Hepatic GI with notes Fall 2010

Chapter 39Assessment and Management of Patients With Hepatic Disorders : 

Chapter 39Assessment and Management of Patients With Hepatic Disorders

Anatomy and Physiology of the Liver : 

Anatomy and Physiology of the Liver Largest gland of the body Located in the upper right abdomen A very vascular organ that receives blood from the GI tract via the portal vein and from the hepatic artery Circulation into the liver Portal vein (drains the GI tract)- rich in nutrients,, lacks oxygen Hepatic artery- rich in O2 Hepatic vein drains liver and empties into inferior vena cava

Metabolic Functions : 

Metabolic Functions Glucose metabolism- glucose converted to glycogen & stored in the liver. Ammonia conversion- from protein breakdown Protein metabolism- albumin, clotting factors, prothrombin Fat metabolism- esp. during times of starvation Vitamin and iron storage- Vitamin A, B, D, copper and iron Drug metabolism- Bile formation Bilirubin excretion

Gerontologic Considerations of Liver : 

Gerontologic Considerations of Liver Size and weight decrease Decrease in blood flow Decrease in repair of liver cells Reduced drug metabolism Decline in drug clearance Increase in cholesterol secretion in bile (causing an increased prevalence in gallstones)

Risk Factors for Liver Disease : 

Risk Factors for Liver Disease Alcohol – men who consume more than 4 drinks/day and women who consume more than 3/day Hepatotoxic drugs- acetaminophen (Tylenol), valproic acid (Depekene) and ketonconazole (Nizoral) Drug abuse – either IV or injectable Foreign travel Multiple sexual partners

Liver Function Studies (See Table 39-1) : 

Liver Function Studies (See Table 39-1) ALT, AST, GGT- most freqqently used Serum protein studies Pigment studies: direct and indirect serum bilirubin, urine bilirubin, and urine bilirubin and urobilinogen Prothrombin time Serum alkaline phosphatase Serum ammonia Cholesterol Liver biopsySee Chart 39-2 Ultrasonography CT MRI

Hepatic Dysfunction : 

Hepatic Dysfunction Causes: Most common cause is malnutrition related to alcoholism. Infection- bacteria or virus Anoxia Metabolic disorders Toxins Nutritional deficiencies Hypersensitivity states Manifestations: Jaundice Portal hypertension, ascites, and varices Hepatic encephalopathy or coma Nutritional deficiencies

Jaundice : 

Jaundice Yellow- or green-tinged body tissues, sclera, and skin due to increased serum bilirubin levels Types Hemolytic-increased destruction of RBC’s Hepatocellular- damaged liver cells Obstructive- obstruction of bile duct Hereditary hyperbilirubinemia Hepatocellular and obstructive jaundice types are most associated with liver disease.

Signs and Symptoms Associated with Hepatocellular and Obstructive Jaundice : 

Signs and Symptoms Associated with Hepatocellular and Obstructive Jaundice Hepatocellular Patient may appear mildly or severely ill. Lack of appetite, nausea, weight loss Malaise, fatigue, weakness Headache, chills, and fever if infectious in origin Obstructive Dark orange-foamy urine and light clay-colored stools Dyspepsia and intolerance to fatty foods Pruritus- itchy skin

Portal Hypertension : 

Portal Hypertension Obstructed blood flow through the liver results in increased pressure throughout the damaged liver Results in: Ascites Esophageal varices

Ascites: Fluid in Peritoneal Cavity Due To: : 

Ascites: Fluid in Peritoneal Cavity Due To: Portal hypertension stimulates vasoldlation and the renin angiotensin system which decreases metabolism of aldosterone in the liver Decreased synthesis of albumin by the liver End Result is accumulation of fluid in the peritoneal cavity SX: increased abd girth, rapid weight gain, SOB, striae, distended veins over abd wall, umbilical hernias, F&E imbalances

Treatment of Ascites : 

Treatment of Ascites Measure abd girth and patient’s weight daily Low-sodium diet (500mg - 2g Na/day) Diuretics- Spironolactone (Aldactone) Bed rest- prevents activation of the renin-angiotensin system Paracentesis- removal of fluid from peritoneal cavity Administration of salt-poor albumin- helps increase blood volume which will decrease Na retention Transjugular intrahepatic portosystemic shunt (TIPS)

Paracentesis : 

Paracentesis Void prior to procedure Sit upright Monitoring during procedure Monitoring after procedure Monitor puncture site for leaking or bleeding Avoid heavy lifting or straining

Paracentesis TIPS : 

Paracentesis TIPS

Nursing Management of Ascites : 

Nursing Management of Ascites Monitor I/O’s Measure Abdominal girth q shift Daily weights Monitor labs (electrolytes, ammonia levels, albumin) Avoid all alcohol and adhere to low sodium diet Consult doctor before taking any new medications Instruct on importance of follow-up care Teach self care (dietary, daily weights, abdominal girth, medications)

Esophageal Varices : 

Esophageal Varices Develop in the majority of patients with cirrhosis Develop in the esophogus, stomach or as hemorrhoids Manifestations include hematemesis, melena, general deterioration, and shock.(cool clammy skin, hypotension, tachycardia) Patients with cirrhosis should undergo screening endoscopy every 2 years.

