NSG 4530: Exam 1 (Metabolism)

What laboratory tests are used to diagnose hepatitis B?

ALT: Elevated AST: Elevated ALP: Normal or elevated Total bilirubin level: Elevated Hepatitis B surface antigen (HBsAg): Presence indicates that the individual is infectious. However, a client who is vaccinated against HBV will have a positive HBsAg, indicating immunity to the disease

What laboratory tests are used to diagnose hepatitis C?

ALT: Elevated AST: Elevated ALP: Normal or elevated Total bilirubin level: Elevated Hepatitis C virus antibodies (anti-HCV): Detects presence of antibodies to hepatitis C infection Enzyme immunoassay (EIA): Detects presence of antigens or antibodies to hepatitis C infection HCV RNA polymerase chain reaction (PCR): Qualitative test to detect the presence and amount of HCV

What is the client and family education for someone with cirrhosis?

Abstain from alcohol and engage in an alcohol recovery program if needed Consult with the provider prior to taking any over-the-counter medications or herbal supplements Follow diet guidelines -High-calorie, moderate-fat diet -Low-sodium diet (if there is excessive fluid in the peritoneal cavity) -Low-protein (if encephalopathy,elevated ammonia) -Small, frequent, well-balanced nutritional meals -Nutritional supplement drinks or shakes and a daily multivitamin -Replacement and administration of vitamins due to the inability of the liver to store them -Fluid intake restrictions in blood sodium is low

What is the medical management of hepatitis B?

Acute infection: No medications; supportive care Chronic infection: Antiviral medications: tenofovir, adefovir dipivoxil, interferon alfa-2b, peginterferon alfa-2a, lamivudine, entecavir, and telbivudine

What kind of diet should a client with hepatitis B have?

Adequate nutrition should be maintained. Proteins are not restricted. Protein intake should be 1.2 to 1.5 g/kg/day. Measures to control the dyspeptic symptoms and general malaise include the use of antacids and antiemetic agents, but all medications should be avoided if vomiting occurs. If vomiting persists, the patient may require hospitalization and fluid therapy. Because of the mode of transmission, the patient is evaluated for other bloodborne disease

What laboratory tests are used to diagnose hepatitis A?

Alanine aminotransferase (ALT): Elevated; expected reference range is 4 to 36 units/L Aspartate aminotransferase (AST): Elevated; expected reference range is 0 to 35 units/L Alkaline phosphatase (ALP): Normal or elevated; expected reference range is 30 to 120 units/L Total bilirubin level: Elevated; expected reference range is 0.3 to 1.0 mg/dL Hepatitis A virus antibodies (anti-HAV): Presence indicates the presence of

What is ascites?

An albumin-rich fluid accumulation in the peritoneal cavity

What is hepatitis?

An inflammation of liver cells

What is asterixis?

An involuntary flapping of the hands, may be seen in stage II encephalopathy. Simple tasks, such as handwriting, become difficult. A handwriting or drawing sample (e.g., star figure), taken daily, may provide graphic evidence of progression or reversal of hepatic encephalopathy. Inability to reproduce a simple figure in two or three dimensions

What is pruritus?

An uncomfortable, irritating sensation that creates an urge to scratch that can involve any part of the body Patients with liver dysfunction resulting from biliary obstruction commonly develop severe pruritus due to retention of bile salts

What is the medical management of esophageal varices?

Bleeding from esophageal varices is an emergency that can quickly lead to hemorrhagic shock. The patient is critically ill, requiring aggressive medical care and expert nursing care, and is usually transferred to the intensive care unit (ICU) for close monitoring and management. The extent of bleeding is evaluated, and vital signs are monitored continuously if hematemesis and melena are present. Because patients with bleeding esophageal varices have intravascular volume depletion and are subject to electrolyte imbalance, IV fluids, electrolytes, and volume expanders are provided to restore fluid volume and replace electrolytes. Caution must be taken with volume resuscitation so that overhydration does not occur, because this would raise portal pressure and increase bleeding. Although a variety of pharmacologic, endoscopic, and surgical approaches are used to treat bleeding esophageal varices, none is ideal, and most are associated with considerable risk to the patient.

What is the route of transmission for hepatitis B?

Blood

What is the route of transmission for hepatitis C?

Blood

What laboratory tests are used to diagnose cirrhosis?

Blood liver enzymes: Elevated initially Lactate dehydrogenase (LDH), ALT and AST are elevated due to hepatic inflammation. ALT and AST retire to normal when liver cells are no longer able to create an inflammatory response. ALP increases in cirrhosis due to intrahepatic biliary obstruction -ALT: Expected reference range 4 to 36 units/L -AST: Expected reference range 0 to 35 units/L -ALP: Expected reference range 30 to 120 units/L Blood bilirubin: Elevated Bilirubin levels are elevated in cirrhosis due to the inability of the liver to excrete bilirubin Bilirubin, indirect (unconjugated): Elevated; expected reference range 0.2 to 0.8 mg/dL Bilirubin, total: Elevated; expected reference range 0.3 to 1.0 mg/dL Blood protein -Decreased due to the lack of hepatic synthesis -Expected reference range 6.4 to 8.3 g/dL Blood albumin -Decreased due to the lack of hepatic synthesis -Expected reference range 3.5 to 5 g/dL Hematological tests -RBC: Decreased -Hemoglobin: Decreased -Hematocrit: Decreased -Platelet count: Decreased PT/INR -Prolonged due to decreased synthesis of prothrombin Ammonia levels -Increase when hepatocellular injury (cirrhosis) prevents the conversion of ammonia to urea for excretion -Expected reference range 6 to 47 μmol/L (10 ti 80 mcg/dL) Blood creatinine levels -Can increase due to deteriorating kidney function, which can occur as a result of advanced liver disease

What are the diagnostic procedures for fatty liver (hepatic steatosis)?

Blood test -Used to look at liver enzyme levels, with elevated enzymes signaling inflammation in the liver Physical exam Imaging studies -CT scan, an ultrasound, or an MRI may be used to check the condition of the liver Medical and family history Liver biopsy can also be used to find the extent of the liver damage

What poses the greatest risk for infection of hepatitis C virus in the workplace?

Blood transfusions and sexual contact once accounted for most cases of HCV in the United States, but other parenteral means, such as sharing of contaminated needles by those who use IV or injection drugs and unintentional needlesticks and other injuries in health care workers now account for a significant number of cases People who are at particular risk for HCV include those who use IV or injection drugs, people who are sexually active with multiple partners, patients receiving frequent transfusions, those who require large volumes of blood, and health care personnel

What is hepatic encephalopathy?

Central nervous system dysfunction frequently associated with elevated ammonia levels that produce changes in mental status, altered level of consciousness, and coma

What are the possible complications of hepatitis?

