Liver, Biliary Tract, & Liver, Biliary Tract, & Pancreas ProblemsPancreas Problems

Nur 302Nur 302

Unit IUnit I

Liver, Biliary Tract & Liver, Biliary Tract & Pancreas ProblemsPancreas Problems JaundiceJaundice Hemolytic jaundiceHemolytic jaundice Hepatocellular JaundiceHepatocellular Jaundice Obstructive jaundiceObstructive jaundice

Viral HepatitisViral Hepatitis

Inflammation of the liver.Inflammation of the liver. Types: A,B,C,D,E,GTypes: A,B,C,D,E,G Epstein-Barr, herpes, Epstein-Barr, herpes,

cytomegalovirus, coxsackievirus, cytomegalovirus, coxsackievirus, rubella rubella

Presence of antigens & antibodiesPresence of antigens & antibodies Outbreaks of hepatitis – type A, Outbreaks of hepatitis – type A, 50% type B, 20% type C, 30% type A 50% type B, 20% type C, 30% type A

Hepatitis AHepatitis A

Fecal-oral route, outbreaks caused by Fecal-oral route, outbreaks caused by fecal contaminated food or drinking fecal contaminated food or drinking water.water.

Crowded conditions, poor sanitation & Crowded conditions, poor sanitation & hygiene, undeveloped countries, hygiene, undeveloped countries, shellfish from contaminated watershellfish from contaminated water

Most infectious 2 wks before s/s & 1wk Most infectious 2 wks before s/s & 1wk after s/s start.after s/s start.

No chronic carrier No chronic carrier

Hepatitis BHepatitis B

Percutaneous, permucosal, or Percutaneous, permucosal, or perinatal exposure, sexually perinatal exposure, sexually transmitted disease.transmitted disease.

100X more infectious than HIV; 100X more infectious than HIV; can live on dry surface for 7 dayscan live on dry surface for 7 days

Carrier state - antigen HBsAg for Carrier state - antigen HBsAg for 6-12 mo.6-12 mo.

Immunity – antigen anti-HBs-AgImmunity – antigen anti-HBs-Ag

Hepatitis CHepatitis C

Transmission- pericutaneousTransmission- pericutaneous At risk: IV drugs, bld transfusion, At risk: IV drugs, bld transfusion,

hemodialysis, tattooing, hi risk hemodialysis, tattooing, hi risk sexual behavior, organ sexual behavior, organ transplants, health care workerstransplants, health care workers

Hepatitis DHepatitis D

Delta virusDelta virus Transmission - percutaneousTransmission - percutaneous Can turn mild or chronic hepB Can turn mild or chronic hepB

into severe, chronic, progressive, into severe, chronic, progressive, active hepatitis & cirrhosis active hepatitis & cirrhosis

Can occur as coinfection with Can occur as coinfection with hepB or as superinfection hepB or as superinfection

Hepatitis EHepatitis E

Transmission – fecal-oral route, Transmission – fecal-oral route, esp contaminated drinking water.esp contaminated drinking water.

Enteric non-A, non-B hepatitisEnteric non-A, non-B hepatitis Occurs in developing countries, Occurs in developing countries,

epidemics in India, Asia, Mexico, epidemics in India, Asia, Mexico, Africa. In US rarely, only after a Africa. In US rarely, only after a person traveled.person traveled.

Hepatitis GHepatitis G

Recently discovered.Recently discovered. Found in blood donors & Found in blood donors &

transmitted by transfusion.transmitted by transfusion. Co-exists with other hepatitis Co-exists with other hepatitis

viruses.viruses. Not associated with chronic Not associated with chronic

hepatitis or cirrhosis.hepatitis or cirrhosis.

PathophysiologyPathophysiology

Inflammation of liver -> Cell Inflammation of liver -> Cell degeneration & necrosisdegeneration & necrosis

Proliferation & enlargement of Kupffer Proliferation & enlargement of Kupffer cellscells

Interrupted flow of bile & cholestasisInterrupted flow of bile & cholestasis If no complications, liver cells If no complications, liver cells

regenerate, resume normal appearance regenerate, resume normal appearance & function.& function.

