Hepatic

Question 1

Liver anatomy

Answer 1

Located behind the ribs in the upper right abdominal cavity
Normally it is not palpable
Consists of two larger lobes and two smaller lobes
Able to regenerate

Question 2

Liver circulation

Answer 2

Circulation is of major importance to liver function
75% of the blood supply comes from the portal vein which drains the GI tract (nutrients)
25% comes from the hepatic artery (oxygen)
Hepatic vein drains the liver and empties into the IVC
Hold approximately 450ml of blood

Question 3

Liver function

Answer 3

Glucose, fat, protein, and drug metabolism
Conversion of ammonia to urea
Vitamin and iron storage (A, D, K, E, B12)
Bile formation
Bilirubin excretion

Question 4

Liver function tests

Answer 4

Alanine aminotransferase (ALT)- Best indicator for liver injury
Aspartate aminotransferase (AST)- Also elevated with damage to the heart, skeletal muscle, kidney, and pancreas
Alkaline phosphatase (ALP)- Elevated in severe liver or biliary disease
Gamma-glutamyl transpeptidase (GGT)- Increases 12-24 hours after heavy alcohol consumption

Question 5

Hepatitis A transmission

Answer 5

Transmission is usually through fecal-oral route:
1. Contaminated drinking water
2. Food contaminated by infected person who did not wash their hands after going to the bathroom
Sexual transmission
Transfusion of infected blood
Incubation period is 4-6 weeks
Found in feces up to 2 weeks before symptoms occur and 1 week after
Can be contagious up to 3 months after

Question 6

Hepatitis A symptoms

Answer 6

Generally mild or absent: Fever, fatigue, loss of appetite, N&V, abdominal pain, jaundice, joint pain
Treatment is supportive in nature
No long term liver damage and chronic state is unknown
Long-term immunity against further infection
Vaccine available

Question 7

Hepatitis B transmission

Answer 7

Found in blood, semen, cervical secretions, saliva, and wound drainage
Transmission is through direct contact with blood and blood products, sexual contact, contact with contaminated objects
Transmission can occur from pregnant mother to child if infected in third trimester or at birth
High risk groups: healthcare workers, IV drug users, homosexual men, people with multiple sex partners
Incubation is 6 weeks to 6 months, transmission possible

Question 8

Hepatitis B symptoms

Answer 8

Symptoms are similar to HAV
Hallmark signs are joint pain, high fever, and rash
95% will resolve and have immunity
Can exist as an asymptomatic carrier state or chronic active state especially in those who are immunocompromised
Rarely progresses to liver failure
Increased risk of hepatocellular carcinoma
Vaccine available

Question 9

Hepatitis C etiology

Answer 9

Accounts for
-40% of cases of end-stage cirrhosis
-60% of hepatocellular carcinoma
There are about 100 different strains, which makes development of a vaccine difficult

Question 10

Hepatitis C transmission

Answer 10

Found in blood, blood products, transplanted tissue
Transmitted through contact with blood and blood products.
Can be sexually transmitted
Most common transmission route in the US is IV drug use (48%)

Question 11

Hepatitis C symptoms/carriers

Answer 11

15% to 25% of cases spontaneously clear the acute infection, The rest develop chronic infection
Can exist as an asymptomatic carrier
Incubation period is 35 to 72 days
Symptoms include fatigue, fever, anorexia, weight loss, and abdominal pain
May be asymptomatic
Often not diagnosed until signs of cirrhosis emerge

Question 12

Hepatitis D

Answer 12

Requires a simultaneous infection with HBV for replication
Transmitted through blood and body fluids
Incubation lasts for 1 to 6 months
IV drug users have a high rate of HDV infection
Symptoms are the same as HBV infection but may be more severe
Infected are more likely to progress to chronic active hepatitis and cirrhosis

Question 13

Hepatitis E

Answer 13

Uncommon in the US
Found in Southeast Asia, India, North Africa, and Mexico
Globally there are 20 million cases per year
Transmitted through fecal-oral route
Incubation period 15 to 60 days
Symptoms are similar to HAV
Usually self-limiting but can lead to severe sudden liver failure
Vaccine available

Question 14

Hepatitis G

Answer 14

Not much is known about this virus
Transmission is through the skin or through sexual contact
Most infected are asymptomatic and incubation time is unknown
Been detected in 50% of IV drug users, 30% of hemodialysis clients, and 15% of those with HBV or HCV
Those with HIV that are also infected with HGV have improved survival rates. It is thought that HGV inhibits HIV reproduction

Question 15

Hepatitis pathophysiology

Answer 15

Inflammation and edema of the liver
This obstructs the bile canaliculi and causes obstructive jaundice
Liver cell necrosis, hyperplasia, and scarring
In mild cases there is little damage
Normally a chronic and slow process
There are rare cases of acute sudden and sever hepatitis caused by a co-infection of HBV and HDV
Liver regeneration begins within 48 hours after tissue injury

Question 16

Hepatitis clinical phase 1

Answer 16

Prodromal phase

• Exposure to appearance of jaundice
• Vague flu like symptoms with anorexia, nausea, vomiting, abdominal pain, malaise, fever, RUQ pain

