Liver Disease

Medical-Surgical Nursing

Jonathan Q. Ibalio, MD
Study Outcomes:
➢Understand the meaning, causes and manifestations of liver
disease.
➢Discuss the different causes of viral Hepatitis:
▪ Causative agent
▪ Mode of transmission
▪ Manifestation
▪ Complications
▪ Prevention and management
▪ Prognosis
▪ Diagnosis and Tests
The liver
❖ the largest solid organ in the body
❖ Bile production and excretion

❖ Excretion of bilirubin, cholesterol, hormones, and

drugs
❖ Metabolism of fats, proteins, and carbohydrates

❖ Enzyme activation

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The liver
❖ Storage of glycogen, vitamins, and minerals
❖ Synthesis of plasma proteins, such as albumin, and

clotting factors
❖ Blood detoxification and purification

❖ A liver can regrow to a normal size even after up to

90% of it has been removed

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What is liver disease?
• referring to chronic conditions that do progressive
damage to the liver over time:
• viral infections
• toxic poisoning
• metabolic conditions
What are the stages of chronic liver
disease?
I. Hepatitis.
II. Fibrosis.
III. Cirrhosis.
IV. Liver failure.
Stage 1: Hepatitis
➢Inflammation is your liver’s response to injury or toxicity.
➢It’s an attempt to purge infections and start the healing
process. Acute hepatitis (an immediate and temporary
response) often accomplishes this.
➢But when the injury or toxicity continues, so does the
inflammation. Chronic hepatitis causes hyperactive
healing that eventually results in scarring (fibrosis).
Stage 2: Fibrosis
➢Fibrosis is a gradual stiffening of your liver as thin bands
of scar tissue gradually add up.
➢Scar tissue reduces blood flow through the liver, which
reduces its access to oxygen and nutrients.
➢Thie liver’s vitality begins to gradually decline.
➢Some amount of fibrosis is reversible; liver cells can
regenerate, and scarring can diminish if the damage slows
down enough for it to recover.
Stage 3: Cirrhosis
➢Cirrhosis is severe, permanent scarring in ther liver.
➢This is the stage where fibrosis is no longer reversible.
➢The liver no longer has enough healthy cells left to work
with, its tissues can no longer regenerate.
➢May still slow or stop the damage at this stage.
➢Cirrhosis will begin to affect the liver function, but the
body will attempt to compensate for the loss, so patients
might not notice at first.
Stage 4: Liver failure
➢Liver failure begins when the liver can no longer function
adequately for the body’s needs.
➢This is also called “decompensated cirrhosis” — the
body can no longer compensate for the losses.
➢As liver functions begin to break down, patients begin to
feel the effects throughout the body.
➢Chronic liver failure is a gradual process, but it is
eventually fatal without a liver transplant.
Symptoms and Causes
➢Chronic liver disease often won’t cause symptoms in the
early stages.
➢Sometimes it begins with an episode of acute hepatitis.
➢You might have a fever, stomachache or nausea for a brief
period while your immune system works to defeat the
infection.
➢If it doesn’t defeat it, it becomes a chronic infection.
➢Some other causes of liver disease might also begin with
more acute symptoms or have occasional episodes of acute
symptoms.
Symptoms and Causes
➢Early symptoms of liver disease tend to be vague. They
might include:
❑Upper abdominal pain.
❑Nausea or loss of appetite.
❑Fatigue and malaise (feeling generally tired and ill).
Symptoms and Causes
➢Symptoms when your liver function begins to
decline. This happens in the later stages of liver
disease.
➢One of the first side effects of declining liver
function is that bile flow stalls in your biliary tract.
➢The liver no longer produces or delivers bile
effectively to the small intestine.
Symptoms and Causes
➢Bile begins to leak into the bloodstream. This causes
specific symptoms, including:
✓Jaundice (yellow tint to the whites of the eyes and skin).
✓Dark-colored urine.
✓Light-colored stool.
✓Digestive difficulties, especially with fats.
✓Weight loss and muscle loss.
✓Musty-smelling breath.
✓Hepatic encephalopathy.
✓Pruritus (itchy skin, but with no visible rash).
What are the complications of end-stage
liver disease?
➢End-stage liver disease refers to decompensated
cirrhosis and liver failure, when the liver has lost the
ability to regenerate and is slowly declining.
➢The most significant side effects of end-stage liver
disease are:
• portal hypertension
• primary liver cancer (hepatocellular carcinoma).
• Complications of these two conditions are the leading
causes of hospitalization and death in people with
cirrhosis and liver failure.
Portal hypertension
➢Portal hypertension happens when scarring in the liver
compresses the portal vein that runs through it.
➢High blood pressure in the portal vein causes the body to
divert blood flow to other veins connected with it, which
become enlarged and stretched thin.
➢These veins can leak, break and bleed.
➢Internal bleeding from these varices can be sudden,
severe and life-threatening.
Viral Hepatitis
Hepatitis A
❖ It spreads from person to person through intimate contact,
injected drugs, and shared food and drinks.
❖ Most people get it by eating or drinking something that’s
tainted by fecal matter.
❖ It can spread easily in overcrowded areas or in unsanitary
conditions; after floods or other natural disasters, where you
can be exposed to sewage.
❖ You might not have any symptoms.

