Hepatic Disorders1

Hepatic Disorders Overview

Liver Anatomy and Function

The liver is the largest internal organ in the body, second only to the skin, and it plays a vital role in various physiological processes.

• Location: Found in the Right Upper Quadrant (RUQ) of the abdomen.

• Functions:

  • Detoxification: Breaks down and eliminates toxins, drugs, and metabolic byproducts from the bloodstream.

  • Drug Metabolism: Modifies pharmaceutical substances to enhance their excretion.

  • Blood Clotting: Produces clotting factors essential for proper hemostasis.

  • Synthesis of Albumin: Regulates osmotic pressure and transports various substances in the blood.

  • Bile Production: Necessary for digestion, particularly in the emulsification of fats.

  • Regenerative Capacity: The liver can regenerate itself following injury, allowing for the recovery from acute damage.

Cirrhosis Pathophysiology Overview

Cirrhosis is a progressive disease characterized by severe liver scarring and dysfunction. Key features include:

• Extensive Fibrosis: Formation of fibrotic bands disrupts normal liver architecture.

• Nodular Regeneration: Growth of nodular structures in response to damage.

• Bile Duct Blockage: Leads to cholestasis (impaired bile flow), impacting both hepatic and systemic circulation.

• Consequences of Cirrhosis: Ultimately results in liver shrinkage, difficulty in function, and potential liver failure.

Common Types of Cirrhosis

1. Post Necrotic Cirrhosis:

   • Causes: Viral Hepatitis (notably Hepatitis C), exposure to hepatotoxic substances such as certain drugs and toxins.

2. Laennec’s Cirrhosis (Alcoholic Cirrhosis):

   • This is the most prevalent type, resulting from chronic alcohol abuse.

3. Biliary Cirrhosis:

   • Often linked to chronic biliary obstruction or autoimmune issues that affect bile flow.

Common Causes of Cirrhosis

• Primary Causes:

  • Alcoholic liver disease.

  • Viral Hepatitis Types B and C.

  • Autoimmune hepatitis.

  • Nonalcoholic fatty liver disease (NAFLD).

  • Exposure to drugs and chemical toxins.

• Contributing Factors:

  • Gallbladder disease.

  • Metabolic syndromes and genetic predispositions.

  • Cardiovascular disease.

Complications of Cirrhosis

Complications arise from liver dysfunction, including:

• Portal Hypertension: Increased pressure in the portal vein can lead to serious health issues.

• Ascites: Accumulation of fluid in the abdominal cavity.

• Esophageal Varices: Enlarged veins that can rupture, leading to hemorrhage.

• Splenomegaly: Enlargement of the spleen due to increased pressure.

• Jaundice: Yellowing of the skin and eyes due to bilirubin accumulation.

• Hepatic Encephalopathy: Cognitive dysfunction resulting from the liver's inability to detoxify ammonia.

• Anemia and Hepatorenal Syndrome:

Portal Hypertension

• Portal hypertension is characterized by elevated blood pressure in the portal vein,

• leading to the development of varices that pose a risk for lifethreatening bleeding and high morbidity/mortality rates.

Splenomegaly

The spleen’s normal functions include filtering blood and storing platelets. Complications from splenomegaly can lead to severe hematological issues:

• Anemia: Signs may include pallor and fatigue.

• Thrombocytopenia: Symptoms include increased susceptibility to bleeding and bruising. 1st sign that pt has liver dysfunction.

• Lymphocyte Dysfunction: Results in decreased immunity and increased infection risk.

Ascites and Gastroesophageal Varices

• Ascites: Characterized by excessive fluid accumulation in the peritoneal cavity, requiring monitoring and potential therapeutic interventions.

• Esophageal Varices: occurs when fragile, thin-walled esophageal veins become distented from increased pressure; management may require endoscopic procedures to prevent rupture

  • bleeding from the increase pressure is a life threatening medical emergency.

  • hematemesis (vomiting blood) or melena black, tarry stools)

    • treatment

      • sengstaken blakemore tube used for controlling bleeding in upper GI tract

Biliary Obstruction

• Impairments in bile production can affect fat absorption, particularly concerning fat-soluble vitamins K

  • 
    

• jaundice

  • yellowish coloration of the skin

  • late-stage cirrhosis

What is Bile?

Bile is a substance produced by the liver and stored in the gallbladder, crucial for digestion:

• Functions:

  • Aids in the digestion and absorption of dietary fats and fat-soluble vitamins (A, D, E, K).

  • Facilitates the excretion of bilirubin formed during the breakdown of red blood cells.

