NCMB316 LECTURE: Prelim Week

04
Hepatitis, Liver Cirrhosis, Esophageal Varice, etc.
Bachelor of Science in Nursing 3YB
Professor: Dr. Potenciana A. Maroma
HEPATITIS, LIVER CIRRHOSIS, ESOPHAGEAL VARICE, ETC.
Major Functions of The Liver
• Bile production and excretion
• Excretion of bilirubin, cholesterol, hormones and drugs
• Metabolism of CHO, CHON and fats
• Storage of glycogen, vitamins and minerals
• Synthesis of plasma proteins, such as albumin and
clotting factors
• Detoxification

Viral Hepatitis B
- DNA virus, identified in all body fluids: blood, saliva,
synovial fluid, breast milk, ascites, cerebral spinal fluid, etc.
- Transmitted by blood and body fluids (saliva, semen,
vaginal secretions): often from contaminated needles
among IV drug abusers; intimate/sexual contact
- Accounts for 50% of cases of fulminant hepatitis
- In an adult who develops acute hepatitis B, there is
Hepatitis
approximately 10% chance that it will progress into chronic
hepatitis; in the neonate the chance is 90% for chronic
hepatitis.
- Incubation period is very long: 1 - 6 months

Hepatitis A B C D E
- Infectious inflammation of the liver parenchyma caused
by viruses.
- Widespread inflammation of the liver tissue
- Liver cell damage due to hepatic cell degeneration and
necrosis
- Proliferation and enlargement of the kupffer cells
- Inflammation of the periportal areas causing interruption of
bile flow
Viral Hepatitis A
- RNA virus transmitted via fecal-oral route.
- Poor hygiene or contaminated food and shellfish increase
risk of transmission
- Incubation period: 15 – 45 days
- Practice food hygiene to prevent hepatitis A

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316 LECTURE: WK4 – HEPATITIS, LIVER CIRRHOSIS, ESOPHAGEAL VARICE, ETC.

Viral Hepatitis C
- RNA virus generally transmitted predominantly by blood
products
- Currently the most common hepatitis among IV drug
abusers and in prisons
- Before 1990 it accounted for 90% of transfusion hepatitis
- Incubation: 2 weeks - 6 months
- High risk of progression to chronic form (70 – 80%)
- Associated with extrahepatic manifestations commonly:
mixed cryoglobulinemia and polyarteritis nodosa

Assessment findings
• Preicteric stage (prodromal phase) = 1 week
- Anorexia (major manifestation), N&V, fatigue,
constipation or diarrhea, weight loss
- RUQ discomfort, hepatomegaly, splenomegaly,
lymphadenopathy
• Icteric stage
- Fatigue, weight loss, light-colored stools, dark urine
- Continued hepatomegaly with tenderness,
lymphadenopathy, splenomegaly
- Jaundice, pruritus
• Posticteric stage
Viral Hepatitis D - Fatigue, but an increased sense of well-being,
- RNA virus that infects either simultaneously with hepatitis hepatomegaly gradually decreasing
B or as a super-infection in a person with chronic hepatitis Collaborative Management
B • Promotion of rest to relieve fatigue
- Hepatitis D infection cannot occur unless there is current • Maintenance of food and fluid intake
and ongoing replication of the hepatitis B virus • 3,000 ml/day of fluids for fever and vomiting; monitor I and
- Overall, this infection carries the highest risk among acute O, weight
viral hepatitis for fulminant disease; the risk is even greater • Well – balanced diet; encourage fruit juices and non-
in super-infection carbonated beverages
- Predominantly seen in patients exposed to blood products • Fats may need to be restricted
(drug addicts and hemophiliacs). If anti-hbs antibodies are • Alcoholic beverages should be avoided
present, then that person is immune to hepatitis B and D • Prevention of injury
• advise client to use soft toothbrush or swabs
• administer Vitamin K as ordered
• Provision of comfort measures
• Relaxing baths, backrubs, fresh linens and quiet dark
environment
• Relieve pruritus through the following measures:
- Use of cool, light, non-restrictive clothing
- Use of soft, dry, clean bedding, use of warm baths
- Application of emollient creams and lotions to dry skin.
- Maintenance of a cool environment
- Administration of antihistamines as ordered
- Use of diversional activities, e.g. reading, TV and radio
Viral Hepatitis E
- Similar to Hepatitis A with fecal or oral transmission, Liver Cirrhosis
there is no chronic form - Chronic, progressive disease characterized by
- The risk of fulminant disease has been described mainly in inflammation, fibrosis, and degeneration of the liver
pregnant patients parenchymal cells
- Destroyed liver cells are replaced by scar tissue, resulting
in architectural changes & malfunction of the liver

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316 LECTURE: WK4 – HEPATITIS, LIVER CIRRHOSIS, ESOPHAGEAL VARICE, ETC.

