4 A and P ReviewLargest internal organ-weighs around 3 lbs!
5 A LiverB Hepatic veinC Hepatic arteryD Portal veinE Common bileductF StomachG Cystic ductH Gallbladder
6 Blood Supply – 2 sources Hepatic artery: Portal vein – 1000ml/min 500ml/min of oxygenated blood.30% of Cardiac output goes to the liverPortal vein – 1000ml/minpartly oxygenated blood supplies % O2 plus rich supply of nutrients, toxins, drugsfrom stomach, small and large intestines, pancreas and spleen
7 Hepatic Blood Supply (Cont’d) Both empty into capillaries/sinusoidsLiver filters the bloodHepatic vein to inferior vena cava
10 Metabolic Functions of the liver “Body’s Refinery” Over 400 functionsPrimary role in anabolism and catabolismPrompt: who remembers anabolism? And catabolism?Anabolism- simple to complex (ie glucose to glycogen)Catabolism- complext to simple (ie glycogen to glucose)
11 Metabolic Functions of the Liver 1. Metabolism of Glucose2. Protein Storage3. Fatty acids4. CholesterolGlucagon- from pancreas, causes liver to break glycogen back down to glucose into bloodstream. However, also stimulates insulin so that the glucose can be used by body’s cells
12 Other functions Immunologic Blood storage Plasma protein synthesis ClottingWaste products of hemoglobinFormation and secretion of bileSteroids and hormonesAmmoniaDrugs, alcohol and toxins metabolism
13 To Summarize…. The liver: changes food into energy removes alcohol and poisons from the bloodmakes bile, a yellowish-green liquid that helps with digestion
14 Hepatitis Simply means inflammation of the liver Viral hepatitis “itis” means inflammation, “hepa” means liver.Viral hepatitisMost common causeViral types include A, B, C, D, E, and G
15 Hepatitis Other possible causes Drugs (alcohol) Chemicals Autoimmune liver diseaseBacteria (rarely)
16 Hepatitis Etiology Causes A, B, C, D, E, and G virus Cytomegalovirus Epstein-Barr virusHerpes virusCoxsackie virusRubella virus
17 Hepatitis A Hepatitis A virus (HAV) RNA virus Transmitted fecal–oral route, parenteral (rarely)Frequently occurs in small outbreaks
18 Hepatitis A61,000 cases of hepatitis A occur annually in the United States10 million cases of hepatitis A occur worldwideNearly universal during childhood in developing countries
19 Hepatitis A Hepatitis A virus (HAV) Found in feces 2 or more weeks before the onset of symptoms and up to 1 week after the onset of jaundicePresent in blood brieflyNo chronic carrier state
20 Hepatitis A: Incubation Period 2-6 weeksAcute onsetMild flu-like manifestationsSymptoms last up to 2 monthsLiver usually repairs itself, so no permanent effects
21 Hepatitis A Hepatitis A virus (HAV) Anti-HAV immunoglobulin M (IgM) Appears in the serum as the stool becomes negative for the virusDetection of IgM anti-HAV indicates acute hepatitis
22 Hepatitis A Hepatitis A virus (HAV) Anti-HAV immunoglobulin G (IgG) IgG anti-HAV: Indicator of past infectionPresence of IgG antibody provides lifelong immunity
23 Hepatitis A: Mode of Transmission Mainly by ingestion of food or liquid infected with the virusPoor hygiene, improper handling of food, crowding housing, poor sanitation conditions are all factors related to Hepatitis A
24 Hepatitis A: Mode of Transmission (Cont’d) Occurs more frequently in underdeveloped countriesContaminated watersDrinking water, contaminated seafoodFood-borne Hepatitis A outbreaks usually due to infected food handlerContamination of food during preparation
26 Hepatitis A: Vaccine2 doses IMInitial doseBooster in 6 to 12 months
27 Post-exposure Prophylaxis Standard IG-immune globulinGiven IM within 2 weeks of exposureHepatitis A VaccineIG is recommended for persons who do not have anti-HAV antibodies and have had food borne exposure or close contact with HAV-infected person
28 Remember 2/2/2/2 Rule 2 doses IM for vaccination Signs & symptoms last 2 monthsContagious 2 weeks before signs & symptomsPost-exposure dose given IM within 2 weeks of exposureMust report within one day
29 Hepatitis B Nearly 400 million people infected with Hepatitis B 50% to 75% active viral replication73,000 new cases of Hepatitis B annually in United StatesIncidence decreased due to HBV vaccine29
