NURSING MANAGEMENT OF ADULTS WITH DISORDERS OF THE LIVER Spring 2009 1

TOPICS TO BE REVIEWED HEPATITIS CIRRHOSIS STEATOHEPATITIS (FATTY LIVER) HEPATIC ABSCESS LIVER TRAUMA CANCER OF LIVER LIVER TRANSPLANT 2

NORMAL FUNCTION OF LIVER MAIN FUNCTIONS OF THE LIVER: storage, protection, metabolism Maintains normal serum glucose levels Ammonia conversion Protein metabolism Fat metabolism Vitamin and Iron storage Drug metabolism and detoxification 3

LIVER FUNCTION: GLUCOSE METABOLISM What happens to glucose in the liver? Where is it stored? When is it released? What is gluconeogenesis? When does it take place? 4

LIVER FUNCTION: AMMONIA CONVERSION When gluconeogenesis takes place what is the byproduct of the process? What happens to the byproduct? What do the bacteria in the intestines produce as a byproduct? How is this byproduct removed? 5

LIVER FUNCTION: PROTEIN METABOLISM What is the liver’s job in terms of synthesizing plasma proteins? What does the liver need to complete it’s job? 6

LIVER FUNCTION: FAT METABOLISM What is the liver’s job in terms of fat metabolism? When does the liver do this? What are the results of this metabolism used for? 7

LIVER FUNCTION: VITAMIN & IRON STORAGE Stores which fat soluble vitamins? What other vitamins are stored in the liver? What are these vitamins responsible for? Which minerals are stored in the liver? 8

LIVER FUNCTION: DRUG METABOLISM and DETOXIFICATION THE FOLLOWING CLASSIFICATION OF DRUGS ARE METABOLIZED BY THE LIVER? What else is metabolized by the liver? What does the liver do in terms of detoxification? 9

NORMAL FUNCTION: bile secretion What is the liver’s job with Bile? When is bile secreted? Where is Bile collected and stored? How is this related to Billirubin? When do Billirubin levels increase? 10

LIVER FUNCTION: PROTECTION What does the liver’s protection function involve? What do the cells do?

LIVER FUNCTION CONTINUED Inactivates Hormones Estrogen Testoterone Progesterone Aldosterone cortisol Sinusoids store blood (about 200-400 cc) 12

DISORDER OF THE LIVER HEPATITIS 13

Hepatitis Widespread viral inflammation of liver cells Hepatitis A (HAV) Hepatitis B (HBV) Hepatitis C (HCV) Hepatitis D (HDV) Hepatitis E (HEV) Hepatitis F and G are uncommon (HFV, HGV) DRUG INDUCED HEPATITIS Occurs as a secondary infection 14

Hepatitis A (HAV) Similar to that of a typical viral syndrome; often goes unrecognized Spread via the fecal-oral route by oral ingestion of fecal contaminants Contaminated water, shellfish from contaminated water, food contaminated by handlers infected with hepatitis A Also spread by oral-anal sexual activity (Continued) 15

Hepatitis A (HAV)(Continued) Incubation period for hepatitis A is 15 to 50 days. Disease is usually not life threatening. Disease may be more severe in individuals older than 40 years of age. Many people who have hepatitis A don’t know it; symptoms are similar to a gastrointestinal illness. 16

Hepatitis B (HBV) Spread is via unprotected sexual intercourse with an infected partner, sharing needles, accidental needle sticks, blood transfusions, hemodialysis, maternal-fetal route. Symptoms occur in 25 to 180 days after exposure; symptoms include anorexia, nausea and vomiting, fever, fatigue, right upper quadrant pain, dark urine, light stool, joint pain, and jaundice. (Continued) S&P 17

Hepatitis B (HBV) (Continued) Hepatitis carriers can infect others, even if they are without symptoms. 18

Hepatitis C (HCV) Spread is by sharing needles, blood, blood products, or organ transplants (prior to 1992), needle stick injury, tattoos, intranasal cocaine use. Incubation period is 21 to 140 days. Most individuals are asymptomatic; damage occurs over decades. Hepatitis C is the leading indication for liver transplantation in the U.S. NOT TRANSMITTED BY CAUSUAL OR INTIMATE HOUSEHOLD CONTACT S&P 19

Hepatitis D (HDV) Transmitted primarily by parenteral routes Incubation period 14 to 56 days HDV coinfects with HBV and needs it presence to replicate S&P 20

Hepatitis E (HEV) Present in endemic areas where waterborne epidemics occur and in travelers to those areas (India, Asia, Africa, Middle East, Mexico, Central America & South America) Also seen in travellers coming from these areas Transmitted via fecal-oral route Resembles hepatitis A Incubation period 15 to 64 days S&P 21