• imbalance in bile production

  • Gallstones (cholelithiasis): imbalance of bile salts, cholesterol, and bilirubin leads to stone formation

  • jaundice: buildup of bilirubin in the bloodstream due to bile flow obstruction

  • Malabsorption of fats: inadequate bile production results in steatorrhea (fatty stools) and vitamin deficiencies

  • cholecystitis: inflammation of gallbladder, often due to gallstones blocking bile flow

Late Stages of Cirrhosis Symptoms

Common symptoms indicative of advanced liver disease include:

• Jaundice and Icterus: Yellowing of the skin and sclera.

• Purpuric lesions, such as petechiae, pinpoint, red-purple hemorrhagic lesions) or ecchymoses (large purple, blue, or yellow brusies)

• Skin Changes: Presence of rashes, purpuric lesions, palmar erythema, and spider angiomas.

• Ascites: Visible abdominal distension due to fluid accumulation.

• Vitamin Deficiencies: Including but not limited to A, D, E, and K deficiencies.

Hepatic Encephalopathy

• PSE: a complex cognitive syndrome that results from liver failure and cirrhosis.

  • pt reports; sleep disturbances, mood disturbance, mental status changes, and speech problems

  • stage 1

    • subtle manifestations that may not be recognized immediately

    • personality changes (agitation, belligerence)

    • emotional lability (euphoria, depression)

    • impaired thinking

    • inability to concentrate

    • fatigue, drowsiness

    • slurred or slowed speech

    • sleep pattern disturnances

  • stage 2

    • continuing mental changes

    • mental confusion

    • disorientation to time, place or person

    • Asterixis (hand flapping)

  • stage 3

    • progressive deterioration

    • marked mental confusion

    • muscle twitching

    • hyperreflexia

    • asterixis (hand flapping)

  • stage 4

    • unresponsiveness, leading to death in most pt

    • unarousable, obtunded

    • no asterixis

    • seizures

    • fetor hepaticus ( liver breath-musty, sweet, odor)

Cirrhosis Assessment

• History: Obtaining details about age, gender, medication use, employment history, alcohol intake, needlestick injury, sexula, fmaile, social histories

• Physical Assessment: Monitoring signs such as fatigue, weight fluctuations, anorexia, vomiting, and abdominal discomfort, abdo pain, abdominal assessment (measuring girth)

• Abdominal Girth Measurement: Essential for evaluating ascites.

• Psychosocial Assessment: Considering social and alcohol-related histories.

Lab Findings for Cirrhosis

• Serum Enzymes: hepatic cell destruction, hepatitis

  • Elevated levels of AST (0-35) and ALT (4-36) signal liver damage; ALT is the more specific marker.

• Bilirubin Levels: (0.3-1.0)

  • Elevated total and direct bilirubin levels indicate liver dysfunction. (hepatic cell disease)

  • elevated serum indirect unconjugated bilirubin: cirrhosis

• Serum Proteins:

  • A decrease in total protein and albumin levels is observed in severe liver disease. (UNDERNUTRITION)

  • increased serum total protein: acute liver disease

• Ammonia Levels: Increased serum ammonia concentrations suggest advanced liver dysfunction.(10-80)

• Prolonged PT/INR: hepatic cell damage and decreased synthesis of prothrombin

Diagnostics for Liver Issues

• Imaging Assessments:

  • Utilize CT, MRI, abdominal x-rays, and liver ultrasound for diagnosis.

• Specialized Assessments:

  • Include transient elastography and arteriography, alongside EGD (directly visualize upper Gi tract to detect complication of liver failure) and ERCP for biliary concerns.

Treatments for Liver Disorders

• Fluid Management: Administer diuretics (spironolactone and furosemide)

  • caution sodium, potassium imbalances

  • monitor intake and output

• Electrolyte Imbalances: Correct elevated BUN and hematocrit levels through appropriate interventions.

• Nutritional Support: Implement low-sodium diets and ensure vitamin and mineral supplementation.

• Paracentesis: A medical procedure used to remove excessive fluid from the abdomen, alleviating discomfort.

• Hemorrhage Prevention: Regularly assess for esophageal varices due to their potential to cause significant GI bleeding.

• Ammonia Management: Administer lactulose to facilitate ammonia excretion and reduce confusion risks.

• Pruritus Management: Address skin itching associated with bilirubin build-up.

• Medication Guidance: Avoid narcotics that can further delay drug metabolism.

