Lewis: Medical-Surgical Nursing, 8th Edition
Chapter 44: Nursing Management: Liver, Pancreas, and Biliary Tract Problems
Key Points – Printable
JAUNDICE
Jaundice, a yellowish discoloration of body tissues, results from an alteration in normal
bilirubin metabolism or flow of bile into the hepatic or biliary duct systems, which results in the
concentration of bilirubin in the blood becoming abnormally increased.
The three types of jaundice are hemolytic, hepatocellular, and obstructive.
o Hemolytic (prehepatic) jaundice is due to an increased breakdown of red blood cells
(RBCs), which produces an increased amount of unconjugated bilirubin in the blood.
o Hepatocellular (hepatic) jaundice results from the liver’s altered ability to take up
bilirubin from the blood or to conjugate or excrete it.
o Obstructive (posthepatic) jaundice is due to decreased or obstructed flow of bile
through the liver or biliary duct system.
DISORDERS OF THE LIVER
HEPATITIS
Hepatitis is an inflammation of the liver. Viral hepatitis is the most common cause of
hepatitis. The types of viral hepatitis are A, B, C, D, E, and G.
Hepatitis A Virus
o Hepatitis A virus (HAV) is an RNA virus that is transmitted primarily through the
fecal-oral route by ingestion of food or liquid infected with the virus; hence, poor
hygiene, improper handling of food, crowded situations, and poor sanitary conditions
are all factors related to HAV.
o The greatest risk of transmission occurs before clinical symptoms are apparent.
Hepatitis B Virus
o Hepatitis B virus (HBV) is a DNA virus that is transmitted perinatally by mothers
infected with HBV; percutaneously (e.g., IV drug use); or horizontally by mucosal
exposure to infectious blood, blood products, or other body fluids (e.g., semen, vaginal
secretions, saliva).
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.
Key Points – Printable 44-2
o HBV is a complex structure with three distinct antigens: the surface antigen
(HBsAg), the core antigen (HBcAg), and the e antigen (HBeAg).
Hepatitis C Virus
o Hepatitis C virus (HCV) is an RNA virus that is primarily transmitted
percutaneously.
o The most common mode of HCV transmission is the sharing of contaminated needles
and paraphernalia among IV drug users. Other factors include high-risk sexual behavior,
occupational exposure, hemodialysis, and perinatal transmission.
Hepatitis D, E, and G Virus
o Hepatitis D virus (HDV) is an RNA virus that cannot survive on its own. It requires
HBV to replicate.
o Hepatitis E virus (HEV) is an RNA virus that is transmitted by the fecal-oral route.
o Hepatitis G virus (HGV) is a sexually transmitted virus. HGV coexists with other
viral infections, including HBV, HCV, and HIV.
Clinical manifestations of hepatitis are divided into acute and chronic phases. There is
some slight variation in manifestation among the types of hepatitis. In general:
o Many patients with acute hepatitis have no symptoms.
o The acute phase may be anicteric or icteric (symptomatic, including jaundice). Other
symptoms of the acute phase include malaise, anorexia, fatigue, nausea, occasional
vomiting, and abdominal (right upper quadrant) discomfort.
o Physical examination may reveal hepatomegaly, lymphadenopathy, and sometimes
splenomegaly.
o Most patients with acute viral hepatitis recover completely with no complications.
o Like acute infection, those in the chronic phase may be asymptomatic. Others, however,
may have intermittent or ongoing malaise, fatigue, myalgias, arthralgias, and hepatomegaly.
Complications that can occur include fulminant hepatic failure, chronic hepatitis,
cirrhosis of the liver, and hepatocellular carcinoma.
o Fulminant viral hepatitis results in severe impairment or necrosis of liver cells and
potential liver failure.
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.
Key Points – Printable 44-3
o Approximately 75% to 85% of patients who acquire HCV and many HBV infections will go
on to develop chronic (lifelong) viral infection.
Diagnostic tests are used to distinguish among the various forms of viral hepatitis by
evaluating for the presence of viral antigens and the subsequent development of antibodies to
them.
There is no specific treatment or therapy for acute viral hepatitis.
Drug therapy for chronic HBV and HBC is focused on decreasing the viral load, aspartate
aminotransferase (AST), and alanine aminotransferase (ALT) levels, and the rate of disease
progression.
o Chronic HBV drugs include interferon, lamivudine (Epivir), adefovir (Hepsera), entecavir
(Baraclude), telbivudine (Tyzeka), and tenofivir (Viread).
o Treatment for HCV includes pegylated -interferon (Peg-Intron, Pegasys) given with
ribavirin (Rebetol, Copegus).
