Hepatic and Biliary Disorders Flashcards
most common disorder of the biliary system
cholelithiasis
what is cholelithiasis
stone in the gallbladder
- vary in size, shape, and composition
risk factors for cholelithiasis
Female
Multiparity
Age 40 and older
Estrogen therapy
Sedentary lifestyle
Familial tendency
Obesity
Rapid weight loss
Diabetes Mellitus
Cirrhosis
clinical manifestations of cholelithiasis
Symptoms vary from mild to severe
Epigastric Distress
* Fullness, abdominal distention, vague pain in RUQ of abdomen
Biliary Colic
* RUQ abdominal pain that radiates to the back or right shoulder
* Nausea/Vomiting
* Pain will fluctuate (can last from 30 minutes to 6 hours)
* Chills
* Belching/Bloating
* Marked tenderness in RUQ on deep inspiration
Pain more severe when stones moving or obstructing
When an obstruction of the bile ducts occurs:
* Dark amber, foamy urine
* Clay-colored stools
* Pruritis
* Intolerance to fatty foods
* Steatorrhea
— Excessive fat in stool due to lack of bile acid in the
intestine leading to fat malabsorption
* Jaundice
what is cholecystitis
acute inflammation of gallbladder
gallbladder becomes filled with purulent fluid (pus)
repeated episodes of what will lead to development of cholecystitis
obstruction of the cystic duct
CLINICAL MANIFESTATIONS OF CHOLECYSTITIS
- Indigestion
- Fever, chills
- Jaundice
- Pain, tenderness, and rigidity of RUQ
— Radiates to back, right shoulder or scapula - Nausea/vomiting
- Restlessness
- Diaphoresis
- Leukocytosis
- Positive Murphy Sign
— Right subcostal tenderness
—you will press on right upper quandrant and find pt in sever pain***
diagnostics studies of cholecystitis
Ultrasound
HIDA Scan
ERCP (Endoscopic retrograde cholangiopancreatography)
Percutaneous transhepatic cholangiography
* Increased WBC count
* Increased alkaline phosphatase level
* Increased liver enzyme levels
* Potential increased bilirubin level with bile duct obstruction
PHARMACOLOGIC THERAPY FOR CHOLELITHIASIS
Treatment dependent on stage of disease
Uses in symptomatic patients
* Ursodeozycholic acid (Ursodiol)
* Chenodeozycholic acid (Chenodiol)
what is an ERCP (Endoscopic retrograde cholangiopancreatography)
- Endoscope utilized to visualize the common bile duct through the duodenum
- Utilizes x-ray techniques to view the ductal structures of the biliary tract
- Helpful in detecting and treating bile duct stones
- Placement of stents for blocked bile ducts
ERCP with Sphincterotomy
Removes gallstones and bile duct blockages
CARING FOR THE PATIENT - ERCP
- Conscious Sedation
- Initially, patient placed in the left side-lying position with knees flexed
— Then, once the endoscope is placed in the duodenum, the patient will be positioned in a prone or semi-prone position - Patient may experience abdominal discomfort for a few hours following the ERCP
- Complications: Pancreatitis, sepsis, hemorrhage, aspiration
EXTRACORPOREAL SHOCK-WAVE LITHOTRIPSY (ESWL)
- Used if stones cannot be removed via endoscope or not a surgical candidate
- High-energy shock waves disintegrate gallstones
- Takes 1 to 2 hours
- Used in conjunction with bile acids (Ursodiol or Chenodiol)
LAPAROSCOPIC CHOLECYSTECTOMY
- Removal of the gallbladder is performed through a small incision or puncture made through the abdominal wall at the umbilicus.
- Four incision sites
- Abdominal cavity is inflated with carbon dioxide to assist in inserting the laparoscope and aid in visualizing the
abdominal structures. - Once the cystic duct is dissected, the common bile duct will be visualized by ultrasound or cholangiography to evaluate the anatomy and identify stones
- Gallbladder is then removed after the bile and small stones are aspirated
pros of a laparoscopic cholecystectomy
Minimal postoperative pain
* Referred pain to right shoulder
Less risk of a paralytic ileus
Few complications
* Bile Duct Injury - stone gets stuck
* Bile Peritonitis - sepsis to death
cholecystectomy
Gallbladder is removed through an open
abdominal incision
* Location: Right Subcostal
Bile Leak
* Drain Placement
* Placed in gallbladder bed and brought out through a puncture
wound in the skin
* Drainage amount decreases and drain will be removed
acute care of treating hepatic and biliary disorders
Nursing goals
* Treat pain
* Relieve nausea and vomiting
— Gastric Decompression
— Antiemetics
* Provide comfort and emotional support
* Maintain fluid and electrolyte balance and nutrition
* Observe for complications
what is acute pancreatitis
Inflammatory process of the pancreas due to activated pancreatic enzymes
* Self-digestion of the pancreas by its own proteolytic
enzymes (Trypsin)
common causes of acute pancreatitis
- Gallbladder disease (gallstones)**
- Alcohol abuse**
- Drug use
- Trauma
- Viral infections (Cytomegalovirus (CMV), Mumps)
- Peptic ulcer disease
- Hyperlipidemia
