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Liver, biliary, and pancreatic needs

Therapeutic nursing interventions

NSG 4037 Adult Nursing III2007

Liver, pancreas, biliary system

Normal Pancreas Disorders of the exocrine pancreasAcute pancreatitis

Inflammation of the pancreasAutodigestion of pancreasFat necrosis Hemorrhage

Acute pancreatitis Pancreatitis

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Pancreatitis Disorders of the exocrine pancreasRisk factors of Acute pancreatitis

Alcohol abuse-major causeCholelithiasisAbdominal trauma

Disorders of the exocrine pancreasEtiology of Acute pancreatitis

Exact cause unknownProteins may plug the small pancreatic ductules.HyperlipidemiaHypercalcemiaPancreatic traumaPancreatic ischemiaDrugs ( antibiotics, anticonvulsants, thiazides, sulfonamides, valproic acid, diuretics)

Disorders of the exocrine pancreasPathophysiology of pancreatitis

When protease and lipase are activated before secreted into the intestine then pancreatic tissue damage occursOnce inflammation begins, a vicious circle of further tissue damage continues.

Disorders of the exocrine pancreasClinical manifestations of A.pancreatitis

Mild, nonspecific abdominal pain progressing to severe pain Local peritonitisPain in mid-epigastrium radiating to back as well as the chest, flanks, and lower abdomenNausea & vomiting due to pain

Disorders of the exocrine pancreasTypical features of client w/ pancreatitis

Distressed, anxiousAbdominal distention and tendernessFever r/t paralytic ileus Turners sign- bluish discoloration of left flankCullen’s sign- bluish discoloration of the periumbilical areaJaundice-uncommon

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Disorders of exocrine pancreasSevere circulatory complications in A. pancreatitis

Hypotension, pallor, cool, clammy skin,hypovolemia

Disorders of the exocrine pancreasOther findings

Cerebral abnormalities, belligerence, confusion, psychosis, and comaTransient hyperglycemia and diabetes may developHigh serum amylase and lipaseChest films show left atelectasis, left pleural effusion, elevated left hemidiaphragmAbdominal films show air in duodenal loop, distention of the colon, gallstones

Disorders of the exocrine pancreasMedical management of A.pancreatitis

Reduce painMaintain volume status, electrolyte balance, and nutritionMaintain pancreatic restTreat complicationsOther measures

Disorders of the exocrine pancreasNursing management

Assess and manage painUse non pharmacologic measures for pain reliefKeep NPO and provide oral hygieneMonitor vital signs for hemodynamic changesMonitor urine outputMonitor respirations and breath soundsMonitor anxiety

Disorders of the exocrine pancreasSurgical management

Indicated in uncertainty of diagnosisTreatment of secondary pancreatic infections, necrosis or abscessCorrection of associated biliary tract diseaseProgressive deterioration despite optimal supportive care

Disorders of the exocrine pancreasPostoperative nursing management

Understand the procedure that was performedKnow location and purpose of all drainsContinually assess tubes and drains.If T tube becomes nonfunctional alert the MD ASAP.

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Disorders of the exocrine pancreasDischarge planning

Verbalize disease process and how to prevent recurrenceDiscuss medication regimenDiet modificationManifestations of recurrence

Disorders of the exocrine pancreasChronic pancreatitis

Progressive fibrosis and degeneration of pancreasDestruction occurs by repeated attacks of pancreatitisDamage is irreversible involving both endocrine and exocrine functions

Disorders of the exocrine pancreasClinical manifestations

Pain may be continuous, intermittent VomitingConstipationFever Jaundice Abdominal distentionFoul, fatty stoolsdiabetes

Icteric sclera

Disorders of the exocrine pancreas

Pancreatic pseudocystsLocalized collections of pancreatic secretions in a cystic structure usually adjacent to the pancreasClinical picture is abdominal pain, early satiety N & V.

