test 8

Hep B

1-6 months S/S: Fever, N/V, Hepatomegaly S/E: Cirrhosis, chronic hepatitis, hep CA

average weight loss following bariatric surgery is

10-35% within 2-3 years

Which hepatitis have vaccines?

A and B

Ammonia levels

Adult: 10-80 child: 40-80

What results abnormally high accumulation of bile in blood?

Bilirubin

What is the hormone that causes the gallbladder to contract and release bile?

Cholecystokinin

Which quadrant of the body is majority of the liver located

RUQ

Cholestasis causes focal accumulation of cholesterol, manifested by raised lesions called:

Skin xanthomas

Roux-en-Y gastric bypass

Stomach stapled portion , small intestine relocated

Bile formation

Transport conjugated bilirubin, once it has been released into dueodum it aids into digestion of fat solube vitamins

What causes jaundice? Why is there a build-up of bilirubin?

Albumin protein carries heme to liver > converts to bilirubin > Albumin takes the UNCONJUGATED not water soluble heme to the liver to get CONJUGATEDCauses: Macrophages eat up the blood cell and hgb broken up to heme and globin. Globin is broken up to amino acid.

tx for asities

low sodium diet diuretics paracentesis albumin!

What are the two major blood vessels that supply the liver with blood? Where does the blood for each system come from?

*Hepatic artery - Delivers oxygenated blood**Hepatic portal vein- delivers deoxygenated blood containing newly absorbed nutrients, drugs, microbes, toxins FROM the GI tract.

how does cirrhosis affect the anatomy of the liver?

- Major scar tissue formation in the liver.-ETOH cirrhosis is which the scar tissue surrounds portal areas caused by chronic alcoholism and is most common type. -Postnecrotic cirrhosis: Late result of acute viral hepatitis-Biliary cirrhosis: Scaring occurs in liver around bile ducts from chronic biliary obstruction ; less common

How is ammonia formed? What is its effect on the neurological system? How is it normally excreted?

-Amino acids from protein for gluconeogenesis results in the formation of ammonia as a by product. Liver converts metabolically generated ammonia into urea. Ammonia produced by bacteria in the intestines is removed from portal blood for urea synthesis. Liver convers ammonia a toxin into urea excreted in urine.

How is albumin produced? What is its effect on fluid shifts?

-Synthesized by liver. Where there is decreased synthesis of albumin by the damaged liver, other contributing factors like sodium retention, they all contribute to the movement of fluid from vascular system into peritoneal space called ascites.

treatment for portal HTN

1. Beta blockers to prevent 1st bleeding episode2. Balloon Tamponade to control hemorrhage.3. Vasopressin to constrict distal esophageal veins and reduce inflow to portal system. Don't give if pt has CAD due to the constriction. If you must give then youll give with Nitroglycerin4. Endoscopic Sclerotherapy- acute hemorrhage only5. Endoscopic variceal Ligation EVL-1st line of treatment6. Transjugular Intrahepatic Portosystemic Shunt: Acute uncontrolled variceal bleeding refractory to pharm or endoscopy therapy. LAST alternative.7. Surgical bypass : Shunt

4 stages encephalopathy

1. Normal level of consciousness with periods lethargy 2. increased drowsiness; asterix; fetor hepaticus 3.stuporous; asterixis 4. comatose

Alcoholic Induced Hepatitis

1. fatty liver disease : reversable if you stop ETOH 2. hepatitis due to inflammation and necrosis - may be reverisble 3.cirrhosis - dead liver cells replaced by scar tissue leading to failure 4.liver shrinks > portal HTN > liver failure

BMI for surgery

35+ with a cormobidy (htn, dm) or just BMI of 40 can have surgery at BMI 30 if they have 2DM, metabolic syndrome

ALP

45-115 U/L

total protein

6.3-7.9

after bowel sounds returned and oral intake is resumed following bariatric surgery, 6 small feedings of how many cal should be consumed

600-800

HDL

<50 or 60

LDL

>100

Triglycerides

>145

A greater risk for obesity is assessed by a waist circumference that is >__ inches for women and >____ inches for men.

>35 >40

What is hepatorenal syndrome?

A type of progressive kidney failure seen in people with severe liver damage, most often caused by cirrhosis Reduced amount of perfusion by the kidney induced by severe hepatic injury

What intervention does the nurse anticipate providing for the patient with ascites that will help correct the decrease in effective arterial blood volume that leads to sodium retention?

