X GI: Accessory Organs (Ms Si, Burke Chp 27) Flashcards
Digestive Track
Mouth - Esophagus - Sm Intestines (DJI) - Lg Intestines - Rectum - Anus
Is the liver a part of the digestive tract?
No, it’s an accessory organ
Accessory Organs to digestion
- Liver
- Gall Bladder
- Pancreas
- Biliary Tract (made of biliary ducts)
biliary tree
a system of vessels that directs Bile from the liver, gallbladder and pancreas through a series of ducts into the duodenum. The exit hole into the duodenum is called the papilla of Vater. (hepatic duct, cystic duct, common bile duct)
Liver facts
- largest glandular organ
- located - RUQ below diaphragm, over Gall Bladder. RT lobe larger than L.
- can NOT palpate from outside body. If you can, there is a problem.
What is the largest organ?
The Skin. Liver is the largest GLANDULAR organ
Construction of Liver
- 2 Lobes
- thousands of lobules per Lobe
- lobules made of hepatic cells.
Functions of the Liver
- Metabolic
- Hematologic
- Digestive
- Produces: Bile/Cholesterol
- Converts: Glucose –> Glycogen
- Regulates: BG
- Filters: blood; remove drugs/ETOH
- Stores: Glucose, ADEK (fat sol vits)
Function of Liver (Michael Linares, Simplenursing.com)
(People Drink So Much) Produce: (Albumin, Bile, Clot Fac) Detox Storage (glycogen) Metabolize (NH3 --> Urea)
How does liver react to BG? Hi or Lo
BG UP - liver stores glucose
BG LO - liver converts glycogen to glucose when pancreas secretes Glucagon to stimulate liver to do so.
What is BILE? Where made and stored?
- fluid made by liver, stored in GB.
- It emulsifies fat
Bile made of
H20, E, cholesterol, bile pigments, bile salts
What are bile pigments?
they give stool color. from breakdown of RBCs.
- Bilirubin
- Biliverdin
How much Bile does Liver secrete?
700 - 1200ml/day
Bile salts are made from?
Cholesterol
What is the digestive Fx of Bile
- fat digestion
- absorption of fat soluble vits
Statins stimulate the liver’s production of what? What is the overall effect?
Bile salts,
LO cholesterol, by using up cholesterol
Lipitor
Zocor
Pravachol (pravastin)
How much bile does the Gall Blader store?
How much bile does the Liver produce?
- 50ml
- 700 - 1200ml
Rhabdomyolysis
muscle cramping. s/e of taking statins
Gall Bladder, Def and Fx
sac that stores bile
The Biliary Tract ducts connect what?
Liver, GB, Duodenum
What bile ducts are in the Biliary Tract?
Hepatic bile duct, Cystic duct, Common Bile Duct (CBD)
see pic
Fx of Hepatic Bile Duct
receives bile from liver lobules
Fx of Cystic Duct
carries bile from GB
Fx of Common Bile Duct (CBD)
Hepatic duct merged w Cystic duct into CBD, to empty into duodenum
What type of gland is the Pancreas?
Endocrine and Exocrine
- Exocrine - secrete into ducts (Amylase, Lipase, Protease digestive enzymes)
- Endocrine - secreted into blood (i.e. insulin)
where is Pancreas located?
behind stomach
What does the pancreas secrete?
ENZYMES for digestion (Amylase, lipase, Protease)
HORMONES to reg BG (Glucagon (+BG), Insulin (-BG))
GASTRIN (stim secretion of gastric acid)
***Where do the CBD and Pancreatic Duct meet?
Ampulla of Vater (see pic)
***What does the Spinchter of Oddi do, where is it?
at base of CBD and pancreatic duct. It regulates the amount of bile released into the duodenum (see pic)
Cholecystitis
(GB) (Bladder) (inflam)
Chole cyst itis
- Inflammation of the GB
- 90% caused by cholelithiasis
Cholelithiasis
Presence of gallstones, in ductal system or in GB itself.
What are most cases of Cholecystitis caused by?
Cholelithiasis (Gall Stones)
Types of Gallstones
- Cholesterol (75% of stones)
- Pigment (Black and Brown)
What secretes Cholesterol?
Cholesterol is secreted by the liver into Bile.