Portal HPN

• Types
o Laênnec’s cirrhosis
- associated with alcohol abuse and malnutrition;
characterized by an accumulation of fat in the
liver cells, progressing to widespread scar
formation.
o Postnecrotic cirrhosis
- results in severe inflammation with massive
necrosis as a complication of viral hepatitis Pathology
o Cardiac cirrhosis 1) In portal hypertension
- occurs as a consequence of RSHF; manifested by - plasma shift into interstitial spaces within the liver due
hepatomegaly with some fibrosis. to the increase pressure. The collection of fluids shifts
o Biliary cirrhosis out of the Glisson’s capsule and accumulate in the
- associated with biliary obstruction, usually in the peritoneal cavity
common bile duct; results in chronic impairment 2) The liver is unable to metabolize protein, thereby
of bile excretion hypoalbuminemia occurs
Assessment - result to decreased oncotic pressure, fluids shift out of
• Anorexia, weakness, weight loss (liver is unable to the IVC, and accumulate in the peritoneal cavity.
metabolize nutrients and store fat-soluble vitamins) 3) The liver is unable to excrete adrenal cortex hormone, one
• Fever (in response to tissue injury) of which is aldosterone
• Jaundice, pruritus, tea colored urine (due to bilirubin in - Hyperaldosteronism leads to retention of sodium and
the blood) water
• remember!!! bilirubin is conjugated initially before 4) Esophageal varices = 2° to backpressure
excretion 5) Internal hemorrhoids, leg varicosities, and dependent
• Increased Bleeding tendencies. (liver is unable to store Vit. edema
K. There is also impaired production of clotting factors) - due to venous stasis, increasing hydrostatic pressure.
This leads to shifting of plasma into interstitial space
Consequences of Portal HPN:
• Hepatomegaly= initially, then the liver shrinks in size as
fibrosis replaces the liver parenchyma
• Splenomegaly= due to increased backpressure of the
blood
• Caput medusae (dilated veins over the abdomen)

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316 LECTURE: WK4 – HEPATITIS, LIVER CIRRHOSIS, ESOPHAGEAL VARICE, ETC.

• Spider angioma (telangiectasia / dilated capillaries over - acne

the face and anterior trunk)= due to increased estrogen - deepening of voice
• Palmar erythema. This is also due to elevated estrogen - Virilism (development or premature development of
level in males. male secondary sexual characteristics)
• Ascites
Hepatic Encephalopathy
- Accumulation of AMMONIA because the liver cannot
convert ammonia into urea that can lead to hepatic coma
(Ammonia is by product of CHON metabolism)
- initial manifestations: BEHAVIORAL changes and MENTAL
changes
- Other findings in advanced stages are:
• asterixis – flapping tremors of the hands
• confusion / disorientation
• delirium / hallucination
• fetor hepaticus - disagreeable odor from the mouth
• coma
Diagnostic tests
• SGOT or AST, SGPT, LDH, alkaline phosphatase increased
• Serum bilirubin increased
• PT prolonged
• Serum albumin decreased
• Hgb/Hct decreased
Medical Management
• Bedrest
• Hepatic protector- Essentiale, Godex
• Betablockers
• Blood transfusion
• Diuretic
• Vitamin K
• Antibiotics- Neomycin
• Paracentesis
• Albumer infusion
• Antihistamine
• Laxative
• Enema
• Diet- low sodium, high CHO, Low CHON, Low fat
Nursing interventions
• Provide sufficient rest and comfort
- Provide bed rest with bathroom privileges.
- Encourage gradual, progressive, increasing activity with
planned rest periods.
- Institute measures to relieve pruritus.
o Do not use soaps and detergents
o Bathe in tepid water followed by application
of an emollient lotion.
o Provide cool, light, nonrestrictive clothing.
o Keep nails short to avoid skin excoriation
from scratching.
o Apply cool, moist compresses to pruritic
areas.
• Promote nutritional intake
• Males (estrogen) will result to: - Encourage small frequent feedings.
- Decreased libido, Impotence, Fall of body hair, Atrophy - Promote a high-calorie, low- to moderate- protein, high
of testicles, gynecomastia CHO, low-fat diet, with supplemental vitamin therapy
• Females (androgen) (vitamins A, B- complex, C, D, K, and folic acid)
- Hirsutism

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316 LECTURE: WK4 – HEPATITIS, LIVER CIRRHOSIS, ESOPHAGEAL VARICE, ETC.

