Hepatic Problems

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Hepatic Problems
2011-09-29 12:46:54
Hepatic Problems

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  1. Causes of Acute Hepatic Failure (AHF)
    • Primary disease process (breakdown of organ itself); SHOCK
    • Complication of chronic liver disease
    • MODS
    • Hypoglycemia (carb metabolism failure)
  2. Causes of Fulminant Hepatic Failure (FHF)
    • Viral infections: Hep A, B, and C; Cytomeglovirus; EVB (mono)
    • Hepatoxins: acetaminophen, mushroom toxins, Insoniazid, Hydrocarbons
  3. FHF characteristics
    • Rapid, massive destruction
    • Widespread necrosis
  4. FHF Criteria
    • No preexisting liver disease; healthyl iver
    • Encelphalopathy level: significant mental status change; stage 3 or 4
    • Rate of onset: < 8 weeks
  5. LFTs (trends)
    • ALT: increase
    • AST: increase
    • Alk Phos: decrease initally, will increase as problems persist
    • Bilirubin: increase; liver can't break down bile, jaundice; chronic indicator
    • Albumin: decrease; liver failure
    • PT: increased; liver failure, when vit. K decreases
    • Platelet count: decreased; portal HTN and spleen issue
    • Serum protein electrophoresis: serum smear; look at cells to see what's going on in liver
  6. Hepatic Encelphalopathy
    • Hallmark of AHF
    • Altered neuro status caused by build up of ammonia or hepatic origin; breakdown of proteins
    • Associated w/ hypoglycemia, cerebral edema
  7. Stage 1 of Hepatic encelphalopathy
    • Awake but mental clouding
    • Restlessness
    • Altered sleep pattern
    • Impaired computation, handwriting, intellectual abilities; analytical deficits
    • Diminished muscle coordination
    • ECG: mild to moderate, slowing of brain firing, usually no ECG here
  8. Stage 2 of Hepatic encelphalopathy
    • Decreased LOC
    • Lethary (sluggish)
    • Drowsiness
    • Disorientation to time and place
    • Confusion
    • Asterixis (jumping of limb when touched)/ Diminished reflexes
    • Slurred speech
    • ECG: mild to moderate, slowing of brain function, usually no ECG here
  9. Stage 3 of Hepatic encelphalopathy
    • Stupor but able to arouse
    • No spontaneous eye opening
    • Hyperactive reflexes (jerking, bouncing)
    • Seizures
    • Rigidity
    • Abnormal posturing; flexion and extension
    • ECG: severe abnormalities, may or may not see seizure activity
  10. Stage 4 of Hepatic encelphalopathy
    • Coma
    • Seizures
    • Dilated pupils (still responsive)
    • Flaccidity
    • ECG: severe, abnormalities and brain problems
    • No amt of stimulation will wake them up, no brain interaction
  11. Metabolic Dysfunction of AHF
    • Protein metabolism dysfunction: ascites, hypoalbuminemia, hepatic encelphalopathy, impaired clotting factors
    • Cab metabolism dysfunction: hypoglycemia
    • Fat metabolism dysfunction: N/V, anorexia, constipation or dirrhea
    • Prolonged PT: vit K issue
  12. Effects of AHF on body systems
    • Neuro: encelphalopathy
    • CV: hypotension
    • GI: N/V, diarrhea, constipation, anorexia, ascites
    • Hematopoeitic: impaired coags
    • Pulm: tachypnea, crackles, pulmonary edema, portal HTN, fluid back up
  13. Portal HTN
    • Back flow issue
    • Caused by cirrhosis
    • Over time will devlop varices to help relieve pressure
  14. Portal HTN pathogenesis
    Hepatic parenchymal damage, increased pressure required to perfuse liver, increased capillary resistance, portal HTN
  15. What does portal HTN result in?
    • Chronic liver disease: development of varices
    • Acute liver disease: no varices, congestion in splenic organs
  16. Hepatorenal syndrome
    • Renal failure secondary to severe liver failure in absence of renal pathology
    • Severe, rapidly progressing renal failure
    • Uremia/oliguria
    • Cr levels >2.5
    • Cr cleareance <20 in less than 2 weeks
    • Need to treat liver issue first
  17. Spontaneous Bacterial peritonitis
    • Ascites fluid becomes infected
    • Translocation of bacteria: bowel to ascites
    • Fever, pain
  18. Treatment of esophageal varices
    • Prophylaxis: prevent initial bleeding
    • Meds: beta blockers, nitrates (if no response from beta blockers)
    • Hemodynamic resuscitation
  19. Treatment of Hemorrhage: hemodynamic resuscitation
    • Blood products and crystalloids
    • Maintain Hct >30%
    • Clotting factors: platelet replacement
    • Always want current type and screen (expires q 24hrs)
    • Initally need fluid for perfusion, CO, and BP; then need blood asap
  20. Treatment of Hemorrhage: Control Bleeding
    • Vasopressin: vasocontrictor; only a bandaid, not permanent
    • Nitro: to dilate when vasopressin contricts
    • Octreotide (IV): inhibits release of vasodilatory hormones, vasocontriction of splanchnic vessels
    • Endoscopic therapy: First line, sclerosing chemical, on Protonix after 3-5 stopped bleeding
  21. Treatment of Hemorrhage: Preventative
    • TIPS: shunt made between hepatic and portal veins, kept open w/ metal shunt; decompresses portal system and controlling bleeding
    • Complications: stent dysfunction, thrombosis, retraction, displacement, stenosis
    • Put in in the OR
  22. Sengstaken-Blakemore tube
    • Creates pressure in esophagus w/ balloon
    • Risk of rupturing esophagus
    • Maintain O2