Question 17

Hepatitis clinical phase 2

Answer 17

Icteric phase

• Begins with appearance of jaundice, usually 5-10 days after initial symptoms. Some have no jaundice
• Increase in the symptoms of the prodromal phase
• Ends with progressive clinical improvement

Question 18

Hepatitis clinical phase 3

Answer 18

Convalescent phase

• Increased sense of well-being, jaundice is resolved, usually after 2-3 weeks of acute illness
• Time to full recovery varies

Question 19

Hepatitis diagnostic labs

Answer 19

Liver function tests
-AST (8-48 wnl)
-ALT (7-55 wnl)
-ALP (45-115 wnl)
-Bilirubin (0.1-1.2 mg/dL wnl)
Serological tests for viral antigens, antibodies, or the virus itself

Question 20

Hepatitis liver biopsy

Answer 20

Done to evaluate type of liver disease or if cancer is present
Percutaneous procedure using CT or ultrasound
After procedure – keep patient lying on right side for minimum of 2 hours to splint puncture site
Monitor vitals

Question 21

Hepatitis prevention

Answer 21

Education for high risk groups

HAV & HBV vaccines

Question 22

Hepatitis treatment at home

Answer 22

Rest, good nutrition and fluid intake, avoid alcohol

Follow up with PCP

Question 23

Immune globulin to treat hepatitis

Answer 23

Immune globulin is available for HAV & HBV post-exposure prophylaxis
HAV - single dose given within 2 weeks of exposure
HBV - first dose given as soon as possible up to 1 week post-exposure, second dose given 1 month after exposure

Question 24

How long can a patient with hepatitis take an antiviral medication?

Answer 24

24 to 48 weeks

Question 25

Nursing management of hepatitis

Answer 25

``` Most hepatitis clients are treated on an outpatient basis Education about prevention -Hand hygiene -Safe sex practices -Needle exchange programs -Vaccinations Education about treatment -Rest -Diet, foods that are pleasing -Avoiding alcohol -Avoiding acetaminophen -Medications -Procedures ```

Question 26

Cirrhosis etiology

Answer 26

Irreversible, progressive deterioration of the liver that results from chronic liver disease Gradual & prolonged course 12th leading cause of death in U.S. Excessive alcohol ingestion, Hepatitis B & C, biliary obstruction

Question 27

Cirrhosis pathophysiology

Answer 27

Prolonged injury from toxins, inflammation, and metabolic derangements The damaged or dead liver cells are repaired or replaced with tissue that is more fibrous that the original tissue Liver cells regenerate but in an abnormal pattern Creates nodules The development of cirrhosis depends on the length of time, severity of injury, liver’s reaction to the assault

Question 28

How does alcohol abuse affect cirrhosis?

Answer 28

Alcohol ingestion decreases fatty acid utilization and increases fat deposits in the liver Called fatty liver Can potentially be reversed if no further alcohol is consumed, but never 100% better

Question 29

How does chronic inflammation affect cirrhosis?

Answer 29

When bile ducts are obstructed hepatocytes are injured leading to an inflammatory response This prolonged response/inflammation leads to fibrosis and regenerative nodules

Question 30

Early signs of cirrhosis

Answer 30

May be asymptomatic until severe dysfunction GI disturbances – anorexia, dyspepsia, flatulence, N/V, diarrhea, or constipation Fatigue and weakness Abdominal pain – dull, heavy feeling in right upper quadrant Enlarged liver Bleeding or bruising

Question 31

Late signs of cirrhosis

Answer 31

``` Jaundice Ascites Edema Spider angiomas Palmar erythema Muscle wasting Weight loss Spontaneous bruising Gastroesophageal varices Encephalopathy ```

Question 32

Cirrhosis diagnostics

Answer 32

AST, ALT, ALP, GGT will be elevated, but may be normal in early cirrhosis Serum albumin decreased (albumin is synthesized by the liver) PT & PTT increased (lack of vit. K) Bilirubin increased (liver rids body of bilirubin in the bile) Serum ammonia level elevated (byproduct of protein metabolism, liver converts to urea) Liver biopsy

Question 33

Nursing management of cirrhosis

Answer 33

Assess Skin color and condition Bleeding precautions Daily weights and measurement of abdominal girth I&O Monitor for declining neurological status Education about lifestyle changes, diet, medications, procedures Avoidance of alcohol Emotional support and possibly referral to support groups

Question 34

Complication of cirrhosis: jaundice

Answer 34

Jaundice is a yellowish discoloration of the skin, sclera, and mucous membranes Associated with increased amounts of bilirubin in the blood Bilirubin is the byproduct of hemolysis Becomes clinically evident with serum bilirubin levels above 2.5 mg/dl Clients also often suffer from pruritus

