H476- Liver Failure

If you have liver failure what complications can happen with storage?

Malnutrition because they can't absorb or store

Normal portal venous pressure

Normal portal venous pressure is 2 to 6 mm Hg Greater 10 mm Hg see distensions of vessels Varices develop after 12 mm Hg

What medication is hard on the liver from a cardiac point?

Statins.. May need to get your liver checked

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clinical manifestations

Esophageal Varices

complex of tortuous, enlarged veins at lower end of esophagus

Where is bile stored?

gallbladder

Kupffer cells fight what?

infection

Caput Medusae

large collateral veins

Cirrhosis

liver cells destroyed... fibrosis

Hepatitis

liver cells inflamed

Medications to help with someone who can't store?

prenatal vitamins, folic acid, thymine, multivitamin

Decreased Enzymes

protein/albumin (liver won't be producing these)

Elevated ammonia level

pt might be confused, will be on ventilator with no sedation at all because ammonia will be sedating them

Hepatic Encephalopathy Treatment- Lactulose

-*first line treatment* -draws the ammonia from the blood stream into the stool to be excreted -*causes diarrhea*

Ascites

-accumulation of serous fluid in peritoneal or abdominal cavity -several mechanisms (portal hypertension, hypoalbuminemia, hyperaldosteronism- cause kidneys to hold onto sodium=more water retention, then it will go into the tissue)

Secretory Function

-bile production -bile secretion -bilirubin conjugation (results of liver breaking down hemoglobin or RBC)

Vascular Function

-blood storage -blood filtration (filters used up clotting factors, alcohol, RBC turn into bilirubin)

Liver Failure

-damage to the hepatocytes (any type of liver cell) of the billiard drainage system -injury from drugs, toxins, infection, trauma, inflammation and immune response

What happens in cirrhosis?

-destruction of health liver cells that *over time* get replaced by fibrotic tissue -affects structure, vascular system, internal function -biggest complication is portal hypotension (blood is supposed to come in through the portal vein but it can't)

Liver Failure Complications

-portal hypertension -esophageal and gastric varices -peripheral edema -abdominal ascites -hepatic encephalopathy -hepatorenal syndrome -coagulopathies

Hepatic Encephalopathy Signs and Symptoms

1.Tremors, Slurred Speech, Impaired decision making 2.Drowsiness, loss of sphincter control, Asterixis 3.Confusion and somnolence 4.Coma, unresponsiveness to pain, GI alterations

How much cardiac output (blood volume) sit in the liver?

25%. So if you get cut on the liver you can get a lot of blood loss

Bleeding Varices- Baloon Tamponade: Minnesota Tube

4 openings: gastric aspiration, esophageal aspiration, gastric balloon inflation, and esophageal balloon inflation

Portosystemic Shunts

A, Portacaval shunt. The portal vein is anastomosed to the inferior vena cava, diverting blood from the portal vein to the systemic circulation. B, Distal splenorenal shunt. The splenic vein is anastomosed to the renal vein. The portal venous flow remains intact, and esophageal varices are selectively decompressed. (The short gastric veins are decompressed.) The spleen conducts blood from the high-pressure esophageal and gastric varices to the low-pressure renal vein.

Elevated Enzymes

AST/ALT, bilirubin, cholesterol, ptt, ammonia

Hepatic Encephalopathy Treatment- Metronidaazole

Antibiotic that destroys normal bacteria found in the bowel thereby decreasing protein breakdown and ammonia production

Why does the spleen get large?

Blood flow issue. The blood that is going to liver can't get in so it backs up to the spleen and the spleen starts to try to filter that blood

Hepatorenal Syndrome Treatment

CRRT/Hemodyalysis/liver transplant

Since there is swelling what complication might you see?

Increased ICP. This is a late and very severe affect of ammonia level

Liver failure (Hepatitis) Progression

Inflammation to Edema to Restricted Blood Flow

What would be a complication to removing too much fluid during a paracentesis?

It will drop the blood pressure too much. Give colloids, albumin to help with potential drop in bp

What do the ducts do?

