THE METABOLISM System

• Assessment of the Endocrine and Metabolic Systems

HISTORY

• During the health history interview, help the client sequence the recalled
experiences and manifestations.

• Biographical and Demographic Data

1. client’s age,

2. gender,

3. ethnic background, and

4. geographical residence

• Cont’d..

• Current Health

1. Chief Complaint

-Ask the client to indicate when the problem began: onset, duration, intensity, and
characteristics of the problem; and any alterations in usual health status

• 2. Clinical Manifestation

-Ask the client about pain, infection/inflammation, gastrointestinal manifestations,

skin changes, perfusion problems, sensory/mental status changes, visual changes,
and urinary/reproductive changes

ANATOMY AND PHYSIOLOGY REVIEW

Metabolism

• The entire collection of chemical reactions that occur in all living cells

• Depends on the availability of fuel (glucose and fatty acids) and oxygen, and
on the balance of anabolic against catabolic processes

• Function of Chemical Reaction Process

• The basis of life

• Allowing cells to grow and reproduce

• Maintain the cellular structures and to respond to their environment

• Structure of the metabolic systems

LIVER

• The liver is located in the upper right-hand portion of the abdominal cavity,
beneath the diaphragm and on top of the stomach, right kidney, and
intestines.

• The liver, a dark reddish-brown organ that weighs about 3 pounds, has
multiple functions.

• Two distinct sources that supply blood to the liver:

• Oxygenated blood flows in from the hepatic artery.

• Nutrient-rich blood flows in from the hepatic portal vein.

• The liver represents about 20 percent of the body's blood supply at any given
moment.

• The superior and inferior mesenteric veins and the splenic vein join to
form the portal vein.

Moreover…

• The portal vein carries nutrients, metabolites, and toxins from the digestive
organs to the liver for processing, detoxification, or assimilation.

• Blood pressure in the portal system sinuses is low;

• The functional unit of the liver is the lobule, and the hepatocyteis the major
cell.

• Bile is formed in the hepatocytes

• Endothelial and Kupffer cells form the walls of the sinusoids.

Liver…

• The liver consists of two main lobes, both of which are made up of thousands
of lobules.

• These lobules are connected to small ducts that connect with larger ducts to
ultimately form the hepatic duct.

What are the functions of the liver?

• The liver regulates most chemical levels in the blood and excretes a product
called bile
 • All of the blood leaving the stomach and intestines passes through the liver.

• The liver processes this blood and breaks down the nutrients and drugs in the
blood into forms that are easier to use for the rest of the body.

• Some of the more well-known functions include the following:

• production of certain proteins for blood plasma

• production of cholesterol and special proteins to help carry fats through the
body

• conversion of excess glucose into glycogen for storage (This glycogen can
later be converted back to glucose for energy.)

• regulation of blood levels of amino acids, which form the building blocks of
proteins

• processing of hemoglobin for use of its iron content (The liver stores iron.)

• conversion of poisonous ammonia to urea (Urea is one of the end products of

protein metabolism that is excreted in the urine.)

• clearing the blood of drugs and other poisonous substances

• regulating blood clotting

• resisting infections by producing immune factors and removing bacteria from

the blood stream

Liver conditions

Hepatitis

• Inflammation of the liver, usually caused by viruses like hepatitis A, B, and C.

Hepatitis can have non-infectious causes too, including heavy drinking, drugs,
allergic reactions, or obesity.

• Cont’d…

Cirrhosis

• Long-term damage to the liver from any cause can lead to permanent
scarring, called cirrhosis. The liver then becomes unable to function well.

• Cont’d…

Liver cancer
 • The most common type of liver cancer, hepatocellular carcinoma, almost
always occurs after cirrhosis is present.

• Cont’d…

Liver failure

• Liver failure has many causes including infection, genetic diseases, and
excessive alcohol.

Ascites

• As cirrhosis results, the liver leaks fluid (ascites) into the belly, which
becomes distended and heavy.

• Cont’d…

Gallstones

• If a gallstone becomes stuck in the bile duct draining the liver, hepatitis and
bile duct infection (cholangitis) can result.

Hemochromatosis

• Allows iron to deposit in the liver, damaging it. The iron also deposits
throughout the body, causing multiple other health problems.

• Cont’d…

Primary sclerosing cholangitis

• A rare disease with unknown causes, primary sclerosingcholangitis causes

inflammation and scarring in the bile ducts in the liver.

Primary biliary cirrhosis

• In this rare disorder, an unclear process slowly destroys the bile ducts in the
liver. Permanent liver scarring (cirrhosis) eventually develops.