Rash, angioedema, arthritis, fever, Rash, angioedema, arthritis, fever, malaisemalaise

Collaborative CareCollaborative Care

Rest, well balanced dietRest, well balanced diet Antiemetics, Benadryl, NO Antiemetics, Benadryl, NO

phenothiazinesphenothiazines Immunoglobulin for hepB or hepAImmunoglobulin for hepB or hepA Alpha inferonAlpha inferon wks after exposure, hepA vaccine –wks after exposure, hepA vaccine –

pre-exposure prophylaxispre-exposure prophylaxis HepB vaccine prophylaxis, post HepB vaccine prophylaxis, post

exposure- hepatitis B immune globulinexposure- hepatitis B immune globulin

Nursing Care: Nursing Care: HepatitisHepatitis

Health PromotionHealth Promotion Assessment of Assessment of

jaundicejaundice Adequate Adequate

nutritionnutrition RestRest Home CareHome Care

Toxic, Drug-induced & Toxic, Drug-induced & Idiopathic HepatitisIdiopathic Hepatitis Ingestion, inhalation, parenteral injection Ingestion, inhalation, parenteral injection

of chemicalsof chemicals Systemic poisons- carbon tetrachloride, Systemic poisons- carbon tetrachloride,

gold compounds, converted toxic gold compounds, converted toxic metabolites (acetaminophen)metabolites (acetaminophen)

Drugs – Halothane, INH, Diuril, AldometDrugs – Halothane, INH, Diuril, Aldomet Elderly, previous liver diseasedElderly, previous liver diseased Idiopathic - autoimmune Idiopathic - autoimmune

Cirrhosis of the LiverCirrhosis of the Liver

Degeneration & destruction of liver Degeneration & destruction of liver cellscells

Abnormal bld vessel & bile duct Abnormal bld vessel & bile duct relationships from fibrosisrelationships from fibrosis

Lobules of irreg size & shape & Lobules of irreg size & shape & impeded bld flow from overgrowth of impeded bld flow from overgrowth of new & fibrous tissuenew & fibrous tissue

Insidious, progressive, chronic diseaseInsidious, progressive, chronic disease

Types of CirrhosisTypes of Cirrhosis

Alcoholic, portal or nutritional cirrhosis: fat Alcoholic, portal or nutritional cirrhosis: fat accumulation in liver cells, scar formation.accumulation in liver cells, scar formation.

Post necrotic- re: hepatitis, broad bands scar Post necrotic- re: hepatitis, broad bands scar tissue.tissue.

Biliary: due to chronic biliary obstruction or Biliary: due to chronic biliary obstruction or infection. Jaundice, diffuse fibrosis.infection. Jaundice, diffuse fibrosis.

Cardiac: R heart failure, constrictive Cardiac: R heart failure, constrictive pericarditis, tricuspid insufficiencypericarditis, tricuspid insufficiency

Cell necrosis, scar tissue, nodules, decr Cell necrosis, scar tissue, nodules, decr cellular nutrition, hypoxia-> decreased cellular nutrition, hypoxia-> decreased functioning of liver functioning of liver

Clinical ManifestationsClinical Manifestations

Insidious- anorexia, dyspepsia, n/v, flatulence, Insidious- anorexia, dyspepsia, n/v, flatulence, diarrhea or constipation, dull, heavy feeling in diarrhea or constipation, dull, heavy feeling in RUQ, enl liver & spleenRUQ, enl liver & spleen

JaundiceJaundice Skin lesions – spider angiomas, palmer erythemaSkin lesions – spider angiomas, palmer erythema Hematologic – thrombocytopenia, anemia, Hematologic – thrombocytopenia, anemia,

leukopenia, coagulation disordersleukopenia, coagulation disorders Endocrine disturbances – hormone inactivationEndocrine disturbances – hormone inactivation Peripheral neuropathy – deficiency in folic acid, Peripheral neuropathy – deficiency in folic acid,

thiamine, B-12. thiamine, B-12.

