Liver Disorders Kelle Howard, MSN, RN, CNE Fall 2013 From the notes of: John Nation, RN, MSN...

Liver Disorders

Kelle Howard, MSN, RN, CNEFall 2013

From the notes of:John Nation, RN, MSNCharlene Morris, RN, MSNAustin Community College

Overview of Today’s Lecture

• A & P Review• Hepatitis A• Hepatitis B• Hepatitis C• Cirrhosis • Portal Hypertension• Esophageal Varices• Hepatic Encephalopathy• Hepatorenal Syndrome• Liver Transplant

A and P Review

A and P ReviewA and P Review

Largest internal organ

Do you know how much it weighs?

• A Liver• B Hepatic vein• C Hepatic artery• D Portal vein• E Common bile duct• F Stomach• G Cystic duct• H Gallbladder

Blood Supply – 2 sources

• Hepatic artery:– 500ml/min of oxygenated blood– How much of cardiac output goes to the liver?

• _____________

• Portal vein:– 1000ml/min of partially oxygenated blood – partly oxygenated blood supplies 50 - 60% O2

• plus rich supply of nutrients, toxins, drugs

– from stomach, small and large intestines, pancreas and spleen

Hepatic Blood Supply (Cont’d)

• Both empty into capillaries/sinusoids

• Liver filters the blood

• Hepatic vein to inferior vena cava

Metabolic Functions of the liver

• “Body’s Refinery”--- Over 400 functions

• Primary role in anabolism and catabolism

Metabolic Functions of the Liver

Metabolism 1. Carbohydrates

2. Fats

3. Protein

Other functions• Immunologic

• Blood storage

• Plasma protein synthesis

• Clotting

• Waste products of hemoglobin

• Formation and secretion of bile

• Steroids and hormones

• Ammonia

• Drugs, alcohol and toxins metabolism

To Summarize….

The liver:– changes food into energy – removes alcohol and poisons from the blood– makes bile, a yellowish-green liquid that helps

with digestion

Hepatitis

• Simply means inflammation of the liver– “itis” means inflammation, “hepa” means

liver.

• Viral hepatitis – Most common cause– Viral types include A, B, C, D, E, and G

Hepatitis

• Other possible causes– Drugs (alcohol)

• drug-induced liver injury (DILI) is now the leading cause of acute liver failure (ALF), exceeding all other causes combined (FDA)

– Chemicals– Autoimmune liver disease– Bacteria (rarely)

Other Liver toxic drugs:Agomelatine (antidepressant)AllopurinolAmitriptyline (antidepressant)Amiodarone (antiarrhythmic)Atomoxetine [80]

Azathioprine[81]

Halothane (a specific type of anesthetic gas)Hormonal contraceptivesIbuprofen and indomethacin (NSAIDs)Isoniazid (INH), rifampicin, and pyrazinamide (tuberculosis-specific

antibiotics)Ketoconazole (antifungal)Loratadine (antihistamine)Methotrexate (immune suppressant)Methyldopa (antihypertensive)Minocycline (tetracycline antibiotic)Nifedipine (antihypertensive)Nitrofurantoin (antibiotic)(acetaminophen in the United States) can cause hepatitis when taken

in an overdose. The severity of liver damage may be limited by prompt administration of acetylcysteine.

Phenytoin and valproic acid (antiepileptics)Troglitazone (antidiabetic, withdrawn in 2000 for causing hepatitis)Zidovudine (antiretroviral i.e., against HIV)

What other common drug is not on this list?

Usually, if you remove the drug, liver will return to normal function within months.

Hepatitis • Other Causes

– Cytomegalovirus

– Epstein-Barr virus

– Herpes virus • 1 & 2

– Coxsackie virus

– Rubella virus

Hepatitis A• Hepatitis A virus (HAV)

– RNA virus

– How is it transmitted? • fecal–oral route• parenteral (rarely)

– Frequently occurs in small outbreaks

Hepatitis A(incidence)

• 25,000 new cases of hepatitis A occur annually in the United States

• 1/3 of all Americans have had it– but now have immunity

• Approx. 100 people in US die each year

• 10 million cases of hepatitis A occur worldwide– nearly universal during childhood in developing countries

(hepatitisfoundation.org)

Hepatitis A

• Hepatitis A virus (HAV)

– Found in feces:• 2 or more weeks before the onset of symptoms• up to 1 week after the onset of jaundice