30 Hepatitis B Hepatitis B virus (HBV) DNA virus Transmission of HBV Perinatally by mothers infectedPercutaneously (IV drug use)Mucosal exposure to infectious blood, blood products, or other body fluids
31 Hepatitis B Hepatitis B virus (HBV) Transmission occurs when infected blood or other body fluids enter the body of a person who is not immune to the virus
32 Hepatitis B Hepatitis B virus (HBV) Sexually transmitted disease Can live on a dry surface for 7 daysMore infectious than HIV
33 Hepatitis B- Precautions Source: Uptodate PREVENT INFECTION OF FAMILY — Acute and chronic hepatitis B are contagious. Thus, people with hepatitis B should discuss measures to reduce the risk of infecting close contacts. This includes the following:Discuss the infection with any sexual partners and use a latex condom with every sexual encounter.Do not share razors, toothbrushes, or anything that has blood on it.Cover open sores and cuts with a bandage.Do not donate blood, body organs, other tissues, or sperm.
34 Hepatitis B- Precautions Source: Uptodate Immediate family and household members should have testing for hepatitis B. Anyone who is at risk of hepatitis B infection should be vaccinated, if not done previously. (See "Patient information: Adult immunizations".)Do not share any injection drug equipment (needles, syringes).Clean blood spills with a mixture of 1 part household bleach to 9 parts water.
35 Hepatitis B- Prevention Hepatitis B cannot be spread by:Hugging or kissing* (some disagreement)Sharing eating utensils or cupsSneezing or coughingBreastfeedingSource: Uptodate
36 Hep B Incubation Period 6-24 weeksPreventionVaccine-3 dosesInitial doseDose at 4 weeksDose 5 months later
37 Post-exposure Hep B Hepatitis B Immune globulin IM in 2 doses First dose within 24 hours to 7 days of exposureSecond dose 20 to 30 days post-exposureProvides short-term immunityGive HBV vaccine concurrently- vaccine can be beneficial post- exposure
38 Hepatitis B Hepatitis B virus (HBV) Complex structure with three antigensSurface antigen (HBsAg)Core antigen (HBcAg)E antigen (HBeAg)Each antigen—a corresponding antibody may develop in response to acute viral Hepatitis B
39 Hepatitis B Virus Presence of Hepatitis B Surface Antibodies Indicates immunity from HBV vaccinePast HBV infectionWith chronic infection, liver enzyme values may be normal or ↑15% to 25% of chronically infected persons die from chronic liver disease
40 Hepatitis CApproximately 170 million people are infected with the hepatitis C virus (HCV)Estimated 30,000 new cases diagnosed annually40
41 Hepatitis C8000 to 10,000 people in the United States die each year from complications of end-stage liver disease secondary to HCVApproximately 30% to 40% of HIV-infected patients also have HCV41
42 Hepatitis C Hepatitis C virus (HCV) Transmitted primarily percutaneouslyRisk factorsIV drug useMost common mode of transmission in United States and CanadaBlood transfusions
43 Hepatitis C Hepatitis C virus (HCV) Risk factors (cont’d) Hemodialysis High-risk sexual behaviorHemodialysisOccupational exposurePerinatal transmission
44 Hepatitis C: Transmission Hepatitis C virus (HCV)Up to 10% of patients with HCV cannot identify a sourceRisk of body piercings, tattooing, and intranasal drug use in transmission of HCV
45 Hepatitis C Diagnostic Studies Anti-HCV antibodyHCV RNA45
56 Icteric or Jaundice Phase Usually 5-10 days after pre-icteric symptomsJaundice results when bilirubin diffuses into tissuesSclera jaundicedUrine darkens due to excess bilirubin being excretedIf bilirubin cannot flow out of liver, stool will be light or clay-colored
62 Fulminant HepatitisResults in severe impairment or necrosis of liver cells and potential liver failureDevelops in small percentage of patientsOccurs because ofComplications of Hepatitis BToxic reactions to drugs and congenital metabolic disorders
63 Diagnostic tests Liver function studies ALT (Alanine aminotransferase) – elevates: enzyme in liver cells released into bloodstream with injury or disease (0 – 50) normalAST (Aspartate aminotransferase) – elevates: enzyme in liver & heart cells released into bloodstream (0 -41)GGT – gamma glutamyltransferase: present in all cell membranes, inj or disease = elevates in cell lysis, (8 – 55). increases when bile ducts are blocked & hepatitis. Elevated until function returns.
