Liver Diseases

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Liver Diseases

• Joan M. Pino-Talbot RN MSN APN CS
• Rutgers University Fall 2005

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Anatomy of the pancreas

• The pancreas is an elongated, tapered organ
  located across the back of the abdomen, behind
  the stomach. The right side of the organ (called
  the head) is the widest part of the organ and
  lies in the curve of the duodenum (the first
  section of the small intestine). The tapered left
  side extends slightly upward (called the body of
  the pancreas) and ends near the spleen (called
  the tail).

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The pancreas is made up of two types of tissue

• exocrine tissueThe exocrine tissue secretes
  digestive enzymes. These enzymes are secreted
  into a network of ducts that join the main
  pancreatic duct, which runs the length of the
  pancreas.
• endocrine tissueThe endocrine tissue, which
  consists of the islets of Langerhans, secretes
  hormones into the bloodstream.

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FUNCTION OF THE LIVER

• The liver regulates most chemical levels in the
  blood and excretes a product called bile, which
  helps carry away waste products from the liver.
  All the blood leaving the stomach and intestines
  passes through the liver. The liver processes
  this blood and breaks down the nutrients and
  drugs into forms that are easier to use for the
  rest of the body. More than 500 vital functions
  have been identified with the liver. Some of the
  more well-known functions include the following

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Glucose metabolism
Ammonia conversion
Protein metabolism
Fat metabolism
Vitamin and iron storage
Drug metabolism
Bile formation
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Bilirubin excretion Hepatic Dysfunction Cirrhosis
Jaundice Esophageal varices Substance
abuse Hepatitis A Hepatitis B Hepatitis
C Hepatitis D Hepatitis E
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jaundice
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Jaundice

• Jaundice is a yellowish discoloration of the skin
  and of the whites of the eyes caused by
  abnormally high levels of the pigment bilirubin
  in the bloodstream.

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liver enlargement, portal hypertension
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• An enlarged liver (hepatomegaly) usually
  indicates liver disease.
• An enlarged liver (hepatomegaly) usually
  indicates liver disease. However, many people
  with liver disease have a normal-sized or even a
  shrunken liver. An enlarged liver usually causes
  no symptoms. However, if the enlargement is
  extreme, it may cause abdominal discomfort or a
  feeling of fullness. If the enlargement occurs
  quickly, the liver may be tender to the touch.
  When performing a physical examination, a doctor
  can usually estimate the size of the liver by
  feeling whether it extends below the level of the
  ribs.

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• Portal HypertensionPortal hypertension is
  abnormally high blood pressure in branches of the
  portal vein, the large vein that brings blood
  from the intestines to the liver.
• Varicose veins in the esophagus (esophageal
  varices) and in the upper part of the stomach
  bleed easily and sometimes massively. Varicose
  veins in the rectum may also bleed, though this
  is much less common.

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• The portal vein receives blood drained from the
  entire intestine and from the spleen, pancreas,
  and gallbladder. After entering the liver, the
  vein divides into right and left branches and
  then into tiny channels that run through the
  liver. When blood leaves the liver, it drains
  back into the general circulation through the
  hepatic vein

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Symptoms

• Protein-containing fluid (ascitic fluid) may leak
  from the surface of the liver and intestines and
  expand (distend) the abdominal cavity, a
  condition called ascites.
• Portal hypertension often enlarges the spleen
  (which drains its blood supply into the portal
  vessels via the splenic vein).

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• Varicose veins in the esophagus (esophageal
  varices) and in the upper part of the stomach
  bleed easily and sometimes massively. Varicose
  veins in the rectum may also bleed, though this
  is much less common.

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• Two factors can increase blood pressure in the
  portal blood vessels increased volume of blood
  flowing through the vessels and increased
  resistance to the blood flow through the liver.
  In Western countries, the most common cause of
  portal hypertension is increased resistance to
  blood flow caused by cirrhosis (most often due to
  excessive alcohol intake).

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Varicose veins in the esophagus
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Diagnosis

• An ultrasound scan may be used to examine the
  blood flow in the portal blood vessels and to
  detect the presence of fluid in the abdomen.
• A computed tomography (CT) scan can also be used
  to look for and examine any collateral vessels.
  In rare cases, a needle can be inserted through
  the abdominal wall and into the liver or spleen
  to directly measure pressure in the portal system
  (manometry)

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Treatment

• To reduce the risk of bleeding from esophageal
  varices, a doctor may try to reduce the pressure
  in the portal vein. One way is to give
  propranolol INDERAL
• Bleeding from esophageal varices is a medical
  emergency . Drugs such as vasopressin PITRESSIN
  or octreotide SANDOSTATIN may be given
  intravenously to constrict the bleeding veins,
  and blood transfusions are given to replace lost
  blood.