❖ It usually goes away by itself within 6 months without any

long-term harm.

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Hepatitis A
❖ Hepatitis A is an acute or short-term infection, which means
people usually get better without treatment after a few
weeks.
❖ In rare cases, hepatitis A can be severe and lead to liver

failure and the need for an emergency liver transplant to

survive.
❖ Hepatitis A does not lead to long-term complications, such

as cirrhosis, because the infection only lasts a short time.

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How common is hepatitis A?
o After the hepatitis A vaccine became available in
1995, the rate of hepatitis A infections declined by 95
percent
o Hepatitis A is more common in developing countries

where sanitation is poor and access to clean water is

limited.
o Hepatitis A is more common in parts of Africa, Asia,

Central and South America, and Eastern Europe

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Who is more likely to get hepatitis A?
o developing countries
o have sex with an infected person

o men who have sex with men

o use illegal drugs, including drugs that are not injected

o experience unstable housing or homelessness

o live with or care for someone who has hepatitis A

o live with or care for a child recently adopted from a country

where hepatitis A is common

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What are the complications of hepatitis A?
➢ People typically recover from hepatitis A without
complications.
➢ Liver failure due to hepatitis A is more common in adults

older than age 50 and in people who have another liver

disease.

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What are the symptoms of hepatitis A?
➢ Some people have symptoms 2 to 7 weeks after they come in contact with the
virus.
➢ People with hepatitis A typically get better without treatment after a few weeks.
➢ In some cases, symptoms can last up to 6 months.
➢ These symptoms may include
➢ dark yellow urine
➢ diarrhea
➢ feeling tired
➢ fever
➢ gray- or clay-colored stools
➢ joint pain
➢ loss of appetite
➢ nausea
➢ pain in the abdomen
➢ vomiting
➢ yellowish eyes and skin, called jaundice
➢ Some people infected with hepatitis A have no symptoms, including many
children younger than age 6.

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What causes hepatitis A?
➢ The hepatitis A virus causes this type of hepatitis and spreads
through contact with an infected person’s stool.
➢ Contact can occur by:
➢ eating food made by an infected person who did not wash his or her hands after
using the bathroom
➢ drinking untreated water or eating food washed in untreated water
➢ placing a finger or an object in your mouth that came into contact with an infected
person’s stool
➢ having close personal contact with an infected person, such as through sex or
caring for someone who is ill
➢ You cannot get hepatitis A from
➢ being coughed on or sneezed on by an infected person
➢ sitting next to an infected person
➢ hugging an infected person
➢ A baby cannot get hepatitis A from breast milk.

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How to diagnose hepatitis A?

➢ based on symptoms and a blood test.

➢ A blood test will detect antibodies to the hepatitis A virus

called immunoglobulin M (IgM) antibodies

➢ If the blood test finds antibodies to the hepatitis A virus

that are not IgM antibodies, then you are immune to

hepatitis A, due to either past hepatitis A infection or
hepatitis A vaccination.

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How to treat hepatitis A?
➢ Treatment includes:
▪ Resting
▪ drinking plenty of liquids
▪ eating healthy foods.
➢ Medicines to help relieve symptoms.