Chronic hepatitis -Ongoing inflammation of the liver cells -Results from hepatitis B, C, or D -Increases the client's risk for liver cancer Fulminant hepatitis -Extremely severe and potentially fatal form of viral hepatitis -Clients develop manifestations of viral hepatitis, then within hours or days develop severe liver failure -No medications, supportive care Cirrhosis of the liver -Permanent scarring of the liver that is usually caused by chronic inflammation Liver cancer Liver failure: Irreversible damage to liver cells, with decreased ability to function adequately to meet the body's needs Hepatic encephalopathy: A life-threatening complication of liver failure. Toxic substances, which are normally detoxified by the liver, enter systemic circulation. Ammonia levels rise and enter the brain, causing clients to develop changes in neurologic status that can progress to stupor, asterixis (hand flapping), fetor hepaticus (fruity, musty breath odor), seizures, and coma

What is the route of transmission for hepatitis D?

Coinfection with HBV

What is the medical management of hepatitis C?

Combination therapy with peginterferon alfa-2a and ribavirin is the preferred treatment

What is the pharmacological therapy/management of hepatitis C?

Combination therapy with peginterferon alfa-2a and ribavirin is the preferred treatment

What is jaundice?

Condition where the body tissues, including the sclerae and the skin, become tinged yellow or greenish-yellow, due to high bilirubin levels

What surgical interventions are used to treat esophageal varices?

Balloon tamponade -Although used infrequently today, balloon tamponade therapy may be used to temporarily control hemorrhage and to stabilize a patient with massive bleeding prior to other definitive management -When indicated, balloon tamponade can be successful; however, there are risks. Displacement of the tube and the inflated balloon into the oropharynx can cause life-threatening obstruction of the airway and asphyxiation -Nursing measures include frequent mouth and nasal care. For secretions that accumulate in the mouth, tissues should be within easy reach of the patient. Oral suction may be necessary to remove secretions TIPS (Transjugular intrahepatic portosystemic shunt) -A TIPS procedure is indicated for the treatment of an acute episode of uncontrolled variceal bleeding refractory to pharmacologic or endoscopic therapy. In 10% to 20% of patients for whom urgent band ligation or sclerotherapy and medications are not successful in eradicating bleeding, a TIPS procedure can effectively control acute variceal hemorrhage by rapidly lowering portal pressure -Potential complications of TIPS include bleeding, sepsis, heart failure, organ perforation, shunt thrombosis, and progressive liver failure

What are the diagnostic procedures for esophageal varices?

Because varices are present in 50% of patients with cirrhosis, it is recommended that patients who have been diagnosed with cirrhosis undergo screening endoscopy. If no varices are detected on initial endoscopy, the test should be repeated in 2 to 3 years in an effort to identify and treat large varices, which are the ones most likely to bleed. If small varices are identified on initial endoscopy, the test should be repeated in 1 to 2 years

What is bile formation?

Bile is continuously formed by the hepatocytes and collected in the canaliculi and bile ducts. It is composed mainly of water and electrolytes such as sodium, potassium, calcium, chloride, and bicarbonate, and it also contains significant amounts of lecithin, fatty acids, cholesterol, bilirubin, and bile salts. Bile is collected and stored in the gallbladder and is emptied into the intestine as needed for digestion. The functions of bile are excretory, as in the excretion of bilirubin; bile also serves as an aid to digestion through the emulsification of fats by bile salts

What lab value measures jaundice?

Bilirubin

What is bilirubin excretion?

Bilirubin is a pigment derived from the breakdown of hemoglobin by cells of the reticuloendothelial system, including the Kupffer cells of the liver. Hepatocytes remove bilirubin from the blood and chemically modify it through conjugation to glucuronic acid, which makes the bilirubin more soluble in aqueous solutions. The conjugated bilirubin is secreted by the hepatocytes into the adjacent bile canaliculi and is eventually carried in the bile into the duodenum

What are the manifestations of compensated cirrhosis?

-Abdominal pain -Ankle edema -Firm, enlarged liver -Flatulent dyspepsia -Intermittent mild fever -Palmar erythema (reddened palms) -Splenomegaly -Unexplained epistaxis -Vague morning indigestion -Vascular spiders

What is the pharmacological therapy/management of hepatitis B?

-Acute infection: No medications;supportive care -Chronic infection: Antiviral medications; tenofovir, adefovir, dipivoxil, interferon alfa-2b, peginterferon alfa-2a, lamivudine, entecavir, and telbivudine

What are the risk factors of cirrhosis?

-Alcohol use disorder -Chronic viral hepatitis (hepatitis B,C, or D) -Autoimmune hepatitis (destruction of the liver cells by the immune system) -Steatohepatitis (fatty liver disease causing chronic inflammation) -Damage to the liver caused by medications, substances, toxins, infections -Chronic biliary cirrhosis (bile duct obstruction, bile stasis, hepatic fibrosis) -Cardiac cirrhosis resulting from severe right heart failure inducing necrosis and fibrosis due to lack of blood flow

What are the manifestations of decompensated cirrhosis?

-Ascites -Clubbing of fingers -Continuous mild fever -Epistaxis -Gonadal atrophy -Hypotension -Jaundice -Muscle wasting -Purpura (due to decreased platelet count) -Sparse body hair -Spontaneous bruising -Weakness -Weight loss -White nails

What are the nursing assessment elements of hepatitis?

-Aversion to eating/lack of interest in food; altered taste sensation -Abdominal pain/cramping -Loss of weight; poor muscle tone

What is the pharmacological therapy/management of cirrhosis?

-Because the metabolism of most medications is dependent upon a functioning liver, general medications are administered sparingly, especially opioids, sedatives, and barbiturates -Diuretics: Decrease excessive fluid in the body -Beta-blocking agent: Used for clients who have varices to prevent bleeding -Lactulose: Used to promote excretion of ammonia from the body through the stool -Nonabsorbable antibiotic: Can be used in place of lactulose Many patients who have end-stage liver disease (ESLD) with cirrhosis use the herb milk thistle (Silybum marianum) to treat jaundice and other symptoms. This herb has been used for centuries because of its healing and regenerative properties for liver disease. Silymarin from milk thistle has anti-inflammatory and antioxidant properties that may have beneficial effects, especially in hepatitis, alcohol-induced liver injury and hepatocellular carcinoma

What is the nutritional management of hepatic encephalopathy?

-Minimize the formation and absorption of toxins, principally ammonia, from the intestine. -Keep daily protein intake between 1.2 and 1.5 g/kg body weight per day. -Avoid protein restriction if possible, even in those with encephalopathy. -For patients who are truly protein intolerant, provide additional nitrogen in the form of an amino acid supplement. The use of branched-chain amino acids should be a consideration in patients with cirrhosis. It has improved outcomes in varied populations with the disease. -Provide small, frequent meals and 3 small snacks per day in addition to a late-night snack before bed.

What are the different liver function tests used to diagnose liver problems?

-Serum aminotransferase: AST, ALT, GGT, GGTP, LDH -Serum protein studies -Direct and indirect serum bilirubin, urine bilirubin, and urine bilirubin and urobilinogen -Clotting factors -Serum alkaline phosphatase -Serum ammonia -Lipids

What are the risk factors of hepatitis C?

-Substance use disorder (injectable substances) -Blood, blood products, or organ transplants -Contaminated needle sticks, unsanitary tattoo equipment -Sexual contact

What are the risk factors of hepatitis D?

-Substance use disorder (injectable substances) -Unprotected sex with infected individual

What is the expected reference range of ammonia levels?

