GI, Biliary, Liver, and Pancreatic Flashcards
1
Q
As cirrhosis progresses, the liver becomes ____ and ____.
These ____ block____and _____throughout the liver
A
- Liver becomes fibrotic and Nodular
* Nodules block bile duct and blood flow
2
Q
Compression caused by excessive______ causes impairments in ____ and _____ flow.
A
- fibrous tissue
* Blood and Lymph
3
Q
What does the liver look like in early vs late cirrhosis
A
- Early- Enlarged, firm and hard
* Late - Shrunken w/decreased function
4
Q
viral hepatitis, certain drugs and toxins, cause this type of cirrhosis?
A
*Postnecrotic cirrhosis
5
Q
Early S/S of cirrhosis?
A
- Fatigue
- Weight change, anorexia, vomiting
- Abdominal pain/Liver tenderness due to hepatomegaly
6
Q
Later S/S of Cirrhosis
A
- Icterus(jaundice) of skin and sclera
- Dry, pruritic skin
- Purpa, Petichiae, ecchymosis, Telangiectases (Spider veins)
- Peripheral edema
- Osteoporosis
- Ascites
- Vitamin deficiency (D,E,K,A)
7
Q
4 Risk factors for cirrhosis?
A
- Hep C, leading cause in US
- Hep B+D leading cause world wide
- Alcohol/Binge drinking
- Obstruction of bile duct from gallbladder or autoimmune disease
8
Q
How many alcoholic drinks per day and for what time period increase the risk of cirrhosis for men and women?
A
- Women - 2-3 drinks/day over 10 years
* Men - 6 drinks per day over 10 years
9
Q
A complication of cirrhosis where pressure in portal vein is 5 mmhg or higher? Patho of this complication?
A
*Hepatic Cell damage causes Fibrosis, leading to narrowing of the portal veins leading to PORTAL HYPERTENSION (5mmhg or more of pressure in portal vein.
10
Q
A complication of cirrhosis where excess fluid fills the peritoneal area? Describe patho of this complication. How does albumin play a part in this?
A
- Portal hypertension leads to fluid being pushed from blood vessels and into tissue/large open spaces like the peritoneal area. This is known as ASCITES.
- Albumin is synthesized in the liver and this decreases in later stages of cirrhosis. Low albumin allows fluids to be leaked into tissues and 3rd spacing like acites
11
Q
A complication of cirrhosis where kidney failure follows the failure of the liver. Patho of this complication?
A
- HEPATORENAL SYNDROME, where portal hypertension leads to system vasodilation.
- Activation of Vasoconstrictive agents and vasoconstriction of vessels leads to decreased blood flow to kidneys.
- Lack of blood flow leads to increase of prostaglandins and decrease of GFR, causing kidneys to fail.
12
Q
A complication of cirrhosis where neurological dysfunction occurs due to the build up of toxins in the brain? Describe patho of this complication.
A
- HEPATIC ENCEPHALOPATHY
- Blood flow is shunted away from liver due to portal hypertension and narrowing of portal veins.
- Reduced blood flow leads to decreased liver function
- Decreased liver function, leads to less detoxification of blood, and build up of toxins such as ammonia.
- Toxins travel to brain leading to mental deficits and confusion, and eventually coma.
13
Q
Condition where arm is stretched and wrist is dorsiflexed, causes involuntary jerking movements of the hand? What is this a sign of?
A
- Asterixis
* Sign of Hepatic Encephalopathy
14
Q
A complication of cirrhosis where yellowing of skin and whites of eyes occurs? Patho of this complication?
A
- JAUNDICE
- a less functioning liver is unable to excrete bilirubin into bile, therefore it remains in the blood stream, causing Jaundice.
15
Q
Why are coagulation defects seen in cirrhosis of the liver?
A
The liver produces coagulation factors, and is unable to do this when the liver loses functionality.
16
Q
A complication of cirrhosis where veins in the esophagus are abnormally enlarged and ballooned. Patho of this complication? What are some risks of this?
A
- ESOPHAGEAL VARICES
- An increase of blood flow to the veins of the esophagus due to a cut back on blood that can flow through liver due to scarring causes these veins to enlarge and balloon.
- Coughing, chest trauma, physical exercise, could cause spontaneous bleeding and airway obstruction.
17
Q
Assessment for ascites? How, Where, and when is this done?
A
- Measure abdominal Girth
- Measured daily
- Measure at umbilicus while pt is supine and at end of exhalation.
