NURS 405B Hepatic Disorders Review PDF

**Liver functions** - Major role in glucose metabolism - Ammonia conversion - Protein metabolism - Fat metabolism - Vitamin and iron storage - Bile formation - Bilirubin excretion - Drug metabolism **History & assessment** - LFT's abnormal - Health history - Exposur...

**Liver functions** - Major role in glucose metabolism - Ammonia conversion - Protein metabolism - Fat metabolism - Vitamin and iron storage - Bile formation - Bilirubin excretion - Drug metabolism **History & assessment** - LFT's abnormal - Health history - Exposure to hepatotoxic substances or infectious agents - Occupational, recreational, travel history - Hx alcohol & drug use - Medications (Tylenol, Ketoconazole, valproic acid) - Family history gall stone disease **Liver function tests** +-----------------------------------+-----------------------------------+ | **Aspartate Aminotransferase** | - Normal 10-40 U/mL | | | | | **(AST)** | - **↑ cirrhosis, hepatitis, | | | liver cancer (not | | | specific) \> 40 u/mL** | +===================================+===================================+ | **Alanine Aminotransferase** | - Normal: 8-40 U/mL | | | | | **(ALT)** | - **↑ in liver disorders \> 40 | | | U/mL** | +-----------------------------------+-----------------------------------+ | **Gamma-Glutamyl Transferase** | - Normal 0-30 U/L | | | | | **(GGT)** | - **↑ in cholestasis but also | | | alcoholic liver disease \> 30 | | | U/L** | +-----------------------------------+-----------------------------------+ | **Bilirubin** | - Normal direct serum bilirubin | | | 0.1-0.4 mg/dL | | | | | | - Serum bilirubin total 0.3-1 | | | mg/dL | | | | | | - **↑ in liver disease** | | | | | | - **Jaundice sclera & skin | | | yellow or greenish-yellow | | | when bilirubin \>2.0 mg/dL** | +-----------------------------------+-----------------------------------+ | **Protein** | - Normal total protein 7-7.5 | | | g/dL | | | | | | - **↓ in liver disease** | +-----------------------------------+-----------------------------------+ | **Albumin** | - Normal serum albumin 3.5-5.2 | | | g/dL | | | | | | - **↓ level in liver disease** | +-----------------------------------+-----------------------------------+ | **PT** | - Normal 11-13 seconds | | | | | | - **↑ in liver disease \> 13 | | | seconds** | +-----------------------------------+-----------------------------------+ | **INR** | - Normal \1.1** | +-----------------------------------+-----------------------------------+ | **Alkaline Phosphatase** | - Normal 52-142 u/L | | | | | | - **↑ in liver disease \> 142 | | | u/L** | +-----------------------------------+-----------------------------------+ | **Ammonia** | - Normal 15-45 mcg/dL | | | | | | - **↑ in liver disease/hepatic | | | encephalopathy \> 45 mcg/dL** | +-----------------------------------+-----------------------------------+ | **Platelets** | - Normal 150,000-450,000 mcL | | | | | | - **↓ in liver disease \< | | | 150,000 mcL** | +-----------------------------------+-----------------------------------+ - **Signs of liver dysfunction** - **Pallor** - **Jaundice** - Assess skin & sclera - Skin excoriation- pruritus - **Muscle atrophy of extremities, weakness** - **Malaise, fatigue** - **Fever** - **Edema, weight gain** - **↑ abdominal girth, abdominal pain** - **Petechiae or bruising, spider angiomas, palmar erythema** - Hematochezia, hematemesis, melena - **Cognitive** - Changes in mental acuity - Personality - Sleep disturbances - ↓ recall - ↓ memory - ↓ abstract thinking - **General tremor** - **Asterixis** - **Slurred speech** - **Acute Liver Failure** - **Sudden severe liver impairment lasts [\ 2.0 mg/dL - **Intense itching of skin** - **Urine orange & foamy** - **↓ bile in intestines** - **Stool light or clay colored** - **Dyspepsia, intolerance to fatty foods** - Several types - Hemolytic, hepatocellular, obstructive jaundice, & hereditary - **Hepatocellular & obstructive jaundice associated w/ liver disease** - **Edema** - Result of - ↓ plasma albumin - ↑ production of Aldosterone Na^+^ & H~2~O absorption, ↑ K^+^ excretion - **Portal hypertension** - ↑ pressure throughout portal venous system - Obstruction or impaired blood flow through damaged liver - Commonly associated w/ hepatic cirrhosis - Major consequences ascites & varices - **Gastrointestinal varices** - **Obstruction of blood