Liver Problems

Liver Problems

Patricia Cohen, DNP, MSN, RN

Cirrhosis

  • Definition: Cirrhosis is a chronic disorder characterized by the diffuse destruction and fibrotic regeneration of hepatic cells, leading to hepatic insufficiency.

Cirrhosis Landscape and Treatment Progression

  • Precirrhotic Disease: Duration ranges from 10-35 years.
  • Compensated Cirrhosis: Lasts approximately 10-15 years.
  • Decompensated Cirrhosis: Progresses over 3-5 years.
  • Liver Failure or Transplant: End stage, requiring significant medical intervention or transplant.

Cirrhosis: Causes

  • Laennec's: Related to alcohol consumption.
  • Cholestatic: Conditions causing bile obstruction leading to cirrhotic changes.
  • Postnecrotic: The most common type attributed to Hepatitis C infection.
  • Cardiac: Cirrhosis resulting from chronic heart diseases.
  • Hemochromatosis: Genetic disorder causing excess iron accumulation in the body.

Metabolic Functions of the Liver

  • Carbohydrate Metabolism: Involves glucose regulation and conversion of excess glucose to glycogen for storage.
  • Protein Metabolism: Includes:
    • Synthesis of nonessential amino acids.
    • Production of plasma proteins and clotting factors.
    • Conversion of ammonia to urea for excretion.
  • Fat Metabolism: Forms lipoproteins and ketones, synthesizes and breaks down cholesterol, and breaks down triglycerides.
  • Detoxification: Involves the processing of harmful toxins and hormones.

Clinical Implications of Liver Damage

  • Increased Ammonia Levels: Ammonia can become neurotoxic, affecting brain function.
  • Low Protein Levels: Especially albumin, can lead to fluid accumulation (third spacing) and increased infection risk.
  • Bleeding Changes: Prolonged Prothrombin Time (PT) of 12.5 sec and elevated INR (≥1.1).
  • Symptoms: Purpura, petechiae, and bruising due to impaired coagulation.

Hepatic Lobule Structure

  • Portal Triad: Consists of a bile duct, portal vein, and hepatic artery.
  • Sinusoids: Blood vessels lined with Kupffer cells that perform phagocytosis of bacteria.
  • Central Vein: Drains blood from lobules into the hepatic vein.
Functions Impacted by Liver Damage
  • Jaundice: Due to excessive bilirubin; causes itchy skin excoriations and clay-colored stools.
  • Bowel Habits: Intolerance to fats, dark foamy urine due to bilirubin in urine.

Nutritional Functions of the Liver

  • Storage: The liver stores vitamins (fat-soluble A, D, E, K; water-soluble B vitamins), minerals (iron and copper), albumin, and beta globulins.
  • Malnutrition Risks: Increases bleeding due to Vitamin K deficiency.
Anatomical Landmarks
  • Major Vessels: Inferior vena cava, aorta, hepatic artery, and portal vein.
  • Associated Organs: Gall bladder and common bile duct.

End Stage Liver Disease Findings

Neurological Findings

  • Hand Tremors/Flapping: Known as asterixis, indicative of hepatic encephalopathy.
  • Sleep-Wake Reversal: Disruption in normal sleep patterns.
  • Cognitive Impairment: Difficulty concentrating.
  • PSE: Portal systemic encephalopathy leading to confusion and lethargy.
  • Peripheral Neuropathy: Degeneration causing paresthesia.

Dermatological Findings

  • Jaundice: Yellowing of skin and sclera.
  • Extreme Itching: Often leading to skin abrasions.
  • Changes in Body Hair: Includes changes to pubic hair, caput medusae (dilated veins).
  • Dermatological Symptoms: Spider angiomas, palmar erythema, ecchymosis, and petechiae.

Gastrointestinal Findings

  • Breath Odor: Musty breath indicative of liver dysfunction.
  • Appetite Changes: Significant anorexia and symptoms like hemorrhoids, right upper quadrant (RUQ) pain, varices, malnutrition, fetor, splenomegaly, clay-colored stools, diarrhea, and nausea.
  • Muscle Wasting: Indicative of malnutrition.

Hematological Findings

  • Anemia and Thrombocytopenia: Reduced red blood cells and platelets.
  • Impaired Coagulation: Leading to increased PT and INR values.

Immune System Findings

  • Leukopenia: Low white blood cell count escalating infection risk and spontaneous bacterial peritonitis (SBP).

Endocrine/Reproductive Findings

  • Hormonal Imbalances: Increased aldosterone, ADH, and estrogen. Resulting symptoms include gynecomastia, testicular atrophy, palmar erythema, and oligomenorrhea in females.