18
Q
In Patients with cirrhosis Liver may be _____ and extend ______. It will be ____ and feel _____.
A
- enlarged
- extends below costal margin
- Papable
- Firm and nodular
19
Q
In liver disease what labs are increased?
A
- Bilirubin (0.3-1.2)
- Liver enzymes-ALT(8-40), AST(10-40), LDH(100-200), AP (30-120)
- Ammonia (15-45)
- Pt/INR, PTT(12-16 seconds)
20
Q
In liver disease what labs are decreased?
A
- Serum albumin/proteins
* Platelets if splenomegaly (thrombocytopenia)
21
Q
List 5 ways to manage third spacing and fluid retention in cirrhosis patients.
A
- 1-2 Gram sodium diet
- Diuretics
- Multivitamins (due to livers inability to store them)
- Paracentesis to drain ascites
- TIPS procedure.
22
Q
What is TIPS procedure? Why is this done? Who is eligible for this?
A
- Transjugular Intrahepatic Portosystemic Shunt
- Stent is placed using guidewire, diverting blood flow from portal vein into hepatic vein.
- Reduces pressure gradient between portal and systemic circulations, which reduces bleeding and fluid back up.
- Done for end stage liver disease
23
Q
What is a paracentesis? How is this done?
A
- Needle or cath is placed into peritoneal area to obtain ascites sample or drain fluid.
- Done in IR w/ local anesthesia and U/S
24
Q
What are two crucial things for the nurse to remember to do for paracentesis
A
- Weight client before/after procedure and document
* Have client empty bladder before procedure to avoid injury
25
Therapy used for Tamponade if endoscopy or TIPS are not possible? How does this work? Why is this dangerous?
* Minnesota or Sengstaken-Blakemore tube with esophageal stents
* tube placed in nose to stomach, attached baloons inflated to apply pressure to bleeding varices
* If tube slips, can cause esophageal perforation or asphyxia
26
What diet should a client be eating to reduce the risk of hepatic encephalopathy? Why? What else may be ordered?
* MODERATE protein
* Ammonia is by product of protein breakdown, want to limit this to avoid toxicity
* Branch-chained amino acids
27
Laxative that promotes excretion of ammonia in the stool? How is this administered? How many stools per day is the goal? What should be monitored for?
* LACTULOSE - PO/ENEMA
* 2-3 stools per day is goal
* Monitor for hypokalemia and dehydration
28
What is the difference between Non-alcoholic fatty liver disease and non-alcoholic steatohepatitis (NAFL VS NASH). What is NAFLD associated with and a risk for?
* NAFL - fatty liver w/o inflammation vs NASH - fatty liver w/inflammation similar to ETOH liver. (remeber FL for flat liver/ no inflammation.)
* Associated w/ obesity and metabolic syndrome
* Create risk for CVD, DIABETES, HTN, GALLBLADDER DISEASE.
29
What is hepatitis and what is the most common type? What occurs after?
* Inflammation of hepatic cells
* Viral is the most common
* Enlarged liver and Portal Hypertension
30
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HEPATITIS A
Primary transmission?
Incubation period?
S/S?
Survival/death of virus?
```
* Oral/Fecal-Contaminated foods
* 15-30 days
* Mild flu/GI illness for most - Can be severe for people over 40 or w/ preexisting liver disease
* survives on hands/resistant to detergents, dies w/bleach and very high temps.
* THIS IS MOSTLY ACUTE
31
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HEPATITIS B
Primary transmission?
Incubation period?
S/S?
Survival/death of virus?
```
* Bloodborne- Needles, unprotected sex
* 25-180 days
* RUQ pain, jaundice, fever, anorexia, dark urine/w/light stool, asymptomatic for many people
* Most clear virus and develop immunity, some become carriers, asymptomatic but at risk for liver issues.
* ACUTE AND CHRONIC
32
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HEPATITIS C
Primary transmission?
Incubation period?
S/S?
Survival/death of virus?
```
* Bloodborne - IV drug use
* 7 weeks
* Most people asymptomatic and unaware
* Not transmitted through casual or intimate contact, however, do not share personal household items., No vaccine.
* ACUTE AND CHRONIC
33
HEPATITIS D
Primary transmission?
Incubation period?
* Bloodborne - IV drug use and also sexual contact
* 14-56 days - usually seen with HEP B infection as well.
* ACUTE AND CHRONIC
34
HEPATITIS E
Primary transmission?
