Liver Disorders

Liver Disorders

Introduction

  • Presented by: Jessica Cheuk

  • Contact: cheukyyj@hku.hk

Learning Outcomes

After this lecture, students should be able to:

  • Describe the location and functions of the liver.

  • Explain the liver function tests in relation to pathophysiologic alterations of the liver.

  • Identify the clinical manifestations of liver disorders & cirrhosis.

  • Describe the complications associated with cirrhosis.

  • Describe the nursing care for patients undergoing liver biopsy and abdominal paracentesis.

  • Describe nursing and interprofessional management strategies for patients with liver disorders & cirrhosis.

Functions of the Liver

Metabolic Functions

  • Blood Clotting: Synthesis of prothrombin (factor I), fibrinogen (factor II), and factors V, VII, IX, and X.

  • Carbohydrate Metabolism: Involves:

    • Glycogenesis: Conversion of glucose to glycogen.

    • Glycogenolysis: Breakdown of glycogen to glucose.

    • Gluconeogenesis: Formation of glucose from amino acids and fatty acids.

  • Detoxification: Inactivation of drugs and harmful substances and excretion of their breakdown products.

  • Fat Metabolism:

    • Synthesis of lipoproteins.

    • Breakdown of triglycerides into fatty acids and glycerol.

    • Formation of ketone bodies.

    • Synthesis of fatty acids from amino acids and glucose.

    • Synthesis and breakdown of cholesterol.

  • Protein Metabolism:

    • Synthesis of nonessential amino acids and plasma proteins (excluding gamma globulin).

    • Synthesis of clotting factors.

    • Deamination of amino acids in the colon to form ammonia (NH3), which is then converted to urea (NH4).

  • Metabolism of Steroid Hormones: Such as aldosterone, estrogen, and testosterone.

Secretory Functions

  • Bile Production: Formation of bile, which contains bile salts, bile pigments (predominantly bilirubin), and cholesterol.

  • Bilirubin Management: Conjugation and secretion of bilirubin.

Vascular Functions

  • Blood Filtration: Breakdown of old red blood cells (RBCs), white blood cells (WBCs), bacteria, and other particles.

  • Blood Reservoir: Temporary storage of blood within circulation.

Storage Functions

  • Nutrient Storage:

    • Stores glucose as glycogen.

    • Stores vitamins:

    • Fat-soluble: A, D, E, K.

    • Water-soluble: B1, B2, cobalamin, folic acid.

    • Stores fatty acids, minerals (iron, copper), and amino acids in the form of albumin and β-globulins.

Common Liver Disorders

  1. Hepatitis

  2. Non-alcoholic Fatty Liver Disease (NAFLD)

  3. Cirrhosis

Hepatitis

  • Types of Hepatitis:

    • Infectious:

    • Viral, Bacterial, Fungal, Parasites.

    • Non-infectious:

    • Alcohol, Drugs, Autoimmune, Chemicals, Herbs.

  • Definition: Widespread inflammation of liver cells.

Viral Hepatitis

  • Categories of Viruses:

    • Hepatitis A virus (HAV)

    • Hepatitis B virus (HBV)

    • Hepatitis C virus (HCV)

    • Hepatitis D virus (HDV)

    • Hepatitis E virus (HEV)

Hepatitis A Virus (HAV)

  • Characteristics:

    • Ribonucleic acid (RNA) virus of enterovirus family.

    • Resistant to detergents and acids but susceptible to chlorine (bleach) and extremely high temperatures.

    • Symptoms similar to flu-like infection.

    • Transmitted via fecal-oral route (contaminated water and food).

  • Serological Markers:

    • Hepatitis A IgM indicates acute infection.

    • Hepatitis A IgG without anti-HAV IgM indicates past infection.

  • Prevention: Vaccination and thorough hand washing.

Hepatitis B Virus (HBV)

  • Characteristics:

    • Double-shelled particle containing DNA (HBcAg, HBsAg, HBeAg).

  • Modes of Transmission:

    • Perinatal from infected mothers to infants.

    • Percutaneous (in contact with infectious blood or body fluids).

    • Sexual transmission.

  • Serological Markers:

    • Presence of anti-HBs indicates immunity (from vaccine or past infection).

    • Presence of HBsAg indicates chronic HBV infection.

Blood Test for Hepatitis B

  • HBsAg (Hepatitis B Surface Antigen): Marker of infectivity, indicating acute or chronic infection.

  • Anti-HBs (Hepatitis B Surface Antibody): Indicates previous infection or vaccination.

  • HBeAg (Hepatitis B E Antigen): Indicates high infectivity; used for clinical management.