Disorders of the exocrine pancreasPancreatic cancer

Fourth common cause of death from cancer90% die within first yearLinked to diabetes mellitus, alcohol use smoking, high fat diet, obesity

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Pancreatic cancer Disorders of the exocrine pancreasPancreatic cancer

Medical treatment- radiation therapyChemotherapySurgical management- Whipple’s procedure

Disorders of the exocrine pancreasPancreatic trauma

RareHigh morbidity, mortalityInjuries to surrounding tissues likely

Disorders of the exocrine pancreasCystic fibrosis

Hereditary, chronic diseaseAutosomal recessiveChildhood disease but many people are surviving into adulthoodMalabsorption of lipids due to decrease lipase formation

Bile Ducts Bile flow

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Biliary ducts

Ampulla of Vater

Sphincter of Oddi

Biliary tract disordersCholelithiasis ( gallstones)

Cholecystitis- inflammation of gall bladderInfections TumorsCongenital malformations

CholelithiasisCholesterol Gallstones (cholelithiasis)

Biliary tract disorders-risk factorsCholelithiasis - gallstones

Increasing ageWomen more than menDiabetes mellitusObesity Crohn’s diseaseCirrhosis

Biliary tract disordersGallstones are crystalline structures formed by hardening and adhering of bile constituents.

Gallstones

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Gangrenous gallbladderand stones Biliary tract disorders

Gallstone formation involves several factors

Bile must become supersaturated with cholesterol or calciumSolute must precipitate from solution as solid crystalsCrystals must come together and fuse to form stones

Biliary tract disordersClinical manifestations

Similar to other disordersMost specific and characteristic is pain or biliary colic.Starts in the upper midline areaRadiate to the back and right shoulder blade.Nausea and vomiting may occur

Biliary tract disordersChronic cholecystitis

Angina pectorisChronic pancreatitisEsophagitisHiatal herniaPeptic ulcerPyelonephritisSpastic colitis

Acute CholecystitisAcute appendicitisAcute hepatitisAcute myocardial infarctAcute pancreatitisAcute pyelonephritisPerforated ulcerPleurisyRight lower lobe pneumonia

Biliary tract disordersClinical manifestations

Restless, trying to get comfortableMay persist few hours or daysIf common bile duct blocked, jaundice and pancreatitis will occurAssessment is very important as biliary colic and coronary artery disease symptoms are remarkably similar

Biliary tract disordersConfirming diagnosis

Abdominal ultrasound is test of choiceERCP can also detect stones in the common bile duct as well as tumors, strictures.

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Biliary disordersStone extraction

Biliary tract disordersMedical management

Reduce painMonitor fluid and electrolytesEndoscopyGallstone dissolutionExtracorporeal shock wave lithotripsyMonitor for complications

Biliary tract disorders Nursing management

Assess and manage painComfort measures

Insert NG tube if orderedAdminister IV fluids

Assess lab values

Observe for injury post procedure

Biliary tract disordersSelf-care

The client will need to learn about diet changes, drugs, ways to prevent recurrence

Biliary tract disordersSurgical management

Lap cholecystectomyContraindications- stones present in common bile ductComplications- damage to biliary tract, hemorrhage. Lap chole. carries a two fold increase in risk of complications compared to open.

Biliary tract disordersCholecystectomy

Open procedure- removal of gallbladder through abdominal incisionT-tube placed in common duct after removing stones. Drains bile while duct is healingMonitor respiratory status closelyAssess CV statusMonitor pain frequently.

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Biliary tract disordersAcute cholecystitis

Acute inflammation of gallbladder wall90% due to stone in gallbladder and obstruction of cystic duct5% of cases no stones found Due to obesity and sedentary lifestyle

Biliary tract disordersAcute cholecystitis

Similar to chronic but pain lasts longerN & VLow grade feverMild jaundice in some casesRUQ tenderness and leukocytosisMurphy’s sign

Biliary tract disordersNursing management

Assessment is critical because several other disease processes produce the same manifestations.These patients will receive antibiotics.

Biliary tract disordersChronic Cholecystitis

Sometimes occurs following acute episodeCan occur independentlyPain is less severeLeukocyte count is higherUsually repeated attacks

Biliary tract disordersCholedocholithiasis

Stones in the common ductCan occur in the absence of a gallbladder

Cholangitis Inflammation of bile ductLab tests- wbc elevated

Bilirubin and alk. phosphatase-elevatedAmylase- check to determine pancreatitis

Biliary tract disordersSclerosing cholangitis

Inflammatory disease of bile ducts that cause fibrosis and thickening of walls and stricturesImportant complications of AIDS.