Albumin infusion Albumin infusions help to correct decreases in effective arterial blood volume that lead to sodium retention. The use of this colloid reduces the incidence of postparacentesis circulatory dysfunction with renal dysfunction, hyponatremia, and rapid reaccumulation of ascites associated with decreased effective arterial volume.

cholestasis

Biliary disease disrupt flow called cholestasis because its unable to drain effectlivly into dueodoum so it trys to find new roots and becomes enlarged. As the flow continues to become clogged it becomes enlarged and green.

Hepatocellular Jaundice (Hepatic jaundice)

Caused by inability of damaged liver cells to clear normal amounts of bilirubin from the blood. Cellular damage may be caused by hepatitis viruses. Cirrhosis of liver is a form of hepatocellular disease that may produce jaundice. Elevated AST/ALT indicating cellular necrosis. Pt will be very sick

Obstructive Jaundice

Caused by occlusion of the bile duct from a gallstone, an inflammatory process, a tumor, pressure from an enlarged organ. Pressure on the channels from swelling of the liver or by an inflammatory exudate within the ducts themselves. Bile cannot flow normally into intestines due to blockage in liver so it is reabsorbed and carried throughout the body staining the skin, mucous membranes, sclerae, excreated in urine which is deep orange and foamy.

PHentermine

Causes apetitie suppression PhenTERMine: short TERM use (12 weeks) Short TERM because bad side effects happen long term Contraindicated with heart disease, uncontrolled HTN, hyperthyroid, glaucoma

What is portal hypertension? What are the major complications that result?

Characterized by an increased resistance to flow in the portal venous system and sustained increase in portal venous pressure Major complications: Splenomegaly Systemic hypertension Hemorrhoids Esophageal varices*

What are the major causes and signs/symptoms of cirrhosis?

Chronic, progressive disease; destruction of parenchymal cells; resulting in scar tissue formation replacement of normal liver tissue.S/S: GI disturbance, dull heavy RUQ feeling. Enlarged liver and spleen. Fever, lethargy, weight loss

Which two ducts merge to end at the Sphincter of Oddi

Common bile duct and pancreatic duct

which two ducts does bile pass through from the liver to be stored in the gallbladder?

Common hepatic duct and the cystic duct

How do diseases of the liver affect metabolism of drugs?

Decreased plasma binding of drugs due to decreased albumin levels-Breakdown of whatever substance is going to be a lower process. They can get toxicity.

orlistat

Diminishes intestinal absorption and metabolism of fats oily stools

jaundice

Discoloration of skin from abnormal bilirubin concentration in blood. Inability of damaged liver cells to clear normal amounts of bilirbubin in blood, seems into urine turning it pale and frothy and same for stools.

hepatorenal syndrome

End stage of a sequence of reductions in renal perfusion induced by increasingly severe hepatic injury. Lack of pathological changes in kidney; no evidence of dehydration or obstruction of the urinary tract or any other renal disorder.

Which of the following below is a cause of jaundice? Excessive destruction of RBC's Impaired uptake of bilirubin by the liver cells Increased conjugation of bilirubin Obstruction of bile flow in the cuniculi of hepatic lobules

Excessive destruction of RBC's Impaired uptake of bilirubin by the liver cells Obstruction of bile flow in the cuniculi of hepatic lobules

Hep A

Fecal oral 4 weeks s/e: HA, Fever, Hepatomeagly Vaccine, bed rest, nutrition

asities

Fluid in peritoneal cavity. Result of portal HTN Blood passing the liver is adverted to perotneal pressure., Fluid leaks out into the peritoneal cavity. Body releases ADH in response and Aldosterone. ADH conserves fluid promoting reabsorption water by kidneys and increases water retention and sodium retention which can increase and fluid accumulation and build up even further. No s/s of cirrhosis until its advanced such as nutritional deficiencys. Small intesntine is less able to digest nutrients.

Process used when glycogen stores are used up & the liver makes glucose from other substances.

Gluconeogenesis

Liver converts glucose into glycogen to maintain normal levels of BGL

Glucose metabolism

What specific substance does the liver store and convert to be used when blood sugar is low?

Glycogen

The process of converting glycogen into glucose during low levels of blood sugar is called?

Glycogenolysis

Where is bilirubin derived from?

Heme portion of the hemoglobin of the RBC

What are the two blood vessels that supply the liver with nutrients and oxygen?

Hepatic artery and the hepatic portal vein

A client and spouse are visiting the clinic. The client recently experienced a seizure and says she has been having difficulty writing. Before the seizure, the client says that for several weeks she was sleeping late into the day but having restlessness and insomnia at night. The client's husband says that he has noticed the client has been moody and slightly confused. Which of the following problems is most consistent with the client's clinical manifestations?

