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Hepatic / GI
At the end of this self study the participant will:
• Verbalize causes of hepatic failure and
pancreatitis
• Describe assessment findings of the patient
with liver disease and pancreatitis.
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Hepatic Function
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Manufacture of heparin
Modification of fats
Manufacture of bile
Manufacture of coags
• Synthesis of ammonia
to urea
• Plasma protein
formation
• Drug/alcohol/hormone
detox
• Synthesis of glycogen
Common Medications that can be
Hepatotoxic
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Amiodarone
Phenytoin
INH/Rifampin
Sulfas
Erythromycin
Tricyclic
Antidepressants
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Estrogen
Acetaminophen
Hydralazine
Tetracycline
Rezulin
Lovastatin
Acetaminophen Toxicity
• 8 gm (15 extra strength Tylenol) taken in a 24 hour
period can cause significant liver damage.
• It is recommended the general public do not exceed 4
gm/24 hours.
• Consumption of > 4 alcoholic drinks/ day then
recommendation decreased to not to exceed 2 gm/24
hours.
• > 3 drinks/day = 4 oz. liquor, 4 beers, or 16 oz. wine.
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Lab Tests
• ALT – Elevated in alcohol abuse, gallstones,
mononucleosis, medications, more specific for liver
problems than AST
• AST – Elevates in MI, bruised kidney, pancreas
problems, and liver disease (with use/abuse of
Alcohol, Statins & Tylenol)
• Alk Phos – Elevated for extra- and intrahepatic biliary
obstruction, sepsis. If elevated but GGPT normal,
more likely bone disorder
• GGPT-Most indicative of biliary obstruction (with alk
phos).
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Lab Tests
• Bilirubin - Result of hemoglobin breakdown.
– Elevates in liver failure R/T inability of liver to
convert bili to soluble form.
– Jaundice, itching, dark urine when total bili
reaches 3 mg/dl
• Serum Proteins – Albumin, Globulin & fibrinogen
– Decreased with liver dz, starvation,
malabsorption, poor iron intake
– Increased with hemoconcentration: N/V/D, poor
kidney function.
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Coagulation
• Prothrombin Time
– PT normal 11.0-15.0 seconds
– INR normal 0.81-1.20
– Physician alert value (automatic call back): >5.0
INR
• Partial Thromboplastin Time
– Ptt normal 23.0-36.0 seconds
– Physician alert value (automatic call-back): >150
seconds
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Ammonia
• Protein metabolism: ammonia is converted to urea
• Elevated levels affect acid-base balance, brain
function (encephalopathy)
• Asterixis (Liver flap)
– Assessed by asking patient to hold arms out in front,
hands dorsiflexed. Liver flap is a hand
tremor in this position
• To lower ammonia level
– Lactulose, neomycin, low protein diet
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Assessment
• Ascites
– Contributing factors
• low alb
• increased lymph
• portal htn
• Complications:
• bacterial peritonitis
• umbilical hernia
• hydrothorax
• Edema / anasarca
• Skin changes
– Bruising
– Jaundice
– Pruritis
Ascites
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Coagulopathy of liver disease
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Decreased production of clotting factors
Increased consumption of clotting factors
Production of abnormal clotting factors
Increased bleeding
– Internal
– External
– With interventions (e.g., IV insertion)
– Spontaneous without provocation
Causes of Liver Dysfunction
• Inflammatory Disorders- hepatitis
• Toxins- environmental: huffing, inhaling pesticides,
toxic work environments.
• Drugs- Prescription and illicit.
• Vascular Disorders- heart disease
• Metabolic Disorders [Fatty Liver disease/NASH
(Nonalcoholic Steatohepatitis)]
• Neoplasms- cancers
• *Most common cause of liver failure is drugs/alcohol
and hepatitis C
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Cirrhosis
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Primary: Autoimmune
Secondary: Obstruction (such as stones)
Laennec’s: Alcoholic (50% of all causes)
Cardiac: Right heart failure
Postnecrotic:
– After injury or circulatory obstruction
– Infectious causes
• Cryptogenic
– No cause found – just happens
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Hepatitis
• Inflammation of the liver
• Only A and B have a
vaccine
• C can be treated, however
is the main cause of liver
transplants
• D is parasitic to B.
