GI 3 Flashcards
Functions of liver
carb, fat, steroid, protein metabolism
detoxification
prodution & excretion of bile
storage iron, vit K, minerals blood
yellow pigmentation of sclera, skin, deeper tissues
jaundice
why does jaundice happen
due to a concentration of bilirubin in blood, becomes abnormally increased
how is bilirubin formed
from the breakdown of hemoglobin of old RBC’s
(unconjugated bilirubin released into blood, bound to albumin, not water soluable (cannot be excreted) cannot be filitered by kidneys, builds up in blood)
what does the bilirubin level have to be for jaundice to occur
3 times greater than normal
is jaundice a disease
NO, its a symptom
what is the most common cause of jandice
excessive breakdown of RBC’s or bile excretion obstruction
babies become jaundice because
of excessive destruction of RBC’s
results from excessive RBC destruction, occurs before the liver, has excess unconjugated bilirubin
pre-hepatic jaundice (hemolytic)
causes of hemolytic jaundice
hemolytic anemia, sickle cell, severe burns, newborns
defective uptake, conjugation or excretion of bilirubin within liver, both unconjugated and conjugated bilirubin elevated
hepatic jaundice (hepatocellular)
causes of hepatocellular jaundice
cirrhosis, hepatitis, hepatic carcinoma
what is the major problem in hepatocellular jaundice
conjufation and excretion of bilirubin
decreased or obstructed flow of bile thru liver or biliary duct system, blocks outward flow of bile from liver
post hepatic jaundice (obstructive)
obstruction of bile into the duodenum, clay colored stools with complete obstruction
extrahepatic
pruritis
itching
who would you have a pt come in with a bleeding problem who has a Hx of liver disease
lack of vit K, bile is necessary for absorption of vit k from GI
what Rx do you want to avoid if you have problems with jaundice
ASA, risk of bleeding
any type of inflammation in the liver
hepatitis
what kind of hepatitis is most common
viral hepatitis
wide spread inflmmation of liver, liver cell damage, degeneration and necrosis, bile flow interruption
viral hepatitis
what are causes of hepatitis
viral
alcohol
drugs
Hepatitis A
transmitted thru fecal oral route
occurs in small outbreaks
contagious for 2 weeks prior to symptoms
due to poor hygine, contaminated food, water, poor sanitary conditions
detection of IgM anti-HAV indicates
acute hepatitis
presence of IgG antibody does what
provides lifelong immunity
Hepatitis B
can live up to 7 days on a dry surface, 100x’s more infectious than HIV
transimission by body fluids, blood
HBV Window phase
have a 3 month delay between disapperance HB-antigen & apperance Anti-HB
a positive HBAb or anti-HBs indiciates
recovery, no longer contagious
immunity from HBV vaccine or past HBV infection
Hepatitis C
transmission is blood & blody fluids
HCV damages liver over decades
leading indication for liver transplant
chronic, asymptamatic
only way for survival of hepatitis c is
liver transplant
hepatitis D
also called delta virus
HDV only occurs as co-infection with HBV
Hepatitis E
waterborne infection in india, asia, africa
fecal oral route
causes epidemics after heavy rains and flooding
hepatitis G
blood & bldy fluids
often coexists with other hepatitis viruses (B, C, HIV)
Toxic & drug induced hepatitis
liver damage occurs after exposure to hepatotoxins
autoimmune hepatitis
chronic, autoimmune reaction against normal hepatocytes
treated with corticosteroids, or liver transplant
Hepatitis DX
biopsy, elevated ALT, AST, WBC, increased eosinophils
acute phast of hepatitis
lasts 1-21 days
period of maximal infectivity for hepatitis A
Sx: fatigue, constippation, diarrhea, malaise, RUQ pain, HA photophobia, low grade fever
Icteric phase (jaundice phase)
lasts 2-4 weeks, characterized by jaundice
dark urine
clay colored stools
posticteric phase
(convalescent phase)
begins when jaundicedisappears
lasts weeks to months
hepatomegaly
resulsts in severe impairment or necrosis of liver cells and potential liver failure
fulminant hepatitis
(Hep B &D)
Tx for hepatitis
no specfic Tx, emphasis on rest and adequate nutrition
antiviral Rx: epivir, baraclude, tyzeka, hepsera
antiemetics: zofran, tigan, reglan
prevention for hepatitis A
vaccine can be fiven for pre exposure prophylaxis, immune globulin can be given before or after exposure (1-2 weeks)
prevention hepatitis B
immunization is most effective, HB immune globulin given post exposure provides passive immunity
Preventino of Hepatitis C
no products to prevent HCV
what are the three A’s when preventing accidental exposure
