HEPATIC DISORDERS

Chapter 43 Assessment and Management of Patients with Hepatic Disorders

Review of Anatomy and Physiology

• Liver
    - Largest gland of the body.
    - Located in the upper right abdomen.
    - Highly vascular organ, receives blood from:
      - Gastrointestinal (GI) tract via the portal vein.
      - Hepatic artery.

Liver and Biliary System

• Structure of the bile ducts and associated organs:
    - Diaphragm
    - Liver
      - Right and left hepatic ducts.
      - Gallbladder:
        - Cystic duct leading to the common bile duct.
      - Ampulla of Vater with sphincter of Oddi.
      - Duodenum, tail and head of the pancreas, pancreatic duct.

Section of a Liver Lobule

• Liver lobule structure:
    - Cross-section view includes:
      - Bile duct
      - Portal vein
      - Hepatic artery
      - Hepatic cells:
        - Comprised of branches of the portal vein and hepatic artery.
      - Kupffer cells (macrophages)
      - Sinusoids and canaliculi
      - Central vein

Metabolic Functions of the Liver

• The liver is responsible for several key metabolic functions:
    - Glucose metabolism.
    - Ammonia conversion to urea.
    - Protein metabolism.
    - Fat metabolism.
    - Storage of vitamins and iron.
    - Bile formation.
    - Bilirubin excretion.
    - Drug metabolism.

Liver Function Studies

• Tests to assess liver function include:
    - Serum aminotransferases: AST, ALT, GGT, GGTP, LDH.
    - Serum protein studies.
    - Bilirubin studies (direct and indirect) and urine bilirubin assessment.
    - Clotting factors evaluations.
    - Serum alkaline phosphatase, ammonia, and lipids.
    - Refer to Table 43-1 for detailed data.

Liver Function Tests

• Function tests indicate liver health and are crucial for diagnosing liver disorders:
    - Serum aminotransferases:
      - Alanine aminotransferase (ALT):
        - Levels elevate primarily in liver disorders; monitor hepatitis and cirrhosis courses.
      - Aspartate aminotransferase (AST):
        - Not liver-specific but may increase with cirrhosis, hepatitis, and liver cancer.
      - Gamma-glutamyl transferase (GGT):
        - Elevated levels indicate cholestasis and alcoholic liver disease.

Additional Diagnostic Studies

• Other diagnostic methods include:
    - Liver biopsy.
    - Ultrasonography.
    - CT scans.
    - MRI.

Assessment of the Patient with Alterations of the Liver

• Health history:
    - Evaluate for previous exposure to hepatotoxic substances or infectious agents.
    - Document travel, alcohol, and drug history.
    - Lifestyle assessment.

• Physical assessment:
    - Skin examination.
    - Assessment of cognitive status.
    - Techniques such as palpation and percussion.

Hepatic Dysfunction

• Types of hepatic dysfunction include:
    - Acute or chronic liver disease:
      - Examples include cirrhosis, liver failure due to alcohol use, infections, and fatty liver disease:
        - Nonalcoholic fatty liver disease (NAFLD).
        - Nonalcoholic steatohepatitis (NASH).

Manifestations of Hepatic Dysfunction

• Symptoms to observe:
    - Jaundice.
    - Portal hypertension.
    - Ascites and varices.
    - Hepatic encephalopathy or coma.
    - Nutritional deficiencies.

Jaundice

• Characterized by:
    - Yellow or greenish-yellow coloration of sclera and skin due to increased serum bilirubin levels.
    - Occurs when bilirubin levels exceed 2 mg/dL.

• Types of jaundice:
    - Hemolytic.
    - Hepatocellular.
    - Obstructive leading to hereditary hyperbilirubinemia.

Signs and Symptoms Associated with Hepatocellular and Obstructive Jaundice

• Hepatocellular jaundice:
    - Patient may appear mild to severely ill.
    - Manifestations include lack of appetite, nausea, vomiting, weight loss, malaise, fatigue, weakness, headache, chills, fever, and potential infections.

• Obstructive jaundice:
    - Leads to dark orange-brown urine, clay-colored stools, dyspepsia, fat intolerance, and pruritus.

Portal Hypertension

• Caused by obstructed blood flow through the liver, leads to:
    - Increased pressure within the portal venous system.
    - Can result in ascites and esophageal varices.

Ascites

• Pathophysiology includes:
    - Increased capillary pressure, obstructed venous flow, vasodilation in splanchnic circulation
    - Altered metabolism of aldosterone resulting in fluid retention.
    - Decreased albumin synthesis lowers serum osmotic pressure, leading to fluid movement into the peritoneal cavity.

