Module 7: Hepatobiliary
Hepatitis
Func of Liver: Storage protection & metabolism; Produces bile to break down nutrients; Creates
clotting factors; Stores glycogen, iron, minerals, fat soluble vitamins;Synthesizes
protein/cholesterol
Hepatitis A Hep A: Hardy virus: stays on surface, doesn’t die easily), survives on human hands,
resistant to detergents and acids but destroyed by bleach and extremely high
temperatures
Transmission: Fecal-oral transmission, contaminated water
s/s: Mild flu-like symptoms
Risk factors: Traveling, contaminated water (third world countries high risk),
contaminated lettuce (ex. Salad bars & didn’t wash hands etc.), Fecal-oral; anal
sex, shell fisk
Prevention: Vaccine Hep A (peds)
Hepatitis B Transmission: body fluids
s/s: may give symptoms & how to manage it
- Fever/nausea/vomiting, Right upper quadrant pain,Dark urine with light
stool, Joint pain/muscle pain, jaundice/Icterus (jaundice of sclera of eye
(white part of eyes))
Most people clear the virus & develop immunity, some carriers
hbv- risk for cirrhosis and liver cancer.
Prevention: Vaccine Hep B (3 Parts)
Hepatitis C: Hep C Cannot clear the virus usually become chronic infection (>6months)
Is the leading cause for liver transplant & reinfection; Does damage over
decades
Transmission: Blood to blood transmission
Interventions: Medications (cure or put in chronic readmission)
- S/S: Flu like symptoms
Hepatitis C antibodies can be detected within 4 weeks of infection, can also
measure viral load
Labs for liver Elevated liver enzymes ALT/AST
disease Alkaline phosphatase -> seen in CNP and liver func panel.
Serum bilirubin – if elevated states more jaundice
Urine bilirubin – urine dark orange/amber
Liver Biopsy: stage of liver damage
Ex of how question might be worded: pt w/ jaundice elevated ALT/AST, abdominal
pain
Complications - Liver cells do not regenerate, fulminant (coming on fast)
of Hepatitis - Hep C=Fatal esp if immunocompromised or cirrhosis of liver
- Chronic Hepatitis 6 m+ -> increases risk for cirrhosis & liver cancer
- Many have multiple infections, especially combination of HBV with HCV, or
HIV infections
s/s of Hepatitis - Abdominal pain
- Changes in skin, or sclera (icterus)
- Arthralgia or myalgia
- Diarrhea/constipation
, - Fever w/ acute infx
- Urine – Dark Amber, Dark Orange
- Clay Stools
- Lethargy
- Malaise
- Nausea/vomiting
- Pruritis (excessive itching, dryness causes itching)
Client Education Avoid all medications – OTC meds such as Tylenol (hard on liver) *Tylenol
for hepatitis overdose = liver damage*
- Avoid all alcohol, Rest, good sleep
- Eat small frequent meals, increase carbs, moderate fat and protein (don’t
give rid of all protein -> MODERATE)
- Avoid sexual intercourse until antibody testing is negative -> Hep C
- Follow guidelines for preventing transmission of the disease
Interventions Education family/pt, Maintain sanitation and personal hygiene/hand hygiene
-Drink only bottled water if traveling to underdeveloped countries
-Do not share needles, body piercing, tattoos, razors, nail clippers, toothbrushes
- Use condoms
- Cover cuts or sores.
- Never donate blood if Hepatitis C
- Social stigma with hepatitis, encourage family/ patient to talk ->
Ex. Hep A (fecal oral transmission: from contaminated lettuce) and some ppl
assume from sex contact, sharing needles -> NEVER ASSUME how they contracted
- Hep C stigma from blood transfusion (b4 1992) now screened well -> so
very hard to get by BT
Liver Diseases
Cirrhosis
Extensive, irreversible scarring of the liver caused by chronic reaction to hepatic inflammation
and necrosis. Will progress to end-stage liver disease.
