GI Disorders: Liver, Biliary, Pancreas Flashcards
Liver Diseases
- Hepatitis: inflamm of liver
- Cirrhosis: constant inflamm leading to irreversible fibrosis & scarring
- Liver CA
Primary liver CA vs. Secondary liver CA
- Hepatocellular Carcinoma = primary liver CA
- Secondary liver CA or Liver metastases = metastatic tumors in liver from a tumor outside the liver
Acute liver disease causes (top 3)
- Hep A virus
- Hep B virus new or reactivation
- Drug-induced (mostly Acetaminophen)
Chronic liver disease causes (top 3)
- Hep B and C virus
- Alcohol
- Non-Alcoholic Steatohepatitis (NASH)
Pruritis presentation
- Excessive itching on body, mostly hands and feet
- *Impacts quality of life, including mental health & sleep
Why does pruritus happen?
Caused by accumulation of bile salts under skin d/t liver can’t process bc hepatocytes not functioning properly
Pruritus treatment
- Antihistamines (eg Benadryl) = INEFFECTIVE
- *Cholestyramine removes bile salts
Jaundice presentation
- Yellowing of skin, sclera
- Gray clay-colored stools
- Amber colored urine
- Pruritus
- Elevated serum bilirubin
Why does jaundice happen?
Elevated bilirubin
(Bilirubin usually byprod of RBC breakdown, stored in liver and secreted w bile)
(If liver can’t metabolize and secrete bilirubin, it builds up in plasma)
Obstructive jaundice - types of obstruction in biliary system
- Inflamm/edema
- Scarring
- Fibrosis
- Gallstones migrate into biliary system
- Any obstruction interfering w normal bile flow (eg tumor)
Obstructive jaundice treatment
- Endoscopic procedures w stenting
- Surgery
Jaundice labs
- High total bilirubin
- High direct (conjugated) bilirubin level: greater than 0.3%
- Low indirect (unconjugated) bilirubin level (high see in neonatal jaundice)
Direct (conjugated) bilirubin levels
0.1 - 0.3 mg/dl
Total bilirubin levels
0.3 - 1 mg/dl
Indirect (unconjugated) bilirubin levels
(due to RBC breakdown)
0.2 - 0.8
Hepatic encephalopathy presentation
*CNS disturbances
- Altered mental status
- Decreased LOC
- Changes in motor function
- Confusion, insomnia, somnolence
- Asterixis
Why does hepatic encephalopathy happen?
- Liver can’t metabolize waste products d/t inflamm & hepatocyte malfunction
- Liver scarring causes blood to bypass liver and miss being detoxified
- Waste products, specifically ammonia, accumulate in blood, causing CNS disturbance
Hepatic encephalopathy treatment
- Lactulose: promote excretion of ammonia in stool (can cause diarrhea)
Coagulopathies presentation
- Thrombocytopenia (pltlt < 150,000)
- Prolonged PT & INR
- DIC: combo of clot & excessive bleed (GI tract, pulm, IV sites, wounds, puncture sites)
Portal HTN
Occurs in setting of cirrhosis
Effects of Portal HTN
- Esophageal varices (melena, hematemesis)
- Rectal varices (hemorrhoids, bleed)
- *Ascites
- Splenomegaly
- *Dilated abd veins
- Spider angiomas
Why does portal HTN happen?
- Scarring in liver impede blood flow –> increase pressure in portal vein
- Blood backs up, causing shunting of blood around liver –> increased pressure in surrounding vessels
Ascites
Abnormal accumulation of protein-rich fluid in peritoneal cavity
Ascites presentation
- Abd distension
- Edema in lower extremities
- SOB
- N/V
- Pleural effusions d/t exchange of fluid across diaphragm into pleural space
Why does ascites happen?
