Dysfunctions of Liver, Biliary Tract, and Pancreas Flashcards
1
Q
Functions of the Liver
A
blood clotting carb metabolism detoxification fat metabolism protein metabolism bile production bilirubin blood filtration blood reservoir storage
2
Q
Hepatitis
A
inflammation of the liver
causes:
- viral (most common), 5 types (CMV, EBV = mono)
- alcohol
- medications (esp. ibuprofen)
- chemicals
- autoimmune diseases
- metabolic problems
3
Q
Hepatitis A Virus (HAV)
A
- ranges from mild to acute liver failure
- not chronic
- vaccination available (get when 1 YO, adults at risk)
- RNA virus transmitted via fecal-oral route
- contaminated food or drinking water
- post-exposure prophylaxis with HAV vaccine and immune globulin (IG)
4
Q
Hepatitis B Virus (HBV)
A
- acute or chronic disease
- vaccination available
- DNA virus transmitted:
- perinatally
- percutaneously (needle sticks)
- via small cuts on mucosal surfaces and exposure to infectious blood, blood products, or other body fluids
- post-exposure prophylaxis: vaccine and hepatitis B immune globulin (HBIG)
5
Q
HBV: RF
A
- household contact of chronically infected
- patients on hemodialysis
- health care and public safety workers
- IV drug uses
- recipients of blood products
- higher risk sexual practices
6
Q
Hepatitis C Virus (HCV)
A
- acute: asymptomatic
- chronic: liver damage
- RNA virus transmitted percutaneously
- IV drug use
- higher-risk sexual behaviors
- occupational exposure
- perinatal exposure
- blood transfusion before 1992 (before screening process)
no vaccine
no post-exposure prophylaxis
most common cause of liver transplant in US
7
Q
Hepatitis Pathophysiology
A
acute infection:
- large numbers of hepatocytes are destroyed
- liver cells can regenerate in normal form after resolution of infection
chronic infection: can cause fibrosis and progress to cirrhosis
- chronic HBV is more likely to develop in infants and those under age 5
- HCV infection is more likely than HBV to become chronic
8
Q
Hepatitis: S/Sx (general)
A
classified as acute or chronic
many pts are asymptomatic
sx: intermittent or ongoing
- anorexia
- malaise, fatigue, lethargy
- myalgias/arthralgia
- RUQ tenderness d/t liver inflammation
9
Q
Hepatitis: S/Sx (acute phase)
A
maximal infectivity; lasts 1-6 months
sx during incubation OR no symptoms
- n/v
- RUQ tenderness
- reduced sense of smell
- find food repugnant
- distate for cigarettes
- hepatomegaly
- lymphadenopathy
- splenomegaly
icteric (jaundice) or anicteric
if icteric, pt can also have:
- dark urine
- light or clay-colored stools
- pruritus
10
Q
Hepatitis: S/Sx (convalescent phase)
A
- begins as jaundice is disappearing
- lasts weeks to months
- major problems = malaise, easily fatigued
- hepatomegaly persists
- splenomegaly subsides
11
Q
Hepatitis Recovery
A
most pts recover completely with no complications
most cases of acute hepatitis A resolve
some HBV and most HCV result in chronic hepatitis
12
Q
Hepatitis Complications: Acute Live Failure
A
fulminant hepatic failure (severe and sudden onset)
manifestations include:
- encephalopathy
- GI bleeding
- fever w/ leukocytosis
- renal manifestations (oliguria, azotemia)
liver transplant is usually the cure
13
Q
Hepatitis Complications: Cirrhosis
A
RF:
- male gender
- alcohol use
- associated fatty liver disease
14
Q
Hepatitis Complications: Hepatic Encephalopathy
A
potentially life-threatening spectrum of neurologic, psychiatric, and motor disturbances
results from liver’s inability to remove toxins (especially ammonia)
reduce ammonia formation:
- lactulose (Cephulac), which traps ammonia in gut
- Rifaximin (Xifaxan), antibiotic
- prevent constipation
tx of precipitating cause:
- lower dietary protein intake
- control GI bleeding
- remove blood from GI tract
15
Q
Hepatitis Complications: Ascites
A
accumulation of excess fluid in peritoneal cavity
d/t reduced protein levels in blood, which reduces the plasma oncotic pressure
(fluid can become infected > peritonitis)
(portal HTN, hypoalbuminemia, hyperaldosteronism d/t low perfusion in kidney)
- sodium restriction
- diuretics, fluid removal
- albumin
- Tovaptan (Samsca)
- Paracentesis
- Transjugular intrahepatic protosystemic shunt (TIPS) - shunt blood around liver
16
Q
Hepatitis Complications:
A
- acute liver failure
- cirrhosis
- hepatic encephalopathy