64 Diagnostic testsAlkaline phosphatase – present in liver & bone cells. Elevated in hepatitis.( IU/L)CBC – low RBC, Hct, Hgb related to anemia, RBC destruction, bleeding, folic acid and vitamin deficiencies.Low WBC and PlateletsIncreased blood flow to spleen – cells destroyed faster than neededAFP- alpha fetoprotein– liver cancer markerLactic dehydrogenase LDH5 specific for liver damage
65 Diagnostic tests Bilurubin – direct/conjugated (0-4 umol/L) Coagulation – prolonged prothrombin time due to poor production of prothombin by liver and decreased Vitamin K absorption (Normal PT seconds, INR 0.8 to 1.2)Hyponatremia –hemodilutionHypokalemia, hypophosphatemia, hypomagnesemia –malnutrition & renal lossBilirubin – Total (2-14 umol/L)Bilurubin – direct/conjugated (0-4 umol/L)Changed this slide- prothombin! (not PT/INR)
66 Diagnostic testsSerum albumin – low due to impaired liver production (3.3 – 5)Serum ammonia – high (0 – 150)(10 to 80 ug/l)Glucose and cholesterol –abnormal due to impaired liver functionAbd. Ultrasound – liver size, ascites, ornodulesEsophagascopy – look for varicesLiver biopsyCT, MRI
67 Rx Impacting LiverA host of medications can cause abnormal liver enzymes levels. Examples include:Pain relief medications such as aspirin, acetaminophen (Tylenol), ibuprofen (Advil, Motrin), naproxen (Narosyn), diclofenac (Voltaren), and phenylbutazone (Butazolidine)Anti-seizure medications such as phenytoin (Dilantin), valproic acid, carbamazepine (Tegretol), and phenobarbitalAntibiotics such as the tetracyclines, sulfonamides, isoniazid (INH), sulfamethoxazole, trimethoprim, nitrofurantoin, etc.
68 Rx Impacting LiverCholesterol lowering drugs such as the "statins" (Mevacor, Pravachol, Lipitor, etc.) and niacinCardiovascular drugs such as amiodarone (Cordarone), hydralazine, quinidine, etc.Anti-depressant drugs of the tricyclic type (ie elavil)With drug-induced liver enzyme abnormalities, the enzymes usually normalize weeks to months after stopping the medications.
69 Liver Biopsy Needle biopsy Laparoscopic biopsy: Most common in past Used to remove tissue from specific parts of the liver.
70 Liver Biopsy (Cont’d) Transvenous biopsy Catheter into a vein in the neck and guiding it to the liver.A biopsy needle is placed into the catheter and advanced into the liver.Used for patients with blood-clotting problems or excess fluid
73 Liver Biopsy Adequacy of clotting- PT/ INR, Platelets (Vit. K?) Type and cross match for bloodUsually hold aspirin, ibuprofen, and anticoagulantsChest x-rayConsent form & NPO 4 to 8 hr.