Clinical Manifestations of all Hepatitis Abdominal pain Changes in skin or eye color Arthralgia (joint pain) Myalgia (muscle pain) Diarrhea/constipation Wgt loss Hepatomegaly Fever Lethargy/Malaise Nausea/vomiting Intolerance to fats/dyspepsia Pruritus CHANGES IN COLOR OF URINE AND STOOL 22

ASSESSMENT HEALTH HISTORY Suspected exposure Medical history SIGNS/SYMPTOMS Pre-icteric stage Icteric stage Post-icteric stage HEALTH HISTORY Suspected exposure Medical history 23

SIGNS/SYMPTOMS PRE-ICTERIC STAGE Lasts about 1 week 24

SIGNS AND SYMPTOMS ICTERIC STAGE Lasts 2-6 weeks Jaundice appears Yellow skin, sclera, mucous membranes Dark amber urine Clay colored stools 25

SIGNS AND SYMPTOMS POST-ICTERIC STAGE Lasts 2-6 weeks Jaundice subsides Liver decreases in size Good appetite 26

LABORATORY TESTS FOR HEPATITIS There will be an increase of liver enzymes and serologic markers INDICATING A PRESENCE OF HEPATITIS A, B, C 27

LABORATORY TESTS FOR HEPATITIS A (HAV) Presence of hepatitis A in client: when hepatitis A (HAV) antibodies (anti-HAV) are found in the blood Presence of immunoglobulin M(IgM) antibodies means that ongoing inflammation of liver present (persisits for 4-6 wks) Previous infection indicated by presence of immunoglbulin G (IgG) antibodies which provides permanent immunity to disease 28

LABORATORY TESTS FOR HEPATITIS B (HBV) Serologic markers which indicate client has Hepatitis B (HBV) are: HBsAg (Hepatitis B surface Antigen) Anti-HBc IgM (IgM antibodies to hepatitis B core antigen) If these levels are elevated after 6 months: chronic or carrier state Presence of antibodies to HBsAb (hepatitis B surface antibody): indicates recovery and immunity to hepatitis B Someone immunized will have a positive HBsAb 29

LABORATORY TESTS FOR HEPATITIS C (HCV) ELISA (enzyme linked immunosorbent assay ) SCREENS INITIALLY & for HCV antibodies (anti-HCV): can detect antibodies in 4 wks RIBA: (recumbent immunoblot assay): used to confirm that client has been exposed and has developed antibody HCV PCR (HCV polymerase chain reaction test): confirms presence of circulating active virus 30

LABORATORY TEST FOR HEPATITIS D (HDV) Presence of virus confirmed by identification of intrahepatic delta antigen Also by rise in hepatitis D virus antibodies (anti-HDV) titer Found within a few days of infection 31

LBORATORY TESTS FOR HEPATITIS E (HEV) VIRUS CANNOT BE DETECTED Presence of hepatitis E antibodies (anti-HEV) is found in people infected with virus 32

LABORATORY TESTS CONTINUED A person having a previous infection is indicated by immunoglobulin G (IgG) antibodies. They persist in blood and provide permanent immunity to HAV 33

LABORATORY TESTS INDICATING HEPATITIS TESTS WHICH ARE LOWERED: Leukocytes (leukopenia) Serum albumin Serum glucose (hypoglycemia) PT (prolonged) TESTS WHICH ARE ELEVATED: serum bilirubin Bilirubin in urine ALT AST Alkaline phosphatase elevated or may be normal 34

Nonsurgical Management Physical rest Psychological rest Drug therapy includes: Antiemetics Antiviral medications Immunomodulators Corticosteroids DECREASE # MEDS TO ALLOW LIVER TO REST 35

DRUGS ANTIVIRALS: Lamivudine (Epivir-HBV) Adefovir dipivoxil (Hepsera) USED: to destroy Hepatitis B virus in chronic disease SIDE EFFECTS: alters renal function; granulocytopenia 36

DRUGS IMMUNOMODULATING DRUGS: Interferon(peginterferon alfa-2a) (Pegasys) Oral ribavirin (Virazole) 37

NURSING CARE Diet therapy Hydration No alcohol Low fat, moderate protein, high CHO diet, high calorie Small frequent meals Vit B, C, K 38

PATIENT EDUCATION Hepatitis A Vaccine Hepatitis B vaccine Prevention to health care professionals Knowledge of transmission routes Proper personal hygiene and good sanitation Gamma Globulin Avoid sex until antibody results (negative) Hepatitis A Vaccine Hepatitis B vaccine No vaccine for Hepatitis E Hepatitis C mainly spread through blood transfusions: (screen blood products) 39

CIRRHOSIS DEFINED Chronic Degenerative Causes liver enlargement Causes loss of normal liver function 40