Detergents secreted by liver to dissolve the cholesterol in bile
Why does the liver secrete detergents?
to dissolve the cholesterol in bile.
What ‘detergent’ does the liver produce?
Bile Acids, Lecithin.
to dissolve cholesterol
Causes of Cholesterol Gall stones
1) UP Cholesterol, normal detergent
2) Lo detergent, normal cholesterol
Undissolved chol in GB becomes fat, sticky, forms into stones.
What does the Spleen do?
breaks down RBC and filters blood
BILE PIGMENT: process of forming bile
RBC broken down in Spleen (Hemoglobin) –> Globin (protein) + Heme (iron) –> Biliverdin (pigment) –> Indirect Bilirubin (unconjugated) –> Indirect Billirubin travel to Liver –> joins w Glucuronide molecules –> forms Direct Bilirubin (conjugated)
If you have problems with Indirect Biliruben, where does the problem lie?
Spleen
If you have problems with direct Biliruben, where does the problem lie?
Liver
2 types of Pigment Gall Stones?
Black pigment
Brown pigment
How are Black Pigment GS formed?
excessive bilirubin in Bile. w UP destruction of RBCs, more bilirubin is produced.
How are Brown Pigment GS formed?
bile stasis in GB combines w bacteria and calcium d/t
1) blockage in cystic duct or
2) stenosis of duct
Stenosis
an abnormal narrowing of blood vessel or other tubular organ or structure. aka stricture
Stricture
aka Stenosis. Abnormal narrowing of blood vessel
Risk factors for Gall Stones
- sedentary lifestyles
- sex (female, 25% by 60yrs/50% by 75yrs)(estrogen)
- race (native/Hispanic American)
- Family Hx
- DM, Obesity, Pregnancy
- HRT (hormone replacement therapy)
- Angina
- Diet
Estrogen has what affect on the liver?
causes liver to remove cholesterol from blood and deposit into bile
SS of Cholecystitis/Cholelithiasis
- biliary colic (PRIMARY SYMPTOM, 80% pts)
- RUQ abd pain triggered by fatty meals
- referred R shoulder pain
- severe N/V
- Fever
- Leukocytosis
- Jaundice
- severe
What is the primary symptom of Cholelithiasis and Cholecystitis?
Biliary Colic
in 80% of pts.
-Steady or intermittent pain, sever 15min - 5hr, severe N, RUQ Abd pain.
Cholelithiasis/Cholecystitis: Dx Tests
- Fecal study
- US/CT scan
- HIDA Scan
- ERCP
- Oral Cholecystogram
- IV Cholangiography
- Liver Enzymes
- WBC
- Serum Bilirubin
Fecal Study produces what kind of stool?
Clay Colored Floaters, stool without bile. No bile means you wont digest fat. Clay color means no bile. Float because of HI fat content
Cholelithiasis and Cholecystitis: Complications
- Necrosis/Gangrene (inflamed GB can develop abcess. Can lead to..)
- Fistula
- Pancreatitis
- Perforated GB (Peritonitis)
Fistula
Tunnel formed btwn 2 structures. Inflamed GB sticks to nearby organs. i.e. SI
Pancreatitis
Inflamed pancreas d/t stone in CBD, The digestive enzymes back up into pancreas and eats away at it
Peritonitis
r/t Perforated GB
-inflammation of the peritoneum, which is the membrane that lines
the wall of the abdomen and covers the abdominal organs.
-main cause of secondary peritonitis is the escape of pus from infected abdominal organ, including
.Perforated gall bladder – this small sac stores bile from the liver. A severe infection (cholecystitis) can cause the gall bladder to burst.
Cholelithiasis/Cholecystitis: Rx
- Cholecystectomy w T-tube (GB removal)
- MED: Ursodiol (oral dissolution therapy)
- Lithotripsy (sound waves to break up stones)
Cholelithiasis/Cholecystitis: Cholecystectomy
Removal of the Gall Bladder
Cholelithiasis/Cholecystitis: MED: Ursodiol
.
Cholelithiasis/Cholecystitis: Lithostripsy
sound waves to break up stones
-GS fragmentation (
Cholelithiasis/Cholecystitis: Oral Dissolution Therapy
- med Ursodiol, a naturally occurring bile acid (detergent) to dissolve sm cholesterol gall stones (1-1.5cm).