– Present in blood briefly

– No chronic carrier state

Hepatitis A:Incubation Period

• 2-7 weeks• Acute onset• Mild flu-like manifestations• Symptoms may last up to 2 months

– Children sometimes present with NO symptoms

• Liver usually repairs itself, so no permanent effects

Hepatitis A

• Hepatitis A virus (HAV)– Anti-HAV immunoglobulin M (IgM)

• Appears in the serum as the stool becomes negative for the virus

Hepatitis A

• Hepatitis A virus (HAV)– Anti-HAV immunoglobulin G (IgG)

• Presence of IgG antibody provides lifelong immunity

Hepatitis A:Mode of Transmission

• Mainly by ingestion of food or liquid infected with the virus– poor hygiene – improper handling of food– crowded housing– poor sanitation conditions

Hepatitis A:Mode of Transmission

(Cont’d)

• Occurs more frequently in underdeveloped countries

• Contaminated waters– drinking water, contaminated seafood

• Food-borne Hepatitis A outbreaks usually due to infected food handler– contamination of food during preparation

Hepatitis A: Vaccine

Pre-Exposure• 2 doses IM– Initial dose– Booster in 6 to 12 months

• Children encouraged to get vaccinated

Post-exposure Prophylaxis(PEP)

Standard IG-immune globulinGiven IM within 2 weeks of exposureRecommended for persons who:

do not have anti-HAV antibodies & have had food borne exposure or close contact with HAV-

infected person Provides temporary passive immunity

1-2 months

Hepatitis A VaccineProvides active immunity

Remember 2/2/2/2 Rule

• 2 doses IM for vaccination• Signs & symptoms last 2 months• Greatest risk for transmission occurs before

clinical s/s signs & symptoms– About 2 weeks– Also called the ‘preicteric’ phase

• Post-exposure dose of IG given within 2 weeks of exposure

Hepatitis B(incidence)

• Nearly 1.25 million Americans infected– 350 million world wide

• 5,000 Americans die from cirrhosis caused by Hep B

• 100 Xs more infectious than HIV

• 43,000 new cases of Hepatitis B annually in United States– Incidence decreased due to HBV vaccine

hepatitsfoundation.org

Hepatitis B

• Hepatitis B virus (HBV)DNA virus– Transmission occurs when infected blood or other

body fluids enter the body of a person who is not immune to the virus

Hepatitis B

Hepatitis B virus (HBV)Transmission of HBV

Perinatally by mothers infected90% of infants infected, have chronic HBV

The younger you are the more likely chronic disease will occur Percutaneously Mucosal exposure

infectious blood, blood productsother body fluids

Hepatitis B

• Hepatitis B virus (HBV)– Can live on a dry surface for 7 days– More infectious than HIV

• Who is at risk?

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.

Hepatitis BPrecautions

Source: UptodateSee CDC & medline, medlink, NIH

•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.

Hepatitis BPrecautions

Source: UptodateSee CDC & medline, medlink, NIH

Hepatitis B cannot be spread by:Hugging or kissingSharing eating utensils or cups Sneezing or coughing Breastfeeding

****Some sources say saliva can be source of transmission

Source: UptodateSee CDC & medline, medlink, NIH

Hepatitis BPrevention

Hepatitis BPrevention

Post-exposure Hep B

• Incubation Period – 6-24 weeks

• Hepatitis B Immune globulin• IM in 2 doses

– First dose within 24 hours to 7 days of exposure

– Second dose 20 to 30 days post-exposure• Provides short-term immunity

Hepatitis B Hepatitis B virus (HBV)

Complex structure with three antigens Surface antigen (HBsAg) Core antigen (HBcAg) E antigen (HBeAg)

Each antigen Has a corresponding antibody that may develop

In chronic carriers Surface antigen detected 6-12months after infection Surface antigen remains + Can still transmit the virus 15% to 25% die from chronic liver disease Two drugs available to suppress viral activity and decrease viral load

a-Interferon (ex. Pegasys)Nucleoside analogs

Hepatitis B Virus

• Presence of Hepatitis B Surface Antibodies – Indicates immunity from HBV vaccine

– Past HBV infection

• Oncologist in NJ 2011 – revoked license, $30,000 in finesPut 500 people at risk, 10 confirmed

•2 assisted living facilitiesBlood glucose monitoring machinesNurses transmitted 12 residents confirmed

