Liver Diseases

HEPATITIS

  • What is it? Inflammation of the liver

  • Causes: Viruses; Alcohol; Drugs; Toxins; Metabolic or vascular disorders

  • Severity: Can range from mild to life threatening

TYPES OF VIRAL HEPATITIS

  • Hepatitis A — Fecal-oral route

  • Hepatitis B — Blood, body fluids, sex, needles

  • Hepatitis C — Blood/body fluids

  • Hepatitis D — Needs Hepatitis B to replicate

  • Hepatitis E — Contaminated water/undercooked meat

SIGNS AND SYMPTOMS

  • PRODROMAL

    • Fatigue

    • Nausea/Vomiting

    • Poor appetite

    • RUQ pain

  • ICTERIC

    • Jaundice

    • Dark urine

    • Pale Stools

    • Itching

  • CONVALESCENT

    • Feeling better

    • Labs improve

COMPLICATIONS

  • Chronic hepatitis

  • Cirrhosis

  • Liver failure

  • Liver cancer

  • Some become carriers

DIAGNOSTIC TESTS

  • Liver function tests (LFTs)

    • ALT/AST/ALPALT/AST/ALP

    • Bilirubin

    • Albumin

    • Ammonia

    • Prothrombin

PREVENTION

  • HAND HYGIENE: Ensure hands are well washed and sanitized

  • DO NOT SHARE: Avoid sharing needles, razors, toothbrushes, etc.

  • Safe sex practices: Use condoms and practice monogamy (eyeroll)

  • Vaccines: Hepatitis A and B vaccines

  • Immune globulin (IG) or vaccine depending on type

  • POST EXPOSURE: Blood, organs, and food screening

TREATMENT

  • Supportive Care: Rest, fluids, balanced diet

  • Avoid alcohol and liver-toxic medications (like Tylenol)

  • Hepatitis A and E: Usually recover with supportive care

  • Hepatitis B: Antivirals if chronic

  • Hepatitis C: Direct-acting antivirals

  • Severe cases may require liver transplant

NURSING CARE

  • Monitor: Pain; Nausea; Weight; Nutrition; Liver labs; Bleeding; Mental status

  • Prevent skin breakdown from itching

  • Teach: No alcohol; Avoid Tylenol; Good hygiene; Avoid sharing personal items; Complete full medication regimen; Vaccinate family and close contacts

ACUTE LIVER FAILURE

  • What is it? Rare, but serious

  • Rapid onset within 2 days

  • Signs & Symptoms

    • Vague: Fatigue, GI upset, diarrhea

    • Progressed: Jaundice; Hepatic encephalopathy; Abdominal distention; Bleeding

DIAGNOSTICS

  • ALT/AST/Bilirubin

  • Prothrombin

  • Potassium

  • CT

  • Necrotic, nodular liver

TREATMENT

  • Identify and stop cause

  • IV fluids

  • Proton Pump Inhibitors (PPI) and H2 Blockers

  • Maintain airway: HOB 30°; NPO; NG tube; Possible intubation

  • Avoid stimulation and unnecessary medications

  • Nutrition: Enteral or parenteral

  • Dialysis if overdose-related

PATIENT TEACHING

  • Wash hands

  • Avoid sharing razors/toothbrushes

  • Hepatitis A & B vaccines

  • Balanced diet

  • Acetaminophen: ≤ 3,000 mg/24 hrs

    • Read labels (over 600 meds contain acetaminophen!)