Incubation period?
Survival/death of virus?
* Oral/Fecal transmission - mostly found internationally
* 15-64 days
* Self limiting/ACUTE infections
35
Complication of hepatitis where there is progression of liver necrosis with failure of the liver cells to regenerate?
* Fulminent Hepatitis
| * can be fatal
36
Chronic hepatitis is a complication of hepatitis that occurs as a result of? What can this lead to? Why is this so concerning?
* HBV and HCV
* Leads to cirrhosis and liver cancer
* No HCV vaccine, and is transmissible
37
What should be avoided in hepatitis patients?
* Alcohol
* Acetamenophin
* Sexual intercourse until antigen tests are negative
38
How long is antiviral treatment required for HCV?
24-48 weeks
39
General treatment of hepatitis?
*Lots of rest, High carb/moderate fat and protein diet, small frequent meals
40
What level of precautions should be used with patients with hepatitis in the hospital?
Contact precautions for A+E with active diarrhea, otherwise standard.
41
Vaccine schedule for HEP A?
*2 doses, 6 months apart, starting at 1 year old.
42
PEP for hepatitis A? When should this be done?
* Healthy people 1-40 can receive regular HEP A vaccine, and anyone out of this age range/immunocompromised receives Immunoglobulin A for temp/passive immunity AND the vaccine series.
* Both forms must be given with 2 weeks of exposure.
43
Vaccine schedule for HEP B? What else does this prevent?
* 3 to 4 doses over a 6 months period, starting at birth
| * Also prevents HEP D.
44
What occurs in pancreatitis?
* AUTODIGESTION (organ eats itself)
* Enzymes (amalayse, portease, lipase) are activated in pancreas instead of duodenum.
* Destroys tissues and fluids are able to leak out.
45
Describe S/S of acute pancreatitis.
* Sudden/Severe pain in mid epigastric area/LUQ, radiates to back, left flank or left shoulder.
* pain is worse with supine and improved by bending forward or fetal position
* N/V weight loss.
* Juaundice, cullens sign, grey-turner sign, Paralytic illeus
* Decreased BP and Increased HR means shock
46
What is cullens sign and and what does it indicate?
* Gray-blue discoloration around umbillicus
| * indicates intra-abdominal bleeding
47
What is Grey-Turners sign and what does it indicate?
*Gray-blue discoloration on the flanks - sign of retroperitoneal hemmorhage.
48
How is pancreatitis diagnosed?
CT scan of abdomen with contrast
49
Lab findings in pancreatitis?
* Increased serum values of amylase, lipase, trypsin, elastase and glucose indicate pancreatic damage
* Increased ALT and bilirubin indicate hepatobiliary involvement.
* Increased leukocytes,CRP, ESR indicate inflammation
* Decreased calcium and magnesium levels indicate fat necrosis of the pancreas
* Decreased H+H indicates hemorrhage
50
Pain management for pancreatitis?
* Morphine PCA
* Acid suppressors
* side lying position with knees flexed towards chest.
51
What is administered to prevent infected pancreatic necrosis?
Broad spectrum antibiotics
52
_____ is given to inhibit secretion of pancreatic enzymes. Acts like hormone known as ____. How and when is this given?
* Octreotide
* Somatostatin
* SC injection 1 to 2 times daily.
53
Three most common causes of acute pancreatitis?
* Gallstones
* Alcohol abuse
* Infection
54
Pain management for chronic pancreatitis?
*NSAIDS, avoid longterm opioid use.
55
How many calories do patients with chronic pancreatitis need? What kind of diet? What should be avoided?
* 4,000 to 6,000
* High carb, high, protein, low fat, bland diet - fat causes diarrhea
* Avoid alcohol and caffeine
56
Name of pancreatic enzyme replacement medication? When should pancreatic enzymes be taken and with what? How are these taken? What should be done after taking these?
* Pancrelipase
* Take at beginning of snacks and meals, with glass of water to wash out of mouth.
* Swallow whole or pierce and sprinkle on NON protein foods such as applesauce.
* Wipe lips with wet towel after taking medication to avoid skin irritation.
57
Pancreatic enzymes can be taken after taking what other kind of medication? Why?
* Acid blockers
| * Lipase is destroyed by gastric acid.
58
A priority finding in pancreatitis? Why? How can this be seen.
* Hypocalcemia
* Risk of cardiac dysrythmias
* Positive Trousseau
59
Crucial treatment for acute pancreatitis?
