Assessment and Management of Patients With Hepatic Disorders PDF

# Assessment and Management of Patients With Hepatic Disorders ## The Liver: Anatomic The liver is located in the upper right hand portion of the abdominal cavity, beneath the diaphragm and on top of the stomach, right kidney, and intestines shaped like a cone. The liver is a dark reddish brown or...

# Assessment and Management of Patients With Hepatic Disorders ## The Liver: Anatomic The liver is located in the upper right hand portion of the abdominal cavity, beneath the diaphragm and on top of the stomach, right kidney, and intestines shaped like a cone. The liver is a dark reddish brown organ that weighs about 3 pounds. There are two distinct sources that supply blood to the liver: - Oxygenated blood flows in from the hepatic artery. - Nutrient-rich blood flows in from the hepatic portal vein. The liver holds about 13% of the body's blood supply at any given moment. The liver consists of two main lobes. Both are made up of eight segments that consist of 1,000 lobules (small lobes). These lobules are connected to small ducts (tubes) that connect with larger ducts to form the common hepatic duct. The common hepatic duct transports the bile made by the liver cells to the gallbladder and duodenum (the first part of the small intestine) via the common bile duct. ## The Liver, Gallbladder, and Pancreas The liver is the heaviest gland of the body, weighing about 1.4 kg in an average adult. Of all of the organs of the body, it is second only to the skin in size. The liver is inferior to the diaphragm and occupies most of the right hypochondriac and part of the epigastric regions of the abdominopelvic cavity. The gallbladder (gall-bile) is a pear-shaped sac that is located in a depression of the posterior surface of the liver. It is 7-10 cm (3-4in) long and typically hangs from the anterior inferior margin of the liver. ## Anatomy of the Liver and Gallbladder The liver is almost completely covered by visceral peritoneum and is completely covered by a dense irregular connective tissue layer that lies deep to Windows Explorer The liver is divided into two principal lobes - a large falciform ligament, a fold of the mesentery Although the right lobe is considered by many anatomists, DRATLand a posterior caudate lobe (KAW-dat) has a ## Detoxification of Drugs The liver deals with medication, alcohol, ingested toxins, and the toxins produced by the actions of microbes: - Recycling of erythrocytes: Deactivation of many hormones: including the sex hormones, thyroxine, insulin, glucagon, cortisol, and aldosterone - The production of clotting proteins - Storage of vitamins, minerals, and glycogen - Synthesis of vitamin A - Heat production - Production of bile which helps carry away waste and break down fats in the small intestine during digestion. ## Hepatitis, Viral ### Types of Hepatitis, Viral: A, B, C, D, E, and G **Hepatitis A** - Hepatitis A is caused by an RNA virus of the genus Enterovirus. - This form of hepatitis is transmitted primarily through the fecal-oral route, by the ingestion of food or liquids infected by the virus. - The virus is found in the stool of infected patients before the onset of symptoms and during the first few days of illness. - The incubation period is estimated to be 2 to 6 weeks, with a mean of approximately 4 weeks. - The course of illness may last 4 to 8 weeks - The virus is present only briefly in the serum: by the time jaundice appears, the patient is likely to be noninfectious - A person who is immune to hepatitis A may contract other forms of hepatitis. - Recovery from hepatitis A is usual: it rarely progresses to acute liver necrosis and fulminant hepatitis. - No carrier state exists, and no chronic hepatitis is associated with hepatitis A. **Clinical Manifestations** - Many patients are anicteric (without jaundice) and symptomless. - When symptoms appear, they are of a mild, flulike, upper respiratory infection, with low-grade fever. - Anorexia is an early symptom and is often severe. - Later, jaundice, and dark urine may be apparent - Indigestion is present in varying degrees. - Liver and spleen are often moderately enlarged for a few days after onset. - Patient may have an aversion to cigarette smoke and strong odors; symptoms tend to clear when jaundice reaches its peak - Symptoms may be mild in children; in adults, they may be more severe, and the course of the disease prolonged. **Assessment and Diagnostic Methods** - Stool analysis for hepatitis A antigen - *Serum hepatitis A virus antibodies: immunoglobulin* **Prevention** - Scrupulous hand washing, safe water supply: proper control of sewage disposal - Hepatitis vaccine - Administration of immune globulin, if not previously vaccinated, to prevent hepatitis A if given within two weeks of exposure. - Immune globulin is recommended for household members and for those who are in sexual contact with people with hepatitis A - Pre exposure prophylaxis is recommended for those traveling to developing countries or settings with poor or uncertain sanitation conditions who do not have sufficient time to acquire protection by the administration of hepatitis A vaccine. **Management** - Bed rest during the acute stage: encourage a nutritious diet - Give small, frequent feedings supplemented by IV glucose if necessary during the period of anorexia - Promote gradual but progressive ambulation to hasten recovery. The patient is usually managed at home unless symptoms are severe. - Assist patient and family to cope with the temporary disability and fatigue that are common problems in hepatitis. - Teach patient and family the indications to seek additional healthcare if the symptoms persist or worsen - Instruct patient and family regarding diet, rest, follow-up blood work, avoidance of alcohol, and sanitation, and hygiene measures (hand washing) to prevent the spread of disease to other family members. - Teach patient and family about reducing the risk for contracting hepatitis A: good personal hygiene with careful hand washing; environmental sanitation with safe food and water supply, and sewage disposal. **Hepatitis B** - Hepatitis B virus (HBV) is a DNA virus transmitted primarily through the blood. - The virus has been found in saliva, semen, and vaginal