  • Avoid alcohol

  • Safe sex, no IV drug use, sterile tattoo/piercing

ACETAMINOPHEN TOXICITY

  • Most common cause of Acute Liver Failure

  • Overdose treatment:

    • Activated charcoal (if <4 hours)

    • N-acetylcysteine (Acetadote) antidote

  • Monitor 24 hour Acetaminophen intake

CHRONIC LIVER DISEASE

  • CIRRHOSIS

  • What is it? Scarring of the liver tissues

  • Common causes:

    • Chronic alcohol use

    • Hepatitis B & C

    • Nonalcoholic steatohepatitis (NASH)

  • Usually irreversible

DIAGNOSTIC TESTS (CHRONIC)

  • Liver function tests (LFTs)

    • ALT/AST/ALPALT/AST/ALP

    • Bilirubin

    • Ammonia

    • Prothrombin

  • Imaging

    • Liver biopsy

    • CT

    • MRI

  • Procedure

    • EGD

SIGNS AND SYMPTOMS (CHRONIC)

  • EARLY SIGNS

    • Asymptomatic

  • LATE SIGNS

    • Anorexia, nausea, weight loss

    • RUQ pain, fatigue

    • Ascites, jaundice, GI bleed

    • Spider angiomas, itching

    • Bruising, muscle cramps

COMPLICATIONS (CHRONIC)

  • C: Clotting Defects: Easy bruising, nosebleeds, bleeding gums, GI bleed

  • H: Hepatorenal Syndrome: Poor blood flow to kidneys

  • E: Encephalopathy: Confusion, personality changes

  • A: Ascites: Fluid leaks into belly making it harder to breathe

  • P: Portal Hypertension: Pressure causes big portal veins to burst and bleed

HEPATORENAL SYNDROME

  • Secondary kidney failure from cirrhosis

  • Oliguria and increased sodium retention

  • Treatment:

    • Vasopressin

    • Albumin

    • Possible liver transplant

HEPATIC ENCEPHALOPATHY

  • Caused by increased ammonia levels

  • Signs: Confusion, asterixis

  • Treatment:

    • Lactulose

    • Rifaximin

    • Avoid sedatives, opioids, dehydration

ASCITES

  • Fluid in peritoneal cavity

  • Causes: Portal hypertension, decreased albumin, increased aldosterone

  • Treatment:

    • Diuretics

    • Sodium and water restriction

    • Paracentesis and albumin

    • TIPS (transjugular intrahepatic portosystemic shunt) procedure

PORTAL HTN & VARICES

  • Portal hypertension leads to varices and hemorrhoids

  • Complications: Esophageal varices, hemorrhoids, caput medusae

  • Treatment:

    • Beta blockers

    • Variceal banding

    • Octreotide

    • TIPS

    • Balloon tamponade

NURSING CARE AND PATIENT EDUCATION (CHRONIC)

  • Nursing Care

    • Track intake and output

    • Manage fluids: Low sodium diet; Fluid restriction; Diuretics

    • Lower ammonia levels with lactulose

    • Avoid sedatives/opioids; monitor for bleeding

    • Elevate HOB and monitor respiratory function

  • Patient education:

    • No alcohol

    • Avoid liver-toxic medications

    • Balanced diet with adequate protein

    • Small, frequent meals

    • Report bleeding, confusion, rapid weight gain/swelling

    • Prevent infections

    • Take medications as prescribed

LIVER TRANSPLANT

  • For patients with end stage liver disease

  • Priority: Sickest patients get priority

  • Before transplant:

    • Must be stable

    • Must take daily anti-rejection medication for life

  • Cultural considerations: In Judaism, organ donation is allowed if it saves a life; Rabbi may be consulted in decision making process

  • After transplant: Watch for signs of rejection:

    • Tachycardia

    • Fever over 101°F

    • RUQ pain

    • Jaundice

    • Labs increased (ALT/AST/ALP/PT/bilirubin)

LIVER CANCER

  • Spreads to liver from other cancers

  • Risk factors:

    • Hep B or C

    • Alcohol

    • Smoking

    • Poor nutrition

    • Toxins

  • Symptoms:

    • Confusion

    • Bleeding

    • Jaundice

    • Ascites

  • Treatment:

    • Surgery if caught early

    • Chemotherapy injected into liver or hepatic artery

    • Targeted drug: Sorafenib (Nexavar)

    • Radiation

  • Prognosis: Poor as cancer is usually found late