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How to protect against hepatitis A infection?
➢ You can be protected f from hepatitis A by getting the hepatitis
A vaccine.
➢ If you have had hepatitis A in the past, you cannot get
hepatitis A again. You can still get other types of viral hepatitis
though.
➢ All children should receive the hepatitis A vaccine between 12
and 23 months of age. People who are more likely to be
infected and people with chronic liver disease should also
receive the vaccine.
➢ Doctors give the hepatitis A vaccine in two shots; should get
the second shot 6 to 12 months after the first shot; need to get
both shots to be fully protected against the virus.

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How to protect against hepatitis A infection?
➢ Reduce chance of getting hepatitis A by washing hands
thoroughly with soap and warm water for 15 to 30 seconds
➢ after using the toilet
➢ after changing diapers
➢ before and after handling or preparing food
➢ When in a developing country, drink bottled water.
➢ If you live with, have had sex with, or have had close contact
with someone who has hepatitis A, you shared illegal drugs
with someone who had hepatitis A, you ate food or drank
water possibly containing the hepatitis A virus
➢ A dose of the hepatitis A vaccine or a medicine called hepatitis
A immune globulin should be given shortly after coming into
contact with the virus to prevent infection

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How to prevent spreading hepatitis A to others?

➢ Reduce spreading the infection by washing hands with

warm, soapy water after using the toilet and before fixing
or eating food.
➢ While sick, avoid close contact with others, and don’t

prepare food or serve food to others.

➢ Tell your doctor, dentist, and other health care

professionals that you have hepatitis A.

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How to prevent spreading hepatitis A to others?
➢ Talk with a blood donation center before donating blood.
➢ If patient had hepatitis A when younger than 11, may be

able to donate blood.

➢ If patient had hepatitis A when at age 11 or older, should

not donate blood.

➢ Patient is most contagious—able to spread the virus to

others—during the 2 weeks before having the

symptoms; contagious for up to 3 weeks after developing
symptoms.
➢ Children are often contagious longer than adults.