• Impt. Info…

• Cholangitis is the inflammation of the bile duct

• The classic triad of cholangitis is fever, jaundice, and right upper quadrant
abdominal pain. This triad is known as Charcot's cholangitis triad.

Liver Tests

Blood Tests:
• Liver function panel: A liver function panel which checks how well the liver is
working and consists of many different blood tests.

• ALT (Alanine Aminotransferase): An elevated ALT helps identify liver disease

or damage from any number of causes, including hepatitis.

• AST (Aspartate Aminotransferase): Along with an elevated ALT, the AST

checks for liver damage.

• Alkaline phosphatase: Alkaline phosphatase is present in bile-secreting cells

in the liver; it's also in bones. High levels often mean bile flow out of the liver
is blocked.

• Bilirubin: High bilirubin levels suggest a problem with the liver.

• Albumin: As part of total protein levels, albumin helps determine how well the
liver is working.

• Ammonia: Ammonia levels in the blood rise when the liver is not functioning
properly.

• Hepatitis A tests: If hepatitis A is suspected, the doctor will test liver function
as well as antibodies to detect the hepatitis A virus.

• Hepatitis B tests: Your doctor can test antibody levels to determine if you
have been infected with the hepatitis B virus.

• Hepatitis C tests: In addition to checking liver function, blood tests can

determine if you have been infected with the hepatitis C virus.

• Cont’d…

• Prothrombin Time (PT): A prothrombin time, or PT, is commonly done to see if

someone is taking the correct dose of the blood thinner warfarin (Coumadin).
It also checks for blood clotting problems.

• Partial Thromboplastin Time (PTT): A PTT is done to check for blood clotting
problems.

Imaging tests

• Ultrasound: An abdominal ultrasound can test for many liver conditions,

including cancer, cirrhosis, or problems from gallstones.

• CT scan (computed tomography): A CT scan of the abdomen gives detailed

pictures of the liver and other abdominal organs.

• Liver biopsy: A liver biopsy is most commonly done after another test, such
as a blood test or ultrasound, indicates a possible liver problem.
• Liver and spleen scan: This nuclear scan uses radioactive material to help
diagnose a number of conditions, including abscesses, tumors, and other liver
function problems.

LIVER DISODERS

Interventions for Clients with Liver Problems

LIVER

• The largest organ in the body, divided into two major regions; right
lobe(larger) and left lobe (smaller)

• Location: RUQ of the abdomen

• Blood supply: Hepatic artery(entry) and Hepatic portal vein(exit)

• Vol. of blood flow/minute: 1,500 ml

Function : Storage, protection, and metabolism

• Stores several minerals and vitamins such as the ff.;

o Copper, Fe, Mg, Vit. B2, B12, B6, Folic Acid, Fat-soluble vitamins
(ADEK)

• Protective function:

o “Kupffer cells”- phagocytic function, engulfs harmful bacterias and

anemic RBCs.

o Detoxifies potential harmful compounds(such as: drugs, chemicals, and

alcohol)

• Metabolism:

o Metabolism of proteins; breaks down amino acids to remove ammonia,

w/c is converted into urea and excreted thru urine.

o Synthesizes plasma protiens; albumin, prothrombin, and fibrinogen.

o Carbohydrate metabolism; storing and releasing of glycogen

o Fat Metabolism; Synthesizes, breaks down, and temporarily stores

fatty acids and tryglycerides.

• Forms and continually secretes BILE

ASSESSMENT
• History

• Demographic data

• Family history and genetic risk

• Personal history

• Diet history (Anorexia, dysphagia, dyspepsia)

• Socioeconomic status

• Current Health problem ( symptoms and any treatment taken)

PHYSICAL ASSESSMENT

• Check for:

o Cullen’s sign - intra abdominal bleeding

o Hepatomegaly

o Spleenomegaly

o Borborygmus – loud gurgling sound due to hypermotility of the bowel

o Abdominal Rigidity

o Blumber’s sign – rebound tenderness

o Bruits – for presence of aneurysm, especially over the aorta.

• Note; if this sound is heard, do not percuss or palpate the abdomen. Notify
the health care provider of your findings.

