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Liver Disorders

Liver Disorders. Kelle Howard, MSN, RN, CNE Fall 2013 From the notes of: John Nation, RN, MSN Charlene Morris, RN, MSN Austin Community College. Overview of Today’s Lecture. A & P Review Hepatitis A Hepatitis B Hepatitis C Cirrhosis Portal Hypertension

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Liver Disorders

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  1. Liver Disorders Kelle Howard, MSN, RN, CNE Fall 2013 From the notes of: John Nation, RN, MSN Charlene Morris, RN, MSN Austin Community College

  2. Overview of Today’s Lecture • A & P Review • Hepatitis A • Hepatitis B • Hepatitis C • Cirrhosis • Portal Hypertension • Esophageal Varices • Hepatic Encephalopathy • Hepatorenal Syndrome • Liver Transplant

  3. A and P Review

  4. A and P Review Largest internal organ Do you know how much it weighs?

  5. A Liver B Hepatic vein C Hepatic artery D Portal vein E Common bile duct F Stomach G Cystic duct H Gallbladder

  6. Blood Supply – 2 sources Hepatic artery: 500ml/min of oxygenated blood How much of cardiac output goes to the liver? _____________ Portal vein: 1000ml/min of partially oxygenated blood partly oxygenated blood supplies 50 - 60% O2 plus rich supply of nutrients, toxins, drugs from stomach, small and large intestines, pancreas and spleen

  7. Hepatic Blood Supply (Cont’d) • Both empty into capillaries/sinusoids • Liver filters the blood • Hepatic vein to inferior vena cava

  8. Metabolic Functions of the liver “Body’s Refinery”--- Over 400 functions Primary role in anabolism and catabolism

  9. Metabolic Functions of the Liver Metabolism 1. Carbohydrates 2. Fats 3. Protein

  10. Other functions Immunologic Blood storage Plasma protein synthesis Clotting Waste products of hemoglobin Formation and secretion of bile Steroids and hormones Ammonia Drugs, alcohol and toxins metabolism

  11. To Summarize…. The liver: • changes food into energy • removes alcohol and poisons from the blood • makes bile, a yellowish-green liquid that helps with digestion

  12. Hepatitis Simply means inflammation of the liver “itis” means inflammation, “hepa” means liver. Viral hepatitis Most common cause Viral types include A, B, C, D, E, and G

  13. Hepatitis Other possible causes Drugs (alcohol) drug-induced liver injury (DILI) is now the leading cause of acute liver failure (ALF), exceeding all other causes combined (FDA) Chemicals Autoimmune liver disease Bacteria (rarely)

  14. Other Liver toxic drugs: • Agomelatine (antidepressant) • Allopurinol • Amitriptyline (antidepressant) • Amiodarone (antiarrhythmic) • Atomoxetine[80] • Azathioprine[81] • Halothane (a specific type of anesthetic gas) • Hormonal contraceptives • Ibuprofen and indomethacin (NSAIDs) • Isoniazid (INH), rifampicin, and pyrazinamide (tuberculosis-specific antibiotics) • Ketoconazole (antifungal) • Loratadine (antihistamine) • Methotrexate (immune suppressant) • Methyldopa (antihypertensive) • Minocycline (tetracycline antibiotic) • Nifedipine (antihypertensive) • Nitrofurantoin (antibiotic) • (acetaminophen in the United States) can cause hepatitis when taken in an overdose. The severity of liver damage may be limited by prompt administration of acetylcysteine. • Phenytoin and valproic acid (antiepileptics) • Troglitazone (antidiabetic, withdrawn in 2000 for causing hepatitis) • Zidovudine (antiretroviral i.e., against HIV) • What other common drug is not on this list? • Usually, if you remove the drug, liver will return to normal function within months.

