Liver Disorders

Terminal Learning Objective

• Given a scenario of a patient in a clinical
setting with a liver disorder, provide safe
and effective care IAW Christensen

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 Enabling Learning Objectives
• Given a patient with a liver disorder:
• Identify the functions of the liver
• Given a patient with a liver disorder describe
the etiology, clinical manifestations,
assessment, diagnosis, medical and nursing
management of:
• Cirrhosis
• Hepatitis

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 Enabling Learning Objectives
(Cont)
• Identify the etiology/pathophysiology,
assessment and medical management of a
patient with carcinoma of the liver

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 The Liver
• Largest glandular organ in the body
• Weighs 3lbs
• Located upper right quadrant
• Contains two lobes
• Receives roughly 1.5 l/m of blood

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 The Liver

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 Functions of the Liver
• Formation/excretion of bile
• Synthesis of coagulation factors
• Manufactures cholesterol
• Manufactures albumin
• Detoxifies endogenous and exogenous
toxins
• Filters out old RBC’s and bacteria
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Cirrhosis
 Etiology/pathophysiology
• Degenerative disorder of the liver
• Develops from generalized cellular damage
• Lobes become fibrous
• Parenchyma degenerates
• Lobules become infiltrated with fat
• Fibrous tissue restricts blood flow

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Etiology/Pathophysiology (cont)
• Liver unable to carry out functions
• Disturbances in metabolism/digestion
• Inability to convert ammonia to urea
• Decreased protein synthesis
• Defects in blood coagulation
• Defects in fluid/electrolyte balance

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 Cirrhosis
• Develops slowly over many years
• Liver progresses through stages
• Destruction
• Inflammation
• Fibrotic regeneration
• Hepatic insufficiency

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 Cirrhosis

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 Cirrhosis
• Major types of cirrhosis
• Laennec’s
• Postnecrotic
• Biliary
• Primary
• Secondary
• Cardiac

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 Laennec’s Cirrhosis
• Also called portal or alcoholic cirrhosis
• Found mostly in western world
• Affects more men than women
• Associated with heavy, chronic ETOH intake
• Most common type of cirrhosis

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 Post-necrotic Cirrhosis
• Found world wide
• Caused by
• viral hepatitis
• exposure to toxins
• infection

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 Biliary (Obstructive) Cirrhosis
• Primary
• Result of chronic obstruction/inflammation of
bile ducts
• Occurs more often in women
• Secondary
• Caused by chronic biliary tree obstruction:
gallstones, tumor, atresia

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 Cardiac Cirrhosis
• Associated with:
• Right sided CHF
• Constrictive pericarditis

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 Clinical Manifestations
• Gastrointestinal
• Anorexia
• Nausea & vomiting
• Indigestion
• Diarrhea or constipation
• Abdominal pain

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 Clinical Manifestations
• Gastrointestinal
• Anorexia
• Nausea & vomiting
• Indigestion
• Diarrhea or constipation
• Abdominal pain

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 Clinical Manifestations

• Tissue wasting
• Weight loss/fluid retention
• Ascites/peripheral edema
• Marked abdominal distention
• LE edema
• Decreased albumin production
• Dyspnea

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 Clinical Manifestations
• Manifestations of portal hypertension
• Dilated veins over abdomen
• Splenomegaly
• Prominent distended abdominal vessels
• Distended vessels in
• Esophagus
• Stomach
• Rectum

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 Clinical Manifestations
• Bleeding tendencies
• Impaired formation of clotting factors
• Impaired absorption of vitamin K
• GI bleed
• Anemia

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 Clinical Manifestations
• Jaundice (Icterus)
• Yellowish discoloration of tissue
• Caused by abnormally high bilirubin in the
blood
• Liver cannot convert bilirubin into conjugated
(direct) for and secrete it into bile ducts
• Visible jaundice when serum bili > 3mg/dl

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 Clinical Manifestations
• Jaundice (Icterus) cont
• Clay colored stool
• Deep orange urine
• Skin changes
• Spider angiomata
• Palmar erythema
• Pruritis
• Loss of body hair