• PSYCHOSOCIAL ASSESSMENT

• Note for:

o Interruptions of, or disturbances to, usual activities, including

employment.

o Behavioral changes

• DIAGNOSTIC ASSESSMENT

• Blood Test:

• CBC –anemia and infection

• Prothrombin time – evaluates levels of clotting factors

• Aspartate aminotransferase (AST) 5-40units/L

• Alanine aminotransferase (ALT) 3-35IU/L or 8-20 units/L

• Serum Amylase (56-90IU/L or 25-125units/L) and Lipase (0-110 units/L)

• Con’t

• Serum Bilirubin (total: 0.1-1.0 mg/dL)

• Serum level of Ammonia (15-110 mg/dL

• Oncofetal antigens – Carbohydrate antigen 19-9 (CA19-9: <37 units/mL) and

Carcinoembryonic antigen (CEA: nonsmoker: <2.5 ng/mL, smoker: up to 5
ng/mL)

• DIAGNOSTIC ASSESSMENT

• Urine Test

o presence of amylase indicates pancreatitis

o presence of urobilinogen (a form of bilirubin that is converted by the

intestinal flora and excreted in the urine) indicates hepatic and biliary
obstruction, often precedes the development of jaundice.

• Stool Tests

o Fecal occult blood test (FOBT) measures presence of blood in the stool
indicative of bleeding

o Test for ova and parasites to aid diagnosis of parasitic infection

o Fecal fats (streatorrhea) indicative for malabsorption

• OTHER DIAGNOSTIC TESTS

• X- RAY • Ultrasound

• CT-scan • Liver-Spleen scan

• Endoscopy • Liver Biopsy

Cirrhosis

• Cirrhosis is extensive scarring of the liver, usually caused by a chronic

irreversible reaction to hepatic inflammation and necrosis.

• Complications depend on the amount of damage sustained by the liver.

• In compensated cirrhosis, liver has significant scarring but performs essential
functions without causing significant symptoms.

• Complications

o Portal hypertension

o Ascites

o Bleeding esophageal varices

o Coagulation defects

o Jaundice

o Portal-systemic encephalopathy with hepatic coma

o Hepatorenal syndrome

o Spontaneous bacterial peritonitis

Etiology

• Known causes of liver disease include:

o Alcohol

o Viral hepatitis

o Autoimmune hepatitis

o Steatohepatitis

o Drugs and toxins

o Biliary disease

o Metabolic/genetic causes

o Cardiovascular disease

o Clinical Manifestations

• In early stages, signs of liver disease include:

o Fatigue

o Significant change in weight

o Gastrointestinal symptoms
 o Abdominal pain and liver tenderness

o Pruritus

Clinical Manifestations

• In late stages, the signs vary:

o Jaundice and icterus

o Dry skin

o Rashes

o Petechiae, or ecchymoses (lesions)

o Warm, bright red palms of the hands

o Spider angiomas

o Peripheral dependent edema of the extremities and sacrum

Abdominal Assessment

o Massive ascites

o Umbilicus protrusion

o Caput medusae (dilated abdominal veins)

o Hepatomegaly (liver enlargement)

Other Physical Assessments

• Assess nasogastric drainage, vomitus, and stool for presence of blood

• Fetor hepaticus (breath odor)

• Amenorrhea

• Gynecomastia, testicular atrophy, impotence

• Bruising, petechiae, enlarged spleen

• Neurologic changes

• Asterixis

Laboratory Assessment

• Aminotransferase serum levels and lactate dehydrogenase may be elevated.

• Alkaline phosphatase levels may increase.

• Total serum bilirubin and urobilinogen levels may rise.

• Total serum protein and albumin levels decrease.

• Prothrombin time prolonged; platelet count low

• Decreased hemoglobin and hematocrit values and white blood cell count

• Elevated ammonia levels

• Serum creatinine level possibly elevated

Excess Fluid Volume

• Interventions:

o Diet therapy consists of low sodium diet, limited fluid intake, vitamin
supplements.

o Drug therapy includes a diuretic, electrolyte replacement.

o Paracentesis is the insertion of trocar catheter into the abdomen to

remove and drain ascitic fluid from the peritoneal cavity.

o Observe for possibility of impending shock.

Comfort Measures

• For dyspnea, elevate the head of the bed at least 30 degrees, or as high as
the client wishes to help minimize shortness of breath.

• Client is encouraged to sit in a chair.

• Weigh client in standing position, because supine position can aggravate

dyspnea.