Both hepatitis A vaccine and immunoglobulin (IG) are used for prevention of hepatitis A.
Immunization with HBV vaccine is the most effective method of preventing HBV
infection. For postexposure prophylaxis, the vaccine and hepatitis B immune globulin (HBIG) are
used.
Currently there is no vaccine to prevent HCV.
Most patients with viral hepatitis will be cared for at home, so the nurse must assess the
patient’s knowledge of nutrition and provide the necessary dietary teaching.
TOXIC AND DRUG-INDUCED HEPATITIS
Liver injury and death may occur after the inhalation, parenteral injection, or ingestion
of certain chemical substances.
The two major types of chemical hepatotoxicity are toxic and drug-induced hepatitis.
Treatment is generally supportive.
AUTOIMMUNE/METABOLIC/GENETIC LIVER DISEASES
Autoimmune Hepatitis
Autoimmune hepatitis is a chronic inflammatory disorder of unknown cause. It is
characterized by the presence of autoantibodies, high levels of serum immunoglobulins, and
frequent association with other autoimmune diseases.
Autoimmune hepatitis (in which there is evidence of necrosis and cirrhosis) is treated
with corticosteroids or other immunosuppressive agents.
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.
Key Points – Printable 44-4
Wilson’s Disease
Wilson’s disease is a progressive, familial, terminal neurologic disease accompanied by
chronic liver disease leading to cirrhosis associated with increased storage of copper.
The hallmark of Wilson’s disease is corneal Kayser-Fleischer rings on the cornea.
Treatment seeks to promote the urinary excretion of copper through the use of chelating
agents such as D-penicillamine.
Hemochromatosis
Hemochromatosis is a systemic disease caused by the inappropriate absorption of iron,
leading to cirrhosis, diabetes, heart disease, and hepatocellular carcinoma.
If untreated, it usually progresses organ damage, dependant on the degree of iron
overload, by around age 40.
Primary Biliary Cirrhosis
Primary biliary cirrhosis is a chronic inflammatory condition of the liver characterized by
generalized pruritus, hepatomegaly, and hyperpigmentation of the skin.
The goals of treatment are the suppression of ongoing liver damage, prevention of
complications, and symptom management. Patients are at high risk for developing
hepatocellular cancer.
Nonalcoholic Fatty Liver Disease and Nonalcoholic Steatohepatitis
Nonalcoholic fatty liver disease (NAFLD) is a group of disorders that is characterized by
hepatic steatosis (accumulation of fat in the liver) that is not associated with other causes such
as hepatitis, autoimmune disease, or alcohol.
Nonalcoholic steatohepatitis (NASH) refers to the inflammation and scarring that results
from the accumulation of fat in the liver.
The risk of developing NAFLD is a major complication of obesity. Other risk factors
include diabetes, hypertriglyceridemia, severe weight loss (especially in those whose weight loss
was recent), and syndromes associated with insulin resistance.
Most patients are asymptomatic and there is no definitive treatment. Patients must be
monitored for the progression of NAFLD to liver cirrhosis.
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.
Key Points – Printable 44-5
CIRRHOSIS
Cirrhosis is a chronic progressive disease characterized by extensive degeneration and
destruction of the liver parenchymal cells.
Any chronic (long-term) liver disease, most frequently excessive alcohol intake and viral
hepatitis, can cause cirrhosis. Other causes include malnutrition, biliary obstruction, and right-
sided heart failure.
Manifestations of cirrhosis include jaundice, skin lesions (spider angiomas), hematologic
problems (thrombocytopenia, leucopenia, anemia, coagulation disorders), endocrine problems,
and peripheral neuropathy.
Patients without complications of cirrhosis are said to have compensated
cirrhosis; those who have more than one complication of their liver disease are described
as having decompensated cirrhosis.
