1

Anatomy and physiological overview of Liver

It is the largest gland of the bodyLocated behind the ribs in the right upper quadrant, from 5th-12th rib.

It weighs 1800gms in men and 1400 in women.

It is divided into 4 lobes and multiple lobules.

2

3

What’s special about the blood supply to the liver ?

4

Blood supply

2 sources mainly*75% from portal vein which is rich in nutrients

*25% from hepatic artery which is rich in O2

*A mixture of venous and arterial blood bathes the hepatocytes.

5

Secretions movement

Hepatocytes Pour secretions into small bile

duct

Larger bile duct

6

Hepatic duct +cystic duct

Joins to form common bile duct

Empties into small intestine & spincter of oddi

controls the emptying into the intestine

7

How does the liver function ?

8

Functions of the liver

Glucose metabolismAmmonia conversionProtein metabolismFat metabolismVitamin and iron storage Drug metabolismBile formationBilirubin excretion

9

What is Hepatitis ?

10

Hepatitis

Inflammation of liver cells producing a characteristic cluster of cellular changes

11

How do we classify hepatitis ?

12

Classification of HepatitisVIRALNON

VIRALAUTOIMMUNEBACTERIALPARASITIC

13

Viral

HAVHBVHCVHDVHEVHGV

14

Non viral Hepatitis

DRUG INDUCED

TOXIC HEPATITIS

15

Hepatitis A Virus

16

Hepatitis A

It accounts for 20-25% of clinical hepatitis in developed countries.

Etiology -RNA virus of the enterovirus family.

17

TransmissionFeco-oral routeIngestion of food infectedFound with over crowding and poor sanitation

Poor hand hygiene, hand to mouth contact

Infected food handlerOral & anal intercourse

18

19

Incubation-15-50 days with a mean of 28-30 days period. Illness period is 4-8 wks

Mortality rate -0.5% in <40 yrs 1-2% in > 40 yrs

Carrier-No carrier state

20

Clinical manifestations

Anicteric and symptomlessLow grade fever,headacheAnorexia ,abd painNauseand vomiting(due to toxins released to

detoxify virus)Jaundice and dark urine, claycolured stoolsIndigestion, heart burn and flatulenceAversion to strong odorsGeneralized weaknessAll these clear within 10 days

21

Assessment and diagnostic findings

Hepatomegaly and splenomegaly for few days

Hepatitis A virus found in stool for 7-10 days before illness and 2-3 weeks after symptoms appear.

HAV antibodies detected in serum

22

contd

Raised IgM,IgG AtibodiesElevated liver enzymesUltrasoundCT scanMRI

23

Prevention Scrupulous hand washingSafe food and water supplyVaccine(Havrix,Vaqta)HAV,(Twinrix)HAV+HBV

*Immunoglobulin given IM within 2 wks of exposure for those who never had vaccine- 0.02-0.05mi/kg bodywt.

24

Medical management

Bedrest during acute stageIV fliuds with glucoseRestrict activities to prevent fatigue worsening

AntiemeticsImmunoglobulin

25

Nursing management

Guidelines about Diet(low fat, fluid balance) Rest Followup of blood work Importance of avoiding of alcohol Sanitation Teach family members

Hep b

27

Hepatitis B Virus

28

29

Hepatitis BTransmission-Blood ,percutaneous and permucosal,mother to child.

Incubation period 1-6 months.People at risk- surgeons, lab workers, nurses, dentist, respiratory therapist and staff working in hemodialysis and oncology unit.

Recovery-90% recovery spontaneously.

Mortality-10%.leads to cirrhosis and Ca

30

Risk factors

Exposure to blood and blood products.Health care workersHemodialysisMale homosexualIV drug usersMultiple sex partnersBlood transfusions

31

PATHOPHYSIOLOGY

VIRUS ENTERS IN TO BLD STREAM THROUG H A BREAK OR DIRECT INOCULATION

↓REACHES TO LIVER ,REPLICATED ( 45-180

DAYS) ↓ DESTRUCTION OF LIVER CELLS- SYMPTOMS

32

CLINICAL FEATURES

33

Clinical manifestations

Insidious onset because of long prolonged incubation

Fever and respiratory symptoms are rareArthralgia and rashesLoss of appetite & dyspepsiaAbdominal pain and generalized achesMalaise and weaknessJaundice may or may not be evident