Common causes Alcoholic liver disease, Viral Hepatitis Common Hep C, Autoimmune Hepatitis,
of cirrohosis Steatohepatitis, Drugs and chemical toxins, Gallbladder disease, biliary
*Never assume obstruction, metabolic/genetic causes, Cardiovascular disease
an alcoholic*
Complications: Portal Hypertension
Ascites
Esophageal Varices
- Coagulation Defects
Jaundice
Portal Systemic Encephalopathy with Hepatic Coma
- Hepatorenal Syndrome
- Spontaneous Bacterial Peritonitis
Labs - Elevated AST, ALT(elevated and most specific to liver disase), LDH
inflammation (LDH part of cholesterol shows inflammation) most
- Elevated Bilirubin - makes stools pale (normal >0.3mg/dL)
- Decreased serum protein and albumin
, - Prolonged PT/INR (PT:11-12.5 sec) (INR2-3) Decreased Platelets, RBC’s and
WBC’s
- Increased ammonia levels (normal 15-45)
- Decreased Sodium w/ ascites
- Decreased Hct, Hgb = anemia
s/s of liver - Fatigue
cirrohsis - Decreased weight change (Vitamin deficiency and trouble keep weight in)
Sometimes abdominal distension bc of ascites
- GI symptoms anorexia, nausea, abdominal pain, liver tenderness
- Liver breath=fruity musty = Peter Hepaticas
- Jaundice, icterus, dry skin, rashes
- Look for petechiae, ecchymosis = can go into DIC
- Ascites
- Change in LOC watch neurological function
- Vitamin Deficiencies
- Watch for Hematemesis and frank blood in stool = s/s esophageal varacies
- Every body system is affected by cirrhosis -> skin, heart, respiratory sys
Edu - Medications and nutritional teaching.
- Alcohol Abstinence
Know how to access drain for ascites: side of abdomen
- Plur vac that connects -> drains certain amts, connect tubing and drains
500ccs -> has prescription when to drain -> sterile dressing on area/on site
and infx.
- S/S of Encephalopathy to catch early on: Increased confusion, asterixis
(tremors in hands), trouble writing their name getting worse.
- Patient must avoid all OTC’s especially Tylenol, NSAIDS, vitamins, Advil,
minerals, and Hepatic toxic herbs. ( hard on liver)
- Keep appointment with GI MD
- Report bleeding immediately
Coagulation Defects:
- Inability to absorb fat soluble vitamins
- Lack of bile
w/o vitamin K clotting factors II, VII, IX, X, not produced -> risk for
bleeding/hemorrhaging (especially for cirrhosis -> blood in
emesis/stool/nose/anywhere)
Jaundice
- Risk for infx due to pruritus
- What is it? Yellowing of Skin
Portal Hypotension
What is portal Blood backing up -> increase flow and increases resistance and splenomegaly
hypotension? (spleen enlarges) -> backs up to pancreas portal system=hypertension
(hypertension in portal system); but systemic body system HYPOTENSION
*Complication of Systemic = low bp & Portal = high bp
liver cirrhosis* Cirrhosis or cardiac problems cause portal hypertension
, Causes: Swelling and edema in the interstitial space which provides resistance
to blood flow.
Liver inflammation from Hepatitis
Scarring of the liver from infections or long-term liver disease such as
cirrhosis
Obstruction of flow out of liver from thrombus or embolus
Flow through vena cava blocked by right-heart failure, cardiac
myopathy, or pericarditis
Persistent increase in pressure within the portal vein
Blood flows back into the spleen splenomegaly, thrombocytopenia
Veins in the esophagus, stomach, intestines and abdomen and rectum
become dilated incr. risk for hemorrhage.
Portal hypotension = top priority**
Veins in esophagus/stomach = engorged and dilated veins ex. Like
superior vena cava syndrome, bulging hemorrhoids
Results in ascites, esophageal varices, prominent abdominal veins, and
hemorrhoids.
Portal hypotension get w/ cirrhosis
- Low bp w/ dilated veins
- Engorged dilated veins in abdomen
- Possibly ascites
- Diagnosis w/ cirrhosis
Treatment for portal Nonspecific beta blockers -> for portal hypertension
hypertension Cryoprecipitate ( need more clotting factors bc blood back up - PREVENTION
Ascites
What is it? Free fluid in the peritoneal cavity secondary to increased hydrostatic pressure
*Complication of from portal hypertension – caused by low albumin
liver cirrhosis* The plasma protein in the peritoneal fluid reduces the amount of
protein in the blood shift from the vascular system into the abdomen
Some possible complications:
- Problems w/ gas exchange/ respiratory
- Compresses diaphragm -> resp distress, SOB
- Respiratory compromise
Assessment Daily weights (indicator of fluid retention) and abdominal girth- measured at
the largest diameter & end of exhalation
-Inspect and palpate (lightly) for the presence of inguinal or umbilical hernias
-Minimal ascites is difficult to detect, especially in the obese patient.