74 Liver Biopsy (Cont’d) Consent form & NPO 4 to 8 hr. Vital signs & Empty bladderSupine position, R arm above headHold breath after expiration when needle insertedBe very still during procedure – 20 minutes
77 Complications are:Puncture of lung or gallbladder, infection, bleeding, and pain.
78 After Needle Liver Biopsy Pressure to site, place pt on Rt side to maintain site pressure minimum of 2 hrs. & flat hrs.Vital signs & check for bleedingNPO X 2H afterAssess for peritonitis, shock, & pneumothoraxRt. shoulder pain commoncaused by irritation of the diaphragm muscleusually radiates to the shoulder for a few hours or days.
79 After Needle Biopsy (Cont’d) Soreness at the incision siteAvoid aspirin or ibuprofen for pain control for the first week because they decrease blood clotting, which is crucial for healing. CONSULT HEALTHCARE PROVIDER!Avoid coughing, straining, lifting x 1-2 weeks
80 Hepatitis Care Rest is a priority! Diet –High calorie & protein, Low fatVitamin supplement – B complex & KAvoid alcohol & drugs detoxed in liverLife style changes
99 Cirrhosis Pathophysiology Cirrhosis is the end stage of chronic liver diseaseProgressive, leads to liver failureInsidious, prolonged courseNinth leading cause of death in United StatesTwice as common in men
100 Cirrhosis Pathophysiology Hepatocytes are destroyed and portal hypertension developsLiver cells attempt to regenerateRegenerative process is disorganizedFunctional liver tissue is destroyed and scarring of liver occursNew fibrous connective tissue distorts liver’s normal structure, with impeded blood flow
101 Four Types of Cirrhosis Alcoholic Cirrhosis – formerly called Laennec’sPost necrotic CirrhosisBiliary/obstructive - bile flow obstructed causing damage to liverCardiac- from right side heart failure
102 Alcoholic or Nutritional Cirrhosis (formerly called Laennec’s) Usually associated with alcohol abuseMost common cause of cirrhosisCauses metabolic changes in liver; fat accumulates in liver (fatty liver)Fatty liver potentially reversible if alcohol consumption ceasesSame person came up with the stethescope French doctor.
103 Post Necrotic Cirrhosis Results from complication of viral infections, Hepatitis, or exposure to toxinsLiver shrinks because lobules destroyed, broad bands of scar tissue form within the liver
104 Biliary CirrhosisAssociated with chronic biliary obstruction and infectionRetained bile damages and destroys liver cells, causing fibrosis of liver
105 Cardiac CirrhosisResults from long-standing severe right sided heart failureElevated central venous pressures cause stasis of blood in veins of liver, which leads to fibrosis
106 Early Signs of Cirrhosis Complications and Common Manifestations Hepatomegaly and RUQ painWeight lossWeaknessAnorexiaDiarrhea and constipation
107 Cirrhosis Interventions- Drugs Diuretics-Aldactone (spironolactone): decreases aldosterone levels, K+ sparingLasix (furosemide)Salt-poor albuminNeomycin – decrease ammonia forming organisms. Typically onlyrecommended when unable to tolerate lactuloseLactulose – decreases ammonia forming organisms and inc. acidity of bowel. Goal is 2-3 loose stools per day.Ferrous sulfate and folic acid – to treat anemia/ vitamin deficiency
108 Cirrhosis Interventions- Drugs (Cont’d) Beta blocker: propranolol (Inderal), nadolol- to prevent bleeding of E varices in conjunction with isosorbide mononitrate (Imdur) lowers hepatic venous pressureProton Pump Inhibitors, H2 Receptor Blockers– decrease irritation of varicesSerax (oxazepam) – benzodiazepine for alcohol withdrawal, sedation, sleep. Is metabolized in the liver – use cautiously.