Prevent infection • Assist in NGT and Sengstaken-Blakemore tube insertion

• Prevent skin breakdown by frequent turning and skin care. for balloon tamponade
• Provide reverse isolation for clients with severe
leukopenia; pay special attention to hand-washing
technique.
• Monitor WBC.
• Monitor/prevent bleeding.
• Administer diuretics as ordered
• Provide client teaching & D/C planning concerning:
• Avoidance of agents that may be hepatotoxic (sedatives,
opiates, or OTC drugs detoxified by the liver)
• How to assess for weight gain and increased abdominal
girth
• Avoidance of persons with upper respiratory infections
• Recognition and reporting of signs of recurring illness (liver
tenderness, increased jaundice, increased fatigue,
anorexia)
• Avoidance of all alcohol • Never leave the patient unattended during esophageal
• Avoidance of straining at stool, vigorous blowing of nose balloon tamponade
and coughing, to decrease the incidence of bleeding • Closely monitor the lumen pressure
o Dilated tortuous veins usually found in the • Check VS q30 minutes. Maintain drainage and suction on
submucosa of the lower esophagus; however they the suctions ports
may develop higher in the esophagus or extend into • Watch for signs of respiratory distress while the tube is in
the stomach place. If this will happen, call another nurse to notify the
o Causes: physician and quickly pinch the tube at the patient’s
- Commonly caused by PORTAL hypertension secondary nose and cut it with scissors, remove the tube
to liver cirrhosis • Deflate the esophageal balloon for about 30 minutes every
8-12 hours
• Provide frequent mouth and nose care
Surgical Management
• Endoscopic sclerotherapy
- sclerosing agent is injected directly into the varix with
a flexible fiberoptic endoscope to promote
thrombosis & sclerosis of bleeding sites
• Endoscopic Variceal ligation (variceal banding)
• Shunt procedures

Cholelithiasis
- “gallstones”
- FAT, FEMALE, FORTY, FERTILE
- More common in women after age 40 (estrogen therapy),
Assessment Findings women taking oral contraceptives, and in the obese
• Hematemesis (vomiting of bright red blood) • Cholecystitis
• Melena (passing out of black, tarry stools) - acute or chronic inflammation of the gallbladder
• Hepatomegaly • Theory of Stone formation:
• Splenomegaly Metabolic factors (obesity, pregnancy, DM,
• Jaundice hypothyroidism,stasis) MAY all lead to
• Ascites stagnation of bile in the gallbladder
• Signs of SHOCK!!! (Tachycardia, Hypotension, Tachypnea,
Cold clammy skin)
Diagnostic Evaluation
• Upper GI endoscopy to identify the cause & site of bleeding excessive absorption of water
• Serum liver function test
Nursing Interventions
• Monitor VS strictly (note: signs of shock), LOC
• Maintain NPO, Monitor blood studies
precipitation of salts (stones)
• Administer O2, Blood Transfusion, Vasopressin (Pitressin)
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316 LECTURE: WK4 – HEPATITIS, LIVER CIRRHOSIS, ESOPHAGEAL VARICE, ETC.

- Gallstones are composed primarily of cholesterol (80%), • Maintain/monitor functioning of T-tube