• Assessment includes monitoring abdominal girth and weight daily, noting striae and distended veins, and using percussion techniques.

Treatment of Ascites

• Management strategies include:
    - Low-sodium diet.
    - Diuretics (e.g., spironolactone).
    - Bed rest.
    - Paracentesis for fluid removal.
    - Salt-poor albumin administration.
    - Transjugular intrahepatic portosystemic shunt (TIPS).
    - Other methods: peritoneovenous shunt.

Diuretic Medications for Ascites

• Most commonly used diuretic:
    - Spironolactone (first-line therapy in cirrhosis-related ascites).
    - Furosemide can be added cautiously.
    - Ammonium chloride and acetazolamide are contraindicated due to potential hepatic coma.

Pathophysiology of Hepatic Encephalopathy and Coma

• Life-threatening condition characterized by:
    - Accumulation of ammonia and other toxic metabolites.

• Key alterations in acute and chronic liver disease:
    - Hepatic insufficiency: liver's failure to detoxify metabolic by-products.
    - Portosystemic shunting: collateral circulation allows unprocessed substances to enter systemic circulation.

• Early signs include mental changes and motor disturbances.

Assessment and Stages of Hepatic Encephalopathy

• Assessment involves:
    - EEG monitoring.
    - Changes in level of consciousness (LOC).
    - Evaluating for potential seizures.
    - Checking for fetor hepaticus, fluid and electrolyte levels, and ammonia levels.

• Staging of hepatic encephalopathy referred in Table 43-3.

Medical Management of Hepatic Encephalopathy

• Strategies include:
    - Addressing precipitating causes.
    - Lactulose to lower serum ammonia concentrations.
    - IV glucose to minimize protein catabolism.
    - Reducing ammonia levels from the GI tract via gastric suction, enemas, and oral antibiotics.
    - Discontinuing sedatives, analgesics, and tranquilizers,
    - Monitoring and treating complications and infections.

Esophageal Varices

• Found in:
    - Approximately 30% of patients with compensated cirrhosis.
    - Approximately 60% of patients with decompensated cirrhosis.

• Mortality rates for first bleeding episode range from 10% to 30%, depending on severity.

• Manifestations include:
    - Hematemesis (vomiting blood), melena (black stools), general deterioration, and potential shock.

• Patients should undergo screening endoscopy every 2 to 3 years.

Treatment of Bleeding Varices

Immediate Management

• Treat for shock:
    - Provide oxygen.
    - Administer IV fluids, electrolytes, volume expanders, and blood products.
    - Use vasopressin, somatostatin, or octreotide to reduce bleeding.
    - Combine nitroglycerin with vasopressin for coronary vasodilation.
    - Propranolol and nadolol can reduce portal pressure, often combined with other treatments.
    - Balloon tamponade may be required.

Interventional Treatments

• Options include:
    - Endoscopic sclerotherapy.
    - Endoscopic variceal ligation (esophageal banding).
    - TIPS procedure.
    - Additional therapies and surgical management such as bypass procedures and devascularization.

Nursing Management of Esophageal Varices

• Ensure a safe environment to prevent injury, bleeding, and infections.

• Administer prescribed therapies and monitor for complications.

• Encourage deep breathing and position changes to alleviate pressure.

• Provide education and support to patients and families.

Hepatitis Overview

• Types of Hepatitis:
    - Viral Hepatitis:
      - Necrosis and inflammation of liver cells.
      - Transmission modes:
        - A and E: fecal–oral route.
        - B and C: bloodborne.
        - D: only occurs in individuals with Hepatitis B.
        - G and GB virus-C: not well defined.
    - Non-viral Hepatitis:
      - Toxic and drug-induced forms.

Hepatitis A

• Transmission: poor hand hygiene; fecal–oral.

• Incubation period: 2 to 6 weeks.

• Illness duration: 4 to 8 weeks.

• Mortality rates:
    - 0.5% for individuals under age 40.
    - 1% to 2% for those over age 40.

• Symptoms:
    - Mild flu-like symptoms, low-grade fever, anorexia, jaundice (later onset), dark urine, and epigastric distress.

Management of Hepatitis A

• Prevention:
    - Good handwashing, safe water, proper sewage disposal,
    - Vaccination and immunoglobulin for contacts to provide passive immunity.

• Supportive care during acute phase such as bed rest and nutritional support.

Hepatitis B

• Transmission via blood, saliva, semen, and vaginal secretions; sexually transmitted and can be passed to infants at birth.

• Major global contributor to cirrhosis and liver cancer.