15 to 45 µ/dL (11 to 32 µmol/L)

What is the expected reference range of albumin levels?

3.4 to 5.4 g/dL

What are the risk factors of hepatitis E?

Ingestion of food or water contaminated with fecal waste

What is hepatorenal failure?

Kidney failure that occurs with advanced liver disease and in the absence of other causes of kidney failure Serum creatinine greater than 1.5 mg/dl or 133 umol/l (normal less than 0.9 mg/dl or 120 umol/l)

What is the pharmacological therapy/management of hepatic encephalopathy?

Lactulose (Cephulac) is given to reduce serum ammonia levels. It acts by trapping and expelling the ammonia in the feces -Possible side effects of lactulose include intestinal bloating and cramps, which usually disappear within a week. To mask the sweet taste, which some patients dislike, it can be diluted with fruit juice. The patient is closely monitored for hypokalemia and dehydration Other management strategies include IV administration of glucose to minimize protein breakdown, administration of vitamins to correct deficiencies, and correction of electrolyte imbalances (especially potassium) Antibiotics may also be added to the treatment regimen. Neomycin, metronidazole (Flagyl), and rifaximin (Xifaxan) have been used to reduce levels of ammonia-forming bacteria in the colon

What is compensated cirrhosis?

Less severe, often vague symptoms, that may be discovered secondarily at a routine physical examination

What are the diagnostic procedures for cirrhosis?

Liver biopsy (most definitive) -A liver biopsy identifies the progression and extent of the cirrhosis -To minimize the risk of hemorrhage, a radiologist can perform the biopsy through the jugular vein, which is threaded to the hepatic vein to obtain tissue for a microscopic evaluation -This is done under fluoroscopy for safety because this procedure can be problematic for cirrhosis clients due to an increased risk for bleeding complications

What is the route of transmission for hepatitis A?

Fecal-oral

What is the route of transmission for hepatitis E?

Fecal-oral

What is the pathophysiology of hepatic encephalopathy?

First, hepatic insufficiency may result in encephalopathy because of the inability of the liver to detoxify toxic by-products of metabolism. Second, portosystemic shunting, in which collateral vessels develop as a result of portal hypertension, allows elements of the portal blood (laden with potentially toxic substances usually extracted by the liver) to enter the systemic circulation

What is the client and family education for someone with hepatitis?

Follow vaccination recommendations according to the CDC Follow infection control precautions according to the CDC Reinforce and use safe injection practices -Aseptic technique for preparation medications -Sterile, single-use, disposable needle and syringe for each injection -Single-dose vials whenever possible -Needleless systems or safety caps Use proper hand hygiene (before preparing and eating food, after using the toilet or changing a diaper) When traveling to underdeveloped countries, drink purified water, and avoid sharing eating utensils and bed linens

What are the functions of the liver?

Glucose metabolism, ammonia conversion, protein metabolism, fat metabolism, vitamin and iron storage, bile formation, bilirubin excretion, drug metabolism

What is the progression of cirrhosis?

Healthy liver -> Fatty liver -> Fibrosis -> cirrhosis

What is the medical management of hepatitis E?

In most cases, hepatitis E goes away on its own in about 4-6 weeks. These steps can help ease your symptoms: -Rest -Eat healthy foods -Drink lots of water -Avoid alcohol

What are the manifestations of ascites?

Increased abdominal girth and rapid weight gain are common presenting symptoms of ascites. The patient may be short of breath and uncomfortable from the enlarged abdomen, and striae and distended veins may be visible over the abdominal wall. Umbilical hernias also occur frequently in those patients with cirrhosis. Fluid and electrolyte imbalances are common.

What are the diagnostic procedures for hepatitis?

Liver biopsy. This is the most definitive diagnostic approach, and it is used to identify the intensity of the infection and the degree of liver damage Pre-procedure nursing actions -Explain the procedure -Witness informed consent -Ensure the client fasts starting at midnight on the day of the procedure in case surgery is needed due to a complication -Administer medications as prescribed Intraprocedure nursing actions -Assist the client into the supine position with the upper right quadrant of the abdomen exposed -Assist the client with relaxation techniques Instruct the client to exhale and hold for at least 10 seconds while the needle is inserted -Instruct the client to resume breathing once the needle is withdrawn -Apply pressure to the puncture site Post-procedure nursing actions -Assist the client to a right side-lying position and maintain for several hours -Monitor vital signs -Assess for abdominal pain -Assess for bleeding from the puncture site -Assess for manifestations of pneumothorax (dyspnea, cyanosis, restlessness) due to accidental puncture of the pleura or lung

What is albumin indicative of?

Low albumin levels might indicate a problem with your liver, kidneys or other health conditions. High albumin levels are typically the result of dehydration or severe dehydration Decreased serum albumin levels are not seen in acute liver failure because it takes several weeks of impaired albumin production before the serum albumin level drops. The most common reason for a low albumin is chronic liver failure caused by cirrhosis

What imaging studies are used to diagnose hepatitis?

Magnetic resonance elastography (MRE). This noninvasive imaging can be done instead of a liver biopsy. It mixes magnetic resonance imaging technology with patterns formed by sound waves bouncing off the liver. This makes a map that shows places where the liver is stiff. Stiff liver tissue means scarring of the liver, called fibrosis. Transient elastography. Another test of liver stiffness is a type of ultrasound that sends vibrations into the liver. The test measures how fast the vibrations go through liver tissue.

What happens when albumin is decreased?

Many patients with liver dysfunction develop generalized edema caused by hypoalbuminemia due to decreased hepatic production of albumin

What is the medical management of hepatic encephalopathy?

Medical management focuses on identifying and eliminating the precipitating cause, if possible, initiating ammonia-lowering therapy, minimizing potential medical complications of cirrhosis and depressed consciousness, and reversing the underlying liver disease, if possible. Correction of the possible reasons for the deterioration such as bleeding, electrolyte abnormalities, sedation, or azotemia is essential

What is the nursing intervention for pruritus?

Monitor closely for skin breakdown. Implement measures to prevent pressure injuries. Pruritus, which is associated with jaundice, will cause the client to scratch. Encourage washing with cold water and applying lotion to decrease the itching

How do you monitor the effectiveness of a TIPS procedure?

Monitor the client's weight

What is the pharmacological therapy/management of hepatitis E?

No medications; supportive care

What is the medical management of hepatitis A?

No specific treatment exists for hepatitis A. Your body will clear the hepatitis A virus on its own. In most cases of hepatitis A, the liver heals within six months with no lasting damage. Hepatitis A immunization is recommended for post-exposure protection Immunoglobulin is recommended for post-exposure protection for clients older than 40 years, younger than 12 months, who have chronic liver disease, who are immunosuppressed, or who are allergic to the vaccine

What is a coma?

State of unconsciousness marked by profound suppression of responses to external and internal stimuli (state of unarousable unresponsiveness) Absence of asterixis; absence of deep tendon reflexes; flaccidity of extremities. EEG markedly abnormal

What is the cause of jaundice?