awareness attentivness, anticipation
nutritional therapy for hepatitis
vitamin supplements b-complex vitamins, vitamin K
what needs to be done after diagnosis of Heptitis
follow up for at least one year after diagnosis, avoid alcohol
wilsons disease
increase of copper in liver, develop kayser-fleicher rings, leads to liver failure, Tx is chelating agents to promote exretion of exess copper
genetic
hemochromatosis
increase absorption of iron leads to cirrhosis, unTx can lead to death
a chronic progressive disease of the liver with irreversible scarring of the liver, tissue becomes nodular and fibrotic
cirrhosis
what is the most common cause of cirrhosis
alcohol
is cirrhosis fatal
yes
cirrhosis caused by alcohol use, proceded by fatty infiltration of the liver cells, widespread scar formation
alcoholic (laennec’s) cirrhosis
cirrhosis caused by a complication of tocix, viral or autoimmune hepatitis, liver becomes small and distorted
postnecrotic cirrhosis
cirrhosis associated with chronic biliary obstruction and infection, liver enlarges, firm and green
biliary cirrhosis
cirrhosis caused by longterm severe right sided heart failure
cardiac cirrhosis
when do S/Sx of cirrhosis begin
when about 80% of liver damage has occured
when do jaundice and peripheral edema occur in cirrhosis
last stages
small dilated vessels, bright red center and spider like branches
spider angiomas
red area palm of hand blanches with pressure
palmar erythema
how is splenomegaly caused
backup of blood from portal vein
why do people with cirrhosis have bleeding tendencies
decreased production of hepatic clotting factors
(II, VII, IX, X)
what dietary deficiencies occur with cirrhosis
thiamine, floic acid, vit B12
increased resitance to blood flow through the liver, portal vein pressure increases
portal HTN
complex tortuous veins at lower end of esophagus
esophageal varices
colalrteral circulation which involves the superficial veins of the abd wall leading tothe development of dilated veins around the umbilicus
caput medusae
shift of fluid in abd bc of lack of protein bc the liver isnt functioning properly
abd distention and weigh tgain
ascites
liver damage causs blood to enter systemic circutaion without liver detozification, liver is unable to convert ammonia to urea or blood shunted past liver so ammonia stays in systemic circulation
hepatic encephlopaty
what are S/Sx of hepatic encephalopaty
inapproptiate behavior to coma
flapping tremor invovles arms and hands
asterixis
musty, sweetish odor detected on the pts breath
fetor hepaticus
toes curl when touch bottom of feet
babinski sign
4 stages of hepatic encephalopaty
prodromal
impending (asterixis)
stuporous
comatose (+ babinski)
functional renal failure without structural abnormality of kidneys, decreased arterial volume which leads to renal vasoconstriction with renal failure
hepatorenal syndrome
what is the most specific lab test done for liver
ALT
what kind of nursing care should be done for someone with chirrohsis
rest, admin of B12, management of ascites, prevent variceal bleeding, avoid alcohol
provides for continuous reinfusion of ascitic fluid fromthe abd to the vena cava or jugular
peritoneovenous shunt
wjat RX can be given to help prevent bleeding in espohageal varices
vasopressin
decreaes portal pressure by constriction
3 lumens to apply pressure to bleeding areas, gastic aspiration, gastric balloon, esophageal balloon
sengstaken-blakemore tube
what is important with a sengstaken-blakemore tube
monitor airway, syringe at bedside to deflate balloon
which shunt is used to decrease incidence of hepatic encephalopathy
warren shunt (distal spenorenal shunt)
what should the nurse do for a esophafeal varices
administer FFP & PRBC
vit K
H2 receptor blockers/PPI
what should be given for a pt with hepatic encephalopathy
lactulose
(forms lactic acid in bowel, so bacteria cant grow so traps ammonia in the gut and expels it)
what special diet should someone with ascite/edema follow
low sodium diet
paracentesis
have pt void prior to to avoid knicking the bladder
what is the most common complication of balloon tamponade
aspiration pneumoina
what surgical procedure can be done for varices
balloon tamponade
where does liver Ca usually metastazise from
lun, breast colon
elevated serum alpha-fetoprotein
tumor marker
used to treat inoperable cancer of liver, pancreatic & bile ducts & tumor obstructions
percutaneous biliary drainage
what is used in end-stage liver disease, acute liver failure, primary liver tumors
liver transplant
who is not a candidate for transplant