Major complications of cirrhosis include portal hypertension, esophageal and gastric
varices, peripheral edema and ascites, hepatic encephalopathy, and hepatorenal syndrome.
o Portal hypertension, a persistent increase in blood pressure in the portal venous
system, is characterized by increased venous pressure in the portal circulation, as well
as splenomegaly, large collateral veins, ascites, systemic hypertension, and
esophageal varices.
o Bleeding esophageal varices, tortuous veins at the lower end of the esophagus, are the
most life-threatening complication of cirrhosis.
o Ascites is the accumulation of serous fluid in the peritoneal or abdominal cavity, and
may be accompanied by dehydration, hypokalemia, and peritonitis.
o Hepatic encephalopathy is considered a terminal complication in liver disease. A
characteristic symptom of hepatic encephalopathy is asterixis (flapping tremors).
o Hepatorenal syndrome is characterized by functional renal failure with advancing
azotemia, oliguria, and intractable ascites.
Diagnostic test results in cirrhosis include elevations in liver enzymes, decreased total
protein, fat metabolism abnormalities, and positive liver biopsy.
There is no specific therapy for cirrhosis.
Management of ascites is focused on sodium restriction, diuretics, and fluid removal.
Peritoneovenous shunt is a surgical procedure that provides continuous reinfusion of ascitic fluid
into the venous system.
The main therapeutic goal for esophageal and gastric varices is avoidance of bleeding
and hemorrhage.
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.
Key Points – Printable 44-6
o If the patient has esophageal and/or gastric varices, the nurse observes for any signs of
bleeding from the varices (e.g., hematemesis and melena).
o If bleeding occurs, the nurse must be prepared. The management of bleeding varices
includes prophylactic, therapeutic, and emergency interventions.
o A transjugular intrahepatic portosystemic shunt (TIPS) may be created to redirect portal
blood flow.
o Patients are monitored for spontaneous bacterial peritonitis, which can occur after
variceal hemorrhage.
Management of hepatic encephalopathy is focused on reducing of ammonia formation
and treating precipitating causes. The focus of nursing care of the patient with hepatic
encephalopathy is on maintaining a safe environment, sustaining life, and assisting with
measures to reduce the formation of ammonia.
The diet for the patient with cirrhosis without complications is high in calories (3000
cal/day) with high carbohydrate content and moderate to low-fat levels. Sodium restrictions are
placed on the patient with ascites and edema.
An important nursing focus is the prevention and early treatment of cirrhosis.
FULMINANT HEPATIC FAILURE
Fulminant hepatic failure, or acute liver failure, is a clinical syndrome
characterized by severe impairment of liver function associated with hepatic
encephalopathy.
The most common cause is drugs, usually acetaminophen in combination with alcohol.
Manifestations include jaundice, coagulation abnormalities, and encephalopathy.
With intense support, survival rates are 10% to 25%. Liver transplantation is the
treatment of choice.
LIVER CANCER
Hepatocellular cancer is the most common type of primary liver cancer.
The manifestations are similar to cirrhosis, making it difficult to diagnose in its early
stage.
Prevention of liver cancer is focused on identification and treatment of chronic viral
hepatitis (B and C). Treatment of chronic alcohol ingestion may also lower the risk of liver cancer.
Treatment of liver cancer depends on the size and number of tumors, presence of
spread beyond the liver, and age and overall health of the patient. Overall the management is
similar to that for cirrhosis.
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.
Key Points – Printable 44-7
LIVER TRANSPLANTATION
Indications for liver transplant include chronic viral hepatitis, congenital biliary
abnormalities (biliary atresia), inborn errors of metabolism, hepatic malignancy (confined to the
liver), sclerosing cholangitis, acute hepatic failure, and chronic end-stage liver disease.
Postoperative complications of liver transplant include bleeding, rejection, and infection.
The patient who has had a liver transplant requires highly skilled nursing care.
DISORDERS OF PANCREAS
ACUTE PANCREATITIS
Acute pancreatitis is an acute inflammatory process of the pancreas. The primary
etiologic factors are biliary tract disease (most common cause in women) and alcoholism
(most common cause in men). It is also associated with hypertryglyceridemia.
The pathophysiologic involvement of acute pancreatitis is classified as either mild
pancreatitis (edematous or interstitial) or severe pancreatitis (necrotizing pancreatitis).
Abdominal pain usually located in the left upper quadrant is the predominant
symptom of acute pancreatitis. Other manifestations include nausea, vomiting,
hypotension, tachycardia, and jaundice.
Two significant local complications of acute pancreatitis are pseudocyst and
abscess. A pancreatic pseudocyst is a cavity continuous with or surrounding the outside
of the pancreas.
The primary diagnostic tests for acute pancreatitis are serum amylase and lipase.