• Incubation period: 1 to 6 months.

• Manifestations:
    - Variable symptoms similar to Hepatitis A: loss of appetite, dyspepsia, abdominal pain, malaise, possible jaundice.

Management of Hepatitis B

• Medications for chronic infection include:
    - Alpha interferon, entecavir (ETV), and tenofovir (TDF).

• Support includes bed rest, nutritional enhancement, and vaccination for high-risk groups and infants.

• Adhere to standard precautions and screening of blood products.

Hepatitis C

• Transmission through blood and sexual contact, including needle sharing.

• Most prevalent bloodborne infection; often leads to liver cancer and the necessity for transplantation.

• Incubation period: variable, ranging from 15 to 160 days, mild symptoms, chronic carrier state is common.

Management of Hepatitis C

• Use of antiviral medications.

• Alcohol exacerbates the disease; medications affecting the liver should be avoided.

• Prevention through public health measures, safe needle programs, and blood supply screening.

Hepatitis D

• Risks limited to those with Hepatitis B.

• Transmission through blood and sexual contact, including IV drug use and multiple transfusions.

• Associated with higher likelihood of fulminant liver failure or chronic hepatitis.

• Incubation period: 30 to 150 days; interferon alfa is the sole licensed treatment.

Hepatitis E

• Transmitted via fecal–oral route, particularly from contaminated water.

• Incubation period: 15 to 65 days; self-limiting and resembles Hepatitis A with no chronic form.

• Preventable through hygiene and sanitation efforts.

Other Liver Disorders

• Nonviral hepatitis:
    - Includes toxic and drug-induced variants.

• Fulminant hepatic failure: a rapid progression of liver failure.

Hepatic Cirrhosis

• Types of cirrhosis include:
    - Alcoholic: Scar tissue around portal areas.
    - Postnecrotic: Broad scar tissue bands.
    - Biliary: Scarring near bile ducts.

• Pathophysiology involves deterioration of liver function leading to:
    - Enlargement of liver, portal obstruction, ascites, potential infections, varices, vitamin deficiencies, anemia, and mental decline.

Care of Patients with Cirrhosis of the Liver

• Nursing interventions focus on:
    - Promoting rest and improving nutritional status,
    - Skin care, reducing injury risk, and monitoring complications.

Nursing Interventions for Cirrhosis Patients

• Promoting Rest:
    - Supportive measures for optimal positioning to aid respiratory efficiency.
    - Planned mild exercise with appropriate rest periods.

• Improving Nutritional Status:
    - Monitor Intake and Output (I&O).
    - Encourage small, frequent meals with high-caloric content, restricting sodium.
    - Provide nutritional supplements including water-soluble forms of fat-soluble vitamins if steatorrhea is present.

• Providing Skin Care:
    - Frequent positional changes and gentle care to reduce scratching associated with pruritus.

• Reducing Injury Risk:
    - Focus on preventing falls and avoiding trauma due to bleeding risks.

Collaborative Problems and Complications in Cirrhosis Patients

• Complications include:
    - Bleeding and hemorrhage.
    - Hepatic encephalopathy.
    - Fluid volume excess.

Cancer of the Liver

• Types:
    - Primary liver tumors: often linked to hepatitis B and C; specifically Hepatocellular carcinoma (HCC).
    - Liver metastasis: infrequently originates in the liver but can be a common metastasis site.

• Manifestations may include persistent right upper quadrant (RUQ) pain, weight loss, anemia, jaundice, and ascites.

Nonsurgical Management of Liver Cancer

• Challenges due to underlying cirrhosis complicating surgical options; major focus on palliative care strategies:
    - Radiation therapy.
    - Chemotherapy.
    - Percutaneous biliary drainage.

Surgical Management of Liver Cancer

• Preferred treatment for HCC if it is confined to one lobe and liver function remains adequate.

• The liver's regenerative capabilities allow for several surgical interventions:
    - Lobectomy.
    - Cryosurgery.
    - Liver transplantation.

Nursing Care for Patients Undergoing Liver Transplantation

• Preoperative Interventions:
    - Emotional support, education, and encouragement to prepare patients.

• Postoperative Interventions:
    - Close monitoring for infection, vascular complications, and assessing liver functionality.
    - Address caregiver health and stress.

Patient Education for Liver Transplant

• Emphasize lifelong adherence to therapeutic regimens, especially for immunosuppressive agents:
    - Recognize signs and symptoms indicating complications requiring consultation with the transplant team.
    - Adhere to follow-up testing and appointments to ensure ongoing care and recovery.