The bilirubin concentration in the blood may be increased in the presence of liver disease, if the flow of bile is impeded (e.g., by gallstones in the bile ducts), or if there is excessive destruction of red blood cells. With bile duct obstruction, bilirubin does not enter the intestine; as a consequence, urobilinogen is absent from the urine and decreased in the stool

What are the manifestations of esophageal varices?

The client may present with hematemesis, melena, or general deterioration in mental or physical status and often has a history of alcohol abuse. Signs and symptoms of shock (cool clammy skin, hypotension, tachycardia) may be present

What is the nursing management of hepatic encephalopathy?

The nurse is responsible for maintaining a safe environment to prevent injury, bleeding, and infection. The nurse administers the prescribed treatments and monitors the patient for the numerous potential complications. The potential for respiratory compromise is great given the patient's depressed neurologic status. The nurse encourages deep breathing and position changes to prevent the development of atelectasis, pneumonia, and other respiratory complications. Despite aggressive pulmonary care, patients may develop respiratory compromise. They may require intubation and mechanical ventilation to protect the airway, and they are frequently admitted to the ICU. The nurse communicates with the patient's family to inform them about the patient's status and supports them by explaining the procedures and treatments that are part of the patient's care. If the patient recovers from hepatic encephalopathy and coma, rehabilitation is likely to be prolonged. Therefore, the patient and family will require assistance to understand the causes of this severe complication and to recognize that it may recur

What are the safety considerations for clients with cirrhosis?

The obstruction to blood flow through the liver caused by fibrotic changes also results in the formation of collateral blood vessels in the GI system and the shunting of blood from the portal vessels into blood vessels with lower pressures. As a result, the client with cirrhosis often has prominent distended abdominal vessels, which are visible on abdominal inspection, and distended blood vessels throughout the GI tract. The esophagus, stomach, and lower rectum are common sites of collateral blood vessels. These distended blood vessels form varices or hemorrhoids, depending on their location -Closely assess for signs and symptoms of GI bleeding: check all secretions for frank or occult blood. Observe the color and consistency of stools, NG drainage, or vomitus. -Observe the presence of petechiae, ecchymosis, and bleeding from one or more sites. -Monitor pulse, BP (and CVP if available). -Note changes in mentation and LOC. -Monitor hemoglobin and hematocrit and clotting factors.

When should a lactulose regimen be modified?

The patient receiving lactulose is monitored closely for the development of watery diarrhea stools, because they indicate a medication overdose. Serum ammonia levels are closely monitored as well.

What kind of diet should a client with cirrhosis have if ascites is absent?

The patient with cirrhosis without ascites, edema, or signs of impending hepatic coma should receive a nutritious, high-protein diet, if tolerated, supplemented by vitamins of the B complex, as well as A, C, and K. The nurse encourages the patient to eat

How many/what size meals should a client with cirrhosis eat per day?

The patient with cirrhosis without ascites, edema, or signs of impending hepatic coma should receive a nutritious, high-protein diet, if tolerated, supplemented by vitamins of the B complex, as well as A, C, and K. The nurse encourages the patient to eat. If ascites is present, small, frequent meals may be better tolerated than three large meals because of the abdominal pressure exerted by ascites

What are the expected findings of ascites?

The presence and extent of ascites are assessed by percussion of the abdomen. When fluid has accumulated in the peritoneal cavity, the flanks bulge when the patient assumes a supine position. The presence of fluid can be confirmed either by percussing for shifting dullness, by detecting a fluid wave, or by performing ballottement technique

What happens when clotting factors are decreased?

The production of blood clotting factors by the liver is also reduced due to hepatic dysfunction, leading to an increased incidence of bruising, epistaxis, bleeding from wounds, and, as described previously, GI bleeding

What is ammonia conversion?

The use of amino acids from protein for gluconeogenesis results in the formation of ammonia as a by-product. The liver converts this metabolically generated ammonia into urea. Ammonia produced by bacteria in the intestines is also removed from portal blood for urea synthesis. In this way, the liver converts ammonia, a potential toxin, into urea, a compound that is excreted in the urine

What is the pharmacological therapy/management of ascites?

The use of diuretic agents along with sodium restriction is successful in 90% of patients with ascites. Spironolactone (Aldactone), an aldosterone-blocking agent, is most often the first-line therapy in patients with ascites from cirrhosis. When used with other diuretic agents, spironolactone helps prevent potassium loss. Oral diuretic agents such as furosemide (Lasix) may be added but should be used cautiously, because long-term use may induce severe sodium depletion (hyponatremia)

What is postnecrotic cirrhosis?

There are broad bands of scar tissue. This is a late result of a previous bout of acute viral hepatitis

What is the medical management of hepatitis D?

There's no cure yet for HDV. Until doctors come up with better options, the drug prescribed most often is pegylated interferon alfa (peg-IFNa) -Peg-IFNa doesn't work well for everyone. It can also cause many side effects, like lack of energy, weight loss, flu-like symptoms, and mental health issues like depression

What is Laennec's (alcoholic) cirrhosis?

This occurs when the scar tissue characteristically surrounds the portal areas. This is most frequently caused by chronic alcoholism and is the most common type of cirrhosis.

What imaging studies are used to diagnose cirrhosis?

Ultrasound -Used to detect ascites, hepatomegaly, splenomegaly, biliary stones, or biliary obstruction Abdominal x-rays and CT scan -Used to visualize possible hepatomegaly, ascites, and splenomegaly MRI -Used to visualize mass lesions and determine whether the liver is malignant or benign Esophagogastroduodenoscopy -This is performed under moderate (conscious) sedation to detect the presence of esophageal varices, ulcerations in the stomach, or duodenal ulcers and bleeding Endoscopic retrograde cholangiopancreatography -Used to view the biliary tract to assist in removing stones, to collect specimens for biopsy, and for stent placement

What is vitamin and iron storage?

Vitamins A, B, and D and several of the B-complex vitamins are stored in large amounts in the liver. Certain substances, such as iron and copper, are also stored in the liver

What happens when bilirubin is increased?

When the bilirubin concentration in the blood is abnormally elevated, all of the body tissues, including the sclerae and the skin, become tinged yellow or greenish-yellow, a condition known as jaundice

What are the manifestations of jaundice?

When the bilirubin concentration in the blood is abnormally elevated, all of the body tissues, including the sclerae and the skin, become tinged yellow or greenish-yellow, a condition known as jaundice. Jaundice becomes clinically evident when the serum bilirubin level exceeds 2.0 mg/dL (34 mmol/L)

What is the pharmacological therapy/management of esophageal varices?

Pharmacologic agents -Propranolol (Inderal)/nadolol (Corgard) -Vasopressin (Pitressin) -Octreotide (Sandostatin) Injection sclerotherapy Endoscopic variceal ligation

What are the different types of cirrhosis?

Postnecrotic, Laennec's (alcoholic), and biliary cirrhosis

What are the safety considerations for clients with hepatitis?

