Care of Patients with Liver Problems

Care of Patients with Liver Problems

• Cirrhosis is liver scarring, a major cause in the USA is chronic alcoholism, followed by Hepatitis C. In other countries, Hepatitis B and D are major causes.

Pathophysiology of Cirrhosis

• Fibrotic bands of connective tissue form
• Hepatic inflammation occurs
• Liver cells are destroyed
• Nodular tissue forms

Liver Function Tests

• AST (Aspartate Transaminase) elevated (8-48 U/L)
• ALT (Alanine Transaminase) elevated (7-55 U/L)
• Alkaline Phosphatase elevated (45-115 U/L)
• Total Bilirubin elevated (0.2-1.2 mg/dL)
• Albumin decreased (3.5-5.0 mg/dL)

Types of Liver Cirrhosis

• Laennec's (alcoholic)
• Post-necrotic
• Biliary
• Cardiac

Complications of Cirrhosis

• Portal Hypertension
• Bleeding esophageal varices
• Jaundice (yellow discoloration of the skin), caused by hepatocellular disease or intrahepatic obstruction
• Ascites (fluid buildup in the peritoneal cavity) caused by decreased circulating plasma protein, reduced albumin production, and decreased colloid osmotic pressure
• Esophageal varices affect 50% of patients.
• Hematemesis (vomiting blood) and Melena (black tarry stools) are complications
• 30% of patients with varices will hemorrhage within 2 years of diagnosis
• 50% mortality rate for patients who experience hemorrhage

Treatment for Esophageal Varices

• Fluid resuscitation
• Blood transfusions (normal 150,000-450,000 platelets, <150,000 is thrombocytopenia)
• Fresh frozen plasma
• Vasopressin (Pitressin)

Additional Treatment for Esophageal Varices

• Beta-blockers (Propanolol, Nadolol)
• Sengstaken-Blakemore tube
• Mechanical ventilation

Endoscopic Procedures

• Endoscopic Variceal Ligation (EVL)
• Endoscopy Sclerotherapy (EST)

Portal Systemic Encephalopathy

• Complication of cirrhosis
• Mechanism is unclear
• Ammonia levels are high

Nutritional Therapy

• Collaborate with a nutritionist
• Include families
• Consider cultural sensitivity

Drug Therapy for Encephalopathy

• Lactulose
• Neomycin Sulfate
• Metronidazole

Nursing Management

• Assess for loss of consciousness (LOC)
• Check for asterixis (liver flap)
• Check for fetor hepaticus (liver breath)

Viral Hepatitis

• Hepatitis A virus (HAV)
• Hepatitis B virus (HBV)
• Hepatitis C virus (HCV)
• Hepatitis D virus (HDV)
• Hepatitis E virus (HEV)

Hepatitis A

• Route of transmission is fecal-oral
• Incubation period is 2-4 weeks
• Can be asymptomatic
• Diagnosis by serological testing (IgG and IgM antibodies)

Hepatitis B

• Prevalent worldwide
• About 300 million people have chronic HBV infection
• More than one million in the US

Hepatitis C

• Transmission is blood-to-blood (IV drug use, needle sticks, etc.)
• Intranasal cocaine sharing
• Pharmacological treatment (Epclusa, Harvoni) cure rates range from 95-99% after 12 weeks
• High cost ($26,000-78,000 for treatment without insurance)

Hepatitis D

• Requires the presence of HBV to replicate
• Transmitted by blood
• More severe than other viral hepatitis

Hepatitis E

• One of the most common causes of acute hepatitis
• Waterborne
• Prevalent in Asia, Africa, Middle East, South and Central America

Cancer of the Liver

• Early stages are often asymptomatic
• Later symptoms include weight loss, anorexia, weakness, RUQ pain, jaundice, and bleeding

Treatment of Liver Cancer

• Surgical intervention
• Chemotherapy (not often an option)
• Transplantation

Liver Transplantation

• Best candidates are those with end-stage liver disease or primary liver cancer
• Patients with active alcoholism, substance abuse, or metastatic tumors are not usually candidates

Post Transplantation

• Common complications include graft rejection and infection
• Immunosuppressant therapy (Cyclosporine, Tacrolimus) can cause hypertension and renal insufficiency
• Steroids (Prednisone) can cause hypertension and hyperglycemia
• Vaccinations and antibiotics are important