109 Nursing Diagnoses - Cirrhosis Fluid Volume deficitIneffective protection: bleedingDisturbed thought processIneffective breathing patternImpaired skin integrityImbalanced nutrition: less than body requirements
110 Cirrhosis Interventions- Diet and fluids Low protein (sometimes), high carbohydrate, high calorie-if signs of acute hepatic encephalopathyWith cirrhosis and no hepatic encephalopathy, high carbohydrate, high protein, low saltLow sodium-500 mg-2gmsAt first sign of encephalopathy or ammonia level increasing- decrease protein intake (sometimes)Early stage for liver regeneration- need high protein-(75-100gms)
111 Later Manifestations of Cirrhosis Jaundice Jaundice occurs as a result of the decreased ability to conjugate and excrete bilirubinIn the late stages of cirrhosis, patient is usually jaundiced
114 Cirrhosis- Hepatocellular or intrahepatic jaundice Diseased liver cells can’t clear normal amounts of bilirubin from the blood.
115 Obstructive or Extrahepatic Jaundice Due to the interference with the flow of bile in the hepatic duct.Liver is conjugating bilirubin but it cannot reach small intestines so is released into blood stream
116 Due to excessive destruction of RBC’s. Hemolytic JaundiceDue to excessive destruction of RBC’s.transfusion reactionFaulty hemoglobin – sickle cellAutoimmune destruction of RBC’s
117 Major Complications of Cirrhosis Portal hypertensionVariceal bleedingAscitesSpontaneous bacterial peritonitisHepatorenal syndromeHepatic encephalopathy
119 Portal HypertensionThe portal vein carries about 1500 ml/min of blood from the small and large bowel, spleen, and stomach to the liver.Any obstruction or increased resistance to flow or, rarely, pathological increases in portal blood flow may lead to portal hypertension with portal pressures over 12 mm Hg.alcoholic and viral cirrhosis are the leading causes of portal hypertension in Western countries.
120 Portal Hypertention (Cont’d) Increases in portal pressure cause development of a portosystemic collateral circulation with resultant compensatory portosystemic shunting and disturbed intrahepatic circulation.These factors are partly responsible for the important complications of chronic liver disease, including variceal bleeding, hepatic encephalopathy, ascites, hepatorenal syndrome, recurrent infection, and abnormalities in coagulation.Variceal bleeding is the most serious complication and is an important cause of death in patients with cirrhotic liver disease.
129 Treatment of esophageal varices Active bleedingCentral line & pulmonary artery pressuresBlood transfusions & fresh frozen plasma for clotting factorsSomatostatin or Vasopressin – constrict gut vesselsNitroglycerin- to counter negative affects of vasopressinAirway/trachLater prevention of re-bleedingBeta-blockersLong-acting nitratesSoft food, chew well, avoid intra-abdominal pressureProtonix (pantoprazole)
131 Sclerotherapy:A sclerosant solution (ethanolamine oleate or sodium tetradecyl sulphate) is injected into the bleeding varix or the overlying submucosaComplications can include fever, dysphagia and chest pain, ulceration, stricture, and (rarely) perforation.
132 Band ligation:Band ligation is achieved by a banding device attached to the tip of the endoscope
134 Balloon Tube Tamponade: The balloon tube tamponade may be life saving in patients with active variceal bleeding if emergency sclerotherapy or banding is unavailableThe main complications are gastric and esophageal ulceration, aspiration pneumonia, and esophageal perforation.
135 Minnesota Tube- Four lumens: one for gastric aspiration two to inflate the gastric and esophageal balloonsone above the esophageal balloon for suction of secretions to prevent aspiration
136 Sengstaken-Blakemore Tube Three Lumens:Esophageal balloon inflationGastric balloon inflationGastric aspiration
137 Long term Management of Esophageal Varices Repeated endoscopic treatmentRepeated endoscopic treatment eradicates esophageal varices in most patients, recurrent variceal bleeding is uncommon.Because portal hypertension persists, patients at risk for recurrent varicesLong term drug treatmentThe use of beta-blockers after variceal bleeding has been shown to reduce portal blood pressures and lower the risk of further variceal bleeding.Prophylactic managementMost patients with portal hypertension never bleed, and it is difficult to predict who will. Beta blockers have been shown to reduce the risk of bleeding.