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Biliary tract disordersCarcinoma of gallbladder

5% of all cancers but most common of biliary tract70% of patients have gallstonesUnrelenting RUQ pain, weight loss, jaundice and palpable mass (RUQ)Prognosis poor

Hepatic disordersThe liver

Central role in many essential physiologic processesLipid synthesis, detoxifies endogenous and exogenous substances

Hepatic disordersJaundice (icterus)

Yellow pigmentation of the sclerae, skin and deeper tissues caused by the excessive accumulation of bile pigments in the blood.

Common manifestation in many liver and biliary disorders

Hepatic disordersUnconjungated hyperbilirubinemia

Result from overproduction of bilirubin as a result of hemolysis

Conjugated hyperbilirubinemia- impaired excretion of bilirubin from the liver resulting from hepatocellular disease, drugs, sepsis, hereditary disorders or extrahepatic biliary obstruction.

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Hepatic disordersClinical manifestations

Yellow sclerae,yellowish orange skin, clay-colored feces, tea-colored urine, pruritis, fatigue, and anorexia.

Medical managementDetermine cause, reduce pruritus and maintain skin integrity

Jaundice

Hepatic disordersNursing management

Observe for jaundice, assess taste, and assess pruritusAdminister oral antihistamines as ordered, cholestyramines (Questran), frequent application of lotionSoft bed linen, keep room cool

Hepatic DisordersDisturbed body image

Reassure client that the discoloration is usually temporary, encourage personal hygieneExplain about jaundice, and how long it will last

Hepatic disordersHepatitis

Inflammation of liverCaused by viruses, toxins, or chemicalsViral hepatitisToxic hepatitisChronicAlcoholic

Viral HepatitisViral hepatitis

Occurs worldwideMost common blood borne infection in US and most of worldMost common types-Hepatitis A, B, C,D,and E Hepatitis F and G not considered serious health threats

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Viral Hepatitis transmissionHepatitis A- infectious hepatitis

Caused by infected water, milk, and foodEspecially raw shellfish from contaminated waters

Hepatitis B-Contact with serum of an infected person is the major mode of transmission. Other body fluids can also transmit.

Viral Hepatitis transmissionHepatitis C- drug use 60% of cases

Tattoing or body piercing can allow transmissionParenterally transmitted like Hep.B

Hepatitis D transmitted through bloodHepatitis E- rare in US. Short incubation and does not become chronic

Viral HepatitisPrevention

Strict hand-washing after bowel movements is requiredStrict hand-washing after contact with contaminated utensils, bedding, clothing.Clients with HBV and HCV should not share razors, toothbrushes, cigarettes or other personal items

Viral hepatitisHepatitis A- vaccine available

Household contacts of persons with HAV should be given immune globulin to prevent spread. Inactivated vaccine should be given to persons traveling to endemic areas and also those with risk factors.

Viral hepatitisHepatitis B

HBV-for active immunity, 3 IM injections given at 0, 1, and 6 months.

Hepatitis CTransmission and prevention similar to HBV

Treated with interferon injections

Viral hepatitisHepatitis D

Hepatitis D must coexist with HBV, the vaccine for HBV helps to prevent HDV

Hepatitis E,F and GHygiene precautions are necessary for prevention of E. No vaccines as yet+-

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Viral HepatitisPathophysiology

Inflammation of the liver with areas of necrosis occur and the damage leads to function impairment

Clinical manifestationsEarly-jaundice, lethargy, irritability, pruritis,myalgia, anorexia, n &v, abd. pain, diarrhea or constipation, fever, flu-like manifestations

Viral hepatitisIrritability and drowsiness are signs of hepatic encephalopathy when severeDeterioration of handwriting is an early sign of hepatic encephalopathy.

Viral hepatitisLiver is larger and is tender to palpation

Bleeding tendencies due to reduced absorption of vitamin K.

Viral HepatitisPrognosis

8-10 weeks liver function tests return to normal

Viral HepatitisMedical management

Reduce fatigueMaintain fluid and nutritional balanceReduce effects of hepatitisMedications to avoid- chlorpromazine, aspirin, acetaminophen, and sedatives.