Hepatitis Overview

A group of infectious conditions characterized by inflammation of liver cells, resulting from five primary viral pathogens:

• Hepatitis A (HAV): Typically an acute infection; vaccination is available.

• Hepatitis B (HBV): Can be both acute and chronic; vaccination is effective for prevention.

• Hepatitis C (HCV): Primarily chronic and can lead to serious liver damage; no vaccination is available.

• Hepatitis D (HDV): Co-exists with HBV; no vaccine exists.

• Hepatitis E (HEV): Generally acute; also associated with contaminated water.

Routes of Transmission for Hepatitis

• HAV: Fecal-oral transmission, commonly through shellfish caught in contaminated water sources

  • preventing

    • proper handwashing

    • avoiding contaminated food or water

    • receiving immunoglobulin within 14 days if exposed to the virus

    • receiving HAV vaccine before traveling to areas where disease is common

    • receiving vaccine if living or working in enclosed areas with others

• HBV: Transmitted via blood and body fluids, often through unsafe sexual practices or sharing of needles.

  • sharing razors, accidental needlesticks, birth, blood transfusion (before 1992), hemodualysis

    • preventions

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• HCV: Primarily blood-to-blood contact,

  • illicit IV drug needle sharing

  • blood, blood products or organ transplant before 1992

  • needstick

  • healthcare workers

  • prisoners

  • sharing of drug paraphernalia

• HDV: parenteral (occurs with hepB)

  • defective RNA virus that needs helper function of HBV

  • parenteral routes, especially in those who use IV drugs

• HEV: Fecal-oral route similar to HAV, associated with contaminated drinking water.

Hepatitis Signs & Symptoms

Common manifestations of hepatitis include:

• Abdominal discomfort, particularly in the RUQ.

• Jaundice indicated by yellowing of the skin and sclera.

• Gastrointestinal symptoms such as diarrhea or constipation, light-colored stools, and dark urine.

• General systemic symptoms: fever, fatigue, malaise, loss of appetite, nausea/vomiting, dry skin, and pruritus.

Diagnostics for Hepatitis

• Laboratory Assessments:

  • Liver enzyme tests (AST, ALT) alongside serological analyses for antigen detection.

• Diagnostic Procedures:

  • Consider liver biopsy or ultrasound for definitive diagnosis.

Prevention of Viral Hepatitis in Healthcare Workers

• Adhere to standard precautions for infection control.

• Utilize needleless technology to minimize risks of needle-stick injuries.

• Ensure vaccinations are up to date, particularly for Hepatitis B, where applicable.

• Promptly follow up post-exposure to provide appropriate prophylaxis and monitoring.

Hepatitis Management Summary

• Hepatitis A: Transmitted via fecal-oral route, managed with supportive care and vaccination.

• Hepatitis B: Requires blood/body fluid precautions; vaccination is essential.

• Hepatitis C: Managed mainly with antiviral therapy; no vaccine available.

• Hepatitis D: A concurrent infection requiring active Hepatitis B; lacks a vaccine.

• Hepatitis E: Generally self-limiting; associated prevention strategies target hygiene and water safety.

Liver Transplant Considerations

Liver transplantation becomes necessary for advanced liver disease cases such as end-stage renal disease (ESRD) or acute liver failure. Factors to consider include:

• Exclusion Criteria: Severe cardiovascular or respiratory complications, or failure to comply with treatment protocols.

• Post-transplant Management: Ongoing monitoring for acute graft rejection and risk of infections, alongside managing potential hepatic complications.

• Psychosocial Support: Addressing emotional well-being and medication side effects during recovery.

  • side effects of immunosuppressive drugs

  • long- term manangamet

Postoperative Assessment and Prevention

• Acute Graft Rejection: Monitoring for signs such as tachycardia, fever, jaundice, and RUQ pain or flank pain, diminished bile drainage or changes in bile color or increased jaundice

  • lab changes: increased levels of bilirubin, prolonged PPT, transaminases, alkaline phosphate

    • prevention: prophylaxis with immunosuppressants agents, cyclosporine plus antirejection drugs

• Infection Prevention Strategies: Employing antibiotic prophylaxis and maintaining a sterile environment.

• Hepatic Complications Monitoring: decreased bile drainage, increased RUQ abdo pain with distention and guarding, N/V, increased jaundice, clay-colored stools, Lab values (increased bilirubin, transaminases)

  • report s/s to surgon immediately

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• Acute Kidney Injury Monitoring: Closely observe urine output and report any immediate concerns.

  • monitor all drugs with nephrotoxic side effects

  • prevent hypotension