Chapter 48 Liver, Biliary Tract and Pancreas Problems

The liver, pancreas, and gallbladder are closely positioned together anatomically and highly associated in their digestive functions. Nursing care focuses on helping the patient and caregiver manage symptoms and develop ways to cope with the diagnosis and sometimes, prognosis. Disorders of the Liver Hepatitis-the inflammation of the liver. • Most often caused by viruses. o Viral hepatitis is a public health problem • Other causes o Alcohol o Medications o Chemicals o Autoimmune diseases o Metabolic problems Viral hepatitis-there are several types. • Hepatitis A o A self-limiting infection that can cause a mild flu-like illness and jaundice. o Can cause acute liver failure o Transmitted primarily through the fecal-oral route. o Foodborne outbreaks are usually due to food that is contaminated by infected food handlers o The greatest risk of transmission occurs before clinical symptoms appear o Virus is found in feces 1 to 2 weeks before the onset of symptoms and at least 1 week after the onset o HAV vaccination and thorough hand washing are the best measures to prevent outbreaks. o Isolation is not needed for HAV, but if the patient is incontinent of stool or has poor hygiene, they should be placed in a private room. • Hepatitis B o A blood-borne pathogen that can cause either acute or chronic hepatitis o Several ways of transmission are ▪ perinatally from mothers infected with HBV to their infants ▪ percutaneously ▪ small cuts on mucosal surfaces and exposure to infectious blood, blood products, or other body fluids ▪ Sexual transmission o At-risk persons ▪ Those who live with chronically HBV-infected ▪ patients on hemodialysis ▪ health care personnel ▪ public safety workers ▪ IV drug users ▪ recipients of blood products ▪ Native Alaskans, Pacific Islanders, and Native Americans o If gastrointestinal (GI) bleeding occurs, feces can be contaminated with the virus from the blood. o There is no evidence of fecal-oral transmission o Organ and tissue transplantation is another potential source of infection o HBV is a complex structure with 3 distinct antigens: surface antigen (HBsAg), core antigen (HBcAg), and e antigen (HBeAg). o In most people who acquire HBV infection as an adult, the infection completely resolves without any long-term complications. o In chronic HBV infections, he liver may range from a normal-appearing liver to severe liver inflammation and scarring (fibrosis). o . HBsAg in the serum for 6 months or longer after infection indicates chronic HBV infection. o To prevent HBV, identify those at risk, screen them and vaccinate if not infected. o The first dose of Hep B vaccine should be given at age 6-18 months. • Hepatitis C o type of hepatitis that can result in both acute illness and chronic infection. o Acute Hep C can be hard to detect unless a diagnosis is made with laboratory testing. o Most common causes ▪ injection drug users ▪ MSM with HIV infection. ▪ High-risk sexual behavior o HCV is an RNA virus that is blood-borne and primarily transmitted percutaneously. o Most patients usually develop chronic infection. o Most people are unaware of their infection because symptoms are generally mild o HBV and HCV account for most cases of liver cancer o HCV is the most common reason for liver transplantation in the US. o A positive antibody test is usually enough for a diagnosis. o There is currently no vaccine for Hep C o Teach patient to modify high-risk behaviors, use infection control precautions, be screened. o Hep C patients are not recommended to have IG or antiviral agents. • Hepatitis D o also called delta virus o only those who are infected with HBV can be infected with HDV o it can be acquired at the same time as HBV o There is no vaccine for HDV • Hepatitis E o transmitted by the fecal-oral route. o The usual mode of transmission is drinking contaminated water. o occurs primarily in developing countries o Usually acute and self-resolving o Pregnant women may be affected severely Pathophysiology • During acute viral hepatitis, large numbers of infected hepatocytes are destroyed. This can lead to a wide range of liver-related dysfunction o Bile production, coagulation, blood glucose, and protein metabolism can be affected o Detoxification and processing of drugs, hormones, and metabolites (e.g., ammonia from protein catabolism) may be disrupted • Liver cells can regenerate after an acute infection • Chronic viral hepatitis and be silent causing destruction of infected hepatocytes • Scar tissue can develop and compromise liver function • Fibrosis can lead to cirrhosis and liver failure Systemic effects • The manifestations of this activation are rash, angioedema, arthritis, fever, and malaise. • Cryoglobulinemia (abnormal proteins found in the blood), glomerulonephritis, vasculitis, and involvement of other organs can occur from immune complex activation. Acute Hepatitis • In