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Liver Dysfunction and Pancreatitis. Nursing 210. Liver Anatomy and Physiology. Largest internal organ Weighs about 1500 grams Located right upper quadrant Figure 39-1 p.1075. Anatomy and Physiology. Approximately 75% of the blood supply comes from the portal vein

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Liver dysfunction and pancreatitis

Liver Dysfunction and Pancreatitis

Nursing 210


Liver anatomy and physiology
Liver Anatomy and Physiology

  • Largest internal organ

  • Weighs about 1500 grams

  • Located right upper quadrant

  • Figure 39-1 p.1075


Anatomy and physiology
Anatomy and Physiology

  • Approximately 75% of the blood supply comes from the portal vein

    • Drains the GI tract and is rich in nutrients

  • Remainder of blood supply enters by hepatic artery

    • Rich in oxygen

  • All blood leaves the liver through hepatic vein to the inferior vena cava


Liver functions
Liver Functions

  • Glucose metabolism

    • Important role in metabolism of glucose and regulation of blood glucose

    • Converts glucose to glycogen (storage)

    • Breaks down glycogen into glucose (energy)

    • Additional glucose is synthesized through gluconeogenesis (amino acids or lactate)


Liver functions1
Liver Functions

  • Ammonia Conversion

    • Ammonia (potential toxin) is byproduct of gluconeogenesis

    • Liver converts ammonia into urea

    • Also removes ammonia produced by intestinal bacteria from portal blood

    • Urea is excreted in urine


Liver functions2
Liver Functions

  • Protein Metabolism

    • Synthesizes all plasma proteins except gamma globulin

      • Albumin (osmotic pressure)

      • Alpha and beta globulins

      • Blood clotting factors

      • Specific transport proteins

      • Prothrombin: liver needs vitamin K


Liver functions3
Liver Functions

  • Fat Metabolism

    • Fatty acids broken down into ketones

    • Provide source of energy for muscles and other tissues

    • Occurs when glucose is limited as in starvation or uncontrolled diabetes

    • Fatty acids also used for synthesis of cholesterol, lipoproteins and other complex lipids


Liver functions4
Liver Functions

  • Vitamin and Iron Storage

    • Vitamins A, B12, D and several B-complex vitamins stored in liver

    • Iron and copper


Liver functions5
Liver Functions

  • Drug Metabolism

    • Liver metabolism generally results in loss of activity of the medication

    • Certain oral meds absorbed by GI tract may be metabolized by liver to such a great extent (first-pass effect) that bioavailability is decreased


Liver functions6
Liver Functions

  • Bile Formation

    • Mainly water and electrolytes (potassium, calcium, bicarbonate, chloride)

    • Continuously made by hepatocytes and stored in gallbladder

    • Emptied into intestine when needed for digestion


Liver functions7
Liver Functions

  • Bilirubin Excretion

  • Pigment derived from breakdown of hemoglobin

  • Modified by hepatocytes through conjugation to be more soluble in aqueous solutions

  • Conjugated bilirubin is carried by bile into duodenum for excretion


Liver function and lab tests
Liver Function and Lab Tests

  • Blood Studies (review Brunner p. 1079)

    • Serum Aminotransferase

      • AST

      • ALT

    • Elevated levels usually indicate cellular damage to the liver

    • > 70% of liver cells may be damaged before LFT’s become elevated


Blood studies cont
Blood Studies, cont.

  • Pigment studies

    • Serum bilirubin, direct

    • Serum bilirubin, total

    • Urine bilirubin

  • These studies measure ability of liver to conjugate and excrete bilirubin

  • Abnormal results are seen in liver and biliary tract disease


Blood studies cont1
Blood Studies, cont.

  • Serum Ammonia

    • Liver converts ammonia to urea. Ammonia rises in liver failure

  • Protein Studies

    • Serum albumin

      • Low levels seen with liver disease

  • Serum globulin

    • Elevated levels with advanced cirrhosis and chronic active hepatitis


Blood studies cont2
Blood Studies, cont.

  • Tumor Marker

    • Alpha-fetoprotein (AFP)

    • Increased levels are seen with hepatic carcinoma

  • Prothrombin Time (PT)

    • Time required for a firm fibrin dot to form

    • In liver dysfunction, increase clotting time with increased risk of bleeding


Liver biopsy
Liver Biopsy

  • Used to obtain a specimen of liver tissue

  • Done under local anesthesia

  • Complications:

    • Pneumothorax

    • Peritonitis

    • Hemorrhage


Manifestations of liver dysfunction
Manifestations of Liver Dysfunction

  • Jaundice

  • Ascites

  • Portal Hypertension

  • Esophageal Varices

  • Hepatic Encephalopathy

  • Nutritional Deficiencies


Jaundice
Jaundice

  • Also known as icterus, a yellow discoloration of the skin, sclerae and mucous membranes

  • Caused by elevated bilirubin levels in the blood

  • Jaundice becomes clinically evident when the serum bilirubin level exceeds 2.5mg/dL

  • Several types of Jaundice: Hemolytic, Hepatocellular, Obstructive, and Hereditary Hyperbilirubinemia


Jaundice cont
Jaundice, cont.