- Lowers cholesterol secreted into the bile
- 1-2yrs to take effect
- still will return after stopping Ursodiol
(i. e. 102 yrs old pt took this instead of sx.)
Cholesystectomy w T-tube
- purpose is to keep the CBD (common bile duct) open. Get rid of residual gall stones
- promotws flow of bile
- 4-6wks, external tube
Cirrhosis
- Scarring of Liver
- chronic degenerative disease
- –> End Stage Liver Disease
Cirrhosis: Pathos
- destruction of liver tissue
- separation of lobules by fibrous tissue
- dev of abnormal nodules
- abnormal vasculature
- repeated liver damage, r/t disease/chemicals
- repairs w Fibrous tissue –> nodular shape
- scar tissue restricts blood flow
- leads to UP pressure in Portal Venus System
- leads to port HTN
Portal HTN
?
Splenic + Sup Mesenteric veins dump into
Hepatic Portal Vein –> liver for purification –> thru hepatic vein to Inferior Vena Cava to Rt. Atrium of Heart. (SEE PIC)
Liver makes Clotting Factor to…
clot blood when injured.
Liver uses what to make Clotting Factor?
proteins (amino acids) from the digestive tract through Portal System.
Portal HTN
complication of cirrhosis
- blood backs up in portal vein –> UP pressure in vein
- affects all veins draining into Portal Vein
- veins not designed for hight pressure. Arteries are.
- vein w rupture –> massive hemorrhaging
Complications of Impaired blood flow
- Portal HTN –> though liver
- Ascites
- Esophageal Varices (like hemorrhoids)
Na+ follows H2O
Na+ follows H2O
Portal HTN –> Ascites. How?
Cirrhosis complications
altered vessel permeability + fluid leakage into abdomen
fluid follow protein
Liver CAN’T make Albumin –> fluid exits blood–> decrease in circulating volume (water is collecting in interstitial spaces) –> UP in Aldosterone (secreted by Adrenal gland r/t LO blood volume) –> kidneys retain Na + H2O –> UP press in vessels –> more Portal HTN –> upper body vein distension –> Esophageal Varices
Complications of Cirrhosis, Portal HTN (again)
- Portal HTN
- liver not making albumin
- fluid leakage into abdomen
- ascites
- body senses LO blood volume
- kidney retains fluid
- UP Blood Volume AND Interstitial fluid
Type of Cirrhosis
- Alchoholic Cirrhosis (Laennec’s)
- Post necrotic Cirrhosis
- Biliary Cirrhosis
- Cardiac Cirrhosis
Achoholic Cirrhosis
- PRIMARY cause of Cirrhosis in US
- results after 10yrs heavy drinking
- liver breaks down ETOH to Toxic substances –> inflammation –> liver cell destruction
Postnecrotic Cirrhosis
- necrosis of whole hepatic nodules w scarring
- cause: acute hepatitis, infections, hepatotoxins
Secondary Biliary Cirrhosis
- bile building up in liver
- liver bile duct destruction
- cause: unknown, gall stones, tumor
Cardiac Cirrhosis
- chronic R sided HF from Cor pulmonale
- hepatic congestion –> fibrosis
Cor Pulmanale
abnormal enlargement of the right side of the heart as a result of disease of the lungs or the pulmonary blood vessels.
Fibrosis
,
If R Atrium is blocked, blood backs up in the head –>
Distended Vein –Back up in Liver. (review heart)
Hepatomegly
Enlarged liver and Edema in lower extremeties
If L atrium blocks, where would backup be?
Lungs, pulmonary edema (review heart)
Causes of Cirrhosis
- ETOH
- chronic Hep B/C
- Autoimmune disease
- Non ETOH fatty liver disease
- Prolonged exposure to toxic material
- OTC (tylenol), Rx Drugs
Nonalchoholic fatty liver disease (Steatosis)
Fat accumulating in liver
- Obese
- lobules separate, scarring
- build up of extra fat in liver cells not caused by alcohol. It is normal for the liver to contain some fat. However, if more than 5% - 10% percent of liver’s weight is fat, then it is called a fatty liver (steatosis).
