The Hepatic System

Question 1

Liver

Answer 1

Sole source of albumin and other plasma proteins and also produces 500 to 1500 ml of bile each day

Question 2

Functions of the Liver

Answer 2

More than 500 separate digestive, endocrine, excretory, and hematologic functions

Question 3

With what does the liver interact with?

Answer 3

Endocrine and GI systems

Question 4

Other functions

Answer 4

Other important functions of the liver include production of clotting factors and storage of vitamins.

Question 5

What does the liver filter?

Answer 5

Filters all of the blood from the GI system

Question 6

The liver is the storage location for what

Answer 6

Fat soluble vitamins, handles cholesterol homeostasis
Stores ions and copper, plays a role in hematology with clotting factors and protein synthesis

Question 7

The liver and the gut are the key organs for what

Answer 7

nutrient absorption and metabolism

Question 8

The liver has the largest numbers of phagocytic cells, why is that important?

Answer 8

It contributes to a functional immune system by reducing the amount of bacteria, viruses, and toxins that enter the body

Question 9

Signs and Symptoms of Hepatic Disease

Answer 9

GI symptoms, edema/ascites, dark urine, light-colored or clay-colored feces, and right upper abdominal pain

Question 10

Dark urine and Light stools

Answer 10

Occur when the serum bilirubin level increases from normal (0.1 to 1.0 mg/dl) to a value of 2 or 3 mg/dl

Question 11

Skin changes

Answer 11

Associated with the hepatic system include jaundice, pallor, and orange or green skin

Question 12

Spider angiomas

Answer 12

May be vascular manifestations of increased estrogen levels

Question 13

Palmer erythema

Answer 13

Warm redness of the skin over the palms, also called liver palms

Question 14

Neurologic symptoms

Answer 14

Such as confusion, sleep disturbances, muscle tremors, hyperactive reflexes, and asterixis, may occur

Question 15

When can peripheral nerve function be impaired?

Answer 15

When liver dysfunction results in increased serum ammonia and urea levels

Question 16

Asterixis (Flapping tremors or liver flap)

Answer 16

Motor disturbance
Inability to maintain wrist extension with forward of the UE
Test for asterixis is asking the client to extend the wrist and hand with the rest of the arm supported on a firm surface or with the arms held out in front of the body
Observe for quick, irregular extensions and flexions of the wrist

Question 17

Where does pain present with hepatic disease

Answer 17

Locations of pain associated with hepatic and biliary systems include thoracic pain between scapulae, R shoulder, R UT, R interscapular, or R subscapular areas

Question 18

Hepatic osteodystrophy

Answer 18

Abnormal development of bone, can occur in all forms of cholestasis (bile flow suppression) and hepatocellular disease

Question 19

Bone pain

Answer 19

Osteoporosis
Osteomalacia (rare)

Both- decreased bone mass

Question 20

Painful osteoarthropathy

Answer 20

Develops in the wrists and ankles as a nonspecific complication of chronic liver disease

Question 21

Other Signs and Symptoms

Answer 21

Intense exercise should be avoided when the liver is compromised
Increased risk of coagulopathy also occurs with liver disease
Liver flap or asterixis can be observed in uremia, respiratory failure, and severe heart failure
Tremor is absent at rest, decreased by intentional movement, and maximal on sustained posture, (usually BIL)

Question 22

Cirrhosis

Answer 22

A progressive loss of normal tissue that is replaced with fibrosis and nodular regeneration. Many diseases, medications, and toxins can damage the liver and ultimately lead to cirrhosis, but the most common in the United States include alcohol abuse, hepatitis C virus (HCV), and nonalcoholic liver disease

Question 23

Hepatitis

Answer 23

Chronic and Viral

An acute or chronic inflammation of the liver caused by a virus, a chemical, a drug reaction, or alcohol abuse

Question 24

Chronic Hepatitis

Answer 24

Comprises several diseases that are grouped together because they have common clinical manifestations and all are marked by chronic necroinflammatory injury that can lead insidiously to cirrhosis and end-stage liver disease

Question 25

Causes of chronic hepatitis

Answer 25

Multiple causes including viruses, medications, metabolic abnormalities, and autoimmune disorders

Question 26

Which ones can progress to chronic hepatitis?