bile salts, Ca++, bilirubin & CHONs - Ensure that T-tube is connected to closed gravity
Assessment Findings drainage.
• Most patients are asymptomatic. - Avoid kinks, clamping, or pulling of the tube.
• When symptomatic; PAIN in RUQ and epigastric pain - Measure and record drainage every shift
lasting approximately 30 min. - Expect 300 – 500 ml bile-colored drainage for the 1st 24°
• Fever & leukocytosis (WBC) then 200 ml/24° for 3 - 4 days
• Charcot triad - Assess for signs of peritonitis
o fever - Monitor color of urine and stools (stools will be light
o jaundice colored if bile is flowing through T tube but normal color
o pain in RUQ pain (ascending cholangitis) should reappear as drainage diminishes)
• Intolerance for fatty foods (steatorrhea, N&V, sensation of - Assess skin around T-tube; cleanse frequently and keep
fullness) dry
• Pruritus, easy bruising, dark amber urine • Provide client teaching and discharge planning concerning
Diagnostic Tests - Adherence to dietary restrictions
• Direct bilirubin, transaminase, alkaline phosphatase, WBC, - Resumption of ADL
amylase, lipase: all increased o avoid heavy lifting for at least 6 weeks
• Oral cholecystogram (gallbladder series): positive for o resume sexual activity as desired unless ordered
gallstone otherwise by physician
Nursing interventions - clients having laparoscopy cholecystectomy
• Administer pain medications as ordered and monitor for usually resume normal activity within two weeks
effects. o Recognition and reporting of signs of complications
(fever, jaundice, pain, dark urine, pale stools,
• Administer IV fluids as ordered.
pruritus)
• Provide small, frequent meals of modified diet, low fat (if
oral intake allowed)
Pancreatitis
• Provide care to relieve pruritus
- An inflammatory process with varying degrees of
• Provide care for the client with a cholecystectomy or
pancreatic edema, fat necrosis, or hemorrhage
choledochostomy
- Proteolytic and lipolytic pancreatic enzymes are activated
Medical management
in the pancreas rather than in the duodenum, resulting in
• Supportive treatment: NPO with NG intubation and IV fluids tissue damage and autodigestion of the pancreas
• Diet modification with administration of fat- soluble - Occurs most often in the middle aged
vitamins - Causes:
• Drug therapy • Alcoholism/ alcohol abuse
• NSAIDS- Ketorolac • Biliary tract disease/ biliary obstruction
o Narcotic analgesics for pain • Trauma, viral infection, peptic ulcer disease, abscesses
o Morphine vs Demerol
• Drugs (anti hypertensives, steroids, thiazide diuretics,
o Anticholinergics (atropine) may be used for pain
antimicrobials, immuno suppressives, oral
o Antiemetics
contraceptives)
Surgery
• Metabolic disorders (hyperparathyroidism,
• Cholecystectomy with choledochotomy hyperlipidemia)
- removal of the gallbladder with insertion of a T-tube
• Unknown/ autoimmune
into the common bile duct if common bile duct
Assessment Findings
exploration is performed
- Pain (LUQ radiating to back, flank, or substernal area)
• Choledochotomy accompanied by DOB (shallow respiration with pain),
- Opening of common duct, removal of stone, and
aggravated by eating
insertion of a t-tube
- N&V, decreased/absent bowel sounds,
• Laparoscopic cholecystectomy - Abdominal tenderness w/ muscle-guarding
- Performed via laparoscopy for uncomplicated cases - (+) Grey Turner’s spots (ecchymoses on flanks)
when client has not had previous abdominal surgery - (+) Cullen’s sign (ecchymoses of periumbilical area)
• Cholecystostomy - Tachycardia
- Opening of the gallbladder to remove stones Diagnostic Tests
Nursing Interventions • Serum amylase (>300 somogyi units) & lipase
• Provide routine pre-op care • urinary amylase
• Provide routine post-op care • blood sugar
• Position client in semi-Fowler’s or side-lying positions; • lipid levels
reposition frequently.
• Serum calcium
• Splint incision when turning, coughing, and deep breathing
• CT scan: enlargement of the pancreas
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316 LECTURE: WK4 – HEPATITIS, LIVER CIRRHOSIS, ESOPHAGEAL VARICE, ETC.

Nursing Interventions
• Administer analgesics, antacids, and anticholinergics as
ordered, monitor effects
• Withhold food/fluid and eliminate odor and sight of food
from environment to decrease pancreatic stimulations
• Maintain NGT and assess for drainage.
• Institute Non-pharmacologic measures to decrease pain.
o Assist client to positions of comfort (knee chest, fetal
position)
o Teach relaxation techniques and provide a quiet, restful
environment.
• Provide client teaching and discharge planning
concerning
• Dietary regimen when oral intake permitted
o High CHO, high CHON, low-fat diet
o Eating small, frequent meals instead of three large
ones
o Avoiding caffeine products
o Eliminating alcohol consumption
o Maintaining relaxed atmosphere after meals
• Recognition/reporting of signs of complications
o Continued N&V
o Abdominal distension with increasing fullness
o Persistent weight loss
o Severe epigastric or back pain
o Frothy/foul-smelling bowel movements
o Irritability, confusion, persistent elevation of
temperature (2 days)
Medical Management
• Drug therapy
- Analgesics (MORPHINE) to relieve pain. NO to
DEMEROL, because of its toxic effects to the brain.
- Smooth-muscle relaxants to relieve pain
o papaverine, nitroglycerin
- Anticholinergics to decrease pancreatic stimulation
o atropine, propantheline bromide
o Antacids to decrease pancreatic stimulation
o H2-antagonists, vasodilators, calcium
gluconate
- Diet modification
- NPO usually for a few days to promote GIT rest
- Peritoneal lavage
- Dialysis if the condition is severe

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