Cirrhosis: Early SS
- N/V/Constip/Diar
- loss appetite
- flatulence
- abd discomfort
- hepatomegaly
- LO Hgb
- Jaundice
- Fever (pyrexia)
Hepatomegaly: Early SS
- sharp edge on palpation (normally you can’t palpate liver)
- cells filled w fat
Hepatomegaly: Late SS
- Dyspnea
- Pruritis/Jaundice (d/t liver not breaking down bilirubin. Bilirubin collecting in skin causes itching)
- Collateral Blood vessels (vessels in GI system that w shunt blood away from portal venus system (PVS)
- Spider Telangiectasia (spider veins)(dilated BV. cheecks, nose, neck, chin, tongue sometimes, purple/red
- Gall Stones
Collateral Blood Vessels
abnormal blood vessels that connect the aorta with the pulmonary arteries. The aorta is a blood vessel that carries blood from the heart to arteries throughout the body.
Portal Venus System
refers to the vessels involved in the drainage of the capillary beds of the GI tract and spleen into the capillary bed of the liver. Blood flow to the liver is unique in that it receives both oxygenated and deoxygenated blood.
Hepatomegaly: more Late SS
- Ascites/Edema
- Esophageal Varices
- Caput Medusae (distended abd veins)
- ***confusion (hepatic encelopathy)
- Vit LO, anemia (b/c can’t store vitamins)
Hepatic Encelopathy
- Liver –>produces ammonia with filtering (toxic to body esp brain) –> out in URINE.
- when system fails, ammonia builds up in body affecting brain.
Cirrhosis: Dx tests
- Liver biopsy (scarring?)
- liver enzymes (UP blood)
- UP Bilirubin in blood b/c liver can’t process it
- UP NH3 in blood b/c liver can’t convert it.
Cirrhosis: more Dx tests
- UP coagulation times (liver no making enough CF, longer to clot)
- LO serum albumin, total protein
- US, CT scan, MRI, ERCP
ERCP (Endoscopic Retrograde Cholangio-Pancreatography)
procedure that enables your physician to examine the pancreatic and bile ducts. A bendable, lighted tube (endoscope) about the thickness of your index finger is placed through your mouth and into your stomach and first part of the small intestine (duodenum).
Hepatomegaly: Med Mgt Goal
-Goal to prevent further damage
Hepatomegaly: Med Mgt Diet
- eliminate ETOH, Hepatotoxins (tylenol)
- Diet: UP calorie/protein, LO fat/Na+, take vitamins (b/c liver can’t store)
- If Hepatic Encelopathy present? LO protein because liver not breaking down anything well and protein will result in NH3 in body.
Hepatomegaly Diet if Hepatic Encelopathy present?
LO protein because liver not breaking down anything well and protein will result in NH3 in body.
Hepatomegaly: more Med Mgt
- Antiemetics (N)
- Diuretics (fluid mgmt)
- Anti HTN (treat Portal HTN)
- Antihistamines (for pruritis)
- Cholesterol binding meds
- Treatment of varices
Hepatomegaly: Complications
- Ascites
- Esophageal Varices
- Hepatic Encelopathy
Ascites
-excess fluid in peritoneal cavity (portal HTN, backup of blood flow)
Ascites Rx
depends on severity
- 1st:
- BR, I+O, fluid/Na+ restriction
- Vit supp (liver can’t store vits)
- Diuretics (take away fluids)
- Albumin (draw fluids into blood)
Ascites Rx (agressive)
LAST RESORT
-LeVeen Continuous Peritoneal Jugular Shunt (redirects Ascitic fluid from abd cavity to SVC - to R atrium.
(learn heart)
Ascites: Surgical Shunting
-Divert blood from Venus portal system - venus system
-portacaval shunt: portal vein (base of liver) connected to IVC
(learn heart)
Portacaval shunt
Portal vein attached to IVC and cut off from liver. (See pic)
Ascites: Paracentesis
- removal of fluid from peritoneal cavity
- Rx for massive ascites
- remove 2-6L of fluid
Varisces
Varices are dilated veins in the distal esophagus or proximal stomach caused by elevated pressure in the portal venous system, typically from cirrhosis.
Gastrointestinal Varices
Gastric varices are dilated submucosal veins in the stomach, which can be a life- threatening cause of bleeding in the upper gastrointestinal tract.