Viral HepatitisNursing management

Manage fatigue- encourage rest but also encourage some activity to diminish muscle loss due to bedrest. Bed exercises.Modify diet- encourage breakfast, avoid fatty foods, optimum protein, multiple small meals.Avoid alcoholProvide vitamin supplementsRelieve N & VRelieve anxiety

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Viral hepatitisComplications of hepatitis

Typically recover completely from the illness in 3-16 weeks. Clients with HBV tend to experience more complications, could lead to destruction of liverCirrhoses or chronic active hepatitis could result

Hepatic disordersChronic hepatitis

Liver inflammation continues beyond a period of 3-6 monthsChronic hep B follows acute in 5% of casesChronic hep C follows in 70% of case

Hepatic disordersToxic hepatitis

Most commonly, the causative agent is a toxic metabolite formed by the drug-metabolizing enzymes within the liverLiver necrosis occurs within 2-3 days after acute exposure to a dose-related hepatotoxin

Hepatic disordersAlcoholic hepatitis

Acute or chronicMost frequent cause of cirrhosisAnorexia, nausea, abdominal pain, hepatomegaly, spleenomegaly, jaundice, ascites, fever, and elevated bilirubinLiver biopsy reveals fatty hepatic tissue

Hepatic disordersCirrhosis

Chronic, progressive disease characterized by widespread fibrosis and nodule formation.Normal flow of blood, bile is altered by fibrosis

Cirrhosis Four major types

AlcoholicPostnecrotic- toxin inducedBiliaryCardiac

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A close up view of micronodularcirrhosis in a liver with fatty

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Cirrhosis Etiology and risk factors

Excessive alcohol ingestionGenetic predisposition Biliary cirrhosisUse of drugs (acetaminophen, methotrexate, isoniazid)Nutritional deficits r/t jejunal bypassHepatic congestion from R-sided heart failure

Cirrhosis Pathophysiology

Nodular consistency with bands of fibrosisAlters flow of bile and blood thru liverPortal vein hypertension

Cirrhosis

Medical managementMonitor for complications

Ascites, bleeding esophageal varices, renal failure, hepatic encephalopathy

Maximize liver functionA nutritious diet with adequate calories and proteinRestrict sodium and fluids in ascitesAdequate rest

Treat underlying causePrevent infection

Cirrhosis Nursing management

Assess for early signs- liver enlargement and lab dataAssess psychosocial status to guide planningMonitor for hemorrhagePrevent hemorrhage- falls, abrasionsProvide client teachingMonitor diet and provide teaching

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Cirrhosis Complications of cirrhosis

Portal hypertensionPortal vein is likely to be obstructed by a thrombus or a tumorAltered blood flow in liver is responsible for portal hypertensionCirrhosis is most common causeRight-sided heart failure

Cirrhosis Portal hypertension

Manifestations- tortuous epigastric vessels that branch off the umbilicus and lead toward the sternum and ribs.Enlarged palpable spleen, internal hemorrhoids, bruits, and ascites

Cirrhosis Portal hypertension

Medical managementPreventing/controlling hemorrhage esp. in esophageal varices and spleen

Sclerotherapy- sclerosing agent flows into varicesTransjugular intrahepatic portosystemic shuntVasopressin in light of variceal bleedingBalloon tamponade

Portal hypertensionSurgical management

Endoscopic band ligationPortosystemic shunt

Figure 1 Rubber band (arrow) placed over a varix

Garcia-Pagán JC and Bosch J (2005) Endoscopic band ligation in the treatment of portal hypertensionNat Clin Pract Gastroenterol Hepatol 2: 526–535 doi:10.1038/ncpgasthep0323

This figure is provided courtesy of Dr J Llach.

Portal hypertensionTIPS- shunt

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Sengstaken-Blakemore tube Cirrhosis Nursing management

Assess for presence of hemorrhageTeach patient to reduce risk

Avoid strainingAvoid rough foodsDevelop emergency plan in case of rupture

List of all emergency numbers ready and discuss plan with family members

Cirrhosis Monitor for hemorrhage

Assess vital signs, urine output, assess with restoration of circulating blood volume

Prevent esophageal necrosisPrevent aspiration pneumoniaPrevent nares erosionPrevent airway obstructionMonitor level of consciousnessProtect from injury

Cirrhosis Ascites

With increase in portal pressure, plasma leaks directly from the liver capsule and the congested portal vein into the peritoneal cavity.Liver’s ability to synthesize albumin leads to low levels in blood and then leakage of protein into the peritoneal cavity. This decreases the osmotic pressure and secretion of aldosteronestimulates the kidneys to retain sodium and water. Thus increasing ascitic fluid