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• An endoscopic examination is usually done to
  confirm that the bleeding is from varices. The
  veins can then be blocked off with rubber bands
  or with injections of a chemical given through
  the endoscope.
• If the bleeding continues or recurs repeatedly, a
  surgical procedure may be done to create a bypass
  (called a shunt) between the portal venous system
  and the general (systemic) venous system.

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Cirrhosis

• Cirrhosis is the seventh leading cause of death
  in the United States, according to the National
  Institute of Diabetes and Digestive and Kidney
  Diseases (NIDDK). Because of chronic damage to
  the liver, scar tissue slowly replaces normal
  functioning liver tissue, progressively
  diminishing blood flow through the liver.

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What causes cirrhosis?

• The most common cause of cirrhosis is alcohol
  abuse. Other causes include the following
• hepatitis and other viruses
• use of certain drugs
• chemical exposure
• bile duct obstruction
• autoimmune diseases
• obstruction of outflow of blood from the liver
  (i.e., Budd-Chiari syndrome)
• heart and blood vessel disturbances

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Ascites
ascites accumulation of fluid in the abdominal
cavity
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ALCOHOL (ETOH)

• Alcohol abuse is a leading cause of morbidity and
  mortality throughout the world. It is estimated
  that in the United States as many as 10 of men
  and 3 of women may suffer from persistent
  problems related to the use of alcohol.

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• Alcohol affects many organ systems of the body,
  but perhaps most notably affected are the central
  nervous system and the liver. Almost all ingested
  alcohol is metabolized in the liver and excessive
  alcohol use can lead to acute and chronic liver
  disease. Liver cirrhosis resulting from alcohol
  abuse is one of the ten leading causes of death
  in the United States.

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REMEMBER,

• LIVER DISEASE IS NOT THE ONLY LIFE-THREATENING
  COMPLICATION OF ALCOHOL USE DISORDERS. ALL
  ALCOHOLICS MUST ABSTAIN FROM DRINKING AS NUMEROUS
  OTHER ALCOHOL-RELATED MEDICAL, SOCIAL AND
  PSYCHOLOGICAL PROBLEMS CAN LEAD TO MORBIDITY AND
  MORTALITY

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Alcohol-Induced Liver Disease

• Alcohol-induced liver disease, as the name
  implies, is caused by excessive consumption of
  alcohol and is a common, but preventable,
  disease.
• Did you know? Women are more prone to liver
  damage from drinking alcohol than men.

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Three primary types of alcohol-induced liver
disease

• Fatty Liver
• Alcoholic hepatitis
• Alcoholic cirrhosis

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• Fatty liver is excessive accumulation of fat
  inside the liver cells.Fatty liver is the most
  common alcohol-induced liver disorder. The liver
  is enlarged, causing upper abdominal discomfort
  on the right side.

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Fatty Liver (Steatosis)

• Alcohol abuse can lead to the accumulation of fat
  within hepatocytes, the predominant cell type in
  the liver.
• A similar condition can also be seen in some
  obese people who are not alcohol abusers.

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• Fatty liver is reversible if the patient stops
  drinking, however, fatty liver can lead to
  steatohepatitis.
• Steatohepatitis is fatty liver accompanied by
  inflammation and this condition can lead to
  scarring of the liver and cirrhosis.

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Alcoholic hepatitis

• Alcoholic hepatitis is an acute inflammation of
  the liver, accompanied by the destruction of
  individual liver cells and scarring.
• Symptoms may include fever, jaundice, an
  increased white blood cell count, an enlarged,
  tender liver, and spider-like veins in the skin.

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Hepatitis

• Alcohol can cause acute and chronic hepatitis.
  The patient who presents with alcoholic hepatitis
  is usually a chronic drinker with a recent
  episode of exceptionally heavy consumption.

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• Alcoholic hepatitis can range from a mild
  hepatitis, with abnormal laboratory tests being
  the only indication of disease, to severe liver
  dysfunction with complications such as jaundice
  (yellow skin caused by bilirubin retenti hepatic
  encephalopathy (neurological dysfunction caused
  by liver failure), ascites (fluid accumulation in
  the abdomen), bleeding esophageal varices
  (varicose veins in the esophagus), abnormal blood
  clotting and coma.

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Alcoholic cirrhosis

• Alcoholic cirrhosis is the destruction of normal
  liver tissue, leaving non-functioning scar
  tissue.