  • Anti-HBe (Hepatitis B E Antibody): Indicates low infectivity in chronic HBV.

  • Anti-HBc IgM: Indicates acute infection.

  • Anti-HBc IgG: Indicates previous or ongoing infection.

Hepatitis C Virus (HCV)

  • Characteristics:

    • RNA virus and blood-borne.

  • Common Transmission Modes:

    • Sharing contaminated needles among drug users.

    • High-risk sexual behavior and sharp exposures.

    • Major cause of liver failure and cancer.

  • Serological Marker:

    • Presence of anti-HCV indicates Hepatitis C infection.

Preventive Measures for Viral Hepatitis

  • General Measures:

    • Hand washing, avoid sharing personal items.

    • HBIG administration for one-time exposure (e.g., needle stick).

    • Active immunization: HBV vaccine.

  • Percutaneous Transmission:

    • Blood screening for donors:

    • HBV: HBsAg.

    • HCV: Anti-HCV.

    • Use disposable needles and syringes.

  • Sexual Transmission Precautions:

    • Acute exposure: HBIG to partners of HBsAg-positive persons.

    • HBV vaccine for uninfected sexual partners; condoms usage is recommended.

  • Considerations for Health Care Personnel:

    • Use standard infection control precautions.

    • Minimize contact with potentially infectious blood.

Drug Therapy for Hepatitis

  • Acute Hepatitis:

    • No specific therapies for HAV infection.

    • Treatment for severe HBV cases only.

    • Monitoring for spontaneous clearance in acute HCV cases, with direct-acting antivirals (DAAs) when necessary.

  • Chronic Hepatitis B:

    • Drug therapy aims to reduce viral load and liver enzyme levels, preventing complications like cirrhosis and liver cancer.

Drug Classes Used

  • Immune Modulators:

    • Example: Pegylated interferon.

    • Mechanism: Antiviral, antiproliferative, immune-regulating.

    • Indication: Chronic hepatitis B and C.

  • Nucleoside and Nucleotide Analogs:

    • Examples: Entecavir, Lamivudine, Telbivudine, Tenofovir.

    • Mechanism: Inhibit HBV DNA polymerase, prevent viral replication for chronic HBV treatment.

Non-alcoholic Fatty Liver Disease (NAFLD)

  • Definition: Condition characterized by fat accumulation in the liver not attributed to significant alcohol consumption.

  • Progression: Can advance to non-alcoholic steatohepatitis (NASH), leading to cirrhosis and liver cancer.

  • Diagnosis:

    • Ultrasound, CT scan, MRI, and liver biopsy.

Cirrhosis

  • Pathophysiology: Progressive destruction of functional liver tissue replaced by fibrous scar tissue:

    • Hepatocytes and liver lobules destroyed.

    • Lost metabolic functions and disrupted blood/bile flow, leading to portal hypertension.

  • Irreversible Disease Process

Mechanism of Cirrhosis Development

  1. Toxin or Disease →

  2. Inflammation

  3. Degeneration and destruction of hepatocytes →

  4. Tissue becomes nodular (excess fibrous tissue) blocking normal flow →

  5. Impaired hepatic function → development of metabolic abnormalities.

Common Causes of Cirrhosis

  • Alcoholic liver disease.

  • Viral hepatitis.

  • Autoimmune hepatitis.

  • Steatohepatitis (from fatty liver).

  • Drug and chemical toxins.

  • Gallbladder disease (e.g., primary sclerosing cholangitis).

  • Metabolic/genetic causes.

Pathophysiology of Liver Disorders

  • Disruption in Function:

    • Decreased protein metabolism → lower albumin, clotting factors.

    • Glucose storage and metabolism impairment.

    • Reduced bile production.

    • Impaired steroid hormone metabolism.

    • Bilirubin conversion issues leading to jaundice.

    • Portal hypertension from disrupted blood flow.

Clinical Manifestations of Liver Dysfunction

  • Jaundice Types:

    • Pre-hepatic/Hemolytic Jaundice: Excessive RBC destruction → increased unconjugated bilirubin.

    • Intra-hepatic/Hepatic Jaundice: Impaired function → raised conjugated and unconjugated bilirubin.

    • Obstructive Jaundice: Impaired bilirubin excretion → increased conjugated bilirubin.

Portal Hypertension

  • Definition: Impaired blood flow increases pressure in the portal venous system, leading to:

    • Esophageal/gastric varices, hemorrhoids, splenomegaly, ascites, portal systemic encephalopathy.

Complications Arising from Portal Hypertension

  • Esophageal/gastric varices leading to potential massive hemorrhage.