- Portal HTN –> high press –> accumulation of substances –> confused kidney so hold onto fluid
- Contributing factor = decreased albumin
Ascites treatment
- Sodium restriction (< 2g/day)
- Diuretics (spironolactone & furosemide)
- Paracentesis (removal of ascites via needle)
Hepatitis
Inflammation prevents normal liver function
- Limited ability to detoxify substances
- Decreased prod of proteins & clotting factors
- Inability to store vitamins, fat & carbs
Hepatitis risk factors
- Hep virus (acute or chronic)
- Alcohol (chronic)
- Prescribed meds (acute): statins, phenytoin, isoniazid, anabolic steroids
- OTC meds (acute): NSAIDs, Acetaminophen
- Toxins (acute)
- Autoimmune (acute)
Hep A Virus
- Acute
- Vaccine available
Hep A transmission
- Fecal
- Oral
- Contaminated food/water
- Close contact w infected persons
Hep B Virus
- Acute/chronic
- Vaccine available
Hep B transmission
- Blood
- Bodily fluids
- Vertical transmission
Hep C virus
- NO vaccine
- Acute/chronic
Hep C transmission
- Blood
- Bodily fluids
- Vertical transmission
Cirrhosis
Chronic disease of liver causes: cell destruction, fibrosis, scarring
Irreversible
Cirrhosis top 3 causes
- Chronic HBV/HCV infection
- Alcohol
- NASH
Cirrhosis liver transplant
- Hep C related cirrhosis is most common reason for transplant
- Childs Pugh or MELD score
Cirrhosis nursing assess
- VS: infection, FVE, FVO
- Resp: SOB d/t ascites or pleural effusions, pulse ox
- Peripheral edema
- Bleed: gums, ecchymosis, epistaxis, petechiae
- Skin, sclera, urine, stool color
- Mental status
- I&O
- *Acid-base disorders: resp alkalosis (tachypnea, high ammonia, hypoxia), met alkalosis (diarrhea, diuretics)
Cirrhosis nursing intervention
- Administer prescribed diuretics & electrolyte replacement: K d/t diuretics, MG d/t ETOH abuse and diarrhea, PHOs d/t diuretics & ETOH abuse
- Restrict sodium and fluid intake
- Restrict protein intake
- HOB & leg elevation
- Administer vitamin K, blood products, FFP, Cyropercipitate
- Promote rest & skin integrity: bathe in tepid water, emollients
Cirrhosis pt education
- Disease process
- Dietary & fluid restrict
- No alc intake
- Meds metabolized by liver or herbs & supplements
- Diet and nutrition; adequate calories
- Bleeding precautions
Liver cancer transplant
Development of small localized HCC in cirrhotic liver –> move up pt in transplant list
Liver CA surgical intervention
- Partial hepatectomy
- Reserved for 1-4 small liver metastases in setting of no other metastatic disease in body
Liver CA nursing assess
- Pain & advocate for pain control
- Psychosocial issues: anxiety, fear, depression
- Therapeutic side effects: neutropenia, skin alterations, N/V, etc.
Liver CA pt teaching
- Explain CA therapies
- Potential side effects & complications
Cholecystitis
Inflamm of gallbladder caused by obstructed bile flow
- Calculous cholecystitis: stones present
- Acalculous cholecystitis: NO stones
Cholecystitis risk factors
- Increased age
- Female > male
- European descent > African descent
- Obesity
- Rapid weight loss or weight loss surgery
- Diet high in saturated fats
- Pregnancy (elevated progesterone)
- Meds: estrogen, octreotide, cholesterol-lowering meds
Calculous cholecystitis
- Vary in size (pea - softball), number (single - multiple)
- Vary in composition: cholesterol (most common), pigmented (excess bilirubin), mixed (combo of both)
- Most found blocking cystic duct or common bile duct = choledocholithiasis
Acalculous cholecystitis
Biliary stasis (bile flow stops or is reduced) d/t:
- Decreased gallbladder contraction
- Sphincter of Oddi spasms
- Possibly r/t sepsis, surgery, DM
- D/t factors that stop release of cholecystokinin (hormone activated by eating that causes gallbladder to contract)
Cholecystitis surgical treatment
- Laparoscopic cholecystectomy
- T-tube (biliary drainage tube)
Laparoscopic cholecystectomy
- General anesthesia
- Several small incisions in abdomen
- CO2 gas instilled in abd for visualization
- Laparoscope (small thin telescope) and surgical instruments inserted thru incisions to remove gallbladder
T-tube (biliary drainage tube)
If stones present in common bile duct, monitors bile drainage + connected to drainage bag to make a closed system
Cholecystitis nursing assessment
- VS: increased temp & decreased BP = inflamm & infection, tachypnea = pain & anxiety
- Pain
- Skin turgor: dehydration
- Abd assessment: rebound tenderness, guarding, +Murphy’s sign, rigid abd muscles
- Stool: clay-colored stools, do they float or are they oily (steatorrhea)
- I&Os
- LFTs high, BUN/Cr high, K low, WBC high
Cholecystitis nursing intervention
Preoperative:
- Maintain NPO