flow in liver & portal HTN** - **Leads to collateral blood vessels in GI system, dilated tortuous veins** - **Blood flows from high pressure portal system to lower pressure vessels** - Weaker vessels are not meant for high pressure - As result ↑ size over time - **Common sites** - Esophagus, stomach, lower rectum - **Weaker vessels, fragile, rupture, & bleed easily** - **Manifestations** - **Caput medusae** - **Signs of bleeding** - Occult blood in stool - Frank blood - Hematemesis, melena - ↓ mental status - Signs of hemorrhagic shock - **Factors that ↑ risk of bleeding from varices** - **↑ exertion** - Lifting heavy objects - Straining w/ bowel movement - Sneezing, coughing, vomiting - **Esophagitis** - Irritation of esophagus from poorly chewed foods or irritating fluids - Meds erode esophagus - **Esophageal varices** - Present in 30% pt's w/ compensated cirrhosis & 60% pts w/ decompensated cirrhosis - Mortality rate 10-30% after first bleeding episode - After first bleed high risk for recurrent bleed (70%) & death (30-50%) - Bleeding → ↑ nitrogen load, ↑ ammonia, ↑ risk of encephalopathy - **Assessment of varices** - **Endoscopy, direct visualization** - **Patients with cirrhosis should be screened for varices** - CT scan & angiography - **Varices Management** - **Beta-blockers** - **Propranolol or Coreg** - ↓ portal pressure - ↓ risk of bleeding - **Bleeding** - **Can quickly lead to hemorrhagic shock** - Need to monitor vital signs closely - I & O's - Replace fluid & blood loss - Caution not to over resuscitate ↑ blood pressure → ↑ risk of bleeding - **Foley insertion for close I & O monitoring** - **NPO if actively bleeding** - **Vasoactive meds** - Octreotide (Somatostatin analog) or vasopressin - Cause splanchnic vasoconstriction → ↓ bleeding from varices - **Sengstaken Blakemore Tube** - Tube inserted through nose to stomach - Balloon tamponade to temporarily control hemorrhage & stabilize pt - Infrequently used - Tube has two inflatable balloons, one esophageal & one gastric - Compresses bleeding varices in stomach or esophagus - Stops bleeding 90% but 60-70% return, need to treat - Must be in ICU, close monitoring - Tube in for no longer than 12 hrs preferred - Pt's require frequent oral care & suctioning - Should test balloon before insertion - **Risks** - **Displacement** - **Obstruction of airway & asphyxiation** - **Aspiration** of blood into lungs - Ulceration & necrosis of mucosal lining - Perforation - Endoscopic sclerotherapy - Variceal banding +-----------------------+-----------------------+-----------------------+ | | **Endoscopic | **Variceal Banding** | | | Sclerotherapy** | | +=======================+=======================+=======================+ | **Procedure** | - Injection of | - Endoscope loaded | | | sclerosing agent | with elastic band | | | through | which is then | | | fiberoptic | loaded onto | | | endoscope into or | varices | | | adjacent to | | | | bleeding varices | - Bleeding varices | | | | suctioned into | | | - Promotes | tip of endoscope, | | | thrombosis & | band slipped over | | | sclerosis | it → necrosis, | | | | ulceration, | | | | eventual | | | | sloughing of | | | | varices | +-----------------------+-----------------------+-----------------------+ | **Indications** | - **Treat acute GI | - **Treat acute | | | hemorrhage** | bleeding** | | | | | | | - **Not for | - ↓ rates of | | | prevention** | re-bleed, | | | | mortality, | | | | procedure r/t | | | | complications | | | | | | | | - **First line | | | | treatment for | | | | prevention of | | | | bleeding** | +-----------------------+-----------------------+-----------------------+ | **Complications** | - Acute hemorrhage | - Superficial | | | | ulceration, | | | - Perforation | dysphagia | | | | | | | - Aspiration | - Chest discomfort | | | | | | | - Esophageal | - Rarely esophageal | | | strictures | strictures | +-----------------------+-----------------------+-----------------------+ | **Additional | - Antacids, H2 | | | treatment** | antagonists, or | | | | PPI's to | | | | counteract | | | | chemical effects | | | | of the agent | | +-----------------------+-----------------------+-----------------------+ | | |  | +-----------------------+-----------------------+-----------------------+ - **Anemia** - **Neurologic deterioration, hepatic encephalopathy** - **Life threatening