34

Cont…

Light colored feces and dark urine(if jaundice occurs)

Hepatomegaly 12-14 cms vertically and tenderness

Splenomegaly in fewPosterior cervical lymphnodes

35

Assessment and diagnosis

specific antibody in serum like HBcAg,HBsAg,HBeAg,HBxAg

HBsAg appears in the circulation in 80%-90% of infected patients,1-10 wks after exposure & 2-8 wks before the onset of symptoms

HBV DNA detected HBcAg Is not always detected in serum

36

Prevention

Preventing transmissionScreening of blood donorsUse of disposable needlesGood protection during blood collectionWork areas disinfected daily Use protective devices when neededPatient educationDiscourage blood donation

37

Cont…….

Active immunizationRecommended for high risk individualsCombined hepatitis A &B vaccine for >18

yrsTwinrix- 3 dosesRecombivax HB-yeast recombinant Hep B

vaccineIM in 3 doses with 6 months intervalDeltoid muscle universal response for all

new born

38

Cont…..

Passive immunityHepatitis B immune globulin Used for those exposed to virus and not taken vaccine before

Used for needle stick injuries,perinatal exposure

39

What is the best choice of treatment for hepatitis B ?

Medications

41

Medical management

Alpha interferon as the single modality of therapy.- Enhance bodys immune activity

5 million units daily/10 million units 3 times a wk for 4-6 months

Results in remmission in 1/3rd patients Prolonged course might have additional benefits Side effects-fever,nausea,myalgia,fatigue,bone

marrow suppression, thyroid dysfunction,alopecia and delayed infection

42

Cont…..

Antiviral agents-Lamivudine,Adefovir,oral nucleoside analogues.

Drugs help control disease progression by supressing viral reproduction in liver

Once daily for yearsBedrest-Until hepatomegaly and serum

bilirubin falls.Antacids and antiemeticsFluid therapyNutritious diet

43

Nursing management

Symptomatic supportGradual resumption of physical activity

Advice avoidance of sexual activity

Minimize social isolationReduce fear and anxiety by proper explanation of treatment plans

44

Hepatitis C

Prevalence –adults,40-59 yrs African-AmericansCause for death –hepatocellular carcinoma

People at risk -IV drug users Multiple sex partners

frequent blood trasfusions

Health care personnel

45

Incubation period -15-60 daysClinical course of diseaseIt is similar to Hep B Symptoms are mildChronic carrier state occurs frequently

Increased risk of cirrhosis and cancer

46

contd

47

Risk factors

Exposure to blood and blood products.Health care workersHemodialysisMale homosexualIV drug usersMultiple sex partnersBlood transfusionsBorne to hep C –infected mother

48

Do we have medications to treat Hepatitis C !!!

49

Treatment

Avoid alcoholAvoid hepatotoxic drugsCombination of antiviral -ribavarin interferon is effective-pegylated interferon-I inj each week

Screening blood donors reduces risk

50

Hepatitis D

Cause- *Small circular RNA virus,delta virus.

* It is also called subviral satellite

* Can propogate only with the help of another virus.

*It can occur with HBV and by superinfection.

51

Risk groupIntravenous drug usersHomosexual and multiple sex aprtners

Unscreened blood transfusionsHemphiliacs and other clotting disorders patient

52

Transmission –Bloodborne Percutaneous

Permucosal Sexual Rarely perinatal

53

Pathogenesis

Limited only to liver

Can replicate only in liver

Histological changes results in hepatocellular necrosis and inflammation

54

Clinical features

Found only in acute phase of diseaseMild feverJaundiceMuscle acheDark urineNauseaVomitiingLoss of appetite

55

Cont……

HeadacheDizzziness light colored stools & may contain pus

SpleenomegalyPrurituis

56

DIAGNOSIS

Serological tests-using radioimmunoassay or enzyme immunoassay kits

PCR-can detect 10-100 copies of HDV genome

IgM in serumAnti HDV antibodies present

57

Prevention

Informing sex partner and safe sex

Hepatitis B vaccineDon’t share razor,toothbrush and personal articles

Immunization with recombinant purified HDAg-S provide complete protection

58

Treatment

Massive doses of Interferon9-12 million units 3 times a wk*12 months

5 million units daily*12 monthsAntivirals are ineffectiveLiver transplantation

59

Immune prophylaxis

Vaccination against HBV protects Hepatitis D

60

Hepatitis E Virus

61

Hepatitis E

Caused by hepatitis E virus.It is a positive single stranded RNA

Transmission –feco oral Animals as reservoirs Consuming wild boar

and deer meatEpidemiology- highest among

adolescence and adults.