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Hepatitis B
• You get hepatitis B from somebody else, such as through
unprotected sex or taking drugs with shared needles.
• If it lasts longer than 6 months, it makes you more likely to
get liver cancer or other diseases.
• If you have hepatitis B, you can pass it to your baby at
birth.
Hepatitis B
• Hepatitis B is a viral infection that causes liver
inflammation and damage.
• Viruses invade normal cells in your body. Many viruses
cause infections that can spread from person to person.
• The hepatitis B virus spreads through contact with an
infected person’s blood, semen, or other body fluids.
• The hepatitis B virus can cause an acute or chronic
infection.
Hepatitis B
• Acute hepatitis B
❖Acute hepatitis B is a short-term infection. Some people have
symptoms, which may last several weeks.
❖In some cases, symptoms last up to 6 months.
❖Sometimes the body is able to fight off the infection and the
virus goes away.
❖If the body isn’t able to fight off the virus, the virus does not go
away, and chronic hepatitis B infection occurs.
Hepatitis B
• Acute hepatitis B
❖Most healthy adults and children older than 5 years who have
hepatitis B get better and do not develop a chronic hepatitis B
infection.
Hepatitis B
• Chronic hepatitis B
❖Chronic hepatitis B is a long-lasting infection.
❖Your chance of developing chronic hepatitis B is greater if you
were infected with the virus as a young child.
❖About 90 percent of infants infected with hepatitis B develop a
chronic infection.
❖About 25 to 50 percent of children infected between the ages of
1 and 5 years develop chronic infections.
❖However, only about 5 percent of people first infected as adults develop chronic
hepatitis B.6
How common is hepatitis B?
➢2 percent or more of the population is infected in areas
such as Africa, Asia, and parts of the Middle East,
Eastern Europe, and South America
➢Hepatitis B infection has been especially common in
some parts of the world, such as sub-Saharan Africa and
parts of Asia, where 8 percent or more of the population
was infected.
➢The hepatitis B vaccine has been available since the
1980s
➢The annual rate of acute hepatitis B infections went
down 88.5 percent between 1982 and 2015.
➢In 2017, the annual number of hepatitis B infections rose
in some states.
➢Experts think the rise was related to increases in
injection drug use. Injection drug use increases the risk
of hepatitis B infection.
Who is more likely to get hepatitis B?
• People are more likely to get hepatitis B if they are born to a
mother who has hepatitis B. The virus can spread from mother to
child during birth.
• People are more likely to have hepatitis B if they
✓were born in a part of the world where 2 percent or more of the population
has hepatitis B infection
✓didn’t receive the hepatitis B vaccine as an infant, and have parents who
were born in an area where 8 percent or more of the population had
hepatitis B infection
✓are infected with HIV, because hepatitis B and HIV spread in similar ways
What are the complications of hepatitis B?
• Hepatitis B may lead to serious complications.
• Acute hepatitis B complications
• Can lead to acute liver failure, a condition in which the liver fails suddenly.
People with acute liver failure may require a liver transplant.
• Chronic hepatitis B can lead to
• cirrhosis, a condition in which scar tissue replaces healthy liver tissue
and prevents your liver from working normally. Scar tissue also partly
blocks the flow of blood through the liver. As cirrhosis gets worse, the liver
begins to fail.
• liver failure, in which the liver is badly damaged and stops working. Liver
failure is also called end-stage liver disease. People with liver failure may
require a liver transplant.
What are the complications of hepatitis B?
• Chronic hepatitis B can lead to
• liver cancer; blood tests and an ultrasound or another type of imaging test
to check for liver cancer. Finding cancer at an early stage improves the
chance of curing the cancer.
• In people who have ever had hepatitis B, the virus may become active
again, or reactivated, later in life. When hepatitis B is reactivated, it may
start to damage the liver and cause symptoms. Reactivated hepatitis B
can lead to acute liver failure.
What are the complications of hepatitis B?
• People at risk for reactivated hepatitis B include those
who
• take medicines that reduce the activity of the immune system
• chemotherapy to treat cancer
• medicines prescribed to treat conditions that involve the
immune system, such as inflammatory bowel disease,
rheumatoid arthritis, and psoriasis
• medicines prescribed for people receiving an organ transplantk
or bone marrow transplant
• corticosteroids, if taken for more than a few weeks
• take hepatitis C medicines
• have HIV infection
What are the symptoms of hepatitis B?
• Many people infected with hepatitis B have no symptoms.
• Some people with acute hepatitis B have symptoms 2 to 5
months after they come in contact with the virus.
• These symptoms may include
✓dark yellow urine
✓feeling tired
✓fever
✓gray- or clay-colored stools
✓joint pain
✓loss of appetite
✓nausea
✓pain in the abdomen
✓vomiting
✓yellowish eyes and skin, called jaundice
What are the symptoms of hepatitis B?
• If you have chronic hepatitis B, you may not have
