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. 1 Hepatic Function • • • • 2 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 • • • • • • 3 Amiodarone Phenytoin INH/Rifampin Sulfas Erythromycin Tricyclic Antidepressants • • • • • • 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. 4 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). 5 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. 6 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 7 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 8 Assessment • Ascites – Contributing factors • low alb • increased lymph • portal htn • Complications: • bacterial peritonitis • umbilical hernia • hydrothorax • Edema / anasarca • Skin changes – Bruising – Jaundice – Pruritis Ascites 9 Coagulopathy of liver disease • • • • 10 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 11 Cirrhosis • • • • • 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 12 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. 13 • 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 14 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 15 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 16 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 17 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): 18 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 19 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) 20 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) 21 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) 22