Diagnostic StudiesDiagnostic Studies

Liver enzymes elevated, PT prolongedLiver enzymes elevated, PT prolonged Cholesterol & Protein levels decreasedCholesterol & Protein levels decreased Serum & urine bilirubin increased, Serum & urine bilirubin increased,

stool decreasedstool decreased Liver scan,biopsy, analysis of ascitic Liver scan,biopsy, analysis of ascitic

fluid fluid Esophagogastroduodenoscopy, Esophagogastroduodenoscopy,

angiogramangiogram Lytes, CBC, ammonia levelLytes, CBC, ammonia level

Peripheral Edema & Peripheral Edema & AscitesAscites Peripheral edema @ ankle & presacral area - Peripheral edema @ ankle & presacral area -

decr. albumin -> decr colloidal osmotic decr. albumin -> decr colloidal osmotic pressure. Increased portalcaval pressure pressure. Increased portalcaval pressure from portal hypertension.from portal hypertension.

Ascites- hypertension in liver->proteins move Ascites- hypertension in liver->proteins move bld via capillaries to lymph->leak into bld via capillaries to lymph->leak into peritoneal cavity-> osmotic pres pulls water. peritoneal cavity-> osmotic pres pulls water. Lo albumin & hyperaldosteronism adds to Lo albumin & hyperaldosteronism adds to ascites formation.ascites formation.

S/S- abd distention, wt gain, distended abd S/S- abd distention, wt gain, distended abd wall veins, dehydration, decr output, wall veins, dehydration, decr output, hypokalemia. hypokalemia.

Collaborative CareCollaborative Care

Na restriction: 250-500mg Na/dayNa restriction: 250-500mg Na/day Salt poor albuminSalt poor albumin Diuretics: Aldactone, Dyrenium, Diuretics: Aldactone, Dyrenium,

Midamor, LasixMidamor, Lasix Fluid removal via paracentesis or Fluid removal via paracentesis or

retroperitoneal shuntretroperitoneal shunt Monitor lytes and fluid balanceMonitor lytes and fluid balance

Portal Hypertension & Portal Hypertension & Esophageal VaricesEsophageal Varices Compression, destruction of hepatic & Compression, destruction of hepatic &

portal veins & sinusoids-> obstruction portal veins & sinusoids-> obstruction portal bld flow-> portal hypertension.portal bld flow-> portal hypertension.

Collateral circulation – lower esophagus, Collateral circulation – lower esophagus, parietal peritoneum, rectum-> varices parietal peritoneum, rectum-> varices where collateral & systemic circulation where collateral & systemic circulation meet.meet.

Esophageal varices, fragile, tolerate hi Esophageal varices, fragile, tolerate hi pressure poorly, tortuous, bleed easily. pressure poorly, tortuous, bleed easily. Life threatening complication. Life threatening complication.

Hepatic Hepatic EncephalopathyEncephalopathy Ammonia in systemic circulation without Ammonia in systemic circulation without

liver detoxification.liver detoxification. Ammonia from metabolism of P shunted Ammonia from metabolism of P shunted

past liver or liver unable to convert past liver or liver unable to convert ammonia to urea-> lg amt ammonia-> ammonia to urea-> lg amt ammonia-> crosses blood-brain barrier->neuro s/s crosses blood-brain barrier->neuro s/s

S/S: LOC changes from lethargy to coma, S/S: LOC changes from lethargy to coma, disorientation, asterixis, writing disorientation, asterixis, writing impairments, hyperventilation, impairments, hyperventilation, hypothermia, grimacing, grasping, fetor hypothermia, grimacing, grasping, fetor hepaticushepaticus

Collaborative CareCollaborative Care

Protein restrictionProtein restriction Neomycin po or enemasNeomycin po or enemas Lactulose (Cephalac)Lactulose (Cephalac) Control GI blding, remove bld Control GI blding, remove bld

from intestinal tract, treat lyte & from intestinal tract, treat lyte & acid/base imbalanceacid/base imbalance

Liver transplantLiver transplant

Nursing Care: Nursing Care: EncephalopathyEncephalopathy Neuro assessment q2h - LOC, Neuro assessment q2h - LOC,

reflexes, pupils, sensory & motorreflexes, pupils, sensory & motor Check lytes, acid/base balance, Check lytes, acid/base balance,

ammoniaammonia Decrease ammonia with lactulose, Decrease ammonia with lactulose,

enemasenemas Possible tube feeding- lo-no Possible tube feeding- lo-no

protein, hi CHO & fldsprotein, hi CHO & flds

Hepatorenal SyndromeHepatorenal Syndrome

Renal failure- possibly due to Renal failure- possibly due to redistribution of blood flow from redistribution of blood flow from kidneys or hypovolemiakidneys or hypovolemia

