1Liver sources of blood
oxygen rich from hepatic artery
nutrient rich from portal vein
2after being filtered in the liver, blood leaves via _______ ______ and joints with the ________ _____ ______ to go to the heart
hepatic veins, inferior vena cava
3the splanchinic circulation is a _____ pressure system
low
4Signs and symptoms of hepatic impairment
GI symptoms
edema/ascites
dark urine, light or clay colored stools,
R UQ abdominal pain,
Skin changes (jaundice, bruising, spider angioma, palmar erythema),
Neurologic involvement (confusion, sleep disturbance, muscle tremors, asterixis),
MSK pain (thoracic, interscapular, R UT, R shoulder, R subscapular areas),
Hepatic osteodystrophy (abnormal development of bone) osteomalacia, osteoporosis -> bone pain
5Jaundice is characterized by
yellow discoloration of skin, sclerae, and muscous membranes
6Jaundice results from
overproduction of bilirubin, decreased metabolism of bilirubin, obstruction of bile flow, presence of liver disease
7what is cirrhosis
scarring caused by chronic, progressive inflammation in the liver
8most common causes of Cirrhosis
EtOH use, Hep C
9If at irreversible cirrhosis, what treatment is best?
transplant provides best therapy for long term survival
10What is portal hypertension?
SERIOUS
increased hepatic sinusoidal pressure (over 6 mm Hg)
pressure in the portal vein that is at least 5 mm Hg higher than the pressure in the IVC
11portal hypertension can cause _______ to the stomach, esophagus, and umbilicus, and rectum
backflow
12dilated vessels -> ? -> ?
gastroesophageal varices (dilated veins), concern for bleeding if it bursts
13portal hypertension can be caused by
cirrhosis
14Why is portal hypertension relevant to PT
GI symptoms, life threatening
PT treatments like coughing and bracing can increase portal hypertension
15What is ascites
accumulation of fluid in peritoneal cavity
16ascites is typically caused by
cirrhosis or portal hypertension
17ascites may cause _____ and increased ___
dyspnea, RR - fluid displaces the diaphragm
18Treatment for ascites
paracentesis - removes the fluid, Sodium restriction and diuretic use, sometimes fluid restriction
19what will you notice in patients with ascites?
weight gain, bloating, SOB, increased RR
20PT relevance for ascites
patient positioning, breathing, presence of edema, fluid restriction
21What is hepatic encephalopathy?
decreased level of consciousness
22hepatic encephalopathy often has an _______ onset, and is _______
insidious, reversible
23in pts with hepatic encephalopathy, what signs will you notice?
mild changes in ability to concentrate -> significant, obvious mental status changes
24What should you consider when pt has a liver complication?
Exercise intensity - low for portal hypertension
Risk of infection
Coagulation impairment - low grades of joint mobs
Skin care
neuro screening (cognitive, balance, reflexes)
25Blood work for Liver Function tests what?
levels of certain enzymes and proteins in blood, measures hepatic damage rather than overall function
26What is hepatitis
inflammation of the liver
27causes of hepatitis
viral, chemical, drug, or alcohol induced
28types of hepatitis
acute and chronic
29mild-moderate cases of hepatitis rarely need
hospitalization
30Focus in pts with hepatitis
prevent spread of infectious agents and avoiding further liver damage
31long term hepatitis leads to
cirrhosis
32Clinical considerations of people with hepatitis
spreading infection to others
self-care during active infection
gradual return to premorbid activity levels - don't stress about deconditioning
33what kind of self care can ppl do for hepatitis
avoid strenuous activity and ingestion of hepatotoxins like alcohol and acetaminophen
34viral hepatitis symptoms
malaise, fatigue, mild fever, nausea, vomiting, RUQ discomfort, anorexia, occasional diarrhea
35Most common types of hepatitis
Hep B and C
36what is considered chronic hepatitis?
6 mos +
37causes of chronic hepatitis
virus, drugs, autoimmune disease, alcohol
38chroic hep can lead insidiously to
cirrhosis and end stage liver disease
39treatment of chronic hep
antivirals, immunomodulatory therpeutics
40complications of chronic hep
cirrhosis, hepatocellucal cancer, portal hypertension
4190% of heavy drinkers develop ______ ____ and 10-35% develop _______ and a minority progress to develop ______
fatty infiltrates, hepatitis, cirrhosis
42alcohol related liver disease is mostly _____ but sometimes can experience
asymptomatic - n/v, abd pain, jaundice, fever, weight loss
43over 40% of deaths from cirrhosis are
alcohol related
44treatment of alcohol related liver disease
alcohol cessation, nutritional support/education, corticosteroids
45although uncommon, _____ are currently the most common cause of acute liver failure
drugs
46what is a predictable drug reaction
dose-related, injury occurs soon after ingestion
acetaminophen, penicillin, aspirin ...
47what is an unpredictable drug reaction
unrelated to dose, injury may occur days or months after ingestion
48risk factors of hepatotoxicity
age, pregnancy, genetic predisposition, concurrent medication use, alcohol use
49clinical manifestations of hepatotoxicity
upper quadrant pain
50PT role in pts with hepatotoxicity
pt education!
51types of liver injury
toxic and traumatic
52what is toxic liver injury
exposure to chemicals/toxins
53toxic chemicals in the liver lead to
liver necrosis
54symptoms of toxic liver injury
jaundice, cholestasis, chronic hepatitis
55prognosis of toxic liver injury
good if toxin is withfrawn and never reintroduced, liver toxicity becomes more severe with advancing age
56types of traumatic liver injury
Blunt - s/p fall or MVA
Penetrating - GSW, knife wounds
57common results of traumatic liver injury
pulmonary infections, abscess formation
58PT role for pts with traumatic liver injury
prevent respiratory complications, optimize skin care, extremity movement, functional mobility
59Congestive heart failure is a major cause of
liver congestion
60decreased cardiac output can cause _______ congestion, and _______ perfusion of the liver
backward, decreased
61decreased cerebral perfusion, hypoxemia, and electrolyte imabalance may all contribute to state of ______, often seen with congestive heart failure
confusion
62Liver abscess occurs in individuals with
underlying disorders
63risk factors of a liver abscess
DM, infected hepatic cysts, metastic liver tumors with secondary infection, diverticulitis, liver cirrhosis
64clinical manifestations of liver abscess
R sided abdominal and/or shoulder pain, N/V/F and diaphoresis, rapid weight loss
65complications of a liver abscess
rupture -> direct spread of infection
66PT role in people who have a liver abscess
encouraging movement, coughing, deep breathing
67liver _______ in size and weight with advancing age which leads to _______ blood flow
decreases, diminished
68Age _____ _____ lead to any predictable changes in liver function tests, therefore any abnormal values reflect
does not, disease
69with aging, liver becomes more fibrotic but not synonymous with
pathologic (cirrhotic) changes
70severe hepatic illness _____ ___________ as well by older individuals
not tolerated
71Indications for liver transplantation
Cirrhosis, necrosis, carcinoma, biliary atresia and metabolic disorders, others
72Rehab post transplant: acute care
POD #1
bed mobility, transfers, functional training
ROM exercises
Edema assessment
Balance assessment
Gait assessment/training
D/c planning
73Rehab post transplant: outpatient
PT education - energy conservation techniques and resting when necessary
Balance/coordination training
strength training
endurance training
postural re-education
74If pt is on immunosupressants, they are at an increased risk of developing
life-threatening infections