Provide specific information regarding prevention and transmission of disease: contacts may require gamma-globulin; personal items should not be shared; observe strict handwashing and sanitizing of clothes, dishes, and toilet facilities while liver enzymes are elevated. Avoid intimate contact, such as kissing and sexual contact, and exposure to infections, especially URI. Discuss the side effects and dangers of taking OTC and prescribed drugs (acetaminophen, aspirin, sulfonamides, some anesthetics) and necessity of notifying future healthcare providers of diagnosis -Some drugs are toxic to the liver; many others are metabolized by the liver and should be avoided in severe liver diseases because they may cause cumulative toxic effects and chronic hepatitis

What are the physical assessment findings of cirrhosis?

-Cognitive changes -Altered sleep/wake pattern -Gastroesophageal bleeding (enlarged esophageal veins [varices] develop and burst, causing vomiting and passing of blood in bowel movements) or portal hypertensive gastropathy, which causes bleeding of gastric mucosa) -Splenomegaly caused from backup of blood into the spleen, which can cause thrombocytopenia and platelet destruction -Ascites (bloating or swelling due to fluid buildup in the abdomen and legs) -Jaundice (yellowing of skin) and icterus (yellowing of the eyes) from decreased excretion of bilirubin, resulting in an increase of circulating bilirubin levels -Petechiae (round, pinpoint, red-purple lesions), ecchymoses (large yellow and purple-blue bruises), nosebleeds, hematemesis, melena (decreased synthesis of prothrombin, deteriorating hepatic function) -Palmar erythema (redness, warmth of the palms of the hands) -Spider angiomas (red lesions, vascular in nature with branches radiating on the nose, cheeks, upper thorax, shoulder) -Dependent peripheral edema of extremities and sacrum -Asterixis (liver flapping tremor): coarse tremor characterized by rapid, nonrhythmic extension and flexion of the wrists and fingers -Fetor hepaticus (liver breath): fruity or musty odor

What are the nursing assessment elements of cirrhosis?

-Complaints of fatigue and weakness -Reports of abdominal pain or discomfort -Presence of ascites (abdominal fluid accumulation) evidenced by distension and shifting dullness on percussion -Nausea, vomiting, or changes in appetite -History of alcohol abuse or excessive alcohol consumption -Complaints of jaundice (yellowing of the skin and eyes) -Presence of pruritus -Reports of weight loss or changes in body weight -History of coagulation disorders or easy bruising -Signs of hepatic encephalopathy, such as altered mental status, confusion, or asterixis (flapping tremor) -Presence of spider angiomas (dilated blood vessels) or palmar erythema (reddening of the palms) -Elevated liver enzymes (ALT, AST), bilirubin, and INR (international normalized ratio)

What are the expected findings of cirrhosis?

-Fatigue -Weight loss, abdominal pain, distention -Pruritus (severe itching of skin) -Confusion or difficulty thinking (due to the buildup of waste products in the blood and brain that the liver is unable to get rid of) -Personality and mentation changes, emotional lability, euphoria, depression

What are the physical assessment findings of hepatitis?

-Fever -Vomiting -Dark-colored urine -Clay-colored stool -Jaundice

How should the diet of a client with hepatic steatosis be modified?

-Fruits and vegetables -High-fiber plants like legumes and whole grains -Significantly reducing intake of certain foods and beverages including those high in added sugar, salt, refined carbohydrates, and saturated fat -No alcohol

What is the pharmacological therapy/management of hepatitis A?

-Hepatitis A immunization is recommended for post-exposure protection -Immunoglobulin is recommended for post-exposure protection for clients order than 40 years, younger than 12 months, who have chronic liver disease, who are immunosuppressed, or who are allergic to the vaccine

What is the cause of hepatitis?

-Immune cells in the body attacking the liver -Infections from viruses (such as hepatitis A, hepatitis B, or hepatitis C), bacteria, or parasites -Liver damage from alcohol or poison -Medicines, such as an overdose of acetaminophen -Fatty liver

What are the risk factors of hepatitis A?

-Ingestion of contaminated food or water, especially shellfish -Contact with infected stool (incontinent individuals, anal sexual activity)

What are the manifestations of liver disease?

-Jaundice -Portal Hypertension: Ascites, Esophageal Varices, and Hepatic Encephalopathy (other: Splenomegaly, hepatorenal failure, asterixis, coma, gynecomastia, spider angiomata, palmar erythema, Increased bilirubin, decreased albumin, decreased clotting factors)

What is the anatomy of the liver?

-Largest gland of the body -Located in the upper right abdomen -A very vascular organ that receives blood from GI tract via the portal vein and from the hepatic artery

What is the cause of cirrhosis?

-Long-term alcohol abuse. -Ongoing viral hepatitis (hepatitis B, C and D). -Nonalcoholic fatty liver disease, a condition in which fat accumulates in the liver. -Hemochromatosis, a condition that causes iron buildup in the body. -Autoimmune hepatitis, which is a liver disease caused by the body's immune system. -Destruction of the bile ducts caused by primary biliary cholangitis. -Hardening and scarring of the bile ducts caused by primary sclerosing cholangitis. -Wilson's disease, a condition in which copper accumulates in the liver. -Cystic fibrosis. -Alpha-1 antitrypsin deficiency. -Poorly formed bile ducts, a condition known as biliary atresia. -Inherited disorders of sugar metabolism, such as galactosemia or glycogen storage disease. -Alagille syndrome, a genetic digestive disorder. -Infection, such as syphilis or brucellosis. -Medications, including methotrexate or isoniazid.

What are the client goals/outcomes with cirrhosis?

-Manage and monitor liver function in patients with cirrhosis. -Address complications associated with cirrhosis, such as portal hypertension or ascites. -Provide supportive care to manage symptoms and improve quality of life. -Educate patients on dietary modifications and fluid restriction, if necessary. -Administer medications to manage symptoms and slow disease progression, if applicable. -Monitor for and manage complications like hepatic encephalopathy or variceal bleeding. -Offer counseling and support for lifestyle modifications, including alcohol cessation and weight management.

What are the client goals/outcomes with hepatitis?

-Manage symptoms and provide supportive care. -Prevent further liver damage and promote liver health. -Monitor liver function and assess disease progression. -Administer antiviral medications, if applicable. -Educate patients on lifestyle modifications to minimize liver stress. -Prevent transmission of hepatitis to others. -Address complications or comorbidities associated with hepatitis.

What is the evaluation of nursing/client goals/outcomes for cirrhosis?

-The client will demonstrate progressive weight gain toward a goal with the client-appropriate normalization of laboratory values. -The client will experience no further signs of malnutrition. -The client will demonstrate stabilized fluid volume, with balanced I&O, stable weight, vital signs within the client's normal range, and absence of edema. -The client will maintain skin integrity. -The client will verbalize reduced itching or the ability to tolerate itching without scratching. -The client will identify individual risk factors and demonstrate behaviors/techniques to prevent skin breakdown. -The client will maintain an effective respiratory pattern; be free of dyspnea and cyanosis, with ABGs and vital capacity within the acceptable range. -The client will maintain homeostasis in absence of bleeding The client will demonstrate behaviors to reduce the risk of bleeding. -The client will maintain the usual level of mentation/reality orientation. -The client will initiate behaviors/lifestyle changes to prevent or minimize the recurrence of the problem. -The client will verbalize understanding of changes and acceptance of self in the present situation. -The client will identify feelings and methods for coping with a negative perception of self. -The client will verbalize understanding of the disease process/prognosis, and potential complications. -The client will identify/initiate necessary lifestyle changes and participate in care.