Answer 26

Hepatitis B (HBV) with or without hepatitis D virus (HDV), HCV, and GB virus (GBV)

Question 27

Viral Hepatitis

Answer 27

Each of the recognized hepatitis viruses belongs to a different virus family, and each has a unique epidemiology

Question 28

Hep A

Answer 28

Pathogen: HAV, Picornaviridae Symptoms: Fever, headache, malaise, jaundice Incubation: 2-6 wks Transmission: Ingestion Test: IgM antibodies

Question 29

Hep B

Answer 29

Pathogen: HBV, Hepadnaviridae Symptoms: Severe liver damage, chronic disease occurs Incubation: 3-26 wks Transmission: Parenteral, sexual contact Test: IgM antibodies

Question 30

Hep C

Answer 30

Pathogen: HCV, Flaviviridae Symptoms: Same as HBV, more chronic Incubation: 2-33 wks Transmission: Parenteral Test: PCR of viral RNA

Question 31

Hep D

Answer 31

Pathogen: HDV, Deltaviridae Symptoms: Severe liver damage, high mortality rate Incubation: 6-26 wks Transmission: Parenteral, when coinfected with HBV Test: IgM antibodies

Question 32

Hep E

Answer 32

Pathogen: HEV, Caliciviridae Symptoms: Pregnant women may be at high risk and show high mortality, not chronic disease Incubation: 2-6 wks Transmission: Ingestion Test: IgM antibodies, PCR of viral RNA

Question 33

Jaundice

Answer 33

Clinically characterized by yellow discoloration of the skin, sclerae, and mucous membranes. Jaundice occurs as a result of an overproduction of bilirubin, defects in bilirubin metabolism (in uptake by the liver or conjugation), the presence of liver disease, or obstruction of bile flow

Question 34

Drug-Induced Liver Injury

Answer 34

Many drugs or toxins can cause injury to the liver More than 1,000 medicinal agents, chemical, and herbal remedies are recognized as producing hepatic injury

Question 35

Alcoholic Liver Disease (ALD)

Answer 35

Ranging from alcoholic steatosis (fatty liver, occurring in 90% of heavy drinkers) and alcoholic steatohepatitis to alcoholic hepatitis and cirrhosis

Question 36

ALD Incidence/Risk Factors

Answer 36

Genetics Women are vulnerable to developing ALD at lower daily intake levels of alcohol than men Coexisting HCV, smoking, and obesity

Question 37

ALD Pathogenesis

Answer 37

Accumulation of fat Damage to the liver consisting of inflammation, necrosis of individual cells, and early fibrosis Large nodules of fibrotic liver tissue Reduction in oxidation of hepatic fatty acids=Increase lipogenesis

Question 38

ALD Manifestations

Answer 38

Fatty liver infiltrate Nausea, vomiting, abdominal pain, jaundice, anorexia, fever, and weight loss

Question 39

What symptoms do people with alcoholic hepatitis or cirrhosis manifest?

Answer 39

Tender hepatomegaly, fever, and jaundice Muscle wasting, spider angiomata, palmar erythema, gynecomastia, or testicular atrophy

Question 40

Malignant Liver Neoplasms

Answer 40

4th leading cause of death from cancer worldwide and the 5th leading cause of cancer deaths among men in the US Linked to cirrhosis, particularly HBV, HCV, and alcoholic-related cirrhosis

Question 41

Metastatic Malignant Tumors

Answer 41

The liver is one of the most common sites of metastasis from other primary cancers (colorectal, stomach, pancreas, esophagus, lung, breast, melanoma) Metastatic tumors occur 20x more often than primary liver tumors and constitute the bulk of hepatic malignancy