Follows diuretic therapy, GI Follows diuretic therapy, GI hemorrhage or paracentesishemorrhage or paracentesis

Tx: salt poor albumin, salt & Tx: salt poor albumin, salt & water restrictions, diuretic water restrictions, diuretic therapytherapy

Nursing Care: CirrhosisNursing Care: Cirrhosis

Health PromotionHealth Promotion Bed rest & prevent complicationsBed rest & prevent complications Nutrition- oral hygiene, supplementsNutrition- oral hygiene, supplements Assess: jaundice, edema, ascites, Assess: jaundice, edema, ascites,

bleeding, LOC, dyspneableeding, LOC, dyspnea Skin careSkin care Altered body imageAltered body image Monitor lytes, liver & coag studies, Monitor lytes, liver & coag studies,

ammonia, CBCammonia, CBC

Home CareHome Care

Written instructions- fluid & diet Written instructions- fluid & diet restrictionsrestrictions

Teach pt & family- s/s Teach pt & family- s/s complications, meds & side complications, meds & side effects, observe for bleeding, skin effects, observe for bleeding, skin care, protection from infectioncare, protection from infection

Counseling & referral to Counseling & referral to community health nursecommunity health nurse

Liver CancerLiver Cancer

Metastasis, h/o cirrhosis, chronic hepB or Metastasis, h/o cirrhosis, chronic hepB or CC

Malignant cells enlarge & mis-shape liverMalignant cells enlarge & mis-shape liver Hemorrhage or necrosis commonHemorrhage or necrosis common Dx: hard to differentiate bet cirrhosis & Dx: hard to differentiate bet cirrhosis &

CaCa Rx: palliative, lobectomy, chemo, poor Rx: palliative, lobectomy, chemo, poor

prognosis, death in 4-7 monthsprognosis, death in 4-7 months Nsg care: same as advanced liver Nsg care: same as advanced liver

disease disease

Endoscopic Retrograde Endoscopic Retrograde CholangiopancreatograpCholangiopancreatographyhy ERCPERCP The scope is brought in through the esophagus, The scope is brought in through the esophagus,

the stomach and into the bile ducts. A contrast the stomach and into the bile ducts. A contrast fluid is injected. The gallbladder does not fluid is injected. The gallbladder does not become visible. The hepatopancreatic duct become visible. The hepatopancreatic duct does not show signs of obstruction.does not show signs of obstruction.Conclusion: No signs of obstruction of the Conclusion: No signs of obstruction of the hepatopancreatic duct, obstruction in the hepatopancreatic duct, obstruction in the gallbladder or the cystic duct cannot be gallbladder or the cystic duct cannot be excluded. excluded.

Nursing Care???Nursing Care???

ERCP Nursing CareERCP Nursing Care

Explain procedure & get consentExplain procedure & get consent NPO 8 hours before ERCPNPO 8 hours before ERCP Sedation before & during ERCPSedation before & during ERCP Antibiotics if orderedAntibiotics if ordered Post ERCP – check perforation, Post ERCP – check perforation,

infection, s/s pancreatitis, VS, infection, s/s pancreatitis, VS, check gag reflexcheck gag reflex

Cholecystitis & Cholecystitis & CholelithiasisCholelithiasis S/S cholecystitis: indigestion, moderate-> S/S cholecystitis: indigestion, moderate->

severe pain, URQ tenderness, referred to R severe pain, URQ tenderness, referred to R shoulder & scapula, n/v, restless, diaphoreticshoulder & scapula, n/v, restless, diaphoretic

S/S cholelithiasis: none, s/s depend if stones S/S cholelithiasis: none, s/s depend if stones are moving or not, spasms can be severe, are moving or not, spasms can be severe, tachycardia, diaphoresis, 3-6 hr after meal, tachycardia, diaphoresis, 3-6 hr after meal, when lie down, s/s bile blockagewhen lie down, s/s bile blockage