Esophageal Varices
Dilated, tortuous veins in Esophagus d/t portal HTN
- HI mortality rate
- caused by straining (bm, cough, sneeze) result in rupture
Esophageal Varices S/S
Usually none until massive hemorrhaging
Esophageal Varices Mortality Rate
- Hi mortality rate
- pts who bleed 1ce, have 70% rebleed rate. (50% survival)
- 1/3 of rebleeds are fatal
Bleeding Esophageal Varices: Dx
Dx: endoscopy
Bleeding Esophageal Varices: Rx
- Endoscopy (2 types)
- Med
- Balloon tamponade
Bleeding Esophageal Varices:
Types of Endoscopy
- Sclerotherapy: inject irritant into Varices causing it to clot
- Ligation of Varices: rubber band around Varices and cut off
Bleeding Esophageal Varices: Med?
Vasopressin (vasoconstrictor)
Bleeding Esophageal Varices: Balloon Tamponade (Sengstaken-Blakemore Tube)
use of balloons inserted into the esophagus, stomach or uterus, and inflated to alleviate or stop refractory bleeding.
Hepatic Encephalopathy
-Ammonia accumulating in brain, impairs brain cell function.
Hepatic Encephalopathy: SS
- changes in MS (mental status)
- Motor disturbances (i.e. Asterixis)
- Hepatic Coma
Asterixis
Asterixis (also called the flapping tremor, or liver flap) is a tremor of the hand when the wrist is extended, sometimes said to resemble a bird flapping its wings.
-liver in trouble, affecting brain
How is ammonia processed in body?
(NH3) Ammonia –>broken down in LIVER –> into UREA –> excreted in URINE
NH3 –> crosses BBB (blood, brain barrier) –> damages neurons (change in MS, LOC) and astrocytes (motor problems)
Recommended diet w or w/out Hepatic Encephalopathy
- Ammonia by product of protein metabolism
- w Hepatic Enc: NO PROTEIN (because it will increase NH3 in body)
- w out Hep Enc: HIGH PROTEIN to build up body from sickness, prevent ascites
Hepatic Encephalopathy MM/NI
- monitor neuro status (Orientation, LOC, Gain, Speech, PERRLA, MAE)
- daily NH3 levels
- I/O
- diet: no protein
- MED: Neomycin (LO bacteria in colon)
- MED: Lactulose (LO NH3 by causing diarrhea, bacteria out to reduce NH3)
Hepatic Encephalopathy MEDS
- Neomycin (antibiotic)
- Lactulose (lower NH3 by causing diarrhea, bacteria out to reduce NH3)
Lactulose
- CLASS: Laxative, NH3 detoxicant
- ACTION: prevents absorption of NH3 in colon
- USE: Hepatic Encephalopathy
- ADMIN: oral, rectal (solution via PO, NGT, Enema)
- S/E: N/V/D
- NI: monitor NH3 levels
Cirrhosis: NI
- monitor VS
- SS: hemorrhage, LO prod of clotting factors, varices d/t portal HTN
- precautions: bleeding since no CF
- report changes: monitor MS
- Diet/Nutrition: educate patient
- skin care: pruritis d/t bilirubin in skin
- I+O, abd, girth measurement, daily weight
- counseling/support in alcoholism
If on bleeding precautions: RANDI
R: razor, electric A: aspirin, NO N: needles,small gauge D: decrease needle sticks I: injury, protect from
Observe for:
- Hematuria, Melena
- Nose bleeds
- Gingivital bleeding
- Bruising
Carcinoma of Liver
- rare
- Secondary carcinoma more common than primary. Secondary means it metastasized to liver and didn’t originate there.
Liver CA Risk Factors
- Hep B/C (genetic makeup of hep b found in genetic makeup of CA cells. Hep C known to cause Cirrohsis)
- Cirrhosis
- ETOH abuse
- Aflatoxin BI (chem from mold in food: peanuts, rice, wheat, soy, corn)
- drugs; bcp, hormone replacement
- chem; bpa etc
Liver CA S/S
- hepatomegaly
- weight loss
- edema/ascites
- portal HTN
- abd pain
- N/V
Liver CA: Dx Tests
- Liver enzymes
- AFP (alpha-fetoprotein, usually LO in adults, HI in fetus’, in Live CA, it’s HI)
- CT Scan/MRI/US
- ERCP
- Hepatic Arteriography
- Liver Biopsy
ERCP
Endoscopic retrograde cholangiopancreatography, or ERCP, is a specialized technique used to study the bile ducts, pancreatic duct and gallbladder. Ducts are drainage routes; the drainage channels from the liver are called bile or biliary ducts. The pancreatic duct is the drainage channel from the pancreas.