Intervention #1Paracentesis number one treatment for this, may need a port placed if
frequent drainage is required
- Watch for fluid shift/electrolyte imbalance: Hypernatremia,
hypotension
What to watch for after a paracentesis? -> peritonitis s/s & BP, HR, fever
Preop
- Lay on their side
- Go down to radiology/xray/ US to see how much fluid
- Check fluid amt -> Not enough fluid ex. 200 cc -> not ready for
paracentesis
Hepatitis
Func of Liver: Storage protection & metabolism; Produces bile to break down nutrients; Creates
clotting factors; Stores glycogen, iron, minerals, fat soluble vitamins;Synthesizes
protein/cholesterol
Hepatitis A Hep A: Hardy virus: stays on surface, doesn’t die easily), survives on human hands,
resistant to detergents and acids but destroyed by bleach and extremely high
temperatures
Transmission: Fecal-oral transmission, contaminated water
s/s: Mild flu-like symptoms
Risk factors: Traveling, contaminated water (third world countries high risk),
contaminated lettuce (ex. Salad bars & didn’t wash hands etc.), Fecal-oral; anal
sex, shell fisk
Prevention: Vaccine Hep A (peds)
Hepatitis B Transmission: body fluids
s/s: may give symptoms & how to manage it
- Fever/nausea/vomiting, Right upper quadrant pain,Dark urine with light
stool, Joint pain/muscle pain, jaundice/Icterus (jaundice of sclera of eye
(white part of eyes))
Most people clear the virus & develop immunity, some carriers
hbv- risk for cirrhosis and liver cancer.
Prevention: Vaccine Hep B (3 Parts)
Hepatitis C: Hep C Cannot clear the virus usually become chronic infection (>6months)
Is the leading cause for liver transplant & reinfection; Does damage over
decades
Transmission: Blood to blood transmission
Interventions: Medications (cure or put in chronic readmission)
- S/S: Flu like symptoms
Hepatitis C antibodies can be detected within 4 weeks of infection, can also
measure viral load
Labs for liver Elevated liver enzymes ALT/AST
disease Alkaline phosphatase -> seen in CNP and liver func panel.
Serum bilirubin – if elevated states more jaundice
Urine bilirubin – urine dark orange/amber
Liver Biopsy: stage of liver damage
Ex of how question might be worded: pt w/ jaundice elevated ALT/AST, abdominal
pain
Complications - Liver cells do not regenerate, fulminant (coming on fast)
of Hepatitis - Hep C=Fatal esp if immunocompromised or cirrhosis of liver
- Chronic Hepatitis 6 m+ -> increases risk for cirrhosis & liver cancer
- Many have multiple infections, especially combination of HBV with HCV, or
HIV infections
s/s of Hepatitis - Abdominal pain
- Changes in skin, or sclera (icterus)
- Arthralgia or myalgia
- Diarrhea/constipation
, - Fever w/ acute infx
- Urine – Dark Amber, Dark Orange
- Clay Stools
- Lethargy
- Malaise
- Nausea/vomiting
- Pruritis (excessive itching, dryness causes itching)
Client Education Avoid all medications – OTC meds such as Tylenol (hard on liver) *Tylenol
for hepatitis overdose = liver damage*
- Avoid all alcohol, Rest, good sleep
- Eat small frequent meals, increase carbs, moderate fat and protein (don’t
give rid of all protein -> MODERATE)
- Avoid sexual intercourse until antibody testing is negative -> Hep C
- Follow guidelines for preventing transmission of the disease
Interventions Education family/pt, Maintain sanitation and personal hygiene/hand hygiene
-Drink only bottled water if traveling to underdeveloped countries
-Do not share needles, body piercing, tattoos, razors, nail clippers, toothbrushes
- Use condoms
- Cover cuts or sores.
- Never donate blood if Hepatitis C
- Social stigma with hepatitis, encourage family/ patient to talk ->
Ex. Hep A (fecal oral transmission: from contaminated lettuce) and some ppl
assume from sex contact, sharing needles -> NEVER ASSUME how they contracted
- Hep C stigma from blood transfusion (b4 1992) now screened well -> so
very hard to get by BT
Liver Diseases
Cirrhosis
Extensive, irreversible scarring of the liver caused by chronic reaction to hepatic inflammation
and necrosis. Will progress to end-stage liver disease.