* NPO for 48 hours so pancreas can rest, jejunal feedings may be started after 48 hours unless ileus is present.
* Fluid replacement with isotonic fluids
* Pain management
* calcium replacement
60
Fullness in the epigastric region and a palpable mass in this patient are most likely due to? seen in what? What is used to see this?
* pancreatic pseudocyst.
* Chronic pancreatitis
* CT scan with contrast.
61
S/S of chronic pancreatitis
* Continuous burning or gnawing epigastric pain, with periods where the pain becomes very intense
* Ascites
* Pleural effusions
62
Most common GI disorder seen in clinical practice? When do symptoms often appear?
* IBS
| * Young adulthood
63
4 POSSIBLE etiology of IBS?
* Environmental - Dietary fats/foods with furctose
- Small bowel bacterial overgrowth
* Immunologic and genetic - increased proinflammatory interleukins
* Hormonal - Women twice as likely to have this in US.
* Stress and depression associated with IBS
64
S/S of IBS? What remains normal?
* Cramps and Abdominal pain - LLQ is common
* Constipation/Diarrhea - Belching, anorexia, gas, bloating, MUCUS IN STOOLS
* Labs and weight are usually normal.
65
How to determine whether a patient has small intestinal bacterial overgrowth in IBS?
Hydrogen breath test
66
Describe hydrogen breath test.
* Pt is NPO for 12 hours (except H20)
* Pt blows into hydrogen analyzer
* Pt ingests sugar and additional breath tests taken every 15 minutes for an hour or more.
67
Diet to help treat IBS?
* CLEAN EATING
* 30-40G fiber/Day
* 8-10 glasses of liquid per day
* Low FODMAP diet( fermentable oligosaccharides, disaccharides, monosaccharides, and polyols)
68
What can be kept to determine food triggers?
*Food/symptom diary
69
Ulcerative colitis is the widespread inflammation of ____ and ______. Can extend to ______. Characterized by?
* Rectum
* Rectosigmoid colon
* Extends to whole colon
* Remissions and exacerbations
70
In UC Intestinal mucosa becomes_____, _____and ____.
* Hyperemic
* Edematous - Can lead to partial bowel obstruction
* Reddened
71
What four things can form as a result of severe inflammation? What do Abscesses result in?
* Bleeding
* Erosions
* Ulcers
* Abscesses - result in tissue necrosis
72
In UC - in the younger age range of ______, which gender is UC more common in? What about middle to older age range?
*15-25 - More women than men
| 55-65 - More men than women
73
ULCERATIVE COLITIS S+S - MNemonic ULCERS
U - urgent/frequent bowel movements (Tenesmus)
L- loss of weight/low RBCs (anemia)
C- colicky pain/cramps relieved with defecation
E- electrolyte imbalances/elevated temp
R - rectal bleeding
S- Severe diarrhea (blood, pus, mucus) about 10-20 times per day.
74
Similarities Between Chrons and Ulcerative colitis
1. Both forms of ____
2. Both have causes that are____
3. Both have _____ followed by periods of _____.
4. Both have increased risk of _____?
5. Both consist of recommended diets of____, ____, ____, ____, and ____.
6. Both are treated with the same ____?
1. Both forms of Inflammatory Bowel disease
2. Unknown causes
3. Both have flare ups followed by periods of remission
4. Colon Cancer
5. Low Fiber, low fat, High calorie, High Protein, Lots of hydration
6. Medications are similar
75
Differences Between Chrons and Ulcerative colitis?
1. Chron's Disease can affect _____ in what kind of pattern? While UC can affect ____ in what kind of pattern?
2. Chron's vs UC lining affected?
3. Surgery for chrons vs UC?
1. Chron's affects whole GI tract from mouth to anus, in a scattered pattern (Skip lesions) and UC affects only large intestine (colon) and rectum in a continuous pattern.
2. Chon's affects Deeper into the layers while UC affects mainly inner lining.
3. Chron's has no surgical cures while UC can be cured by colectomy and illeostomy.
76
Mnemonic for complications of chron's disease?
*Abscessing Fistulas May Form Sepsis*
A-Abscess forms (pocket full of bacteria) which can rupture and causes fistula
F- Fistulas are holes/connections that connect to different organs or parts of an organ that aren't usually supposed to be connected.
M- Malnourishment due to small intestines inflammation and not being able to absorb nuterients
F- Fissures - tearing
S-Strictures- scar tissue build up that narrows wall of intestines, bowel obstruction can occur.