advanced cardiac disease, respiratory disease, alcohol abuse, metastatic tumors
what complications can a pt have with a liver transplant
graft rejection, infection
an acute inflammatory process of the pancreas
pancreatitis
what is the most common reason for pancreatitis
biliary tract disease
what enzymes aid with autodigestion
trypsinogen, elastase, phospholipase A
causes hemorrhage by producing dissolution of the elastic fibers of blood vessels
elastase
activated by trypsin and bile acids, plays a major role in autodigestion
phospholipase A
activated by trypsin by enterokinase, enzyme can digest the pancreas and can activate other proteolytic enzymes
trypsinogen
what can stimulate the production of digestive enzymes
alcohol
S/Sx of pancreatitis
LUQ or epigastric pain, aggrivated by eating high fat meals or alcohol intake
bluish periumbilical discoloration
cullens sign
bluish color in flank
turners sign
cullen or turners sign
sign of pancreatitis
a psecavity surrounding outside of pancreas filled with necrotic products and liquid secretions
pseudocyst
if a pseudocyst perforates it causes
peritonitis
a large fluid containing cavity within pancreasresults from necrosis in pancreas, requires surgical drainage
pancreatic abscess
tetany is caused by
hypocalcemia
serum amylase & lipase that is elevated could be what
pancreatitis
as a nurse what should you look for with pancreatitis
VS, hemmorrhage, fluid/electrolyte balance, NPO, LR
DO NOT use D5W bc you dont want the pancreas to have to work harder to make insulin
endoscopic sphincterotomy
used when stone blocking Oddi duct
ERCP is used when
gallstone blocking
diet for pancreatitis
high carb, low fat, high protein
what position should a pt lay with pancreatitis
side lying, with HOB elevated 45 degrees, knees up to abdomen
signs of hypocalcemia
tetany, numbness around lips/fingers, positive chvostek or trousseau signs
signs of hyperglycemia
polyuria, polyphagia, polydipsia
continuous prolonged, inflammaroty and fibrosing process of the pancreas
chronic pancreatitis
inflammation of sphincter of Oddi associated with cholelithiasis
chronic obstructive pancreatits
causes of chronic obstructive pancreatitis
cancer of ampulla of Vater
cancer of duodenum, or pancreas
inflammation of sphincer of Oddi
chronic calcifying pancreatitis happens where
head of the pancrea and around the pancreatic duct
S/Sx of chronic pancreatitis
heavy, gnawing feeling, burning cramp like
chronic pancreastitis is a precursor to what
pancreatic cancer
in pancreatic cancer what will the serum amylase/lipase be
may be increaed slightly or not at all
elevated sedimentation rate
indicates inflammation
choledochojejunostomy
CBD anastomosed into jejunum
bypasses obstruction of tumor
Roux-en-Y pancreaticjejunostomy
pancreatic duct opened & anastomosed to jejunum
all surgery for chronic pancreatitis is
palliative
cholecystojejumonstomy
connect GB to jejunum to go around obstruction
whipple procedure
radical pancraticoduodenectomy
S/Sx of carcinoma of pancreas
asymptamatic @ 1st, then rapid weight loss, abd pain radiates to back, pain related to eating
what does the gallbladder do
collects and concentrates and stores bile
inflammation of gallbladder
cholecystitis
calculous
acute cholecystitis, with cholelithiasis (stones)
acalculous
cholecystitis without cholelithiasis
who is at highest risk for cholecystitis
over age 40, females, multiparous women (mult pregnancy)
5 F’s of risk factors
Fourty
Female
Fertile
Family Hx
Fat
calculous is mostly commonly associated with
obstruction
acalculous occurs in older adults and those who have what hx
trauma, extensive burns, or recent surgery
what are stones made of
bile salts, cholestrole
what is the most common factor for cholecystitis
e. Coli (bacteria)
develops when balance that keeps cholesterol, bile salts, and calcium in solution is altered
cholelithiasis
what is the most common form of stone
cholesterol
spasm of biliary duct trying to push stone through
biliary colic
S/Sx of cholelithiasis
pain in RUQ, and R shoulder
if your pt has pain triggered by a high fat meal, and blumbergs sign
acute cholecystitis
rebound tenderness
blumbergs sign
S/Sx when you have a total obstruction of GB
jaundice
dark amber foamy urine
clay colored stools
pruritus
bleeding tendencies
steatorrhea
when a stone is lodged in ducts or moving may cause spasm what is this called
biliary colic
why would a person have pruitis with cholelithiasis
bc of bile salts
why would a pt have bleeding tendencies with cholelithiasis
bc vit k is not being absorbed