Hepatic Arteriography
- local anesthetic
- needle in arm artery
- catheter fed thru needle into hepatic artery
- contrast dye injected
- xrays display hepatic artery
Liver CA: MM
- lobectomy - removal of a lobe
- systemic chemo
- hepatic artery perfusion of chemo
- tumor ablation
- liver transplant
Hepatic Artery Perfusion of Chemo
- LIver CA gets blood from hepatic artery
- Chemo administered thru Hepatic Artery directly to Tumor
- Higher concentration of chemo delivered to tumors
Theoretically: won’t get systemic effects on effect straight to liver tumor. In actuality it does have systemic effects
What does CA need to live?
a blood supply
Liver CA: NI, Nursing Interventions
- monitor VS
- monitor S/S hemorrhage
- Precautions: bleeding
- Monitor MS/ report changes
VS is ALWAYS an expected
Nursing Intervention
Liver CA: NI (same as Cirrhosis)
- diet/nutrition education
- skin care
- I/O, abd girth measurements, daily weight
- MEDS education
- counseling/support on Alchoholism
Liver CA: Prognosis
Poor, death 1yr post dx
Pancreatitis
- Inflammation of Pancreas
- Acute/Chronic
- Cause: *Gall stones, *ETOH, auto immune, virus, trauma, ERCP, drugs (Tylenol, Estrogen, Chemo, HIV med, Hep AB Vaccine
Pancreatitis Causes
- *Gall stones,
- *ETOH,
- auto immune
- virus
- trauma
- ERCP
- drugs (Tylenol, Estrogen, Chemo, HIV med, Hep AB Vaccine)
Pancreatitis: Pathos
- Enzymes activated in pancreas
- auto digestion
- -> necrosis, pseudocysts, abcesses
Pancreatitis: Enymes activated in Pancreas
{Amylase, protease, lipase}
enzymes released through pancreatic duct
Pancreatitis: Auto Digestion
enzymes start breaking down pancreas, not food outside
Pancreatitis: Pseudocysts
sac of enzymatic pancreatic exudate that forms on or around pancreas. if ruptures, can lease to hemorrhage.
–> abcess
Pancreatitis: S/S - ACUTE
- upper Abd Pn radiating to back
- swollen, tender abd
- N/V
- Fever
- Tachycardia
Pancreatitis: S/S - CHRONIC
- Chronic upper Abd Pn
- N/V
- Anorexia/Weight Loss (d/t food not digesting because enzymes stay in pancreas)
- Steatorrhea (fatty stool b/c all fat still there, not digested)
Pancreatitis: Dx Tests
- Amylase/Lipase (serum/urine, UP b/c not going to cystic duct, spilling into blood (Endo/Exocrine)
- Hyperglycemia (no insulin from Pancreas)
- CT Scan/US
Chronic Inflammation causes ?
Scarring
Pancreatitis: Acute Rx
- Eliminate causes(ETOH, remove GS)
- minimize damage to pancreas/rest pancr
- hydrate (IV not oral b/c that will stimulate pancreas to make more enzymes.)
- Pain Mgmt (very painful)
Pancreatitis: more Rx
- NPO
- IV fluid
- Abx
- Abcess/Cyst drainage
- PCA (pt controlled analgesic)
Pancreatitis: Chronic Rx
-Pain mgmt (NSAIDs, not narcotic or opiods b/c w cause more problems)
-Diet (lofat, sm meals)
-No ETOH
-Pancreatic Enzymes
MED Pancrelipase w 1st bite of food,tab
MED: Octreotide( Sandostatin), hormone suppresses Gh secreation (used in Gigantism to supress GH secretion)
Hepatitis
- 5 types, viral that cause physical problems
- 1 type (Hep G) is asymtomatic
- all types almost identical in Incubation, mode of transmission, prognosis
How is Hepatitis transmitted?