Dx: ultrasound, cholangiogram, Dx: ultrasound, cholangiogram, cholecystogram cholecystogram

Collaborative CareCollaborative Care

Cholecystitis: control pain, antibiotics, fldsCholecystitis: control pain, antibiotics, flds Cholelithiasis: cholesterol solvents, Cholelithiasis: cholesterol solvents,

lithotripsy, endoscopic sphincterotomy, lithotripsy, endoscopic sphincterotomy, surgerysurgery

Surgery: cholecystectomy, laparoscopic Surgery: cholecystectomy, laparoscopic cholecystectomycholecystectomy

Transhepatic biliary catheterTranshepatic biliary catheter Meds: anticholinergics, analgesics, fat Meds: anticholinergics, analgesics, fat

soluble vitamins, bile salts, Demerol, soluble vitamins, bile salts, Demerol, Questran, dietQuestran, diet

Nursing Care: GB Nursing Care: GB DiseaseDisease Health promotionHealth promotion Acute GB attack: relieve pain, n/v, Acute GB attack: relieve pain, n/v,

assessment of progression of s/s & s/s assessment of progression of s/s & s/s obstruction bile duct, observe s/s bleeding obstruction bile duct, observe s/s bleeding at mucous membranes, assess for at mucous membranes, assess for infectioninfection

Post endoscopy; assess s/s pancreatitis, Post endoscopy; assess s/s pancreatitis, perforation, bleedingperforation, bleeding

Post-op: referred pain to shoulder, place in Post-op: referred pain to shoulder, place in Simm’s position, prevent resp Simm’s position, prevent resp complications, care of T-tube complications, care of T-tube

Cancer of the Cancer of the GallbladderGallbladder UncommonUncommon Relationship bet Ca GB & chronic Relationship bet Ca GB & chronic

cholelithiasis or cholecystitischolelithiasis or cholecystitis S/S: insidious, same as GB disease, S/S: insidious, same as GB disease,

later s/s biliary obstructionlater s/s biliary obstruction Rx: surgery, symptomatic, supportiveRx: surgery, symptomatic, supportive Nursing care: supportive, pain relief, Nursing care: supportive, pain relief,

skin care, hydration, comfort skin care, hydration, comfort

Chronic PancreatitisChronic Pancreatitis

Progressive destruction & fibrotic Progressive destruction & fibrotic replacement of tissuereplacement of tissue

Chronic obstructive pancreatitisChronic obstructive pancreatitis Chronic calcifying pancreatitisChronic calcifying pancreatitis S/S: pain, malabsorption with wt S/S: pain, malabsorption with wt

loss, jaundice, dark urine, loss, jaundice, dark urine, steatorrhea, DMsteatorrhea, DM

Dx: secretin stimulation testDx: secretin stimulation test

Collaborative CareCollaborative Care

Diet, pancreatic enzyme replacement, Diet, pancreatic enzyme replacement, control of diabetescontrol of diabetes

Antacids, anticholinergic meds, H2 Antacids, anticholinergic meds, H2 blockers, bile salts, insulinblockers, bile salts, insulin

Surgery if obstructionSurgery if obstruction Nursing Care: health promotion: diet, Nursing Care: health promotion: diet,

pancreatic enzymes, diabetic teaching, pancreatic enzymes, diabetic teaching, avoid alcohol, referrals for narcotic or avoid alcohol, referrals for narcotic or alcohol dependence alcohol dependence

Pancreatic CancerPancreatic Cancer

Over 50% tumors @ head of pancreas-> Over 50% tumors @ head of pancreas-> obstruction of common bile duct->jaundiceobstruction of common bile duct->jaundice

S/S: pain, rapid wt loss, anorexia, nausea, S/S: pain, rapid wt loss, anorexia, nausea, jaundicejaundice

Dx: CEA, CA19-9, ultrasound, CT, ERCP-> Dx: CEA, CA19-9, ultrasound, CT, ERCP-> samples for cytology & biopsysamples for cytology & biopsy

Rx: Whipple’s procedure, radiation, chemoRx: Whipple’s procedure, radiation, chemo Nursing Care: supportive, comfort, help pt Nursing Care: supportive, comfort, help pt

& family grieve & family grieve