  15. Hepatitis Other Causes Cytomegalovirus Epstein-Barr virus Herpes virus 1 & 2 Coxsackie virus Rubella virus

  16. Hepatitis A Hepatitis A virus (HAV) RNA virus How is it transmitted? fecal–oral route parenteral (rarely) Frequently occurs in small outbreaks

  17. Hepatitis A(incidence) 25,000 new cases of hepatitis A occur annually in the United States 1/3 of all Americans have had it but now have immunity Approx. 100 people in US die each year 10 million cases of hepatitis A occur worldwide nearly universal during childhood in developing countries (hepatitisfoundation.org)

  18. Hepatitis A Hepatitis A virus (HAV) Found in feces: 2 or more weeks before the onset of symptoms up to 1 week after the onset of jaundice Present in blood briefly No chronic carrier state

  19. Hepatitis A:Incubation Period 2-7 weeks Acute onset Mild flu-like manifestations Symptoms may last up to 2 months Children sometimes present with NO symptoms Liver usually repairs itself, so no permanent effects

  20. Hepatitis A Hepatitis A virus (HAV) Anti-HAV immunoglobulin M (IgM) Appears in the serum as the stool becomes negative for the virus

  21. Hepatitis A Hepatitis A virus (HAV) Anti-HAV immunoglobulin G (IgG) Presence of IgG antibody provides lifelong immunity

  22. Hepatitis A:Mode of Transmission Mainly by ingestion of food or liquid infected with the virus poor hygiene improper handling of food crowded housing poor sanitation conditions

  23. Hepatitis A:Mode of Transmission (Cont’d) Occurs more frequently in underdeveloped countries Contaminated waters drinking water, contaminated seafood Food-borne Hepatitis A outbreaks usually due to infected food handler contamination of food during preparation

  24. Hepatitis A:VaccinePre-Exposure 2 doses IM Initial dose Booster in 6 to 12 months Children encouraged to get vaccinated

  25. Post-exposure Prophylaxis(PEP) Standard IG-immune globulin Given IM within 2 weeks of exposure Recommended for persons who: do not have anti-HAV antibodies & have had food borne exposure or close contact with HAV-infected person Provides temporary passive immunity 1-2 months Hepatitis A Vaccine Provides active immunity

  26. Remember 2/2/2/2 Rule 2 doses IM for vaccination Signs & symptoms last 2 months Greatest risk for transmission occurs before clinical s/s signs & symptoms About 2 weeks Also called the ‘preicteric’ phase Post-exposure dose of IG given within 2 weeks of exposure

  27. Hepatitis B(incidence) Nearly 1.25 million Americans infected 350 million world wide 5,000 Americans die from cirrhosis caused by Hep B 100 Xs more infectious than HIV 43,000 new cases of Hepatitis B annually in United States Incidence decreased due to HBV vaccine hepatitsfoundation.org

  28. Hepatitis B Hepatitis B virus (HBV) DNA virus Transmission occurs when infected blood or other body fluids enter the body of a person who is not immune to the virus

  29. Hepatitis B Hepatitis B virus (HBV) Transmission of HBV Perinatally by mothers infected 90% of infants infected, have chronic HBV The younger you are the more likely chronic disease will occur Percutaneously Mucosal exposure infectious blood, blood products other body fluids

  30. Hepatitis B Hepatitis B virus (HBV) Can live on a dry surface for 7 days More infectious than HIV Who is at risk?

  31. Hepatitis B Precautions Source: Uptodate See CDC & medline, medlink, NIH • PREVENT INFECTION OF FAMILY — Acute and chronic hepatitis B are contagious. Thus, people with hepatitis B should discuss measures to reduce the risk of infecting close contacts. This includes the following: • Discuss the infection with any sexual partners and use a latex condom with every sexual encounter. • Do not share razors, toothbrushes, or anything that has blood on it. • Cover open sores and cuts with a bandage. • Do not donate blood, body organs, other tissues, or sperm.