- ascites
17
Q
Hepatitis: Dx
A
- specific antigen and/or antibody for each type of viral hepatitis
- liver function tests
- viral genotype testing
- physical assessment findings
- liver biopsy
- FibroScan (special u/s for liver that allows you to see how much scarring/fibrosis is in liver)
- FibroSure (FibroTest)
18
Q
Hepatitis: Tx - Medications
A
acute HAV infection: no specific meds
acute HBV infection: only if severe
acute and chronic HCV infection:
- DAAs (direct-acting antivirals): block proteins needed for replication
- 12wk oral regiment (>95% chronic HCV cure)
supportive drug therapy:
- antihistamines for pruritus
- antiemetics
- Promethazine (Phenergan)
- Ondansetron (Zofran)
19
Q
Chronic Hepatitis B: Drug Therapy
A
Interferon:
- naturally occurring immune protein
- antiviral, anti-proliferative, and immune-modulating effects
- pegylated interferon (PegIntron, Pegasys) given subcutaneously
- SE = flu like symptoms, depression
20
Q
Hepatitis Nutritional Therapy
A
- check albumin levels
- weight weekly at minimum
- small meals w/ snacks (largest meal in AM)
- vitamin supplements (liver damage may limit absorption and metabolism of fat-soluble vitamins A, D, E, and K)
- limit sodium if edema or ascites occurs
- antiemetics for n/v
21
Q
Hepatitis: Nursing Assessment (Objective Data)
A
low grade fever jaundice rash hepatomegaly splenomegaly abnormal lab values
22
Q
Cirrhosis
A
- end-stage of liver disease, irreversible
- extensive degeneration and destruction of liver cells
- results in replacement of liver tissue by fibrous and regenerative nodules
- usually happens after decades of chronic liver disease
- most common causes in US are chronic hepatitis C and alcohol-induced liver disease
other causes:
- right sided heart failure
- extrememe dieting, malabsorption, obesity
- environmental factors
- genetic predisposition
23
Q
Cirrhosis: S/Sx
A
few sx in early-stage disease:
- fatigue and enlarged liver may be early sx
- blood tests may be normal (for compensated cirrhosis)
late manifestations:
- result from liver failure and portal hypertension (jaundice, peripheral edema, ascites)
- other: skin lesions, hematologic problems, endocrine problems, and peripheral neuropathies
- liver becomes smaller, nodular
24
Q
Cirrhosis: Complications
A
- PORTAL HTN
- PERIPHERAL EDEMA: decreased colloidal oncotic pressure form impaired liver synthesis of albumin
- ASCITES: accumulation of serous fluid in peritoneal cavity
- ESOPHAGEAL VARICIES (most threatening complication)
- HEPATIC ENCEPHALOPATHY
- ASTERIXIS
- IMPAIRED IN WRITING: difficulty in moving pen left to right
- FETOR HEPATICUS (musty, sweet odor of patient’s breath)
25
Esophageal Varicies
prevent bleeding/hemorrhage
- avoid alcohol, aspirin, and NSAIDs
- screen for presence w/ endoscopy w/ possible ligation
- balloon tamonade
- nonselective beta-blockers
If bleeding occurs, stabilize patient, manage airway, start IV therapy and blood products
drug therapy (restrict blood flow into portal):
- Octreotide (Sandostatin)
- Vasopressin
supportive measures for acute bleed
- fresh frozen plasma
- packed RBCs
- Vitamin K
- proton pump inhibitors
- Lactulose (Cephulac) - enema that causes diarrhea, and rifaximin (Xifaxan)
26
Cirrhosis: Dx
- liver enzyme tests (alkaline phosphatase, AST, ALT, GGT)
- total protein, albumin levels
- serum bilirubin, globulin levels
- cholesterol levels
- prothrombin time
- u/s elastography (Fibroscan)
- MRI
- Liver bx
27
Cirrhosis: Nutritional Therapy
diet for pt w/o complications:
- high calories (3000 cal/day)
- high carb
- moderate to low fat
- between-meal snacks
- protein restriction rarely needed
protein supplements for protein-calorie malnutrition
low-sodium diet for patient w/ ascites and edema
-seasonings to make food more palatable
oral hygiene
offer preferred foods
explanation of dietary restrictions
collaborate w/ dietician
28
Cirrhosis: Measures to Relieve Pruritis
- cholestyramine or hydroxyzine
- baking soda or Alpha Keri baths
- lotions, soft or old linen
- antihistamines
- temp control
- short nails; rub with knuckles
- monitor color of urine and stool
29
Pancreatitis
acute inflammation ranging from mild edema to severe hemorrhagic necrosis
pancreas produces trypsinogen which is released into small intestine where it is activated to trypsin for digestion
