Hepatic and Pancreatic Disorders Flashcards
What is cirrhosis?
irreversible scarring of liver due to hepatic inflammation and necrosis
What are some complications of cirrhosis?
– complications depend of amount of damage
- portal hypertension – major complication
- development of nodular tissue – blocks bile ducts and blood flow
- hepatomegaly – due to blockage of bile and blood, causing fluid to accumulate
- ascites – free fluid accumulation in abdominal cavity –> hypoperfusion of kidneys –> renal failure –> more ascites
- bleeding esophageal varices
- coagulation defects – clotting factors 2, 7, 9, 10
- jaundice – due to inability to excrete bilirubin
-
hepatic encephalopathy – toxins that cannot be cleared by the liver accumulate in the blood and travel to the brain, impacting brain function
- end-stage liver failure
- ALOC – from elevated ammonia
- elevated ammonia
- hepatorenal syndrome – impaired kidney function due to liver disease
-
bacterial peritonitis
- presents as increased leukocytes
What are the 3 types of cirrhosis?
- Laennec’s: alcoholic
-
postnecrotic: viral hepatitis or drugs
- usually caused by hep C
- biliary: biliary obstruction in gallbladder or autoimmune disease
What are some causes of liver disease?
- hepatitis C – leading cause of cirrhosis
- alcohol
- drugs and toxins
- IV drug use can cause liver disease
- acetaminophen
- gallbladder disease – obstruction in common bile duct –> enlarged liver and liver damage
- metabolic / genetic causes
- cardiovascular disease
What are the early and late signs and symptoms of liver disease?
– early:
- fatigue
- weight changes
- GI symptoms
- N/V
- anorexia
- abdominal pain
- liver tenderness
- pruritis
– late:
- jaundice and icterus (jaundice sclera)
- dry skin
- rashes
- petechiae
- ecchymoses
- warm, bright red palms
- spider angioimas
- peripheral dependent edema
- extremities
- sacrum
What are some assessments that might indicate liver disease?
- ascites
- protrusion of umbilicus
- caput medusae (dilated abdominal veins) – AKA medusa veins in abdomen
- hepatomegaly
- bloody stools
- fector hepaticus (fruity/musty breath)
- amenorrhea
- genital changes
- asterixis (inability to sustain posture, resulting in rapid, jerking movements)
What are the lab values to look out for with liver disease?
- increased ALT
- specific to liver
- increased AST
- specific to cardiac, muscle, kidney, brain
- increased lactate dehydrogenase (LDH)
- due to destruction of liver cells
- increased alkaline phosphatase
- due to biliary obstruction
- increased total bilirubin
- increased total urobilinogen
- increased prothrombin time
- damaged liver cannot produce enough prothrombin, decreasing clotting time
- increased ammonia
- increased creatinine
- decreased total protein
- decreased albumin
- decreased platelets
- decreased H&H
What are some interventions for ascites?
- nutrition
- low sodium
- fluid restrictions
- vitamin supplements and electrolyte replacements
- banana bags = thiamine, folic acid, magnesium sulfate
- drugs
- diuretics
- paracentesis
- important to assess for hypovolemia since body has become accustomed to excess fluid
- elevate HOB to minimize SOB
- sit in chair
- surgical
- shunting fluid out of venous system
- peritoneovenous
- portocaval
- transjugular intrahepatic portosystemic shunt (TIPS) – controls long-term ascites; reduces variceal bleeding
- shunting fluid out of venous system
How are pts assessed for hemorrhage?
endoscopy – screen pts early, especially UGIB
What are some interventions for esophageal bleeds?
- drugs
- non-selective beta blockers
- sandostatin
- vasopressin
- endural
- coreguard
- non-selective beta blockers
- gastric intubation
- esophagogastric tamponade – short-term control of bleeds
- blood transfusion
- vasoactive therapy
- endoscopic procedures
- magnet at base of esophagus
- esophageal variceal ligation
- sclerotherapy
- TIPS
What are some interventions for hepatic encephalopathy?
- control elevated ammonia levels
- ammonia is toxic to brain
- liver filters out
- produced from protein breakdown
- restricted protein diet
- drugs
- lactulose – promotes ammonia excretion
- neomycin sulfate
- intestinal antiseptic – eliminates good bacteria to decrease ammonia production
- metronidazole – intestinal antiseptic
What is hepatits? Why are they important?
