Getting to Know: The Liver

LIVER

-          Storages  vitamins A, B, D; iron; and copper

-          Synthesizes plasma proteins, including albumin and globulins

-          Synthesizes the clotting factors vitamin K and prothrombin

-          Storages glycogen and synthesizes glucose from other nutrients (gluconeogenesis)

-          Breakdowns fatty acids for energy

-          Produces bile

-          Detoxifies and excretes waste products

HEPATITIS

-          Is a viral infection of the liver associated with a broad spectrum of clinical manifestations from non-symptom-producing infection through icteric hepatitis to hepatic necrosis

Hepatitis A

-          Caused by a ribonucleic acid (RNA) virus of the enterovirus family

-          Mode of transmission is primarily fecal-oral, usually through ingestion of food or liguids contaminated with the virus

-          Incubation period is 3 to 5 weeks, with the average being 4 weeks

-          Occurrence is worldwide, usually among children and young adults

Hepatitis B

-          A double-shelled particle containing DNA

-          Mode of transmission is primarily through blood (percutaneous and permucosal route)

-          Incubation period is 2 to 5 months

-          Occurrence is for all ages but mostly affects young adults

Hepatitis C

-          Was formerly called non-A, non-B hepatitis; an RNA virus

-          Mode of transmission is through blood or blood products

-          Incubation period varies from 1 week to several months

-          Most common form of posttransfusion hepatitis

-          Occurs in all age-groups

Hepatitis D (Delta Hepatitis)

-          A defective RNA agent that appears to replicate only with hepatitis B virus. It requires HBsAg to replicate

-          Mode of transmission and incubation period are the same with Hepatitis B

-          Occurrence in the United States is primarily among I.V. drug abusers or multiply-transfused patients

Hepatitis E

-          Noneveloped single-strand RNA virus

-          Mode of transmission is fecal-oral, but because this virus is inconsistently shed in feces, detection is difficult

-          Occurrence is primarily in India, Africa, Asia, and Central America

-          More severe in pregnant women

Clinical Manifestations

                Hepatitis A

1.       May have no symptoms

2.       Prodromal symptoms: fatigue, anorexia, malaise, headache, low-grade fever, nausea and vomiting

3.       Highly contagious usually 2 weeks before the onset of jaundice

4.       Icteric phase: jaundice, tea-colored urine, clay-colored stool, and right upper quadrant tenderness

Hepatitis B

1.       Symptom onset usually more insidious and prolonged compared with HAV

2.       May be asymptomatic

3.       One week to 2 months of prodromal symptoms: fatigue, anorexia, transient fever, abdominal discomfort, nausea and vomiting, headache

4.       Extrahepatic manifestations may include myalgias, photophobia, arthritis, angioedema, urticaria, maculopapular eruptions, skin rashes, and vasculitis

5.       Jaundice in icteric phase

6.       In rare cases, it may progress to fulminant hepatic failure, also called fulminant hepatitis

7.       May become chronic active or chronic persistent (aymsptomatic hepatitis)

Hepatitis C

                -  Same with HBV but usually less severe

Hepatitis D

                - Same with HBV but more severe

Diagnostic Evaluation

1. Elevated serum transferase levels; aspartate transaminase (AST) and alanine transaminase (ALT) for all forms of hepatitis
2. Radioimmunoassays that reveal immunoglobulin (Ig) M antibodies to hepatitis virus in acute phase of HAV
3. Radioimmunoassay to include HBsAg, anti-HBc, anti-HBsAg detected in various stages of HBV
4. Lver biopsy to detect chronic active phase, progression, and response to therapy

MANAGEMENT

                All types of Hepatitis

1.       Rest according to patient’s level of fatigue

2.       Therapeutic measures to control dyspeptic symptoms and malaise

3.       Hospitalization for protracted nausea and vomiting or life-threatening complications

4.       Small, frequent feedings of a high-caloric, low-fat diet; proteins are restricted when the liver cannot metabolize protein by-products, as demonstrated by symptoms

5.       Vitamin K injected subcutaneously if PT is prolonged

6.       I.V. fluid and electrolyte replacement as indicated

7.       Administration of antiemetic for nausea

8.       After jaundice has cleared gradual increase in physical activity. This may require many months

9.        

For HBV patients

- For those patients found to have active viral replication, treatment with nucleoside analogs (Epivir) have shown some efficacy

For HCV patients

                - Treatment of the virus with long-acting injectable interferons in combination with the oral antiviral ribavirin (Virazole) may induce a sustained response of undetectable viral levels in about 50% of people

                - Close monitoring during long treatment period is imperative

COMPLICATIONS

1. Dehydration, hypokalemia
2. Chronic “carrier” hepatitis or chronic active hepatitis
3. Cholestatic hepatitis
4. Fulminant hepatitis ( liver transplantation may be necessary)
5. HBV and HCV carriers have a higher risk of developing hepatocellular carcinoma

NURSING DIAGNOSES

1. Imbalanced Nutrition: Less Than Body Requirements related to effects of liver dysfunction

Nursing Interventions

·         Encourage frequent small feedings of high-calorie, low-fat diet. Avoid large quantities of protein during acute phase of illness

·         Encourage eating meals in a sitting position to decrease pressure on the liver

·         Encourage taking pleasing meals in an environment with minimal noxious stimuli (odors, noise, interruptions)

·         Administer antiemetics as prescribed

2. Deficient Fluid Volume related to nausea and vomiting

Nursing Interventions

·         Provide frequent oral fluids as tolerated

·         Administer I.V fluids for patients with inability to maintain oral fluids

·         Monitor intake and output

3. Activity Intolerance related to anorexia and liver dysfunction

Nursing Interventions

·         Promote periods of rest

·         Promote comfort by administering analgesics as prescribed

·         Provide emotional support

·         Encourage gradual resumption of activities and mild exercise during convalescent period

4. Disturbed Through Processes related to encephalopathy because of impaired liver function

Nursing Interventions

·         Monitor for signs of encephalopathy; lethargy and somnolence with mild confusion and personality changes

·         Monitor for worsening of condition from stupor to coma

·         Maintain calm and quiet environment. Reorient patient as needed