What is the evaluation of nursing/client goals/outcomes for hepatitis?

-The client will maintain adequate hydration, as evidenced by stable vital signs, good skin turgor, capillary refill, strong peripheral pulses, and individually appropriate urinary output. -The client will report an improved sense of energy. -The client will perform ADLs and participate in desired activities at the level of ability. -The client will verbalize understanding of the disease process, prognosis, and potential complications. -The client will identify the relationship between signs/symptoms of the disease and correlate symptoms with causative factors. -The client will verbalize understanding of therapeutic needs. -The client will initiate necessary lifestyle changes and participate in treatment regimen.

What does the physical assessment consist of for someone with suspected liver problems?

-The nurse assesses the patient for physical signs that may occur with liver dysfunction, including the pallor often seen with chronic illness and jaundice. -The skin, mucosa, and sclerae are inspected for jaundice, and the extremities are assessed for muscle atrophy, edema, and skin excoriation secondary to scratching. -The nurse observes the skin for petechiae or ecchymotic areas (bruises), spider angiomas, and palmar erythema. -The male patient is assessed for unilateral or bilateral gynecomastia and testicular atrophy due to hormonal changes. -The patient's cognitive status (recall, memory, abstract thinking) and neurologic status are assessed. -The nurse observes for general tremor, asterixis (involuntary flapping movements of the hands), weakness, and slurred speech.

What are the risk factors of hepatitis B?

-Unprotected sex with infected individual -Infants born to infected mothers -Contact with infected blood -Substance use disorder (injectable substances)

What are additional risk factors of hepatitis?

-Unscreened blood transfusions (prior to 1992) -Hemodialysis -Percutaneous exposure (dirty needles, sharp instruments, body piercing, tattooing, use of another person's substance use paraphernalia or personal hygiene tools) -Ingestion of food prepared by a hepatitis-infected person who does not practice proper sanitation precautions -Travel/residence in underdeveloped country (using tap water to clean food products, drinking contaminated water) -Eating or living in crowded environments (correctional facilities, dormitories, universities, long-term care facilities, military base housing)

What is the treatment for elevated prothrombin time or INRs?

-Vitamin K may be given to decrease your INR and bleeding. -Blood components may be given during a transfusion to help stop your bleeding. Blood components are the parts of blood that help it to clot. Examples are clotting factors, platelets, and plasma

What is cirrhosis?

A chronic liver disease characterized by fibrotic changes, the formation of dense connective tissue within the liver, subsequent degenerative changes, and loss of functioning cells

What is gynecomastia?

A condition of overdevelopment or enlargement of the breast tissue in men or boys

What are the diagnostic findings for ascites?

A fluid wave is likely to be found only if a large amount of fluid is present. The ballottement technique is a palpation technique performed to identify a mass or enlarged organ within an abdomen with ascites. Ballottement can be performed in two different ways: single handed or bimanually. Daily measurement and recording of abdominal girth and body weight are essential to assess the progression of ascites and its response to treatment

What is splenomegaly?

A palpable enlarged spleen which is a common manifestation of portal hypertension

What is palmar erythema?

A skin condition that makes the palms of your hands turn red

What are the nursing interventions for ascites?

Dietary modifications -The goal of treatment for the patient with ascites is a negative sodium balance to reduce fluid retention. Table salt, salty foods, salted butter and margarine, and all canned and frozen foods that are not specifically prepared for low-sodium (2-g sodium) diets should be avoided Pharmacologic therapy -The use of diuretic agents along with sodium restriction is successful in 90% of patients with ascites Bed rest -In patients with ascites, an upright posture is associated with activation of the renin-angiotensin-aldosterone system and sympathetic nervous system. This causes reduced renal glomerular filtration and sodium excretion and a decreased response to loop diuretics. Therefore, bed rest may be a useful therapy, especially for patients whose condition is refractory to diuretic agents Paracentesis -Paracentesis is the removal of fluid (ascites) from the peritoneal cavity through a puncture or a small surgical incision through the abdominal wall under sterile conditions The use of shunts -Transjugular intrahepatic portosystemic shunt (TIPS) is a method of treating ascites in which a cannula is threaded into the portal vein by the transjugular route. -To reduce portal hypertension, an expandable stent is inserted to serve as an intrahepatic shunt between the portal circulation and the hepatic vein. This is extremely effective in decreasing sodium retention, improving the renal response to diuretic therapy, and preventing recurrence of fluid accumulation Other therapies -Ascites can also be treated by the insertion of a peritoneovenous shunt to redirect ascitic fluid from the peritoneal cavity into the systemic circulation via an abdominal and a thoracic catheter that drain into the superior vena cava through a one-way valve

What are esophageal varices?

Dilated, tortuous veins that are usually found in the submucosa of the lower esophagus but may develop higher in the esophagus or extend into the stomach

What imaging studies are used to diagnose esophageal varices?

Endoscopy is used to identify the bleeding site, along with ultrasonography, CT scanning, and angiography. Another diagnostic tool, the endoscopic video capsule, can detect esophageal varices but does not substitute for endoscopy unless this test cannot be performed. Standard endoscopy is superior to video capsule for the diagnosis of esophageal varices

What is the pathophysiology of esophageal varices?

Esophageal varices are dilated, tortuous veins that are usually found in the submucosa of the lower esophagus but may develop higher in the esophagus or extend into the stomach. This condition is almost always caused by portal hypertension, which results from obstruction of the portal venous circulation within the damaged liver Because of increased obstruction of the portal vein, venous blood from the intestinal tract and spleen seeks an outlet through collateral circulation (new pathways for return of blood to the right atrium). The effect is increased pressure, particularly in the vessels in the submucosal layer of the lower esophagus and upper part of the stomach. These collateral vessels are not very elastic; rather, they are tortuous and fragile, and they bleed easily

What are the possible complications of cirrhosis?

Hepatic encephalopathy/portal systemic encephalopathy -Clients who have a poorly functioning liver are unable to convert ammonia and other waste products to a less toxic form. These products are carried to the brain and cause neurologic manifestations. Clients are treated with medications such as lactulose to reduce the ammonia levels in the body via intestinal excretion. Reductions in dietary protein are indicated as ammonia is formed when protein is broken down by intestinal flora Esophageal varices -Portal hypertension (elevated blood pressure in the veins that carry blood from the intestines to the liver) is caused by impaired circulation of blood through the liver. Collateral circulation is subsequently developed, creating varices in the upper stomach and esophagus. Varices are fragile and can bleed easily Acute graft rejection post liver transplantation -This typically occurs between 4 and 10 days after surgery and occurs when the recipient's bone marrow creased T-cells to attack the new organ Fluid volume excess -Patients with advanced chronic liver disease develop cardiovascular abnormalities. These occur due to an increased cardiac output and decreased peripheral vascular resistance, possibly resulting from the release of vasodilators. A hyperdynamic circulatory state develops in patients with cirrhosis, and plasma volume increases. -The greater the degree of hepatic decompensation, the more severe the hyperdynamic state -Fluid retention may be noted in the development of ascites, lower extremity swelling, and dyspnea

What are the different categories of viral hepatitis?