Renal Findings

  • Hepatorenal Syndrome: Impaired renal function associated with liver failure.
  • Bilirubin Levels: Elevated due to liver dysfunction.

Cardiovascular Findings

  • Portal Hypertension: Increased vasculature pressure leading to dysrhythmias, fatigue, and edema.

Pulmonary Findings

  • Respiratory Complications: Includes pleural effusions, shortness of breath (SOB), and dyspnea.

Fluid and Electrolyte Findings

  • Fluid Volume Status: Typically hypovolemic.
  • Ascites Development: Fluid accumulation seen in abdominal cavity, often coupled with hypocalcemia and hypokalemia, alongside water retention leading to hyponatremia or hypernatremia.

Laboratory Values in Cirrhosis

Key Lab Tests

  • ALT (Alanine Aminotransferase): Normal range; elevations may indicate liver damage.
  • AST (Aspartate Aminotransferase): Normal range of 0-35 units/L; may be elevated in liver disease.
  • ALP (Alkaline Phosphatase): Levels can indicate biliary obstruction if significantly elevated.
  • Bilirubin: Normal range of 0.3-1.0 mg/dL; elevated in liver dysfunction.
  • Ammonia: Normal range 10-80 mcg/dL; potential elevations in hepatic failure.
  • PT (Prothrombin Time): Normal range of 11-12.5 secs; prolonged time indicates clotting dysfunction.
  • Platelet Count: Normal range of 150,000-400,000 mm³; low levels indicating thrombocytopenia.
  • Albumin: Normal range of 3.5-5 g/dL; low levels signify liver function impairment.

Liver Biopsy Procedure

  • Pre-procedure Requirements: NPO (nothing by mouth) after midnight, coagulation studies performed.
  • Patient Instructions: Instruct the patient to exhale and hold their breath for 10 seconds during the procedure.
  • Post-procedure Monitoring: Watch for bleeding; the patient should remain on their right side. Monitor for signs of hypovolemic shock and pneumothorax.

Interventions for Liver Disease

General Interventions

  • Positioning: HOB (head of bed) elevated for comfort and to reduce ascites.
  • Nutritional Support: Administer vitamins A, C, K, folic acid, and thiamine as ordered; fluid and sodium restriction as appropriate.
  • Diuretics: Administer to decrease ascites.
  • Monitoring: Check intake and output; monitor electrolytes and daily weight.
  • Abdominal Girth Measurement: Measure and mark daily to monitor fluid status.

Skin Care Recommendations

  • Personal Hygiene: Use clippers/file for nails; avoid excessive soap; pat skin dry and apply moisturizers.
  • Prevent Scratching: Cotton gloves and long sleeves should be worn to minimize skin excoriation.
  • Bleeding Precautions: Use a soft toothbrush to prevent gingival bleeding; monitor skin for petechiae and ecchymosis.

Portal Hypertension

  • Definition: Refers to increased pressure in the peritoneal capillaries, impacting the circulation of blood.
  • Complications:
    • Ascites: Fluid accumulation in the abdominal cavity.
    • Caput Medusae: Appearance of varices on the abdomen.
    • Development of Collateral Circulations: To bypass high-pressure areas leading to varices in the esophagus and hemorrhoids.
    • Hepatic Encephalopathy: Due to shunting of ammonia and toxins into general circulation, causing mental status changes.

Management and Nursing Interventions

  • Screening: Routine screening for varices in all cirrhotic patients.
  • Medications: Non-selective beta-blockers to manage portal pressure; vasoactive medications such as Octreotide and Vasopressin.
  • Endoscopic Treatments: Endoscopic Variceal Ligation (EVL) and Endoscopic Sclerotherapy (EST) without surgical approaches.
  • Acute Bleeding Management: Actions may involve balloon tamponade, transjugular intrahepatic portosystemic shunt (TIPS), and monitoring via nasogastric tube (NGT) to detect bleeding. Blood replacement such as PRBC (packed red blood cells) and Fresh Frozen Plasma (FFP) may be required.
  • Preventing PSE: Administer lactulose or neomycin to manage ammonia levels and prevent hepatic encephalopathy.

Sengstaken-Blakemore Tube

Nursing Implications

  • Patient Monitoring: Continuous assessment of airways, cut balloons in case of respiratory distress; ensure suction capabilities.
  • Complications: Risk of tube migration, airway obstruction, and aspiration; maintain balloon not inflated more than 12 hours.

Medications in Liver Disease Management

  • Octreotide: Stops bleeding from varices without affecting blood pressure or coronary flow; appropriate for CAD patients.
  • Vasopressin: For variceal bleeding; causes vasoconstriction reducing portal pressure; contraindicated in CAD patients. Monitor for signs of myocardial infarction.