Question 35

Complication of cirrhosis: portal hypertension

Answer 35

Obstructed blood flow through the damaged liver results in increased pressure throughout the portal venous system 75% of the blood supply to the liver comes from the portal vein which drains the GI tract Normal pressure in the portal system is 3 mmHg. With portal hypertension the pressure is >10 mmHg Causes increased pressure in the vessels, GI tract, spleen, and pancreas (Esophageal and rectal varices)

Question 36

Complication of cirrhosis: esophageal varices

Answer 36

Dilated, thin walled vein found in the submucosa of the lower esophagus and can extend into the stomach Prone to rupture causing massive, life-threatening hemorrhage Rupture due to: Ulceration, poorly chewed food, increased intra-abdominal pressure from coughing, straining to go to the bathroom, sneezing, lifting heavy objects Contributing factors include: erosion from gastric acid, elevated venous pressure from portal hypertension, and decreased clotting factors

Question 37

Esophageal varices symptoms

Answer 37

Hemataemesis Black, sticky, fouling smelling feces Hypovolemic shock Individuals who have recurrent esophageal bleeding from portal hypertension usually die within a year

Question 38

Esophageal varices diagnostics

Answer 38

EGD | CT & MRI

Question 39

Esophageal varices medication

Answer 39

Octreotide (Sandostatin) – treatment of portal hypertension. Mechanism of action is unclear. Slows blood flow into the portal vein. Vitamin K

Question 40

Urgent treatment of esophageal varices

Answer 40

Banding (preferred) -Placement of rubber bands on the varices by endoscopy Sclerotherapy -Injection of agents that cause the varies to become sclerotic Balloon tamponade (short term) -Sengstaken-Blakemore tube -Special NG tube with 3 lumens -Direct pressure to bleeding vessel -Monitor for airway obstruction, aspiration

Question 41

Nursing management of esophageal varices

Answer 41

``` Observe for bleeding Monitor for signs of hypovolemic shock Monitor the airway Administer blood and blood products NPO Oral care Emotional support Education ```

Question 42

Complication of cirrhosis: ascites

Answer 42

An accumulation of peritoneal fluid in the abdominal cavity Portal hypertension causes a higher pressure gradient within the vasculature than in the abdominal cavity which causes fluid to leak out Failure of the liver to metabolize aldosterone increases sodium and water retention by the kidneys Decreased synthesis of albumin by the liver decreases oncotic pressure causes fluid to leak out

Question 43

Ascites symptoms

Answer 43

``` Increased abdominal girth Rapid weight gain Shortness of breath Abdominal striae Distended veins over the abdominal wall ```

Question 44

Ascites treatment

Answer 44

``` Dietary modifications -Sodium and fluids restrictions Diuretics: Spironolactone (Aldactone) Albumin adminstration Paracentesis TIPS procedure ```

Question 45

Paracentesis to treat ascites

Answer 45

Needle punctures the abdominal cavity to remove accumulated fluid Reserved for patient with impaired respiratory status or abdominal pain caused by severe ascites Temporary measure – fluid will reaccumulate Removal is usually 1-2 liters Larger volume removal has some risk of fluid and electrolyte imbalance IV albumin may be administered to replace proteins

Question 46

TIPS procedure to treat ascites

Answer 46

Transjugular intrahepatic portosystemic shunt Helps to relieve ascites and portal hypertension Catheter is inserted through the internal jugular vein, threaded down to the hepatic vein, and a shunt is placed between the hepatic and portal veins This allows some blood to bypass the liver and reduce the portal pressure

Question 47

Complication of cirrhosis: Hepatic Encephalopathy

Answer 47

A life threatening complications of liver disease occurring with profound liver failure and results in high levels of ammonia circulating in the blood Ammonia is produced in the liver as a by-product of protein and amino acid breakdown. The colon and small intestine are also sites of ammonia production Normally the liver converts ammonia into urea and it is then excreted by the kidneys

Question 48

Hepatic Encephalopathy progression

Answer 48

Early phase – normal LOC, periods of lethargy and euphoria, reversal of day/night sleep patterns Progresses – disorientation, mood swings, agitation, increased drowsiness Stupor, difficult to arouse, marked confusion, incoherent speech Finally – coma

Question 49

Hepatic Encephalopathy Clinical manifestations

Answer 49

Asterixis -Flapping tremor of the hands -When holding the arm out with the hand up after a few seconds the hand will fall and return to flexed up -Simple tasks such as handwriting become difficult Fetor hepaticus -Sweet, slightly fecal odor to the breath -Described like freshly mowed grass, acetone, or old wine -Due to accumulation of digestive by-products that liver unable to degrade

Question 50

Hepatic Encephalopathy Treatment

Answer 50

Low protein diet Neomycin sulfate is given to reduce the gut flora able to produce ammonia Lactulose is administered to reduce serum ammonia levels Orally or as an enema Oxazepam (Serax) is a benzodiazepine not metabolized by the liver, used for agitation Patient are usually referred for a liver transplant

Question 51

Liver transplant

Answer 51

Indicated for those with end stage liver disease Known as a solid organ liver transplant (OLTX) Not considered until the client demonstrates deteriorating functional status i.e. increasing bilirubin levels, refractory ascites, varices, encephalopathy