complication** - Survival rate 40% at 1 year, consider eligibility liver transplant - **Neuropsychiatric manifestation of liver failure, w/ portal HTN** - Insidious subtle onset - **R/t hepatic insufficiency** - Liver unable to detoxify toxic byproducts of metabolism - **Ammonia is a major factor** - **Factors that ↑ ammonia level** - Ingestion of products high in ammonia - High protein diet - GI bleed - Bacterial infection, fever - Uremia, alkalosis, hypokalemia - Dehydration, surgery - Meds (sedatives, analgesics, diuretics that cause hypokalemia) - **Manifestations** - **Mental status change & motor disturbances early** - Confused, unkempt, alteration of mood - Initially ↑ in deep tendon reflexes eventually ↓ deep tendon reflexes later on - **Changes in sleep patterns** - Sleep during day, restless, insomnia at night - As progress difficult to awaken, disoriented to time & place - **Asterixis** - Stage two encephalopathy - **Constructional apraxia** - Handwriting difficult, can't reproduce figures - **Fector hepaticus** - **Later signs coma & seizures** - **Medical management** - **Treat underlying causes & symptoms** - **Lactulose** - Ammonia absorbed in stool & expelled - Goal 2-3 bowel movements per day - Monitor diarrhea, intestinal bloating & cramps - Sweet taste, can be diluted w/ fruit juice - Monitor for hypokalemia & dehydration - Other laxatives should be avoided - **Antibiotics** - Neomycin, metronidazole, rifaximin - ↓ levels of ammonia forming bacteria in colon (questionable if there is long-term benefit) - **Vitamin deficiency** - Vitamin A, C, & K deficiencies - Can have ↑ risk of bleeding from vitamin K deficiencies - **Causes** - ↓ production, processing & storage - Chronic gastritis, impaired GI fxn - Vitamin deficiency → ↑ risk of anemia → severe fatigue - **Medical management** - Based on symptoms - H~2~ antagonists for gastric distress - Vitamins & nutritional supplements - **Coagulation abnormalities** - ↓ platelets, ↑ PT, ↑ INR - **Infection & peritonitis (spontaneous bacterial peritonitis)** - Peritonitis w/o intra-abdominal source - Likely results from translocation of intestinal flora - Bacteria ascites - Treat with antibiotics - May lead to hepatorenal syndrome - **Hepatorenal syndrome** - Rapid deterioration of kidney function in patients with liver disease - **Hepatopulmonary syndrome** - Secondary to dilated blood vessels in pulmonary system secondary to liver disease leading to hypoxemia & shortness of breath - **Ascites** - **Portal obstruction & ascites are late manifestations of cirrhosis** - **Causes** - **Blood can't flow well through liver →** - Vasodilation splanchnic circulation - Blood backs up into spleen & GI tract becomes congested - **Liver fails to metabolize aldosterone** - ↑ Na^+^ & H~2~O retention - ↑ intravascular fluid volume - **↓ synthesis of albumin by damaged liver → ↓ oncotic pressure** - **Manifestations** - ↑ abdominal girth, rapid weight gain - Shortness of breath - Discomfort, large abdomen, umbilical hernias - Striae & distended veins - Fluid & electrolyte imbalances - **Assessment** - **Detected through perfusion, shifting dullness or fluid wave** - **Flanks bulge in supine position** - **Record/monitor abdominal girth & body weight** - Ultrasound & CT scans - **Complications** - Can lead to an altered bowel function - Protein/albumin rich fluid accumulates in peritoneal cavity - 20L or more may accumulate - ↓ albumin in serum → ↓ oncotic pressure of serum → ↑ fluid accumulate in peritoneal cavity - ↑ portal pressure results in movement fluid into peritoneal cavity - **Medical Management** - **Dietary modifications** - **Low sodium diet** - If doesn't improve w/ \< 2g daily, may be restricted to 500 mg daily - Caution some salt substitutes include - Ammonia (hepatic encephalopathy) - Potassium (caution renal impairment) - **Diuretic agents** - **Spironolactone- First line therapy** - K+ sparing - **Furosemide second line** - Can cause hyponatremia in the long term - **Daily weight goal \< 2.2 lb (1 kg gain) per day** - **Fluid restrict only if Na+ low** - Encephalopathy can ↑ with dehydration & hypovolemia - **Medical Management of Cirrhosis** - Can't reverse fibrosis - Goal to stop it or slow down - Based on symptoms - Vitamin & nutritional supplements/management - Potassium sparing diuretics - Lactulose or Rifaximin - Avoidance of alcohol - **Paracentesis** - Removal of fluid from peritoneal cavity - Done through puncture in abdominal wall - Ultrasound guidance - Diagnostics & therapeutic - Examination of ascitic fluid - Treatment of high-volume ascites - Large volume (5-6L) safe to treat - Administration of albumin or other colloid - ↓ incidence of circulatory & renal dysfxn, hyponatremia - ↓ rapid re-accumulation of ascites - Temporary removal of fluid - Ascites rapidly recurs - Require repeat fluid removal - **Trans jugular intrahepatic portosystemic shunt (TIPS)** - Cannula placed in portal vein to ↓ portal HTN - Stent inserted between portal circulation & hepatic vein - Effective ↓ Na+ retention, improve renal response diuretics - Prevent recurrence fluid accumulation - Treat refractory ascites - ↑ risk of encephalopathy - Cost \> paracentesis - Typically 2^nd^ line therapy - Ascites in cirrhosis 50% mortality rate - **Nursing management** - Vital signs, I & O monitoring - Abdominal girth measurement - Daily weight, nutritional assessments - Parenteral nutrition if GI tract needs rest - Vitamin supplements - Folic acid & iron supplements - Nutritional supplements - Eliminate alcohol - Encourage small frequent meals - Low sodium diet - Neurologic assessments - Respiratory status - Serum ammonia, creatinine, & electrolyte levels - Signs hepatic encephalopathy - Skin care, lotions for irritated skin - ↓ risk of falls - Provide emotional support - Assess delirium, withdrawal - Serum ammonia level - Protein intake maintain at 1.2-1.5 g/kg/day - Electrolyte monitoring - Discontinue sedatives, tranquilizers, & analgesics, when possible - **Educate** - Low Na+ diet, medications, avoid alcohol - Check w/ provider before starting new meds or supplements - **Liver biopsy** - **Needle aspiration small amount tissue** - **Evaluate disorders of liver parenchyma & lesions** - **Most common complications** - Bleeding - Peritonitis - r/t blood or bile in peritoneum after - **Prior to biopsy** - Coagulation studies- treat abnormalities prior - **Post biopsy position** - Pt lay on right side - **Liver Cancer** - **Primary liver cancer is uncommon** - **Risk factors** - Hepatitis, chronic liver disease, cirrhosis, chemical exposure - **75% of liver cancers are hepatocellular carcinoma** - 2^nd^ leading cause of cancer r/t mortality - Rare in the US - Typically, unresectable due to rapid growth & metastasis - Early detection is not common - **Metastasis from other sites to the liver is more common than primary liver cancer** - **Clinical manifestations** - **Pain first signs** - Continuous dull ache in RUQ, epigastrium or back - Weight loss, decrease strength, anorexia, anemia - Enlarged irregular liver - Jaundice, if bile ducts occluded - Ascites, if obstruct portal veins - Other manifestations - ↑ bilirubin, alkaline phosphatase, AST, LDH - Hypercalcemia, hypoglycemia possible - Serum alpha-fetoprotein tumor marker - ↑ in 80-90% of patients - Levels \> 200 ng/mL - **Diagnostics** - X-rays, CT scans, MRI's - Don't typically do biopsy unless unable to resect r/t high risk of seeding the tumor &/or bleeding - **Treatment** - **Radiation therapy** - **External beam**- not traditionally used - **More common trans-arterial & percutaneous interstitial radiation therapy** - Delivers treatment right to the cells - **Chemotherapy** - For advanced liver cancer - Sorafenib- targeted therapy standard - Systemic chemo may be used but has variable effectiveness - Embolization of tumor with chemo → necrosis of tumor - **Palliative percutaneous biliary drainage** - Bypass biliary ducts to drain bile when outflow is obstructed - **Complications** - Sepsis - Leakage of bile - Hemorrhage - **Immunotherapy** - **Transcatheter arterial embolization** - **Surgical management** - Lobectomy - Local ablation - Liver transplantation - **Liver transplantation** - **Indications** - **Treat life threatening irreversible end stage liver disease r/t** - Acute liver failure - Metabolic liver diseases, hepatitis, primary biliary cirrhosis - Some hepatic malignancies, sclerosing cholangitis, NASH, etc. - **Goal to perform before disease progresses to GI bleeding & hepatic coma** - **Total removal of diseased liver** - **Replaced with healthy liver from deceased donor or right lobe of living donor** - **Pre-transplant screenings** - Evaluation of