  32. Hepatitis B Precautions • Immediate family and household members should have testing for hepatitis B. • Anyone who is at risk of hepatitis B infection should be vaccinated, if not done previously. (See "Patient information: Adult immunizations".) • Do not share any injection drug equipment • (needles, syringes). • Clean blood spills with a mixture of 1 part household bleach to 9 parts water. Source: Uptodate See CDC & medline, medlink, NIH

  33. Hepatitis B Prevention Hepatitis B cannot be spread by: • Hugging or kissing • Sharing eating utensils or cups • Sneezing or coughing • Breastfeeding • ****Some sources say saliva can be source of transmission Source: Uptodate See CDC & medline, medlink, NIH

  34. Hepatitis B Prevention • Vaccine-3 doses • Initial dose • Dose at 4 weeks • Dose 5 months later • Developed in the 80s

  35. Post-exposure Hep B Incubation Period 6-24 weeks Hepatitis B Immune globulin IM in 2 doses First dose within 24 hours to 7 days of exposure Second dose 20 to 30 days post-exposure Provides short-term immunity

  36. Hepatitis B Hepatitis B virus (HBV) Complex structure with three antigens Surface antigen (HBsAg) Core antigen (HBcAg) E antigen (HBeAg) Each antigen Has a corresponding antibody that may develop In chronic carriers Surface antigen detected 6-12months after infection Surface antigen remains + Can still transmit the virus 15% to 25% die from chronic liver disease Two drugs available to suppress viral activity and decrease viral load a-Interferon (ex. Pegasys) Nucleoside analogs

  37. Hepatitis B Virus Presence of Hepatitis B Surface Antibodies Indicates immunity from HBV vaccine Past HBV infection

  38. Hepatitis B –Outbreaks • Oncologist in NJ • 2011 – revoked license, $30,000 in fines • Put 500 people at risk, 10 confirmed • 2 assisted living facilities • Blood glucose monitoring machines • Nurses transmitted • 12 residents confirmed

  39. Hepatitis C 3.2 million Americans chronically infected 1.8% of the population 75-85% of those infected will remain chronically infected Approximately 170 million people are infected with the hepatitis C virus (HCV) 17,000 new cases each year in US 8,000-10,000 Americans die each year from ESLD s/t chronic Hep C Approximately 30% to 40% of HIV-infected patients also have HCV Source: CDC.gov

  40. Hepatitis C Hepatitis C virus (HCV) RNA virus No vaccination available Transmitted primarily percutaneously

  41. Hepatitis C Risk Factors IV drug use Most common mode of transmission in United States and Canada Blood transfusions Incidence reduced to 1/1million However, if received blood prior to 1992 are at risk

  42. Hepatitis C Risk Factors (cont) High-risk sexual behavior* more data needed on this Hemodialysis Occupational exposure Sharing personal care items such as? Perinataltransmission Body piercings & tattooing * Up to 10% cannot identify the source

  43. Hepatitis CDiagnostic Studies Anti-HCV antibody HCV RNA

  44. Hepatitis D Hepatitis D virus (HDV) Also called delta virus Defective single-stranded RNA virus Cannot survive on its own Requires the helper function of HBV to replicate

  45. Hepatitis D HBV-HDV co-infection ↑ Risk of fulminant hepatitis Virulent More severe acute disease

  46. Hepatitis E Hepatitis E virus (HEV) RNA virus Transmitted fecal–oral route No serological test in US Most common contaminated drinking water occurs primarily in developing countries

  47. Hepatitis G Hepatitis G virus (HGV) RNA virus Poorly characterized parenterally & sexually transmitted virus Can be transmitted by blood transfusion Coexists with other hepatitis viruses and HIV Does not appear to cause liver damage by itself

  48. Pathophysiology of Hepatitis Acute infection- widespread inflammation of liver tissue Liver damage mediated by Cytotoxic cytokines Natural killer cells Liver cell damaged results in hepatic cell necrosis With time & no complications Liver cells will regenerate Eventually resume their normal appearance & function

  49. Common Manifestationsof Hepatitis Predictable course among all the viruses Incubation Phase: after exposure to virus many times no symptoms 30% HBV & 80% HCV asymptomatic

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