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 Assessment
• Early Subjective • Early Objective
• N&V • Anemia
• Loss of appetite • Fever
• Fatigue, weakness • Jaundice
• Abdominal discomfort, • Weight loss
indigestion flatulence

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 Assessment (Cont)
• Later Subjective • Later Objective
• Same as early but more • Epistaxis
intense • Purpura
• Dyspnea • Hematuria
• Severe fatigue • Spider hemangioma
• Coagulopathies
• Hemorrhage
• Splenomegaly
• Disorientation

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 Diagnostic Findings
• Labs
• Elevated liver enzymes
• Decreased serum albumin
• Elevated ammonia
• Decreased glucose
• Abnormal CBC
• Prolonged PT
• Abnormal urinalysis
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 Diagnostic Tests
• Tests:
• ERCP
• Esophagoscopy with barium
• Scans and Biopsy
• Ultrasound
• Paracentesis

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 Medical Management
• Eliminate causes
• Decrease buildup of fluids
• Bedrest
• Fluid and sodium restriction
• Daily weights
• Strict I&O’s

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 Medical Management
• Diuretics
• Aldactone
• Lasix
• Hydrodiuril
• Na+ poor albumin infusions

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 Medical Management
• Prevent further damage to liver
• Eliminate ETOH
• Monitor liver function
• High calorie/carb diet with adequate PRO
• Low fat/low sodium diet

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 Medical Management
• Paracentesis:
• Fluid removal via gravity or vacuum from
peritoneal cavity
• Possible complications
• Abdominal organ perforation
• Wound infection
• Bladder puncture

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 Paracentesis

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 Medical Management
• Paracentesis continued
• Position in high Fowlers
• Fluid removal 30-90 min!!!
• Monitor patient for hypovolemia and
electrolyte imbalance
• Monitor for bleeding/drainage

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 Medical Management
• Peritoneal jugular shunt (LeVeen)
• One way valve moving fluid from peritoneal
cavity to superior vena cava
• Complications may be severe
• Hemodilution
• Pulmonary edema/CHF
• Wound infection, peritonitis, septicemia
• Occlusion of shunt by thrombus

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 Medical Management
• Monitor/prevent bleeding
• Assess stools/emesis/gums
• FFP infusions

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 Medical Management:
Monitor/Prevent Complications
• Portal hypertension/esophageal varices
• Cirrhotic intrahepatic veins create resistance
• Blood backs up into portal vein and diverting
channels in stomach/esophagus
• May rupture suddenly or over several days
• Variceal bleed

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 Management of a Medical
Emergency
• Airway
• Aspiration 2° bleeding
• 2 large bore IV’s (18 ga or larger)
• IV Vasopressin directly into vena cava
• Gastric Lavage
• Sengstaken-Blakemore tube
• Surgical shunting-around the liver
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 Supportive Care: Ruptured
Varices
• Maintain adequate oxygenation
• Transfusion of blood products
• Electrolyte replacement
• Cathartics
• Antibiotics

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 Hepatic Encephalopathy
• CNS manifestations of liver failure often
lead to coma or death
• Liver is unable to breakdown ammonia
• Ammonia crosses blood-brain barrier;
interferes w/neurotransmission, brain
metabolism.

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 Hepatic Encephalopathy

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 Hepatic Encephalopathy
• Signs and symptoms
• Inappropriate behavior
• Disorientation
• Flapping tremors
• Twitching extremities
• Stupor
• Coma

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 Hepatic Encephalopathy
• Therapy initiated with the goal of reducing
blood ammonia levels
• Reduction of protein in diet
• Lactulose
• Antibiotics
• Maintain fluids/electrolyte balance
• Monitor VS

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 Hepatic Encephalopathy

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 Hepatic Encephalopathy
• Nursing interventions:
• Monitor for hemorrhage
• Monitor fluids/electrolytes
• Provide adequate nutrition
• Provide meticulous skin care
• Monitor mental status changes & report
• Teach & assess understanding of contributing
factors such as ETOH
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Hepatitis
 Hepatitis
• Inflammation of the liver resulting from
• Viral agents
• Exposure to toxic substances
• Lengthy ETOH abuse
• May be acute or chronic