Question 42

Pancreas

Answer 42

Both an exocrine and an endocrine gland. Its primary function in digestion is exocrine secretion of digestive enzymes and pancreatic juices, transported through the pancreatic duct to the duodenum

Question 43

Pancreas Endocrine Function

Answer 43

Involves the secretion of glucagon and insulin by islet of Langerhans cells for the regulation of carbohydrate metabolism

Question 44

Pancreatitis

Answer 44

Potentially serious inflammation of the pancreas and surrounding organs that may result in autodigestion of the pancreas by its own enzymes Acute: brief and reversible Chronic: recurrent or persisting

Question 45

Acute Pancreatitis

Answer 45

An inflammatory process of the pancreas that can involve surrounding organs as well as cause a systemic reaction

Question 46

Acute Pancreatitis Risk Factors

Answer 46

Alcohol Gallstones Hypertriglyceridemia

Question 47

3 Levels of Acute Pancreatitis

Answer 47

1. Mild-local or systemic complications in organ failure is absent 2. Moderate-local complications with or without organ failure for less than 24 hours 3. Severe-Persistent organ failure for more than 48 hours with involvement of one or more organs

Question 48

Chronic Pancreatitis

Answer 48

Characterized by the development of irreversible changes in the pancreas secondary to chronic inflammation

Question 49

Chronic Pancreatitis Risk Factors

Answer 49

Alcohol Smoking Genetic predisposition

Question 50

Pancreatic Cancer

Answer 50

Represents the third leading cause of cancer mortality in the United States, with more than 45,000 deaths each year Lowest 5-yr survival rate after diagnosis (9%) of any type of cancer

Question 51

Pancreatic Cancer Symptoms

Answer 51

Initially nonspecific and vague or subtle in onset (e.g., anorexia, malaise, nausea, fatigue, pruritus), which contribute to the delay in diagnosis Abdominal pain Weight loss Jaundice

Question 52

Gallbladder

Answer 52

Acts as a reservoir for bile, stores and concentrates the bile during fasting periods and then contracts to expel the bile into the duodenum in response to the arrival of food

Question 53

Bile

Answer 53

Helps in alkalinizing the intestinal contents and plays a role in the emulsification, absorption, and digestion of fat

Question 54

Biliary System - Cholelithiasis (gallstone disease)

Answer 54

One of the most common GI diseases in the United States, occurring in an estimated 25 million people, or 10% to 15% of the adult population

Question 55

Gallstones

Answer 55

Occurs when stones form in the bile at the gallbladder as a result of changes in the normal components of bile

Question 56

Complications of Cholelithiasis Choledocholithiasis

Answer 56

Defined as calculi in the common bile duct, choledocholithiasis occurs in 5% to 20% of persons with gallstones and has the same etiology and pathogenesis Complications can be severe, including pancreatitis and cholangitis

Question 57

Acute Cholangitis

Answer 57

Obstruction and stasis of bile from choledocholithiasis, biliary strictures, or malignancy can lead to a suppurative infection of the biliary tree

Question 58

Acute Cholangitis Symptoms

Answer 58

Those in biliary obstruction (pain) plus fever and jaundice

Question 59

Acute cholangitis can be categorized into three stages: grade I, mild; grade II, moderate; and grade III, severe

Answer 59

1. Mild cholangitis does not meet the criteria for either severe or moderate cholangitis 2. Moderate cholangitis have an elevated white blood cell count, fever, age over 75 years, hyperbilirubinemia, and hypoalbuminemia 3. Severe acute cholangitis manifests with at least one new organ dysfunction

Question 60

Acute Cholecystitis

Answer 60

Inflammation of the gallbladder, may be acute or chronic and occurs most often as a result of impaction of gallstones in the cystic duct, causing obstruction to bile flow and painful distention of the gallbladder

Question 61

Asterixis

Answer 61

Motor disorder characterized by the intermittent loss of muscle tone when attempting to maintain a set position