Hepatitis B –Outbreaks

Hepatitis C• 3.2 million Americans chronically infected

– 1.8% of the population– 75-85% of those infected will remain chronically infected

• Approximately 170 million people are infected with the hepatitis C virus (HCV)

• 17,000 new cases each year in US

• 8,000-10,000 Americans die each year from ESLD s/t chronic Hep C

• Approximately 30% to 40% of HIV-infected patients also have HCV

• Source: CDC.gov

Hepatitis C

• Hepatitis C virus (HCV)– RNA virus– No vaccination available– Transmitted primarily percutaneously

Hepatitis C

Risk Factors IV drug useMost common mode of transmission

in United States and Canada

Blood transfusionsIncidence reduced to 1/1millionHowever, if received blood prior to

1992 are at risk

Hepatitis CRisk Factors (cont)

» High-risk sexual behavior* more data needed on this» Hemodialysis» Occupational exposure» Sharing personal care items such as?» Perinatal transmission» Body piercings & tattooing *

» Up to 10% cannot identify the source

Hepatitis CDiagnostic Studies

•Anti-HCV antibody•HCV RNA

Hepatitis D

• Hepatitis D virus (HDV)– Also called delta virus– Defective single-stranded RNA virus– Cannot survive on its own– Requires the helper function of HBV to

replicate

Hepatitis D

–HBV-HDV co-infection• ↑ Risk of fulminant hepatitis• Virulent

–More severe acute disease

Hepatitis E

Hepatitis E virus (HEV)RNA virusTransmitted fecal–oral routeNo serological test in USMost common

contaminated drinking water occurs primarily in developing countries

Hepatitis G

• Hepatitis G virus (HGV)– RNA virus– Poorly characterized parenterally & sexually

transmitted virus– Can be transmitted by blood transfusion– Coexists with other hepatitis viruses and HIV– Does not appear to cause liver damage by itself

Pathophysiology of Hepatitis

Acute infection- widespread inflammation of liver tissueLiver damage mediated by

Cytotoxic cytokines Natural killer cells

Liver cell damaged results in hepatic cell necrosis

With time & no complications Liver cells will regenerate Eventually resume their normal appearance & function

Common Manifestationsof Hepatitis

Predictable course among all the viruses

• Incubation Phase: – after exposure to virus– many times no symptoms

• 30% HBV & 80% HCV asymptomatic

Common Manifestationsof Hepatitis

Acute Phaseanicteric or ictericIf symptoms occur

(anicteric – without jaundice) Lasts 1-4 months Flu-like symptoms

General malaise Fatigue Body aches, headache GI symptoms

nausea/vomiting, diarrhea, abdominal discomfort Chills, low grade fever Weight loss

Icteric Phase(symtomatic, including jaundice)

Usually 5-10 days after anicteric symptomsJaundice

results when bilirubin diffuses into tissuessometimes accompanied by puritis

• When jaundice occurs, fever subsides• Liver usually enlarged and tender

Common Manifestationsof Hepatitis

Convalescent Phase

• Healing generally within 3-16 weeks• Begins as jaundice is disappearing• GI symptoms minimal• Biggest complaint

– Fatigue

Common Manifestationsof Hepatitis

HepatitisA, B, & C

(summary)Hep AAlmost all cases resolveMany are anictericOnset more acute, s/s flu like

Hep BMore insidious, s/s more severeMany result in chronic infection

Hep CMany asymptomaticMany result in chronic infectionHigh rate of persistence & leads to chronic liver disease

Hepatitis Complications

• Fulminant Hepatic Failure• Chronic Hepatitis• Cirrhosis• Hepatocellular Carcinoma

Fulminant Hepatitis

• Results in severe impairment or necrosis of liver cells and potential liver failure

• Develops in small percentage of patients• Occurs because of

• complications of Hepatitis B• toxic reactions to drugs and congenital

metabolic disorders

Diagnostic tests• Liver function studies

– ALT (Alanine aminotransferase)• elevates: enzyme in liver cells released into bloodstream with

injury or disease • (0 – 50) normal

– AST (Aspartate aminotransferase)• elevates: enzyme in liver & heart cells released into bloodstream• (0 -41) normal

– GGT – gamma glutamyltransferase• present in all cell membranes, injury or disease

– elevates in cell lysis– (8 – 55)normal – increases when bile ducts are blocked & hepatitis– elevated until function returns.