PATHOPHYSIOLOGY Fibrotic bands of connective tissue change the structure of the liver Inflammation causes degeneration and destruction of liver cells Tissue becomes nodular Nodules block bile ducts and normal blood flow throughout the liver Blood flow changes occur from compression by the fibrous tissue 41

TYPES OF CIRRHOSIS Laennec’s cirrhosis: chronic ETOH, nutritional deficiencies Biliary Postnecrotic cirrhosis: hepatic necrosis Cardiac: congestion and tissue damage due to heart failure 42

ETIOLOGY Known causes of liver disease include: Alcohol Viral hepatitis Autoimmune hepatitis Steatohepatitis Drugs and toxins Biliary disease (Continued) 43

ETIOLOGY CONTINUED Metabolic/genetic causes Cardiovascular disease 44

EARLY SIGNS AND SYMPTOMS CIRRHOSIS Same for all types regardless of the cause Start out vague, like flu General weakness, Fatigue Anorexia, Indigestion Abnormal bowel function (constipation, or diarrhea) Abdominal pain/liver tenderness 45

LATE S & S Jaundice, pruritus, dry skin, warm bright red palms of hands (palmar erythema), rashes Edema, ascites, significant wgt change, peripheral dependent edema extremities and sacrum Bleeding tendencies/Anemia/petecchiae, echymosis Infections Menstrual irreg/gynecomastia/impotence Renal failure/dark amber urine Clay colored stools 46

ASSESSMENT INSPECTION: Jaundice Caput medusae: dilated abd veins, striae, spider angiomas Contour of abdomen: Distension: massive ascites Everted umbilicus (umbilicus protrusion) HEPATOMEGALY, SPLENOMEGALY 47

Other Physical Assessments Assess nasogastric drainage, vomitus, and stool for presence of blood Fetor hepaticus (breath odor) Amenorrhea Gynecomastia, testicular atrophy, impotence Neurologic changes: changes in LOC, leading to coma, Asterixis 48

HOW TO ELICIT ASTERIXIS Have client extend the arm, dorsiflex the wrist Extend the fingers OBSERVE rapid non-rhythmic extensions and flexions 49

Laboratory Assessment AST: Aminotransferase serum levels and LDH: lactate dehydrogenase may be elevated from hepatic cell destruction. Alkaline phosphatase levels may increase from obstructive jaundice. Total serum bilirubin from hepatic disease and urobilinogen levels may rise from hepatocellular obstruction or liver disease. decrease. (Continued) 50

Laboratory Assessment (Continued) Fecal urobilinogen is decreased due to obstructive liver disease Total serum protein and albumin levels decreased Prothrombin time prolonged; platelet count low Decreased hemoglobin and hematocrit values due to anemia and white blood cell count S&P 51

LABORATORY ASSESSMENT CONTINUED Elevated ammonia levels: liver cannot excrete ammonia BUN and Serum creatinine level possibly elevated due to decreased renal function 52

COMPLICATIONS: PORTAL HYPERTENSION Increase pressure in portal vein Comes from obstruction of blood flow from pressure by CT bands (see patho) New channels looked for Blood flows back to spleen (splenomegaly) Veins become dilated (esophagus, stomach, intestines, abdomen, rectum) 53

PORTAL HYPERTENSION (CONTINUED) Results in: Ascites Esophageal varices Prominent abdominal veins (caput medusae) hemorroids 54

COMPLICATION: ASCITES DEFINED AS: Accumulation of free fluid within the peritoneal cavity With increased hydrostatic pressure from portal hypertension fluid leaks into peritoneal cavity Albumin in fluid hypoalbuminemia 55

ASCITES CONTINUED Hypovolemia renal vasoconstriction Renin-angiotensin system triggered Sodium and water retention Leads to increased hydrostatic pressure Perpetuates the cycle of ASCITES 56

COMPLICATIONS ASCITES: Bed rest, HOB up 30 degrees or higher; or sitting in chair Abdominal girth measurements bid wgts standing Strict fluid restriction; strict I & O, vitamin supplements Salt free diet/diuretics/electrolyte replacement 57

Excess Fluid Volume (Continued) Paracentesis is insertion of trocar catheter into abdomen to remove & drain fluid from the peritoneal cavity. Observe for possibility of impending shock, electrolyte imbalances: albumin IV. 58

EXCESS FLUID SURGICAL MANAGEMENT CONTINUED LAVEEN SHUNT (peritoneovenous shunt): surgical procedure, tube placed in peritoneal cavity, drain fluid into superior vena cava PORTACAVAL SHUNT: (See p 1378 fig 62.4) surgical shunting diverts portal venous blood flow from the liver TIPS (transjugular intrahepatic portalsystemic shunt): non surgical procedure creating a connection within the liver between the portal and systemic circulation to reduce portal pressure 59