138 Transjugular Intrahepatic Portosystemic Shunt Special procedures – fistula created with portal vein and hepatic vein and then stents placed to keep it open.Bypasses the liver by returning blood to hepatic vein to inferior vena cava
142 TIPS:Shunted blood containshigh ammoniaCan lead to:hepatic encephalopathy
143 Splenomegaly due to Portal hypertension The spleen enlarges as blood is shunted to splenic veinThis increases rate of destruction of RBCs, WBCs, and plateletsDecreases storage capacity of spleenCauses anemia, leukopenia and thrombocytopenia
144 Ascites – Complication of Cirrhosis Blood flow diverted to mesenteric vesselsIncreased capillary pressure leads to fluid leaving vessels out into peritoneal cavityHigh pressure in liver causes fluid to leave liver into peritoneal cavityThis fluid is plasma filtrate with high concentration of albuminMinerals- Ca++ is attached to albumin decreases so phosphorus increases.K+ is low due to aldosterone
145 Four Factors Lead to Ascites HypoproteinemiaIncreased Na+&H2O retentionIncreased capillarypermeabilityPortal Hypertension
146 Responses to third spacing Loss of albumin to ascites leads to hypoproteinemia, depletion of plasma proteinsLoss of blood volume = lowered BPReflexes aimed at returning blood pressure to normal include release of aldosteroneIncreases reabsorption of NA+ back into blood and H2O follows, thus increasing blood volume
154 Liver FailureComplex syndrome characterized by impairment of many organs and body functionsTwo conditions:Hepatic EncephalopathyHepatorenal Syndrome
155 Hepatic encephalopathy: Alteration in neuro status due to accumulation of ammonia Build-up of other substances such as hormones, GI toxins, drugs also contribute
156 Where does ammonia come from? A by-product of protein metabolismProtein and amino acids are broken down by bacteria in GI tract, producing ammonia.Liver converts this to urea which is eliminated in the urine
157 Precipitating Factors – all place demands on liver Bleeding esophageal varicesIngestion of narcotics or barbiturates, anestheticsExcessive protein intakeElectrolyte imbalanceHemodynamic alterationsDiureticsSevere infectionBlood transfusions
163 Medical Management Hepatic Encephalopathy NeomycinLactuloseProtein reduction
164 Hepatorenal syndrome Complication of Hepatic Failure
165 Hepatorenal syndrome Complication of Hepatic Failure kidneys may appear normal physically but functioning impaired.Usually sudden decrease Urine production, increase BUN & Creatinine, jaundice and signs of liver failurePoor prognosis- most die within 3 wks without transplantThink due to decreased perfusion &/or toxins from failure of liver
166 Liver DialysisBridge to transplantDialyze 6 hours at a time
167 Donors: Live donor liver transplants are an excellent option. Liver regenerates to appropriate size for their individual bodies.Survival rates increase / shorter wait timeThe donor - a blood relative, spouse, or friend, will have extensive medical and psychological evaluations to ensure the lowest possible risk.
169 Potential donors evaluated for: Blood type and body size are critical factors in determining who is an appropriate donor.Potential donors evaluated for:liver disease, alcohol or drug abuse, cancer, or infection.hepatitis, AIDS, and other infections.matched according to blood type and body size.Age, race, and sex are not considered.Cadaver donor have to wait
171 Liver transplant complications Rejection. About 70% of all liver-transplant patients have some degree of organ rejection prior to discharge.Anti-rejection medications are given to ward off the immune attack.InfectionMost infections can be treated successfully as they occur.Cancer