Liver, Biliary, and Pancreatic Disorders Flashcards
right lobe of the liver is separated from the right lung and pleura by the
right dome of the diaphragm
80% of the blood to the liver comes from the
portal veins
20% of the blood (oxygen-rich) to the liver comes from the
hepatic artery
hepatic artery supplies liver with
oxygenated blood
portal vein drains the viscera (abdomen and spleen) and delivers blood to
the liver
central veins in the liver join to form the _________ which drains into the inferior vena cava
hepatic vein
small bile ducts throughout the liver join to form the ________ which carries bile formed in the liver and other secretions
hepatic duct
the cystic duct comes from the gallbladder to release bile and combines with the hepatic duct to then form the _________ which empties into the small intestine
common bile duct
Functions of the liver
Glucose Metabolism
Protein Metabolism
Fat Metabolism
Conversion of Ammonia
Bile Formation
Bilirubin Excretion
Drug Metabolism
Vitamin and Iron Storage
The liver stores what vitamins?
vitamins A,D,E,K, and B12
up to ___% of the liver can be damaged before you see a change in lab values
70%
Portal Vein brings glucose to liver to
store as glycogen
When the liver converts glycogen to glucose when needed
Glycogenolysis
glucose synthesized from non-carbs (proteins or lactate)
Gluconeogenesis
The liver breaks down fatty acids for production of energy into
ketone bodies and cholesterol/lipids
the liver synthesizes which plasma proteins?
albumin, clotting factors, fibrinogen
Vit K is required for
clotting factor synthesis
provides colloidal osmotic pressure within vascular system
Albumin
Vit K needs ____ to be absorbed
bile
Prothrombin cannot be made without
Vit K
Function of bile
to digest fats
Function of Kupffer cells :
Remove bacteria, debris , RBC
formed by hepatocytes, collected in bile ducts
Bile
Made of water, electrolytes, fatty acids, cholesterol, bilirubin, bile salts
bile
Pigment from breakdown of hemoglobin
bilirubin
Colors feces brown
bilirubin
A byproduct of gluconeogenesis that is converted to urea then excreted in urine (also a byproduct of bleeding)
Ammonia
the liver metabolizes these hormones
estrogen and aldosterone
refers to black stools that occur as a result of gastrointestinal bleeding.
Melena
A neurological disorder that causes a person to lose motor control of certain areas of the body.
Asterixis
Liver function tests:
specific to liver, elevated with liver disease;
hepatitis, cirrhosis
ALT (alanine aminotransferase)
Liver function tests:
increased with damage to the heart, liver,
muscle, kidney
AST (aspartate aminotransferase)
Liver function tests:
increased with alcohol abuse
GGT (gamma glutamyl transferase)
Liver function tests:
found in bones, liver and intestines (an increase is seen with biliary obstruction w/o bone disease)
ALP ((alkaline phosphatase)
cholestasis
bile is stasis
Liver function tests:
elevated in ischemic hepatitis
LDH
chemical elevated in liver failure
Ammonia
Elevated if bile duct obstruction, decreased in parenchymal liver disease
Cholesterol
For biopsy coagulation studies, must have consent and have
patient void prior
Post-Op biopsy care:
Right side position for 2-4 hours, apply pressure dressing
Stages of liver damage:
stage 1
healthy liver
Stages of liver damage:
stage 2 (reversible)
fatty liver
Stages of liver damage:
stage 3 (thickening/hardening)
liver fibrosis
Stages of liver damage:
stage 4
cirrhosis
Replacement of normal liver tissue with fibrosis/scar tissue
cirrhosis
Type of cirrhosis:
chronic alcoholism, most common cirrhosis
Alcoholic
Type of cirrhosis:
scarring after viral hepatitis
Post necrotic
Type of cirrhosis:
scarring to liver around the bile ducts, less common cirrhosis
Biliary
Type of cirrhosis:
from Right sided heart failure
Cardiac
80% of patients diagnosed _________ remain asymptomatic for the next 10 years (may have vague symptoms only)
compensate
Early signs of compensate are subtle:
GI, anorexia, nausea, vomiting , changes in bowel
symptoms advanced from portal HTN
Decompensated
Late signs of decompensate:
Portal Hypertension, ascites, edema, varices, encephalopathy
Late cirrhosis
decompensated
Scarred liver cells can not process the blood returning from GI, blood backs up in these organs causing high pressure
Portal Hypertension
Obstruction of venous blood flow through liver – increased capillary pressure
Increased intravascular volume
Decreased production of albumin
-FLUIDS SHIFT into PERITONEAL CAVITY
Liver can’t metabolize aldosterone – kidneys then retain Sodium and H2O
ASCITES
Collateral blood vessels -
Esophagus, stomach, lower rectum (hemorrhoids) develop new blood vessels to drain blood
VARICES
Blood with ammonia can not be metabolized in liver – gets circulated
Hepatic encephalopathy (in brain)
Shunting of blood
The obstructed spleen from the portal HTN: thrombocytopenia/anemia
Splenomegaly
keeps fluid where it belongs
albumin
spleen destroys
platelets and RBC’s
large veins on abdomen
caput medusae
Nursing interventions for Cirrhosis Patients
high carb, limited protein, low sodium diet
Smaller more frequent meals
Assess: abdominal percussion
Daily weights
Treating Ascites
Spironolactone
Fluid restrictions
Sodium Restrictions
Albumin
Daily weights, measure abdominal girth
Assess rate and effectiveness of respirations
blocks aldosterone and spares potassium
Spironolactone
keep fluid in intracellular space
Albumin
In ascites, respiratory issues are caused by
large abdomen
Catheter inserted to drain fluid
Often will give Albumin after procedure
Have patient void prior
Have patient sitting up in chair/bed
PARACENTESIS
Stent inserted from portal vein to hepatic to decrease pressure / divert blood
TIPS
TIPS
Transjugular Intrahepatic Portosystemic Shunt
The nurse assess pt with ascites. VSS BP: 128/78, P: 118, RR 28, Temp 98.9 Pulse ox 89% on room air. What is first thing to do?
a. Assess heart sounds
b. Prepare for paracentesis
c. Raise HOB
d. Assess lung sounds
c. Raise HOB
Life threatening condition from dilated, thin walled veins in submucosa of lower esophagus
Esophageal Varices
due to portal HTN - may rupture when chemically or mechanically irritated or when pressure is increased due to sneezing, coughing, Valsalva maneuver or excessive exercise
Esophageal Varices
Bleeding esophageal varies is an
EMERGENCY
Same process of esophageal varices causes veins in rectum to bulge
hemorrhoids
Medication that constricts esophageal veins to stop bleeding
Octreotide
Med given ASAP, before endoscopy
octreotide
med injected to cause inflammation & sclerosis
Endoscopic Sclerotherapy
after endoscopy, Pt remains NPO after until
return of GAG reflex
NGT with balloon inflated in esophagus to stop bleeding
Sengstaken Blakemore Tube
Risks of balloon tamponade
Tube dislodges, airway obstruction, (cut port for balloon to deflate ASAP)
Esophageal Varices is a risk factor for any patient admitted with
advanced cirrhosis
Hepatic Encephalopathy =
END STATE CIRRHOSIS
Portal HTN shunting of unfiltered blood (ammonia) to circulation
Hepatic Encephalopathy
Causes of high ammonia in hepatic encephalopathy:
GI bleeding (varices, melena) increase levels of Ammonia
High Protein diet, bacterial infection
Hypokalemia & alkalosis
Signs & Symptoms of hepatic encephalopathy:
Mental changes, motor disturbance, asterixis
Sleep….to COMA
Hepatic Encephalopathy Treatment
Lactulose
Antibiotic (neomycin)
Diet : monitored protein, high carb
laxative that traps and expels ammonia in feces (enema or oral)
Lactulose
Hepatic Encephalopathy can be reversible if
treated promptly
The nurse is giving lactulose to patient with hepatic encephalopathy. What effect should be seen
a. Increase urine output
b. Impaired level of consciousness
c. Increased bowel movements
d. Nausea and vomiting
c. Increased bowel movements
jaundice is seen with serum bilirubin levels
> 2.0 mg/dL
Type of Jaundice:
increase in destruction of RBC pigments in blood, cannot be excreted fast enough. Not
dangerous unless it gets very high
hemolytic
Type of Jaundice:
occlusion of the bile duct, can be intra or extrahepatic. Bilirubin cannot flow into the
intestines and “backs up” and is then reabsorbed into the blood
obstructive
Type of Jaundice:
seen with damaged liver cells that cannot clear bilirubin - seen with alcoholic damage and with medications that can cause hepatotoxicity
hepatocellular
Bile can’t flow into intestines causing
clay colored stool
Excess bile yellows skin/sclera and urine becomes
orange & frothy
Icteric
yellow sclera
Prolonged Jaundice predisposes pt to
stones and CNS damage
Manifestations of Liver Disease:
Edema from
hypalbuminemia
Manifestations of Liver Disease:
Thrombocytopenia causing
large spleen
Manifestations of Liver Disease:
Vitamin Deficiency
Vit A, D, E, K, Thiamin
Manifestations of Liver Disease:
Large belly BUT
Malnourished
Manifestations of Liver Disease:
Pruritus from retention of bile salts from
biliary obstruction / cholestasis
Manifestations of Liver Disease:
Gynecomastia, amenorrhea, testicular atrophy from
liver’s inability to metabolize hormones
Manifestations of Liver Disease:
Elevated Respiratory rate r/t
ascites
Common virus with symptoms similar to mono
Cytomegalovirus
Hepatitis by mode of transmission:
fecal/oral route; poor sanitation, person to person contact
- waterborne/foodborne
Hep A
Hepatitis by mode of transmission:
- by intimate contact with carriers or those w/acute disease; sexual and oral-oral contact
- perinatal transmission from mothers to infants
Hep B
Hepatitis by mode of transmission:
transfusion of blood and blood products; exposure to contaminated blood through equipment or drug paraphernalia
Hep C
Hepatitis by mode of transmission:
Contact with infected blood (occurs only in people already infected with Hep B)
Hep D
Hepatitis by mode of transmission:
Eating contaminated food or drink. Dangerous to pregnant women
Hep E
HCV antibodies testing basic info
If test is reactive its is most likely positive and RNA test is needed. both test confirm diagnosis
the 3 hepatitis antigens
surface antigen
E antigen
Core antigen
Blood born Heps
B/D and C
Food borne Heps
A and E
Liver cancer is usually caused by
another cancer in the body
Primary liver cancer is usually caused by
Hep B, C or cirrhosis
Hepatic Encephalopathy assessment requires
neuro checks
Bile made in liver travels via the common hepatic duct to the
common bile duct to the duodenum
Not all bile goes straight to the common bile duct, some is stored in
GB via the cystic duct
Liver makes up to ___cc of bile daily
700cc
GB can hold _____cc of bile
30-50cc
What does the gallbladder do?
Digest fats via the bile salts and cholesterol
Alkalize intestinal contents to aide in digestion
Inflammation of GB
Cholecystitis
90% of Acute cholecystitis from
Stones
Calculous in common duct:
choledocholithiasis
Calculous (stone) in GB:
cholelithiasis
GB condition caused by burns, severe trauma, major surgery, obstruction of cystic duct, or bacterial
Acalculous
More common in women older than 40, multiparous, increase weight
Chronic Cholecystitis
Older person with cholecystitis and comorbidities may have no symptoms until
septic
stone blocks bile flow – GB distends becomes inflamed and infected. Fever, possible palpable mass
Acute Cholecystitis
after heavy meal GB contracts b/c can not release bile – the GB can become gangrene!!
Biliary colic
tenderness in RUQ on deep inspiration or when GB palpated
Murphy’s sign
Vitamin Deficiency with cholelithiasis why??
Can not absorb fat sol vitamins w/o BILE!
Diagnostic test where tube goes down toward the duodenum then curves up into gallbladder
ERCP - Endoscopic Retrograde cholangiopancreatography
Can treat confirmed choledocholithiasis- CBD stone can be extracted with
ERCP
80% of patients with acute GB inflammation will achieve remission with:
IV Fluids
NG suction
Pain relievers * treat pain!!!
Antibiotic
Rest
Medication – For non obstructing stones taken for up to a year
UDCA (Agtigall)
Non surgical GB stone treatment:
Laser pulse directed under endoscopy/fluoroscopic guidance directly to stone
Intracorporeal Lithotripsy
Non surgical GB stone treatment:
Shock waves directed at gallstones to fragment stones. Fragmented stones are then either spontaneously passed or removed via endoscope.
ESWL - Extracorporeal Shock Wave Lithotripsy:
