Hepatology 101: What are the Different Liver Labs?

There’s a recycling company inside the body that manufactures three important elements that keep the body going – albumin, bile, and coagulation factors – or what we call the ABCs. Keep this acronym in mind because it will be useful when remembering the different components that the liver produces that will be discussed due to their importance in determining diagnostic results.

Albumin

The first on our ABC acronym is albumin. Albumin is mainly responsible for the following:

  • Drawing fluid into the intravascular spaces
  • Binding heavily with calcium

If clients have liver disease or any condition that involves the liver, expect that their albumin to be lower than the normal level which is 3.5 to 5.0. And since albumin is directly correlated with calcium levels, albumin will determine whether calcium will go up or down either. Normal calcium count is 9.0 to 10.5.

On the other hand, calcium has a teeter-totter effect with phosphorus; when calcium goes up, phosphorus goes down. Therefore, if albumin is low, you can expect phosphorus to be high.

Bile

The second letter in the ABC acronym is bile. Bile is primarily responsible for transporting bilirubin and excess cholesterol in the body. Insufficient bile or the absence of it will increase bilirubin, which will cause jaundice or the yellowing of the skin.

Jaundice in Newborns

What happens to newborns that have yellowish skin? Bilirubin is the breakdown of hemoglobin or the red blood cells. When newborns are birthed, there will be an exchange from the placenta to the umbilical cord, and the body of the baby will try its best to get rid of excess red blood cells from the mother. Thus, jaundice occurs. Because of this situation, they are placed under bilirubin lights to ensure that the body excretes bilirubin efficiently.

Jaundice in Diseased Livers

On the other hand, jaundice with adult clients who are suffering from liver disease is because of the poor transportation of bile. Once bile is compromised, there will be no mode of transportation for bilirubin and cholesterol; therefore, bilirubin and cholesterol will skyrocket.

Total cholesterol which is supposedly below 200 is going to increase dramatically, reaching up to 500. Low-density lipoproteins (LDLs) which are supposed to be less than 100 will become high, too. Even the high-density lipoproteins (HDLs) or the good cholesterols that are supposedly less than 40 will escalate.

Coagulation Panel

Last on the ABC acronym is the coagulation panel, which is in charge of blood clotting. Without these coagulation factors, everything that makes the blood clot – fibrin and fibrinogen – will no longer be produced. What are the different determinants of the coagulation factors and their normal values?

  1. Partial thrombin (PT) or prothrombin time – 12 to 15
  2. Partial thromboplastin time (PTT) – 30 to 60
  3. International normalized ratio (INR) – 0.9 to 1.2

If there is a liver malfunction, all the standard values provided above will go up drastically. But it is important to note that these numbers may differ from one hospital policy to another; therefore, it is best to get acquainted with the normal values of your institution. The PTT panels usually vary, but the INR stays the same.

Keep in mind that if the factors that are mainly responsible for clotting are decreased, clotting or coagulation time will take a while or completely stop. Therefore, the coagulation panel will exhibit elevated values because it indicates that clotting time is taking some time or is not happening at all.

AST and ALT

So, aside from the ABCs, other liver labs are done, and these are the AST and ALT tests. The alanine aminotransferase (ALT) is very specific for the liver that is an indicator of functionality. On the other hand, the aspartate aminotransferase (AST) is broader because it does not only consider the liver but also takes into account the status of the body. We’ll be discussing these two elements further in our other lectures.

You can also check that out our other nursing-related topics at Simple Nursing’s website and YouTube channel.

Hepatology Review: What is Hepatic Encephalopathy?

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Continuing from a series of lectures on the liver, we have indicated the importance of remembering the PDSM Recycling Company. This recycling company is the liver and PDSM suggests the liver’s primary functions – Produce, Detox, Storage, and Metabolize.

When it comes to hepatic encephalopathy, the liver’s metabolic properties are compromised.

Focusing on Metabolism

What does metabolism have to do with hepatic encephalopathy? The liver metabolizes ammonia into urea. Ammonium, on the other hand, is the waste product of protein. In our previous lectures, we have discussed that ammonium can be considered as the wrapper of a protein bar.

The Wrapper

Normally, if there’s waste inside the body, it will be filtered by the liver and is metabolized into something that can be excreted. This is what happens with ammonia.

Ammonia goes into the liver to be metabolized as urea and is then excreted through the kidneys and into the potty. So, what happens if the liver is broken due to scarring or other injuries? Aside from the other functions being compromised, metabolism cannot happen. Therefore, converting ammonia into urea will be difficult for the liver.

The ammonia (wrapper) will now stay inside the bloodstream and will travel around the body and affect the vital organs like the brain. The wrapper is now wreaking havoc inside the body, and one of the primary manifestations that ammonia has reached the brain is altered level of consciousness (LOC).

Decreasing Ammonia

As a medical professional, what are the things that you can do to make sure that protein is no longer broken down to prevent wrappers circulating in the bloodstream?

What are the ways to combat ammonia?

  1. Protein must be withheld.

This is to prevent the small intestine from breaking down protein and causing the release of more ammonia going into the compromised liver. Advising the client to have a low protein diet is also a must.

  1. Give lactulose.

Lactulose acts like a small garbage bin that scoops up ammonia from the blood and into the potty. Therefore, if you give your client lactulose, expect that they will have severe diarrhea. Make sure that the restroom or commode is accessible to your client.

  1. Give neomycin.

Neomycin is a type of antibiotic that kills all of the bacteria in the gut that causes the breaking down of the protein. One thing you have to take note of is that neomycin will kill off not only the bad but also the good bacteria in the stomach. It’s like having a SWAT team go inside a bank, killing off not just the hostage-takers but the bank tellers, managers, and clients as well.

For this reason, neomycin is given on a short-term basis just to decrease the presence of ammonia inside the body.

Nursing Considerations

When taking care of clients with hepatic encephalopathy, there are a couple of nursing considerations that must be made.

  1. Safety.

Since the client has altered level of consciousness, medical professionals must make sure that the client’s safety is the main priority. Therefore, padding the side rails of the bed is necessary. Restraining the client is no longer allowed which is why it is essential to ask the family members to sit with the client or have a CNA to sit at the bedside and watch over the client to promote safety and prevent any liabilities.

  1. Give drugs like lactulose and neomycin.
  2. Promote low protein diet, usually depending on the doctor’s order and the severity of the ammonia level.
  3. Maintain skin integrity.

The liver produces albumin, bile, and coagulation factors. If a client that is at risk for bleeding, due to the absence of coagulation factors, is on bed rest for the entirety of your shift, he or she is also at risk for the following:

  • Bedsores
  • Open wounds
  • Bleeding
  • Bruises
  • Pruritus – happens due to the increased amount of ammonia that causes skin inflammation leading to irritation.

When dealing with skin integrity, you have to do the following:

  • Cool compress
  • Anti-itch lotion

Summary

One of the main considerations with clients who have hepatic encephalopathy is their safety due to altered LOC. Always include drugs like lactulose and neomycin. Low protein diet must be emphasized. Finally, you have to watch out for skin irritation like pruritus and bleeding.

For other nursing topics, drop by SimpleNursing.com.

Hepatology Review: Portal Hypertension & Ascites

Part three of our liver lecture will focus on portal hypertension and mainly, ascites.

What is Ascites?

Ascites is what we refer to as “third spacing.”  When clients come into the hospital with massive abdomens, it is most likely because of fluid accumulation within the abdominal cavity. But why is there increased fluid inside the abdomen?

Portal Hypertension

Ascites relates back to the scarring of the liver that has caused blockage with portal hypertension; that is if the diagnosed portal hypertension is greater than 10mm/Hg. To measure portal hypertension, doctors would send a small tube down the throat, into the stomach, through the duodenum, and up the portal vein to measure the amount of pressure stressing on the portal vein which caused portal hypertension.

Albumin

So, there’s increased pressure being pushed on the vein and also a decrease in albumin. Albumin levels are usually 3.5 – 5.0; same with potassium. Albumin functions as a water magnet because it attracts water. Albumin also transports drugs and binds heavily with calcium.

The absence of albumin production in the liver will cause calcium levels inside the body to deteriorate, drug transportation within the system will be compromised, and most importantly, water will escape from the vascular spaces because there is are no magnets to pull it inside.

If this happens, there will be increased capillary pressure due to the scarring that is caused by inefficient water absorption into the veins. Thus, water escapes into the third spaces, abdominal cavities, and connective tissues. For this reason, your client will present a huge abdomen.

Medical Management

When your client has ascites, doctors will result in paracentesis. Paracentesis is done by sticking a needle inside the peritoneal cavity and draining the fluid out. Once the needle is inside the abdominal cavity, fluid will be drained into containers. Albumin will then be administered to increase the colloid pressure inside the veins which will cause water to be attracted back into the vascular spaces for “re-vascularization.”