acute hepatitis, most patients have no symptoms and may not know they have been infected • Symptoms they may see o Amprexoa o Lethargy o Nausea o Vomiting o Skin rashes o Diarrhea o Constipation o Malaise o Fatigue o Myalgias o Arthralgias o Flu-like symptoms o RUQ tenderness • Usually lasts 1-6 months • Physical examination often reveals o Hepatomegaly o Lymphadenopathy o abdominal tenderness o sometimes splenomegaly • this is a period of maximal infectivity • the patient may be icteric or anicteric • Jaundice, a yellowish discoloration of body tissues • Signs of jaundice may include o Urine may be darker o Stools may be clay colored o Pruritus o Yellow sclera o Yellow skin • Complications that can result from acute hepatitis are acute liver failure, chronic hepatitis, cirrhosis of the liver, portal hypertension, and liver cancer. • Follow up is important. Relapses can occur with hepatitis B and C. Acute Liver Failure • a serious condition with a poor prognosis • Manifestations include: o Encephalopathy o GI bleeding o disseminated intravascular coagulation (DIC) o fever with leukocytosis o renal manifestations (oliguria, azotemia) o ascites o edema o hypotension o respiratory failure o hypoglycemia o bacterial infections, o thrombocytopenia o coagulopathies • Liver transplantation is usually the cure. Chronic hepatitis • Chronic HBV is more likely to develop in infants that are infected by mothers. • HCV is more likely to become chronic. • Many patients with Chronic HCV develop: o Chronic liver disease o Cirrhosis o Portal hypertension o Liver cancer • Risk factors for progression to cirrhosis o Male gender o Alcohol use o Concomitant fatty liver disease o Excess iron deposition in the liver • Manifestations of chronic hepatitis o Anemia o Coagulation problems o Spider angiomas palmar erythema o Gynecomastia o Ascites • Diagnostic studies o Blood work o Liver function tests o Liver biopsy o Ultrasound elastography o FibroSure Interprofessional Care • There is no specific treatment for acute viral hepatitis. • In patients with chronic viral hepatitis, care may involve hepatologists, infectious disease specialists, pharmacists, dietitians, and mental health or substance use specialists. • No drug therapies for HAV • Supported drug therapy may include antihistamines for itching and antiemetics for nausea. Chronic Hepatitis B • Drug therapy focuses on decreasing the Hep B viral load and liver enzymes. • Preventing development of cirrhosis, PH, Liver failure and liver CA • First line therapies include nucleoside and nucleotide analogs and sometimes interferon. Chronic Hepatitis C • Treatment of chronic hep C is patient specific. • Treatment is primarily the use of DAAs, which block proteins. • Typically, a 12-week regimen with oral drugs • Chronic Hepatitis C is now curable with DAAs. Drug- and Chemical-induced liver diseases Alcohol use is the most frequent cause of both acute and chronic liver disease. It can cause injury and necrosis. Acute alcohol hepatitis-syndrome of: • Hepatomegaly • Jaundice • Elevated liver enzymes • Low-grade fever • Possible ascites • Prolonged PT time If liver function does not recover after abstaining from alcohol for 6 months or longer, liver transplantation may be considered. Chemical hepatotoxicity • This is liver injury caused by exposure to certain compounds. • Liver toxicity has decreased since the 1980s due to the decrease in these compounds Drug-induced liver injury • Can present similarly to other forms of liver disease. • Many drugs can cause an increase in liver enzymes. • The most common cause of acute liver failure is acetaminophen. • Any drug causing damage should be stopped. Autoimmune Hepatitis • A chronic inflammatory disorder of the liver in which the patient’s own immune system attacks the liver. • Cause is unknown. • Mostly effects women • Laboratory tests are useful in diagnosis. • Liver biopsy is often done to confirm the diagnosis. • Most patients develop chronic hepatitis. • Prednisone is recommended. Wilson’s Disease • Autosomal recessive disorder involving cellular copper transport. • A defect in biliary excretion leads to accumulation of copper in the liver, causing progressive liver injury and cirrhosis. • It usually appears between ages 5 and 35. • The hallmark of Wilson’s disease is corneal Kayser-Fleischer rings. Hemochromatosis • Condition in which excess iron accumulates in the body • Usually caused by a genetic defect. Primary Biliary Cholangitis • Previously known as biliary cirrhosis • A chronic disease associated with other autoimmune disorders. • Most patients diagnosed with PBC are middle-aged women. • The goals of treatment are suppressing ongoing liver damage, preventing complications, and symptom management. • Drugs given are meant to decrease bile in the liver. Primary Sclerosing Cholangitis • a disease of unknown cause characterized by chronic inflammation, fibrosis, and strictures (narrowing) of the medium and large bile ducts both inside and outside the liver. • Most patients with PSC also have ulcerative colitis or, less often, Crohn’s disease. • Drug therapy has no proven benefit. Nonalcoholic Fatty Liver Disease and Nonalcoholic Steatohepatitis • NAFLD refers to a wide spectrum of liver diseases ranging from a fatty liver to NASH to cirrhosis. • NAFLD is the accumulation of fatty infiltration in the hepatocytes. • NASH the fat accumulation is associated with varying degrees of inflammation and fibrosis of the liver. • NAFLD is increasing because of the growing number of people who are obese. • NAFLD should be considered in patients with risk factors: o Obesity o Diabetes o Hyperlipidemia o Hypertension • Elevated liver function tests are usually the first sign. • Ultrasound and CT scans can diagnose. • Definitive diagnosis is by a liver biopsy. Cirrhosis • End stage of liver disease. • Liver tissue is replaced by fibrosis. • Usually happens after decades of chronic liver disease. • Most common cause is Hep C and alcohol-induced liver disease. • Around 20% of patients with chronic hepatitis C and 25% of those with chronic hepatitis B develop cirrhosis. Cardiac cirrhosis • Cardiac cirrhosis includes a spectrum of hepatic problems that result from long-standing, severe, right-sided heart failure. • Treatment is aimed at managing the patient’s underlying heart failure. • Clinical manifestations o Few symptoms in the early stages. o Later manifestations: ▪ Jaundice ▪ Peripheral edema ▪ Ascites ▪ Skin lesions ▪ Hematologic problems ▪ Endocrine problems ▪ Peripheral neuropathies o in the advanced stages, the liver becomes small and nodular. Jaundice • Results from decreased ability to conjugate and excrete bilirubin into the small intestines. • The connective tissue has an overgrowth that compresses the bile ducts causing an obstruction. • This results in an increase in the bilirubin in the vascular system, and jaundice occurs. Skin Lesions • Spider angiomas are small dilated blood vessels with a bright red center with spiderlike branches. • Palmar erythema is a red area that blanches with pressure. Hematologic Problems • Thrombocytopenia • Leukopenia • Anemia • Coagulation disorders • The first 3 are thought to be caused by splenomegaly • Coagulation problems result from the liver’s inability to make prothrombin Endocrine problems • In men with cirrhosis: o Gynecomastia o Loss of axillary and pubic hair o Testicular atrophy o Impotence with loss of libido • Younger women may develop amenorrhea. • Older women may have vaginal bleeding. Peripheral Neuropathy • This is a common finding in alcoholic cirrhosis. • It is probably due to a dietary deficiency of thiamine, folic acid, and cobalamin. Complications • Portal hypertension • Esophageal and gastric varices • Peripheral edema • Abdominal ascites • Hepatic encephalopathy • Hepatorenal syndrome One or more complications is decompensated cirrhosis. Portal Hypertension and Esophageal and Gastric Varices • Structural changes lead to obstruction of blood flow in and out of the liver. • Portal hypertension is characterized by increased venous pressure in the portal circulation, splenomegaly, large collateral veins, ascites, and gastric and esophageal varices. • Esophageal varices are a complex of tortuous, enlarged veins at the lower end of the esophagus. • Gastric varices are found in the upper part of the stomach. These are fragile. • Patients may present with melena or hematemesis. • Ruptured esophageal varices are the most life-threatening complication of cirrhosis and considered a medical emergency. Peripheral Edema and Ascites • Peripheral edema occurs in the lower extremities and presacral area. • Can occur before, concurrently or after ascites development. • Ascites is the accumulation of serous fluid in the peritoneal or abdominal cavity. • When the lymphatic system is unable to carry off the excess proteins and water, they leak into the peritoneal cavity. • A second mechanism of ascites formation is hypoalbuminemia resulting from the liver’s decreased ability to synthesize albumin. • A third mechanism of ascites is hyperaldosteronism, which occurs when the damaged hepatocytes metabolize aldosterone. • Ascites is manifested by abdominal distention with weight gain. • Patients may have o Hydration o Decrease in urine output o Hypokalemia o Low potassium due to diuretic therapy o Spontaneous bacterial peritonitis Hepatic Encephalopathy • Neuropsychiatric manifestation of liver disease. • A major source of ammonia is in the intestines. • When blood is shunted past the liver via the collateral vessels or the liver is so damaged that it is unable to convert ammonia to urea, the levels of ammonia in the systemic circulation increase. • Manifestations include o Neurologic and mental responsiveness o Impaired consciousness o Inappropriate behavior o Asterixis o Apraxia o Fetor hepaticus