62

Clinical features

WeaknessFatigueFeverRt upper abd pain,abd tendernessNausea,vomiting,diarrhoeaSore throatJoint painMalaise Wt lossJaundice, brown urine, clay stools

63

Diagnostic

Elevated antibodies of hep E- RT-PCR

64

Prevention-Improving sanitation Proper disposal of human waste Good standards of public water supply Personal hygiene & sanitary food

preparationVitamin supplementsDiet- highcoh-

65

Are there any more types of viral hepatitis?

66

Hepatitis G

Cause-Hepatitis G virus a distant relative of hepatitis C virus

People at risk-Those getting repeated transfusionsIV drug usersMother to newbornSexual transmission

67

Diagnosis-DNA testingTreatment-No specific treatmentBedrestAvoid alcoholBalanced diet

68

Prognosis –It is mild illness and doesnot last long.

69

Hepatitis TT virus

Found in the year 1997Found in patient in Japan with post

transfusion hepatitis

70

Non-Viral hepatitis

Toxic hepatitis Drug induced

71

Causes

Alcohol overuseDirect hepatotoxicityIdiosyncratic hepatotoxicityCholestatic reactionsMetabolic & autoimmune disorders

Infectious agents

72

s/s

AnorexiaNausea and vomitingJaundiceDark urineHepatomegalyAbdominal painClay colored stoolsPruritus

73

Diagnosis

WBC countIncreased eosinophil countLiver biopsy

74

Treatment

Remove the causative agent by lavage

Catharsis and hyperventilationAntidote-Eg acetyl cysteineCorticosteroids if drug induced

75

Autoimmune hepatitis

Body’s immune system attacks liver cells

Treatment CorticosteroidsAzathioprine Liver transplant

76

Bacterial Hepatitis

77

Pathophysiology of hepatitis

Damage to liver parenchyma Persistent inflammation

Hepatocyte fibrosis

Cirrhosis

78

Complications

79

Nursing care

Pain in upper right quadrant related to inflammation of liver and arthralgia

?

80

Activity intolerance ,fatigue and tiredness related to the disease process

?

81

Nausea related to stimulation of vomiting centre associated with inflammation of GIT, gaseous distension due to impaired fat digestion and obstruction of bile flow.

82

Risk for fluid volume deficit related to decreased oral intake associated with vomiting and diaphoresis.

83

Risk for imbalanced nutrition less than body requirement related to nausea,vomiting,decreased appetite and inability to digest.

84

pruritus related to stimulation of itch fibers in the skin by bile acid metabolites which accumulate in the blood as a result of bile flow obstruction

85

Potential for complications of hepatitis,bleeding, progressive liver degeneration(fulminant hepatitis,chronic acute hepatitis) related to decreased production of clotting factors and continued degeneration and necrosis of hepatocytes.

86

Deficient knowledge regarding disease process,treatment and home care related to ignorance

87

Home care teaching

Wash hands after urinating and having a bowel movement.

Donot share personal articles eg brush,razor.

Donot share utensils,cigarettes and food

Use disposable syringes eg vit B12 injections

Use condom for sexual intercourse

88

Cont…..

Donot donate bloodAvoid alcohol atleast for 6 months-1 year

Avoid contact with industrial toxinsTake acetaminophen only as prescribed

Hepatitis immune globulin and vaccine for family members

89

Bibliography

Suzanne.C.Smeltzer.,& Brenda.G.Bare.,&Janie.L.Hinkle.,& kerry.(2008).Brunner and Suddarths textbook of Medical and Surgical Nursing.Philadelphia:Lippincott .

90

THANK YOU