Chapter43 2

Chapter Overview

• Assessment and Management of Patients with Hepatic Disorders

• Author: Wolters Kluwer Health | Lippincott Williams & Wilkins

Anatomy and Physiology of the Liver

• Largest Gland of the Body

• Location: Upper right abdomen

• Vascular Structure: Receives blood from the gastrointestinal tract via the portal vein and from the hepatic artery.

Liver and Biliary System

• Anatomy:

• Diaphragm

• Liver

• Gallbladder

• Spleen

• Varied ducts: Left and Right hepatic ducts, ampulla of Vater, sphincter of Oddi

Cross-section of a Liver Lobule

• Structure:

• Includes bile duct, portal vein, hepatic artery, hepatic cells, and central vein

• Unique arrangement facilitates optimal metabolic function

Metabolic Functions of the Liver

• Key Functions Include:

• Glucose metabolism

• Ammonia conversion

• Protein metabolism

• Fat metabolism

• Storage of vitamins and iron

• Bile formation

• Bilirubin excretion

• Drug metabolism

Clinical Questions

• Q1: True/False - Majority of blood supply to the liver comes from the portal vein, which is poor in nutrients.

• A1: False (It is rich in nutrients from the GI tract.)

Liver Function Studies

• Tests Include:

• Serum aminotransferase levels: AST, ALT, GGT, GGTP, LDH

• Protein studies

• Serum bilirubin tests

• Clotting factors

• Serum alkaline phosphatase and ammonia

• Lipid studies

Liver Function Tests

• Indicators of Liver Injury:

• AST and ALT levels rise primarily in liver disorders

• GGT indicates cholestasis; associated with alcoholic liver disease

Additional Diagnostic Studies

• Include:

• Liver biopsy

• Ultrasonography

• CT and MRI scans

Patient Assessment Techniques

• Health History:

• Previous exposure to hepatotoxic substances, infectious agents, lifestyle (travel, alcohol, drugs)

• Physical Assessment:

• Skin changes, cognitive status, palpation, and percussion

Hepatic Dysfunction

• Conditions include:

• Acute or chronic liver failure, cirrhosis, alcoholic liver disease, infections

• Fatty liver disease (NAFLD, NASH)

Manifestations of Hepatic Dysfunction

• Key symptoms:

• Jaundice

• Portal hypertension

• Ascites and varices

• Hepatic encephalopathy and coma

• Nutritional deficiencies

Jaundice

• Definition: Yellowing of skin and sclera due to increased serum bilirubin (exceeds 2 mg/dL)

• Types:

• Hemolytic, hepatocellular, obstructive

• Related to hereditary conditions and liver disease

Symptoms of Jaundice Types

• Hepatocellular Jaundice:

• Symptoms: Illness, loss of appetite, fatigue, fever/infection

• Obstructive Jaundice:

• Symptoms: Dark urine, clay-colored stools, fat intolerance, pruritus

Portal Hypertension

• Definition: Increased pressure due to obstructed blood flow through the liver

• Results in: Ascites, esophageal varices, splenomegaly

Ascites

• Causes and Mechanisms:

• Portal hypertension increases capillary pressure; sodium and fluid retention due to hepatic dysfunction

• Signs: Increased abdominal girth, striae, distended veins

Assessment of Ascites

• Monitoring:

• Daily girth and weight

• Fluid presence via percussion techniques

• Watch for electrolyte imbalances

Treatment of Ascites

• Management Includes:

• Low-sodium diet

• Diuretics (e.g., spironolactone)

• Paracentesis and shunting procedures

Treatment of Ascites - Spironolactone

• First-line therapy: Effective in managing ascites from cirrhosis.

• Other diuretics like furosemide may be added carefully.

Hepatic Encephalopathy and Coma

• Pathophysiology:

• Ammonia accumulation due to liver dysfunction leads to neurotoxicity

• Symptoms include: Mental changes, motor disturbances

Assessment and Staging of Hepatic Encephalopathy

• Techniques:

• EEG, loc changes, seizure activity, monitoring ammonia levels

• Stages should be referenced from the appropriate clinical table

Medical Management of Hepatic Encephalopathy

• Strategies Include:

• Lactulose to lower ammonia levels, IV glucose, dietary management, and preventing complications

Esophageal Varices

• Incidence: Common in compensated and decompensated cirrhosis

• Management Strategies:

• Routine screening and emergency interventions for bleeding episodes

Treatment of Bleeding Varices

• Initial Steps: Treat shock, administer oxygen, fluids, blood products

• Medications: Vasopressin, octreotide to control bleeding

• Endoscopic Procedures: Sclerotherapy and ligation techniques

Nursing Management of Esophageal Varices

• Focus on safety, education, and complication monitoring

Hepatitis Overview

• Types:

• Viral (A, B, C, D, E) and non-viral hepatitis (toxic, drug-induced)

Hepatitis A

• Transmission: Fecal-oral route, poor hygiene

• Incubation: 2-6 weeks; symptoms may last 4-8 weeks

Management of Hepatitis A

• Emphasis on hygiene, vaccination, nutritional support

Hepatitis B

• Transmission: Via blood and other body fluids, sexually

• Prevention: Vaccination and standard precautions

Hepatitis C

• Common bloodborne infection linked to severe liver disease.

• Management: Antiviral medications and prevention strategies

Hepatitis D and E

• D: Only occurs in patients with Hepatitis B; significant risk for liver failure

• E: Fecal-oral transmission similar to Hepatitis A; self-limiting

Other Liver Disorders

• Categories: Nonviral hepatitis, toxic, drug-induced hepatitis, and fulminant hepatic failure

Hepatic Cirrhosis

• Definition: Scarring of the liver tissue

• Types: Alcoholic, postnecrotic, biliary

Care and Interventions for Cirrhosis Patients

• Focus on rest, nutrition, skin/falls care, and complications management

Liver Cancer

• Primary liver tumors associated with Hepatitis B and C

• Management: Surgical options recommended when appropriate

Nursing Care During Liver Transplantation

• Pre and Postoperative Care: Focus on patient education, support, and monitoring for complications