Run through the liver and helps the liver communicate with the pancreas and other organs (exocrine function)

Sandostatin

a little more selective and constrictive vasculature of the gut

what does protein metabolize into?

ammonia turns into uria

Hepatitis presentation

ascites, jaundice/maybe green, spider angiomas (vein pattern)

Vasopession

helps with blood pressure, arterial constriction

If someone can't break down carbohydrates what happens?

higher blood sugar, fat (uria- greasy stools), increased ammonia level

Gastric Varices

upper portion of stomach

Types of Viral Hepatitis (most common causes)

•A: fecal contamination •B: blood-borne, sexual transmission (hepatitis B vaccine is given) •C: blood-borne •D: combined with hepatitis B •E: fecal-oral •G: blood-borne, sexual transmission *can take up to 16 weeks to recover from viral hepatitis

Nonviral Hepatitis Treatment

•Activated Charcoal (only if within one hour of ingestion of Tylenol) •N-acetylcysteine (Mucomyst) (given up to 10 hours after ingestion)

Storage Function

•Blood •Glucose •Vitamins (A, B12, D, E, K) •Fat

Bleeding Varices

•Can lead to hemorrhagic shock; monitor closely for signs and symptoms •IV fluid & blood product replacement •IV Vasopressin / Pitressin •IV Sandostatin / Octreotide •Beta blockers / Propanolol •Secure airway

Metabolic Function

•Carbohydrate, fat, and protein metabolism •Synthesis of clotting factors (can give factor 8 or nine if they are missing these clotting factors and are actively bleeding) •Removal of activated clotting factors (DIC or some type of bleeding disorder can occur) •Detoxification of drugs

Nonviral Hepatitis

•Chemicals and medications that are hepatotoxic •Toxic or drug-induced •Chemicals such as carbon tetrachloride, chloroform or medications such as acetaminophen, anticonvulsants, or antituberculosis agents

Coagulopathies

•Decreased production of fibrinogen and other clotting factors (Bruising, bleeding gums, hemorrhage, DIC) •Decreased capability of removing activated clotting factors

Nutritional Therapy

•High in calories •Increased carbohydrates •Moderate to low fat •Protein ok except in severe acute states

Portal Hypertension

•Increased venous pressure in portal circulation •Splenomegaly (because blood cannot get in) •Large collateral veins •Ascites •Gastric and esophageal varices •"CHF"

Diagnostic Studies

•Liver enzyme tests •Total protein, albumin levels •Serum bilirubin •Cholesterol levels •Prothrombin time •Ammonia •Ultrasound (Fibroscan) (degree of cirrhosis widespread) •Liver biopsy (definitive diagnosis)

More Signs and Symptoms

•Low grade fever •Enlarge/tender liver •Jaundice

Ascites Treatment

•Monitor abdominal girth, weight gain, and respiratory status •Sodium restriction to reduce fluid retention •Diuretics •Paracentesis (Removal of fluid through a small incision in the abdominal wall) •Transjugular Intrahepatic Portosystemic Shunting (TIPS)

Initial Signs and Symptoms

•Nausea and vomiting •Right upper quadrant pain •Abdominal distention •Fatigue •Brown urine •Clay colored stools

Hepatic Encephalopathy

•Neurotoxic effects of ammonia •Abnormal neurotransmission •Astrocyte (brain) swelling •Inflammatory cytokines •Liver unable to convert increased ammonia •Ammonia crosses blood-brain barrier

Management

•No definitive treatment (hepatitis C does have a treatment) •Rest •Nutritional support •Prevention of spread of the virus •Fluids •Antinausea •Small frequent meals if they can eat •Vitamins

Endoscopic Banding

•Places a small rubber band around the base of the varix •Done with endoscopy

Hepatorenal Syndrome- Liver Failure S/S

•Portal hypertension •Ascites •Hypoalbuminemia •End-stage cirrhosis (will need a transplant)

Sclerotherapy

•Sclerosing agent is injected via endoscope into the varices •Anti-acids are administered post procedure

TIPS

•Stent is placed to serve as a shunt between the portal circulation and hepatic vein

Fulminant

•Sudden and severe impairment of liver function in a previously healthy person (whole body starts to get affected by this) •Viral hepatitis is a common cause; also certain hepatotoxic medications and chemicals •Rapid recognition, early treatment, and assessing for viability of liver transplantation •Antidotes for hepatotoxic medications •Cerebral edema is a complication because of the the ammonia level

Treatment

•Vitamin K (check IRN.. If high this is an indicator for the need of vitamin K) •FFP (fresh frozen plasma) •Platelets

Hepatorenal Syndrome- Renal Failure S/S

•azotemia (elevated BUN and creatine) •Oliguria (not making good urine output) •No structural abnormality of kidneys