- cont food, H2O via fecesd (hand to mouth)
- body fluid/blood
How does Hepatitis affect liver cells
cells become damaged and can lead to necrosis
Hepatitis: Can liver cells regenerate?
YES
Hepatitis: How are Liver cells affected w severe inflammation
scar tissue forms. Obstructing normal blook/bile flow, causing further damage –> eschemia
Hepatitis A
- most common type
- oral fecal trans
- often spread by food workers
- mollusk shellfish (clam, scallops, muscles, cont. H2O)
- Incubatino - 15 - 50 days
Hep A: Incubation
15 - 50 days
Hepatitis B
- transmitted parental (veins/needles)
- cont blood
- transfusion
- Dialyisis
- direct contact w body fluids (semen, vaginal, saliva)
- *** Healthcare workers most at risk (OR/ED/ICU/Phlebotomists, lab techs)
- Incubation 60-90days
Hep B Incubation time
60 - 90days
Hep B, C, D similarities
- pt can be asymptomatic
- can carry virus in liver cells
- can have it and not even know
Hep C
- trns thru cont needles
- blood transfusion
- Hemodyalisis
- maternal fetal trans
- multiple/infected sex partners
Hep C Incubation time
2wks - 6mos
What are the most serious types of HEP?
- Hep B and C
- can progress –> chronic hepatities –> cirrhosis –> liver CA –> death
Hep D
- always associated w current Hep B infection (co-infection)
- trans prenatally, sexually
- incubation 2-8wks
Hep D incubation time
2-8wks
Hep E
- fecal cont of H2O
- rarely seen in US (Asia, Mid East, Mex)
- fecal oral trans
- China recently released vaccine for Hep E
- Incubation 26 - 42 days
Hep E Incubation time
26-42 days
What strains of Hepatitis are there vaccines for?
only A/B
Hep G
- usually co-infection w Hep C
- blood bourne exposure
- Europe/Australia/Asia
General Hepatitis S/S
- pruritis (d/t bile under skin)
- Hepatomegaly
- enlarged lymph nodes
- weight loss
- general malaise
- aching muscles
- photo phobia
- dyspepsia (indigestion)
- H/N
- chills
- abd pain
- Diarrhea
- Constipatin
d/t liver not able to process bilirubin
- jaundice
- dark amber urine
- clay colored stool
Hepatitis MM
- treat symptoms
- small frequent meals
- LO fat, HI carb
- IV fluids
- Vit C, K, B complex
- avoid unnecessary meds so liver doesn’t work so hard
- prevent transmission
- pt education
- bed rest for several weeks
Drugs w Hepatotoxic effects
- Phenothiazines (thorazine, stelazine, compazine, NAUSEA)
- Sedatives
- Hiv meds,estrogen ,Tylenol,TB meds
Hep A: Tx
- HAV (Hep A Vaccine), 2 doses, 6 mos apart
- can be giving from 12mos old
- well balanced diet to help Liver heal
- 4-6 sm meals/day
What do you administer to pt exposed to Hep A?
IG, Immune Serum Globulin (Gamma globulin)
immune serum globulin (gamma globulin)
A sterile solution of globulins derived from pooled human blood that contains antibodies that are normally present in the blood of adults, used as a passive immunizing agent against rubella, measles, and hepatitis A and as treatment for hypogammaglobulinemia.
Hep B Tx
- VAC: HBV (Hep B vaccine)
- MED: Epivir, Hepsera, Interferon\
- MED: HBIG (hep B immune globulin)
- VAC: RECOMBIVAX HB (3 doses, IM, protect up to 15yrs, produces immunity in 95% of vaccinated)
- VAC: TwinRix
MED: Lamivudine (Epivir)
Treats hepatitis B infection and human immunodeficiency virus (HIV) infection. HIV causes acquired immune deficiency syndrome (AIDS). This medicine does not cure hepatitis B, HIV, or AIDS, but it may help slow the disease progress.
?????? Interferon
Interferons are a group of signaling proteins made and released by host cells in response to the presence of several pathogens, such as viruses, bacteria, parasites, and also tumor cells.
MED: HBIG, Hepatitis B immune globulin
Prevents hepatitis B from occurring again in HBsAg-positive patients after a liver transplant. It is also used preventatively after exposed to hepatitis B virus.