secretions and can be transmitted through mucous membranes and breaks in the skin. - Hepatitis B has a long incubation period (1 to 6 months) - It replicates in the liver and remains in the serum for long periods, allowing transmission of the virus. - Those at risk include all healthcare workers, patients in hemodialysis and oncology units, sexually active homosexual and bisexual men, and IV drug users. - About 10% of patients progress to a carrier state or develop chronic hepatitis. Hepatitis B remains a major worldwide cause of cirrhosis and hepatocellular carcinoma. - Symptoms may be insidious and variable: subclinical episodes frequently occur, fever, and respiratory symptoms are rare. Some patients have arthralgias and rashes. - Loss of appetite, dyspepsia, abdominal pain, general aching, malaise, and weakness may occur. - Jaundice may or may not be evident. With jaundice, there are light-colored stools and dark urine. - Liver may be tender and enlarged. The spleen is enlarged and palpable in a few patients. Posterior cervical lymph nodes may also be enlarged. **Assessment and Diagnostic Findings** - Hepatitis B surface antigen appears in blood of up to 90% of patients. - Additional antigens help to confirm diagnosis. **Prevention** - Screening of blood donors - Good personal hygiene - Education **Hepatitis B Vaccine Medical Management** - Alpha-interferon has shown promising results - Lamivudine (Epivir) and adefovir (Hepsera) - Bed rest and restriction of activities until hepatic enlargement and elevation of serum bilirubin and liver enzymes have disappeared. - Maintain adequate nutrition; restrict proteins when the ability of the liver to metabolize protein byproducts is impaired. - Administer antacids and antiemetics for dyspepsia and general malaise; avoid all medications if patient is vomiting - Provide hospitalization and fluid therapy if vomiting persists. **Nursing Management** - Convalescence may be prolonged and recovery may take 3 to 4 months; encourage gradual activity after complete clearing of jaundice. - Identifies psychosocial issues and concerns, particularly the effects of separation from family and friends if the patient is hospitalized. If not hospitalized, the patient will be unable to work and must avoid sexual contact. - Include family in planning to help reduce their fears and anxieties about the spread of the disease. - Educate patient and family in home care and convalescence. - Instruct patient and family to provide adequate rest and nutrition. - Inform family and intimate friends about risks of contracting hepatitis B. - Arrange for family and intimate friends to receive hepatitis B vaccine or hepatitis B immune globulin as prescribed. - Caution patient to avoid drinking alcohol and eating raw shellfish. - Inform family that follow-up home visits by home care nurses are indicated to assess progress and understanding, reinforce teaching, and answer questions. - Encourage patient to use strategies to prevent the exchange of body fluids, such as avoiding sexual intercourse or using condoms. - Emphasize the importance of keeping follow-up appointments and participating in other health promotion activities and recommended health screenings. **Hepatitis C** - A significant portion of cases of viral hepatitis are not A, B, or D: they are classified as hepatitis C. - It is the primary form of hepatitis associated with parenteral means (sharing contaminated needles, needle sticks, or injuries to healthcare workers, blood transfusions) or sexual contact. - The incubation period is variable and may range from 15 to 160 days. - The clinical course of hepatitis C is similar to that of hepatitis B: symptoms are usually mild. - A chronic carrier state occurs frequently - There is an increased risk for cirrhosis and liver cancer after hepatitis C - A combination therapy using ribavirin (Rebetol) and interferon (Intron-A) is effective for treating patients with hepatitis C and in treating relapses. **Hepatitis D** - Hepatitis D (delta agent) occurs in some cases of hepatitis B - Because the virus requires hepatitis B surface antigen for its replication, only patients with hepatitis B are at risk. It is common in IV drug users, hemodialysis patients, and recipients of multiple blood transfusions. - Sexual contact is an important mode of transmission of hepatitis B and D. Incubation varies between 30 and 150 days. - The symptoms are similar to those of hepatitis B except that patients are more likely to have fulminant hepatitis and progress to chronic active hepatitis and cirrhosis. - Treatment is similar to that for other forms of hepatitis. **Hepatitis E** - The hepatitis E virus is transmitted by the fecal-oral route, principally through contaminated water and poor sanitation. - Incubation is variable and is estimated to range between 15 and 65 days. In general, hepatitis E resembles hepatitis A. - It has a self-limited course with an abrupt onset. Jaundice is almost always present. Chronic forms do not develop. - The major method of prevention is avoiding contact with the virus through hygiene (hand washing). - The effectiveness of immune globulin in protecting against hepatitis E virus is uncertain. **Hepatitis G** - (The latest form) is a posttransfusion hepatitis with an incubation period of 14 to 145 days - Autoantibodies are absent - The risk factors are similar to those for hepatitis C ## Liver Cirrhosis - Cirrhosis is a chronic, progressive disease that causes extensive degeneration and destruction of parenchymal - Cirrhosis is a chronic disease characterized by replacement of normal liver tissue with diffuse fibrosis that disrupts the structure and function of the liver. - There are three types of cirrhosis or scarring of the liver - **Alcoholic cirrhosis**: in which the scar tissue characteristically surrounds the portal areas. This is most frequently caused by chronic alcoholism and is the most common type of cirrhosis. - **Postnecrotic cirrhosis**: in which there are broad bands of scar tissue. This is a late result of a previous bout of acute viral hepatitis. - **Biliary cirrhosis**: in which scarring occurs in the liver around the bile ducts. This type of cirrhosis usually results from chronic billiary obstruction and infection (cholangitis); it is much