Diagnostic tests– Alkaline phosphatase• present in liver & bone cells• elevated in hepatitis• (44-147 IU/L) normal

– CBC• low RBC, HCT, Hgb

– Low WBC and Platelets

– AFP• alpha fetoprotein– liver cancer marker

– Lactic dehydrogenase • LDH5 specific for liver damage

Diagnostic tests• Coagulation

– (Normal PT 12-15 seconds, INR 0.8 to 1.2)

• Hyponatremia • Hypokalemia• Hypophosphatemia• Hypomagnesemia• Bilirubin

– total (2-14 umol/L)

– direct/conjugated (0-4 umol/L)

Diagnostic tests• Serum albumin

(3.3 – 5) normal

• Serum ammonia (0 – 150)(10 to 80 ug/l) normal

• Glucose and cholesterol • Abdominal Ultrasound • Esophagascopy• Liver biopsy• CT, MRI

Needle biopsyMost common in past

Laparoscopic biopsyUsed to remove tissue from specific parts of the liver.

Liver Biopsy

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

Liver Biopsy (Con’t)

Liver Biopsy(interventions)

• Adequacy of clotting• Type and cross match for blood• Usually hold aspirin, ibuprofen, and

anticoagulants• Chest x-ray

Liver Biopsy interventions

• Consent form & NPO 4 to 8 hr. • Vital signs & Empty bladder• Supine position, R arm above head• Hold breath after expiration when needle

inserted• Be very still during procedure

Complications are:

Puncture of lung or gallbladder, infection, bleeding, and pain.

After Needle Liver Biopsy

• Pressure to site, place pt on Rt side to maintain site pressure minimum of 2 hrs. & flat up to 12-14 hrs.

• Vital signs & check for bleeding

• NPO X 2H after

• Assess for peritonitis, shock, & pneumothorax

• Rt. shoulder pain common– caused by irritation of the diaphragm muscle – usually radiates to the shoulder for a few hours

or days

After Needle Biopsy (Cont’d)

• Soreness at the incision site

• Avoid aspirin or ibuprofen for pain control for the first week

• Avoid coughing, straining, lifting x 1-2 weeks

Hepatitis Care

• Rest is a priority!

• Diet –high calorie & protein, low fat– Vitamin supplement – B complex & K– Avoid alcohol & drugs

• detoxify in liver

• Life style changes

Meds for Chronic Hepatitis

• Chronic HBV• Pegylated a-interferon (Pegasys, PEG-Intron)• Nucleoside/Nucleotide analogs

– Lamivudine (Epivir)– Adefovir (Hepsera)– Entecavir (Baraclude)– Telbivudine (Tyzeka)

• Chronic HCV• Pegylated a-interferon (Pegasys, PEG-Intron)• Ribavirin (Rebetol, Copegus)

• Some can be used in children as young as 3 years old

Hepatitis Nursing Management

Nursing assessment• Past health history

– Hemophilia – Exposure to infected persons – Ingestion of contaminated food or water – Past blood transfusion (before 1992)

• Medications (use and misuse)– APAP– Phenytoin – Halothane – Methyldopa

Hepatitis Nursing Management

Nursing assessment con’t• IV drug and alcohol abuse• Weight loss• Dark urine• Fatigue• Right upper quadrant pain• Pruritus• Low-grade fever• Jaundice• Abnormal laboratory values

Hepatitis Nursing Management

• Nursing diagnoses– Imbalanced nutrition: Less than body requirements– Activity intolerance– Ineffective therapeutic regimen management

• Overall goals: Planning– Relief of discomfort– Resumption of normal activities – Return to normal liver function without complications

Hepatitis Nursing Management

• Nursing implementation (broadly summarized)

– Health promotion• Hepatitis A

– Education– Vaccination– Good hygiene practices

• Hepatitis B– Vaccination– Education– Workplace safety

• Hepatitis C– Education– Infection control precautions– Modification of high-risk behavior

Hepatitis Nursing Management

Nursing implementation • Acute intervention

– Rest– Jaundice

• Assess degree of jaundice• Small, frequent meals

• Ambulatory and home care– Dietary teaching – Assessment for complications– Regular follow-up for at least 1 year after diagnosis– Avoid what?

Hepatitis Nursing Management

Evaluation • Expected outcomes

– Adequate nutritional intake – Increased tolerance for activity– Verbalization of understanding of follow-up care– Able to explain methods of transmission and

methods of preventing transmission to others