Cirrhosis Ascites

Abdominal distention, bulging flanks, and downward protruding umbilicusTests to confirm- paracentesis, abdominal xrays, ultrasound and CT scan

Cirrhosis Ascites

Medical managementCorrect fluid and electrolyte imbalanceParacentesisAlbuminDiet modificationsPromote effective breathing patternsMaintain skin integrity

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Cirrhosis Nursing management

Percussion of abdomen-dull with ascitesMeasurement of girthAssess for ascitesAssess distress caused by ascitesRestrict fluidsMonitor intake and outputAdminister albumin and diureticsAvoid hepatotoxinsMonitor after paracentesis

Cirrhosis Hepatic encephalopathy

Liver cannot metabolize ammoniaAmmonia is CNS depressantReduced mental alertness, confusion and restlessness.Loss of consciousness, seizures, and irreversible coma in terminal stage

Cirrhosis Hepatic encephalopathy

Medical managementID and treat precipitating causes.Reduce ammonia in blood and bacteria in colonMaintain fluid volume balance

Cirrhosis Nursing management

Evaluate psychophysiologic statusEncourage bowel cleansing Assess fluid volume statusComplications of immobility

Fatty liver (hepatic stenosis)Lipid infiltration- metabolic diseaseCauses

Chronic alcoholismProtein malnutrition in early lifeDiabetes mellitusObesityJejunileal bypassChronic illness that impairs nutritionReye’s syndrome in children

Fatty liverManifestations

Moderate to severe infiltration- asymptomaticMassive infiltration- anorexia, abdominal pain, and sometimes jaundiceFat embolism can occur and cause death

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Fatty liver Fatty liverNursing interventions

Help direct patients to correct causePrepare for diagnostic proceduresGiving emotional supportGiving supportive physical careDesigning teaching guidelines that promote proper diet and prevent recurrence

Liver neoplasmsPrimary Metastatic

Arise from lungs, GI tract, and breasts

Benign hepatic tumorsFound in women 20-30 y/oAssociated with oral contraceptive useRisk for rupture and hemorrhageDiagnosed with CT scan, USMay be surgically excised

Malignant hepatic tumorsPrimary hepatocellular cancer

Rising due to high prevalence of hepatitis CCirrhosisChronic liver diseaseAnabolic steroid use

Metastatic hepatic cancersCommon site for metastasis

High rate of blood flowSpread by direct extension from adjacent organsVia hepatic arterial systemVia portal venous system

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Metastatic liver disease Metastatic hepatic cancersClinical manifestations

Early indicators-vagueOnly specific to primary tumorAnorexia, diaphoresis, fever, weight loss, weaknessActive liver disease, such as abdominal pain, ascites, and hepatomegalyElevated serum alkaline phosphataseAbnormal US, CT, MRI

Metastatic hepatic cancerMedical management

Relief of manifestations and promote palliationChemotherapyRadiation therapyBiliary drainage

Metastatic hepatic cancerNursing management

Assess for metabolic malfunctions, pain, bleeding, ascites, edemaPrepare client for diagnostic testingOffer support for them to cope with uncertainty and fear

Liver transplantationSurgical management

Indications-severe, irreversible liver diseasePrimary and secondary biliary cirrhosisHepatitis-chronic with cirrhosisPrimary sclerosing cholangitisBiliary atresia (pediatric)Confined hepatic malignancyWilson’s diseaseAlcoholic cirrhosis

Liver transplantationNursing management

Postop care is to monitor for rejection, infection, and occlusion of vesselsImmunosuppressive therapyConstant monitoring of respiratory, cardiovascular, neurologic and hemodynamic status

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Liver abscessLocalized collection of pus and organisms within the parenchyma of liverDevelops for 3 reasons

Bacterial cholangitisPortal vein bacteremiaAmebiasis

Rare disordersHematochromatosis-disorder of iron metabolism

Amyloidosis- a proteinaceous, starch-like substance that can infiltrate the liver and other organs.

Congenital conditionsWilson’s disease- related to copper accumulation in tissues of the liver, brain, and kidney. May be fatal

Caroli’s syndrome- dilated bile ducts and cyst formations

Congenital hepatic fibrosis- portal hypertension from portal vein fibrosis

Liver traumaPenetrating injury or blunt traumaEither cause hemorrhageControl hemorrhage