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• Symptoms may include those of alcoholic hepatitis
  in addition to portal hypertension, enlarged
  spleen, ascites, kidney failure, confusion, or
  liver cancer.
• In the United States, alcohol abuse is the
  leading cause of liver cirrhosis.

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Symptoms of alcohol-induced

• Symptoms of alcohol-induced liver disease depend
  on how much and how long a person has been
  drinking alcohol. The following are the most
  common symptoms of alcohol-induced liver disease.

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• enlarged liver
• fever
• jaundice - yellowing of the skin and eyes.
• increased white blood cell count
• spider-like veins in the skin
• portal hypertension
• enlarged spleen ascites - fluid build-up in the
  abdominal cavity.
• kidney failure
• confusion

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Diagnostic procedures for alcohol-induced liver
disease may include the following

• laboratory tests
• liver function tests - a series of special blood
  tests that can determine if the liver is
  functioning properly.
• liver biopsy - a procedure in which tissue
  samples from the liver are removed (with a needle
  or during surgery) from the body for examination
  under a microscope.

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Specific treatment for alcohol-induced liver
disease is based on

• your age, overall health, and medical history
• extent of the disease
• your tolerance for specific medications,
  procedures, or therapies
• expectations for the course of the disease
• your opinion or preference
• The goal of treatment is to restore some or all
  normal functioning to the liver. Treatment
  usually begins with abstinence from alcohol. The
  liver has great restorative power and is often
  able to repair some of the damage caused by
  alcohol. In most cases, the only damage it cannot
  reverse is scarring from cirrhosis.

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Treatment

• The most important measure in the treatment of
  alcoholic liver disease is to ensure the total
  and immediate abstinence from alcohol.
• vitamins, especially thiamin, to correct the
  deficiencies that may have resulted from chronic
  alcohol abuse.

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Chronic Liver Disease / Cirrhosis

• Chronic liver disease is marked by the gradual
  destruction of liver tissue over time. Several
  liver diseases fall under this category,
  including the following
• cirrhosis of the liver
• fibrosis of the liver

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• Cirrhosis is the seventh leading cause of death
  in the United States, according to the National
  Institute of Diabetes and Digestive and Kidney
  Diseases (NIDDK).

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Symptoms of cirrhosis

• abnormal nerve function
• ascites - fluid build-up in the abdominal cavity.
  
• breast enlargement in men
• coughing up or vomiting blood
• curling of fingers (Dupuytren's contracture of
  the palms)
• gallstones
• hair loss
• itching
• jaundice - yellowing of the skin and eyes.
• kidney failure
• liver encephalopathy

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Symptoms of cirrhosis continued

• muscle loss
• poor appetite
• portal hypertension
• redness of palms
• salivary gland enlargement in cheeks
• shrinking of testes
• spider-like veins in the skin
• weakness
• weight loss

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The most common cause of cirrhosis is alcohol
abuse. Other causes include the following

• The most common cause of cirrhosis is alcohol
  abuse. Other causes include the following
• hepatitis and other viruses
• use of certain drugs
• chemical exposure
• bile duct obstruction
• autoimmune diseases
• obstruction of outflow of blood from the liver
  (i.e., Budd-Chiari syndrome)
• heart and blood vessel disturbances

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Other causes include the following continued

• Alpha1-antitrypsin deficiency
• high blood galactose levels
• high blood tyrosine levels at birth

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Diagnostic procedures for cirrhosis may include
the following

• laboratory tests
• liver function tests - a series of special blood
  tests that can determine if the liver is
  functioning properly.
• liver biopsy - a procedure in which tissue
  samples from the liver are removed (with a needle
  or during surgery) from the body for examination
  under a microscope.
• cholangiography - x-ray examination of the bile
  ducts using an intravenous (IV) dye (contrast).
• computed tomography scan (CT or CAT scan) - a
  diagnostic imaging procedure using a combination
  of x-rays and computer technology to produce
  cross-sectional images
• ultrasound (Also called sonography.)

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Treatment for cirrhosis

• Specific treatment for cirrhosis will be
  determined by your physician based on
• your age, overall health, and medical history
• extent of the disease
• your tolerance for specific medications,
  procedures, or therapies
• expectations for the course of the disease
• your opinion or preference

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What is fibrosis?

• Fibrosis is the growth of scar tissue due to
  infection, inflammation, injury, or even healing.
  The overgrowth of scar tissue can occur in almost
  any organ. Fibrosis in the liver can inhibit the
  organ's proper functioning. Liver fibrosis is
  usually the result of cirrhosis.