Hepatitis A, Hepatitis B, Hepatitis C, Hepatitis D, Hepatitis E

What laboratory tests are used to diagnose hepatitis E?

Hepatitis E virus antibodies (anti-HEV): Presence indicates the presence of HEV

What are the expected findings of hepatitis?

History of exposure to infected blood, stool, or body fluid Influenza-like manifestations -Fatigue -Decreased appetite with nausea -Abdominal pain -Joint pain

What laboratory tests are used to diagnose hepatitis D?

Identification of intrahepatic delta antigen Hepatitis D virus antibodies (anti-HDV): Presence indicates the presence of HDV

What is the nursing management of ascites?

If a patient with ascites from liver dysfunction is hospitalized, nursing measures include assessment and documentation of intake and output (I&O), abdominal girth, and daily weight to assess fluid status. The nurse also closely monitors the respiratory status because large volumes of ascites can compress the thoracic cavity and inhibit adequate lung expansion. The nurse monitors serum ammonia, creatinine, and electrolyte levels to assess electrolyte balance, response to therapy, and indications of hepatic encephalopathy

What kind of diet should a client with cirrhosis have if ascites is present?

If ascites is present, small, frequent meals may be better tolerated than three large meals because of the abdominal pressure exerted by ascites

What does the health history consist of for someone with suspected liver problems?

If liver function test results are abnormal, the patient is evaluated for liver disease. In such cases, the health history focuses on previous exposure of the patient to hepatotoxic substances or infectious agents The patient's occupational, recreational, and travel history may assist in identifying exposure to hepatotoxins (e.g., industrial chemicals, other toxins). The patient's history of alcohol and drug use, including but not limited to the use of intravenous (IV) or injection drugs, provides additional information about exposure to toxins and infectious agents. Many medications (including acetaminophen [Tylenol], ketoconazole [Nizoral], and valproic acid [Depakene]) are responsible for hepatic dysfunction and disease. A thorough medication history should address all current and past prescription medications, over-the-counter medications, herbal remedies, and dietary supplements The history also includes an evaluation of the patient's past medical history to identify risk factors for the development of liver disease. Current and past medical conditions, including those of a psychological or psychiatric nature, are identified. The family history includes questions about familial liver disorders that may have their origin in alcohol abuse or gallstone disease, as well as other familial or genetic disorder

What is the nursing management of esophageal varices?

Nursing assessment includes monitoring the patient's physical condition and evaluating emotional responses and cognitive status. The nurse monitors and records vital signs and assesses the patient's nutritional and neurologic status. This assessment assists in identifying hepatic encephalopathy If complete rest of the esophagus is indicated because of bleeding, parenteral nutrition is initiated. Gastric suction usually is initiated to keep the stomach as empty as possible and to prevent straining and vomiting. The patient often complains of severe thirst, which may be relieved by frequent oral hygiene and moist sponges to the lips. The nurse closely monitors the blood pressure. Vitamin K therapy and multiple blood transfusions often are indicated because of blood loss. A quiet environment and calm reassurance may help to relieve the patient's anxiety and reduce agitation Bleeding anywhere in the body is anxiety provoking, resulting in a crisis for the patient and family. If the patient has been a heavy user of alcohol, delirium secondary to alcohol withdrawal can complicate the situation. The nurse provides support and explanations about medical and nursing interventions to prepare both the patient and the family, because these procedures can be difficult to undergo and observe. Close monitoring of the patient helps in detecting and managing complications

What are the nursing interventions for hepatitis?

Optimize Nutritional Balance -Encourage mouth care before meals -Recommend eating in an upright position -Encourage the intake of fruit juices, carbonated beverages, and hard candy throughout the day -Consult with the dietitian, and nutritional support team to provide a diet according to the patient's needs, with fat and protein intake as tolerated Promote Adequate Fluid Balance -Monitor I&O, and compare with periodic weight. Note enteric losses: vomiting and diarrhea -Assess vital signs, peripheral pulses, capillary refill, skin turgor, and mucous membranes -Check for ascites or edema formation. Measure abdominal girth as indicated -Observe for signs of bleeding: hematuria, melena, ecchymosis, oozing from gums, puncture sites Promote Gradual Ambulation and Managing Fatigue -Monitor for recurrence of anorexia and liver tenderness or enlargement -Monitor serial liver enzyme levels -Institute bed red or chair rest during the toxic state. Provide a quiet environment; limit visitors as needed -Recommend changing position frequently. Provide and instruct caregiver in good skin care Prevent Skin Breakdown and Maintaining Skin Integrity -Observe skin for areas of redness, and breakdown -Encourage the use of cool showers and baking soda or starch baths. Avoid the use of alkaline soaps. Apply calamine lotion as indicated -Suggest the use of knuckles if the desire to scratch is uncontrollable. Keep fingernails cut short, and apply gloves on the comatose patient or during hours of sleep. Recommend loose-fitting clothing. Provide soft cotton linens -Provide a soothing massage at bedtime Provide Emotional Support -Assess effect of illness on economic factors of patient and SO -Contract with patient regarding time for listening. Encourage discussion of feelings/concerns -Avoid making moral judgments regarding lifestyle -Discuss recovery expectations

What is the medical management of cirrhosis?

Paracentesis -Used to relieve ascites Endoscopic variceal ligation/endoscopic sclerotherapy -Varices are either sclerosed or banded endoscopically -There is a decreased risk of hemorrhage with banding Transjugular intrahepatic portosystemic shunt -This is performed in interventional radiology for client who require further intervention with ascites or hemorrhage Surgical bypass shunting procedures -This is a last resort for clients who have portal hypertension and esophageal varices. Ascites is shunted from the abdominal cavity to the superior vena cava Liver transplantation -Portions of healthy liver from deceased donors (most commonly trauma victims) or living donors can be used for transplant -The transplanted liver portion will regenerate and grow in size based on the needs of the body -The client must meet the transplant criteria to be eligible -Clients who have severe cardiac and respiratory disease, metastatic malignant liver cancer, or alcohol/substance use disorder are not candidates for liver transplantation

What are the nursing interventions for cirrhosis?

Respiratory status -Monitor oxygen saturation levels and distress. Provide comfort measures by positioning the client to ease respiratory effort (can be compromised by plasma volume excess and ascites). Have the client sit in a chair or elevate the head of the bed to 30° with feet elevated Skin integrity -Monitor closely for skin breakdown. Implement measures to prevent pressure injuries. Pruritus, which is associated with jaundice, will cause the client to scratch. Encourage washing with cold water and applying lotion to decrease the itching Fluid balance -Monitor for indications of fluid volume excess. Keep strict I&O, obtain daily weights, and assess ascites and peripheral edema. Restrict fluids and sodium if prescribed Vital signs -Monitor vital signs and pain level Neurologic status -Monitor for deteriorating mental status and dementia consistent with hepatic encephalopathy. Monitor for asterixis (coarse tremor of wrists and fingers) and fetor hepaticus. Lactulose can be given to aid in excretion of ammonia Nutritional status -High-carbonate, high-protein, moderate-fat, and low-sodium diet with vitamin supplements (thiamine, folate, multivitamins) Gastrointestinal status -In the presence of ascites, measure abdominal girth daily over the largest part of the abdomen. Mark the location of tape for consistency. Observe for potential bleeding complications Pain status -Assess pain, and administer analgesics and gastrointestinal antispasmodics as needed

What is decompensated cirrhosis?