VAC: RECOMBIVAX HB
is a vaccine indicated for prevention of infection. caused by all known subtypes of hepatitis B virus.
-3 doses, IM, protect up to 15yrs, produces immunity in 95% of vaccinated)
VAC: Twinrix
is a vaccine against hepatitis A and hepatitis B, manufactured by GlaxoSmithKline. Twinrix is administered over 3 doses.
The name was created because it is a mixture of two earlier vaccines — Havrix, an inactivated-virus Hepatitis A vaccine, and ENGERIX-B, a recombinant Hepatitis B vaccine. TWINRIX, HAVRIX and ENGERIX-B are registered trademarks of GlaxoSmithKline; if the same vaccine is available from others, it will have another name.
Twinrix first entered the market in early 1997.
Hep C Tx
- no vaccine
- drug Tx
- MED: Rebetol, Intron A Pegasys. (use combo to get rid of virus)
- Liver transplant
- 50% ppl w liver trans are HepC+
MED:Ribavirin (Rebetol)
Treats hepatitis C. Used together with an interferon medicine, such as Intron® A, Peg-Intron®, or Pegasys®.
Hepatitis Nutrition Mgmt
- collect data
- Hx of previous contact
- if test +, have to notify people w possible exposure
- must be reported to state dept of public health by law
- assess pt for respiratory distress
If liver not metabolizing drugs, what can result?
-mental confusion –> coma
Hepatitis Education
- hand washing
- limit contact
- proper handling of body secretions
- after recovery, NO ETOH for 1 yr
- long slow convalescence
- emotional/psych support
- develop new hobby. Long convalescence
Hepatitis can cause massive necrosis of liver cell in small amount of patients resulting in death of 75% of ppl
.
Asictes/Edema is a sign of ?
Liver failure
Major post op concern for Liver transplant recipients?
- Rejection and Infection
- monitor for hemorrhage and drainage
- I/O
- preventing PNA ( re-positioning, coughing w splint)
Why drug is given to aid in successful liver transplant?
-Cyclosporine.
An effective immunosuppressant to help lower rejection rate
-major reason for success of transplants
What causes Liver abscesses?
Bacteria
-can have 1 or multiple accesses
Liver Abscess S/S
- Fever
- Chills
- Abd pn/tenderness, URQ
- hepatomegaly
- jaundice
- Anemia
Liver Abscess M/M
- IV Abx
- per cutaneous drainage of Liver abscess
- open surgical drainage if abscess ruptures
Liver Enzymes
Inflamed or injured liver cells leak higher than normal amounts of certain chemicals, including liver enzymes, into the bloodstream, which can result in elevated liver enzymes on blood tests. The specific elevated liver enzymes most commonly found are:
- Alanine transaminase (ALT)
- Aspartate transaminase (AST)
*** Dx Tests: T-Tube Cholangiogram
Done post op to diagnose retained ductal stones for pts who have had cholecytectomy and to demonstrate good flow of bile –> duodenum
T-shaped rubber tube placed in bile duct where dye injected and xrays taken.Tube can stay temp to keep duct open and allow drainage of bile
*** Dx Tests: T-Tube Cholangiogram: NI
- ***Bag should be left at level of abdomen
- If tube left temp, protect from sepsis by connecting to closed drainage system
- if tube removed, site should stay covered w sterile dressing
- ensure no Iodine allergy
- NPO after midnight
*** Dx Tests: Liver Biopsy
Safe simple method to Dx pathologic liver conditions. Special long needle inserted thru skin btwn 6/7 or 8/9 intercostal spaces and into liver.
- Pt supine w RT arm over head and instructed to exhale fully. DONT BREATH while needle inserted. Used via US or CT guidance.
- look at platelets
- INR ordered (bleeding time) to ensure you will clot
*** Dx Tests: Liver Biopsy: Post Op
- monitor VS q 15min x 2
- q30min x 4
- q1hr x 4
- some pain common
- severe pn w leakage of bile
- ensure pneumothorax (collapsed lung) doesn’t happen d/t improper needle placement.
- pt on RT side min 2 hrs after. Splint puncture side to help compress liver to prevent bleeding.
- monitor for hemmorhage
