liver and pancreas Flashcards
Stages of liver damage:
Health liver Fatty liver (increase liver due to fat deposits) Fibrosis liver (formation of scar tissue) Cirrhosis liver (liver cell destruction)
What is total bilirubin
The direct and indirect bilirubin (total is combined direct and indirect)
– waist product from breakdown of blood cells
Total bili range
0.3-1.0
ALT
helps metabolize proteins
8-40
AST
Helps metabolize protein and ALT
10-40
GGT
0-30
LDH (lactic acid dehydrogenase)
shows erythrocyte damage
100-225
Alk phos
Breaks down proteins and elevares in bone cancer or problems
30-120
Amylase
23-85
pancreatic enzyme - elevates with not working well
lipase
0-160
elevates with not working well
Jaundice: patho
impairment of bodies ability to metabolize and secrete bilirubin
serum bilirubin levels > 3
Jaudice: cause –> hepatocellular
Hepatitis, hepatotoxins
Jaundice: cause –> obstructive process
Cholelithiasis
Cancer
pancreatitis
Hemolytic jaundice
Increased production of bilirubin due to hemolysis
Multiple transfusions
Hereditary hyperbilirubinemia
Impaired bilirubin metabolism
May require transplant
portal HTN
Increased resistance to blood flow through the liver and increased blood flow due to vasodilation in the splanchnic circulation
Portal HTN: complications
Ascites
Gastroesophageal varices
Esophageal varices: endoscopic therapies
Esophageal banding
Sclerotherapy
Balloon tamponade
Esophageal varices: sclerotherpy
used for acute bleed to promote thrombosis
Ascites
Loss of fluid into the peritoneal space causes further sodium and water retention by the kidneys
Ascites: dietary modification
decrease Na
Ascites: diuretics
Spironolactone and furosemide Daily weight (may have weight loss daily limit)
Ascites: paracentesis
temporary removal
Ascites: TIPS
Diverts blood flow from high pressure hepatic bed to low pressure vascular bed
Increases risk of hepatic encephalopathy
Ascites: complications
Fluid overload
E coli
peritonitis – spontaneous from all the pressure changes
Long term antibiotic therapy after diagnostic paracentesis
Cirrhosis: patho
normal liver tissue is replaced by fibrotic tissue in response to damage to liver cells
more prone to ulcers
Focused assessment changes
Hepatic encephalopathy: assessment
Anorexia NV muscle waisting urine for presence of bilirubin stool tan or gray with jaundice resp. status itching hepatorenal encephalopathy
Hepatic encephalopathy: labs/diagnostics
EGD Liver Biopsy liver labs increased bili low albumin
Hepatic encephalopathy: interventions
Oral hygiene - promote intake and high calories Manange skin integrity I&O and daily weight BP (hypotension from varices) HR IV fluids Balloon tamponade for varices
Hepatic encephalopathy: complications
Ascites jaundice hepatorenal syndrome Bleeding varices coagulation defects Encephalopathy
Hepatic encephalopathy: albumin
Get it if they’re exceedingly low or if we are trying to minimize effect of its loss after paracentesis
Hepatic encephalopathy: education
- skin care
- medications
- no ETOH
- bowel maintenance
- Na restriction and food selections
- nutritional supplements
- NSAID acetaminophen safety
- follow ups
- check with provider pharmacist for OTC
- ascites
- weigh and log
- support groups
What is alcoholic liver disease
Excessive consumption of alcohol
AST/ALT > 2
How do we ID someone of having alcoholic liver disease?
CAGE questions
Supportive groups
Hepatitis A B and C
Inflammation of the liver from a viral source
Hepatitis: vaccines
only for A and B
Hepatitis: prevention
follow up to minimize the complication of cirrhosis and liver cancer
What are general s/s of hepatitis
fatigue loss of appetite abdominal pain diarrhea vomiting joint pain jaundice
Hepatitis: labs and dx
liver enzymes specific immunoglobulin tests serum and urine bili coags ultrasound liver biopsy
Hepatitis interventions
rest balanced diet small, frequent means IV nutrition if needed fluids - oral or IV if needed I&O fluid/electrolyte balance
Hepatitis meds
- -antipruitics
- antiemetics
- anti virals
hepatitis education
- treatment recommendations
- transmission and prevention
- complications relapse follow up care
- B C- cannot donate blood
Hepatitis A
Fecal oral person to person infected food if the food maker is a carrier positive forever immunizations available (2 doses)
Hepatitis B: transmission
Blood, sexual secretions transmission
Mother to baby (biggest transmission)
Hepatitis B: incubation
long incubation period
Hep B: prevention transmission
sexual protection
vaccine
Hep B: antiviral therapy depending on viral levels
The higher the viral load
What is important to keep in mind for hepatitis vaccines
Just because you’ve been vaccinated doesn’t mean you carry the correct antibodies
What is the primary cause of liver cancer?
Hepatitis B
Hepatitis C: transmission
Primarily drug IV use
- blood to blood
Hep C: s/s
may have no s/s
Hepatitis C: prognosis
20-50% clear infection spontaneously
Antiviral therapy can cure it
Majority develop chronic infection. it can progress to cirrhosis if untreated - slow to develop
What is the leading cause of drug induced liver disease?
Acetaminophen - should not exceed 3-4,000 mg a day
other causes: abx, NSAIDS, TB meds
Why are medications that have a “first pass effect” a leading causing to drug induced liver disease?