Hepatic encephalopathy

portal HTN

High pressure in portal vein, develops when resistance to blood flow into or through liver in increased due to scaring and fibrosis due to cirrhosis. Blood backs up leading to dilation to esophagus, legs, rectum as well as BP increasing.

A patient that has complications of the liver may suffer from vitamin K deficiency resulting in:

Hypoprothrombinemia

Lifestyle modification is aimed at weight loss and

IMPROVING DIET HABITS, INCREASING PHYSICAL ACTIVITY, ADDRESSING BARRIERS TO CHANGE, SELF MONITORING AND STRATEGIZING ONGOING LIFESTYLE CHANGES (SLEEP)

Hemolytic Jaundice (Prehepatic Jaundice)

Increased destruction of RBC; effect is that the plasma is rapidly flooded with bilirubin so that the liver although functioning normally cannot excrete the bilirubin so that the liver. Encountered in patients with hemolytic transfusion reactions. Bilirubin in blood is predominantly unconjugated or free. can be congential such as sickle cell, thalassemia, etc or aquired : trauma, vit B12 deficency, folic acid deficiency, chemicals/intoxins, hypophosphatemia

What are specialized macrophages in the lining of the sinusoid that engulfs & destroys bacteria?

Kupffer cells

is administered to reduce serum ammonia levels in clients with hepatic encephalopathy.

Lactulose (Cephulac) is administered to reduce serum ammonia levels in clients with hepatic encephalopathy.

Encephalophy

Lactulose, Neomycin

hepatic encephalopathy

Life threatening complication of liver that occurs with PROFOUND liver failure. It is a neuropsychological manifestation of hepatic failure associated with portal HTN and the shunting of blood from the portal venous system to systemic circulation.

A client has massive bleeding from esophageal varices. In what order from first to last should the interprofessional team provide care for this client? All options must be used.

Maintain a patent airway. Control hemorrhaging. Replace fluids. Relieve the client's anxiety.

prioties for chirrohsis tx

Maintain airway, assess respirations and O2 sats, position patient to decrease aspiration risk, help the HCP control hemorrhage bleeding or decrease changes of anemia/shock, restore circulation blood volume lost through provides/fluids, decrease anxiety by explaining procedure

ALT

NORMAL levels Males: 10-40 Females: 7-35 Increase primarily in liver disorders and may be used to monitor the course of hepatitis or cirrhosis or effects of treatment that may be toxic to liver.

Hep C

No vaccine available

ALP

Normal levels vary by age. Males and females 1-12 years old: <350, 12-14 years old <500, >15 years old 25-100

AST

Normal values male: 14-20, Females 10-36 Measure course of hepatoxicity. May increase in cirrhosis, hepatitis, liver CA. Present in the tissues that have high metabolic activity; therefore, level may be increased if there is damage to or death of tissue of organs such as the heart, liver, skeletal muscle, kidney.

A client is actively bleeding from esophageal varices. Which medication would the nurse most expect to be administered to this client?

Octreotide Sandostatin causes selective splanchnic vasoconstriction by inhibiting glucagon release and is used mainly in the management of active hemorrhage. Propranolol (Inderal) and nadolol (Corgard), beta-blocking agents that decrease portal pressure, are the most common medications used both to prevent a first bleeding episode in clients with known varices and to prevent rebleeding. Beta-blockers should not be used in acute variceal hemorrhage, but they are effective prophylaxis against such an episode.

Major complications of cirrhosis and pathologically how do they occur

Portal obstruction and Asities: Fluid in peritoneal cavity - Nursing interventions: Decrease sodium level Portal Hypotension Hepatic Encephalopathy and Coma -Life threatening neuropsychiatric complication of liver disease that occurs with profound liver failure Liver enlargement Infection and peritonitis GI varices Edema Vit deficiency and anemia Mental detoriation

Which type of jaundice occurs when bile is obstructed between the liver and intestines?

Post-hepatic jaundice

Secondary biliary cirrhosis

Prolonged obstruction from biliary tree so gall stones. Bile accumulates due to obstruction.

The nurse is completing a health history and physical assessment on a client admitted with esophageal varices and cirrhosis. What signs and symptoms alert the nurse to a potential internal hemorrhage?

Pulse 108 bpm, temperature 97.7°F (36.5°C), distended abdomen, and nausea

cirrhosis tx

Rest, B complex, No ETOH/ASA/NSAIDS.-Asities: Low sodium diet, diuretics, paracentesis, albumin-Varices (from elevated pressure in the veins): Sandostatin, Vasopressin, NTG, B-Blockers, balloon tamponade, ligationPriorities: Maintain airway, assess respirations and O2 sats, position patient to decrease aspiration risk, help the HCP control hemorrhage bleeding or decrease changes of anemia/shock, restore circulation blood volume lost through provides/fluids, decrease anxiety by explaining procedure

Patients with dumping syndrome after gastric surgery, should consume at least 16 ounces of fluid with each meal.