Common causes Alcoholic liver disease, Viral Hepatitis Common Hep C, Autoimmune Hepatitis,
of cirrohosis Steatohepatitis, Drugs and chemical toxins, Gallbladder disease, biliary
*Never assume obstruction, metabolic/genetic causes, Cardiovascular disease
an alcoholic*
Complications: Portal Hypertension
Ascites
Esophageal Varices
- Coagulation Defects
Jaundice
Portal Systemic Encephalopathy with Hepatic Coma
- Hepatorenal Syndrome
- Spontaneous Bacterial Peritonitis
Labs - Elevated AST, ALT(elevated and most specific to liver disase), LDH
inflammation (LDH part of cholesterol shows inflammation) most
- Elevated Bilirubin - makes stools pale (normal >0.3mg/dL)
- Decreased serum protein and albumin
, - Prolonged PT/INR (PT:11-12.5 sec) (INR2-3) Decreased Platelets, RBC’s and
WBC’s
- Increased ammonia levels (normal 15-45)
- Decreased Sodium w/ ascites
- Decreased Hct, Hgb = anemia
s/s of liver - Fatigue
cirrohsis - Decreased weight change (Vitamin deficiency and trouble keep weight in)
Sometimes abdominal distension bc of ascites
- GI symptoms anorexia, nausea, abdominal pain, liver tenderness
- Liver breath=fruity musty = Peter Hepaticas
- Jaundice, icterus, dry skin, rashes
- Look for petechiae, ecchymosis = can go into DIC
- Ascites
- Change in LOC watch neurological function
- Vitamin Deficiencies
- Watch for Hematemesis and frank blood in stool = s/s esophageal varacies
- Every body system is affected by cirrhosis -> skin, heart, respiratory sys
Edu - Medications and nutritional teaching.
- Alcohol Abstinence
Know how to access drain for ascites: side of abdomen
- Plur vac that connects -> drains certain amts, connect tubing and drains
500ccs -> has prescription when to drain -> sterile dressing on area/on site
and infx.
- S/S of Encephalopathy to catch early on: Increased confusion, asterixis
(tremors in hands), trouble writing their name getting worse.
- Patient must avoid all OTC’s especially Tylenol, NSAIDS, vitamins, Advil,
minerals, and Hepatic toxic herbs. ( hard on liver)
- Keep appointment with GI MD
- Report bleeding immediately
Coagulation Defects:
- Inability to absorb fat soluble vitamins
- Lack of bile
w/o vitamin K clotting factors II, VII, IX, X, not produced -> risk for
bleeding/hemorrhaging (especially for cirrhosis -> blood in
emesis/stool/nose/anywhere)
Jaundice
- Risk for infx due to pruritus
- What is it? Yellowing of Skin
Portal Hypotension
What is portal Blood backing up -> increase flow and increases resistance and splenomegaly
hypotension? (spleen enlarges) -> backs up to pancreas portal system=hypertension
(hypertension in portal system); but systemic body system HYPOTENSION
*Complication of Systemic = low bp & Portal = high bp
liver cirrhosis* Cirrhosis or cardiac problems cause portal hypertension
, Causes: Swelling and edema in the interstitial space which provides resistance
to blood flow.
Liver inflammation from Hepatitis
Scarring of the liver from infections or long-term liver disease such as
cirrhosis
Obstruction of flow out of liver from thrombus or embolus
Flow through vena cava blocked by right-heart failure, cardiac
myopathy, or pericarditis
Persistent increase in pressure within the portal vein
Blood flows back into the spleen splenomegaly, thrombocytopenia
Veins in the esophagus, stomach, intestines and abdomen and rectum
become dilated incr. risk for hemorrhage.
Portal hypotension = top priority**
Veins in esophagus/stomach = engorged and dilated veins ex. Like
superior vena cava syndrome, bulging hemorrhoids
Results in ascites, esophageal varices, prominent abdominal veins, and
hemorrhoids.
Portal hypotension get w/ cirrhosis
- Low bp w/ dilated veins
- Engorged dilated veins in abdomen
- Possibly ascites
- Diagnosis w/ cirrhosis
Treatment for portal Nonspecific beta blockers -> for portal hypertension
hypertension Cryoprecipitate ( need more clotting factors bc blood back up - PREVENTION
Ascites
What is it? Free fluid in the peritoneal cavity secondary to increased hydrostatic pressure
*Complication of from portal hypertension – caused by low albumin
liver cirrhosis* The plasma protein in the peritoneal fluid reduces the amount of
protein in the blood shift from the vascular system into the abdomen
Some possible complications:
- Problems w/ gas exchange/ respiratory
- Compresses diaphragm -> resp distress, SOB
- Respiratory compromise
Assessment Daily weights (indicator of fluid retention) and abdominal girth- measured at
the largest diameter & end of exhalation
-Inspect and palpate (lightly) for the presence of inguinal or umbilical hernias
-Minimal ascites is difficult to detect, especially in the obese patient.
Intervention #1Paracentesis number one treatment for this, may need a port placed if
frequent drainage is required
- Watch for fluid shift/electrolyte imbalance: Hypernatremia,
hypotension
What to watch for after a paracentesis? -> peritonitis s/s & BP, HR, fever
Preop
- Lay on their side
- Go down to radiology/xray/ US to see how much fluid
- Check fluid amt -> Not enough fluid ex. 200 cc -> not ready for
paracentesis