- Administer IV fluids & meds (abx, pain meds, antiemetics)
- Semi-fowler position
Post-operative:
- Cough & deep breathing to prevent atelectasis
- Mobility, monitor incision sites for infection
T-tube care:
- Empty drainage bag as necessary
- Skin care
Cholecystitis pt teaching
- S&S of infection, jaundice
- Pain med education
- Constipation prevention, low-fat diet
- Shower instead of bathing, timing to first shower
- When to remove bandages
- Activity level: no heavy lifting
- No driving while on narcotic
T-tube:
- Care of insertion site, monitor bile color and amount, assess for jaundice
Acute pancreatitis
- Mild to severe
- Severe cases of often present w life-threatening complications
- Acute pancreatitis is reversible
- Common causes: gallstones, alcohol, surgery
Chronic pancreatitis
- Chronic dz
- Irreversible
- Alteration of exocrine and endocrine function of pancreas
- Incidence increases w age
- Common causes: prolonged alcohol use, cystic fibrosis, hyperlipidemia/hypertrigylceridemia
Acute pancreatitis
Inflamm of pancreas caused by release of pancreatic enzymes that “autodigest” pancreas and tissue
Acute pancreatitis risk factors
- Gallstones: women > men, gallstones obstruct bile duct and area where common bile duct pancreatic duct empty into dudoenum
- Alc: men > women, 1/3 of all cases, usually after binge drink
Other causes:
- Trauma
- Surgery
- Bile duct abnormalities
- Medication reactions
- Infectious organisms
Acute pancreatitis clinical manifestations
- *Sudden severe epigastric pain in LUQ, mid-abd, radiation to back shoulder & blades
- *Signs of severe acute pancreatitis Grey Turner’s sign: flank bruising d/t leaking exudate and blood
- *Cullen’s sign: umbilicus bruising indicating hemorrhage, inflamm & tiss damage
Acute pancreatitis nursing assess
- VS: increased T, HR, tachypnea, low BP
- Oxygen status: pleural effusion
- Pain
- Abd assess: rebound tenderness, guarding, rigid abd muscles
- *Grey turner’s sign or Cullen’s sign
- *Serum amylase high, serum glucose high, hypocalcemia
Acute pancreatitis nursing intervention
- Maintain NPO status
- IV fluid administration
- Provide enteral nutrition per orders
- Administer ordered meds: analgesics, antiemetics, histamine blockers/PPIs, antispasmodics, sedatives
- Encourage cough and deep breathing
Acute pancreatitis pt education
- *Dz symptoms, progression, diagnostic procedures, interventions
- *Abstain from alc
- Abstain from smoking
- Nutritional counsel, low-fat diet, small freq meals, vitamin supplements
- Med education
Chronic pancreatitis risk factors
*Heavy alc consumption = #1 cause
Other risk factors:
- Age
- African American race
- Hereditary disorder of pancreas
- Cystic fibrosis
- Hypercalcemia, hyperlipidemia, hypertriglyceridemia
Chronic pancreatitis
Inflamm cause release of pancreatic enzyme –> autodigestion of pancreas for prolonged time –> fibrosis, loss of normal pancreatic function
Chronic pancreatitis clinical manifestations
- Upper abd LUQ pain that radiates to back
- Pain worsens after overeating or drinking (especially alc)
- N/V
- Weight loss despite regular eating pattern
- Diarrhea
- Pale/clay-colored stools
- Steatorrhea or oily stools
Chronic pancreatitis nursing assess
- Vital signs + weight
- Labs: blood gluc, amylase, lipase, LFTs
- Pain & abd exam
- Jaundice: skin, sclera, stool
Chronic pancreatitis nursing interventions
- Administer meds as ordered: pancreatic enzymes, GI prophylaxis
- Pain relief measures
- Nutritional eval + consult
Chronic pancreatitis pt teaching
- Avoid alc
- Do not chew pancreatic enzymes (extended-release formulation)
- Low fat diet
- Avoid foods irritating gastric lining
- Alc and smoking cessation programs
Pancreatic CA
- Ductal adenocarcinoma
- Neuroendocrine tumors
- Insulinomas
- Glucagonomas
Pancreatic CA risk factors
*Exact cause unknown
High associations:
- Cigarette smoking
- High-fat diet
- Consumption of meats, fried foods, refined sugars, nitrates
- Diabetes
- Chronic pancreatitis
- Family hx of pancreatic CA
- Ashkenazi Jewish descent
- African American race
- Age > 60 yrs
- Men > women
Pancreatic CA medical/nursing management
- Pain: opioids, nerve blocks
- Exocrine/endocrine: insulin, pancreatic enzymes
- Biliary obstruct: endoscopic stenting procedures to restore bile flow
- Weight loss: high calorie diet, appetite stimulants
- Palliative care
- Psychosocial/spiritual support
Locally advanced unresectable dz:
- Palliative concomitant chemo + radiation therapy
Metastatic dz:
- Palliative systemic chemo + investigational chemo
Pancreatic CA nursing management
- Pain management (PCA) + assess
- *NG tube to low suction: DO NOT MANIPULATE. Could disrupt anastomosis.