SMALL FREQUENT MEALS, LOW CARB DIET, LOW FOWLERS POSITION DURING 30-60 MINS AFTER EATING, DO NOT DRINK FLUIDS WITH MEALS.

Describe the major functions of the liver. What are the results of alterations in function?

Salt production - emulsification of fats in intestine. *** Malabsorption of fat and fat souble vits. Elimintation of bilirubin - Heptatocytes remove conjugated bilirubin > bile canalicuil < duodenum > Convert to urobilinogen > excrete in feces and absorbed through intestinal mucosa and portal blood. *****Bilirubin elevation/jaundice Drug metabolism- bioavaliablity of PO are decreased due to low protein Carb metabolism - Glucose taken up by portal venous blood > convert to glycogen for storage > convert back to glucose glycogenolysis to main BGL levels. Fat metabolism- broken down for energy. **Impaired synthesis of cholesterol Protein metabolism **Elevated ammonia levels , decreased albumin and clot factors. Kuppler cells - filtrate blood and remove old RBC/bacteria **increased exposure to bacteria/foreign matter

first line of meds for asities

Spironolactone (Aldactone), an aldosterone-blocking agent, i

portal htn complications

Splenomegaly Systemic HTN Hemorrhoids - to much pressure Esophageal varices - Weakening areas of esophagus or anywhere in GI tract that causes weaking and bleedings so patients with portal HTN can have GI bleeds or low hematocrit ; Preform upper endoscopy to stop active bleeding

4 stages of hepatic encephalopathy

Stage 1: Normal level of consciousness with periods of lethargy and euphoria; reversal of day-night sleep patterns. Normal ECG Stage 2: Increased drowsiness; disorientation; inappropriate behavior; mood swings agitation. Asterixis; fetor hepaticus. Abnormal ECG with generalized slowing. Stage 3: Stuporous; difficult to rouse; sleeps most time; marked confsion; incoherent speech. Youll see asterixis, increased deep tendon reflex, abnormal ecg. Stage 4: Comatose; not respond to painful stimuli. Absense of asterixis; no deep tendon reflex, flaccidity of extremities. Abnormal ecg.

Gluconeogenesis

Synthesis additional glucose

which medication is used to decrease portal pressure, halting bleeding of esophageal varices?

Vasopressin

Locaserin

Watch for high fevers, agitation, diarrhea. CALL PROVIDER AND HOLD MEDICATIONS

This is one of the most important plasma proteins that contribute to colloidal osmotic pressure

albumin

What carries unconjugated bilirubin to the liver to be conjugated or a water-soluble form?

albumin

What is a waste product, toxic to the body in high amounts, and made in intestines with bacteria?

ammonia

Portal HTN

ascites; varices; splenomegaly; hemorrhoids; caput medusae Obstructed blood flow due to scar tissue and fibrotic changes. Something is going on that is blocking or the cells are just not working properly. The blood that is coming from portal vein to the liver becomes to back flow because the cells cannot take that much blood anymore since it is not working.

Dysphagia

chew food throughly

The right and left hepatic ducts combine to form which of the following?

common hepatic duct

Which blood vessel carries nutrients and toxic materials from the organs to be filtered by the liver?

hepatic portal vein

Which vessel joins the central vein that empties venous blood into the inferior vena cava?

hepatic vein

following bariatric surgery, disruptioon at surgical site may cause leakage of gastric contetns into peritoneal cavity, casuing

inffection and possible sepsis

Primary biliary cirrhosis

inflammation and scaring of intrahepatic ducts, portal inflammation and destruction of liver tissue. Its enlarged and green from accumulating bile.

Liraglutide

liraGLUTide: think injection (not in the glute muscle) but subq G for gastric emptying is SLOWED

Which is the most common cause of esophageal varices

portal hypertension

Sleeve gastrectomy

portion of stomach removed

One of the most common skin symptoms of cholestasis that is highly related to bile salts:

pruritus

tx for varices

sandostatin vasopression - not in CV pt NTG- help with S/E of vaso BBlockers Baloon tamponade ligation

antiobesity medications work by inhibiting GI absorption of fat and altering central brain receptors to enchance

satiety and reduce cravings

dumping syndrome

small frequent meals, low carb diet, low fowlers position during 30-60 mins after eating. NO FLUIDS WITH MEALS

What is the major function of the gallbladder?

store bile

T or F Never insert an NG tube in patients have had bariatric surgery EVEN with a bowel obstruction

t