COMPLICATION: BLEEDING ESOPHAGEAL VARICES DEFINED: fragile thin walled esophageal veins become distended from pressure Portal hypertension blood backs up from liver to esophageal and gastric vessels 60

COMPLICATIONS ESOPHAGEAL VARICES MEDICAL EMERGENCY LIFE THREATENING S&S: hematemesis, melena, shock Can occur spontaneously Can be caused by any activity that Abdominal pressure 61

TREATMENT OF BLEEDING ESOPHAGEAL VARICES IV fluids/electrolytes/volume expander/ transfuse ESOPHAGOGASTRIC BALLOON TAMPONADE: via Sengstaken-Blakemore tube Compressing bleeding vessels with this tube 62

SENGSTAKEN-BLAKEMORE TUBE Used to control bleeding Esophageal balloon Gastric balloon 3 lumens 1 for gastric lavage 1 for inflating the esophageal balloon 1 for inflating the gastric balloon 63

SENGSTAKEN-BLAKEMORE TUBE: NRSG CARE MD inserts tube with HOB 30-45 degrees MOST SERIOUS COMPLICATION: ASPIRATION AND AIRWAY OCCLUSION SURGICAL SCISSORS AT BEDSIDE Monitor for respiratory distress Suction saliva from upper esophagus, nasopharynx Check nostrils frequently, cleanse and lubricate to prevent ulceration Removed after bldg controlled 64

RUPTURE OF ESOPHAGEAL VARICIES Vasopressin: constriction arterial bed Somatostatin: decreases bldg without vasoconstrictive effects of Vasopressin Propranolol: beta blocker to decrease portal pressure 65

COMPLICATION: COAGULATION DEFECTS synthesis of bile in liver Prevents absorption of fat soluble vitamins (vit K) Without vit K clotting factors are not produced susceptible to bleeding Abnormal PT (prolonged or ) 66

COMPLICATION: SPLENOMEGALY Backup of blood into spleen Spleen destroys platelets thrombocytopenia (first sign of liver dysfunction) 67

COMPLICATION: JAUNDICE Liver cells cannot excrete bilirubin circulating bilirubin levels LABORATORY TESTS: changes with hepatocellular jaundice Serum bilirubin (indirect and direct) Urine bilirubin Urobilinogen stool: normal to Urobilinogen urine: normal to 68

COMPLICATIONS: PORTAL SYSTEMIC ENCEPHALOPATHY (PSE) Also called HEPATIC ENCEPHALOPATHY AND HEPATIC COMA SEE: neurologic symptoms Impaired LOC Impaired thinking Impaired neuromuscular disturbances ACUTE AND REVERSIBLE with early intervention CAUSED BY: elevated ammonia levels 69

NURSING DIAGNOSIS Activity intolerance Fluid volume deficit Fluid volume excess Ineffective breathing patterns Risk for hemorrhage Risk for infection Altered nutrition Pain Sexual dysfunction 70

NURSING DIAGNOSIS CONTINUED Altered thought processes Risk for violence 71

NURSING CARE Bed rest with controlled activity, prevent clots Prevent infection (pneumonia) Assess for bleeding Treat dry itching skin: no soap, soft linens, lotions, antihistamines Assess F & E status, bid wgts, abd girth once shift, I&O, fluid restriction, amt of dietary protein Assess neuro status q 2 hr Psychological support/abstinence of alcohol 72

Fatty Liver (Steatohepatitis) Fatty liver is caused by the accumulation of fats in and around the hepatic cells. Causes include: Diabetes mellitus Obesity Elevated lipid profile Many clients are asymptomatic. 73

Hepatic Abscess Liver invaded by bacteria or protozoa causing abscess Pyrogenic liver abscess; amebic hepatic abscess Treatment usually involves: Drainage with ultrasound guidance Antibiotic therapy S&P 74

Liver Trauma The liver is the most common organ injured in clients with penetrating trauma of the abdomen, such as gunshot wounds and stab wounds. Clinical manifestations include abdominal tenderness, distention, guarding, rigidity. Treatment involves surgery, multiple blood products. 75

Cancer of the Liver One of the most common tumors in the world LIVER BX: done in same day surgery, local anesthetic, done through skin. CRITICAL THAT COAGULATION TESTING BE DONE. MAJOR SE: hemorrhage Most common c/o: abd discomfort Tx includes: Chemotherapy/Surgery S&P 76

Liver Transplantation Used in the treatment of end-stage liver disease, primary malignant neoplasm of the liver Donor livers obtained primarily from trauma victims who have not had liver damage Donor liver transported to the surgery center in a cooled saline solution that preserves the organ for up to 8 hours S&P 77

Complications Acute, chronic graft rejection Infection Hemorrhage Hepatic artery thrombosis Fluid and electrolyte imbalances Pulmonary atelectasis Acute renal failure Psychological maladjustment 78