Albumin Side Effects

After giving albumin, there will be significant changes that will happen to your client’s condition.

The client’s blood pressure is going to skyrocket. Because the water magnet has been increased and activated to bring all the fluid back into the veins from the abdominal cavity, the veins are going to swell. Pulses will be strong and bounding. Headaches will also occur because of the increased pressure.

Countering Side Effects

To counter the side effects of giving albumin, excess water must be taken out of the equation. The goal is to get the water or the extra fluid out of the body by administering diuretics.

Diuretics decrease the amount of blood volume. With albumin, water from the third spaces is pulled into the vascular areas resulting in increased dilution but decreased electrolytes; it’s like having so much water but not enough sugar.

So, diuretics like Lasix and hydrochlorothiazide are given to cut down the water supply and make sure that the blood mix is equal. Lasix (furosemide) is the drug of choice due to its ability to push intravenously inside the body.

A Quick Summary

So, we have discussed a couple of noteworthy things about ascites – its causes and management. To review:

  1. Ascites is that third spacing.
  2. Third spacing is due to portal hypertension that is greater than 10 mm/Hg.
  3. The liver, which is mainly affected by portal hypertension caused by scarring, is responsible for the production of albumin.
  4. Portal hypertension leads to inefficient albumin production which mainly causes ascites. Ascites is a condition that keeps fluid from going into the vascular areas.
  5. Albumin is given to bring water back into the vascular spaces.
  6. Diuretics are administered to decrease blood volume and prevent albumin side effects.

Client Education

The main reason why ascites exists is due to a liver problem. Even if all types of measures are given to fix the signs and symptoms, if one does not focus on solving the main problem or replace the liver, the problem will persist.

Help liver clients understand why they are suffering from different liver diseases like the irreversible condition – liver cirrhosis. Treating the signs and symptoms are not enough; there must be long-term solutions to fix the primary problem.

Client education is important. Suggest Alcoholics Anonymous for liver clients who are into deep with their alcohol consumption. Make your clients understand the ill-effects of their actions which can also lead to a variety of health conditions like pancreatitis, esophageal varices, and ascites. By being aware of the toxic effects of alcohol, you are teaching your client how to take care of themselves and lead a healthy lifestyle.

Client education is a primary responsibility of nurses – educate the community with risk factors that are damaging to the liver and its surrounding organs.

In our next lecture, we will be discussing hepatitis and its difference with cirrhosis.

Until next time!

Liver Cirrhosis Pathophysiology Sing-Along

Memorizing becomes easier with a song. A topic so extensive requires a certain technique that would make it painless for students to remember.

At SimpleNursing.com, Mike has created a song to the tune of “It’s Beginning to Look a Lot Like Christmas”, making it more fun and interesting for students to recall everything there is to know about the pathophysiology of liver cirrhosis. Cool!

The liver cirrhosis song goes:

It’s beginning to look a lot like cirrhosis

Jaundice of the skin

From the hyper-bilirubin

Waste products of hemoglobin

Due to a lack of bile-production

 

It’s beginning to look a lot like ascites

Fluid in the abdomen

From the portal hypertension

The lack of albumin

Increase capillary pressure causing third spacing

 

The liver acts like recycling company

With four major roles and responsibilities

Detoxing ammonia and drug metabolism

Storing glycogen, producing bile

Coagulation factors and albumin

 

It’s beginning to look a lot like encephalopathy

With altered LOC

Too much ammonia in the blood

A by-product of protein metabolism

Give lactulose to aid the excretion

 

It’s beginning to look a lot like cirrhosis

Soon we’ll do a paracentesis

Drain the fluid from the abdomen

Then give albumin

Bring the fluid back into the vascular spaces

 

If you are able to master this by heart, you are guaranteed 82% or higher on your next nursing exam!

Liver Mash-Up Discourse

Wasn’t that song entertaining? Now, to be able to figure out what it all means, let’s to go into the nitty-gritty details revolving around an ailing liver, mainly: cirrhosis, portal hypertension, ascites, encephalopathy, and all the other conditions. Full lectures are available at SimpleNursing.com.

Liver physiology

Before going into the factors that make your liver sick, let’s make a short detour and review what your liver does exactly.

Think of it this way – your liver as a recycling company. It’s called PDSM – People Drink So Much Recycling Company. We named it that because your liver acts as a detoxifier for a lot of different things, mainly alcohol. People who get intoxicated quite so often have a higher risk of developing liver problems.

What is PDSM?

P stands for produce.

The liver produces A, B, and C.

  • A is for Albumin. It has three responsibilities mainly:
    • fluid attraction in the vascular spaces
    • attracts and transports drugs
    • heavily bind with calcium

An easy way to remember the functions of albumin is to think of it as Al Pacino in the movie “Scarface”. It’s not a family-friendly movie but it would ease the burden of you remembering what albumin does. Al Pacino, in Scarface, is a drug lord of a drug cartel and his main goal is to transport drugs, living near Miami which will remind you of the body of water. Cocaine is what he transports which will remind you of calcium because, in its true form, calcium is white.

  • B is for Bile. The bile is the bus of the liver, transporting bilirubin. Bilirubin is a breakdown of old hemoglobin and red blood cells. The red blood cells advance to the spleen where it gets converted into bilirubin. Then, it goes back through the vascular system and into the liver where it gets converted into bile litter. The bile bus basically transports bilirubin and it also transports cholesterol.

As the body breaks down food or drugs, it gets metabolized and is sent directly to the liver to be detoxed in filters and is produced into something that the body can utilize. The liver also detoxifies the body of extra cholesterol to decrease its levels and flushing the excess out of the body in the form of feces. Which is why, if you have a malfunctioning liver, your cholesterol will shoot up and your LDL and HDL will be unbalanced. Bad cholesterol (LDL) will rise and your good cholesterol (HDL) will decrease. In most cases, total cholesterol skyrockets more than 200.

  • C is for Coagulation factors. This makes the blood clot; thus, decreasing the coagulation time. To determine if the clotting factors are in place, we have the PT, PTT, and INR. The absence of coagulation factors makes a person prone to bleeding. Scabs will not be formed. This means that if you have a liver abnormality like hepatitis or cirrhosis, profuse bleeding will occur.

For a person with liver cirrhosis, the laboratory results yield a low albumin and high bilirubin, causing jaundice. The cholesterol levels shoot up of more than 200; LDLs will go more than 100; HDLs will be less than 40.

D stands for detoxifies.

The liver basically detoxes our body from alcohol or what is also referred to medically as ETOH or toxicity. It acts as a detoxifier. Before your alcohol or whatever it is that you have consumed must first go through the liver which is more like your “customs” or your “border patrol”.

Kupffer cells or, as Mike would like to call them – Mr. Kupffer, is that group of cells inside the liver that are responsible for detoxification. So before any of your medications would go into the bloodstream to be distributed to the parts of the body, it would first have to be absorbed in the small intestine first and then that’s the time that it passes the liver – your customs. 

Exam tip: When asked, what is faster: onset of PO medication or intravenous medication? Since the intravenous medication does not have to go through the first pass phenomenon and it is administered directly into the bloodstream, the answer would be intravenous medication.

S stands for storage.

Glycogen storage is another function of the liver. Glycogen is a collection of glucose which is utilized by the body during activities for energy production. Glycogen is a huge wall of glucose and glucose is its building blocks.

How is this knowledge useful for our daily lives? When a person, an athlete, requires sufficient amount of energy before a race or a competition, he or she will undergo carb loading. Here, the athlete will consume tons of carbohydrates the night before so the liver would recognize that there is an abundance of glucose so it would store it collectively as glycogen. When the time comes that the person will need the extra energy, the liver would detect that and would then peel off bits of glucose for the body to use.

M stands for metabolism.

Metabolism is the process of conversion, the breaking down of elements for the purpose of utilization. Ammonia is metabolized into urea.

By principle, ammonium is a by-product of protein metabolism that is used up by the body for muscle building. Ammonium is transported to the liver to be metabolized into ammonia and gets converted into urea. Urea is excreted by your kidneys from your body in the form of urine.

Mechanism of urine production

Once urea gets launched into the bloodstream, it passes to the renal artery and goes in the kidneys. Within the kidneys, urea is processed by glomeruli for filtering and is then passed on to the ureters, down to your bladder becomes urine.

What happens when waste inside the body is not properly excreted?

They go into the bloodstream and your body will go into toxification, resulting in encephalopathy which is basically the brain being intoxicated with so many by-products. Clients who have encephalopathy display a wide array of signs and symptoms like the altered level of consciousness and unstable behavior.

Which is why the doctor will often ask if the ammonia levels of a client who is acting erratically with altered level of consciousness have been checked. The most common denominations would be your ALTs and ASTs.

So there you have it, the major functions of a normal liver. Next discussion will focus on the liver breaking down; thus the basis of the song above.