerations for various age groups and cultures.

Concepts

  • Priority Concepts for Liver Disease:

    • Cellular regulation

    • Nutrition

  • Interrelated Concepts:

    • Fluid and electrolyte balance

    • Inflammation

    • Pain

Functions of the Liver

  • Metabolism:

    • Converts excess glucose to glycogen.

    • Breaks down old red blood cells;

    • Kupffer Cells (phagocytes) break down hemoglobin into iron and bilirubin.

    • Bilirubin is excreted in bile and eliminated in stool (brown color).

    • Breaks down fats and synthesizes cholesterol.

    • Protein Metabolism:

    • Ammonia is a byproduct of protein metabolism.

    • The liver converts ammonia to urea (BUN).

    • Detoxification:

    • Filters blood to remove toxins and pathogens (e.g., alcohol, medications, hormones such as estrogen).

  • Produces:

    • Bile: Helps carry away waste and break down fats.

    • Albumin: Keeps water in the capillaries, binds to calcium (Ca+).

    • Clotting Factors: Fibrinogen and prothrombin.

    • Cholesterol and Lipoprotein: Regulate cholesterol levels.

    • Thrombopoietin: Signals bone marrow to produce platelets.

  • Stores:

    • Glycogen.

    • Minerals: Iron and copper.

    • Vitamins: A, C, D, E, K, B12.

Liver Disease Pathophysiology

  • Cirrhosis:

    • Definition: Extensive, irreversible scarring of the liver.

    • Development: Typically slow, progressive, prolonged.

    • Causes: Usually chronic reaction to hepatic inflammation and necrosis.

    • Inflammation caused by toxins or disease leading to destruction of hepatocytes.

    • Characterized by widespread fibrotic (scarred) bands of connective tissue.

    • Tissues become nodular, leading to decreased blood and lymph flow.

      • Early disease: Enlarged, firm liver.

      • Later stages: Liver shrinks in size and hardens, leads to decreased liver function.

    • Results in end-stage liver disease.

Types of Cirrhosis

  • Postnecrotic Cirrhosis:

    • Caused by viral hepatitis, certain drugs or toxins.

  • Laennec’s (Alcoholic) Cirrhosis:

    • Caused by chronic alcoholism.

  • Biliary Cirrhosis (Cholestasis):

    • Caused by biliary obstruction or autoimmune disease.

Cirrhosis: Etiology and Genetic Risk Factors

  • Major Causes:

    • Hepatitis C: Leading cause of cirrhosis and liver cancer in the U.S.

    • Hepatitis B and D: Most common causes of cirrhosis worldwide.

    • Non-Alcoholic Fatty Liver Disease (NAFLD): Affects 30% of Americans.

    • Non-Alcoholic Steatohepatitis (NASH): Linked to obesity, type 2 diabetes, metabolic syndrome.

  • Genetic Risk:

    • PNPLA3 Gene: Latinos at the highest risk.

  • Alcohol Use:

    • Excessive and prolonged use has a direct toxic effect on hepatocytes.

    • Leads to inflammation, destruction, scarring, and cellular necrosis.

  • Other Causes:

    • Drugs and chemical toxins, autoimmune hepatitis, gallbladder disease, metabolic causes, cardiovascular disease.

    • Some systemic viral infections can induce acute hepatitis.

Common Complications of Liver Disease

  • Portal Hypertension:

  • Ascites:

  • Esophageal Varices: Life-threatening;

  • Portal Hypertensive Gastropathy:

  • Splenomegaly:

    • Results in destruction of platelets and red blood cells (RBC).

  • Thrombocytopenia & Anemia:

  • Biliary Obstruction:

  • Decreased Vitamin K: Leads to increased bleeding.

  • Jaundice: Often accompanied by pruritus.

  • Hepatic Encephalopathy:

    • Chronic liver disease and cirrhosis are common causes of death in the U.S.

Hepatic Encephalopathy (HE)

  • Definition:

    • A condition where toxins from the gut bypass the liver and impair brain function.

  • Grades of HE:

    • Grade 4: Coma.

    • Grade 3: Sleepy, hard to get attention.

    • Grade 2: Confused, goofy, stumbling.

    • Grade 1: Poor attention, mood changes, often referred to as minimal HE.

    • Key Point: Not dementia, can be reversible with treatment (e.g., lactulose).

Stages of Hepatic Encephalopathy

  • Stage I:

    • Subtle manifestations may go unrecognized:

    • Personality changes.

    • Behavioral changes (agitation, belligerence).

    • Emotional lability (euphoria, depression).

    • Impaired thinking.

    • Inability to concentrate.

    • Fatigue, drowsiness.

    • Slurred or slowed speech.

    • Sleep pattern disturbances.

  • Stage II:

    • Continuing mental changes:

    • Mental confusion.

    • Disorientation to time, place, or person.

    • Asterixis (hand flapping).

  • Stage III:

    • Progressive deterioration:

    • Marked confusion, stuporous but arousable.

    • Abnormal electroencephalogram (EEG) tracing.

    • Muscle twitching, hyperreflexia, asterixis (hand flapping).

  • Stage IV:

    • Unresponsiveness leading to death:

    • Unarousable, obtunded, no response to painful stimulus.

    • No asterixis, positive Babinski sign, muscle rigidity.