Fluid and Electrolyte Management

• Interventions:

o Fluid and electrolyte imbalances are common as a result of the disease

or treatment, test for:

 Blood urea nitrogen level

 Serum protein level

 Hematocrit level
  Electrolytes

• Surgical Interventions

o Peritoneovenous shunt

o Portocaval shunt

o Transjugular intrahepatic portosystemic shunt

Potential for Hemorrhage

• Interventions include:

o Identifying the source of bleeding and initiating measures to halt it

o Massive esophageal bleeding

o Esophageal varices

o Nonsurgical management includes:

 Drug therapy: possibly nonselective beta blocker

 Gastric intubation

 Esophagogastric balloon tamponade

• Management of Hemorrhage

• Blood transfusions

• Endoscopic procedures

• Transjugular intrahepatic portal-systemic shunt

• Surgical management

• Potential for Portal-Systemic Encephalopathy

• Interventions include:

o Role of ammonia

o Reduction of ammonia levels

o Diet therapy using simple and brief guidelines

o Drug therapy:

 Lactulose
  Neomycin sulfate

 Metronidazole

Hepatitis

• Widespread viral inflammation of liver cells

• Hepatitis A

• Hepatitis B

• Hepatitis C

• Hepatitis D

• Hepatitis E

• Hepatitis F and G are uncommon

Hepatitis A

• Similar to that of a typical viral syndrome; often goes unrecognized

• Spread via the fecal-oral route by oral ingestion of fecal contaminants

• Contaminated water, shellfish from contaminated water, food contaminated

by handlers infected with hepatitis A

• Also spread by oral-anal sexual activity

• Incubation period for hepatitis A is 15 to 50 days.

• Disease is usually not life threatening.

• Disease may be more severe in individuals older than 40 years of age.

• Many people who have hepatitis A don’t know it; symptoms are similar to a
gastrointestinal illness.

Hepatitis B

• Spread is via unprotected sexual intercourse with an infected partner, sharing

needles, accidental needle sticks, blood transfusions, hemodialysis, maternal-
fetal route.

• Symptoms occur in 25 to 180 days after exposure; symptoms include

anorexia, nausea and vomiting, fever, fatigue, right upper quadrant pain,
dark urine, light stool, joint pain, and jaundice.

• Hepatitis carriers can infect others, even if they are without symptoms.
Hepatitis C

• Spread is by sharing needles, blood, blood products, or organ transplants

(prior to 1992), needle stick injury, tattoos, intranasal cocaine use.

• Incubation period is 21 to 140 days.

• Most individuals are asymptomatic; damage occurs over decades.

• Hepatitis C is the leading indication for liver transplantation in the U.S.

Hepatitis D

• Transmitted primarily by parenteral routes

• Incubation period 14 to 56 days

Hepatitis E

• Present in endemic areas where waterborne epidemics occur and in travelers

to those areas

• Transmitted via fecal-oral route

• Resembles hepatitis A

• Incubation period 15 to 64 days

• Clinical Manifestations

o Abdominal pain

o Changes in skin or eye color

o Arthralgia (joint pain)

o Myalgia (muscle pain)

o Diarrhea/constipation

o Fever

o Lethargy

o Malaise

o Nausea/vomiting

o Pruritus

• Nonsurgical Management
 o Physical rest

o Psychological rest

o Diet therapy

• Drug therapy includes:

o Antiemetics

o Antiviral medications

o Immunomodulators

Fatty Liver (Steatohepatitis)

• Fatty liver is caused by the accumulation of fats in and around the hepatic
cells.

• Causes include:

o Diabetes mellitus

o Obesity

o Elevated lipid profile

• Many clients are asymptomatic.

Hepatic Abscess

• Liver invaded by bacteria or protozoa causing abscess

• Pyrogenic liver abscess; amebic hepatic abscess

• Treatment usually involves:

o Drainage with ultrasound guidance

o Antibiotic therapy

Liver Trauma

• The liver is the most common organ injured in clients with penetrating
trauma of the abdomen, such as gunshot wounds and stab wounds.

• Clinical manifestations include abdominal tenderness, distention, guarding,

rigidity.

• Treatment involves surgery, multiple blood products.

Cancer of the Liver

• One of the most common tumors in the world

• Most common complaint: abdominal discomfort

• Treatment includes:

o Chemotherapy

o Surgery

Liver Transplantation

• Used in the treatment of end-stage liver disease, primary malignant

neoplasm of the liver

• Donor livers obtained primarily from trauma victims who have not had liver
damage

• Donor liver transported to the surgery center in a cooled saline solution that
preserves the organ for up to 8 hours

• Complications

o Acute, chronic graft o Fluid and electrolyte

rejection imbalances

o Infection o Pulmonary atelectasis

o Hemorrhage o Acute renal failure

o Hepatic artery o Psychological

thrombosis maladjustment