Hepatic Disorders (Cirrhosis, Hepatitis, Portal Hypertension)

Definition/Etiology:

• Definition/Etiology
  • Any condition that damages the liver and prevents it from functioning well and can lead to failure.
  • The liver is a vacuum cleaner of toxins – until it is not. Disorders are early. Failure is late.
  • Usually Chronic (Alcohol abuse) but sometimes acute (Sepsis or Wild mushroom ingestion)
  • Several types of liver failure but the PCCN test focuses on three.
    • Cirrhosis
      • Tylenol toxicity
      • ETOH abuse
    • Hepatitis
      • Viral Infection
    • Portal Hypertension
      • Obstruction of blood flow

Pathophysiology:

• Pathophysiology
  • Any type of liver failure causes the normal blood flow to slow through the liver.
  • This increases the pressure in the vein that carries blood from the intestines and spleen to the liver.
  • This increased pressure in the portal vein will cause fluid to back up and accumulate in the legs and abdomen.
  • Think of a hose with a blockage. Fluid pressure causes “seepage”
• Review Normal Liver Function – especially clotting factors
• Analogy = LATE SYMPTOMS
  • “Whereas heart problems might lead to breathlessness, for example, the liver is like a plodding donkey that carries on without any complaint – until it is too late”.

Noticing: Assessment & Recognizing Cues:

• Subjective
  • Vague, flu-like symptoms
  • SOB
  • “Itchy”
  • Grey stool -lack of bile
• Objective
  • Confusion → Coma
  • Jaundiced skin/sclera
    • Nonwhite patients have a sclera focus
  • Ascites/Enlarged Liver
    • caput medusae -engorged superficial epigastric veins,
  • Bruising/ Bleeding
    • Clotting factors made in liver

Interpreting: Analyzing & Planning:

• Labs
  • H/H & Coags – Bleeding
    • PT/INR, PLTs, Clotting factors
  • Liver Panel
    • AST/ALT/Alk Phos/Bilirubin
  • Ammonia Level
    • Hepatic Encephalopathy
  • BUN/Creatinine
    • Hepatorenal Syndrome
• Diagnostics
  • Abd Ultrasound
    • Kidneys/Ascites
  • CT Chest – Early signs
    • Infiltrates/Effusion
  • CT Head -Late sign
    • Brain damage

Responding: Patient Interventions & Taking Action:

• Pharmacological Interventions
  • Lactulose
    • Bind ammonia to bowels
  • Vitamin K & Blood Product
    • Bleeding/DIC
  • Diuretics
    • Fluid Overload
  • D50
    • Hypoglycemia
• Non-Pharmacological Interventions
  • Paracentesis
    • Ascites = hard to breath
• Adjunct Medical Therapy
  • Hepatologist/Infectious Disease Specialist

Reflecting: Evaluating Patient Outcomes:

• Stabilize for liver transplant
  • Monitor Labs, vitals, Neuro status
  • Monitor/replace electrolytes (Phos)
• Monitor/Treat Complications
  • HIGH risk for Sepsis
  • Brain Bleeds – Coagulopathy
  • Renal Failure – Hepatorenal syndrome from reduced blood flow via portal hypertension
  • Resp Failure – Fluid overload

Linchpins (Key Points):

• Notice -Confusion/Bruising
  • Hepatic encephalopathy & coagulopathy issues
• Interpret
  • Labs & Diagnostics
• Respond
  • Lactulose & Blood products
• Reflect
  • Stabilize & Monitor
    • Goal is usually transplant unless it’s a tylenol overdose