  • Splenomegaly leading to anemia, leukopenia, and thrombocytopenia.

Ascites

  • Definition: Accumulation of plasma-rich fluid in the abdominal cavity.

  • Mechanism: Due to decreased serum colloidal oncotic pressure and various hormonal imbalances.

Hepatic Encephalopathy

  • Description: Result of increased ammonia levels in the blood due to liver dysfunction, leading to:

    • Clinical Presentations: Confusion, agitation, impaired consciousness, asterixis (
      "liver flap"), and other neurological signs.

  • Factors Contributing: Cerebral depressants, dehydration, and infections.

Hepatorenal Syndrome (HRS)

  • Description: A form of functional renal failure associated with liver failure, indicating poor prognosis.

  • Symptoms: Sudden decrease in urinary flow, elevated blood urea nitrogen, and creatinine.

  • Treatment Options: Exclusion of reversible conditions, renal replacement therapy, liver transplant.

Assessment of Liver Function and Diagnostic Tests

Patient Medical History

  • Evaluation of:

    • Viral hepatitis history.

    • Alcohol consumption habits.

    • Medication and occupational history.

    • Family medical background.

Signs of Liver Disease

  • Clinical indicators observed during assessment.

Laboratory Tests

  • Complete Blood Count (CBC): Examining RBC, Hb, WBC, and platelets.

  • Coagulation Profile: Evaluating prothrombin time (PT).

  • Liver Function Tests (LFT) including:

    • Total protein, albumin, serum ammonia.

    • Viral antigens.

    • Serum liver enzyme levels, which may only show abnormalities after significant liver cell damage.

Laboratory Test Results Snapshot (Example)

  • Date: 26/9/2017

  • Parameters:

    • Sodium: 139 mmol/l

    • Potassium: 4.1 mmol/l

    • Creatinine: 80 mmol/l

    • Total Bilirubin: 46 μmol/l (abnormal)

    • ALT: 65 U/L (elevated).

Liver Function Test (LFT) Ranges

  1. Total Bilirubin: 4-23 μmol/L

    • Abnormality indicates jaundice severity.

  2. AST/SGOT: 14-38 U/L

    • Elevated levels indicate hepatocellular disease.

  3. Alkaline Phosphate (ALP): 32-93 U/L

    • Significant elevation may indicate cholestasis or hepatic infiltration.

  4. ALT: 7-36 U/L

    • Evaluates hepatocyte damage.

  5. Albumin: 39-50 g/L

    • Indicators of hepatic synthetic function.

Nursing and Interprofessional Management for Cirrhosis

Overall Management Strategies

  1. Nutrition Therapy:

    • High-carb, moderate-fat, and high-protein diet (if no contraindications).

    • Changes necessary for elevated serum ammonia or encephalopathy symptoms.

    • Sodium and vitamin restrictions/supplements.

    • Incorporate family in dietary counseling.

  2. Medications:

    • Diuretics: Furosemide, spironolactone for managing fluid retention.

    • Laxatives: Lactulose to decrease ammonia production.

    • Anti-infective agents: Neomycin, Metronidazole, Rifaximin to manage gut bacteria.

    • Others: Beta-blockers to manage portal hypertension; vitamin K for bleeding risks, Antacids for gastritis.

  3. Paracentesis:

    • Purpose: Diagnose infections, remove fluid, and check for complications.

  4. Management of Bleeding Esophageal/Gastric Varices:

    • Endoscopic Techniques: EVL, ES for variceal bleeding control.

    • Pharmacological Agents: Terlipressin and others for managing variceal hemorrhage.

Nursing Care Protocols during Therapeutic Paracentesis

  • Before the Procedure:

    • Aseptic technique, patient identification, consent acquisition, and baseline measurements.

    • Patient positioning – supine with head elevated.

  • During the Procedure:

    • Monitoring vital signs and patient condition; securing catheters and drainage.

  • Post-Procedure Care:

    • Frequency of monitoring conditions, ensuring proper drainage, and managing any adverse signs.

References

  • Carpenito, L. J. (2016). Nursing diagnosis: Application to clinical practice (15th ed.). Philadelphia: Lippincott Williams & Wilkins.

  • Hinkle, J. L., & Cheever, K. H. (2018). Brunner and Suddarth’s textbook of medical-surgical nursing. Wolters Kluwer India Pvt Ltd.

  • Ignatavicius, D. D., Workman, M. L., & Rebar, C. (2017). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier Health Sciences.

  • Harding, M., Kwong, J., Hagler, D., Reinisch, C., & Lewis, S. M. (2023). Lewis’s medical-surgical nursing: assessment and management of clinical problems (12th ed.). Elsevier.