Liver Failure Background & Trends

• The liver is a very vascular organ with many blood vessels.

Background Trends of Liver Failure

• In the past, liver damage was known as Laennec’s Cirrhosis and was primarily caused by excessive alcohol consumption.
• In the 70s and 80s, drug use became a significant factor, leading to hepatitis-related cirrhosis.
• In 2024, hepatitis B is common due to IV drug users and combinations of hepatitis C or B.
• In the future, fatty liver and obesity is expected to cause liver cirrhosis due to fatty liver.
• Syndrome X, or metabolic syndrome, are candidates for fatty liver, which includes abdominal obesity, hyperglycemia, and hyperlipidemia.
• Abdominal obesity can indicate diabetes.

Causes of Fatty Liver

• The epidemic of obesity.
• Drug-induced hepatitis and liver injuries (DILI) can also cause liver failure.

Cirrhosis Development

• Cirrhosis leads to the development of nodules on the liver's surface, altering its architecture.
• Liver has 3 main functions when testing for cirrhosis or liver failure.

Ascites

• Ascites is the accumulation of fluid in the peritoneal cavity, decreased level of albumin, and decreased oncotic pressure (3rd spacing).
• Albumin helps maintain oncotic pressure which makes blood flow in a straight direction in vessels.
• Disrupting liver function reduces albumin production, decreasing oncotic pressure and causing “third spacing”.
• Blood/plasma accumulates in the abdominal peritoneal cavity, causing ascites.
• Ascites is primarily water retention, which can lead to infection of the peritoneal cavity or peritonitis, which is equivalent to sepsis.
• Ascites are equivalent to fluid volume excess, leading to hypotension.

Side Note on Fluid Overload

• Fluid overload can result from heart failure, kidney failure, and liver failure.
• Retaining water increases blood volume and blood pressure.
• Advanced cirrhosis leads to low blood pressure and malnutrition.
• Patients may have hypervolemia with thin extremities and a large belly.

Signs and Symptoms of Ascites

• Abdominal and flank distention and weight gain, can lead to complications include:
• Spontaneous Bacterial Peritonitis (SBP): fever, abdominal pain, beard-like rigid abdomen when palpated.
• Sepsis: tachycardia will develop; antibiotics are necessary.
• Massive ascites can cause respiratory distress and pleural effusion due to fluid in the lungs, requiring a semi or high Fowler’s position.
• Umbilical or inguinal hernia can also occur.

Nursing Management of Ascites

• Fluid restriction: 1,000 to 1500mL (1-1.5 L) in 24 hours.
• Strict I&O monitoring to make sure the patient follows the rules.
• Sodium restriction of less than 2 grams.
• Daily weights to monitor fluid retention.
• Measure abdominal girth.
• Compare potassium-wasting with potassium-sparing diuretics: furosemide + spironolactone.
• Electrolyte imbalance is a major issue, potentially leading to cardiac dysrhythmia if potassium levels are off.
• Spironolactone can cause gynecomastia due to its effect on male sex hormones.
• Other potassium-sparing diuretics are amiloride and triamterene.
• Paracentesis involves removing ascites fluid (done by the doctor, not the nurse).

Nursing Management for Paracentesis

• Pre-procedure: informed consent, materials preparation, lab tests request, vitals, and ensure a comfortable sitting position.
• Intra-procedure: Monitor for any complications.
• Post-procedure: check the vital signs, send a lab specimen, consider an albumin infusion, and monitor for complications like bleeding, hypotension, and respiratory distress.
• Ascites treatment often requires repeat paracentesis until liver transplant or death.
• Effectiveness of paracentesis is indicated by decreased patient weight and abdominal girth.
• Review: Diuretics are used for ascites, while 3rd generation cephalosporins like cefotaxime or prophylaxis can be used for SBP.

Hepatic Encephalopathy

• Elevated ammonia levels in the brain due to the liver's inability to detoxify or convert ammonia into urea.
• The GI tract produces ammonia as a byproduct, which is normally detoxified by the liver.
• With cirrhosis, ammonia cannot be converted into urea, leading to neurological symptoms.
• Side note: Ammonia is neurotoxic; elevated ammonia is called hyperamonia, the GI tract produces ammonia, this cannot be converted into urea because the liver is damaged.

Signs and Symptoms of Hepatic Encephalopathy

• DIPS:
• Decreased level of consciousness, which is called hepatic coma.
• Intellectual impairment – affects cognition, meaning memory and ability to concentrate.
• Personality changes
• Sleep inversion.
• There are subclinical sleep disturbances, or it can lead yo hepatic coma.
• Two signs:
• Asterixis is liver flap or flapping tremors of the hands.
• Fetor hepaticus is a bad breath or halitosis.

Treatment to Lower Ammonia Levels

• Lactulose which is a laxative to help poop out and remove ammonia.
• Give lactulose twice a day to have 2-4 loose stool.
• A laxative can be given orally if a person is alert and oriented.
• Give a laxative as an enema if people are in a coma.
• Antibiotics remove bacteria in the GI tract that produce the ammonia and be given as: neomycin or rifaximin
• These are all just temporary relieves of the symptoms.

Review of Hepatic Encephalophaloopathy:

• Lactulose that makes you poop to remove the ammonia and neomycin and rifaximine antibiotic to clean your gi tract.

Portal Hypertension

• Blocked portal vein, which leads to collateral vessels, bursts and bleed.
• Hypotension and tachycardia develop if actively bleeding.