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 Hepatitis
• Seven types (A,B,C,D,E,F & G)
• Distinguished by
• Mode of transmission
• Incubation period

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A B C
Most common type Serum (old name)

10-40 days incubation 28-160 days incubation 2 weeks-6 months

incubation
Direct contact of fecal Contact w/ blood &body Transmission via needle
content via H20 & food fluids sticks; blood
transfusions

D(Delta) E(Enteric non A/non B) F&G

Contact of blood/body Newest type
fluids Found in blood donors

2-10 weeks incubation 15-64 days incubation Can be transmitted via

transfusion
May progress to Fecal contamination of
cirrhosis/ Chronic H20-poor sanitation & Water & Food
hepatitis H20 quality contamination

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 Hepatitis
• Pathological findings in all seven are
identical
• Diffuse inflammatory reaction
• Degeneration/death of liver cells
• Normal liver function slows down

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 Hepatitis
• Outcome effected by virulence, comorbidity
and healthcare available
• Mandated by law that ALL cases of
hepatitis are reported to CDC

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 Hepatitis
• Clinical manifestations
• Symptoms vary
• Patient maybe asymptomatic
• Others develop hepatic failure or hepatic
encephalopathy

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 Hepatitis B

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 Clinical Assessment
• Subjective • Objective
• General malaise • Jaundice
• Headaches/chills • Pruritis
• Photophobia • Dark, amber urine
• RUQ discomfort; N&v • Clay-colored stools
• Diarrhea & • Hepatomegaly
constipation w/lymphadenopathy
• Pruritis • Weight loss
• Rhinitis

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 Jaundice

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 Clinical Diagnosis
• Bilirubin, Gamma GT, AST, ALT, LDH
• Prolonged PT
• Leukopenia & Hypoglycemia
• Serum examined for HAA(A,B,C,D,G)
• Electron microscope for Hepatitis F
• No available test for Hepatitis E

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 Medical Management
• No specific treatment other than supportive
• Prevention of transmission
• Bedrest for several weeks
• No ETOH x 1 year!
• Avoid sedatives
• Low fat/high carb w/vitamin supp(c,b,k)

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 Prevention
• Gamma globulin/immune serum globulin
{A}w/ booster 6-12 months.
• HBiG {B} immediately and one month after
exposure
• Good sanitation & personal hygiene
• Effective sterilization procedures
• Careful screening of food handlers/blood
products
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 Nursing Interventions
• Ensure rest
• Maintain adequate nutrition
• Provide fluids
• Skin care
• Prevent further transmission

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 Nursing Interventions
• STANDARD PRECAUTIONS
• Teach/assess understanding of modes of
transmission, prevention, S&S
• Patient education
• Prognosis

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 Prognosis

A-Recovery high D-High mortality rate

Mortality: 0.5% Progress to cirrhosis
Chronic Hepatitis

B-Most serious forms of hepatitis; E-Mortality rate 10% in pregnant

Long-term health effects women, otherwise not fatal
Mortality: 10%

C-Progresses to Hepatitis, F&G-Uncertain; often coexists with

Cirrhosis,Liver CA, others
Death

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Liver Cancer
 Liver Cancer

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 Liver Cancer
• Primary Ca of liver is rare; previous HX of
cirrhosis
• Some cases associated w/ Hep B or C
• Higher rate in men
• Ca eventually spreads to lungs
• Livers enlarges becomes misshapen
• Hemorrhage, necrosis, tumors
• Difficult to diagnosis from cirrhosis
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 Liver Cancer
• Hepatomegaly, ascites, portal hypertension
• Wt loss, peripheral edema
• Dull ABD pain-RUQ
• Jaundice
• Anorexia
• Frequent pulmonary emboli
• Positive AFP
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 Liver Cancer
• Palliative treatment
• Lobectomy for localized tumors
• Only 30-40% have surgically resectable
disease
• Ca too far advanced for surgery
• Chemotherapy-poor response
• Death most likely in 4 to 7 months.
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 Questions

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 Summary
• Functions of liver
• Cirrhosis
• Types of hepatitis
• Cancer of the liver

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