-problem: d/t injury of the pancreas the activated trypsin refluxes back into pancreas causing auto-digestion and bleeding of the pancreas
prognosis: complete recovery > recurring attacks > chronic
can be life-threatening: severe pancreatitis can result in organ failure, sepsis, 25% mortality rate (pancreatic necrosis)
chronic: constant inflammation results in replacement of active tissue w/ fibrous scar tissue
30
Pancreatitis: Causes
anything that causes injury to pancreas:
- most common cause: gallbladder disease (stones) and then alcoholism
- biliary sludge increases risk
- hypertriglyceridemia (>1000 mg/dL)
- less common: trauma, viral infections, penetrating Duodenal ulcer, & abscesses
31
Acute Pancreatitis: S/Sx
abdominal pain predominant:
- LUQ or mid epigastric
- radiates to back
- sudden onset
- eating worsens pain
- starts when recumbent
- not relieved with vomiting
low-grade fever
leukocytosis
hypotension, tachycardia
jaundice
decreased or absent bowel sounds
crackles or lungs
abdominal skin discoloration (Grey Turner's spots or signs - bluish flank discoloration, Cullen's sign - bluish periumbilical discoloration)
shock
32
Pancreatitis: Complications
Pseudocyst: a cavity surrounding outside of pancreas where necrotic products, enzymes, exudates leak into. May resolve on own or may perforate causing peritonitis. Tx w/ prolonged antibiotics and may require draining - surgical procedure,
Abscess: fluid filled cavity w/in pancreas d/t necrosis of pancreas. May become infected or perforate. Requires surgical drainage to prevent sepsis
33
Acute Pancreatitis: Dx
```
abdominal u/s
x-ray
contrast-enhanced CT scan
ERCP - endoscopic retrograde cholangiopancreatography
EUS - endoscopic ultrasonography
MRCP - magnetic resonance cholangeiopancreatography
angiography
chest x-ray
```
34
Acute Pancreatitis: Conservative Care
shock: plasma or plasma volume expanders (dextran or albumin)
fluid/electrolyte problems:
- lactated ringers solution
- central venous pressure readings
ongoing hypotension: vasoactive drugs (dopamine)
prevent infection:
- enteral nutrition
- antibiotics
- endoscoptically or CT guided percutaneous aspiration
supportive care:
- aggressive hydration
- pain management (IV opioid analgesics, antispasmodic agent)
- management of metabolic complications (O2, glucose levels)
- minimizing pancreatic stimulation (NPO status, NG suction, decreased acid secretion, enteral nutrition if needed)
35
Acute Pancreatitis: Surgical Therapy
for gallstones:
- ERCP plus endoscopic sphincterotomy
- laparoscopic cholecystectomy
36
Acute Pancreatitis: Drug Therapy
```
IV morphine
antispasmodics
antacids
proton pump inhibitors
carbonic anhydrase inhibitors
```
37
Acute Pancreatitis: Nutritional Therapy
-NPO status initially
-enteral versus parenteral nutrition
-monitor triglycerides if IV lipids given
small, frequent feeding when able (high-carb, low-fat)
-no alcohol
-supplemental fat-soluble vitamins
38
Chronic Pancreatitis
continuous, prolonged, inflammatory, and fibrosing process of the pancreas
acute exacerbations (frequent attacks intervals of months or years)
39
Chronic Pancreatitis: Tx
no smoking, no alcohol, no caffeine
meds:
- pancreatic enzyme replacement-enteric coated, fat-soluble vitamins
- PPI
- analgesics for pain relief (morphine or fentanyl patch [Duragesics])
diet:
- bland, low-fat
- small, frequent meals
- high carb die (unless diabetic then moderate and cover with insulin)
if DM develops, insulin or oral diabetic meds
40
Chronic Pancreatitis: S/Sx
abdominal pain
- located in same area as in acute pancreatitis
- heavy, gnawing feeling; burning and cramp-like
- more frequent w/ weight loss
constipaion
mild jaundice w/ dark urine
steatorhea
DM
41
Pancreatic Cancer
cause unknown
RF: chronic pancreatitis, smoking, high fat die, DM, and certain chemical exposures
Dx: at later stage when metastasis has already occurred via CT, u/s, ERCP, MRI
prognosis: die w/in 5-12 months of dx
Sx: same as chronic pancreatitis
Tx: surgery (whipple's procedure), radiation, chemo
42
Gallbladder Disease
Cholelithiasis:
- most common disorder of biliary system
- stones in gallbladder
- RF: female, pregnancy, obesity
```
Cholecystitis-
inflammation of gallbladder:
-confined to mucous lining or entire wall
-gallbladder is edematous