Esophageal Varices

• Vomit blood (hematemesis) and is dangerous,
• Gastric varices stool will be melena and is dangerous.
• Hemorrhoids- bright/fresh red blood in stool.
• The liver is very vascular.
• Die in severe bleeding.
• Portal vein is the most important vessel in your G.I tract in your liver.
• Thinks of the vein as a Port Authority.
• Portal vein also collects all blood from the GI tract.
• Now, all veins blocked are portal hypertension.

Drug Metabolism

• Liver is responsible for metabolizing drugs.
• If dysfunctional, serious adverse effects.
• Be careful with hepatotoxic drugs.
• If liver can’t metabolize, more toxic effect.

Nursing Management

• Beta-blockers. Give propranolol and nadolol. Beta-blockers decrease heart rate and blood pressure. Decrease those blood vessels will not grow bigger and rupture.
• Know if beta blocker is affective via no bleeding episodes.

Other Liver Functions

• Bile: Impaired liver affects bile production, hindering fat absorption.
• Clotting: Impaired liver reduces clotting factor production, increasing bleeding risk.
• Glucagon: Liver failure can lead to hypoglycemia due to impaired glycogen storage.

Paracentesis to Remove Ascites Fluid

• Nursing management for paracentesis: pre informed consent, prepare materials paracentesis tray, extra sterile gloves, lidocaine, collection bottles, needles etc., ask doc for lab test. High fowler and semi-fowler patient positioning.
• To know paracentesis worked patient weight is lower and abdominal Gerd decreased.
• Cephalosporin can be used to give ascites.
• Hepatic encephalopathy: level of ammonia rises the brain as high impairment.
• Asterixis-liver flap- flapping tremors.
• If asked to extend arms, tumors seen due to live liver telling them to extend their arms.

Nursing Management for Cirrhosis

• Vitals should checkup for daily weights as patient comes into the hospital.
• Fluid and sodium restriction if hypervolemia.
• Strictly Monitor I and O.
• Respiratory and neurological assessment.
• Patients should be in Fowlers position.
• Monitor skin and itegrity.
• Telangiectasia, spider nevi etc.
• Daily weights-fluid
• Monitor electrolytes.
• Skin integrity checks, Monitor for skin breakdown bec pt is prone to ascites, edema, & scratching due to pruritus. • Antihistamine lotion – makes me sleepy.
• Cholestyramine to tx pruritus – powder med mixed w/ water. Removes bile deposits from skin.

DILI (Drug-Induced Liver Injury)

• Avoid nephrotoxic and hepatotoxic drugs.

List of Drugs to avoid:

• acetaminophen 2 to 4 grams
• NSAIDS (ibuprofen, naproxen)
• ANTITUBERCULARS/ANTI-TB DRUGS (RIFAMPIN, ISONIAZID, PYRAZINAMIDE, ETHAMBUTOL)
• ANTILIPEMICS (CHOLESTEROL DRUGS)
• Antiepileptic/antiseizure/anticonvulsants-(Seizure drugs )
• Antithyroid drugs(methimazole, PTU-propylthiouracil)
• Antibiotics- amoxicillin-clavulanate.
• Antifungal: fluconazole(used in hiv)
• Antidepressadnts: nortriptyline, bupropion, citalopram, escitalopram, paroxetine, sertraline
• Muscle relaxants: baclofen, tizanidine, methocarbamol, cyclobenzaprine
• Asked in nclex: notorious drugs: amiodarone, Anti-epileptic, anti-tb drugs, acetaminophen, nsaids, herbal medications

Cirrhosis Complications

• More cirrhosis symptoms: Ascites, hepatic encephalopathy, portal hypertension.

Stages of Liver Failure

• Compensated: Early stage
• Decompensated: Advanced/ last stage
• Hepatorenal syndrome: not only the liver will fail, the kidney too
• Hepatopulmonary syndrome- not only the liver will fail. the Kidney too

Hypoglycemia

• because liver will have no more glucagon the stored glycogen
• Hepatocellular Carcinoma- if you have chronic inflammation you will develop liver cancer called hepatocellular.

Hepatic Encephalopathy

• Elevated level of ammonia/hyperammonemia.

Grade of Hepatic Encephalopathy:

• Grade 0 — Minimal changes
• Grade 1- Memory issues
• Grade 2 – Personality and behavioural changes, asterixis
• Grade 3- Somnolent
• Grade 4 – Comatose hepatic coma and unresponsive.

Treatment for Hepatic Encephalopathy

• Lactulose a laxative to use in the blood
• Given a orrally or ngt
• If given a antibiotics kill the GI

Portal Hypertension/Esophageal Varices

• Elevated pressure in your portal venues system it as if like
• Liver has its own pressure blood system. If bloods are blocked narrowed it increases blood pressure.

Two Goals when treating this:

• Prevent Rupture
• Treat:
• Control BP & HR Make sure they're always in the normal range. Ideal is low normal.

Liver failure general mainfestation

• Jaundice
• Pruritus
• abdominal distension
• Altered mental Status
• Bleeding
• Dilated veins—spider angioma, cap

3 Major Types of Infectious Hepatitis

• Hep A, Hep B, and Hep C.

Hepatitis A

• Primarily transmitted by fecal-oral route.
• Vaccine available for it.

Hepatitis B

• Transmitted via the blood or sexually.

Hepatitis C

• High transmission spread due to needlestick injuries.
• No Vaccine is available for it.