- Prescribed medications
- Surgery
acute manifestations of acute pancreatitis
- Severe abdominal pain
— Location: Mid-epigastrium and LUQ
— Occurs 24-48 hours after a heavy meal or
alcohol ingestion
— Pain may be diffuse and/or radiate to the
back
— Unrelieved by antacids - Abdominal distention
- Hypoactive bowel sounds
- Grey-Turner Sign
— Ecchymosis in the flank - Cullen Sign
— Ecchymosis around the umbilicus - Nausea/Vomiting
- Fever
- Jaundice
- Agitation
- Tachycardia
- Hypotension
diagnostics tests for acute pancreatitis
Increased serum amylase/lipase levels**
Increased C-Reactive Protein (CRP) level
Leukocytosis
Hyperglycemia/Glucosuria
Hypocalcemia
Increased serum bilirubin levels
Abnormal findings on ultrasonography/contrast-enhanced CT Scan/MRI
interprofessional care for acute pancreatitis
Goals include:
* Relieving pain and discomfort
* Prevention or alleviation of complications
* ↓ Pancreatic secretions to minimize pancreatic stimulation
* Hydration
* Correction of fluid/electrolyte imbalance
* Prevention/treatment of infections
* Removal of precipitating cause
NURSING MANAGEMENT – RELIEVING PAIN & DISCOMFORT of acute pancreatitis
- Goal: Decrease secretion of pancreatic enzymes to relieve pain
- Analgesics
- NG Tube Suctioning
— Used to relieve severe nausea/vomiting and/or treat
abdominal distention - Bed rest
— Decrease metabolic rate & decrease secretions of
pancreatic and gastric enzymes
NURSING MANAGEMENT – IMPROVING NUTRITIONAL STATUS of acute pancreatitis
- NPO with enteral nutrition
— Prevents pancreatic enzyme release, maintains gut integrity, enhances immune system functioning, and demonstrates lower complication rates - Daily weights
- Electrolyte levels
- CBGs every 4-6 hours
- Oral feedings will gradually be reintroduced as acute symptoms subside
— Diet high in carbohydrates and low in fats/proteins
— Avoid heavy meals and alcoholic beverages
NURSING MANAGEMENT – POTENTIAL COMPLICATIONS of acute pancreatitis
- Fluid & Electrolyte Imbalances
— Assessing skin turgor, moistness of mucous membranes, daily weights, fluid intake and output, NG secretions - Hypocalcemia
— Monitor for Chvostek’s Sign
— Monitor for Trousseau’s Sign - Hypomagnesemia
- Pancreatic Necrosis
- Hypovolemic Shock
- Septic Shock
WHAT ARE ESOPHAGEAL VARICES?
- Dilated, tortuous veins found in the lower esophagus, but can develop higher in the esophagus or extend into the stomach
- Develop due to portal hypertension in relation to liver
disease
clinical manifestations of esophageal varices
Bleeding Esophageal Varices:
* Hematemesis
* Melena
* Deterioration in mental and physical status
* History of alcohol use disorder
Hypovolemic Shock
* Decreasing urine output
* Oliguria
* Hypotension
* Decreased pulse pressure
* Flat neck veins
* AMS
* Delayed capillary refill
* Pallor
* Tachycardia
* Tachypnea
diagnostics of esophageal varices
Esophagogastroduodenoscopy (EGD)
* Assess variceal size, location, and variceal features
— Variceal size helps determine pharmacologic and endoscopic therapies to prevent/manage risk of bleeding
* Acute Care Setting: Procedure typically occurs within 12
hours after stabilization of patient
nursing management of esophageal varices
- Continuous vital sign monitoring
- Signs/Symptoms of Hypovolemia
- CVP Monitoring
- ABG’s
- Intravascular volume depletion
- Urine Output
pharmacologic therapy of esophageal therapy
Antibiotic Therapy
* IV Ciprofloxacin
* IV Ceftriaxone
Octreotide
Somatostatin
Non-selective Beta-Blockers
* Propranolol, Nadolol, Timolol, Carvedilol
IV Vasopressin
* Used in conjunction with IV Nitroglycerin
ENDOSCOPIC THERAPIES for esophageal varices
Esophageal Banding Therapy (Variceal Band Ligation)
* EGD
* Elastic Rubber Band
* Most effective therapy in treating acute hemorrhage of varices
Endoscopic Injection Sclerotherapy
* Sclerosing agent injected into bleeding esophageal varices to promote thrombosis and eventual sclerosis
* Only used to treat acute variceal bleeding if esophageal banding cannot be done
Balloon Tamponade
* Temporary measure to control bleeding during an
active hemorrhage
* Pressure exerted on the upper portion of the stomach and against the bleeding varices by a double balloon
tamponade
* Lethal Complications: Esophageal rupture, aspiration, rebleeding
Transjugular Intrahepatic Portosystemic Shunting (TIPS)
* Used in patients if medications and band ligation are
unsuccessful
* Controls acute variceal hemorrhage by lowering portal
pressure
* Allows blood flowing into the liver from the portal vein to
flow through the TIPS stent directly into the hepatic vein,
which is the vein that drains blood out of the liver. This
reduces portal hypertension.
POST-ENDOSCOPIC THERAPIES
Medications
* Antacids
* Histamine-2 Antagonists
* PPI
Vital Signs
Neurological Status
Nutritional Status
Blood Transfusions
Education & Support