Portal Systemic Encephalopathy (PSE)

  • Symptoms: Subtle cognitive changes, hand tremors, fatigue, sleep-wake reversal, emotional lability, and asterixis.
  • Nursing Interventions: Assess change in level of consciousness (LOC) thoroughly; check vital signs, oxygen saturation, blood sugar, and electrolytes including ammonia levels.
  • Potential PSE Triggers: Include GI hemorrhage, excess dietary protein, electrolyte abnormalities, and infections.
Interventions for PSE
  • Lactulose Administration: Goal of 2-3 soft bowel movements daily to manage ammonia levels.
  • Monitoring: Assess potassium levels and cognitive status; report new symptoms of fetor hepaticus and asterixis to the provider.

Ascites Management

  • Diet and Medications: Low sodium diet and diuretics; monitor electrolytes, weight, and renal function.
  • Fluid Measurement: Abd girth measurements taken daily during expiration, including weight assessments.

Paracentesis Procedure

Nursing Considerations

  • Pre-procedure: Confirm informed consent, patient positioning in supine with HOB elevated, ensure bladder is emptied.
  • During Procedure: Monitor vital signs every 15 minutes and adjust drainage rates if signs of hypovolemic shock. Limiting aspirations ideally to 1500-2000 mL.
  • Post-procedure: Observe for signs of shock, apply dressing over puncture site, and monitor fluid output and characteristics.

Hepatic Syndromes

Hepatorenal Syndrome (HRS)

  • Description: Progressive renal failure secondary to hepatic failure, characterized by oliguria, elevated BUN, and creatinine levels.
  • Management: Requires careful fluid management, daily weights, and respiratory assessment.

Spontaneous Bacterial Peritonitis (SBP)

  • Etiology: Usually caused by bacteria from the bowel due to low protein concentration in ascitic fluid.
  • Diagnosis: Confirmed after paracentesis, presenting with fever and abdominal tenderness.

Patient Teaching for End Stage Cirrhosis

Nutritional Recommendations

  • Dietary Needs: High-calorie, high-carb diet, moderate fat; low sodium, and possible fluid restrictions if ascites present.
  • Protein Restriction for PSE: Limiting protein intake to mitigate confusion without completely eliminating protein intake.
  • Meal Recommendations: Soft foods, small frequent meals, vitamin-enriched liquids, and strict avoidance of ethanol and acetaminophen.

Hepatitis Overview

Types & Transmission

  • Hepatitis A (HAV): Fecal-oral route, symptoms include malaise, jaundice; vaccine available.
  • Hepatitis B (HBV): Blood and body fluids; can lead to chronic infection and liver cancer; vaccine available.
  • Hepatitis C (HCV): Blood-to-blood transmission, major cause of liver complications; no vaccine.
  • Hepatitis D (HDV): Co-infection with HBV, leading to severe liver damage.
  • Hepatitis E (HEV): Also fecal-oral; often resolves without lasting damage.

Risk Factors and Assessment

Hepatitis Assessment Findings

  • Expected Symptoms: RUQ piano, jaundice, changes in urine/stool color, fever, malaise.
  • Lab Findings: Elevated liver enzymes specifically ALT, AST, bilirubin levels.

Management Interventions for Hepatitis

  • Nutritional Support: High carbohydrates and calories, small frequent meals, no alcohol.
  • Medications: Immune globulin for Hep A/B exposure, antivirals for Hep B/C.

Trauma and Cancer in Liver Health

Liver Trauma

  • Symptoms of Consideration: Signs of hypovolemic shock, tachycardia, dizziness; assess for kehr's sign (referred pain).

Liver Cancer

  • Risk Factors: Includes chronic HBV/HCV infection, cirrhosis.
  • Laboratory Markers: Elevated Alpha-Fetoprotein (AFP) and alkaline phosphatase linked to liver cancer.

Liver Transplant Considerations

Candidate Criteria

  • Indications for Transplant: End-stage liver disease, acute liver failure, and specific chronic liver conditions.

Exclusion Criteria

gNon-candidates: Severe cardiovascular disease, metastatic tumors, active substance use disorders.

  • Immunosuppressive Teaching: Importance of hygiene, infection monitoring, and medication adherence.

Early Transplant Complications

  • Monitoring Post-Op: Watch for bleeding, infection signs, and potential hepatic complications.

Acute Graft Rejection Signs

  • Symptoms: Fever, tachycardia, RUQ pain, changes in bile drainage, jaundice; follow with prolonged PT and elevated LFTs.