symptoms until complications develop, which could be
decades after you were infected.
• For this reason, hepatitis B screening is important, even if
you have no symptoms.
What causes hepatitis B?
• The hepatitis B virus causes hepatitis B.
• The hepatitis B virus spreads through contact with an infected
person’s blood, semen, or other body fluids.
• Contact can occur by
• being born to a mother with hepatitis B
• having unprotected sex with an infected person
• sharing drug needles or other drug materials with an infected person
• getting an accidental stick with a needle that was used on an infected person
• being tattooed or pierced with tools that were used on an infected person and
weren’t properly sterilized, or cleaned in a way that destroys all viruses and
other microbes
• having contact with the blood or open sores of an infected person
• using an infected person’s razor, toothbrush, or nail clippers
What causes hepatitis B?
• You can’t get hepatitis B from
• being coughed on or sneezed on by an infected person
• drinking unclean water or untreated water that has not been boiled
• eating food that is unclean or has not been properly cooked
• hugging an infected person
• shaking hands or holding hands with an infected person
• sharing spoons, forks, and other eating utensils
• sitting next to an infected person
• Mothers who have hepatitis B can safely breastfeed their babies.
• If a baby receives hepatitis B immune globulin (HBIG) and starts
receiving the hepatitis B vaccine to prevent hepatitis B infection
shortly after birth, hepatitis B is unlikely to spread from mother to
child through breastfeeding
How to diagnose hepatitis B?
• Based on medical and family history, a physical exam,
and blood tests.
• Medical and family history
• ask about your and about factors that may make an individual
more likely to get hepatitis B.
• may ask whether you have a family history of hepatitis B or liver
cancer.
• ask about other factors that could damage your liver, such as
dri nking alcohol
How to diagnose hepatitis B?
• Physical exam
• Will check for signs of liver damage such as
• changes in skin color
• swelling in your lower legs, feet, or ankles
• tenderness or swelling in theabdomen
What tests do doctors use to diagnose
hepatitis B?
• Use blood tests to diagnose hepatitis B.
• Certain blood tests can show whether you are infected
with hepatitis B.
• whether the infection is acute or chronic
• whether you have an increased chance of liver damage
• whether the virus levels in your body are high or low
• whether you need treatment
• if the infection is not damaging the liver when you are first
diagnosed, it may damage the liver in the future.
How to treat hepatitis B?
• Typically don’t treat hepatitis B unless it becomes
chronic.
• Doctors may treat chronic hepatitis B with antiviral
medicines that attack the virus.
• If blood tests show that hepatitis B could be
damaging a person’s liver, may prescribe antiviral
medicines to lower the chances of liver damage
and complications.
How to treat hepatitis B?
• Medicines takeb by mouth include
• entecavir (Baraclude)
• tenofovir alafenamide (Vemlidy)
• tenofovir disoproxil fumarate (Viread)
• Medicine that is given as a shot is peginterferon
alfa-2a (Pegasys).
• The length of treatment varies. Ask about the side
effects of treatment before taking any other
prescription or over-the-counter medicines.
How to protect from hepatitis B infection?
• By getting the hepatitis B vaccine.
• The hepatitis B vaccine has been available since the
1980s and should be given to newborns, children, and
teens.
• Adults who are more likely to be infected with hepatitis
B or who have chronic liver disease should also get the
vaccine.
• The hepatitis B vaccine is safe for pregnant women.
• Most often given in three shots over 6 months. You must
get all three shots to be fully protected
How to protect from hepatitis B infection?
• Reduce your chance of hepatitis B infection by
• not sharing drug needles or other drug materials
• wearing gloves if you have to touch another person’s blood
or open sores
• making sure your tattoo artist or body piercer uses sterile
tools
• not sharing personal items, such as toothbrushes, razors, or
nail clippers
• using a latex or polyurethane condom during sex
• a medicine called hepatitis B immune globulin (HBIG) to
help prevent infection. You must get the vaccine dose and, if
needed, HBIG shortly after coming into contact with the
virus, preferably within 24 hours.
Hepatitis C
• Hepatitis C is a viral infection that causes liver inflammation
and damage
• Viruses invade normal cells in the body. Many viruses cause
infections that can be spread from person to person. The
hepatitis C virus spreads through contact with an infected
person’s blood.
• No vaccine for hepatitis C
• Hepatitis C can cause an acute or chronic infection.
Hepatitis C
• Acute hepatitis C
– a short-term infection. Symptoms can last up to 6 months.
Sometimes the body is able to fight off the infection and the virus
goes away.
• Chronic hepatitis C
– Chronic hepatitis C is a long-lasting infection; occurs when the body
isn’t able to fight off the virus.
– About 75 to 85 percent of people with acute hepatitis C will develop
chronic hepatitis C.13
 Who should be screened for hepatitis C?