physical & mental health - Hepatic reserve - Likelihood of survival - Past medical history - Degree of need - **Model for End-Stage Liver Disease (MELD) classification** - Level of illness & prediction of 3-month mortality - Includes information on patients' bilirubin levels, INR, creatinine, serum sodium - Indicator of short-term mortality - Assists w/ allocation of organs to most severely ill - Score range from 6 (less severe) to 40 (more severe) - **Pt on call for transplant, need to be available** - **During waiting time may deteriorate further** - May experience complications progressing disease - Many die on waiting list - Goal to treat - Malnutrition, massive ascites, fluid/electrolyte disturbances treat pre surgery - **Ethical considerations** - **Liver transplant** - **Milan criteria transplant in liver cancer** - Single tumor \< 5 cm OR [\ 3 cm in size - ↓ recurrence of liver malignancy post-transplant - Risk of metastasis & recurrence enhanced by immunosuppressive therapy - **Living donor transplant possibility** - Living adult to another adult using right lobe - When pt likely would die while waiting for deceased liver - Careful screening criteria - Major surgery, can lead to complications & even death for donor - **Living donor evaluated by donor team** - Healthy - Hepatic size & anatomy compatible w/ right lobe transplant - Extensive informed consent - Donor advocate team- focuses on donor needs and safety especially in intra & post op period - Clear separations donor & recipient teams - Thorough physical & psychological workup - Coercion must be excluded - **Liver transplant surgical procedure** - Connections of blood vessels & bile duct between donor liver & recipient liver - Biliary anastomosis- t-tube inserted external drainage of bile - If biliary disease may need need Roux-en-Y procedure - **Long procedure** - Portal HTN, many collateral vessels - Extensive blood loss potential - **Post-liver transplant** - **90% one year survival rate** - **Success depends on proper immunosuppression** - Agents include calcineurin inhibitors, cyclosporine, tacrolimus - Corticosteroids used for induction of immunosuppression - Typically multiple agents used - Goal to prevent rejection of transplant - Require these medications for life - **Post-Op Liver Transplant Complications** - **High rate** - **Can be impacted by** - Previous abdominal surgeries, varices, ↓ reserve - Long term systemic problems caused by primary liver disease - **Technical complications reconstructing blood vessels & biliary tract** - **Infection** - Leading cause of death post-transplant - Pulmonary & fungal infections common - ↑ risk of infection due to immunosuppressive therapy - Take precautions to prevent infections - **Rejection** - Major concern - Acute rejection within 4-10 days post op - Signs/symptoms - Tachycardia - Right quadrant pain - Jaundice - Fever - ↑ AST/ALT - **Bleeding intra-operatively & post-operatively** - Common - Intra-operative or post-operative bleeding - May be r/t ischemic injury to donor liver → Coagulopathy, portal HTN, fibrinolysis - Administration platelets, FFP, or blood products - Hemodynamic instability- hypotension r/t - Blood loss, loss of vasomotor tone, vasodilation - Monitor CBC, coagulation factors, electrolytes, etc. - **Obstruction biliary drainage** - **Hypertension** - Calcium channel blockers - Vasodilatory effect, agent of choice - Low interact CYP 450 - ACE & ARB not first line first year post op due to low levels of renin - Thiazide diuretics used when pt need more than one med for BP control - Life-style modifications, low sodium diet & exercise regimen - **Vascular thrombosis or stenosis** - **Nursing management** - Interdisciplinary care many people involved - Pt may need to consider relocation & use of financial resources - Psychosocial implications - Stressful waiting - For living donor transplant - Both pt & donor undergo extensive physical & psychological workup - **Post-op** - Infection prevention - Administration of immunosuppressive medications - Monitor cardiac, pulmonary, renal neurologic, metabolic functions closely - Urine output, heart rate, blood pressure, oxygen saturation, etc. - Liver function tests, electrolyte levels, coagulation studies, LFT's - Bile from t-tube, drain monitoring - Monitor signs rejection - Living donor also closely monitored