77
Complications of UC?
* CART*
* Colon Cancer - especially with history of UC lasting greater than 10 years,.
* Abscesses
* Rupture of Bowel - ulcer creates hole and contents spill into peritoneal cavity
* Toxic Megacolon - colon becomes enlarged and dilated until it is paralyzed and Rupture occurs.
78
colon becomes enlarged and dilated until it is paralyzed and Rupture occurs. What is this and What is this a complication of?
* Toxic megacolon
| * Both UC and Chrons
79
abdominal distention, fever, diarrhea, abdominal pain, dehydration, and tachycardia are all typical symptoms of what complication?
*Toxic megacolon
80
Chrons is an Inflammatory disease of the _____(most often), the_____ or both.
* Small intestine (Most often)
* Colon
* Can be both
81
the distal end of the small intestine that intersects with the large intestine is known as the what? Which disease often affects this?
* Terminal illeum
| * Chron's
82
UC is definitely diagnosed how? Why may the patient have to continue with this diagnostic test?
* Colonoscopy
| * Increased risk for colon cancer due to UC so will need regular colonoscopies.
83
In UC what electrolytes may be decreased and why?
* sodium, potassium, Calcium and albumin
| * Diarrhea and malabsorption
84
What is the first line of pharmacological treatment for Mild-Moderate UC/CD? How do these work? Examples?
Aminosalicylates (Avoid w/ sulfa allergy)
* inhibit prostaglandins to decrease inflammation
- Mesalamine - suppository and PO
- Sulfasalazine
85
Pharmacological treatment for exacerbations in UC/CD?
*systemic glucocorticoids
86
pharmacological Treatment of severe UC/CD?
* glucocorticoids
* Anti-diarrhea - Lmotil, loperamide
* Immunosuppressants - azathioprine, tacrolimus (carry risk of sepsis)
87
Nutritional therpay for UC?
* Npo for severe exacerbations
| * TPN for severely ill and manourished
88
Transmural inflammation causes a _____ intestinal wall leading to what?
* thickend
| * Strictures, ulcerations, fistulas
89
S/S related to stools for Chron's
* 5-6 stools per day
| * Steatorrhea
90
S/S of pain in Chron's
* Constant
* RLQ
* periumbilical pain before/after BMs
91
What labs may be decreased in chron's
* Albumin
* Vitamin B-12
* Folic Acid
* Anemia
92
Why is there Less use of glucocorticoids in Chron's? What can be used instead for Fistulas?
* they can mask sepsis if abscesses or fistulas are present.
| * Metronidazole
93
Intestinal perforation causes what?
* Peritonitis
| * Sepsis/septic shock
94
S/S of peritonitis --5 things
What should be done?
* Abdominal tenderness/rebound tenderness
* Abdominal rigidity/distention
* Absent bowel sounds
* Anorexia and nausea
* Guarding
* Elevated temp, chills, Fever
*NOTIFY PROVIDER, Medical emergency.
95
a condition that involves these small pouch like herniations in bowel wall.
Diverticulosis
96
Inflammation of one (diverticulum) or more diverticula
Diverticulitis
97
*Symptoms for diverticulosis? What should be assessed?
* usually asymptomatic
| * Bowel patterns.
98
Where is pain usually locate w/diverticulitis? How is the pain described? Most common s/s? S/s with severe?
* LLQ/anywhere in abdomen
* Crampy w/ localized tenderness
* Constipation is most common s/s
* N/V seen in severe
* Blood in stool
99
During Diverticulitis when symptoms are occuring, what diet should the patient follow?
* Low fiber
| * Clear liquids or NPO for severe symptoms
100
Where does diverticulitis usually occur?
*sigmoid colon
101
Treatment of Diverticulitis (nonsurgical) -
* broad spectrum abx - cipro,flagyl etc
* Analgesics for pain
* fluids for dehydration
* NGT to rest bowel
102
What should be avoided in treatment for diverticulitis
* Laxatives and enemas
| * Straining of any kind
103
After diverticulitis symptoms have subsided, What should a client's diet look like?
* 25 to 35 grams of fiber/day
* Bulk forming laxatives
* Lots of fluids
104
What should a client with diverticulosis avoid in diet?
* Alcohol
* Limit fat intake
* Any foods containing seeds - nuts, corn/popcorn, cucumbers, tomatoes, figs, strawberries - these can block diverticulum