Treatment of Bleeding Varices : 

Treatment of Bleeding Varices Treat shock Oxygen IV fluids, electrolytes, and volume expanders Blood and blood products Vasopressin- causes vasoconstriction Nitroglycerin may be used in combination with vasopressin to reduce coronary vasoconstriction. Beta blockers to decrease portal pressure; used to prevent an episode of bleeding Invasive Interventions

Balloon Tamponade: Sengstaken-Blakemore Tube : 

Balloon Tamponade: Sengstaken-Blakemore Tube

Endoscopic Sclerotherapy : 

Endoscopic Sclerotherapy

Esophageal Banding : 

Esophageal Banding

Portal Systemic Shunts : 

Portal Systemic Shunts

Hepatic Encephalopathy and Coma : 

Hepatic Encephalopathy and Coma A life-threatening complication of liver disease. May result from the accumulation of ammonia and other toxic metabolites in the blood. Stages Asterixis Constructional Apraxia

Medical Management for Hepatic Encephalopathy : 

Medical Management for Hepatic Encephalopathy Eliminate precipitating cause. Lactulose (Chronulac) to reduce serum ammonia levels IV glucose to minimize protein catabolism Protein restriction Administer neomycin or metronidazole (Flagyl)- decrease ammonia producing bacteria in the GI Discontinue sedatives, analgesics, and tranquilizers.

Nursing Management of Hepatic Encephalopathy : 

Nursing Management of Hepatic Encephalopathy Provide a safe environment Dietary restrictions Limit protein Give animal protein instead of vegetable protein Small frequent meals of complex carbohydrates Daily weights and monitor strict I/O’s Frequent neuro and vital sign checks Monitor bowel movements

Hepatitis (See Chart 39-6) : 

Hepatitis (See Chart 39-6) Viral hepatitis: a systemic viral infection that causes necrosis and inflammation of liver cells with characteristic symptoms and cellular and biochemical changes A B C D E Hepatitis G and GB virus-C Nonviral hepatitis: toxin- and drug-induced

Hepatitis A (HAV) : 

Hepatitis A (HAV) Fecal-oral transmission and also with sexual contact Spread primarily by poor hygiene; hand-to-mouth contact, close contact, or through food and fluids Manifestations: mild flu-like symptoms, low-grade fever, anorexia- often severe, later jaundice and dark urine, Prevention- handwashing, proper disposal of sewage, safe water supplies Vaccination- 2-3 injections over course of a year, for those traveling abroad with poor sanitation, and for high risk groups (homosexual men, IV drug users, staff of day care centers and health care personnel) Immune Globulin- IM admin within 2 weeks of exposure will suppress sx of disease and provide immunity. Also for household members/sexual partners of diagnosed patient

Hepatitis B (HBV) : 

Hepatitis B (HBV) Transmitted through blood, saliva, semen, and vaginal secretions, sexually transmitted, transmitted to infant at the time of birth SX: insidious and variable, similar to hepatitis A, as well as arthralgias and rashes At risk: drug addicts, long-term hemodialysis patients, healthcare personell Prevention- screen blood donors, safety syringes, needless IV systems, Hepatitis B immune globulin- if exposed Vaccine- for those at high risk, pt with Hepatitis C, pt with STD Administered IM (deltoid) in 3 doses.

Hepatitis C : 

Hepatitis C Transmitted by blood and sexual contact, including inadvertent needle sticks, sharing of needles, Risk factors: healthcare worker, IV drug users, sexually active with multiple partners, receiving frequent transfusions A cause of 1/3 of cases of liver cancer and the most common reason for liver transplant Symptoms are usually mild similar to Hepatitis B Chronic carrier state frequently occurs.

Hepatitis D, E, and G : 

Hepatitis D, E, and G Hepatitis D Only persons with hepatitis B are at risk for hepatitis D. Transmission is through blood and sexual contact. Symptoms and treatment are similar to hepatitis B, but patient is more likely to develop fulminant liver failure and chronic active hepatitis and cirrhosis. Hepatitis E Transmitted by fecal-oral route Resembles hepatitis A and is self-limited, with an abrupt onset. No chronic form. Hepatitis G Non A, non B, non C Hepatitis Similar to hepatitis C

Other Liver Disorders : 

Other Liver Disorders Nonviral hepatitis Toxic hepatitis Drug-induced hepatitis Fulminant hepatic failure

Hepatic Cirrhosis : 

Hepatic Cirrhosis Types: Alcoholic Postnecrotic Biliary Liver enlargement, portal obstruction and ascites, gastrointestinal varices, edema, vitamin deficiency and anemia, mental deterioration

Symptoms of Liver Dysfunction : 

Symptoms of Liver Dysfunction

Cancer of the Liver : 

Cancer of the Liver Primary liver tumors Few cancers originate in the liver. Usually associated with chronic liver disease and hepatitis B and C Liver metastasis Liver is a frequent site of metastatic cancer. Manifestations Pain, dull continuous ache in RUQ, epigastrium, or back Weight loss, loss of strength, anorexia, anemia may occur. Jaundice if bile ducts occluded, ascites if obstructed portal veins

Nonsurgical Management of Liver Cancer : 

Nonsurgical Management of Liver Cancer Underlying cirrhosis, which is prevalent in patients with liver cancer, increases risks of surgery. Major effect of nonsurgical therapy may be palliative. Radiation therapy Chemotherapy Percutaneous biliary drainage Laser hyperthermia

Surgical Management of Liver Cancer : 

Surgical Management of Liver Cancer Treatment of choice if confined to one lobe and liver function is adequate Liver has regenerative capacity. Types of surgery Lobectomy Cryosurgery Liver transplant

Liver Transplant : 

Liver Transplant