Cannot have hep D
without B.
• E extremely rare in US,
more prevalent in
underdeveloped countries
• G has few symptoms in
humans.
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• Body Fluid Transmission
– B, C, D, G
• Fecal-oral Transmission
– A, C(rare), E
• Contaminated Food
Ingestion
–A
• Perinatal Transmission
– A, B, C, D
Esophageal Varices
• Primarily caused by portal hypertension
– High pressure causes backup of blood to organs
normally drained by portal system
• Dilated, engorged veins
• Often bleed within one year after discovered(70%
reoccurrence).
• Bleeding painless and massive: difficult to control
(60% stop spontaneously).
• 90% of patients with cirrhosis have varices
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Medical Management of Esophageal
Varices
• Sclerosing Therapy
– Endoscopic procedure, medication (sterile
water or epinephrine) injected into each varix
– Scar tissue develops, closing off varix
Variceal Band
Ligation
• Variceal Band Ligation
– Endoscopic procedure, rubber band
placed around varix
– Varix becomes necrotic, falls off
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Upper GI Bleed Causes
• Main cause is ulcers and gastritis(4.5million
Americans have ulcers).
• Hypoxia of GI mucosa can disrupt mucosal barrier
• Bacteria- h.pylori present in 95% of duodenal and
80% gastric ulcers – h.pylori can be protective,
especially on esophagus
• Cancer
• Peptic Ulcers
• Mallory Weiss Tear (protracted vomiting)
• Esophageal Varices
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Treatments
Medical
Surgical
• Drug Therapy
• Upper GI
– Proton pump inhibitors
– Gastric Oversew
(e.g., Prilosec)
– Vagotomy
– H2 Blockers
– Gastric Resection
(ranitidine, famotidine).
– Gastrectomy
– Antacids
• Lower GI
– Sucralfate
– Resection
– Reglan
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Pancreatitis
• Inflammatory process
• Enzymes activated and released within the pancreas
• Acute and chronic forms; edematous and
hemorrhagic forms.
• Severity ranges from edema to necrosis
• A common mnemonic for the causes of pancreatitis
spells "I get smashed", an allusion to heavy drinking
(one of the many causes):
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IGETSMASH-
idiopathic
gallstone.
ethanol (alcohol)
trauma (gunshot wounds, crush injuries)
steroids
mumps, other viruses (Epstein-Barr, Cytomegalovirus)
autoimmune disease
scorpion sting and also snake bites
hypercalcemia, hyperlipidemia/hypertriglyceridemia
and hypothermia
E - ERCP (Endoscopic Retrograde CholangioPancreatography)
D - drugs (e.g., thiazides, NSAIDS, steroids and duodenal
ulcers
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Panreatitis Assessment
• Abdominal pain
– Greatest in the upper abdomen, may radiate to
back
– May last from hours to day, or continuous
– May be worsened by eating, drinking and/or
alcohol consumption
• Nausea
• Vomiting
• Weight loss (On average patients with pancreatitis
lose 6-12 pounds)
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Pancreatitis Tests
• Elevated:
– Amylase (most common)
– Lipase (most accurate)
– Triglycerides
– WBCs
• Decreased: magnesium, potassium, calcium,
albumin.
• ERCP (yes, the same test that can cause pancreatitis is
also done as a diagnostic measure)
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Pancreatitis Treatment
• Pain control !!!
• NPO (N/G not required unless significant abdominal
distention occurs)
• Antibiotics may be considered for necrotizing or
infectious forms
• Surgery. Last resort (remember islets of langerhans)
• Fluid replacement
• Stop drinking alcohol and smoking (even if cause not
alcohol consumption)
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