– hepatitis: viral inflammation of liver cells by
- hepatitis A
- hepatitis B
- hepatitis C
- hepatitis D
- hepatitis E
– important because hepatitis cases must be reported to local health department who will then notify the CDC
Describe hepatitis A (HAV).
- typical viral syndrome – flu-like symptoms
- often goes unrecognized
- non-specific GI symptoms
- spread via fecal-oral route
- contaminated water, shellfish, foods
- spread via oral-anal sexual activity
- susceptible to chlorine bleach
- incubation = 15 - 50 days
- not life-threatening
- more severe in pts 40+
Describe hepatitis B (HBV).
- spread via
- unprotected sex
- sharing needles/needle sticks
- blood transfusions
- hemodialysis
- maternal-fetal route
- healthcare works often get this type
- incubation = 25 - 180 days
- symptoms:
- anorexia
- N/V
- fever
- fatigue
- RUQ pain
- dark urine
- light stool
- joint pain
- jaundice
- carriers can infect others even without symptoms
Describe hepatitis C (HCV).
- spread via
- sharing needles/needle sticks
- blood/blood products
- organ transplants prior to 1992
- tattoos
- intranasal cocaine
- incubation = 21 - 140 days
- pts are often asymptomatic
- damage occurs slowly over decades
- can be a carrier without symptoms
- leading cause for liver transplants in US
Describe hepatitis D (HDV).
- spread via
- parenteral route
- sexual contact
- incubation = 14 - 56 days
Describe hepatitis E (HEV).
- endemic areas
- waterborne epidemics
- travelers to endemic areas
- spread via fecal-oral route
- similar symptoms to HAV
- incubation = 15 - 64 days
What are important labs to assess for hepatitis infections?
liver panels and liver enzymes
What are some interventions for hepatitis?
– decrease demands of liver
- physical rest
- psychological rest
- nutrition
- restrict proteins
- restrict fats
- high carbs
- drugs
- use medications sparingly to decrease liver damage
- antiemetics
- antivirals
- immunomodulators
What is steatosis?
fatty liver – caused by accumulation of fats in and around liver cells
What causes steatosis?
- DM
- obesity – most common cause
- elevated lipid profile
- alcohol abuse
How does steatosis present?
many pts are asymptomatic and may only present with an elevated liver profile
What are hepatic abscesses? Which pathogens cause hepatic abscesses? How is it diagnosed?
– hepatic abscess: liver invaded by bacteria or protozoa, causing an abscess
– pathogens:
- E. coli
- Staph
- Salmonella
- gallstones – not a pathogen, but you know…
– diagnosed with CT or ultrasound
What are some interventions for hepatic abscesses?
- drainage
- antibiotics
What are some clinical manifestations of liver trauma? What are some interventions for liver trauma?
– clinical manifestations:
- abdominal tenderness
- distention
- guarding
- rigidity
– interventions:
- surgery
- blood products
What is the most common complaint in pts with liver cancer?
– common complaint = abdominal discomfort
- liver cancer is one of the most common tumors in the world
- prognosis is not very good
What are some interventions for liver cancer?
- chemotherapy
- hepatic artery embolization – block blood to tumor
- hepatic arterial infusion (HAI) – chemo drug pumped directly into liver supply to damage tumor
- surgery
– liver cannot tolerate high levels of chemo, so treatments are limited
When is liver transplantation used?
to treat end-stage liver disease
What are some complications of liver transplantation?
- graft rejection
- infection
- hemorrhage
- hepatic artery thrombosis
- fluid and electrolyte imbalance
- pulmonary atelectasis (lung collapse)
- acute renal failure
What is acute cholecystitis? What are the 2 types? What commonly accompanies cholecystitis?
– acute cholecystitis: inflammation of gallbladder
- calculous: inflammation with gallstone
- acalculous: inflammation without gallstone
– cholelithiasis (gallstones) often accompany cholecystitis
- may be accumulation of cholesterol, bile salts, and pigments
What is chronic cholecystitis? What are some signs and symptoms?