• one-time screening of all adults ages 18 to 79 for hepatitis C

in people who have no symptoms.

• Screening tests can help diagnose and treat hepatitis C

before it causes serious health problems.

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 Who is more likely to get hepatitis C?
• People more likely to get hepatitis C are those who
– have injected drugs
– had a blood transfusion or organ transplant before July 1992
– have hemophilia and received clotting factor before 1987
– have been on kidney dialysis
– have been in contact with blood or infected needles at work
– have had tattoos or body piercings
– have worked or lived in a prison
– were born to a mother with hepatitis C
– are infected with HIV
– have had more than one sex partner in the last 6 months or have a
history of sexually transmitted disease

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 What are the symptoms of hepatitis C?
• These symptoms may include
– dark yellow urine
– feeling tired
– fever
– gray- or clay-colored stools
– joint pain
– loss of appetite
– nausea
– pain in your abdomen
– vomiting
– yellowish eyes and skin, called jaundice
– chronic hepatitis C most likely will have no symptoms until complications
develop, which could be decades after infection. For this reason, hepatitis C
screening is important, even if there is no symptoms.

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What causes hepatitis C?
• The hepatitis C virus causes hepatitis C. The hepatitis C
virus spreads through contact with an infected person’s
blood.

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How to diagnose hepatitis C?
• ask about symptoms and history of blood transfusions or
injected drug use.
• examine the body to check for signs of liver damage
– changes in skin color
– swelling in lower legs, feet, or ankles
– tenderness or swelling in abdomen

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How to diagnose hepatitis C?
• Blood tests for hepatitis C :
a. Screening test for antibodies to the hepatitis C virus. A positive
antibody test means you were exposed to the hepatitis C virus at
some point.
b. Hepatitis C RNA test. If your antibody test is positive, a hepatitis C
RNA test to detect RNA—a type of genetic material—from the
hepatitis C virus. The test can show whether you still have the
hepatitis C virus and how much virus is in your blood.
c. Genotype test. test to find out what strain, or form, of hepatitis C virus
you have. At least six specific strains—called genotypes—of hepatitis
C exist.
➢ Genotype 1 is the most common hepatitis C

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How to diagnose hepatitis C?
d. transient elastography, a special ultrasound of liver
e. liver biopsy, in which needle used to take a small piece of
tissue from the liver
➢ provide enough information about a person’s liver damage or
disease

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How to treat hepatitis C?
▪ Several newer medicines, called direct-acting antiviral medicines, have been approved
to treat hepatitis C since 2013.
▪ these medicines can cure chronic hepatitis C in most people with this disease. These
medicines can also cure acute hepatitis C.
▪ daclatasvir (Daklinza)
▪ elbasvir/grazoprevir (Zepatier)
▪ glecaprevir and pibrentasvir (Mavyret)
▪ ledipasvir/sofosbuvir (Harvoni)
▪ ombitasvir/paritaprevir/ritonavir (Technivie)
▪ ombitasvir/paritaprevir/ritonavir/dasabuvir (Viekira Pak, Viekira XR)
▪ simeprevir (Olysio)
▪ sofosbuvir (Sovaldi)
▪ sofosbuvir/velpatasvir (Epclusa)
▪ sofosbuvir/velpatasvir/voxilaprevir (Vosevi)
▪ Newer medicines are sometimes used along with these older hepatitis C medicines:

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How to treat hepatitis C?
▪ Newer medicines are sometimes used along with these
older hepatitis C medicines:
▪ ribavirine
▪ peginterferon alfa-2a (Pegasys) or peginterferon alfa-2b (PEG-
Intron)
▪ Need to take medicines for 8 to 24 weeks to cure hepatitis
C.

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Is a hepatitis C vaccine available?
▪ Researchers are still working on a vaccine for hepatitis C.
▪ vaccines for hepatitis A and hepatitis B. These vaccines can
protect from hepatitis A and hepatitis B infections, which
could further damage the liver.

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Hepatitis D
• Hepatitis D is a viral infection that causes liver inflammation and
damage.
• The hepatitis D virus is unusual because it can only infect you
when you also have a hepatitis B virus infection; hepatitis D is a
double infection.
• protect from hepatitis D by protecting from hepatitis B by getting
the hepatitis B vaccine.
• Hepatitis D spreads the same way that hepatitis B spreads,
through contact with an infected person’s blood or other body
fluids.
• Superinfection VS Coinfection
How to diagnose hepatitis D?
• blood tests to diagnose hepatitis D.
Hepatitis E
• are spread by drinking contaminated water; more common in
developing countries, including parts of Africa, Asia, Central
America, and the Middle East.
• Also spread by eating undercooked pork or wild game
• common in developing countries are likely to cause severe
infections, especially in pregnant women.
• Acute liver failure due to hepatitis E is more common in
– pregnant women
– people who have other liver diseases
– stillbirth, premature birth, or low birthweight
Hepatitis E
• Research suggests that hepatitis E can also spread through
blood transfusion but this is very rare.
• Treatment for acute hepatitis E includes resting, drinking plenty
of liquids, and eating healthy foods
• may treat chronic hepatitis E with ribavirin or peginterferon alfa-
2a (Pegasys).
• No vaccine for hepatitis E is available

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Thank you…