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Hepatic Disorders:
Hepatitis/Cirrhosis

Objectives
Compare and contrast risk factors associated
with hepatitis and cirrhosis
Analyze the etiology and pathophysiology of
hepatitis and cirrhosis
Integrate diagnostic tests with etiology,
pathophysiology, and signs/symptoms of both
disorders
Formulate relevant prioritized nursing diagnoses
that address physical, pyschosocial, and learning
needs and evaluate nursing interventions

Anatomy & Physiology

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

Pathophysiology
Largest organ
Metabolic functions
Bile synthesis
Hepatocytes
Bile secretion

Storage
Mononuclear phagocyte system
Kupffer cells
Phagocytic activity

Metabolic functions

Metabolism glucose
Protein
Fatty acids
Cholesterol

Other Functions

Immunologic
Blood storage
Plasma protein synthesis
Clotting
Storage of vitamins and minerals
Waste products of hemoglobin
Bile formation and secretion
Steroids and hormones
Ammonia
Drugs, ETOH, toxin metabolism

HEPATITIS

Pathophysiology

Inflammation
Hepatic cell necrosis
Proliferation/enlargement Kupffer cells
Cholestasis
Regeneration

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Clinical Manifestations
Acute

Anorexia
N/V
RUQ pain
Bowel irregularity
Malaise
HA
Fever
Arthralgias
Uticaria
Weight loss
Jaundice
Hepatomegaly
Splenomegaly
Pruritus
Dark urine
Bilirubinuria
Light stools
Fatigue

Chronic

Malaise
Easy fatigability
Hepatomegaly

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Phases
Preicteric
Prodromal

Icteric
Jaundice

Posticteric
Convalescent

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Hepatitis A
Fecal/oral
15-50d
S/S

Light stools
Dark urine
Fatigue
Fever
Jaundice

Labs
Vaccine
IgG
Prevention

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Hepatitis B

Percutaneous/permucosal
Sexual contact
Perinatal
45-180d
S/S

30% asymptomatic
Flu
Light stools
Dark urine
Fatigue
Fever
Jaundice

Labs
Prevention

Vaccine
IgG
Safe sex
No sharing of razors,
toothbrushes, needles

Chronicity
Antivirals

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Hepatitis C

Percutnaeous/mucosal
Sexual contact
Perinatal
14-180d
S/S
80% asymptomatic
HBV

Labs
Prevention
Safe sex
No sharing of razors,
toothbrushes, needles

Chronicity
Interferon
antivirals

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Hepatitis D

HBV
2-26wk
Labs
Interferon
HBV vaccine
S/S
HBV

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Hepatitis E

Fecal/oral
Contaminated water
Poor sanitation
15-64d
Labs
S/S
HBV

No vaccine

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Diagnostics

LFT
ALP
Serum bilirubin
Liver biopsy
Antigen specific

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Treatment
Diet

High cal/protein, low fat

Vitamins (B, K)
ETOH/Drugs

Fluid management
Bed rest
Drug therapy

Prevention of HAV and HBV

Interferon
Lamivudine
Ribavirin
Acetaminophen

Cirrhosis

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Pathophysiology
destruction of liver cells, fibrosis and nodule
formation restricting blood and bile flow
Normal hepatic blood pressure is near zero.
Restriction of blood flow in liver dysfunction causes
hypertension, and blood will attempt to find other
pathways, bypass liver
Results in significant impairment of liver function
80% destroyed before signs and symptoms
Liver can regenerate itself if good nutrition, rest,
and no alcohol

Types of Cirrhosis
Classified by risk factors
Post necrotic
Hepatitis

Alcoholic Cirrhosis
Laennecs
metabolic changes in liver, particularly fat

Biliary

obstructive

Cardiac
right side heart failure

Drug induced
INH, rifampin, Tylenol

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Signs & Symptoms

Liver enlarged
Dull pain RUQ
Weakness
Anorexia
Skin
Sclera

Portal hypertension
Splenomegaly
Ascites
Esophageal varices
Hepatic encephalopathy
Hepatorenal Syndrome
Liver failure

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Signs & Symptoms

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Jaundice
Excess bilirubin
Hepatocellular
Cirrhosis

Obstructive
Hemolytic
Excessive destruction of RBCs
Transfusion reaction
Autoimmune
Faulty hemoglobin
Sickle cell

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Diagnostics

LFT
CBC
Coags
Bilirubin
Albumin
Esophagoscopy
Liver biopsy
*See Table 44.15

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Liver Biopsy
3 types

Needle
Laparoscopic
Transvenous

Catheter
Blood clotting problems
Excess fluid

Complications

Puncture of lung or gallbladder

Infection
Bleeding
Pain

Liver Biopsy

Adequacy of clotting- PT/ INR, Platelets (Vit. K?)