– chronic cholecystitis: repeat episodes of cystic duct obstruction resulting in chronic inflammation with calculi almost always present
– s/s
- pancreatitis
- cholangitis – infection of common bile duct
- jaundice
- icterus
- obstructive jaundice
- pruritis
- flatulence
- dyspepsia
- eructation (belching)
- anorexia
- N/V
- abdominal pain – usually after fatty meals
- biliary colic – pain and spasms
- Murphy’s sign – pain on R side that increases with inspiration
- Blumberg’s sign – rebound tenderness
- steatorrhea – due to impaired urobilinogen production
- McBurney’s point pain
What are some interventions for cholecystitis?
- nutrition
- low fat
- fat-soluble vitamins and bile salts
- drugs
- opioids – morphine or hydromorphone
- anticholinergics
- antiemetics
- extracorporeal shock wave therapy – shock waves to reduce pain and help healing
- biliary catheter insertion
- surgery – most common treatment
- cholecystectomy
- laparoscopic = gold standard
- most important postop intervention = pain management
- referred shoulder pain
- free air pain – CO2 retention in abdomen
- most important postop intervention = pain management
- traditional open cholecystectomy
- very rarely done anymore
- only doen with severe biliary obstruction
- laparoscopic = gold standard
- cholecystectomy
Which population most commonly experiences gallbladder cancer? What are some signs and symptoms of gallbladder cancer? What are some interventions?
– women experience gallbladder cancer more than men
- poor prognosis
– s/s
- anorexia
- weight loss
- N/V
- malaise
- jaundice
- hepatosplenomegaly
- chronic, progressive, severe epigastric pain or RUQ pain
– interventions:
- surgery
- radiation
- chemo – not very effective due to proximity to liver
What is acute pancreatitis?
serious, potentially life-threatening inflammation of pancreas causing autodigestion and fibrosis
What are some complications of acute pancreatitis?
- pleural effusion, respiratory distress, pneumonia
- L lung due to pancreatic exudate
- multi-organ failure
- hypercoagulation
- DM
What are some signs and symptoms of acute pancreatitis?
- LUQ pain radiates to back or shoulder
- abdominal tenderness
- rigidity
- guarding
- jaundice
- Cullen’s sign – belly button discoloration
- Turner’s sign – flank and sides discoloration
- decreased bowel sounds
- pancreatic ascites
- vital sign changes – resembles septic shock
- tachycardia
- hypoxia
- hypotension
What are some lab assessments for acute pancreatitis?
- amylase – elevated for a few days
- lipase – elevated for weeks
- trypsin – elevated
- alkaline phosphatase – elevated if biliary involvement accompanies pancreatitis
- WBC – elevated
- glucose – elevated from beta cell damage
- calcium – decreased
What is chronic pancreatitis? What are some interventions?
– chronic pancreatitis: progressive, destructive disease of the pancreas characterized by remissions and exacerbations
- pain is most common symptom
– interventions
- drugs
- opioids
- PPIs
- analgescis
- enzyme replacements to help with digestion
- insulin
- nutrition
Why are pancreatic abscesses dangerous? What is the main symptom of pancreatic abscess? What is the main diagnostic test? What are some interventions?
– can be fatal if untreated; most serious complication of necrotizing pancreatitis
– main symptom = high fever (104 F)
– diagnostic = blood cultures to determine if pt is septic
– interventions:
- drainage
- percutaneous
- laparoscopy
- antibiotics
What is a pancreatic pseudocyst? What are some complications? What are some interventions?
– pancreatic pseudocyst: cyst encapsulated on pancreas
– complications
- hemorrhage from rupture
- infection
- bowel obstruction
- abscess
- fistula
- pancreatic ascites
- epigastric pain that moves to back
– interventions
- surgery
- percutaneous
- endoscopy
- surgical drainage
- may resolve spontaneously
Where is the most common location for a pancreatic carcinoma? Discuss pancreatic carcinoma prognosis and progression.
– head of pancreas most common location
– 5 year survival rates – poor prognosis
– metastasis spreads rapidly through lymph and venous systems
What are some interventions for pancreatic carcinomas?
- drugs – palliative
- radiation
- decrease size and pain
- helps with food absorption
- biliary stent to keep ducts open
- Whipple procedure – removal of multiple portions of pancreas
- success rate is not very good
- radical pancreatectomy
