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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 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
  • 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
  • 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
  • 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)
  • 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
  • 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
  • Outcome – usually mild with recovery
  • Fatality rate less than 1%
  • No carrier state
  • No increased risk of chronic hepatitis, cirrhosis or hepatic cancer
  • 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
  • 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
  • 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
  • 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
  • Treatment with interferon and ribavirin
  • HCV accounts for 30% of liver transplants in US
  • 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
  • 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)
  • 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
  • Clinical manifestations
    • Liver enlargement
    • Ascites
    • Infection and Peritonitis
    • Varices
    • Edema
    • Vitamin deficiency
    • Mental deterioration
  • Treatment
    • No alcohol
    • Well balanced diet, unless:
      • Hepatic Encephalopathy – restrict protein
      • Ascites – restrict sodium
    • Vitamin supplements
      • B-Complex
      • Folic acid
      • A,C,and K
  • 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