  • Symptoms

    • Yellow discoloration of the skin, sclerae and mucous membranes

    • Itching (pruritus) due to deposits of bile salts on the skin

    • Stool becomes light in color

    • Urine becomes deep orange and foamy


Portal hypertension
Portal Hypertension

  • Elevated pressure in the portal venous blood

    • Blood flow through the liver is obstructed

    • Vessels enlarge, collateral circulation develops to take blood back to the systemic circulation

  • Two major sequelae result

    • Ascites

    • Varices


Ascites
Ascites

  • This is the accumulation of fluid in the peritoneal cavity

    • Decrease albumin levels cause decreased oncotic pressure

      • Fluid leaves the plasma and leaks in to the peritoneal cavity and interstitial spaces

      • Decrease volume causes activation of the Renin-Angiotensin system – Na & H2O retained in attempt to return intravascular volume to normal– more edema and ascites


Portal hypertension and ascites
Portal Hypertension and Ascites

  • Symptoms

    • Portal HTN not evident unless bleeding from collateral blood vessels or ascites occurs

    • Ascites – increase abdominal girth, unexplained rapid weight gain

    • Striae and distended veins over abdomen

    • Fluid and electrolyte imbalances

    • Respiratory difficulty may occur due to pressure on the diaphragm


Portal hypertension and ascites1
Portal Hypertension and Ascites

  • Treatment

    • Portal HTN – treat underlying cause

    • Ascites

      • Na and fluid restrictions

      • Diuretic agents (Aldactone, Lasix)

      • Albumin therapy

      • Paracentesis


Varices
Varices

  • Esophageal, gastric, hemorrhoidal

    • Due to elevated pressures in veins that drain into portal system

    • Often source of massive hemorrhage

    • Potential for bleeding increased by blood clotting abnormalities seen in patients with liver disease


Hepatic encephalopathy
Hepatic Encephalopathy

  • Impaired neurological function that occurs with profound liver failure

  • Accumulation of ammonia and other toxic metabolites

  • GI bleeding, high protein diet, bacterial infections

  • Other factors unrelated to increased ammonia levels

    • Dehydration

    • Surgery

    • Medications - sedatives, tranquilizers, analgesics,non sparing potassium diuretics


Hepatic encephalopathy1
Hepatic Encephalopathy

  • Symptoms

    • Stage one

      • Normal level of consciousness w/periods of lethargy and euphoria

      • Slowed thought process

      • Slight confusion

      • Reversal of day – night sleep pattern

      • Clinical signs

        • Asterixis (flapping tremor of hand), impaired writing, normal EEG


Hepatic encephalopathy2
Hepatic Encephalopathy

  • Stage two

    • Disorientation

    • Sleeps most of time, but easily aroused

    • Agitation, mood swings

    • Clinical signs

      • Asterixis, fetor hepaticus (musty odor to breath), abnormal EEG

  • Stage three

    • Deep sleep, difficult to arouse

    • Incoherent speech

    • Clinical signs

      • Increased deep tendon reflexes, rigidity of extremities, markedly abnormal EEG

  • Stage four

    • comatose


Hepatic encephalopathy3
Hepatic Encephalopathy

  • Treatment

  • Restrict protein intake in early stages

  • Lactulose

    • reduce serum ammonia through bowel evacuation

    • Fecal flora are changed to organisms that do not produce ammonia from urea

  • D/C sedatives, tranquilizers, analgesics


  • Viral hepatitis
    Viral Hepatitis

    • Inflammation and necrosis of hepatic cells

    • Bile flow is impaired

    • Necrosis occurs in a spotty pattern

    • Liver cells may regenerate during recovery period


    Viral hepatitis1
    Viral Hepatitis

    • Types

      • Hepatitis A (HAV)

      • Hepatitis B (HBV)

      • Hepatitis C (HCV)

      • Hepatitis D (HDV)

      • Hepatitis E (HEV)


    HAV

    • Also known as “infectious hepatitis”

    • Mode of transmission is fecal – oral route; poor sanitation

    • Incubation period 15-50 days

    • May occur with or without symptoms, flu like

      • Preicteric phase – headache, anorexia, fever

      • Icteric phase – dark urine, jaundice of skin, sclera


    HAV

    • 1995 FDA approved vaccine

    • Recommend for travelers to locations of poor sanitation, high risk groups (homosexual men,IV drug users, day care workers)

    • Nursing management includes

      • Stressing good hygiene

      • Environmental sanitation


    HAV

    • Outcome – usually mild with recovery

    • Fatality rate less than 1%

    • No carrier state

    • No increased risk of chronic hepatitis, cirrhosis or hepatic cancer


    HBV

    • Also known as “serum hepatitis”

    • Transmission – blood and body fluids, through mucous membranes and breaks in skin