Additional studies are used to determine the cause.
Objectives of collaborative care for acute pancreatitis include relief of pain;
prevention or alleviation of shock; reduction of pancreatic secretions; control of fluid and
electrolyte imbalances; prevention or treatment of infections; and removal of the
precipitating cause.
Treatment is principally focused on supportive care, including aggressive
hydration, pain management, management of metabolic complications, and minimization
of pancreatic stimulation.
Nursing management of the patient with pancreatitis focuses on the nursing
diagnoses of acute pain, fluid volume deficit, imbalanced nutrition, and ineffective self-
health management.
CHRONIC PANCREATITIS
Chronic pancreatitis is a continuous, prolonged, inflammatory, and fibrosing process of
the pancreas. The pancreas becomes progressively destroyed as it is replaced with fibrotic
tissue. Strictures and calcifications may also occur.
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.
Key Points – Printable 44-8
Clinical manifestations of chronic pancreatitis include abdominal pain; symptoms of
pancreatic insufficiency, including malabsorption with weight loss; constipation; mild jaundice
with dark urine; steatorrhea; and diabetes mellitus.
When the patient with chronic pancreatitis is experiencing an acute attack, the therapy
is identical to that for acute pancreatitis.
Except during an acute episode, the focus of nursing management is on chronic care and
health promotion. Measures used to control the pancreatic insufficiency include diet, pancreatic
enzyme replacement, and control of the diabetes.
PANCREATIC CANCER
The majority of pancreatic cancers have metastasized at the time of diagnosis. The signs
and symptoms of pancreatic cancer are often similar to those of chronic pancreatitis.
Transabdominal ultrasound and CT scan are the most commonly used diagnostic imaging
techniques for pancreatic diseases, including cancer.
Surgery provides the most effective treatment of cancer of the pancreas; however,
only 15% to 20% of patients have resectable tumors. Medical treatment for pancreatic
cancer includes radiation therapy and chemotherapy.
Because the patient with pancreatic cancer has many of the same problems as the
patient with pancreatitis, nursing care includes many of the same measures. Provide
symptomatic and supportive nursing care, including ensuring adequate nutrition and the
administration of medications and comfort measures to relieve pain. Psychologic support
is essential, especially during times of anxiety or depression.
DISORDERS OF BILIARY TRACT
CHOLELITHIASIS AND CHOLECYSTITIS
The most common disorder of the biliary system is cholelithiasis or stones in the
gallbladder. Cholecystitis, an inflammation of the gallbladder, is usually associated with
cholelithiasis or biliary sludge.
Cholelithiasis develops when the balance that keeps cholesterol, bile salts, and calcium
in solution is altered and precipitation occurs.
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.
Key Points – Printable 44-9
Manifestations of cholecystitis vary from indigestion to moderate to severe pain, fever,
and jaundice. Initial symptoms of acute cholecystitis include indigestion and pain and tenderness
in the right upper quadrant
Cholelithiasis may produce severe symptoms or none at all, depending on whether the
stones are stationary or mobile and whether obstruction is present.
Complications of cholecystitis include gangrenous cholecystitis, subphrenic abscess,
pancreatitis, cholangitis (inflammation of biliary ducts), biliary cirrhosis, fistulas, and rupture of
the gallbladder, which can produce bile peritonitis.
During an acute episode of cholecystitis, treatment is mainly supportive and
symptomatic, focusing on control of pain, control of possible infection with antibiotics, and
maintenance of fluid and electrolyte balance.
Ultrasonography is commonly used to diagnose gallstones.
Treatment of gall stones depends on the patient and stage of disease. Laparoscopic
cholecystectomy is the treatment of choice for symptomatic cholelithiasis. Medical dissolution
therapy is recommended for patients with small radiolucent stones who are mildly symptomatic
and are poor surgical risks.
Postoperative nursing care following a laparoscopic cholecystectomy includes
monitoring for complications such as bleeding, making the patient comfortable, and preparing
the patient for discharge.
The nurse should assume responsibility for recognition of predisposing factors of
gallbladder disease in general health screening.
GALLBLADDER CANCER
Primary gallbladder cancer is rare; its symptoms mimic cholecystitis and cholelithiasis.
Overall, prognosis is poor since disease is usually advanced at the time of diagnosis.
Nursing management, therefore, involves supportive care with attention to nutrition, skin care,
pain relief, and psychosocial concerns.
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.