steatorrhea
fatty stools
murphys sign
pain with inspiration
(cholelithiais)
subphrenic abcess
found under diaphragm, pocket of pus (infection)
labs with cholecystitis
WBC, amalyse, lipase, AST, ALT
visualization of gall bladder & cystic, common hepatic, common bile ducts, pancreatic duct, can retrieve gallstone from distal CBD, dilate strictures, obtain biopsy, diagnoise pseudocysts
endoscopic retrograde cholangiopancreatography
(ERCP)
percutaneous transhepatic cholangiography
inject dye in bile duct, used to diagnose obstructive jaundice & locate stones within bile ducts, filling of hepatic and biliary ducts
what is the gold standard that shows gallstones in the GB and ducts
ultrasound
Labs for gallstone obstruction
increase of all the below:
ALT, AST, alkaline phosphaase
WBC
serum bilirubin (indirect, direct, urinary bilirubin)
serum amylase, lipase (if pancreastic involvement)
Tx for gallstones
pain management
antibiotic Tx
fluid electrolyte balance
anticholinergics (counteract smooth muscle spasms)
endoscopic spincterotomy
removes common bile duct stones, sphincter of Oddi widened, basket is used to retrieve stone
Sphincter of Oddi
where bile duct opens to duodenum
laparoscopic cholecystectomy
4 puncture holes, injury to common bile duct is main complication, discharged in 1-2 days
when is t-tube used
for open cholecysectomy, allows excess bile to drain
T-tube nursing Care
maintain semi fowlers position
keep drainage below level of GB
immediately post op have bloody drainage, then will change to greenish-brown
never irrigate aspirate or clamp without MD order
if pt is allowed to eat clamp tube for 1-2 hours before and after meals
stools will return to brown color (7-10 days)
what Rx can be given for pruritus
questran (cholestyramine)
gets rid of bile salts
if a pt eats too much fat they will have what kind of stools
steatorrhea
cholelithiasis disease is more common in what ethnic background
native americans
what signs of obstruction for GB stones
jaundice, caly colored stools, dark, foamy urine, fever, increased WBC, steatorrhea
post of for laparoscopic cholecystectomy
shoulder pain from irritation of phrenic nerve and diaphargm due to retained CO2, place pt in Sims position, deep breathing
when giving your pt narcotics what do you need to assess
RR
post cholecystectomy syndrome
abd pain with Vomiting following cholecystectomy
jaundice may occur several weeks to months after surgery, ERCP used to find problem
causes of post cholecystectomy syndrome
pseudocyst, common bile leak, bile duct stricture, retained stone, sphincter of Oddi dysfunction
gallbladder cancer
begins in inner layer and grows outward, rare, metastasizes to adjacent organ (liver)
CT and MRI is used for what
staging cancer
ERCP & MRCP
looks at ducts
CEA/CA 19-9
tumor markers
if surgery is not an option what can be done for GB cancer
endoscopic stenting of biliary tree to reduce jaundice
if pt who has gallbladder removed has bruising and bleeding could be bc of what
Vit K deficiency
ALT lab is used for what
enzyme found in liver cells, is a more specific measure of liver damage than AST, some drugs can falsely increase the level of ALT (acetaminophen, salicytates, codeine, oral contraceptives)
AST lab is used for what
non specific marker of hepatic injury found in brain, cardiac, skeletal muscle, kidney, and liver
the level can be falsely decreased in diabetic ketoacidosis, severe liver disease, uremia, pregnancy
GTT lab is used for what
enzyme produced in bile ducts that may be increased with bile duct dieases
useful in determining the source of increased ALP
ALP lab is used for what
relects bile formation and flow, produced in the bile ducts
can be falsely increased due to pregnancy, salicylates, antibiotics, oral DM rxs, oral contraceptives
LDH (lactic dyhydrogenase)
if elevated indicates tissue damage, decreased in radiation and cancer tx, increase in alcoholism, anemia, burns,
prothrombin
used to screen for hemostatic dysfunction involving coagulation system
ammonia
wast product produced during protein digestion, if liver doesnt convert to ammonia into urea ammonia levels rise in blood
bilirubin
byproduct of old red blood vell destruction removed by the liver from blood then secreted into bile, then absorped in intestine
urobilinogen
produced in intestines, some is reabsorbed and returns to liver rest excreted in feces, a banana before test may affect results, also wine, drugs, ascorbic acid, ammonium chloride and antibx, drugs containing sodium bicarb may yield a false positive test