Medications that have a “first pass” effect (large amount is metabolized by the liver before reaching systemic circulation…..liver disease increases bioavailability of these medications
Hepatocellular carcinoma: risk factors
Cirrhosis and chronic B & C hepatitis put you at higher risk for developing this
Hepatocellular carcinoma: hemochromatosis
Excessive retained iron in body. If this value is high, the patient will get blood taken out of the body to decrease this value. The client should also eat a low iron diet
Hepatocellular carcinoma: diagnosis and treatment
Dx: liver biopsy
Tx: liver transplant
What is the Treatment of choice for acute liver failure and ESLD (end stage)
liver transplant
liver transplant: complications
Primary graft non-function
Bleeding
Infection
Rejection
Why is a liver transplant easier than a kidney transplant?
you only need to match the blood type
Cholethiasis
Calculi or gall stone form in gall bladder
Cholelithiasis: s/s
Largely asymptomatic or RUQ pain with referral pain to right shoulder often associated after a fatty meal
Pain associated with obstruction of duct may cause abscess, necrosis and perforation
Usually the pain stimulates after a fatty meal because GB can’t excrete bile (n/v, diarrhea)
Stone can obstruct – peritonitis
Cholecystitis
Acute inflammation of gall bladder
- Repeated obstruction of cystic duct by gallstones
- Empyema of gallbladder causes gallbladder to fill with purulent fluid
- Bile can not leave the gall bladder initiating a chemical reaction causing autolysis and edema, gall bladder becomes distended due to increased pressure and vascular compromise
Cholecystitis: assessment
Pain – severe, steady, colicky. May go away in an hour and just an achy feeling.
Radiation – epigastric, chest, right shoulder
What brought it in
NV Belching Flatulence Fever Jaundice Steatorrhea Bleeding (may impact liver)
Cholecystitis: labs/dx
- Ultrasound
- ERCP
- PercutaneousCholangiography
- CBC
- liver enzymes
- bili
Cholecystitis: interventions
- pain meds &antiemetics
- NPO
- -NG
- -IV fluids
- I & O
- low fat diet
- fat soluble vitamins
- pre and post op care
- T-tube care if open choley
Cholecystitis: meds
- NSAIDS
- morphine / fentanyl
- ursodeoxycholic acid
- cholestyramine
Cholecystitis: education
- medications
- follow up care incision recognize fever
- avoid fatty foods
- increase high fiber
- small meals
- increase diet gradually
Pancreatitis:
inflammation of the pancreas
– Pancreatic duct becomes temporarily obstructed, accompanied by hypersecretion of the exocrine enzymes of the pancreas
– These enzymes enter the bile duct where they are activated and with bile reflux into the pancreatic duct
Pancreatitis: common cause
alcohol
gallstones
Acute pancreatitis: patho
Self digestion of the pancreas by its own proteolytic enzymes (tripsin)
Acute pancreatitis can lead to…
Causes inflammation, necrosis, erosion, hemorrhage
Multiorgan failure
Acute pancreatitis: assess
– pain- LUQ radiates to back - sudden onset piercing
– when last ate
– ETOH intake - can make it worse
- fatty foods - can make it worse
– fever
– N/V
– guarding
– distention
– ileus
– Cullens
– Grey Turners
– tachy
– hypotensive
– pleural effusion, atelectasis, ARDS
Acute pancreatitis: labs/dx
Amylase lipase (both going to be high) glucose gonna be high triglycerides gonna be high Calcium = low Stool – changes Ultrasound MRI
Acute pancreatitis: causes
Idiopathic Gallstones ETOH Trauma Steroids Mumps virus Autoimmune diseases Scorpion stings Hypertriglycermia/hypercalcemia Endoscopic retrograde cholangiopancreatigraphy (ERCP) Drugs
“I GET SMASHED”
Acute pancreatitis: interventions
– NPO
– IV fluids
– NG Tube
– TPN
– Oxygen sat > 95%
– morphine for pain
– HOB 45 deg
– glucose
– hyperglycemia
– PPI / H2 blocker to reduce HCL secretions = prevent pancreatic enzyme secretion
– HR, BP, RR, sat
– vasoactive meds if significant hypotension
– may need surgery (not go to) or ERCP
Acute pancreatitis: Complications
- pseudocyst –rupture= bleeding and infection
- kidney failure
- dev. diabetes
- pancreatic cancer
- respiratory problems
Acute pancreatitis: meds
- pancrelipase
- morphine
- PPI
- antispasmodics
- diyclomine
Acute pancreatitis: education
- triggers to avoid
- avoid fatty foods
- how to take pancreatic enzymes
- signs and symptoms of diabetes
Chronic pancreatitis: patho
Recurrent attacks of severe upper abdominal and back pain accompanied by vomiting
Chronic pancreatitis: nonsurgical management
Pain management
Pancreatic enzyme replacement
PPI to reduce gastric acid inactivation of enzymes
Fat soluble vitamin supplementation
Chronic pancreatitis may develop what
DM
Chronic pancreatitis: surgical management –> Pancreaticojejunostomy
Drainage of pancreatic enzymes into the jejunum
Chronic pancreatitis: surgical management –> Pancreaticoduodenectomy
Relieves pain
Causes of chronic pancreatitis:
Longstanding heavy alc use
smoking
chronic pancreatitis develops slow over time
Pancreatic cancer: s/s
present with pain or jaundice
Rapid and profound weight loss
DM
Diarrhea and steatorrhea
pancreatic cancer: pain management
huge because this is very painful
pancreatic cancer: end of life care
Palliative care in early in this diagnosis to help patient become comfortable because this IS terminal
what percent of people benefit from surgical resection of pancreatic cancer?
only 10-20%