-may be distended with bile or pus
-cystic duct may become occluded
-scarring and fibrosis after attack
```
usually associated with gallstones
43
Cholelithiasis: Etiology and Pathophysiology
-stasis of bile leads to super saturation and changes in composition of bile (biliary sludge)
-immobility, pregnancy, and inflammatory or obstructive lesions in biliary system, decreased bile flow
-develop when balance that keeps cholesterol, bile sales, and calcium in solution is changed, leading to precipitation
-stones may stay in gallbladder or may migrate to cystic or common bile ducts
(may lodge in ducts and cause an obstruction)
44
Gallbladder Disease: S/Sx
vary from severe to none at all
pain more severe when stones moving or obstructing:
- steady, excruciating
- tachycardia, diaphoresis
- residual tenderness in RUQ
- occur 3-6 hours after high-fat meal or when patient lies down
when total obstruction occurs:
- dark amber urine - more bilirubin eliminated in urine
- clay-colored stools - no bilirubin moved to small intestines
- pruitis
- intolerance to fatty foods
- bleeding tendencies: d/t lack or decreased absorption of Vitamin K resulting in decreased production of prothrombin
- steatorrhea
in addition to pain:
- indigestion
- fever, chills
- jaundice
45
Gallbladder Disease: Dx
```
u/s
ERCP
Percutaneous transhepatic cholangiography
Lab tests:
-increased WBC
-increased serum bilirubin level
-increased urinary bilirubin level
-increased liver enzyme levels
-increased serum amylase level
```
46
Cholelithiasis: Tx
dependent on sage of disease
oral dissolution therapy:
- Ursodeozycholic acid (Ursodiol)
- Chenodeozycholic acid (Chenodiol)
Extracorporeal shock-wave lithotripsy (ESWL):
- if stones cannot be removed via endoscope
- high energy shock waves disintegrate gallstones
- takes 1 to 2 hours
- used in conjunction with bile acids
47
Cholecysitis: Tx
control possible infection:
- antibiotic treatment
- NG tube for severe n/v
cholecystotomy:
-opioids for pain control
anticholinergics:
- decrease GI secretions
- counteract smooth muscle spasm
48
Gallbladder Disease: Meds
most common:
- analgesics (morphine)
- anticholinergics (atropine)
- fat-soluble vitamins (A, D, E, K)
- bile salts
49
Gallbladder Disease: Nutritional Therapy
- small, frequent meals with some fat
- diet low in saturated fat
- high in fiber and calcium
- reduced-calorie diet if pt is obese
- avoidance of rapid weight loss
50
Gallbladder Disease: Acute Care
pain management: give drugs as needed before pain becomes severe, observe for SEs
comfort measures: positioning, oral care
manage n/v:
- NG tube, gastric decompression
- oral hygiene, care of nares
- accurate I&O
- maintaining suctioning
- antiemetics
- comfort measures
Pruritus relief measures:
- antihistamines
- baking soda or Alpha Keri baths
- lotions
- soft linen
- control temps
- short, clean nails
- scratch with knuckles
- Cholestyramine
51
Gallbladder Disease: Surgical Therapy
laparoscopic cholecystectomy:
- tx of choice
- removal of gallbladder through 1 to 4 puncture holes
- minimal postoperative pain
- resume normal activities, including work, within 1 week
- few complications
Incision (open) cholecystectomy:
- removal of gallbladder through right subcostal incision
- T-tube inserted into common bile duct (ensures patency of duct, allows excess bile to drain)
52
Transhepatic Biliary Catheter
- preoperative or palliative (when endoscopic drainage fails)
- inserted percutaneously and attached to drainage bag
- replace fluids lost w/ electrolyte-rich drinks
- skin care important
53
Gallbladder Disease: Postoperative Care
laparoscopic cholecystectomy:
- monitor for complications
- patient comfort (referred pain to shoulder from CO2, Sims position, deep breathing, ambulation, analgesia)
- clear liquids
- discharged same day
open-incision cholecystectomy:
- monitor for post-op complications
- T-tube or JP drain maintenance
54
Gallbladder Disease: Ambulatory Care
laparoscopic cholecystectomy:
- remove bandages day after surgery and then can shower
- report sx of infection
- gradually resume activities
- return to work in 1 wk
- may need low-fat diet for several weeks
open-incision cholecystectomy:
- no heavy lifting for 4-6 wks
- usual activities when feeling ready
- may need low-fat diet for 4-6 wks