Results from failure of the liver to synthesize proteins, clotting factors, and other substances and manifestations of portal hypertension

What is biliary cirrhosis?

Scarring occurs in the liver around the bile ducts. This type of cirrhosis usually results from chronic biliary obstruction and infection (cholangitis); it is much less common

What are the diagnostic procedures for hepatic encephalopathy?

Several diagnostic algorithms and a variety of psychometric tests are used in determining the presence and severity of hepatic encephalopathy. The survival rate after a first episode of overt hepatic encephalopathy in patients with cirrhosis is approximately 40% at 1 year. Eligible patients should be referred for liver transplantation after this initial episode

What is the pathophysiology of cirrhosis?

Several factors have been implicated in the etiology of cirrhosis. Nutritional deficiency with reduced protein intake contributes to liver destruction in cirrhosis, but excessive alcohol intake is the major causative factor in fatty liver and its consequences. However, cirrhosis can occur in people who do not consume alcohol and in those who consume a normal diet and have a high alcohol intake Other factors may play a role, including exposure to certain chemicals (carbon tetrachloride, chlorinated naphthalene, arsenic, or phosphorus) or infectious schistosomiasis. Twice as many men as women are affected, although, for unknown reasons, women are at greater risk for development of alcohol-induced liver disease. Most patients are between 40 and 60 years of age

What are spider angiomas?

Small red to purple mark on your skin caused by dilated blood vessels near the surface of your skin. They are most often associated with cirrhosis, especially in alcoholic liver disease

What are the manifestations of hepatic encephalopathy?

The earliest symptoms of hepatic encephalopathy include mental status changes and motor disturbances. The patient appears confused and unkempt and has alterations in mood and sleep patterns. The patient tends to sleep during the day and has restlessness and insomnia at night. As hepatic encephalopathy progresses, the patient may become difficult to awaken and completely disoriented with respect to time and place. With further progression, the patient lapses into frank coma and may have seizures Asterixis, an involuntary flapping of the hands, may be seen in stage II encephalopathy Simple tasks, such as handwriting, become difficult. A handwriting or drawing sample (e.g., star figure), taken daily, may provide graphic evidence of progression or reversal of hepatic encephalopathy. Inability to reproduce a simple figure in two or three dimensions Occasionally, fetor hepaticus, a sweet, slightly fecal odor to the breath that is presumed to be of intestinal origin, may be noticed. The odor has also been described as similar to that of freshly mowed grass, acetone, or old wine. Fetor hepaticus is prevalent with extensive collateral portal circulation in chronic liver disease

What imaging studies are used to diagnose hepatic encephalopathy?

The electroencephalogram shows generalized slowing, an increase in the amplitude of brain waves, and characteristic triphasic waves.

What is protein metabolism?

The liver also plays an important role in protein metabolism. It synthesizes almost all of the plasma proteins (except gamma-globulin), including albumin, alpha-globulins and beta-globulins, blood clotting factors, specific transport proteins, and most of the plasma lipoproteins. Vitamin K is required by the liver for synthesis of prothrombin and some of the other clotting factors. Amino acids are used by the liver for protein synthesis

What is fat metabolism?

The liver is also active in fat metabolism. Fatty acids can be broken down for the production of energy and ketone bodies (acetoacetic acid, beta-hydroxybutyric acid, and acetone). Ketone bodies are small compounds that can enter the bloodstream and provide a source of energy for muscles and other tissues. Breakdown of fatty acids into ketone bodies occurs primarily when the availability of glucose for metabolism is limited, as in starvation or in uncontrolled diabetes. Fatty acids and their metabolic products are also used for the synthesis of cholesterol, lecithin, lipoproteins, and other complex lipids

What is drug metabolism?

The liver metabolizes many medications, such as barbiturates, opioids, sedatives, anesthetics, and amphetamines. Metabolism generally results in drug inactivation, although activation may also occur. One of the important pathways for medication metabolism involves conjugation (binding) of the medication with a variety of compounds, such as glucuronic acid or acetic acid, to form more soluble substances. These substances may be excreted in the feces or urine, similar to bilirubin excretion. Bioavailability is the fraction of the given medication that actually reaches the systemic circulation

What is glucose metabolism?

The liver plays a major role in the metabolism of glucose and the regulation of blood glucose concentration. After a meal, glucose is taken up from the portal venous blood by the liver and converted into glycogen, which is stored in the hepatocytes. Subsequently, the glycogen is converted back to glucose (glycogenolysis) and released as needed into the bloodstream to maintain normal levels of blood glucose

What is the pathophysiology of ascites?

The mechanisms responsible for the development of ascites are not completely understood. Portal hypertension and the resulting increase in capillary pressure and obstruction of venous blood flow through the damaged liver are contributing factors. The vasodilation that occurs in the splanchnic circulation (the arterial supply and venous drainage of the GI system from the distal esophagus to the midrectum, including the liver and spleen) is also a suspected causative factor The failure of the liver to metabolize aldosterone increases sodium and water retention by the kidney. Sodium and water retention, increased intravascular fluid volume, increased lymphatic flow, and decreased synthesis of albumin by the damaged liver all contribute to the movement of fluid from the vascular system into the peritoneal space. The process becomes self-perpetuating; loss of fluid into the peritoneal space causes further sodium and water retention by the kidney in an effort to maintain the vascular fluid volume

What is the medical management of ascites?

The medical management of the patient with ascites includes dietary modifications, pharmacologic therapy, bed rest, paracentesis, the use of shunts, and other therapies. Nutritional therapy -The goal of treatment for the patient with ascites is a negative sodium balance to reduce fluid retention. Table salt, salty foods, salted butter and margarine, and all canned and frozen foods that are not specifically prepared for low-sodium (2-g sodium) diets should be avoided Bed rest -In patients with ascites, an upright posture is associated with activation of the renin-angiotensin-aldosterone system and sympathetic nervous system. This causes reduced renal glomerular filtration and sodium excretion and a decreased response to loop diuretics. Therefore, bed rest may be a useful therapy, especially for patients whose condition is refractory to diuretic agents. Paracentesis -Paracentesis is the removal of fluid (ascites) from the peritoneal cavity through a puncture or a small surgical incision through the abdominal wall under sterile conditions Transjugular Intrahepatic Portosystemic Shunt -Transjugular intrahepatic portosystemic shunt (TIPS) is a method of treating ascites in which a cannula is threaded into the portal vein by the transjugular route. To reduce portal hypertension, an expandable stent is inserted to serve as an intrahepatic shunt between the portal circulation and the hepatic vein. This is extremely effective in decreasing sodium retention, improving the renal response to diuretic therapy, and preventing recurrence of fluid accumulation