Week 14 Care of Patients with Liver Problems PDF

Week 14 Care of Patients with Liver Problems Liver has more than 500 functions Affects every single system in the body Largest organ in our body If it is diseased digestion , nutrition, and metabolism will be affected We can not live without a liver Cirrhosis of the liver (chr...

Week 14 Care of Patients with Liver Problems Liver has more than 500 functions Affects every single system in the body Largest organ in our body If it is diseased digestion , nutrition, and metabolism will be affected We can not live without a liver Cirrhosis of the liver (chronic liver disease) Scarring of the liver (extensive irreversible) ○ Chronic reaction of hepatic inflammation ○ Necrosis ○ Develops over years not weeks major cause of cirrhosis in US ○ chronic alcoholism ○ hepatitis C major cause in other countries ○ hepatitis B ○ hepatitis D Pathophysiology of Cirrhosis Fibrotic bands of connective tissue ○ scarring of liver called fibrosis hepatic inflammation ○ toxins destruction of liver cells  nodular tissue ○ blocks bile ducts ○ block the normal blood flow to the liver ○ liver enlarges and firm in early stage If MD is able to palpate the liver they know that you drink alcohol Then tests will be done to see if liver enzymes are elevated ○ as the process progresses the liver will shrink Decrease liver function ○ Asymptomatic 40% of patients are asymptomatic liver enzymes will be elevated Bilirubin Produced by the normal breakdown of red blood cells High levels show that the red blood cells are broken down to fast and liver is not breaking down waste properly and clearing it from the blood elevated albumin level will be low in cirrhosis and liver disease normal level 3.5-5.0 mg/dL Low indicates chronic liver disease or cirrhosis Main proteins in our body Maintains the oncotic pressure in the blood  When levels are low it causes a decrease in oncotic pressure and this allows fluid to leak from intravascular spaces into the peritoneal cavity ○ Ascites will occur ○ Large belly ○ Pressure on the diaphragm patients will have difficulty breathing ○ diaphragm will be obstructed and patients will need to be upward to be able to breathe liver function tests ○ increase AST ○ Increase of ALT ○ Increase of Alkaline phosphatase Types of Liver Cirrhosis Laennec’s or alcoholic Cirrhosis post necrotic cirrhosis ○ viral hepatitis ○ tylenol overdose antidote that is given is charcoal and then mucomyst it will decrease the effect and prevent to cause damage to liver and prevent the liver going into liver failure biliary cirrhosis ○ chronic biliary obstruction ○ gallbladder disease cardiac cirrhosis  ○ heart failure Complications of Cirrhosis Portal hypertension ○ impaired blood flow through the liver because of increased resistance of fibrosis scar tissue from degeneration of liver tissue ○ sluggish blood flow through the liver and that results in an increased pressure in the portal circulation and that leads to portal hypertension ○ venous drainage of GI tract becomes quite congested ○ blood that backups into the spleen ○ Splenomegaly increased pressure blood backs up into the spleen: holds platelets in our body ○ veins in esophagus, in the stomach, intestines, abdomen, and in the rectum become quite dilated during portal hypertension and end result it becomes elevated venous pressure in the esophagus and lead to bleeding esophageal varices Gastric varices hemorrhoids Ascites Collection of fluid in the peritoneal cavity ○ decreased circulating plasma protein ○ decreased albumin production ○ decreased colloid osmotic pressure ○ fluid shift from the vascular system to the abdomen  ○ results in a form of 3rd spacing reduction of albumin decrease in osmotic pressure Jaundice is a complication of cirrhosis and its described as a yellow discoloration of the skin ○ sclera of eye will be yellow ○ two mechanisms hepatocellular disease liver cells can not excrete bilirubin effectively excessive bilirubin intrahepatic obstruction edema fibrosis scarring of the hepatic ducts Esophageal Varices Affects 50% of patients with cirrhosis ○ hematemesis- vomiting blood ○ melena- black tarry stools 30% will hemorrhage within 2 years of diagnosis very foul smelling melena is old blood active bleeding is bright red blood ○ loss of consciousness due to internally bleeding ○ hypovolemic shock ○ loss of blood 4-500 cc of blood ○ blood pressure will drop ○ heart rate will increase  ○ mortality rate 50% for those that hemorrhage During Cirrhosis production of bile is decreased ○ Prevents the absorption of fat soluble vitamins vitamin K Without this there are certain clotting factors of II, VII, IX, and X are not going to be produced in sufficient quantities This puts patients at risk to bleed out 30% of patients will hemorrhage upon diagnosis within 2 years fat soluble vitamins A ○ vision ○ especially night vision D ○ Softening of bones ○ risk of bone fractures E ○ cells become more stressed K ○ coagulation and blood clotting Treatment for Esophageal Varices Fluid resuscitation ○ IV ○ antecubital area of each arm blood transfusions ○ if they are bleeding  ○ O negative will be given ○ you have to have another RN to verify the blood that is being given platelets will be given ○ normal 150,000-450,000 ○ 95-98% cure rate harvoni ○ 12 weeks >97-99% cure rate cost ○ $26,000 a month for 3 months ○ generic is $10,000 a month ○ copay $9,600 insurance pays $300 ○ hepatitis D virus (HDV) requires the presence of HBV to replicate transmitted by blood clinical course more severe compared to other viruses defective RNA virus having sex with a person with hepatitis D clay color stool dark urine liver has diminished ability to excrete bilirubin bilirubin gives the brown color to stool that is why it is clay color Use same measures to not pass this virus avoiding IV drug use  safe sex making sure blood transfusions are screened no treatment Clinical course is more severe than other Hepatitis virus persistence of Hep D virus is determined by the duration of Hepatitis B Hepatitis D virus accelerates the process of liver disease associated with Hepatitis B ○ hepatitis E virus (HEV) (acute cause) recent travel out of the country to developing countries contamination through oral route waterborne prevalent in Asia, Africa, Middle East, south and central america don’t eat undercooked food undercooked pork ○ parasite and goes to the brain no prophylaxis just make sure you drink bottled water do not use frozen ice hand wash Do not eat undercooked foods Cancer of the Liver Metastatic process, rarely a primary sight of cancer  ○ usually the primary sight will be in a different organ and then spreads to the liver early stage is without symptoms Later in the disease ○ weight loss unexpected weight loss usually signifies cancer ○ anorexia ○ weakness ○ RUQ pain ○ jaundice ○ bleeding Treatment of Liver Cancer Surgical intervention ○ if there is only cancer to liver then it can be removed a lobe can be removed if removed lifespan could be 5 years ○ if you have cancer elsewhere on body and liver this is not good radiation therapy is not an option ○ liver can not tolerate high dose of radiation chemotherapy ○ poor prognosis ○ quite ineffective for liver cancer transplantation ○ hepatitis C can be a good candidate but treatment has to have been completed  treatment has to be done so the new liver will not be affected ○ liver will regenerate ○ you can be a live donor and donate a portion of your liver when diagnosed with liver cancer your outcome to live is not a positive outcome ○ plan for hospice care ○ death Liver Transplantation Best candidate for transplantation ○ end stage liver disease ○ primary liver cancer patients not considered for transplantation ○ active alcoholics or substance abuse ○ metastatic tumors liver is only organ the regenerates Post Transplantation Common complications graft rejection and infection immunosuppressant therapy ○ cyclosporine- hypertension and renal insufficiency ○ tacrolimus- hypertension and renal insufficiency steroids ○ prednisone- causes hypertension and hyperglycemia vaccinations and antibiotics COVID 19 vaccination before transplantation  antibiotics should be administered postoperatively if infections develops