    • Fetor hepaticus: Characteristic liver breath (musty, sweet odor).

    • Seizures.

    • HE can develop slowly in chronic liver disease or rapidly in acute liver dysfunction.

Other Complications of Liver Disease

  • Hepatorenal Syndrome:

    • Poor prognosis, often cause of death; sudden decrease in urine, elevated BUN and creatinine, increase in urine osmolarity.

  • Spontaneous Bacterial Peritonitis (SBP):

    • Symptoms: fever, chills, abdominal pain, tenderness.

    • Diagnosed by paracentesis where leukocyte count exceeds 250.

  • Hepatopulmonary Syndrome:

    • Caused by excessive ascitic volume, leading to dyspnea from intra-abdominal pressure.

Cirrhosis: Assessment - Recognize Cues

  • History Assessment:

    • Factors to consider:

    • Age, gender, employment history (especially exposure).

    • History of needlestick injuries, sexual, family, and social histories.

  • Physical Assessment/Signs and Symptoms:

    • Common symptoms include fatigue, weight change, gastrointestinal symptoms, abdominal pain.

    • Conduct thorough abdominal assessments.

  • Psychosocial Assessment:

    • Evaluate for alcohol withdrawal using CIWA scale.

Laboratory Assessment for Cirrhosis

  • Chemistry Tests:

    • Elevated AST, ALT, LDH (may be normal with advanced liver damage).

    • Increased alkaline phosphatase and GGT with biliary obstruction.

    • Increased serum bilirubin; decreased serum albumin with severe/chronic liver disease.

    • Prolonged PT/INR.

  • CBC:

    • Low platelet count, low RBC, anemia, potential thrombocytopenia; WBC may be decreased.

  • Ammonia Level: Elevated in advanced liver disease.

  • Serum Creatinine: Elevated indicates decreased kidney function.

Imaging and Diagnostic Assessment

  • Types of Imaging:

    • Abdominal X-rays, CT, MRI.

  • Other Diagnostic Methods:

    • Liver ultrasonography, liver biopsy (most definitive), US transient elastography, arteriography, EGD, ERCP.

Analysis: Analyze Cues and Prioritize Hypotheses

  • Potential Diagnoses:

    • Fluid overload due to third spacing of abdominal and peripheral fluid.

    • Potential for hemorrhage due to portal hypertension.

    • Acute confusion and other cognitive changes from elevated serum ammonia levels and/or alcohol withdrawal.

    • Pruritus due to increased serum bilirubin and jaundice.

Planning and Implementation: Generate Solutions and Take Action

  • Intervention Strategies:

    • Managing fluid volume.

    • Preventing or managing hemorrhage.

    • Preventing or managing confusion.

    • Managing pruritus.

Esophageal Varices Treatment

  • Emergency Treatment Tools:

    • Sengstaken-Blakemore tube for hemorrhage from esophageal varices, equipped with three openings for:

    • Gastric aspiration.

    • Inflation of the esophageal balloon.

    • Inflation of the gastric balloon.

    • The esophageal balloon is inflated to maintain a pressure of 20 to 40 mmHg, monitored closely.

Evaluation: Assess Outcomes for Clients

  • Expected Outcomes:

    • Have a decrease in or no ascites.

    • Maintain electrolytes within normal limits.

    • No hemorrhage or effectively managed bleeding.

    • No development of encephalopathy or effectively managed if it occurs.

    • Successfully abstain from alcohol or drugs if these contributed to the disease.

Liver Transplantation

  • Considerations for Patients:

    • Indications: End-stage liver disease (ESLD) or acute liver failure.

    • Preventative Measures:

    • Awareness of transplantation complications.

    • Interventions post-transplant.

    • Evaluate psychosocial impact.

    • Awareness of side effects related to immunosuppressive drugs.

    • Emphasis on long-term management of post-transplant care.

Practice Questions and Answers

  • Question 1: Which assessment finding requires immediate nursing intervention in a client with severe ascites?

    • Options:

    • Confusion

    • Temperature 38.2º C

    • Tachycardia (rate 110 beats/min)

    • Shallow respirations (rate 32 breaths/min)

    • Answer: D - Shallow respirations, as ascites can significantly impair lung function.

  • Question 2: What is the priority nursing intervention in the management of a client with decompensated cirrhosis?

    • Options:

    • Limiting protein intake

    • Managing nausea and vomiting

    • Monitoring fluid intake and output

    • Elevating the head of bed >30 degrees

    • Answer: B - Preventing nausea and vomiting due to the risk of bleeding esophageal varices.

  • Question 3: Which food item will the nurse remove from the dietary tray of a client with hepatic encephalopathy?

    • Options:

    • Salad

    • Apple

    • Bread

    • Legumes

    • Answer: D - Legumes (high protein) can worsen hepatic encephalopathy.

References

  • Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2021). In Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care (10th ed.), Elsevier.

  • Mayo Foundation for Medical Education and Research. (2023, June 21). Liver disease. Retrieved from https://www.mayoclinic.org/diseases-conditions/liver-problems/symptoms-causes/syc-20374502

  • Tapper, E. B., & Curry, M. P. (2018). Hepatitis Caused by Other Viruses. In Handbook of Liver Disease, 78–83. https://doi.org/10.1016/B978-0-323-47874-8.00006-7