Type and cross match for blood
Stop aspirin, ibuprofen, and anticoagulants 1 wk. before
Chest x-ray
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 20 minutes

After Needle Liver Biopsy

Pressure
Right side

minimum of 2 hrs
flat 12-14 hrs

Vital signs & check for bleeding

NPO X 2 hr after
Assess for peritonitis, shock, & pneumothorax
Rt. shoulder pain common
caused by irritation of the diaphragm muscle
usually radiates to the shoulder a few hours or days.

Soreness at the incision site

Tylenol

avoid aspirin or ibuprofen for the first week because they

decrease blood clotting, which is crucial for healing.

Avoid coughing, straining, lifting x 1-2 weeks

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Nursing Assessment
LOC
Reflexes

Hyperreflexia

Pupils
Orientation
Sensory/motor
Asterexis

http://www.youtube.com/watch?v=pAOWjYo-sX4

Coordination
Dysmetria

Fluid/electrolytes

Acid/base imbalances

See table 44.17

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Treatment
Diet

Sodium restriction
High carbs
Mod fat
75-100gm protein

60-80gm/d (hep encephalopathy)

Fluid management
Drug therapy

Diuretics
Laxatives
Anti-infective agents

Surgical/medical interventions

Major Complications of
Cirrhosis
Portal hypertension
Variceal bleeding
Ascites
Spontaneous bacterial peritonitis
Splenomegaly
Hepatorenal syndrome
Hepatic encephalopathy

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Portal Hypertension
Arteriovenous shunting
Marked ascites
Caput medusae
Dilated abdominal veins

Esophageal varices
Hemorrhoids
Hyperslenism
anemia
Neutropenia
Thrombocytopenia

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Surgical/Medical Interventions

Paracentesis
Gastric lavage
Balloon tamponade
Schlerotherapy
Banding
TIPS (transjugular intrahepatic portosystemic
shunt)
Liver transplant

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Ascites
Sodium restriction
Bedrest initially
Diuretics
Spironolactone
Lasix
HCTZ

Fluid removal
Paracentesis
Peritoneovenous Shunt

Ascites
Caput medusae

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Paracentesis

Only used if respiratory distress

Pt will loose 10-30 grams of protein
Pt in sitting position
Empty bladder first
Post--watch for hypotension,
bleeding, shock & infection

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Esophageal varices
Collateral vessels
Complex of swollen, enlarged veins
Portal hypertension

Bleeding
LIFE-THREATENING

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Esophageal varices treatment

Active bleeding
Central line & pulmonary artery pressures
Blood transfusions & fresh frozen plasma for clotting
factors
Somatostatin or Vasopressin constrict gut vessels
Airway/trach
Later prevention of re-bleeding
Beta-blockers
Long-acting nitrates
Soft food, chew well, avoid intra-abdominal pressure
Protonix

Sclerotherapy
sclerosant solution (ethanolamine oleate or sodium tetradecyl sulphate)
Complications
fever, dysphagia and chest pain, ulceration, stricture, and (rarely)
perforation.

Band ligation
Fewer treatment sessions and complications than sclerotherapy.

Balloon tube tamponade

Tube is inserted through the mouth
Correct placement within the stomach is checked by auscultation while injecting air
through the gastric lumen
Gastric balloon is then inflated with 200 ml of air
Gastric balloon is pulled up against the esophagogastric junction, compressing the
submucosal varices
Tension is maintained by strapping a split tennis ball to the tube at the
patient's mouth
Complications
gastric and esophageal ulceration
aspiration pneumonia
esophageal perforation.

Minnesota
Tube

SengstakenBlakemore
tube has only 3
lumens
**Respiratory
assessment**

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Hepatic encephalopathy
Neuropsychiatric manifestation
Decreased liver detoxification>>>
Increased ammonia

Terminal complication
Asterixis

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Treatment HE
Reduce ammonia

Lactulose
Neomycin sulfate
Cathartics
Enemas
Liver transplantation

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Hepatorenal syndrome
Portal HTN + liver decompensation
Systemic vasodilation
Decreased arterial BF
Renal vasoconstriction

Functional renal failure

Azotemia
Oliguria

Liver transplantation

Liver Transplant

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Liver Transplant

Liver transplant complications

Rejection
70%
Medications

Infection
immunosuppression

Cancer

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Patient Teaching

Therapeutic communication
Diet*
Exercise
Lifestyle modifications
Drugs
Follow-up
Resources

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Donors
Live donor
Liver regenerates
5 years

Survival rates increase / shorter wait time

Medical and psychological evaluations
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 for brain dead donor

Review
1. Pathophysiology
1. Cirrhosis
2. Portal hyperetension
3. Liver failure
1. Encephalopathy
2. Hepato-renal
syndrome
2. Signs & Symptoms
3. Treatment
4. Nsg. Care
5. Complications