    • Health care workers at great risk

    • IV drug users and homosexual activity

    • Very long incubation period: 1-6 months

    • May occur without symptoms, may develop arthralgias, rash


    HBV

    • Vaccine used to provide active immunity

    • Recommended for all health care workers

    • Passive immunity is provided through hepatitis B immune globulin (HBIG)

    • Recommended for people exposed to HBV who have not received vaccine or have never had HBV


    HBV

    • Nursing management includes: teaching patient proper nutrition, rest, prevention of spread (blood, body fluids)

    • Fatality 1-10%

    • Carrier state possible

    • Increase risk for cirrhosis, chronic hepatitis and hepatic cancer


    HCV

    • Also known as Non-A, Non-B hepatitis

    • Transmission through blood transfusion, exposure to blood contaminated equipment or drug paraphernalia,sexual contact

    • Incubation 15-160 days

    • Clinical course similar to HBV

    • Chronic carrier state occurs frequently

    • Increase risk for chronic liver disease and cancer


    HCV

    • Treatment with interferon and ribavirin

    • HCV accounts for 30% of liver transplants in US


    HDV

    • Only individuals with HBV are at risk

    • Sexual contact, IV drug use

    • Symptoms similar to HBV, more likely to progress to chronic active hepatitis and cirrhosis

    • Investigation into interferon as treatment


    HEV

    • Transmitted through fecal – oral route

    • Similar to HAV

    • Incubation variable 15-65 days

    • Jaundice usually always present

    • No chronic state


    Toxic and drug induced hepatitis
    Toxic and Drug Induced Hepatitis

    • Toxic hepatitis

      • Inflammatory condition caused by ingestion or inhalation of certain substances

        • Dry cleaning fluid

        • Glue

        • Insecticides – pesticides

        • Poisonous mushrooms

        • Rat poison


    Toxic and drug induced hepatitis1
    Toxic and Drug Induced Hepatitis

    • Drug Induced Hepatitis

      • Tylenol

      • Aspirin

      • Thorazine

      • INH

      • Valium


    Toxic and drug induced hepatitis2
    Toxic and Drug Induced Hepatitis

    • Symptoms

      • Similar to those of viral hepatitis

        • GI and flu type symptoms

        • Jaundice

        • Hepatomegaly

      • Depending of substance, may take days to months for symptoms to appear


    Fulminant hepatic failure
    Fulminant Hepatic Failure

    • Sudden and severely impaired liver function in previously healthy person

    • Liver failure within 8 weeks of first clinical sign

    • Viral hepatitis is most common cause

    • Other causes

      • Acetaminophen

      • Chemicals

      • Wilson’s disease (copper build up in liver)


    Cirrhosis
    Cirrhosis

    • Chronic, degenerative process, replacement of normal tissue with scar tissue

    • Three types

      • Alcoholic (most common, chronic alcoholism)

      • Postnecrotic (acute viral hepatitis)

      • Biliary (chronic biliary obstruction and infection)

    • Other causes:

      • Toxic drug or chemical reaction

      • Unknown cause


    Cirrhosis1
    Cirrhosis

    • Clinical manifestations

      • Liver enlargement

      • Ascites

      • Infection and Peritonitis

      • Varices

      • Edema

      • Vitamin deficiency

      • Mental deterioration


    Cirrhosis2
    Cirrhosis

    • Treatment

      • No alcohol

      • Well balanced diet, unless:

        • Hepatic Encephalopathy – restrict protein

        • Ascites – restrict sodium

      • Vitamin supplements

        • B-Complex

        • Folic acid

        • A,C,and K


    Cirrhosis3
    Cirrhosis

    • Complications

      • Portal hypertension

      • Ascites

      • Hepatic Encephalopathy

      • Esophageal varices (dilated vein)

    • Read Nursing Process, Brunner, p.1103-1105


    Esophageal varices
    Esophageal Varices

    • Dilated veins usually found in submucosa of lower esophagus

    • Occurs in 1/3 of patients with cirrhosis

    • Mortality 45-50%

    • Hemorrhage occurs from muscular exertion, coughing, sneezing, vomiting, reflux of stomach content (especially alcohol)


    Esophageal varices medical management
    Esophageal Varices: Medical Management

    • Non surgical management is preferable due to high rate of mortality with emergency surgery

    • Pharmacologic therapy (Vasopressin) may be initial mode

      • Constriction of arterial bed and decrease in portal pressure

      • Nitroglycerin used to decrease side effect of angina

    • Balloon Tamponade

      • Pressure exerted against bleeding varices


    Esophageal varices1
    Esophageal Varices

    • Medical management

      • Endoscopic Sclerotherapy

        • Sclerosing agent is injected through endoscope into varices to promote thrombosis

      • Esophageal Banding Therapy

        • Provides thrombosis and mucosal necrosis of bleeding sites by band ligation

      • Surgical management

        • Surgical bypass procedures

        • Devascularization and Transection


    Esophageal varices2
    Esophageal Varices

    • Nursing Management

      • Vital signs

      • TPN

      • Prevention of vomiting and straining

      • NG tube for gastric suction

      • Quiet environment, help reduce anxiety


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